Leading from a distance: Experiences of specialist critical care physicians providing telehealth support to rural clinicians

Leading from a distance: Experiences of specialist critical care physicians providing telehealth support to rural clinicians | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Leading from a distance: Experiences of specialist critical care physicians providing telehealth support to rural clinicians Chiara Santomauro, Mia McLanders, Clinton Gibbs, Andrew Rae This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4373306/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: The well-known ‘golden hour’ target for trauma treatment is an unachievable goal in many parts of Australia. In response to the vast population spread in Queensland, Australia, telehealth infrastructure facilitates 24/7 links between rural facilities and specialist critical care physicians who provide advice and coordinate aeromedical retrievals. The purpose of this study was to understand work-as-done for specialist critical care physicians using Queensland Health’s emergency telehealth system to support rural clinicians during acute care. Methods: Semi-structured interviews were conducted with 10 specialist critical care physicians operating under the governance of Retrieval Services Queensland to provide advice to rural clinicians through Queensland Health’s emergency telehealth system. Using an inductive approach, qualitative data were analysed in three phases: immersion; a combination of process coding and in vivo coding; and focused coding. Results: The data revealed that supporting rural teams from a distance can be simultaneously rewarding and challenging. Two categories emerged, each with the same three themes representing key challenges to providing emergency telehealth support. The first category presents these challenges, and the second category describes how telehealth technology can help to overcome, but sometimes contributes to, these challenges. Conclusions: The findings highlight that, although challenging at times, emergency telehealth support goes far beyond clinical advice; it provides an avenue to support isolated clinicians through critical, high-stress situations. The findings have several implications for telehealth technology that could reduce specialists’ mental workload and provide better access to information, thereby improving the quality of support delivered to rural teams during critical care. Critical Care & Emergency Medicine Psychology critical care emergency medicine interviews remote support rural and remote telehealth telemedicine trauma Introduction Critically ill patients, such as those with traumatic injuries, require time-critical treatment for survival. In rural and remote areas, geographical barriers reduce access to specialised expertise, delay treatment, and increase the time taken for critical patients to reach definitive care.( 1 , 2 ) Consequently, mortality rates are significantly higher amongst rural and remote populations compared to urban populations, with risk of death increasing with level of remoteness.( 1 – 5 ) The well-known ‘golden hour’ target for trauma treatment is an unachievable goal in many parts of Australia, a country with one of the largest land masses in the world and almost one third of its population living outside metropolitan areas.( 6 , 7 ) In locations where patients are separated from tertiary care by large geographical distances, aeromedical retrievals and telehealth are two key health services that are crucial to the provision of high-quality treatment and management of critically unwell patients.( 8 – 10 ) Currently, Australia is the only country whose aeromedical retrieval services also provide telehealth services to complement the coordination of patient transfers.( 11 ) Queensland is Australia’s second largest state, spanning over 1.7 million square kilometres, with almost 40% of the state’s 5 million residents residing in rural and remote areas.( 7 , 12 ) In response to the vast population spread, in 2016 Queensland Health was reported to offer more telehealth services than any other Australian state healthcare system.( 13 ) One of these services is a dedicated emergency telehealth system that facilitates 24/7 links between rural facilities and specialist critical care physicians, with bidirectional videoconferencing technology installed in 129 facilities across the state. Each installation includes two ceiling-mounted cameras (providing a birds-eye view of the bedspace and a 90-degree side view), a wall-mounted television screen, and an overhead microphone. The pan-tilt-zoom cameras are remotely controlled by specialist critical care physicians in Brisbane and Townsville operating under the governance of Retrieval Services Queensland (RSQ) who provide critical care advice to referring rural clinicians and lead coordination decisions for all aeromedical retrievals in the state.( 7 , 8 , 14 ) The use of telehealth during emergency and trauma care overcomes vast geographical barriers to accessing specialist advice and support, and consistently demonstrates positive outcomes for rural patients and rural clinicians.( 15 , 16 ) The virtual presence of a trauma specialist improves patient evaluation, diagnosis, and direction of care, increases the efficiency of patient transfers, prevents unnecessary transfers, and reduces length of stay for trauma patients in rural areas.( 17 – 20 ) The COVID-19 pandemic accelerated the uptake and acceptance of telehealth in a time where technology is rapidly advancing, which has provided a unique opportunity to introduce emerging technologies into telehealth services.( 21 , 22 ) However, to understand what system elements can be improved with new technology and where best to direct resources, it is important to understand work-as-done rather than work-as-imagined.( 23 ) Therefore, the aim of the present study was to understand work-as-done for specialist critical care physicians using Queensland Health’s emergency telehealth system to support rural clinicians during acute care. Investigating the facilitators, barriers, and frustrations of the system from the perspective of direct end-users can inform improvement efforts such as the implementation of new systems or technologies, which may lead to improved health outcomes for rural communities. Methods Participants and Recruitment Participants were credentialled medical coordinators, who are all experienced specialist critical care physicians operating under the governance of RSQ to provide critical care advice to referring rural clinicians through Queensland Health’s emergency telehealth system. Purposive sampling was used to recruit ten participants (7 male, 3 female) on a volunteer basis via internal email advertisements. The number of participants was based on achieving geographic diversity—with 5 participants from RSQ’s northern coordination centre (Townsville), and 5 from the southern coordination centre (Brisbane)—and aligns with guidance on the number of interviews necessary to achieve saturation in narrow-scope qualitative research.( 24 , 25 ) Procedure Prior to scheduling the interview, participants were given an information sheet and provided written informed consent. Author CS conducted one-on-one semi-structured interviews online via Microsoft Teams videoconference ( n = 9) or in person in a private office ( n = 1). Each interview lasted approximately 30 to 90 minutes and was held between August and November 2021. Interviews were audio-recorded for transcription. At the start of each interview, participants were asked to briefly describe their general experiences providing emergency telehealth support to rural clinicians. The majority of subsequent interview questions were inspired by the Critical Decision Method (CDM).( 26 ) CDM is an extension of the Critical Incident Technique which provides insight into work-as-done versus work-as-imagined.( 27 ) Participants first recalled a memorable experience where they provided telehealth support to a rural team treating a trauma or emergency patient. Then, CDM-inspired probes were used to recall specific details of the event. However, participants sometimes answered these questions more generally based on their wider experiences. The remainder of the interview included general questions about challenges faced by rural clinicians and desired interventions to improve remote support for trauma and emergency care. Data Analysis Interviews were manually transcribed verbatim by a transcription service (Pacific Transcription) and imported into QSR NVivo v1.6.1 software for analysis. Since there were no a priori predictions of what themes might emerge, an inductive thematic analysis approach was adopted to allow the generation of themes to be fully guided by the data.( 28 ) Author CS led the analysis with mentorship from author AR. Data were analysed in three phases: immersion; first cycle coding; and second cycle coding. The first phase involved an in-depth review of each transcript to explore recurrent themes and trends. The second phase involved a combination of process coding and in vivo coding to capture both observable and conceptual actions in the data, and notable language used by participants.( 29 ) In the third phase, iterative focused coding was used to reveal the most significant themes in the data.( 29 ) As a final step, member checking was conducted to increase the validity of the findings.( 30 ) Requests for feedback were sent to the medical coordinators who participated, and this feedback was incorporated into the results. Researcher Characteristics Our research team consists of three PhD researchers (CS, MM, AR) and one clinician researcher (CG). CS and MM specialise in Human Factors, concerned with the interaction between people and systems. CS is a research fellow who collaborates with healthcare organisations and MM is a healthcare-embedded researcher. CS and MM design and evaluate tools and technologies in healthcare, including telehealth technologies. AR is an associate professor in Safety Science with extensive expertise in qualitative methods. CG is a senior emergency physician, experienced medical coordinator and prehospital and retrieval physician, and the Clinical Director of Research and Evaluation at RSQ. The participants are CG’s colleagues; however, he did not interview them and is not aware of who participated. Ethics Approval Ethics approval was granted by the Human Research Ethics Committees of the Royal Brisbane and Women’s Hospital (HREC/2020/QRBW/62878) and Griffith University (2020/631). Results Saturation was achieved after eight interviews, with the last two interviews generating no significantly novel insights. Participants are referred to as coordinators, and quotations are presented with each participant’s identification number in square brackets [1–10]. Apart from the two coordination centres (Brisbane and Townsville), locations have been deidentified. The terms ‘telehealth’, ‘RSQ’, ‘videoconference’, and ‘VC’ were used interchangeably by participants. Two key categories were identified, each with the same 3 themes, presented in Table 1 . The categories were based on the structure of the interviews; however, the themes emerged directly from the data. Although the interview questions were focused on patient care, the data revealed that participants believe the main benefit of emergency telehealth is not better or more timely patient care, but supporting isolated clinicians through critical, high-stress, unfamiliar situations. However, supporting rural teams from a distance can be simultaneously rewarding and challenging. Coordinators may feel deeply responsible for what takes place in the rural facility, yet are powerless to step in when needed. This creates unique challenges when providing emergency telehealth support to rural teams. The first category presents these challenges in detail, and the second category describes how telehealth technology can help to overcome, but sometimes contributes to, these challenges. Table 1 Categories and themes identified from interviews with medical coordinators about emergency telehealth support. 1.0 Challenges of providing emergency telehealth support 1.1 Establishing and maintaining awareness of the rural situation 1.2 Supporting rural teams from a distance 1.3 Working within the constraints of local capacity and capability 2.0 How telehealth technology facilitates or limits emergency support 2.1 Establishing and maintaining awareness of the rural situation 2.2 Supporting rural teams from a distance 2.3 Working within the constraints of local capacity and capability 1.0 Challenges of providing emergency telehealth support 1.1 Establishing and maintaining awareness of the rural situation. One of the main challenges of providing emergency telehealth support is understanding the clinical situation at the rural facility. Coordinators are typically notified via phone call that a rural team is requesting support, which prompts the videoconference. Most participants reported that the amount of background information provided by rural teams can vary substantially. Several participants recalled experiences where they were unable to obtain any background information prior to joining a videoconference, and had subsequent difficulties obtaining that information during the videoconference (e.g., understanding what led to a patient’s cardiac arrest and whether or not they presented with chest pain). “In different cases there is often a tendency for rural facilities to panic and want you on telehealth straight away…You dial in to a scene that [appears to be] just utter chaos. You’re not sure who you’re talking to, where they are, there’s a patient that looks like a deer in headlights…If I could actually take the doctor from that situation to stand at the side of the room on a handheld phone and speak to me, I would get a clearer handover and a clearer idea of the situation.” [8] Accessing information remotely often means verbally prompting for information. Several coordinators felt that having to prompt the rural team for information can be inefficient and disruptive for the rural team, particularly during high-stress scenarios. “There were pieces of information that I had to prompt for that, perhaps, if I’d been there in the flesh, I could have just looked at myself. So, for example, ‘can you turn the vital signs monitor around, so I can see it properly?’” [2] “It’s just hard to interrupt to get [information]. In the resus room you’d walk over to someone and look down onto their – what they’ve written and things like that, it’s the interrupting to get pertinent information.” [7] Variability in background information prior to joining a videoconference, and difficulty extracting information during a videoconference, can make it harder to provide high-quality support to rural teams via telehealth. 1.2 Supporting rural teams from a distance. Several unique challenges come with providing remote, hands-off support. Despite not being present in person, coordinators generally feel responsible for the situation and its outcomes. Most coordinators feel very responsible, despite acknowledging that some things are outside of their control. However, these feelings of responsibility can depend on the role coordinators adopt and the seniority of the rural staff they are supporting. One coordinator felt that having someone else with whom to share patient management decisions is a primary benefit of emergency telehealth for rural clinicians. “I feel responsible, but wouldn’t take any of the credit for the good work that was done. If anything were to have gone awry…Then I would have taken the responsibility for that.” [1] “I had a guy who failed [intubation]. He failed in front of his staff. That makes it a complication for which I also need to protect that individual. There is a degree of responsibility there. There is a degree of responsibility to the colleague, the patient and staff and the system.” [5] “Oh, I feel completely responsible. As soon as I’m involved in the care, I guess I feel as responsible as I feel when I have the patient in my department.” [10] Some coordinators recalled rewarding experiences and feelings of pride, relief, and satisfaction after remotely guiding a rural team through difficult, high-stakes situations. “I remember thinking, ‘oh, gee, that was a very challenging case. I’m really proud of myself for working out the logistics of getting aircrew and aircraft to that person’…I remember thinking, ‘gee, telehealth was very useful’…I felt like I’d done a challenging resuscitation and had achieved something.” [2] “It was a meaningful case. It was a young woman who was critically unwell and at risk of dying. But also a case that handled well. There was an opportunity to make a big, positive impact.” [6] However, providing support from a distance can be distressing for coordinators. Several coordinators recalled times where they could do nothing but observe what unfolded on their screen, while also knowing that the rural team may be without help for several more hours. “It makes me want to cry now. I thought about that mum and when she came in and they said ‘it’s over’, just devastating. I think there was something really horrible about watching it, but not being part of it. I’d normally be the person delivering that news and you have some contact with them and stuff like that, but yeah, it’s horrible.” [7] “We are essentially saying, ‘sorry, yes, we know you’re critically unwell, it’s going to take this long [for the retrieval team] to get to you’. Unless they are close to one of the bigger centres, like [northern Queensland cities], it usually is anywhere between three to eight hours.” [10] Coordinators sometimes find that they have less command over telehealth, despite being the most senior person involved in the patient’s care. This can make it challenging to guide the rural team, with some coordinators describing situations where their instructions were not followed. This challenge is further exacerbated when supporting incohesive rural teams. “There’s been a couple of times where you’ve felt that maybe you’ve not been as forceful about things as you might have been if you’d physically been there just because of – all [they] can hear is a voice, big brother, you can just hear this voice or you look up and see on the screen…It’s like co-pilot, pilot stuff of when do you take over? You can’t actually really because you’re not there.” [3] “I’ve certainly had resuscitations where they are actually about to do something that they shouldn’t and I’m unfortunately yelling ‘stop, stop, stop’ and [it feels like] no one’s listening to me…I’ve had situations where the doctor has done the opposite to what I’ve said…The nursing staff were basically staring at me over the VC…So that’s quite difficult where you’ve got quite a fractured team because you don’t have that relationship with anybody in the room. It’s very difficult to support them.” [7] Medical coordinators are on dedicated shifts whilst working for RSQ, where their sole responsibility is to the RSQ workload, including coordinating aeromedical retrievals and supporting rural teams. This in itself can increase the complexity of providing telehealth support as they manage multiple competing demands, including multiple videoconferences, retrieval coordination, and note-taking, simultaneously. RSQ nurses support coordinators with these tasks but they are not always available. “I was supporting the nurses through managing [a snake bite], whilst at the same time also having a cardiac arrest in [rural hospital] on the other telehealth screen that we have at the coordination office. [Also] having another phone call about a trauma, and the trauma was the relatively minor part of all of this.” [1] “If I translate the normal practice in the ED, for example, for a cardiac arrest, I’m giving instructions, drug doses, whatever it is, someone is writing them down for me. Whereas, often, that doesn’t happen in telehealth...I’m writing down here, while I’m talking up [here].” [2] Coordinators providing support from a distance must balance their strong feelings of responsibility with a lack of physical presence. A virtual-only presence can reduce coordinators’ perceived authority compared to critical events attended in-person, and can mean that coordinators are not able to provide their entire attention to the event. 1.3 Working within the constraints of local capacity and capability. A further challenge of providing emergency telehealth support is that coordinators need to understand the local capacity and capability, which varies widely across rural facilities, and tailor their support to fit within these conditions. Coordinators commonly mentioned that they do not know the team they are supporting or the resources in the local facility, which limits the support they can provide. “The constraints were sort of around pretty standard equipment in the hospital…‘Oh, we don’t have a BIPAP’, ‘well, yes, you do, but you don’t have the masks’. Like, Jesus…I remember thinking, ‘how the hell could a hospital not have a BIPAP mask?’” [2] “I won't know them, they won't know me. I’ll have no idea of anybody’s skillset or experience…You’re obviously remote and not having, you know, having only met for the first time, I won't know any of the staff names which helps the communication and task delegation and closed loop communication.” [9] “So that’s probably the major limitation. Lack of knowledge about the skill set of the treating clinicians there, which then affects your ability to determine how far you should push them…Particularly in critical situations like this, you can only get the best out of the team that you have got…Yes, I know I’m probably adding value by providing support to the clinician, but I don’t feel I’ve done everything that I could do, in an ideal world.” [10] Not knowing the rural team can also affect the extent to which coordinators feel they are kept ‘in the loop’ and included as a team member, which then affects their ability to tailor the support they provide to be of most value. In some cases, coordinators may be concerned that they are making incorrect assumptions about what has or has not been done or missing information such as subtle cues. “If it’s a very noisy room, you can definitely miss that something was given or not given, and you can make assumptions. I’ve certainly made lots of assumptions over time that because they ordered something, something got given and then eight hours later you find out that that never happened. So, constantly worried that I’m missing something.” [7] “It’s hard over the video camera to get the subtly of the body cues or non-verbal cues from the rest of the team, from the patient, from the care givers that maybe also there in the room.” [9] Most coordinators mentioned that despite not knowing the rural team, they generally trust the information being provided. However, if they perceive that they are supporting a junior or inexperienced team, their scepticism increases. “When [coordinators are] dealing with people that they are not familiar with, there may be that sort of trust, ‘is this the right information?’ But I've been doing that for a long time now that I'm used to [it], so there are some things that you just have to let go and you go, ‘this is what they're telling me, I have to trust that they're telling me that’.” [1] “You've got to understand who's telling you and their clinical experience…You're more hands on or more sceptical of what you're being told by less experienced people.” [6] Not knowing the local facility also means that coordinators are unaware of the broader context they are dialling in to, such as prioritisation of patients and other demands. Some coordinators reported that this lack of awareness affects their ability to guide the rural team appropriately, whereas others felt it not necessary to know everything going on in the rural facility. “I think there was other things going on in the clinic there at the time. I wasn’t particular privy to that…It's just a limitation of the technology, and it probably always should be, that you can't see everything that’s going on.” [1] “This is a pinhole. I'm looking at a certain patient in a certain bed with fixed cameras, but I don't know what else is going on in the room…I don't know if there is a whole tribe of people at the door trying to get in and see someone. Whether they love them or want to murder them.” [5] With emergency videoconferencing systems installed in over 110 rural facilities, it is not currently possible for coordinators to know each facility’s unique capacity and capability. However, without this knowledge, and without any established relationships with the rural clinicians, it can be difficult to gauge the level of support required, the kinds of procedures that are possible, and the competing demands in the rural facility. 2.0 How telehealth technology facilitates or limits emergency support 2.1 Establishing and maintaining awareness of the rural situation. Several factors impact a coordinator’s ability to establish and maintain awareness during an emergency telehealth videoconference, and coordinators employ several strategies to improve their awareness. One of the strategies discussed by several coordinators was to collect as much information as possible from the rural team before the videoconference has begun. “Don't let them put the phone down. While we're setting up, can you just give me a verbal brief on what it is?” [5] “If it's not an immediate, time-critical thing and they're asking for some nuanced clinical advice, then you can sort of offload a bit of the work of the telehealth and the information finding by getting that organised for you prior. By one of the RSQ clinical nurses, for example.” [6] Then, during the videoconference, coordinators primarily use the visual modality to collect information about the patient, rural team, and facility. Some coordinators described this as collecting ‘the ground truth’ about a patient’s state. The visual component of the videoconference also allows coordinators to view the resources in the rural facility, including staffing levels and available equipment. One participant recalled a situation where viewing the room allowed them to find key equipment in the resuscitation bay and instruct the rural team on how to use it. “So, I ring up, and here’s this bloke on oxygen not doing very well. So, he needs some invasive respiratory support. So, I say, ‘look, can you put him on CPAP?’ The answer is, ‘no, we can’t because we don’t have a machine for that’. You know, if – down the phone, that starts and ends there. So, ‘hold on a sec, I can see an Oxylog 3000 in the back of your room. Your ventilator can do CPAP.’ ‘Oh, yeah, we don’t know how to use it.’ ‘That’s fine. Bring it over here. Put it down there, and I will talk you through it.’…‘We don’t have a mask.’ ‘Why don’t you call your local ambulance and get them up? Because they carry the masks.’…So, we’ve got the mask, but it’s designed to be plugged into five-millimetre oxygen tubing, not a ventilator circuit. So, ‘well, hold that up. Yep, you should just be able to pull that out and plug the ventilator’. ‘Yep, we can do that’…So, now we’ve got the ventilator, the circuit, and the mask. We can put it on the patient, and I can talk you through that. We’d sort of gone from, oh, waving a laryngoscope around going, ‘oh shit, we’ve got to intubate this patient, so it’s a complete disaster’, to ‘okay, well now we’ve actually got a plan to save the patient’s life while we come up with the next step.” [2] This example demonstrates how telehealth can be used to support resource-gathering in addition to decision-making and communication. Coordinators generally feel that the advantage of videoconferencing is that they can collect this kind of information firsthand, providing a significant advantage over a phone consultation. Telehealth allows coordinators to confirm or refute verbal information, such as verifying handover information provided prior to the telehealth session, which can be less distracting and intrusive for the rural team. Several coordinators recounted stories where the visual input showed a less critical situation than was described to them over the phone, which, in some cases, prevented an unnecessary retrieval. There were also scenarios where concern increased due to the visual input, changing the treatment and management. “You also work out I guess little heuristics or whatever when you say, ‘oh, they're saying this’, but I can see other things that make me think that that’s not what's going on. But that’s not because of anything deliberate on their behalf, that’s just I guess your clinical acumen as you become more experienced to go, ‘well, this doesn’t fit. So what else is causing that’.” [1] “The ‘end-of-the-bed’ogram’ is really going to help me here because I’m not going to have to ask you a million questions.” [7] “When you have a description from a doctor on the phone and then you go and turn on the telehealth, a picture paints a 1000 words. So sometimes someone can sound okay and then you go and switch on telehealth and you look at them and you just think that - even though you can’t put it into words, that patient just looks rubbish and your level of concern goes up and it changes how we manage things.” [8] The telehealth system was praised by most coordinators, providing a good overall picture and allowing them to zoom in to see fine-grained details. “The resolution is quite amazing…You can zoom in across the room onto a monitor that’s smaller than a laptop screen and be able to see things clearly enough to make a diagnosis off that.” [1] “The pictures we get now are phenomenal, the depth you get, the quality, the zoom in and zoom out are just amazing.” [3] As a result, coordinators generally report that the telehealth system enables them to obtain high-quality visual information. However, half of the participants recalled scenarios where they felt limited by the fixed cameras. Chest drains were a common example of a procedure where it is difficult to provide nuanced guidance with a fixed camera system. “One is chest drains. It's quite hard [with] the fixed system…How am I going to do that? How would I do that if I'm instructing my senior registrar or registrar here? I'm not going to stand on a stepladder at the back of the room. Where I would actually like to be is standing just behind your shoulder.” [5] “The lighting [the local doctor] needed to give her a good view provided a lot of glare on the TV screen, so I struggled to see the incision that she was making, and the size. Also, the angle of the chest tube insertion, it was difficult to see where it was going, I just couldn’t make out the angles with the way that our camera was…I think that’s why the chest tube ended up in the wrong place.” [8] Some coordinators described feeling constrained by the image they receive through telehealth and how it differs from being there in person, with one common example being when rural clinicians unknowingly block their view. “In certain views people are just constantly standing in front of the monitoring equipment, and things like that.” [7] “You can’t see 3D, that’s the problem...There’s a lot that you gain just by standing at the end of a patient’s bed and just looking at a patient. You don’t get - it’s not quite the same when you’re looking on telehealth on a camera.” [8] “Because all said and done, the telehealth is still a 2D image. Although it’s technically in 3D, you’re still relying on the clinician there to relay pretty much everything.” [10] Although the visual modality is very important for coordinators to establish and maintain awareness, it does not remove the importance of good verbal communication, especially in those situations where the view is limited. “[The local doctor] articulated what was happening, which is really useful to the whole team, but particularly when you’re on VC and you can’t grab a bit of paper and have a look yourself…He’d get a gas back and he’d [give] dot points of what was on the gas. So, I could make little notes of what was happening without interrupting and asking questions.” [7] “I couldn’t see physically myself what the position of the tube and what the drain was doing, what the underwater seal was doing, was it bubbling, swinging, that sort of thing. So, I couldn’t appreciate those things myself…You just have to rely on somebody telling you that and you’re not sure whether they’re seeing what you would be expecting to see. So, I think the communication is really important.” [8] Some coordinators noted that the system does not allow them to view multiple camera feeds simultaneously, meaning that they frequently switch back and forth between cameras. “[The camera is] on the roof so if you want to have bird’s eye, you can have bird’s eye and everything but then everything’s just really small and you can't see the patient's work of breathing or the colour that well. Most times I’ll either zoom into the patient and then episodically move to the vital signs.” [9] “It’s like looking at something that’s happening in the distance. I don’t feel that I’m fully aware, because you only have a small part of the room. So, you are either visualising the patient or the monitor, or the clinician.” [10] Additionally, the functionality and usability of the system can worsen depending on who is controlling the cameras and who has initiated the videoconference. For those working in the northern hub, there can be inefficiencies if a RSQ nurse is operating the cameras from the southern hub. “It can be a little bit difficult to operate the system in terms of switching between cameras and driving them remotely…If someone drives it from the centre in [Brisbane], they drive it better, but I have to tell them where to drive, which is the trade-off.” [2] “We find it quite difficult when people ring us, rather than us ringing them, which is easier because it means we can then manipulate the cameras. So, I think people sometimes in a panic dial us, as opposed to us dialling in and it just gives us that added difficulty of not being able to manoeuvre the cameras.” [4] “I quite like getting the nursing staff from Retrieval Services bringing us into the VC consults, but surprisingly that can be really frustrating because they’re in a separate room down in Brisbane and we’re up in Townsville. They can just suddenly decide that I might want to look at the monitor when I actually want to look at the patient, and unfortunately that means, I have to speak into that [rural] room for the [RSQ] nurse to hear me.” [7] Coordinators heavily rely on the visual component of the videoconference to obtain information and maintain awareness of the rural situation. The ability to collect firsthand information allows coordinators to confirm or refute verbal information, and can reduce the need to interrupt rural clinicians. When the visual input is limited (for example, because of the fixed camera system, or when the cameras are controlled by others), coordinators can struggle to maintain awareness and therefore provide tailored support. 2.2 Supporting rural teams from a distance. Despite sometimes feeling a sense of helplessness when providing support from a distance, coordinators perceived that the facilitation of rapport and relationship building is one of the biggest advantages of telehealth. Several coordinators noted that the two-way video feed amplifies the emotional aspect and importantly, it allows the rural team to see who is supporting them. “The thing is that the visual thing does bring the emotional aspect into the room. It's something you face with. Not something you hear.” [5] “I think much more useful is that people put a face to the voice. So, from our perspective to be able to see a face to build the relationship both with the team and the care givers in the room as opposed to this anonymous voice making decisions.” [9] To facilitate rapport building and expectation setting, coordinators often adopt an inquisitive communication style by asking the rural team what is required of them up front, rather than assuming what they want help with. “I suppose the trick in that is about the communication stuff that you do, the non-technology stuff of tailoring it in the right way to value add the best. A part of that is at the beginning saying, ‘well, I was going to do this, are you happy with that? How do you want me to contribute towards this?’ It’s almost having some ground rules there.” [3] “My practice I guess progressed, changed slightly over the years and often [I] just open up with ‘how do you want me to help?’ which is slightly different to my role in the emergency department where I’m automatically, you know, usually a team leader.” [9] Several coordinators mentioned that sometimes they can feel as though they are not contributing much to the treatment or management of the patient. However, telehealth allows them to provide peer support to rural teams and reduce their professional isolation, which seemingly adds more value to the situation than the clinical input it is intended to provide. “We might have helped [avoid a retrieval] in a couple, but it wasn’t a big driver. We actually found that the benefits that we got out of that were that the clinicians felt much more supported…The ones that were scared felt infinitely supported in telehealth.” [3] “I think they were very relieved to have us there…It just didn’t really feel like we did much effective except stare at everybody.” [7] “Most times I feel the main benefit is of supporting the rural teams. Probably that main benefit I suspect and the second one is giving good patient care, more timely patient care…Most times I’m supporting the team.” [9] Coordinators are often sought for reassurance that the team has provided the best level of care possible given the circumstances, and their presence in the room (albeit virtually) is especially important when patient outcomes are poor. “The feedback was that they just found that it [was] reassuring but it was that support that they got, they just thought it was brilliant. It reinforced to them why they’ve got [telehealth] and to us it reinforced, God, we’ve actually value add.” [3] “You don’t realise how valuable it is for them. To say, ‘we’ve done all of this’, and we say, ‘there is nothing else to do. You’ve done everything’.” [7] Another commonly noted form of peer support is sharing the mental load with the rural team because they are often working with minimal staff. As an objective party, coordinators also facilitate shared decision making which can be difficult for rural teams to make on their own because of their community ties. “I think having someone else participating in the discussion around of saying, ‘let’s stop’ and helping with those end-of-life discussions is very powerful as well. You’re the doc there and you live there, and you’ve got to face the family and these people – the family will know that every effort was made, they’ve accessed someone from wherever who’s come in, they’ve helped make the decision. So, turning someone off and not progressing is a big call and I think it allows us to participate in those.” [3] “They were crashing and becoming hypoxic post-intubation and I had to more or less do the cognitive thinking and the troubleshooting for that and provide direct instructions, which I wouldn't have been able to do without seeing the patient.” [6] Some coordinators recalled situations where they relieved some of the rural burden by speaking directly to patients and families on behalf of the team. In some cases, they may retrieve a patient even when it will not change the patient’s outcome, primarily to support the rural team who does not have capacity to manage them. “You can actually have a discussion with the family about the pros and cons of treatment. You can’t touch them, you’re not physically there, but it still allows you to still have that verbal and non-verbal interaction with the family about making some decisions.” [3] “My primary conversation was with the nurse and then with the [patient’s] parents…We just have to get the kid out, because of the parental concern and anxiety, and also to support the nurse, there, I think it was the sole nurse in the community.” [10] In addition to peer support, the telehealth system also allows coordinators to provide value in other ways, for example by remotely guiding rural teams through uncommon procedures, the operation of rarely-used equipment, and the delivery of medications that would otherwise not be possible. “I asked the intensive care paramedic to come out and intubate the patient. So, to intubate this patient, we needed to administer paralytics – muscle relaxant agents – which paramedics aren’t allowed to do. So, I sort of said, at the time, ‘look, I’m happy, I mean, I’m not in the room, but I am running this case, and I’m happy - my name is in the notes, there’s a clear verbal or a written’, and then off we went.” [2] “She needed escharotomy. That was done on the basis of visual approach and some instruction given…Which is not a common surgical technique…That's limb saving.” [5] “I think being able to see what she was looking at, she could pick something up and say, ‘this bit? What do you want me to do with this bit?’ Then I could say, ‘no, turn it around, you use it the other way’.” [8] Many coordinators believed that providing emergency telehealth support, whether that be peer or clinical support, is a specialised skillset different to face-to-face support and phone consultations. “This I find is a much more dedicated event…It's a challenge sometimes. It's a modified skillset.” [5] “I think you can underestimate the skill that’s required to get good at doing these things. Because you think, well I can do it in person, I should be able to do it over a video link. But you’re relying on somebody else being your hands essentially…It’s a big learning curve.” [8] However, not all discussions or tasks are deemed suitable to the videoconference modality. For example, coordinators are sensitive to rural clinicians’ positions within their community, and may offer to discuss sensitive topics on a private phone call away from patients and family. Debriefing was another task deemed unsuitable for telehealth, but something that coordinators often wish to be involved in to provide follow up support. “Sometimes people use telemedicine to do a debrief. The problem is it's all hardwired. You have got to go to the resus bay. Actually, that's probably not the best room. The body is still probably in there.” [5] “We discussed [the procedure] behind the scenes away from the patient so that it didn’t alarm the patient talking about those things and didn’t undermine the patient’s confidence in the doctor…Also, the doctor might feel pressured into saying ‘yes I can do it’, if they’ve got people watching. So, I think to give them the freedom to say privately, ‘look I haven’t done this on my own before, I don’t feel confident’, I think is important.” [8] Most coordinators agreed that simply being present during a rural resuscitation can have a significant, positive impact on the treating team. Coordinators believed that their biggest contribution is not necessarily their specialised knowledge and experience, but rather the peer support they provide during acute cases. The bidirectional telehealth system facilitates rapport building and allows coordinators to provide other forms of peer support such as speaking to patient relatives on the team’s behalf. However, the system does not support all interactions, such as those requiring privacy or debriefing events. 2.3 Working within the constraints of local capacity and capability. Although it can be challenging to gauge the rural situation over telehealth, coordinators agree that knowledge of the rural team, patient state, and resources available is important to optimise the quality of support they provide. Several coordinators noted the importance of understanding the confidence and competence of the rural clinicians, since this will heavily inform the guidance they provide. For example, coordinators tend to take a conservative approach to procedures and will avoid those beyond the rural team’s skillset. Intubation was common example of a procedure that coordinators avoid when supporting inexperienced or unconfident staff. To obtain this information, coordinators can simply ask the clinicians but they may feel pressured to conceal the truth, especially with relatives or other staff present. Therefore, coordinators use telehealth to observe their behaviour and non-verbal cues, such as facial expressions and how they handle equipment. “Someone wants to [intubate] – ‘yes, we can intubate’. Okay. You watch them put the equipment together. They're not familiar…If I watch how people handle equipment, yes there is anxiety and things. But it tells me [a lot].” [5] “This has happened on a few occasions where I’ve said, ‘are you comfortable intubating?’…Then they say, ‘well if it gets to it, then I can do it’. That tells me that they probably haven’t done it often enough, but they’re going to give it a shot. This is probably where I would probably not get them to do it, unless [the patient] start going blue in the face.” [10] Further, coordinators use the visual modality to tailor their roles and tasks to best suit the rural situation. For example, coordinators are careful not to overstep when they are supporting more experienced clinicians, or provide support that is too high level for less experienced staff who need intricate guidance. All coordinators agreed that they most commonly adopt the team leader role during critical situations, especially in nurse-led facilities with no local doctor. “I think that’s a bit of emotional intelligence there in terms of how you insert yourself into the proceedings…Where there’s a number of senior staff there, I think you’ve got to be very careful that you’re not then overstepping it. There’s that more collegiate, respectful thing that they’re running it but you’re there to maybe help them troubleshoot or value add if they get into trouble or help with some decision-making.” [3] “The team leader, who was the senior most clinician doctor there, was in control of the situation. Making sure that all team members were performing to their optimal extent, and I was almost a passive observer and only responded to questions that the team leader had.” [10] The telehealth technology also allows coordinators to provide situation awareness to the local team because they have a birds-eye view and are not preoccupied with their own tasks. This keeps the local team on track and allows them to focus on their manual tasks. “They mostly found it good to have someone watching over and having that external oversight and guidance. They did all the hard work really, I was just able to say, ‘right, so we need to - this is the next step we need to do. We need to do that now, okay, it looks like you're bagging well.’” [1] “All the nurses in the hospital were there helping out and then that one doctor’s doing the intubation, it’s often helpful to have somebody else that can manage the medication, they can keep an eye on the vital signs and the other aspects of it.” [9] Some coordinators were conscious of the delicate balance between providing support and being a distraction, and felt that the visual input was helpful to inform when they ask questions or provide instructions. “In a resus here I would maybe say three or four drugs at the same time, that I want the patient to have, but just sort of taking that step back and slowing things down for small facilities that don’t do this often and potentially only have one, maybe two nurses.” [4] “I find [cardiac arrest] most challenging of all telehealth interactions, simply because you are trying to provide support, but you cannot interfere with the running of the cardiac arrest itself.” [7] To provide tailored clinical support, some coordinators recalled situations where they added other specialists into the videoconference for more specialised advice, such as in burns or paediatric cases. This was a well-regarded feature of the telehealth system that allowed rural clinicians to seamlessly connect with metropolitan specialists. “She proved really difficult to ventilate and I was maxing out my skills and knowledge so we also got an intensivist who was on call for ECMO at that time to dial in and provide some ventilatory support…I think it actually worked pretty well and it was good to also, pretty seamlessly, be able to dial in that extra support.” [6] “I’ve probably done this on one occasion, where I’ve got a paediatric intensivist…Which has been fantastic, because then they actually have seen the patient and they have brought their expertise to the patient bedside, to a patient who is four hours away.” [10] To ensure that the rural team feels fully supported, coordinators can use telehealth to virtually ‘stay’ with the rural team until the retrieval team arrives and assist the rural team in the patient handover if needed. “So, the other thing that we find it very useful for is, is handovers…As a [retrieval] team gets there, the process is that when they get there, they have a look at the patient and before they leave will chat with us as the consultant to be sure everything’s kosher, and they’ve got a plan and all that sort of stuff.” [3] “Then you might still leave the telehealth running in the background, intermittently being monitored by a [RSQ] nurse, but your focus is away while that patient is stable and then you'll get called in for further updates or advice as required.” [6] Coordinators were asked hypothetical questions about whether they could still provide support if telehealth was not available in the memorable events they recalled. Overwhelmingly, they felt that it would have been much more difficult and that emergency telehealth support led to better patient outcomes. “I think that the patient would have died much more incipiently probably – not quite through medical misadventure but because of medical limitations on the nature of the care that could have been provided without the telehealth.” [2] Coordinators use telehealth to directly observe the patient condition, team composition, and resources available, which subsequently informs the kind of support they provide. Coordinators typically adopt a team leader role but may adapt their role to suit the specific team and context. The telehealth technology allows coordinators to keep situation awareness, to determine the right moments to speak, to bring other specialists into the scenario, and to assist in patient handovers. Without the telehealth technology, coordinators believed that patient outcomes would be worse and rural clinicians would be less supported. Discussion This was the first study to explore the experiences of specialist critical care physicians who use telehealth to support the treatment and management of critically ill patients in rural Queensland. Overall, the findings revealed that the perceived value of emergency telehealth is in the support it provides to isolated rural clinicians during critical, high-stress, and unfamiliar situations, more so than altering the direction of patient care. However, coordinators often balance a deep sense of responsibility with the limitations of providing support remotely. The study results highlight some of the challenges to providing emergency telehealth support, and several ways that telehealth technology can help to overcome, but sometimes contributes to, these challenges. One of the challenges is understanding the clinical situation at the rural facility. There is variation in the quality of information provided prior to and during a videoconference, so coordinators use the visual modality of telehealth to confirm, update, or resolve information inconsistencies. Having two ceiling-mounted cameras in each resuscitation bay is crucial to providing high quality support, allowing coordinators to not only assess the patient and vital signs, but also the rural team and available resources. However, the camera angles are not always ideal, particularly when guiding rural teams through procedures. The challenge of feeling responsible despite not being physically present can intensify with lack of resources and varied skillsets available at the rural site. Additionally, providing support from a distance can mean that despite being the most senior clinician involved in a case, coordinators may have less command over the situation when supporting via telehealth. However, telehealth facilitates rapport building through the two-way video feed which is important to allow the rural team to see, not just hear, the specialist who is supporting them. This two-way system was a deliberate design choice to facilitate the social exchange rather than just providing another information source. At the outset, coordinators seek to understand exactly what the rural team needs from them, so that they have a clearly defined role in the scenario. In addition to providing procedural support, coordinators use telehealth to provide peer support and reassurance to the rural team by overseeing critical situations, sharing the responsibility and decision-making, and reducing the emotional burden of speaking to patients and family. Coordinators rarely know the clinicians they are supporting, or the rural context they are dialling in to, which can sometimes mean they are left out of communication, which reduces their ability to tailor the support they provide. Determining the skills and experience of the rural team is vital to tailoring the support provided and direction of care. Since the response provided may be unreliable when coordinators ask directly, they use telehealth to observe rural clinicians’ non-verbal cues to give hints towards their genuine capabilities and confidence. Coordinators most often adopt a team leader role, but what they view over telehealth helps to modify their support and communication style to meet the patient state, the available resources, and the perceived requirements of the rural team. Implications for Telehealth Technology Coordinators strongly believe that Queensland’s emergency telehealth system facilitates high-quality support for rural teams. Participants were especially impressed with the camera image quality, and the foresight to install the infrastructure across rural Queensland. However, the findings revealed several implications for emergency telehealth technology that were either explicitly stated by participants or identified by the researchers (represented by [R]) from the interview content and workarounds discussed. These technologies would all complement, rather than replace, the existing system, and some of the ideas are already under consideration.( 31 ) Portable technology, including hand-held and head-worn devices, were frequently suggested to enable visual angles that are not currently available with the fixed system. Portable videoconferencing devices may benefit situations where the fixed cameras do not provide an ideal view, or when coordinators support the treatment of multiple patients at one site (e.g., mass casualty events).( 32 ) Related, participants were presented with the concept of interactive telepresence, which would allow the coordinator to guide rural clinicians through interventions by virtually annotating on the patient in real time, such as through augmented reality on a head-worn device.( 33 , 34 ) Although some participants expect annotation to be a potentially powerful tool, others felt that the addition of portable cameras would be of most value. Despite providing the most telehealth services in the country,( 13 ) there was consensus that telehealth is still underutilised in Queensland. Coordinators suggested that its use should be expanded to include prehospital environments (e.g., on scene, in aircrafts, in ambulances),( 35 ) remotely-delivered education and training,( 36 ) and non-clinical situations (e.g., to communicate with relatives). Some mentioned that it should be used in more non-emergency clinical consultations between hospitals to reduce unnecessary transfers, but there is hesitation because non-emergency telehealth runs on different systems and is not as easy to use. In the years leading up to this study in 2021, RSQ started a remote education service that utilises web-based videoconferencing systems across Queensland. Similarly, a telehealth service that linked rural and remote facilities with their “hub” regional hospital for advice and support was well-established at that time. In 2022, this service has expanded to now provide Emergency Physician and Nurse Practitioner led low-acuity emergent telehealth consultations 24/7. Another frequent suggestion was system integration to improve remote patient monitoring so that coordinators could maintain camera focus on the patient with the vital signs displayed on a separate screen. Alternatively, introducing a function to view multiple camera feeds simultaneously would allow coordinators to maintain views of both the patient and vital signs at once, rather than switching between cameras [R]. A system designed to allow remote vital signs monitoring was trialled by RSQ over 8 years ago but was poorly adopted due to the complexity of its use. With advances in technology since then, a revisit may prove beneficial. To streamline the process of initiating private conversations with rural clinicians, another potential enhancement is a function that allows coordinators to direct their audio to different sources. This could be useful for handovers at the commencement of the videoconference, or in situations that require privacy like discussing procedural confidence. For example, if a rural clinician dons a headset that connects to telehealth, a one-on-one conversation could take place without needing to mute the telehealth audio and make a separate phone call to another room [R]. It could also be useful for coordinators located in the northern region of Queensland to communicate with RSQ nurses in the southern region who often participate in the videoconference, without distracting clinicians in the rural facility. Better information exchange functionality would allow coordinators to easily share and access images, documentation, clinical notes, medication carts, and policies and guidelines. Currently, visual information (e.g., photographs) is shared through workarounds such as email or text which is not always secure. The introduction of virtual platforms or whiteboards were discussed to provide easier information access and sharing. Implementing a streamlined, formal process or platform for information exchange would not only improve efficiency and patient care, but also quality assurance.( 7 ) This could also address some of the inconsistencies in the quality of information provided to coordinators prior to joining the videoconference, because this subsequently affects the quality of support they are able to provide [R]. Finally, some coordinators suggested improvements that were not directly related to the technology itself, but would ultimately improve the quality of support delivered through the system. Tailored training of effective telehealth practice for both coordinators and rural clinicians could improve communication and efficiency during videoconferences. For example, a telehealth framework could be implemented to guide appropriate expectation setting, role allocation, and teamwork when providing, or accessing, remote emergency support. Additionally, standardising some of the resources (e.g., resuscitation equipment) across rural facilities could remove some of the guess work involved in supporting a team in an unfamiliar facility. Limitations and Future Directions Although participants were recruited evenly from each of the two retrieval coordination centres, the findings are limited to a sample of 10 medical coordinators. Saturation was considered to be achieved but it is possible that other themes may have emerged with more interviews. Further, the findings may not generalise to other states or countries with different emergency telehealth and aeromedical retrieval systems. The similarities and differences could be explored in future research at a national and international level, by comparing these findings to that of other places with aeromedical coordination centres such as New South Wales and Western Australia (the two other Australian states with aeromedical coordination centres) and other geographically vast areas like North America.( 8 , 11 ) Ideally, if any aforementioned improvements are implemented, their impact on emergency telehealth support should be explored from both the individual end-user level, and at the health system level. Conclusions Specialist critical care physicians operating under Retrieval Services Queensland use a dedicated emergency telehealth system to support rural clinicians treating critically ill patients. The findings from this study revealed that emergency telehealth support goes far beyond clinical advice; it provides an avenue to collegially support rural teams through critical, high-stress situations. Supporting rural teams from a distance can be both rewarding and challenging, with telehealth technology helping to overcome, and sometimes contributing to, these challenges. The findings have several implications for telehealth technology that could reduce specialists’ mental workload and provide better access to information, thereby improving the quality of support delivered to rural teams during critical care. Declarations Competing Interests The authors declare that there is no conflict of interest regarding the publication of this article. Funding This work was supported by a Queensland Government Advance Queensland Industry Research Fellowship awarded to Chiara Santomauro [AQIRF149-2019RD2]. Ethics Approval This project was performed in accordance with the Declaration of Helsinki and the Australian Government National Health and Medical Research Council’s National Statement on Ethical Conduct in Human Research and Australian Code for the Responsible Conduct of Research. Ethics approval was granted by the Human Research Ethics Committees of the Royal Brisbane and Women’s Hospital (HREC/2020/QRBW/62878) and Griffith University (2020/631). Prospective participants were given an information sheet and provided written informed consent prior to scheduling the interview. Guarantor C.S. Data Availability The data from this study are available from the corresponding author upon reasonable request. Contributorship All authors contributed to the conception and design of the study and interview questions. CS conducted the interviews and analysed the data, and AR provided assistance with data analysis and interpretation. CS drafted the manuscript and MM, CG, and AR all made substantial revisions to the manuscript. All authors approved the final version. Acknowledgements We thank the participating medical coordinators for volunteering their time to this project. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4373306","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":298990166,"identity":"f0bdac52-a9b3-4e18-a8bc-26359cd89562","order_by":0,"name":"Chiara Santomauro","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0002-7904-0157","institution":"Griffith University","correspondingAuthor":true,"prefix":"","firstName":"Chiara","middleName":"","lastName":"Santomauro","suffix":""},{"id":298990396,"identity":"9320e25f-3d30-469b-9792-e6ab4d59fa91","order_by":1,"name":"Mia McLanders","email":"","orcid":"https://orcid.org/0000-0002-5338-2992","institution":"Metro North Health","correspondingAuthor":false,"prefix":"","firstName":"Mia","middleName":"","lastName":"McLanders","suffix":""},{"id":298990397,"identity":"cccae3c6-d960-45ba-98c0-2ccd83d9beb5","order_by":2,"name":"Clinton Gibbs","email":"","orcid":"https://orcid.org/0000-0003-4011-1867","institution":"Retrieval Services Queensland","correspondingAuthor":false,"prefix":"","firstName":"Clinton","middleName":"","lastName":"Gibbs","suffix":""},{"id":298990398,"identity":"989ba222-940d-4a9e-9cd7-c90a0c24b7f5","order_by":3,"name":"Andrew Rae","email":"","orcid":"https://orcid.org/0000-0002-9540-503X","institution":"Griffith University","correspondingAuthor":false,"prefix":"","firstName":"Andrew","middleName":"","lastName":"Rae","suffix":""}],"badges":[],"createdAt":"2024-05-06 00:42:20","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-4373306/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4373306/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":55977677,"identity":"d9135b02-1a21-4927-ae5d-85cb24b64447","added_by":"auto","created_at":"2024-05-07 05:57:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":621047,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4373306/v1/dc36d384-7ef2-4b93-ad1c-ba0bc762400e.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eLeading from a distance: Experiences of specialist critical care physicians providing telehealth support to rural clinicians\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCritically ill patients, such as those with traumatic injuries, require time-critical treatment for survival. In rural and remote areas, geographical barriers reduce access to specialised expertise, delay treatment, and increase the time taken for critical patients to reach definitive care.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Consequently, mortality rates are significantly higher amongst rural and remote populations compared to urban populations, with risk of death increasing with level of remoteness.(\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) The well-known \u0026lsquo;golden hour\u0026rsquo; target for trauma treatment is an unachievable goal in many parts of Australia, a country with one of the largest land masses in the world and almost one third of its population living outside metropolitan areas.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) In locations where patients are separated from tertiary care by large geographical distances, aeromedical retrievals and telehealth are two key health services that are crucial to the provision of high-quality treatment and management of critically unwell patients.(\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) Currently, Australia is the only country whose aeromedical retrieval services also provide telehealth services to complement the coordination of patient transfers.(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eQueensland is Australia\u0026rsquo;s second largest state, spanning over 1.7\u0026nbsp;million square kilometres, with almost 40% of the state\u0026rsquo;s 5\u0026nbsp;million residents residing in rural and remote areas.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) In response to the vast population spread, in 2016 Queensland Health was reported to offer more telehealth services than any other Australian state healthcare system.(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) One of these services is a dedicated emergency telehealth system that facilitates 24/7 links between rural facilities and specialist critical care physicians, with bidirectional videoconferencing technology installed in 129 facilities across the state. Each installation includes two ceiling-mounted cameras (providing a birds-eye view of the bedspace and a 90-degree side view), a wall-mounted television screen, and an overhead microphone. The pan-tilt-zoom cameras are remotely controlled by specialist critical care physicians in Brisbane and Townsville operating under the governance of Retrieval Services Queensland (RSQ) who provide critical care advice to referring rural clinicians and lead coordination decisions for all aeromedical retrievals in the state.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) The use of telehealth during emergency and trauma care overcomes vast geographical barriers to accessing specialist advice and support, and consistently demonstrates positive outcomes for rural patients and rural clinicians.(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) The virtual presence of a trauma specialist improves patient evaluation, diagnosis, and direction of care, increases the efficiency of patient transfers, prevents unnecessary transfers, and reduces length of stay for trauma patients in rural areas.(\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe COVID-19 pandemic accelerated the uptake and acceptance of telehealth in a time where technology is rapidly advancing, which has provided a unique opportunity to introduce emerging technologies into telehealth services.(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) However, to understand what system elements can be improved with new technology and where best to direct resources, it is important to understand work-as-done rather than work-as-imagined.(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) Therefore, the aim of the present study was to understand work-as-done for specialist critical care physicians using Queensland Health\u0026rsquo;s emergency telehealth system to support rural clinicians during acute care. Investigating the facilitators, barriers, and frustrations of the system from the perspective of direct end-users can inform improvement efforts such as the implementation of new systems or technologies, which may lead to improved health outcomes for rural communities.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eParticipants and Recruitment\u003c/h2\u003e\n \u003cp\u003eParticipants were credentialled medical coordinators, who are all experienced specialist critical care physicians operating under the governance of RSQ to provide critical care advice to referring rural clinicians through Queensland Health\u0026rsquo;s emergency telehealth system. Purposive sampling was used to recruit ten participants (7 male, 3 female) on a volunteer basis via internal email advertisements. The number of participants was based on achieving geographic diversity\u0026mdash;with 5 participants from RSQ\u0026rsquo;s northern coordination centre (Townsville), and 5 from the southern coordination centre (Brisbane)\u0026mdash;and aligns with guidance on the number of interviews necessary to achieve saturation in narrow-scope qualitative research.(\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003eProcedure\u003c/h2\u003e\n \u003cp\u003ePrior to scheduling the interview, participants were given an information sheet and provided written informed consent. Author CS conducted one-on-one semi-structured interviews online via Microsoft Teams videoconference (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9) or in person in a private office (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1). Each interview lasted approximately 30 to 90 minutes and was held between August and November 2021. Interviews were audio-recorded for transcription.\u003c/p\u003e\n \u003cp\u003eAt the start of each interview, participants were asked to briefly describe their general experiences providing emergency telehealth support to rural clinicians. The majority of subsequent interview questions were inspired by the Critical Decision Method (CDM).(\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e) CDM is an extension of the Critical Incident Technique which provides insight into work-as-done versus work-as-imagined.(\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e) Participants first recalled a memorable experience where they provided telehealth support to a rural team treating a trauma or emergency patient. Then, CDM-inspired probes were used to recall specific details of the event. However, participants sometimes answered these questions more generally based on their wider experiences. The remainder of the interview included general questions about challenges faced by rural clinicians and desired interventions to improve remote support for trauma and emergency care.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eData Analysis\u003c/h2\u003e\n \u003cp\u003eInterviews were manually transcribed verbatim by a transcription service (Pacific Transcription) and imported into QSR NVivo v1.6.1 software for analysis. Since there were no a priori predictions of what themes might emerge, an inductive thematic analysis approach was adopted to allow the generation of themes to be fully guided by the data.(\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e) Author CS led the analysis with mentorship from author AR. Data were analysed in three phases: immersion; first cycle coding; and second cycle coding. The first phase involved an in-depth review of each transcript to explore recurrent themes and trends. The second phase involved a combination of process coding and in vivo coding to capture both observable and conceptual actions in the data, and notable language used by participants.(\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e) In the third phase, iterative focused coding was used to reveal the most significant themes in the data.(\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e) As a final step, member checking was conducted to increase the validity of the findings.(\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e) Requests for feedback were sent to the medical coordinators who participated, and this feedback was incorporated into the results.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003eResearcher Characteristics\u003c/h2\u003e\n \u003cp\u003eOur research team consists of three PhD researchers (CS, MM, AR) and one clinician researcher (CG). CS and MM specialise in Human Factors, concerned with the interaction between people and systems. CS is a research fellow who collaborates with healthcare organisations and MM is a healthcare-embedded researcher. CS and MM design and evaluate tools and technologies in healthcare, including telehealth technologies. AR is an associate professor in Safety Science with extensive expertise in qualitative methods. CG is a senior emergency physician, experienced medical coordinator and prehospital and retrieval physician, and the Clinical Director of Research and Evaluation at RSQ. The participants are CG\u0026rsquo;s colleagues; however, he did not interview them and is not aware of who participated.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003eEthics Approval\u003c/h2\u003e\n \u003cp\u003eEthics approval was granted by the Human Research Ethics Committees of the Royal Brisbane and Women\u0026rsquo;s Hospital (HREC/2020/QRBW/62878) and Griffith University (2020/631).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eSaturation was achieved after eight interviews, with the last two interviews generating no significantly novel insights. Participants are referred to as coordinators, and quotations are presented with each participant\u0026rsquo;s identification number in square brackets [1\u0026ndash;10]. Apart from the two coordination centres (Brisbane and Townsville), locations have been deidentified. The terms \u0026lsquo;telehealth\u0026rsquo;, \u0026lsquo;RSQ\u0026rsquo;, \u0026lsquo;videoconference\u0026rsquo;, and \u0026lsquo;VC\u0026rsquo; were used interchangeably by participants.\u003c/p\u003e \u003cp\u003eTwo key categories were identified, each with the same 3 themes, presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The categories were based on the structure of the interviews; however, the themes emerged directly from the data. Although the interview questions were focused on patient care, the data revealed that participants believe the main benefit of emergency telehealth is not better or more timely patient care, but supporting isolated clinicians through critical, high-stress, unfamiliar situations. However, supporting rural teams from a distance can be simultaneously rewarding and challenging. Coordinators may feel deeply responsible for what takes place in the rural facility, yet are powerless to step in when needed. This creates unique challenges when providing emergency telehealth support to rural teams. The first category presents these challenges in detail, and the second category describes how telehealth technology can help to overcome, but sometimes contributes to, these challenges.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCategories and themes identified from interviews with medical coordinators about emergency telehealth support.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChallenges of providing emergency telehealth support\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEstablishing and maintaining awareness of the rural situation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSupporting rural teams from a distance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorking within the constraints of local capacity and capability\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHow telehealth technology facilitates or limits emergency support\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEstablishing and maintaining awareness of the rural situation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSupporting rural teams from a distance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorking within the constraints of local capacity and capability\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e1.0 Challenges of providing emergency telehealth support\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003e1.1 Establishing and maintaining awareness of the rural situation.\u003c/b\u003e One of the main challenges of providing emergency telehealth support is understanding the clinical situation at the rural facility. Coordinators are typically notified via phone call that a rural team is requesting support, which prompts the videoconference. Most participants reported that the amount of background information provided by rural teams can vary substantially. Several participants recalled experiences where they were unable to obtain any background information prior to joining a videoconference, and had subsequent difficulties obtaining that information during the videoconference (e.g., understanding what led to a patient\u0026rsquo;s cardiac arrest and whether or not they presented with chest pain).\u003c/p\u003e \u003cp\u003e\u0026ldquo;In different cases there is often a tendency for rural facilities to panic and want you on telehealth straight away\u0026hellip;You dial in to a scene that [appears to be] just utter chaos. You\u0026rsquo;re not sure who you\u0026rsquo;re talking to, where they are, there\u0026rsquo;s a patient that looks like a deer in headlights\u0026hellip;If I could actually take the doctor from that situation to stand at the side of the room on a handheld phone and speak to me, I would get a clearer handover and a clearer idea of the situation.\u0026rdquo; [8]\u003c/p\u003e \u003cp\u003e Accessing information remotely often means verbally prompting for information. Several coordinators felt that having to prompt the rural team for information can be inefficient and disruptive for the rural team, particularly during high-stress scenarios.\u003c/p\u003e \u003cp\u003e\u0026ldquo;There were pieces of information that I had to prompt for that, perhaps, if I\u0026rsquo;d been there in the flesh, I could have just looked at myself. So, for example, \u0026lsquo;can you turn the vital signs monitor around, so I can see it properly?\u0026rsquo;\u0026rdquo; [2]\u003c/p\u003e \u003cp\u003e\u0026ldquo;It\u0026rsquo;s just hard to interrupt to get [information]. In the resus room you\u0026rsquo;d walk over to someone and look down onto their \u0026ndash; what they\u0026rsquo;ve written and things like that, it\u0026rsquo;s the interrupting to get pertinent information.\u0026rdquo; [7]\u003c/p\u003e \u003cp\u003eVariability in background information prior to joining a videoconference, and difficulty extracting information during a videoconference, can make it harder to provide high-quality support to rural teams via telehealth.\u003c/p\u003e \u003cp\u003e \u003cb\u003e1.2 Supporting rural teams from a distance.\u003c/b\u003e Several unique challenges come with providing remote, hands-off support. Despite not being present in person, coordinators generally feel responsible for the situation and its outcomes. Most coordinators feel very responsible, despite acknowledging that some things are outside of their control. However, these feelings of responsibility can depend on the role coordinators adopt and the seniority of the rural staff they are supporting. One coordinator felt that having someone else with whom to share patient management decisions is a primary benefit of emergency telehealth for rural clinicians.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I feel responsible, but wouldn\u0026rsquo;t take any of the credit for the good work that was done. If anything were to have gone awry\u0026hellip;Then I would have taken the responsibility for that.\u0026rdquo; [1]\u003c/p\u003e \u003cp\u003e\u0026ldquo;I had a guy who failed [intubation]. He failed in front of his staff. That makes it a complication for which I also need to protect that individual. There is a degree of responsibility there. There is a degree of responsibility to the colleague, the patient and staff and the system.\u0026rdquo; [5]\u003c/p\u003e \u003cp\u003e\u0026ldquo;Oh, I feel completely responsible. As soon as I\u0026rsquo;m involved in the care, I guess I feel as responsible as I feel when I have the patient in my department.\u0026rdquo; [10]\u003c/p\u003e \u003cp\u003eSome coordinators recalled rewarding experiences and feelings of pride, relief, and satisfaction after remotely guiding a rural team through difficult, high-stakes situations.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I remember thinking, \u0026lsquo;oh, gee, that was a very challenging case. I\u0026rsquo;m really proud of myself for working out the logistics of getting aircrew and aircraft to that person\u0026rsquo;\u0026hellip;I remember thinking, \u0026lsquo;gee, telehealth was very useful\u0026rsquo;\u0026hellip;I felt like I\u0026rsquo;d done a challenging resuscitation and had achieved something.\u0026rdquo; [2]\u003c/p\u003e \u003cp\u003e\u0026ldquo;It was a meaningful case. It was a young woman who was critically unwell and at risk of dying. But also a case that handled well. There was an opportunity to make a big, positive impact.\u0026rdquo; [6]\u003c/p\u003e \u003cp\u003eHowever, providing support from a distance can be distressing for coordinators. Several coordinators recalled times where they could do nothing but observe what unfolded on their screen, while also knowing that the rural team may be without help for several more hours.\u003c/p\u003e \u003cp\u003e\u0026ldquo;It makes me want to cry now. I thought about that mum and when she came in and they said \u0026lsquo;it\u0026rsquo;s over\u0026rsquo;, just devastating. I think there was something really horrible about watching it, but not being part of it. I\u0026rsquo;d normally be the person delivering that news and you have some contact with them and stuff like that, but yeah, it\u0026rsquo;s horrible.\u0026rdquo; [7]\u003c/p\u003e \u003cp\u003e\u0026ldquo;We are essentially saying, \u0026lsquo;sorry, yes, we know you\u0026rsquo;re critically unwell, it\u0026rsquo;s going to take this long [for the retrieval team] to get to you\u0026rsquo;. Unless they are close to one of the bigger centres, like [northern Queensland cities], it usually is anywhere between three to eight hours.\u0026rdquo; [10]\u003c/p\u003e \u003cp\u003eCoordinators sometimes find that they have less command over telehealth, despite being the most senior person involved in the patient\u0026rsquo;s care. This can make it challenging to guide the rural team, with some coordinators describing situations where their instructions were not followed. This challenge is further exacerbated when supporting incohesive rural teams.\u003c/p\u003e \u003cp\u003e\u0026ldquo;There\u0026rsquo;s been a couple of times where you\u0026rsquo;ve felt that maybe you\u0026rsquo;ve not been as forceful about things as you might have been if you\u0026rsquo;d physically been there just because of \u0026ndash; all [they] can hear is a voice, big brother, you can just hear this voice or you look up and see on the screen\u0026hellip;It\u0026rsquo;s like co-pilot, pilot stuff of when do you take over? You can\u0026rsquo;t actually really because you\u0026rsquo;re not there.\u0026rdquo; [3]\u003c/p\u003e \u003cp\u003e\u0026ldquo;I\u0026rsquo;ve certainly had resuscitations where they are actually about to do something that they shouldn\u0026rsquo;t and I\u0026rsquo;m unfortunately yelling \u0026lsquo;stop, stop, stop\u0026rsquo; and [it feels like] no one\u0026rsquo;s listening to me\u0026hellip;I\u0026rsquo;ve had situations where the doctor has done the opposite to what I\u0026rsquo;ve said\u0026hellip;The nursing staff were basically staring at me over the VC\u0026hellip;So that\u0026rsquo;s quite difficult where you\u0026rsquo;ve got quite a fractured team because you don\u0026rsquo;t have that relationship with anybody in the room. It\u0026rsquo;s very difficult to support them.\u0026rdquo; [7]\u003c/p\u003e \u003cp\u003eMedical coordinators are on dedicated shifts whilst working for RSQ, where their sole responsibility is to the RSQ workload, including coordinating aeromedical retrievals and supporting rural teams. This in itself can increase the complexity of providing telehealth support as they manage multiple competing demands, including multiple videoconferences, retrieval coordination, and note-taking, simultaneously. RSQ nurses support coordinators with these tasks but they are not always available.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I was supporting the nurses through managing [a snake bite], whilst at the same time also having a cardiac arrest in [rural hospital] on the other telehealth screen that we have at the coordination office. [Also] having another phone call about a trauma, and the trauma was the relatively minor part of all of this.\u0026rdquo; [1]\u003c/p\u003e \u003cp\u003e\u0026ldquo;If I translate the normal practice in the ED, for example, for a cardiac arrest, I\u0026rsquo;m giving instructions, drug doses, whatever it is, someone is writing them down for me. Whereas, often, that doesn\u0026rsquo;t happen in telehealth...I\u0026rsquo;m writing down here, while I\u0026rsquo;m talking up [here].\u0026rdquo; [2]\u003c/p\u003e \u003cp\u003eCoordinators providing support from a distance must balance their strong feelings of responsibility with a lack of physical presence. A virtual-only presence can reduce coordinators\u0026rsquo; perceived authority compared to critical events attended in-person, and can mean that coordinators are not able to provide their entire attention to the event.\u003c/p\u003e \u003cp\u003e \u003cb\u003e1.3 Working within the constraints of local capacity and capability.\u003c/b\u003e A further challenge of providing emergency telehealth support is that coordinators need to understand the local capacity and capability, which varies widely across rural facilities, and tailor their support to fit within these conditions. Coordinators commonly mentioned that they do not know the team they are supporting or the resources in the local facility, which limits the support they can provide.\u003c/p\u003e \u003cp\u003e\u0026ldquo;The constraints were sort of around pretty standard equipment in the hospital\u0026hellip;\u0026lsquo;Oh, we don\u0026rsquo;t have a BIPAP\u0026rsquo;, \u0026lsquo;well, yes, you do, but you don\u0026rsquo;t have the masks\u0026rsquo;. Like, Jesus\u0026hellip;I remember thinking, \u0026lsquo;how the hell could a hospital not have a BIPAP mask?\u0026rsquo;\u0026rdquo; [2]\u003c/p\u003e \u003cp\u003e\u0026ldquo;I won't know them, they won't know me. I\u0026rsquo;ll have no idea of anybody\u0026rsquo;s skillset or experience\u0026hellip;You\u0026rsquo;re obviously remote and not having, you know, having only met for the first time, I won't know any of the staff names which helps the communication and task delegation and closed loop communication.\u0026rdquo; [9]\u003c/p\u003e \u003cp\u003e\u0026ldquo;So that\u0026rsquo;s probably the major limitation. Lack of knowledge about the skill set of the treating clinicians there, which then affects your ability to determine how far you should push them\u0026hellip;Particularly in critical situations like this, you can only get the best out of the team that you have got\u0026hellip;Yes, I know I\u0026rsquo;m probably adding value by providing support to the clinician, but I don\u0026rsquo;t feel I\u0026rsquo;ve done everything that I could do, in an ideal world.\u0026rdquo; [10]\u003c/p\u003e \u003cp\u003eNot knowing the rural team can also affect the extent to which coordinators feel they are kept \u0026lsquo;in the loop\u0026rsquo; and included as a team member, which then affects their ability to tailor the support they provide to be of most value. In some cases, coordinators may be concerned that they are making incorrect assumptions about what has or has not been done or missing information such as subtle cues.\u003c/p\u003e \u003cp\u003e\u0026ldquo;If it\u0026rsquo;s a very noisy room, you can definitely miss that something was given or not given, and you can make assumptions. I\u0026rsquo;ve certainly made lots of assumptions over time that because they ordered something, something got given and then eight hours later you find out that that never happened. So, constantly worried that I\u0026rsquo;m missing something.\u0026rdquo; [7]\u003c/p\u003e \u003cp\u003e\u0026ldquo;It\u0026rsquo;s hard over the video camera to get the subtly of the body cues or non-verbal cues from the rest of the team, from the patient, from the care givers that maybe also there in the room.\u0026rdquo; [9]\u003c/p\u003e \u003cp\u003eMost coordinators mentioned that despite not knowing the rural team, they generally trust the information being provided. However, if they perceive that they are supporting a junior or inexperienced team, their scepticism increases.\u003c/p\u003e \u003cp\u003e\u0026ldquo;When [coordinators are] dealing with people that they are not familiar with, there may be that sort of trust, \u0026lsquo;is this the right information?\u0026rsquo; But I've been doing that for a long time now that I'm used to [it], so there are some things that you just have to let go and you go, \u0026lsquo;this is what they're telling me, I have to trust that they're telling me that\u0026rsquo;.\u0026rdquo; [1]\u003c/p\u003e \u003cp\u003e\u0026ldquo;You've got to understand who's telling you and their clinical experience\u0026hellip;You're more hands on or more sceptical of what you're being told by less experienced people.\u0026rdquo; [6]\u003c/p\u003e \u003cp\u003eNot knowing the local facility also means that coordinators are unaware of the broader context they are dialling in to, such as prioritisation of patients and other demands. Some coordinators reported that this lack of awareness affects their ability to guide the rural team appropriately, whereas others felt it not necessary to know everything going on in the rural facility.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I think there was other things going on in the clinic there at the time. I wasn\u0026rsquo;t particular privy to that\u0026hellip;It's just a limitation of the technology, and it probably always should be, that you can't see everything that\u0026rsquo;s going on.\u0026rdquo; [1]\u003c/p\u003e \u003cp\u003e\u0026ldquo;This is a pinhole. I'm looking at a certain patient in a certain bed with fixed cameras, but I don't know what else is going on in the room\u0026hellip;I don't know if there is a whole tribe of people at the door trying to get in and see someone. Whether they love them or want to murder them.\u0026rdquo; [5]\u003c/p\u003e \u003cp\u003eWith emergency videoconferencing systems installed in over 110 rural facilities, it is not currently possible for coordinators to know each facility\u0026rsquo;s unique capacity and capability. However, without this knowledge, and without any established relationships with the rural clinicians, it can be difficult to gauge the level of support required, the kinds of procedures that are possible, and the competing demands in the rural facility.\u003c/p\u003e\n\u003ch3\u003e2.0 How telehealth technology facilitates or limits emergency support\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003e2.1 Establishing and maintaining awareness of the rural situation.\u003c/b\u003e Several factors impact a coordinator\u0026rsquo;s ability to establish and maintain awareness during an emergency telehealth videoconference, and coordinators employ several strategies to improve their awareness. One of the strategies discussed by several coordinators was to collect as much information as possible from the rural team before the videoconference has begun.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Don't let them put the phone down. While we're setting up, can you just give me a verbal brief on what it is?\u0026rdquo; [5]\u003c/p\u003e \u003cp\u003e\u0026ldquo;If it's not an immediate, time-critical thing and they're asking for some nuanced clinical advice, then you can sort of offload a bit of the work of the telehealth and the information finding by getting that organised for you prior. By one of the RSQ clinical nurses, for example.\u0026rdquo; [6]\u003c/p\u003e \u003cp\u003eThen, during the videoconference, coordinators primarily use the visual modality to collect information about the patient, rural team, and facility. Some coordinators described this as collecting \u0026lsquo;the ground truth\u0026rsquo; about a patient\u0026rsquo;s state. The visual component of the videoconference also allows coordinators to view the resources in the rural facility, including staffing levels and available equipment. One participant recalled a situation where viewing the room allowed them to find key equipment in the resuscitation bay and instruct the rural team on how to use it.\u003c/p\u003e \u003cp\u003e\u0026ldquo;So, I ring up, and here\u0026rsquo;s this bloke on oxygen not doing very well. So, he needs some invasive respiratory support. So, I say, \u0026lsquo;look, can you put him on CPAP?\u0026rsquo; The answer is, \u0026lsquo;no, we can\u0026rsquo;t because we don\u0026rsquo;t have a machine for that\u0026rsquo;. You know, if \u0026ndash; down the phone, that starts and ends there. So, \u0026lsquo;hold on a sec, I can see an Oxylog 3000 in the back of your room. Your ventilator can do CPAP.\u0026rsquo; \u0026lsquo;Oh, yeah, we don\u0026rsquo;t know how to use it.\u0026rsquo; \u0026lsquo;That\u0026rsquo;s fine. Bring it over here. Put it down there, and I will talk you through it.\u0026rsquo;\u0026hellip;\u0026lsquo;We don\u0026rsquo;t have a mask.\u0026rsquo; \u0026lsquo;Why don\u0026rsquo;t you call your local ambulance and get them up? Because they carry the masks.\u0026rsquo;\u0026hellip;So, we\u0026rsquo;ve got the mask, but it\u0026rsquo;s designed to be plugged into five-millimetre oxygen tubing, not a ventilator circuit. So, \u0026lsquo;well, hold that up. Yep, you should just be able to pull that out and plug the ventilator\u0026rsquo;. \u0026lsquo;Yep, we can do that\u0026rsquo;\u0026hellip;So, now we\u0026rsquo;ve got the ventilator, the circuit, and the mask. We can put it on the patient, and I can talk you through that. We\u0026rsquo;d sort of gone from, oh, waving a laryngoscope around going, \u0026lsquo;oh shit, we\u0026rsquo;ve got to intubate this patient, so it\u0026rsquo;s a complete disaster\u0026rsquo;, to \u0026lsquo;okay, well now we\u0026rsquo;ve actually got a plan to save the patient\u0026rsquo;s life while we come up with the next step.\u0026rdquo; [2]\u003c/p\u003e \u003cp\u003eThis example demonstrates how telehealth can be used to support resource-gathering in addition to decision-making and communication. Coordinators generally feel that the advantage of videoconferencing is that they can collect this kind of information firsthand, providing a significant advantage over a phone consultation. Telehealth allows coordinators to confirm or refute verbal information, such as verifying handover information provided prior to the telehealth session, which can be less distracting and intrusive for the rural team. Several coordinators recounted stories where the visual input showed a less critical situation than was described to them over the phone, which, in some cases, prevented an unnecessary retrieval. There were also scenarios where concern increased due to the visual input, changing the treatment and management.\u003c/p\u003e \u003cp\u003e\u0026ldquo;You also work out I guess little heuristics or whatever when you say, \u0026lsquo;oh, they're saying this\u0026rsquo;, but I can see other things that make me think that that\u0026rsquo;s not what's going on. But that\u0026rsquo;s not because of anything deliberate on their behalf, that\u0026rsquo;s just I guess your clinical acumen as you become more experienced to go, \u0026lsquo;well, this doesn\u0026rsquo;t fit. So what else is causing that\u0026rsquo;.\u0026rdquo; [1]\u003c/p\u003e \u003cp\u003e\u0026ldquo;The \u0026lsquo;end-of-the-bed\u0026rsquo;ogram\u0026rsquo; is really going to help me here because I\u0026rsquo;m not going to have to ask you a million questions.\u0026rdquo; [7]\u003c/p\u003e \u003cp\u003e\u0026ldquo;When you have a description from a doctor on the phone and then you go and turn on the telehealth, a picture paints a 1000 words. So sometimes someone can sound okay and then you go and switch on telehealth and you look at them and you just think that - even though you can\u0026rsquo;t put it into words, that patient just looks rubbish and your level of concern goes up and it changes how we manage things.\u0026rdquo; [8]\u003c/p\u003e \u003cp\u003eThe telehealth system was praised by most coordinators, providing a good overall picture and allowing them to zoom in to see fine-grained details.\u003c/p\u003e \u003cp\u003e\u0026ldquo;The resolution is quite amazing\u0026hellip;You can zoom in across the room onto a monitor that\u0026rsquo;s smaller than a laptop screen and be able to see things clearly enough to make a diagnosis off that.\u0026rdquo; [1]\u003c/p\u003e \u003cp\u003e\u0026ldquo;The pictures we get now are phenomenal, the depth you get, the quality, the zoom in and zoom out are just amazing.\u0026rdquo; [3]\u003c/p\u003e \u003cp\u003eAs a result, coordinators generally report that the telehealth system enables them to obtain high-quality visual information. However, half of the participants recalled scenarios where they felt limited by the fixed cameras. Chest drains were a common example of a procedure where it is difficult to provide nuanced guidance with a fixed camera system.\u003c/p\u003e \u003cp\u003e\u0026ldquo;One is chest drains. It's quite hard [with] the fixed system\u0026hellip;How am I going to do that? How would I do that if I'm instructing my senior registrar or registrar here? I'm not going to stand on a stepladder at the back of the room. Where I would actually like to be is standing just behind your shoulder.\u0026rdquo; [5]\u003c/p\u003e \u003cp\u003e\u0026ldquo;The lighting [the local doctor] needed to give her a good view provided a lot of glare on the TV screen, so I struggled to see the incision that she was making, and the size. Also, the angle of the chest tube insertion, it was difficult to see where it was going, I just couldn\u0026rsquo;t make out the angles with the way that our camera was\u0026hellip;I think that\u0026rsquo;s why the chest tube ended up in the wrong place.\u0026rdquo; [8]\u003c/p\u003e \u003cp\u003eSome coordinators described feeling constrained by the image they receive through telehealth and how it differs from being there in person, with one common example being when rural clinicians unknowingly block their view.\u003c/p\u003e \u003cp\u003e\u0026ldquo;In certain views people are just constantly standing in front of the monitoring equipment, and things like that.\u0026rdquo; [7]\u003c/p\u003e \u003cp\u003e\u0026ldquo;You can\u0026rsquo;t see 3D, that\u0026rsquo;s the problem...There\u0026rsquo;s a lot that you gain just by standing at the end of a patient\u0026rsquo;s bed and just looking at a patient. You don\u0026rsquo;t get - it\u0026rsquo;s not quite the same when you\u0026rsquo;re looking on telehealth on a camera.\u0026rdquo; [8]\u003c/p\u003e \u003cp\u003e\u0026ldquo;Because all said and done, the telehealth is still a 2D image. Although it\u0026rsquo;s technically in 3D, you\u0026rsquo;re still relying on the clinician there to relay pretty much everything.\u0026rdquo; [10]\u003c/p\u003e \u003cp\u003e Although the visual modality is very important for coordinators to establish and maintain awareness, it does not remove the importance of good verbal communication, especially in those situations where the view is limited.\u003c/p\u003e \u003cp\u003e \u0026ldquo;[The local doctor] articulated what was happening, which is really useful to the whole team, but particularly when you\u0026rsquo;re on VC and you can\u0026rsquo;t grab a bit of paper and have a look yourself\u0026hellip;He\u0026rsquo;d get a gas back and he\u0026rsquo;d [give] dot points of what was on the gas. So, I could make little notes of what was happening without interrupting and asking questions.\u0026rdquo; [7]\u003c/p\u003e \u003cp\u003e\u0026ldquo;I couldn\u0026rsquo;t see physically myself what the position of the tube and what the drain was doing, what the underwater seal was doing, was it bubbling, swinging, that sort of thing. So, I couldn\u0026rsquo;t appreciate those things myself\u0026hellip;You just have to rely on somebody telling you that and you\u0026rsquo;re not sure whether they\u0026rsquo;re seeing what you would be expecting to see. So, I think the communication is really important.\u0026rdquo; [8]\u003c/p\u003e \u003cp\u003eSome coordinators noted that the system does not allow them to view multiple camera feeds simultaneously, meaning that they frequently switch back and forth between cameras.\u003c/p\u003e \u003cp\u003e\u0026ldquo;[The camera is] on the roof so if you want to have bird\u0026rsquo;s eye, you can have bird\u0026rsquo;s eye and everything but then everything\u0026rsquo;s just really small and you can't see the patient's work of breathing or the colour that well. Most times I\u0026rsquo;ll either zoom into the patient and then episodically move to the vital signs.\u0026rdquo; [9]\u003c/p\u003e \u003cp\u003e\u0026ldquo;It\u0026rsquo;s like looking at something that\u0026rsquo;s happening in the distance. I don\u0026rsquo;t feel that I\u0026rsquo;m fully aware, because you only have a small part of the room. So, you are either visualising the patient or the monitor, or the clinician.\u0026rdquo; [10]\u003c/p\u003e \u003cp\u003eAdditionally, the functionality and usability of the system can worsen depending on who is controlling the cameras and who has initiated the videoconference. For those working in the northern hub, there can be inefficiencies if a RSQ nurse is operating the cameras from the southern hub.\u003c/p\u003e \u003cp\u003e\u0026ldquo;It can be a little bit difficult to operate the system in terms of switching between cameras and driving them remotely\u0026hellip;If someone drives it from the centre in [Brisbane], they drive it better, but I have to tell them where to drive, which is the trade-off.\u0026rdquo; [2]\u003c/p\u003e \u003cp\u003e\u0026ldquo;We find it quite difficult when people ring us, rather than us ringing them, which is easier because it means we can then manipulate the cameras. So, I think people sometimes in a panic dial us, as opposed to us dialling in and it just gives us that added difficulty of not being able to manoeuvre the cameras.\u0026rdquo; [4]\u003c/p\u003e \u003cp\u003e\u0026ldquo;I quite like getting the nursing staff from Retrieval Services bringing us into the VC consults, but surprisingly that can be really frustrating because they\u0026rsquo;re in a separate room down in Brisbane and we\u0026rsquo;re up in Townsville. They can just suddenly decide that I might want to look at the monitor when I actually want to look at the patient, and unfortunately that means, I have to speak into that [rural] room for the [RSQ] nurse to hear me.\u0026rdquo; [7]\u003c/p\u003e \u003cp\u003eCoordinators heavily rely on the visual component of the videoconference to obtain information and maintain awareness of the rural situation. The ability to collect firsthand information allows coordinators to confirm or refute verbal information, and can reduce the need to interrupt rural clinicians. When the visual input is limited (for example, because of the fixed camera system, or when the cameras are controlled by others), coordinators can struggle to maintain awareness and therefore provide tailored support.\u003c/p\u003e \u003cp\u003e \u003cb\u003e2.2 Supporting rural teams from a distance.\u003c/b\u003e Despite sometimes feeling a sense of helplessness when providing support from a distance, coordinators perceived that the facilitation of rapport and relationship building is one of the biggest advantages of telehealth. Several coordinators noted that the two-way video feed amplifies the emotional aspect and importantly, it allows the rural team to see who is supporting them.\u003c/p\u003e \u003cp\u003e\u0026ldquo;The thing is that the visual thing does bring the emotional aspect into the room. It's something you face with. Not something you hear.\u0026rdquo; [5]\u003c/p\u003e \u003cp\u003e\u0026ldquo;I think much more useful is that people put a face to the voice. So, from our perspective to be able to see a face to build the relationship both with the team and the care givers in the room as opposed to this anonymous voice making decisions.\u0026rdquo; [9]\u003c/p\u003e \u003cp\u003eTo facilitate rapport building and expectation setting, coordinators often adopt an inquisitive communication style by asking the rural team what is required of them up front, rather than assuming what they want help with.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I suppose the trick in that is about the communication stuff that you do, the non-technology stuff of tailoring it in the right way to value add the best. A part of that is at the beginning saying, \u0026lsquo;well, I was going to do this, are you happy with that? How do you want me to contribute towards this?\u0026rsquo; It\u0026rsquo;s almost having some ground rules there.\u0026rdquo; [3]\u003c/p\u003e \u003cp\u003e\u0026ldquo;My practice I guess progressed, changed slightly over the years and often [I] just open up with \u0026lsquo;how do you want me to help?\u0026rsquo; which is slightly different to my role in the emergency department where I\u0026rsquo;m automatically, you know, usually a team leader.\u0026rdquo; [9]\u003c/p\u003e \u003cp\u003eSeveral coordinators mentioned that sometimes they can feel as though they are not contributing much to the treatment or management of the patient. However, telehealth allows them to provide peer support to rural teams and reduce their professional isolation, which seemingly adds more value to the situation than the clinical input it is intended to provide.\u003c/p\u003e \u003cp\u003e\u0026ldquo;We might have helped [avoid a retrieval] in a couple, but it wasn\u0026rsquo;t a big driver. We actually found that the benefits that we got out of that were that the clinicians felt much more supported\u0026hellip;The ones that were scared felt infinitely supported in telehealth.\u0026rdquo; [3]\u003c/p\u003e \u003cp\u003e\u0026ldquo;I think they were very relieved to have us there\u0026hellip;It just didn\u0026rsquo;t really feel like we did much effective except stare at everybody.\u0026rdquo; [7]\u003c/p\u003e \u003cp\u003e\u0026ldquo;Most times I feel the main benefit is of supporting the rural teams. Probably that main benefit I suspect and the second one is giving good patient care, more timely patient care\u0026hellip;Most times I\u0026rsquo;m supporting the team.\u0026rdquo; [9]\u003c/p\u003e \u003cp\u003eCoordinators are often sought for reassurance that the team has provided the best level of care possible given the circumstances, and their presence in the room (albeit virtually) is especially important when patient outcomes are poor.\u003c/p\u003e \u003cp\u003e\u0026ldquo;The feedback was that they just found that it [was] reassuring but it was that support that they got, they just thought it was brilliant. It reinforced to them why they\u0026rsquo;ve got [telehealth] and to us it reinforced, God, we\u0026rsquo;ve actually value add.\u0026rdquo; [3]\u003c/p\u003e \u003cp\u003e\u0026ldquo;You don\u0026rsquo;t realise how valuable it is for them. To say, \u0026lsquo;we\u0026rsquo;ve done all of this\u0026rsquo;, and we say, \u0026lsquo;there is nothing else to do. You\u0026rsquo;ve done everything\u0026rsquo;.\u0026rdquo; [7]\u003c/p\u003e \u003cp\u003eAnother commonly noted form of peer support is sharing the mental load with the rural team because they are often working with minimal staff. As an objective party, coordinators also facilitate shared decision making which can be difficult for rural teams to make on their own because of their community ties.\u003c/p\u003e \u003cp\u003e \u0026ldquo;I think having someone else participating in the discussion around of saying, \u0026lsquo;let\u0026rsquo;s stop\u0026rsquo; and helping with those end-of-life discussions is very powerful as well. You\u0026rsquo;re the doc there and you live there, and you\u0026rsquo;ve got to face the family and these people \u0026ndash; the family will know that every effort was made, they\u0026rsquo;ve accessed someone from wherever who\u0026rsquo;s come in, they\u0026rsquo;ve helped make the decision. So, turning someone off and not progressing is a big call and I think it allows us to participate in those.\u0026rdquo; [3]\u003c/p\u003e \u003cp\u003e\u0026ldquo;They were crashing and becoming hypoxic post-intubation and I had to more or less do the cognitive thinking and the troubleshooting for that and provide direct instructions, which I wouldn't have been able to do without seeing the patient.\u0026rdquo; [6]\u003c/p\u003e \u003cp\u003eSome coordinators recalled situations where they relieved some of the rural burden by speaking directly to patients and families on behalf of the team. In some cases, they may retrieve a patient even when it will not change the patient\u0026rsquo;s outcome, primarily to support the rural team who does not have capacity to manage them.\u003c/p\u003e \u003cp\u003e\u0026ldquo;You can actually have a discussion with the family about the pros and cons of treatment. You can\u0026rsquo;t touch them, you\u0026rsquo;re not physically there, but it still allows you to still have that verbal and non-verbal interaction with the family about making some decisions.\u0026rdquo; [3]\u003c/p\u003e \u003cp\u003e\u0026ldquo;My primary conversation was with the nurse and then with the [patient\u0026rsquo;s] parents\u0026hellip;We just have to get the kid out, because of the parental concern and anxiety, and also to support the nurse, there, I think it was the sole nurse in the community.\u0026rdquo; [10]\u003c/p\u003e \u003cp\u003eIn addition to peer support, the telehealth system also allows coordinators to provide value in other ways, for example by remotely guiding rural teams through uncommon procedures, the operation of rarely-used equipment, and the delivery of medications that would otherwise not be possible.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I asked the intensive care paramedic to come out and intubate the patient. So, to intubate this patient, we needed to administer paralytics \u0026ndash; muscle relaxant agents \u0026ndash; which paramedics aren\u0026rsquo;t allowed to do. So, I sort of said, at the time, \u0026lsquo;look, I\u0026rsquo;m happy, I mean, I\u0026rsquo;m not in the room, but I am running this case, and I\u0026rsquo;m happy - my name is in the notes, there\u0026rsquo;s a clear verbal or a written\u0026rsquo;, and then off we went.\u0026rdquo; [2]\u003c/p\u003e \u003cp\u003e\u0026ldquo;She needed escharotomy. That was done on the basis of visual approach and some instruction given\u0026hellip;Which is not a common surgical technique\u0026hellip;That's limb saving.\u0026rdquo; [5]\u003c/p\u003e \u003cp\u003e\u0026ldquo;I think being able to see what she was looking at, she could pick something up and say, \u0026lsquo;this bit? What do you want me to do with this bit?\u0026rsquo; Then I could say, \u0026lsquo;no, turn it around, you use it the other way\u0026rsquo;.\u0026rdquo; [8]\u003c/p\u003e \u003cp\u003eMany coordinators believed that providing emergency telehealth support, whether that be peer or clinical support, is a specialised skillset different to face-to-face support and phone consultations.\u003c/p\u003e \u003cp\u003e\u0026ldquo;This I find is a much more dedicated event\u0026hellip;It's a challenge sometimes. It's a modified skillset.\u0026rdquo; [5]\u003c/p\u003e \u003cp\u003e\u0026ldquo;I think you can underestimate the skill that\u0026rsquo;s required to get good at doing these things. Because you think, well I can do it in person, I should be able to do it over a video link. But you\u0026rsquo;re relying on somebody else being your hands essentially\u0026hellip;It\u0026rsquo;s a big learning curve.\u0026rdquo; [8]\u003c/p\u003e \u003cp\u003eHowever, not all discussions or tasks are deemed suitable to the videoconference modality. For example, coordinators are sensitive to rural clinicians\u0026rsquo; positions within their community, and may offer to discuss sensitive topics on a private phone call away from patients and family. Debriefing was another task deemed unsuitable for telehealth, but something that coordinators often wish to be involved in to provide follow up support.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Sometimes people use telemedicine to do a debrief. The problem is it's all hardwired. You have got to go to the resus bay. Actually, that's probably not the best room. The body is still probably in there.\u0026rdquo; [5]\u003c/p\u003e \u003cp\u003e\u0026ldquo;We discussed [the procedure] behind the scenes away from the patient so that it didn\u0026rsquo;t alarm the patient talking about those things and didn\u0026rsquo;t undermine the patient\u0026rsquo;s confidence in the doctor\u0026hellip;Also, the doctor might feel pressured into saying \u0026lsquo;yes I can do it\u0026rsquo;, if they\u0026rsquo;ve got people watching. So, I think to give them the freedom to say privately, \u0026lsquo;look I haven\u0026rsquo;t done this on my own before, I don\u0026rsquo;t feel confident\u0026rsquo;, I think is important.\u0026rdquo; [8]\u003c/p\u003e \u003cp\u003e Most coordinators agreed that simply being present during a rural resuscitation can have a significant, positive impact on the treating team. Coordinators believed that their biggest contribution is not necessarily their specialised knowledge and experience, but rather the peer support they provide during acute cases. The bidirectional telehealth system facilitates rapport building and allows coordinators to provide other forms of peer support such as speaking to patient relatives on the team\u0026rsquo;s behalf. However, the system does not support all interactions, such as those requiring privacy or debriefing events.\u003c/p\u003e \u003cp\u003e\u003cb\u003e2.3 Working within the constraints of local capacity and capability.\u003c/b\u003e Although it can be challenging to gauge the rural situation over telehealth, coordinators agree that knowledge of the rural team, patient state, and resources available is important to optimise the quality of support they provide. Several coordinators noted the importance of understanding the confidence and competence of the rural clinicians, since this will heavily inform the guidance they provide. For example, coordinators tend to take a conservative approach to procedures and will avoid those beyond the rural team\u0026rsquo;s skillset. Intubation was common example of a procedure that coordinators avoid when supporting inexperienced or unconfident staff. To obtain this information, coordinators can simply ask the clinicians but they may feel pressured to conceal the truth, especially with relatives or other staff present. Therefore, coordinators use telehealth to observe their behaviour and non-verbal cues, such as facial expressions and how they handle equipment.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Someone wants to [intubate] \u0026ndash; \u0026lsquo;yes, we can intubate\u0026rsquo;. Okay. You watch them put the equipment together. They're not familiar\u0026hellip;If I watch how people handle equipment, yes there is anxiety and things. But it tells me [a lot].\u0026rdquo; [5]\u003c/p\u003e \u003cp\u003e\u0026ldquo;This has happened on a few occasions where I\u0026rsquo;ve said, \u0026lsquo;are you comfortable intubating?\u0026rsquo;\u0026hellip;Then they say, \u0026lsquo;well if it gets to it, then I can do it\u0026rsquo;. That tells me that they probably haven\u0026rsquo;t done it often enough, but they\u0026rsquo;re going to give it a shot. This is probably where I would probably not get them to do it, unless [the patient] start going blue in the face.\u0026rdquo; [10]\u003c/p\u003e \u003cp\u003eFurther, coordinators use the visual modality to tailor their roles and tasks to best suit the rural situation. For example, coordinators are careful not to overstep when they are supporting more experienced clinicians, or provide support that is too high level for less experienced staff who need intricate guidance. All coordinators agreed that they most commonly adopt the team leader role during critical situations, especially in nurse-led facilities with no local doctor.\u003c/p\u003e \u003cp\u003e \u0026ldquo;I think that\u0026rsquo;s a bit of emotional intelligence there in terms of how you insert yourself into the proceedings\u0026hellip;Where there\u0026rsquo;s a number of senior staff there, I think you\u0026rsquo;ve got to be very careful that you\u0026rsquo;re not then overstepping it. There\u0026rsquo;s that more collegiate, respectful thing that they\u0026rsquo;re running it but you\u0026rsquo;re there to maybe help them troubleshoot or value add if they get into trouble or help with some decision-making.\u0026rdquo; [3]\u003c/p\u003e \u003cp\u003e\u0026ldquo;The team leader, who was the senior most clinician doctor there, was in control of the situation. Making sure that all team members were performing to their optimal extent, and I was almost a passive observer and only responded to questions that the team leader had.\u0026rdquo; [10]\u003c/p\u003e \u003cp\u003eThe telehealth technology also allows coordinators to provide situation awareness to the local team because they have a birds-eye view and are not preoccupied with their own tasks. This keeps the local team on track and allows them to focus on their manual tasks.\u003c/p\u003e \u003cp\u003e\u0026ldquo;They mostly found it good to have someone watching over and having that external oversight and guidance. They did all the hard work really, I was just able to say, \u0026lsquo;right, so we need to - this is the next step we need to do. We need to do that now, okay, it looks like you're bagging well.\u0026rsquo;\u0026rdquo; [1]\u003c/p\u003e \u003cp\u003e\u0026ldquo;All the nurses in the hospital were there helping out and then that one doctor\u0026rsquo;s doing the intubation, it\u0026rsquo;s often helpful to have somebody else that can manage the medication, they can keep an eye on the vital signs and the other aspects of it.\u0026rdquo; [9]\u003c/p\u003e \u003cp\u003eSome coordinators were conscious of the delicate balance between providing support and being a distraction, and felt that the visual input was helpful to inform when they ask questions or provide instructions.\u003c/p\u003e \u003cp\u003e\u0026ldquo;In a resus here I would maybe say three or four drugs at the same time, that I want the patient to have, but just sort of taking that step back and slowing things down for small facilities that don\u0026rsquo;t do this often and potentially only have one, maybe two nurses.\u0026rdquo; [4]\u003c/p\u003e \u003cp\u003e\u0026ldquo;I find [cardiac arrest] most challenging of all telehealth interactions, simply because you are trying to provide support, but you cannot interfere with the running of the cardiac arrest itself.\u0026rdquo; [7]\u003c/p\u003e \u003cp\u003eTo provide tailored clinical support, some coordinators recalled situations where they added other specialists into the videoconference for more specialised advice, such as in burns or paediatric cases. This was a well-regarded feature of the telehealth system that allowed rural clinicians to seamlessly connect with metropolitan specialists.\u003c/p\u003e \u003cp\u003e\u0026ldquo;She proved really difficult to ventilate and I was maxing out my skills and knowledge so we also got an intensivist who was on call for ECMO at that time to dial in and provide some ventilatory support\u0026hellip;I think it actually worked pretty well and it was good to also, pretty seamlessly, be able to dial in that extra support.\u0026rdquo; [6]\u003c/p\u003e \u003cp\u003e\u0026ldquo;I\u0026rsquo;ve probably done this on one occasion, where I\u0026rsquo;ve got a paediatric intensivist\u0026hellip;Which has been fantastic, because then they actually have seen the patient and they have brought their expertise to the patient bedside, to a patient who is four hours away.\u0026rdquo; [10]\u003c/p\u003e \u003cp\u003eTo ensure that the rural team feels fully supported, coordinators can use telehealth to virtually \u0026lsquo;stay\u0026rsquo; with the rural team until the retrieval team arrives and assist the rural team in the patient handover if needed.\u003c/p\u003e \u003cp\u003e\u0026ldquo;So, the other thing that we find it very useful for is, is handovers\u0026hellip;As a [retrieval] team gets there, the process is that when they get there, they have a look at the patient and before they leave will chat with us as the consultant to be sure everything\u0026rsquo;s kosher, and they\u0026rsquo;ve got a plan and all that sort of stuff.\u0026rdquo; [3]\u003c/p\u003e \u003cp\u003e\u0026ldquo;Then you might still leave the telehealth running in the background, intermittently being monitored by a [RSQ] nurse, but your focus is away while that patient is stable and then you'll get called in for further updates or advice as required.\u0026rdquo; [6]\u003c/p\u003e \u003cp\u003eCoordinators were asked hypothetical questions about whether they could still provide support if telehealth was not available in the memorable events they recalled. Overwhelmingly, they felt that it would have been much more difficult and that emergency telehealth support led to better patient outcomes.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I think that the patient would have died much more incipiently probably \u0026ndash; not quite through medical misadventure but because of medical limitations on the nature of the care that could have been provided without the telehealth.\u0026rdquo; [2]\u003c/p\u003e \u003cp\u003eCoordinators use telehealth to directly observe the patient condition, team composition, and resources available, which subsequently informs the kind of support they provide. Coordinators typically adopt a team leader role but may adapt their role to suit the specific team and context. The telehealth technology allows coordinators to keep situation awareness, to determine the right moments to speak, to bring other specialists into the scenario, and to assist in patient handovers. Without the telehealth technology, coordinators believed that patient outcomes would be worse and rural clinicians would be less supported.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis was the first study to explore the experiences of specialist critical care physicians who use telehealth to support the treatment and management of critically ill patients in rural Queensland. Overall, the findings revealed that the perceived value of emergency telehealth is in the support it provides to isolated rural clinicians during critical, high-stress, and unfamiliar situations, more so than altering the direction of patient care. However, coordinators often balance a deep sense of responsibility with the limitations of providing support remotely. The study results highlight some of the challenges to providing emergency telehealth support, and several ways that telehealth technology can help to overcome, but sometimes contributes to, these challenges.\u003c/p\u003e \u003cp\u003eOne of the challenges is understanding the clinical situation at the rural facility. There is variation in the quality of information provided prior to and during a videoconference, so coordinators use the visual modality of telehealth to confirm, update, or resolve information inconsistencies. Having two ceiling-mounted cameras in each resuscitation bay is crucial to providing high quality support, allowing coordinators to not only assess the patient and vital signs, but also the rural team and available resources. However, the camera angles are not always ideal, particularly when guiding rural teams through procedures.\u003c/p\u003e \u003cp\u003eThe challenge of feeling responsible despite not being physically present can intensify with lack of resources and varied skillsets available at the rural site. Additionally, providing support from a distance can mean that despite being the most senior clinician involved in a case, coordinators may have less command over the situation when supporting via telehealth. However, telehealth facilitates rapport building through the two-way video feed which is important to allow the rural team to see, not just hear, the specialist who is supporting them. This two-way system was a deliberate design choice to facilitate the social exchange rather than just providing another information source. At the outset, coordinators seek to understand exactly what the rural team needs from them, so that they have a clearly defined role in the scenario. In addition to providing procedural support, coordinators use telehealth to provide peer support and reassurance to the rural team by overseeing critical situations, sharing the responsibility and decision-making, and reducing the emotional burden of speaking to patients and family.\u003c/p\u003e \u003cp\u003eCoordinators rarely know the clinicians they are supporting, or the rural context they are dialling in to, which can sometimes mean they are left out of communication, which reduces their ability to tailor the support they provide. Determining the skills and experience of the rural team is vital to tailoring the support provided and direction of care. Since the response provided may be unreliable when coordinators ask directly, they use telehealth to observe rural clinicians\u0026rsquo; non-verbal cues to give hints towards their genuine capabilities and confidence. Coordinators most often adopt a team leader role, but what they view over telehealth helps to modify their support and communication style to meet the patient state, the available resources, and the perceived requirements of the rural team.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eImplications for Telehealth Technology\u003c/h2\u003e \u003cp\u003eCoordinators strongly believe that Queensland\u0026rsquo;s emergency telehealth system facilitates high-quality support for rural teams. Participants were especially impressed with the camera image quality, and the foresight to install the infrastructure across rural Queensland. However, the findings revealed several implications for emergency telehealth technology that were either explicitly stated by participants or identified by the researchers (represented by [R]) from the interview content and workarounds discussed. These technologies would all complement, rather than replace, the existing system, and some of the ideas are already under consideration.(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e)\u003c/p\u003e \u003cp\u003ePortable technology, including hand-held and head-worn devices, were frequently suggested to enable visual angles that are not currently available with the fixed system. Portable videoconferencing devices may benefit situations where the fixed cameras do not provide an ideal view, or when coordinators support the treatment of multiple patients at one site (e.g., mass casualty events).(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) Related, participants were presented with the concept of interactive telepresence, which would allow the coordinator to guide rural clinicians through interventions by virtually annotating on the patient in real time, such as through augmented reality on a head-worn device.(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) Although some participants expect annotation to be a potentially powerful tool, others felt that the addition of portable cameras would be of most value.\u003c/p\u003e \u003cp\u003eDespite providing the most telehealth services in the country,(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) there was consensus that telehealth is still underutilised in Queensland. Coordinators suggested that its use should be expanded to include prehospital environments (e.g., on scene, in aircrafts, in ambulances),(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) remotely-delivered education and training,(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) and non-clinical situations (e.g., to communicate with relatives). Some mentioned that it should be used in more non-emergency clinical consultations between hospitals to reduce unnecessary transfers, but there is hesitation because non-emergency telehealth runs on different systems and is not as easy to use. In the years leading up to this study in 2021, RSQ started a remote education service that utilises web-based videoconferencing systems across Queensland. Similarly, a telehealth service that linked rural and remote facilities with their \u0026ldquo;hub\u0026rdquo; regional hospital for advice and support was well-established at that time. In 2022, this service has expanded to now provide Emergency Physician and Nurse Practitioner led low-acuity emergent telehealth consultations 24/7.\u003c/p\u003e \u003cp\u003eAnother frequent suggestion was system integration to improve remote patient monitoring so that coordinators could maintain camera focus on the patient with the vital signs displayed on a separate screen. Alternatively, introducing a function to view multiple camera feeds simultaneously would allow coordinators to maintain views of both the patient and vital signs at once, rather than switching between cameras [R]. A system designed to allow remote vital signs monitoring was trialled by RSQ over 8 years ago but was poorly adopted due to the complexity of its use. With advances in technology since then, a revisit may prove beneficial. To streamline the process of initiating private conversations with rural clinicians, another potential enhancement is a function that allows coordinators to direct their audio to different sources. This could be useful for handovers at the commencement of the videoconference, or in situations that require privacy like discussing procedural confidence. For example, if a rural clinician dons a headset that connects to telehealth, a one-on-one conversation could take place without needing to mute the telehealth audio and make a separate phone call to another room [R]. It could also be useful for coordinators located in the northern region of Queensland to communicate with RSQ nurses in the southern region who often participate in the videoconference, without distracting clinicians in the rural facility.\u003c/p\u003e \u003cp\u003e Better information exchange functionality would allow coordinators to easily share and access images, documentation, clinical notes, medication carts, and policies and guidelines. Currently, visual information (e.g., photographs) is shared through workarounds such as email or text which is not always secure. The introduction of virtual platforms or whiteboards were discussed to provide easier information access and sharing. Implementing a streamlined, formal process or platform for information exchange would not only improve efficiency and patient care, but also quality assurance.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) This could also address some of the inconsistencies in the quality of information provided to coordinators prior to joining the videoconference, because this subsequently affects the quality of support they are able to provide [R].\u003c/p\u003e \u003cp\u003eFinally, some coordinators suggested improvements that were not directly related to the technology itself, but would ultimately improve the quality of support delivered through the system. Tailored training of effective telehealth practice for both coordinators and rural clinicians could improve communication and efficiency during videoconferences. For example, a telehealth framework could be implemented to guide appropriate expectation setting, role allocation, and teamwork when providing, or accessing, remote emergency support. Additionally, standardising some of the resources (e.g., resuscitation equipment) across rural facilities could remove some of the guess work involved in supporting a team in an unfamiliar facility.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and Future Directions\u003c/h2\u003e \u003cp\u003eAlthough participants were recruited evenly from each of the two retrieval coordination centres, the findings are limited to a sample of 10 medical coordinators. Saturation was considered to be achieved but it is possible that other themes may have emerged with more interviews. Further, the findings may not generalise to other states or countries with different emergency telehealth and aeromedical retrieval systems. The similarities and differences could be explored in future research at a national and international level, by comparing these findings to that of other places with aeromedical coordination centres such as New South Wales and Western Australia (the two other Australian states with aeromedical coordination centres) and other geographically vast areas like North America.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) Ideally, if any aforementioned improvements are implemented, their impact on emergency telehealth support should be explored from both the individual end-user level, and at the health system level.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eSpecialist critical care physicians operating under Retrieval Services Queensland use a dedicated emergency telehealth system to support rural clinicians treating critically ill patients. The findings from this study revealed that emergency telehealth support goes far beyond clinical advice; it provides an avenue to collegially support rural teams through critical, high-stress situations. Supporting rural teams from a distance can be both rewarding and challenging, with telehealth technology helping to overcome, and sometimes contributing to, these challenges. The findings have several implications for telehealth technology that could reduce specialists\u0026rsquo; mental workload and provide better access to information, thereby improving the quality of support delivered to rural teams during critical care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting Interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there is no conflict of interest regarding the publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by a Queensland Government Advance Queensland Industry Research Fellowship awarded to Chiara Santomauro [AQIRF149-2019RD2].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics Approval\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project was performed in accordance with the Declaration of Helsinki and the Australian Government National Health and Medical Research Council’s National Statement on Ethical Conduct in Human Research and Australian Code for the Responsible Conduct of Research.\u0026nbsp;Ethics approval was granted by the Human Research Ethics Committees of the Royal Brisbane and Women’s Hospital (HREC/2020/QRBW/62878)\u0026nbsp;and Griffith University (2020/631).\u0026nbsp;Prospective participants were given an information sheet and provided written informed consent prior to scheduling the interview.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eGuarantor\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eC.S.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData Availability\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data from this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eContributorship\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the conception and design of the study and interview questions. CS conducted the interviews and analysed the data, and AR provided assistance with data analysis and interpretation. CS drafted the manuscript and MM, CG, and AR all made substantial revisions to the manuscript. All authors approved the final version.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the participating medical coordinators for volunteering their time to this project. We thank Retrieval Services Queensland, the Queensland Statewide Trauma Clinical Network, and the Jamieson Trauma Institute for assisting with participant recruitment. Finally, we thank the Queensland Government’s Department of Tourism, Innovation, and Sport, Griffith University, the Clinical Skills Development Service, and the Jamieson Trauma Institute for funding and supporting the project.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eMorgan JM, Calleja P. Emergency trauma care in rural and remote settings: Challenges and patient outcomes. International emergency nursing. 2020;51:100880.\u003c/li\u003e\n \u003cli\u003eAlanazy ARM, Wark S, Fraser J, Nagle A. Factors impacting patient outcomes associated with use of emergency medical services operating in urban versus rural areas: A systematic review. International journal of environmental research and public health. 2019;16(10):1728.\u003c/li\u003e\n \u003cli\u003eFatovich DM, Phillips M, Jacobs IG, Langford SA. Major trauma patients transferred from rural and remote Western Australia by the Royal Flying Doctor Service. 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Head-worn displays for healthcare and industry workers: A review of applications and design. International Journal of Human-Computer Studies. 2021;154:102628.\u003c/li\u003e\n \u003cli\u003eGreenfield MJ, Luck J, Billingsley ML, Heyes R, Smith OJ, Mosahebi A, et al. Demonstration of the effectiveness of augmented reality telesurgery in complex hand reconstruction in Gaza. Plastic and Reconstructive Surgery Global Open. 2018;6(3).\u003c/li\u003e\n \u003cli\u003eSantomauro C, McCurdie T, Shuker M, Pollard C. Exploring the feasibility of wearable technologies to provide interactive telepresence sub-specialist support to remote clinicians treating patients with traumatic injuries. Prehospital and Disaster Medicine. 2019;34(s1):s85-s.\u003c/li\u003e\n \u003cli\u003eWinburn AS, Brixey JJ, Langabeer J, Champagne-Langabeer T. A systematic review of prehospital telehealth utilization. Journal of telemedicine and telecare. 2018;24(7):473-81.\u003c/li\u003e\n \u003cli\u003eCheng C, Papadakos J, Umakanthan B, Fazelzad R, Martimianakis MA, Ugas M, et al. On the advantages and disadvantages of virtual continuing medical education: a scoping review. Canadian Medical Education Journal. 2023;14(3):41-74.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"critical care, emergency medicine, interviews, remote support, rural and remote, telehealth, telemedicine, trauma","lastPublishedDoi":"10.21203/rs.3.rs-4373306/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4373306/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction: \u003c/strong\u003eThe well-known ‘golden hour’ target for trauma treatment is an unachievable goal in many parts of Australia. In response to the vast population spread in Queensland, Australia, telehealth infrastructure facilitates 24/7 links between rural facilities and specialist critical care physicians who provide advice and coordinate aeromedical retrievals. The purpose of this study was to understand work-as-done for specialist critical care physicians using Queensland Health’s emergency telehealth system to support rural clinicians during acute care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eSemi-structured interviews were conducted with 10 specialist critical care physicians operating under the governance of Retrieval Services Queensland to provide advice to rural clinicians through Queensland Health’s emergency telehealth system. Using an inductive approach, qualitative data were analysed in three phases: immersion; a combination of process coding and in vivo coding; and focused coding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe data revealed that supporting rural teams from a distance can be simultaneously rewarding and challenging. Two categories emerged, each with the same three themes representing key challenges to providing emergency telehealth support. The first category presents these challenges, and the second category describes how telehealth technology can help to overcome, but sometimes contributes to, these challenges.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThe findings highlight that, although challenging at times, emergency telehealth support goes far beyond clinical advice; it provides an avenue to support isolated clinicians through critical, high-stress situations. The findings have several implications for telehealth technology that could reduce specialists’ mental workload and provide better access to information, thereby improving the quality of support delivered to rural teams during critical care.\u003c/p\u003e","manuscriptTitle":"Leading from a distance: Experiences of specialist critical care physicians providing telehealth support to rural clinicians","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-07 05:49:49","doi":"10.21203/rs.3.rs-4373306/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"10e360ce-b7e4-423b-b919-d3e254b76e9a","owner":[],"postedDate":"May 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":31541773,"name":"Critical Care \u0026 Emergency Medicine"},{"id":31541774,"name":"Psychology"}],"tags":[],"updatedAt":"2024-05-07T05:49:49+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-07 05:49:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4373306","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4373306","identity":"rs-4373306","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}