SC Robson, A Marshall, VJ Snaith, B Beckwith, M Lie, E Van Oudgaarden, A Henderson.

Background to project  Women referred by sonographer to local specialist or Fetal Medicine Centre when problem identified during scan.  Specialised fetal medicine services concentrated in Fetal Medicine Centre at Newcastle.  Women from North Cumbria have significant journeys to make, often at own expense.  Car travel from Barrow-in-Furness to Newcastle: 2hrs 50mins (140 miles), Whitehaven to Newcastle: 2hs 15mins (97 miles).  Telemedicine has the potential to provide specialist obstetric ultrasound and consultation to women within their own unit.  The technology can be used to provide on-site training for local sonographers in ‘advanced’ ultrasound investigations (e.g. fetal and maternal Doppler ultrasound).

Evidence of effectiveness Successful transmission of high quality ultrasound with live guidance, followed by counselling by videoconferencing, is achievable in the majority of cases [1,2]. Even with smaller sized internet connections than now available, image quality was sufficient for diagnosis in >95% of cases [1]. The use of telemedicine was highly acceptable to patients with women expressing a preference for telemedicine consultation compared to face-to-face [2]. [1] Fisk NM et al. BJOG 1996; 103: ; [2] McCrossan BA et al. Prenat Diagn 2012;12:

Innovation  A fetal telemedicine service has not been developed in the UK outside of small projects.  Opportunities to dramatically alter the way fetal medicine services are offered and improve care.  The technology can be used to provide on-site training for local sonographers in ‘advanced’ ultrasound investigations (e.g. fetal and maternal Doppler).  Successful implementation of the technology would be seen as ‘proof of principle’ and wider use of the innovation in other clinical areas would follow.

Project aims  To establish a videoconferencing infrastructure between the obstetric ultrasound unit at West Cumberland Hospital and the Fetal Medicine Unit in Newcastle.  To determine the technical success of the service.  To evaluate the success of utilising the telemedicine technology for training sonographers  To assess women’s views of using a telemedicine ultrasound service, including family costs.  To assess the benefits and barriers to adoption of the service across Cumbria.

Partnership working This project brings together health professionals and academics from all 4 partner organisations with relevant expertise, many of whom have worked together on prior projects. Strong clinical and teaching/training links already exist between the obstetric departments at NCUH and NuTH with established referral pathways for complex fetal problems. The project will further develop these clinical and academic links.

Potential impact of project Reduction in the number of women required to travel to Newcastle for specialist fetal ultrasound. Reduction in associated family costs. Enhanced standard of local obstetric ultrasound by developing local sonographers through telemedicine training. Evidence that a fetal telemedicine service is acceptable to parents and to health professionals Engagement of key local stakeholders and provision of robust evidence as to how the fetal telemedicine service can be implemented across a wider geography and potentially across additional clinical areas.

Evaluation of telemedicine service Number of telemedicine consultations (together with indications) as a proportion of all fetal medicine cases / consultations referred from WCH. Technical success of every new consultation - success will be defined as an ultrasound image quality sufficient to make a definitive prenatal diagnosis. Cost impact - cost components for the NHS including consultation times and staff utilisation.

Ultrasound scan using telemedicine Videoconferencing equipment is set up and connection established. Sonographer undertakes ultrasound scan in usual way. Real-time images and audio are transmitted to NuTH. Information supplied to WCH sonographer via headphones Viewed by Fetal Medicine Consultant and/or sonographer via videoconferencing unit at NuTH.

Videoconferencing equipment - WCH

Videoconferencing unit at NuTH

Sonographer training Training of sonographers will be undertaken at WCH during 20 week anomaly scans (for uterine artery Doppler) and fetal growth scan (for middle cerebral artery Doppler). After an initial tutorial (via videoconference) and assessment of baseline skills, supervised training is undertaken. Sonographers are deemed competent when five successful Objective Structured Assessments of Training (OSATs) are completed for each technique. Results in upskilled workforce, improved care for women and reduction in number of women who need to travel for ultrasound scans.

Patient Evaluation All women who have had a telemedicine scan will be asked to complete a questionnaire to assess their views, acceptability and family costs. Sub-sample of women (n=10-15) will be asked to take part in a telephone interview to gain greater insight of experience.

Qualitative adoption study Information on the benefits and barriers to adoption of the service will be collected using the Stakeholder Empowered Adoption Model (StEAM) Face-to-face and telephone interviews with a range of economic and users stakeholders:  Commissioners  Service managers  Consultants  Sonographers  IT support Researchers will engage with stakeholders before, during and after the pilot Using action research methodology they will feed back findings and modify their approach as required.

The Stakeholder Empowered Adoption Model Provides a process for stakeholder values, benefits and goals to be incorporated so that appropriate evidence is collected to enable adoption to take place.

Challenges Initial difficulty in establishing effective IT link REC and R&D approval required for evaluation of patient experience of telemedicine consultations. Directorate approval from Obstetrics AND Radiology. Senior level clinical approval was gained early in project. Managerial approval had to be escalated to Executive level. Anxiety over sonographer workload, staffing levels and pressure on other ultrasound services.

Progress Project recommenced July 2015 Support gained from NCUH senior managers, sonographers, obstetricians and midwives. Videoconferencing link established and functioning. Good quality real-time ultrasound images transmitted from WCH and successfully viewed at NuTH. Fetal Medicine cases from October 2015

Thank you for listening Project funded by: AHSN North East and North Cumbria Contact: