WHAT FACTORS ARE ASSOCIATED WITH THE USE OF TELETRAUMA
IN NORTHERN BRITISH COLUMBIA?
by
Timothy Wood
BScN, University of Northern British Columbia, 2016

THESIS SUBMITTED IN PARTIAL FULFILMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE
IN
NURSING

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
April 2020
©Timothy Wood, 2020

Abstract
Despite the existence of universal health care for Canadians, health inequalities persist. Those
residing in rural regions of Canada may be at a disadvantage for accessing appropriate services.
To enhance access, a teletrauma program was implemented in the Robson Valley, connecting
rural clinicians during emergency cases. This study was undertaken to better understand the
experiences of teletrauma users and why teletrauma is utilized. Data were gathered from 14
interviews with clinicians, health administrators, a researcher, and a health executive. Guided
by interpretive description methodology, four major themes emerged, including: teletrauma
affects the entire system of care; teletrauma enables a network of care built on
interprofessional relationships; reasons clinicians use teletrauma are multifaceted and
interrelated; and, interconnectedness of the healthcare system. Information from this study
provides insight into the role and function of teletrauma in northern British Columbia and how
it may better serve the needs of rural clinicians.

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Table of Contents
ABSTRACT ............................................................................................................................... II
TABLE OF TABLES .................................................................................................................. VII
TABLE OF FIGURES ............................................................................................................... VIII
DEFINITIONS .......................................................................................................................... IX
ACKNOWLEDGEMENTS .......................................................................................................... XI
1.0 BACKGROUND................................................................................................................... 1
1.1 HEALTH CARE ACCESSIBILITY............................................................................................................. 1
1.2 DISTRIBUTION OF HEALTH RESOURCES ............................................................................................... 2
1.3 GEOGRAPHIC CONTEXT OF RURAL HEALTH CARE DELIVERY...................................................................... 4
1.4.0 TELEHEALTH IN RURAL CANADA ..................................................................................................... 6
1.4.1 Benefits and opportunities.........................................................................................................6
1.4.2 Telehealth for acute care and beyond. ......................................................................................8
1.4.3 Telehealth system components. ................................................................................................9
1.4.4 Telehealth uptake in Canada. ..................................................................................................10

1.5.0 TELEHEALTH SERVICES IN NORTHERN BRITISH COLUMBIA ................................................................. 11
1.5.1 Teletrauma in the Robson Valley. ............................................................................................11

1.6 INJURY AND TRAUMA IN A NORTHERN CONTEXT ................................................................................. 13
1.7 TELETRAUMA FOR RURAL PATIENTS ................................................................................................. 16
1.8 RESEARCH QUESTION ................................................................................................................... 19

2.0 LITERATURE REVIEW ....................................................................................................... 21
2.1 SEARCH METHODOLOGY................................................................................................................ 21
2.2 STUDY SELECTION AND ANALYSIS..................................................................................................... 21
2.3.0 FINDINGS ................................................................................................................................ 23
2.3.1 Study characteristics. ...............................................................................................................24

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2.3.2 Terminology in the literature. ..................................................................................................25
2.3.3 Rurality. ....................................................................................................................................26
2.3.4 Essential system components. .................................................................................................27
2.3.5 Service evaluation aim. ............................................................................................................28
2.3.6 Acceptability. ............................................................................................................................30
2.3.7 Feasibility. ................................................................................................................................32
2.3.8.0 Factors associated with teletrauma use. ..............................................................................33

2.4 DISCUSSION ................................................................................................................................ 38

3.0 METHODS ....................................................................................................................... 41
3.1 OBJECTIVES ................................................................................................................................ 41
3.2 THEORETICAL ORIENTATION ........................................................................................................... 42
3.3 RESEARCH DESIGN ....................................................................................................................... 46
3.4.0 SAMPLE AND RECRUITMENT........................................................................................................ 49
3.4.1 Study setting.............................................................................................................................49
3.4.2 Sampling approach. .................................................................................................................50
3.4.3 Participant recruitment. ...........................................................................................................51

3.5 DATA COLLECTION ....................................................................................................................... 52
3.6 DATA ANALYSIS ........................................................................................................................... 55
3.7 RIGOR ....................................................................................................................................... 58
3.8 ETHICAL CONSIDERATIONS ............................................................................................................. 61
3.9 KNOWLEDGE TRANSLATION ........................................................................................................... 62

4.0 FINDINGS ........................................................................................................................ 64
4.1.0 INTRODUCTION ........................................................................................................................ 64
4.1.1 Participants. .............................................................................................................................65

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4.1.2 Interviews. ................................................................................................................................66
4.1.3 Structure of findings. ................................................................................................................67

4.2.0 TELETRAUMA IN A NORTHERN RURAL CONTEXT............................................................................... 68
4.2.1 The Robson Valley teletrauma program. ................................................................................68
4.2.2 Facilitators to teletrauma use..................................................................................................69
4.2.3 Barriers to teletrauma use. ......................................................................................................72
4.2.4.0 Effects and outcomes of teletrauma. ...................................................................................74

4.3.0 FACTORS ASSOCIATED WITH TELETRAUMA USE ............................................................................... 83
4.3.1 Individual determinants. ..........................................................................................................83
4.3.2 Health Services System. ...........................................................................................................84

4.4.0 TELETRAUMA AS A TOOL TO FOSTER TEAM-BASED CARE ................................................................... 88
4.4.1 Teletrauma is more than the technology. ...............................................................................88
4.4.2 Teletrauma as a dynamic, fluid service. ..................................................................................91
4.4.3 Goals of teletrauma. ................................................................................................................94

4.5.0 INTERCONNECTEDNESS OF THE HEALTHCARE SYSTEM ....................................................................... 98
4.5.1 Teletrauma facilitates connected, compassionate care..........................................................98
4.5.2 Clinicians as vital to rural telehealth models. .......................................................................100

4.6 SUMMARY OF FINDINGS .............................................................................................................. 102

5.0 DISCUSSION AND INTERPRETATION .............................................................................. 104
5.1.0 INTERPRETATION OF FINDINGS .................................................................................................. 104
5.1.1 Teletrauma affects the healthcare system. ...........................................................................104
5.1.2 Teletrauma enables a network of care built on interprofessional relationships. ................108
5.1.3.0 Reasons clinicians use teletrauma are multifaceted and interrelated. .............................111
5.1.4 Interconnectedness of the healthcare system. ......................................................................117

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5.2.0 IMPLICATIONS AND RECOMMENDATIONS..................................................................................... 120
5.2.1 Clinical implications. ..............................................................................................................120
5.2.2 Policy implications..................................................................................................................121
5.2.3 Recommendations..................................................................................................................123

5.3 STRENGTHS AND LIMITATIONS ...................................................................................................... 125
5.4 CONCLUSIONS ........................................................................................................................... 126

REFERENCES ....................................................................................................................... 128
APPENDIX A ........................................................................................................................ 143
APPENDIX B ........................................................................................................................ 146
APPENDIX C ........................................................................................................................ 162
APPENDIX D ........................................................................................................................ 165

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Table of Tables
Table 1: Roles and Locations of Focus for Primary and Secondary Participants (N=14)…..…….….66

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Table of Figures
Figure 1: Geography of British Columbia by Health Authority ………………………….…………………….…4
Figure 2: Geography of British Columbia by Population Density….…………………………………….………5
Figure 3: Map of McBride, Valemount, and Prince George within the Northern Health Authority
(Comprised of Three Health Service Delivery Areas)………………...…………………....………………….……12
Figure 4: Article Selection Flowchart…………………………………………………………………………………….….23
Figure 5: Classification of Factors Associated with Teletrauma Use with Examples………………….34
Figure 6: Health Service Utilization Framework (Andersen & Newman, 1973)………………………...43
Figure 7: Individual Determinants of Health Adopted from Andersen and Newman (1973) …...53
Figure 8: Participant Responses to Teletrauma Survey (N=5)…………………………………………………..75
Figure 9: Interconnectedness as a Unifying Concept ..…………………………………………………………..103
Figure 10: Summary of Implications and Recommendations…………………………………………….……120

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Definitions

Client site. “The site of the client or local provider(s) receiving support from consulting
clinicians” (Provincial Health Services Authority, 2014, p. 4)
Consulting site. “The site the consulting provider broadcasts from” (Provincial Health Services
Authority, 2014, p. 4)
Level 1 Trauma Center. “[A] Level I Trauma Center is a comprehensive regional resource that is
a tertiary care facility central to the trauma system. A Level I Trauma Center is capable of
providing total care for every aspect of injury” (American Trauma Society, n.d., para. 5)
Level 2 Trauma Center. “A Level 2 Trauma Center is able to initiate definitive care for all injured
patients (American Trauma Society, n.d., para. 7)
Level 3 Trauma Center. “A Level III Trauma Center has demonstrated an ability to provide
prompt assessment, resuscitation, surgery, intensive care and stabilization of injured patients
and emergency operations” (American Trauma Society, n.d., para. 9)
Level 4 Trauma Center. “A Level IV Trauma Center has demonstrated an ability to provide
advanced trauma life support prior to transfer of patients to a higher level trauma center. It
provides evaluation, stabilization, and diagnostic capabilities for injured patients” (American
Trauma Society, n.d., para. 11)
Northern Health Authority. The health care organization that is responsible for delivering care
to the Northern Health Authority region in British Columbia
Rural. Rural and small town areas are census subdivisions outside of a central metropolitan
area (urban core population >50,000) or a census agglomeration (urban core population
>10,000) (Statistics Canada, 2015)

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Telehealth. “The use of telecommunications and virtual technology to deliver health care
outside of traditional health-care facilities” (World Health Organization, 2019, para. 1)
Teletrauma. A telehealth service that is designed to meet the needs of those delivering and
managing the care of traumatically injured patients requiring immediate clinical management
Trauma. Acute injuries requiring immediate medical management

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Acknowledgements
I have been privileged with an incredible group of mentors, friends, and colleagues who
have encouraged me in this academic endeavor. I would like to thank my supervisory
committee, Dr. Shannon Freeman, Dr. Davina Banner-Lukaris, and Dr. Melinda Martin-Khan, for
their continued unwavering support, dedication, and guidance throughout this process. Their
insightfulness, persistence, and expertise have inspired me to pursue excellence, and will
continue to shape my future research career. I express my sincere gratitude to each of them.
I would also like to recognize the entire nursing faculty during my time spent there; their
friendship and support motivated me over the last two years. In addition, I would like to
recognize Kristi Boon for her friendship and guidance, and Dr. Caroline Sanders for her wisdom
and kindness. They have all contributed towards my personal and professional growth.
I am proud to be able to call each of these individuals friends and look forward to
working with them in the future as colleagues. Thank you.

xi

1.0 Background
1.1 Health care accessibility
Despite the existence of universal health care for Canadians meant to ensure access to
medically necessary care, rural and remote communities have proportionately fewer health
services and providers available (Pong et al., 2011). Many services have become centralized to
more urban areas requiring rural patients to travel longer distances for care. Compared to
urban patients, those residing in rural areas are least likely to access specialist services (Sibley
and Weiner, 2011); critical care or obstetrics are especially challenging for rural patients to
access (Ministry of Health, 2015). A lack of availability of health services for rural patients can
result in higher all-cause mortality rates (Kulig & Williams, 2012), higher rates of avoidable
deaths (Canadian Institute for Health Information, 2017c), and a three-fold increase in risk of
death in the emergency department (Gomez et al., 2010). Inequitable health care access exists
in northern British Columbia (BC), the region in which this research is located, and is
characterized by variable human, technological, and informational resources.
Despite attempts to enhance access to health care services, including visiting specialists, the
issue of care delivery and service inaccessibility for geographically isolated communities has
long been a problem facing many Canadians (Romanow, 2002). Several reasons have been
attributed to the challenge of rural health care delivery, including geographic dispersion and
low population densities (Hanlon & Halseth, 2005), lack of local human and financial resources
(Ministry of Health, 2015), and the distinct health needs of those living in rural and remote
areas (Pong et al., 2011). The inequalities faced by Canadians who live in rural locations directly
contradict Canada’s legislated mandate to provide universal access to necessary medical care.
1

The Canada Health Act (1985) explicitly mentions ‘accessibility’ as one of its five main
principles, requiring that health care and human resources be available regardless of region.
Provincial governments receive federal funding based on the expectation that each province
abides by these principles and, according to the Canada Health Act (1985), insurance plans
must provide services that do not impede reasonable access to care. However, the term
‘reasonable access’ was only defined in terms of economic accessibility; that is, insured
individuals could receive medically necessary hospital and physician services whether or not
they had the ability to pay (Canada Health Act, 1985). This definition did not take into account
the inability of many Canadians to access care due to geographic barriers. As a result, Health
Canada (2000) made a distinction between economic and physical accessibility to health care
services. Thus, while ambiguity surrounding the term ‘reasonable access’ exists to give
provinces the flexibility to decide which additional services to provide as needed, it has also
contributed to access inequities for rural patients, as evidenced by increasing centralization of
services in more urban areas. Although legislation exists to protect and uphold the principles of
universal health care for Canadians, there remains a stark contrast between what access looks
like for many rural patients in comparison to their urban counterparts.
1.2 Distribution of health resources
Health care and human resources are unequally distributed throughout BC (Pong et al.,
2011), creating a divide between rural and urban patients in terms of health care service
accessibility. Rural patients also access care in ways that are distinct from those in urban
centers, reflective of a lack of local resources (Pong et al., 2011). For those health resources
that do exist in rural settings, services are often organized and delivered differently as

2

compared to urban regions (Pong et al., 2011). More specifically, there is marked differential
access to human health resources for rural versus urban patients (Sibley and Weiner, 2011). For
instance, only 2% of the specialists in BC worked in rural areas in 2017 (Canadian Institute for
Health Information, 2017b) despite 7.4% of BC’s population living in rural regions (Statistics
Canada, 2017). Even when services are available in rural BC, traditional in-person consultations
are typically inaccessible (Copley, Kitson, & Pawlovich, 2017). This gap in human resource
coverage may result in rural patients having to travel long distances to receive care, putting
them at an increased risk for adverse outcomes.
Fragility of health delivery systems also exists for rural communities due to chronic human
health resource shortages, including small numbers of physicians and ageing physicians with
imminent retirements (Ministry of Health, 2015). This problem is not unique to Canada; other
countries with similarly low population densities face like circumstances. Australia, for example,
has long encountered recruitment and retention issues for rural areas. Reasons attributed to
these difficulties have included professional isolation (Lannin & Longland, 2003) and a lack of
local resources (Curran, Fleet, & Kirby, 2006) leading to health inequities similar to those found
in Canada. To attain a more balanced geographical distribution of clinicians across northern BC,
the Northern Health Authority began providing financial incentives for those willing to work and
live in underserved communities. While some health care providers accept these incentives and
work in remote areas for a short time, this method has been demonstrated to have only limited
success for long-term retention (Barer & Stoddart, 1999). A more recent study noted that
recruiting and retaining of nurses in rural Canada remains a challenge despite the existence of
financial incentives (Kulig, Kilpatrick, Moffitt, & Zimmer, 2015). Considering that only 8% of

3

physicians live in rural areas compared to 19% of Canadians (Canadian Medical Association,
n.d.), inequitable distribution of human resources remains problematic for rural health care
delivery. Failed recruitment and retention strategies for rural clinicians coupled with barriers to
accessing appropriate care may be contributing to the existing health disparities in northern BC.
1.3 Geographic context of rural health care delivery
The total population of BC is nearly 5,000,000 individuals spread across greater than
900,000 square kilometers (Statistics Canada, 2017). The Northern Health Authority is the
largest geographic health region in BC and is comprised primarily of rural and remoted
communities (Figure 1). The Northern Health Authority region covers nearly two-thirds of BC’s

|
Fraser Health
|
Interior Health
] Northern Health
|
Vancouver Coastal Health

H Vancouver Wane ~ealth Authority

Figure 1: Geography of British Columbia by Health Authority (Government of BC, n.d.)

4

total landmass (BC Stats, 2012) and services approximately 280,000 residents (BC Stats, 2018).
The vast geography, combined with low population densities (0.4 persons per square kilometer)
(BC Stats, 2012), creates health delivery challenges unique to the region (Figure 2). These
problems are further compounded by the large distances between health facilities, making
travel difficult and often dangerous during inclement weather. Strategies have been adopted by
the Northern Health Authority to combat issues associated with a highly geographically
dispersed patient population. Aligned with the Ministry of Health’s (2015) direction for health

Population
density
/sq. km.

200.67 - 4,809.81

20.67 - 200.66
2.74 - 20.66
0.80 - 2.73
3.29 - 0.79

Figure 2: Geography of British Columbia by Population Density (BC Stats, 2010, as cited in
Foster, Keller, McKee, & Ostry, 2011)

5

services, an objective of the Northern Health Authority’s (2018) Service Plan for 2018/19 –
2020/21 is to optimize access and patient flow to “improve appropriateness, access and
timeliness of specialty and facility-based care” (p. 19) by means of “innovative service delivery
approaches… in a variety of areas across the system” (p. 20). One strategy that aligns with the
Northern Health Authority’s (2018) objectives is telehealth, a service modality that may be
fitting for northern BC’s remote geography.
1.4.0 Telehealth in rural Canada
1.4.1 Benefits and opportunities. Telehealth is a solution that may be used to overcome
the distinct challenges faced by rural communities and has well-recognized positive effects
including improved patient outcomes, enhanced access to care, and cost savings for both
patients and providers (Desai, Williams, & Smith, 2013; Herrington, Zardins, & Hamilton, 2013;
Saurman et al., 2011; Stingley & Schultz, 2014). As a modality of care, telehealth enables the
provision of health management, health promotion, clinician support, education, and
consultation at a distance. The World Health Organization (2019) defines telehealth as “the use
of telecommunications and virtual technology to deliver health care outside of traditional
health-care facilities” (para. 1). Telehealth reduces inequitable access faced by those who are
geographically isolated by capitalizing on the availability of existing telecommunication
infrastructure such as broadband networks (Jong, Mendez, & Jong, 2019). For rural patients,
this may decrease the need to travel long distances for care thereby reducing patient costs and
removing the dangers often associated with highway travel. In some cases, the implementation
of telehealth was able to reduce transfer rates to trauma centers by up to 90%, leading to
significant cost savings without any changes in mortality (Duchesne et al., 2008). As such, the

6

use of telehealth enables patients to access appropriate care from within their own
communities by bringing care directly to the patient. Considering the appropriateness and
benefits of telehealth for rural areas, the Ministry of Health (2015) explicitly mentions
telehealth services for remote regions of BC as being a key strategy moving forward. Thus,
telehealth is a recognized solution with notable positive outcomes that is suitable for northern
BC’s unique geography.
Health service access disparities in rural settings may also be overcome by the use of
telehealth. In northern BC, it has been suggested that the high rates of telehealth utilization
may be due to limited access to health services and a lack of health care providers (Terekhova,
Tabassi, Gabriel, & Jafari, 2017). Because services tend to be concentrated in urban settings,
rural clinicians rely on information and communication technologies to supplement the care
they give. As a means of connecting clinicians, use of telehealth enables professional
development and collegiality, which may in turn improve recruitment and retention in rural
areas (Moffatt & Eley, 2010; Wielandt and Taylor, 2010). Although many rural providers already
deliver excellent emergency care in communities with limited resources, physicians want to
access timely specialist support to ensure the highest quality of care for their patients
(University of British Columbia, 2018). Telehealth may be a solution that addresses the gap in
care that exists for rural patients by offering virtual real-time support to clinicians and may
encourage decentralization of human health resources. Use of telehealth allows patients to
access appropriate care where and when they need it despite being geographical isolated.
Thus, telehealth represents an opportunity to address some of the issues related to a highly
distributed and fragile workforce in rural areas.

7

1.4.2 Telehealth for acute care and beyond. Telehealth may be particularly useful in the
acute care setting. For acutely-ill patients in rural locations, specialist access and timely
treatment are important to support the delivery of quality emergency care. A lack of high-level
expertise in rural and remote areas has been suggested as justification for the implementation
of a tele-emergency service (Al-Kadi et al., 2009; Dyer et al., 2008; Galli, Keith, McKenzie, Hall, &
Henderson, 2008; Hernandez et al., 2016; Latifi et al., 2009; Mohr et al., 2018; Saffle, Edelman,
Theurer, Morris, & Cochran, 2009). Despite a lack of local resources, use of telehealth to access
specialist knowledge and care has had notable positive effects. For example, use of telehealth is
reportedly cost-saving (Demaerschalk et al., 2013; Duchesne et al., 2008; Natafgi et al., 2018;
Wibbenmeyer et al., 2016; Yang et al., 2015b), reducing costs for both the consulting and client
sites. Total hospital costs for a trauma center were $7.6 million prior to telehealth
implementation compared to $1.1 million after service adoption; an 85% reduction in cost
(Duchesne et al., 2008). One reason cited for the substantial decrease in costs is the reduction
in the number of transfers of stable trauma patients allowing hospitals to share the burden of
cost for trauma cases (Duchesne et al., 2008). Similarly, a base-case cost-effectiveness analysis
of medical expenditures demonstrated an annual cost savings of $46,620 per emergency
department when treating 10 acutely-ill and injured children via telehealth as compared to
conventional treatment (Yang et al., 2015b).
Although telehealth for acute care is intuitively understood as being physically present
within the emergency department, other applications have extended these boundaries to prehospital care. Several studies have examined the use of telehealth for stroke evaluation prior to
patient arriving at the emergency department (Barrett et al., 2017; Bergrath et al., 2012; Geisler

8

et al., 2019; Wu et al., 2014). Other pre-hospital applications have included continuous
ambulance telemetry for coronary heart disease patients (Woollard, Pitt, Hayward, & Taylor,
2005) and a remotely-supported pre-hospital ultrasound system (Eadie et al., 2018). Telehealth
has also been discussed in the context of military application in austere operational
environments to aid in the management and evacuation of combat casualties (Nettesheim et
al., 2018; Waterman, Laughlin, Belmont, Schoenfeld, & Pallis, 2014) and for disaster medicine
(Case, Morrison, & Vuylsteke, 2012).
The potential for telehealth to enhance access to care and to improve treatment can
also extend to urban locations where specialists are present but may not be able to access the
patient case in a timely manner. To facilitate rapid access and enhance communication, mobile
phones have been used to send and receive pictures between plastic surgeons thereby
improving care (Farber, Haik Liran, Weissman, & Winkler, 2011). That is, use of telehealth
enabled earlier involvement of senior staff in the care process, improved communication
between clinicians, and increased the ability of clinicians to independently manage similar cases
in the future (Farber et al., 2011). In rural areas, both physical separation and temporal delays
to appropriate health services often exist, resulting in reduced access to proper care.
Considering the wide-ranging scope of applicability and benefits of telehealth for patients and
clinicians, telehealth services are fitting for rural geographies from both physical and temporal
perspectives.
1.4.3 Telehealth system components. Telehealth uses a wide variety of methods to
deliver remote care, including store-and-forward technology, videoconferencing, and secure
messaging systems. For telehealth during emergency care, for example, there is variability in

9

technology used depending on the particular application of the service. This has included a lowbandwidth store-and-forward transmission of echocardiograms to the computer of a remote
cardiologist (Barbier, Vecchia, Mirra, Di Marco, & Cavoretto, 2012) and mobile BlackBerry
Messenger to transmit chest radiographs over a cellular network (Scheuermeyer et al., 2016). In
areas containing less communication infrastructure, such as the province of Alto Amazonas in
Peru, Very High Frequency (VHF) radios and email have been used for voice and data
communication (Martinez, Vollarroel, Seoane, & del Pozo, 2004). In general, the clinical
demands of acute care medicine and environmental factors (such as infrastructure) determine
the system components that are used. Thus, telehealth system design depends on the clinical
situation for which it is intended and the local resources available to service providers.
1.4.4 Telehealth uptake in Canada. Popularity of telehealth in Canada continues to
grow due to the versatility and wide scope of applicability. According to a report produced by
Canada’s Health Informatics Association [COACH] (2015), the number of clinical telehealth
sessions across Canada grew 120% between 2010 and 2014. In terms of number of patients
served, this has equated to nearly half a million Canadians who used telehealth (COACH, 2015).
Another study examining telehealth for primary care in BC found that usage doubled between
2013 and 2015, with the highest rates of use in Northern BC (Terekhova et al., 2017). The
growing interest expressed by rural clinicians (Northern Health Authority, 2018) and increased
service utilization (COACH, 2015) highlights a demand for telehealth services in Canada. As
popularity and demand continue to increase, feasibility of telehealth may also increase.

10

1.5.0 Telehealth services in northern British Columbia
In rural BC, there is increased demand and uptake of telehealth. Specifically, the
Northern Health Authority has created several telehealth services that can provide timely
access to appropriate care, including Tele-Infectious Disease and TeleNephrology. In the wider
BC area, other services offered include TeleMental Health, TeleThoracic, TeleStroke, and Home
Health Monitoring. The breadth of telehealth programs across BC aligns with the Ministry of
Health’s (2015) strategies for service delivery and provides benefits for both local clinicians and
patients. Although telehealth has undeniable benefits for rural and remote regions, limitations
exist. For example, there is little information on telehealth programs in northern BC. Despite
substantial expansion of technology-based health care delivery (COACH, 2015), there is a lack of
knowledge regarding use of telehealth and characteristics of users in BC (Terekhova et al.,
2017). Another drawback is the potential for differential care, including antibiotic prescribing
rates and the uptake of diagnostic testing. For example, it has been noted that clinicians using
telehealth are less likely to order diagnostic tests (3% versus 50%, p<0.01) and have poorer
performance on appropriate antibiotic prescribing (16.7% versus 27.9%, p<0.01) compared to
clinicians who do not use telehealth (Uscher-Pines et al., 2016). Notwithstanding, use of
telehealth has continued to demonstrate positive outcomes and benefits for patients and
providers in rural areas (Marcin, Shaikh, & Steinhorn, 2016). Considering the uptake and growth
of telehealth services in BC, telehealth adoption may be expected to increase as the technology
becomes normalized within the health care system.
1.5.1 Teletrauma in the Robson Valley. To support the delivery of high quality
emergency care in rural BC, the Northern Health Authority implemented a virtual medicine

11

project for remote family physicians who would like on-demand support (University of British
Columbia, 2018). An aim of the project was to facilitate rural clinicians’ access to timely and
useful support from other health professionals during emergency care situations (University of
British Columbia, 2018). Over an 18-month period beginning in 2016, real-time virtual care
consultations were conducted through videoconferencing and secure text-messaging between
clinicians in the Robson Valley and emergency physicians in Prince George, approximately 200
kilometers away (Figure 3). The Robson Valley consists of two small communities, Valemount

Figure 3: Map of McBride, Valemount, and Prince George within the Northern Health Authority
(Comprised of Three Health Service Delivery Areas) (Northern Health Authority, n.d.)
12

and McBride. After hours, McBride and Valemount hospital are staffed by only one physician
and one nurse despite the communities being 90 kilometers apart. The communities are
situated on a highway that is frequented by large numbers of tourists travelling between BC
and the neighboring province, Alberta, particularly in the summer months (May to October).
During the winter months (November to February), many winter sport enthusiasts travel to the
Robson Valley for snowmobiling, skiing, and mountaineering. As a result, these small
communities commonly face demands for more advanced trauma emergency services. The
geographic isolation of these communities, poor cellphone coverage, and wildlife make travel
along the highway dangerous. As a result, clinicians in the Robson Valley may be exposed to
traumatic injury and emergency cases stemming primarily from motor vehicle accidents and
winter sport activities. In particular, motor vehicle accidents often account for the
disproportionately high injury rates in rural areas (Gonzalez, Cummings, Mulekar, & Rodning,
2006; Peek-Asa et al., 2004). Considering the physical location, seasonality, and exposure to
tourism, the Robson Valley presented an opportunity to capitalize on the benefits of
teletrauma. By engaging digital technologies to provide on-demand support during trauma and
emergency management, there was the opportunity to reduce gaps in care and provide
increased support for physicians within the communities.
1.6 Injury and trauma in a northern context
Traumas and injuries disproportionately affect rural areas, being commonly more
frequent and having a higher mortality rate (Peek-Asa et al., 2004; Simons et al., 2010).
Canadian Institute for Health Information (2017a) reports that for the most remote regions of
Canada, such as the North West Territories and the Yukon, injury hospitalization rates in 2016

13

were more than double the national rate. Patients in rural areas also experience a larger
number of deaths. It has been noted that the mortality rate for rural patients is 30% higher
compared to urban patients of the same age (DesMeules et al., 2006). For rural BC, the
Canadian Institute for Health Information (2017c) reports a rate of 280 avoidable deaths per
100,000 people for those residing in the Northern Health Authority region, as compared to 185
for BC and 198 for Canada. The degree of distance from an urban center also appears to
influence the risk of death. That is, the highest death rates are for those patients who live in the
most remote regions (Jong, 2010). Several reasons have been attributed to the large number of
trauma-related deaths, including increased severity of motor vehicle accidents (Muelleman &
Mueller, 1996) and longer time from injury discovery to in-hospital care (Esposito et al., 1995).
Although the reasons may not be fully explicated or understood, rural patients have distinct
health profiles requiring health delivery methods that are appropriate, contextually relevant,
and timely.
Resources may also be inadequate in rural areas and clinicians may be less wellequipped for high acuity patients who require comprehensive services. For rural patients,
greater distance from a Level 1 or Level 2 trauma center equates to longer time to definitive
trauma care. Because trauma care is time sensitive, the proximity of the patient to a facility
with appropriate services is a key factor determining patient outcomes. This is known as the
Golden Hour concept which posits that the risk of death is reduced with prompt care (Sampalis
et al., 1999). It has been identified that over 7 million Canadians remain outside a 1-hour
driving distance to definitive care, and of these, all reside in rural and remote areas (Hameed,
Schuurman, Razek, & Simons, 2010). For those patients who live further than one hour away

14

from a trauma center, the risk of dying in the emergency room was 3.5 (95% CI 2.5 - 4.9) times,
or 350% greater as compared to those with immediate access (Gomez et al., 2010). The
designation of the treating facility also influences outcomes for trauma patients. For example,
patients receiving care at a Level 1 trauma facility have a 25% reduction in mortality as
compared to patients managed at a non-trauma center (MacKenzie et al., 2006). Similarly, the
risk of dying in a tertiary trauma center was 75% lower than in primary centers (Sampalis et al.,
1999). Because there are often barriers to accessing definitive care in rural regions, including
lower-designated facilities and physical isolation, trauma patients may not be receiving
appropriate or timely care. Specifically, prolonged time to coordinated care as a result of
geographic separation and resource availability may therefore contribute to the higher
mortality rates observed in rural populations (Gomez et al., 2010).
For northern BC, a lack of local resources (Ministry of Health, 2015) and substantial
geographical distance to high-level trauma care (Hameed et al., 2010) are known barriers to
accessing definitive care. In regards to these issues, the Ministry of Health (2015) has identified
access to trauma services as being a critical consideration for rural communities in BC.
However, BC has been commended for its successful adaptations to enhance access, despite
geographic isolation and climate, by encouraging local hospitals to become involved early on in
the trauma care process (Hameed et al., 2010). By supporting the role of rural sites in managing
trauma, rural patients and the regional trauma care system may both benefit from the use of
telehealth, and in particular, teletrauma services.

15

1.7 Teletrauma for rural patients
Telehealth is frequently used for emergency and trauma care in community and rural
hospitals. While telehealth for trauma may be broadly described as emergency telehealth, or
‘tele-emergency,’ terminology in the literature is inconsistent and not specific to trauma. Galli
et al. (2008), Henderson (2006), and Sterling et al. (2017) use the term ‘telemergency,’ while
others use ‘tele-emergency’ (Mueller, Potter, MacKinney, & Ward 2014; Natafgi et al., 2018;
Ward et al., 2016). Labels such as ‘emergency telemedicine’ (Ellis, Mayrose, & Phelan, 2006), or
those with similar phrasing, have also been used. Examples of telehealth applications with a
narrower clinical focus include telesonography (Al-Kadi et al., 2009), teleradiology (Ashkenazi et
al., 2007) and tele-airway management (Cho, Chung, Choa, Yoo, & Kim, 2011) despite the fact
that they are all used for emergency situations. The term ‘telehealth’ has also been combined
with particular medical conditions such as stroke, mental illness, and ophthalmology to include
services such as telestroke (Khan et al., 2010), telemental health (Southard, Neufeld, & Laws,
2014), and teleophthamology (Woodward et al., 2016).
Within the emergency care category, telehealth has been adopted specifically for use in
trauma settings. These have included burn evaluation and management (Saffle et al., 2009),
pediatric emergency care support (Yang et al., 2015a), dental trauma diagnosis (Lienert,
Zitzmann, Filippi, Weiger, & Krastl, 2010), and traumatic orthopedic injury evaluation (Jacobs,
Jacobs, van Sonderen, van der Molen, & Sanderman, 2015). Language regarding teletrauma is
equally diverse. Terminology used to describe telehealth services during trauma cases has
included tele-ultrasound (Al-Kadi et al., 2009), virtual critical care (Westbrook et al., 2008), and
teleradiology (Franken et al., 1997). While existing terminology may reflect specific clinical

16

function or technological focus, telehealth for trauma situations may be generalized as
‘teletrauma.’ Thus, teletrauma is the use of telehealth services designed to meet the needs of
those delivering and managing the care of traumatically injured patients. For the purpose of
this thesis, ‘teletrauma’ will refer to any telehealth service used in the context of trauma.
The appropriate management of a trauma patient requires timely and coordinated care,
a large amount of resources, and immediately available expertise. Trauma centers typically
include a surgical subspecialty, such as a trauma surgeon, available 24-hours in urban zones.
Rural and remote communities, on the other hand, may not be equipped with the resources or
clinical experience to effectively manage complex trauma patients (Latifi et al., 2007). For
example, it has been noted that a lack of clinician capacity to manage critically ill patients may
compromise care in rural settings (Jong, 2010). This has created large discrepancies in trauma
care between rural and urban centers, which may result in reduced quality of care, poorer
patient outcomes, and a high rate of patient transfers. For many rural and remote health care
facilities, the majority of trauma cases encountered are immediately transferred to the nearest
center to deliver definitive care (Ashkenazi et al., 2007; Duchesne et al., 2008). However, this
may present a missed opportunity for rural sites to actively participate as key players in a
regional trauma system; teletrauma may facilitate the accurate triage and effective transfer of
the traumatically injured patient. For example, it has been found that the implementation of
telehealth has led to a reduction in unnecessary transfers by identifying only those patients
most in need of transfer, while stable patients are evaluated and eventually discharged locally
(Duchesne et al., 2008). Within the Northern Health Authority, teletrauma has permitted
physicians to conduct procedures and manage patients within the rural community thereby

17

reducing the number of transfers to an urban center (University of British Columbia, 2018). It
also allows some patients to remain in their own community for treatment, thus reducing travel
cost and risk for the patient and the patient’s family. This approach shares the burden of
trauma cases and decentralizes trauma care by engaging a regionalized approach that
emphasizes the important role of rural facilities.
The Golden Hour concept dictates that trauma patients receive definitive in-hospital
care within 60 minutes (Sampalis et al., 1999). Considering the geographic vastness of northern
BC, it is not feasible to construct trauma-capable facilities as a means of extending the 1-hour
catchment area to all rural patients. However, the Northern Health Authority has a regionalized
trauma system whereupon Level 3 and Level 4 centers, often situated in rural and remote areas
of BC, participate in the care process. Teletrauma has been recognized as a possible solution for
extending the geographical reach of regionalized trauma systems (Hameed et al., 2010) and has
been consistently adopted in rural areas (Duchesne et al., 2008; Franken, Harkens, & Berbaum,
1997; Mohr et al., 2018; Roccia, Spada, Milani, & Berrone, 2005; Saffle et al., 2009). Capitalizing
on the existing regional trauma system in northern BC, teletrauma may improve access to the
definitive care provided by larger centers. As a result, the trauma system becomes integrated at
the regional level by relying on rural sites to provide triage and early management of trauma
patients. Additionally, rural clinicians can perform otherwise unfamiliar procedures and develop
professional skills, despite residing in areas with low user densities and less trauma exposure.
Clinician confidence may also be enhanced, having less anxiety regarding unfamiliar cases while
reducing feelings of professional isolation (Lambrecht, 1997). Thus by extending expertise and
clinical support to BC’s periphery via teletrauma, rural sites play a key role in the accurate triage

18

and early care of trauma patients conferring benefits to patients, clinicians, and the trauma
system.
1.8 Research question
Practicing clinicians in McBride and Valemount are vital to the excellent health care that
is delivered to this unique region in northern BC. It is important to engage the perspectives of
rural clinicians to better understand how the Robson Valley functions as a part of the regional
trauma system. Clinicians in these communities have insight into the complexities of rural
trauma care within the context of geographic and professional isolation, resource access
limitations, and the distinct health profiles of rural BC trauma patients. By adopting strategically
designed teletrauma services, clinicians may maximize the function of the Robson Valley as a
rural trauma site and advance the trauma system as a whole. Because teletrauma serves as the
conceptual and physical link between the Robson Valley and an integrated system of trauma
care, clinicians perspectives are essential to understanding teletrauma in a northern context.
Rural clinicians may thus represent the primary drivers, and key knowledge holders, of an
effective regionalized trauma system that relies on teletrauma.
To understand this further, this research will address the research question: What
factors are associated with the use of teletrauma in northern British Columbia? Understanding
the experiences of physicians using teletrauma and the perspectives of key stakeholders will
contribute knowledge on how these services can complement and extend high quality patient
care within the Robson Valley region of northern BC. This research will address gaps in
knowledge and may further catalyze strategic implementation of future teletrauma services in

19

the region and have the potential for large-scale positive effects across all aspects of BC’s
health delivery system.

20

2.0 Literature Review
A systematic search of the literature was conducted to provide an overview of the
empirical knowledge on teletrauma research. Arksey and O’Malley’s (2005) framework for
scoping reviews was used to guide the search methodology. Knowledge gained from this
literature review provides an understanding of the current state of teletrauma research and
identifies gaps and potential directions for future teletrauma research.
2.1 Search methodology
This systematic literature search was guided by Arksey and O’Malley’s (2005) scoping
review methodology. Stages included 1) identification of the research question; 2) identification
of all relevant studies; 3) study selection; 4) charting the relevant data; and 5) collating,
summarizing and reporting the results (Arksey & O’Malley, 2005). This method was selected to
identify, describe, and summarize the knowledge base of relevant literature on teletrauma. The
scoping review methodology allows researchers to draw conclusions about the current
landscape of research on a topic, while remaining methodologically rigorous and allowing the
inclusion of diverse forms of literature (Arksey & O’Malley, 2005). The method is appropriate
given the early state of teletrauma research and its ability to provide a comprehensive review
of the breadth of the literature.
2.2 Study selection and analysis
To examine teletrauma literature, a systematic search of electronic databases was
conducted including Cumulative Index to Nursing and Allied Health Literature (CINAHL)
Complete, Biomedical Reference Collection: Comprehensive, PsycINFO, EconLit, and PubMed.
Keywords included terminology related to any telehealth service, trauma, and a rural setting,

21

while relevant subject headings were used according to the database searched (Appendix A).
The search was reviewed by a health librarian. No date or age limiters were used, since limited
research was available. The search was restricted to peer reviewed articles available in English
and human subjects. Inclusion criteria consisted of care provided in clinic, hospital, or
emergency department and articles having a telehealth component to retain a focus on
telehealth services provided within rural institutions. Articles were excluded if there was no
acute or emergency care situation, or if there was no real-life clinical component. A matrix was
created with clearly defined rules for the screening process to ensure reliability of the review.
The number of excluded articles were recorded at each step. After an initial screening of titles
and abstracts, full text articles were reviewed according to the eligibility criteria and then
selected for inclusion (Figure 4). Information from articles was extracted using a data extraction
framework to organize and ensure consistency of data collection (Appendix B). Framework
headings included the year, study location, study type, objectives, patient group, sample size,
telehealth technology, associated factors, evaluation aim, communication network, and
findings. Headings were created according to the research questions and to provide a
descriptive overview of the current literature.
The Quadruple Aim framework (Bodenheimer & Sinsky, 2014), adapted from Berwick,
Nolan, and Whittington’s (2008) original Triple Aim framework for health care system
optimization, was used to help categorize articles according to evaluation aim. Aims include a)
provider experience, b) patient experience, c) population health, and d) cost optimization.
Although the Triple Aim has been used by health care organizations across the world to guide
the delivery of high quality care (Sikka, Morath, & Leape, 2015), it has been revised to include

22

an integral part of the health care system: the provider experience. The provider experience
has been cited as a necessary prerequisite to achieving the Triple Aim and ensuring a more
balanced view of health system performance (Bodenheimer & Sinsky, 2014). Use of the
Quadruple Aim framework for this literature review permits identification of which aspects of
the health care system are being examined and highlights gaps in teletrauma evaluation
research.
CINAHL (643)

Biomedical Reference (160)

PsycINFO (341)

EconLit (11)

Pubmed (622)

Articles after limiters:
N = 1777
Removal of duplicates (exclude n = 293)
N = 1484
Initial scan of titles and abstracts
(exclude n = 1096)
N = 388
Second scan of titles and abstracts [telehealth for
acute disorders or medical conditions]
(exclude n = 157)
N = 231
Full text review [teletrauma in rural emergency
departments, clinics, or hospitals]
(exclude n = 203)
N = 28

Figure 4: Article Selection Flowchart
2.3.0 Findings
From the original 1777 articles identified after the initial search, 28 articles met the
inclusion criteria and were included in the analysis (Appendix B). Of the studies identified, 16
mentioned patient populations classified as trauma cases. The remaining 12 articles examined
cases meeting the definition of traumatic injury (acute injuries requiring immediate medical
23

management) and were thus included, but did not specifically classify patients as being trauma
patients.
2.3.1 Study characteristics. A large proportion of articles were published within the last
10 years (n=12) although teletrauma research has appeared as early as 1997 (Franken et al.,
1997; Lambrecht, 1997; Rottger, Irving, Broerr, & Tranmer, 1997). Three studies utilized
observational cohort study designs (Mohr et al., 2016; Mohr et al., 2017; Mohr et al., 2018), six
were classified as descriptive analyses (Al-Kadi et al., 2009; Ashkenazi et al., 2007; Dyer et al.,
2008; Ehrlich, Kobrinsky, Petlakh, Rozinov, & Shabanov, 2007; Lambrecht, 1997; Roccia et al.,
2005), three were identified as comparative or before-and-after studies (Jacobs et al., 2015;
Saffle et al., 2009; Westbrook et al., 2008), while the most frequently used design was a
retrospective analysis (n=11). Studies were conducted in 11 different countries, the most
common being the USA (n=15) and Canada (n=3). In total, 16 articles included patient cases that
were specifically considered trauma cases.
Of the 28 studies, 61% (n=17) included a non-teletrauma comparison group in analysis
(i.e. trauma with no telehealth component or phone consultation only). The largest teletrauma
sample sizes examined were n=1,322 telehealth consultations regarding an injury (Brebner et
al., 2004), n=672 reports of dental trauma following accidents (Lienert et al., 2010), and n=519
patients receiving radiology examinations (Franken et al., 1997). Studies with the smallest
teletrauma sample sizes were n=14 clinician surveys evaluating telehealth for ultrasonography
(Al-Kadi et al., 2009), n=2 case reports of telehealth to treat children with severe burns (SyedAbdul et al., 2012), and n=1 case report of a traumatically injured child who received remote
clinical management prior to transfer (Rottger et al., 1997). Articles with a study population

24

that included patients of all ages comprised 61% (n=17) of the total, followed by adults over 18
years (n=4), and pediatric patients under the age of 18 years (n=7).
The communication network for teletrauma programs varied in size: one article studied
telehealth consultations for acute injuries from 14 community hospitals consulting a larger
hospital (Brebner et al., 2004), another examined a telehealth service between nine rural
hospitals consulting a Level 1 trauma center to evaluate and manage burn patients
(Wibbenmeyer et al., 2016), and two articles studied a teletrauma service between eight rural
emergency departments and a consulting academic children’s hospital to examine the
appropriateness of transfers of patients using teletrauma and hospital costs (Yang et al., 2015a;
Yang et al., 2015b). The largest network included maxillofacial trauma cases from 35 rural
hospitals consulting a specialized center (Roccia et al., 2005). Typically, articles described
teletrauma services between a single rural community hospital or emergency department and a
center with a higher level of care (n=13).
2.3.2 Terminology in the literature. The term ‘teletrauma’ is associated with the use of
telehealth technologies for trauma care and management. Few articles (Latifi et al., 2009; Ricci
et al., 2003) used the term ‘teletrauma’ to describe a telehealth system designed for use during
trauma care. Instead, several studies labelled their telehealth service based on the specific
technology used. These included tele-ultrasound (Al-Kadi et al., 2009), teleradiology (Ashkenazi
et al., 2007), and telesonography (Dyer et al., 2008). Although the functions of the individual
systems are similar, the services were labelled based on their diagnostic or technological focus.
This adds to the confusion surrounding terminology of telehealth for trauma care by
introducing a large number of terms used to describe the same general concept. Despite the

25

lack of a formal definition, all telehealth technologies which are used at any point during the
management of traumatic injury may be generalized as ‘teletrauma’ regardless of a focus on a
particular aspect of care (i.e. sonography, basic consultation, or airway management). The
majority of language used combines ‘telehealth’ or ‘telemedicine’ with phrases such as ‘for use
during trauma situations’ or with phrases containing similar wording.
2.3.3 Rurality. The definition of rural varied between articles. Some articles stated that
the client site was rural or remote but did not elaborate on how this was defined (Al-Kadi et al.,
2009; Ehrlich et al., 2007; Elkaim et al., 2010; Lienert et al., 2010; Wibbenmeyer et al., 2016).
Others used officially recognized rural zones, whether provided by a government body or
health care organization, to classify sites as rural (Dharmar et al., 2013; Mohr et al., 2016; Mohr
et al., 2018; Yang et al., 2015a). However, several articles expanded on the meaning of rural by
describing the remote facility characteristics and surrounding geography in relation to a larger
center. For example, Ashkenazi et al. (2007) describe their facility as a “410 bed general hospital
designated as a Level 2 trauma center… located in a rural area and is the only trauma center
available for immediate transfer of injured patients within a 90 km diameter... [and] lacks a
neurosurgical service” (p. 550). Despite a facility designation that is higher than most hospitals
in rural areas, Ashkenazi et al.’s (2007) description of the lack of appropriate services in
conjunction with geographical isolation depicts the challenges faced in rural care delivery. Thus,
rurality was described in distinct ways across the literature.
Several aspects or rurality were identified including geographic separation (Brebner et
al., 2004; Duchesne et al., 2008), lack of appropriate resources (Ashkenazi et al., 2007; Dyer et
al., 2008), temporal barriers to care (Roccia et al., 2005; Saffle et al., 2009; Westbrook et al.,

26

2008), or some combination of these. Moving forward, it may be of use for future studies to
define rurality in terms of these characteristics in addition to the accessibility of surrounding
higher-level services. This will aid in understanding the local context of health service delivery
and how telehealth operates within that context. By identifying the various aspects of the
health system and environment, rural telehealth services may be evaluated more accurately.
2.3.4 Essential system components. Despite the varied language used, the essential
components required for telehealth emergency services in rural areas were consistent
throughout the literature. For trauma care, this typically included a real-time bidirectional
audio-visual videoconferencing system with a dedicated network line (Duchesne et al., 2008;
Dyer et al., 2008; Latifi et al., 2009; Ricci et al., 2003). It was common for teletrauma systems to
have mounted cameras with remote control capabilities (Duchesne et al., 2008; Ricci et al.,
2003; Rogers et al., 2001; Yang et al., 2015a; Yang et al., 2015b), however, most articles
described the system only as having cameras with pan/tilt/zoom functions. One study described
their teleradiology system as an “online consultation process” (Ashkenazi et al., 2007, p. 551) to
view and discuss pathological head computed tomographic findings without further explanation
of what the technology entails. Another used fax, conventional telephone, and a cellphone to
provide remote care from a neurosurgeon to a traumatically injured child (Rottger et al., 1997).
Although different technologies and techniques have been used to establish a teletrauma
system, more than half of the articles (n=15) used some form of videoconferencing. This has
included a two-way audio-visual connection (Marcin et al., 2004; Mohr et al., 2016; Mohr et al.,
2017; Mohr et al., 2018), audiovisual communication system (Ricci et al., 2001; Rogers et al.,
2001; Westbrook et al., 2008; Yang et al., 2015a; Yang et al., 2015b), transmission of audio,

27

visual, and vital signs (Latifi et al., 2009), and the explicit mention of a videoconference system
(Al-Kadi et al., 2009; Brebner et al., 2004; Dharmar et al., 2013; Duchesne et al., 2008; Dyer et
al., 2008; Ehrlich et al., 2007; Lambrecht, 1997; Syed-Abdul et al., 2012). As an example,
Dharmar et al. (2013) describe their system as “a pole-mounted telemedicine system with a
turnkey videoconferencing unit… a flat-screen high-resolution monitor, and an uninterrupted
power supply. The videoconferencing unit provided bidirectional video using a high-definition
camera capable of pan, tilt, and zoom functions” (p. 2389). For teletrauma systems deployed in
rural areas, there were similarities in the types of technology used and the technological
capabilities.
The design, specific elements, and capabilities of the telehealth system were driven by
the needs of the clinical situation in which it was employed, provided appropriate local
infrastructure was in place to facilitate the technological requirements. The technological
components supported assessment of the patient by multiple parties at a distance in real time
without requiring staff at the client site to position cameras (Duchesne et al., 2008; Ricci et al.,
2003); a virtual presence is established at the client site with minimal interference to on-site
staff. The similarities in technological components for rural teletrauma identified across the
literature supports the future development of teletrauma systems designed to meet the needs
of patients and providers. Further knowledge syntheses in this area may be used to contribute
towards the creation of technological guidelines for rural sites wishing to adopt teletrauma
services.
2.3.5 Service evaluation aim. Examination of service evaluation aim permits insight into
how the health care system is being affected by teletrauma services and identifies gaps in

28

research. The majority of articles were classified as having only examined one aspect of
Bodenheimer and Sinsky’s (2014) Quadruple Aim. The most frequently evaluated aim was
population health (n=26). Population health evaluation, in the context of teletrauma, included
analysis of the safe medical management of patients (Ashkenazi et al., 2007), transfer rates
(Duchesne et al., 2008), and clinical outcomes for patients (Syed-Abdul et al., 2012). Provider
and patient experience was typically evaluated using quality of care measures (Dharmar et al.,
2013; Latifi et al., 2009) or satisfaction surveys (Al-Kadi et al., 2009; Brebner et al., 2004; Dyer et
al., 2008; Lambrecht, 1997). Evaluation aims studied the least were patient experience
(Dharmar et al., 2013; Marcin et al., 2004; Saffle et al., 2009) and cost optimization (Duchesne
et al., 2008; Latifi et al., 2009; Saffle et al., 2009; Yang et al., 2015b). Articles categorized under
the cost optimization aim included those evaluating transfer costs for teletrauma patients (Latifi
et al., 2009; Saffle et al., 2009), assessment of total hospital charges (Duchesne et al., 2008),
and a formal economic analysis (Yang et al., 2015b). Teletrauma service evaluations covering
three or more aims were less common (Dharmar et al., 2013; Latifi et al., 2009; Marcin et al.,
2004; Saffle et al., 2009) and usually included an examination of patient and provider
experience as well as population health. Articles with combined evaluation aims typically
included written surveys distributed to patients or providers and either a cost assessment or
examination of clinical outcomes; one identified changes in diagnosis or therapeutic
management of patients (Dharmar et al., 2013) whereas another evaluated patient transport
costs (Latifi et al., 2009; Saffle et al., 2009).
While articles covering multiple evaluation aims could be considered more
comprehensive, each individual aim appeared to be less robustly studied compared to those

29

articles focusing on only one aim. For example, Saffle et al., (2009) distributed a Likert scale
containing only four questions to patients and providers to assess their experience using
teletrauma. Similarly, Marcin et al. (2004) simply asked about level of satisfaction and
importance of the service. Ricci et al. (2003), on the other hand, used a more robust method to
assess patient and provider experience which included interviews, in-person observations, and
questionnaires. This provided a more in-depth analysis of the teletrauma-user experience
through examination of attitudes, perceptions, and behaviors of patients and providers. A
similar finding was discovered for the cost optimization aim; many studies postulate that
teletrauma was (or could be) cost-saving, whereas Yang et al. (2015b) provided more formal
analysis of associated costs. Although it is useful for research to include all aspects of the
Quadruple Aim (Bodenheimer & Sinsky, 2014) to fully understand the effects of a service across
the entire health system, it may be advantageous to capitalize on the robustness of single or
double-aim studies by synthesizing knowledge from multiple articles. Knowledge synthesis in
this area contributes towards a more comprehensive understanding of how teletrauma affects
health systems while relying on robust studies that focus on only one or two aims.
2.3.6 Acceptability. The user experience is frequently evaluated in studies examining
teletrauma services (Al-Kadi et al., 2009; Dharmar et al., 2013; Dyer et al., 2008; Lambrecht,
1997; Mueller et al., 2014; Ricci et al., 2003; Rogers et al., 2001; Saffle et al., 2009; Westbrook
et al., 2008). Teletrauma users include a variety of individuals involved with the encounter,
including health care professionals (nurses, doctors, specialists) from both the client site and
consulting site, patients, and family members of the patient. One article in particular, examining
the impact of teletrauma for critically injured children, evaluated parent as well as provider

30

satisfaction using validated surveys (Dharmar et al., 2013). The authors measured various
aspects of acceptability, assessing quality of care, changes in care, and satisfaction for
teletrauma or telephone consultations. Ninety-five clinicians and 75 parents were surveyed.
Although inter-rater reliability of the care quality tool is limited, the instrument was applied by
two independent pediatric emergency physicians, raising confidence in the accuracy of findings.
The instrument also covered the entire care continuum from information gathering and
diagnosis to discharge planning. In addition, the parent satisfaction survey referred to several
potential sources of satisfaction, including the overall experience, knowledge and skill of the
staff, and whether or not they felt informed. Results were then combined with quantitative
analysis of the teletrauma and telephone consultations, providing a methodological rigorous
examination of user experiences in the context of pediatric trauma care.
Studies involving patient (or family) and provider perceptions of teletrauma have
produced positive results although ‘acceptability’ is measured in different ways across articles
identified; clinicians have judged the system to be easy to use (Ricci et al. 2003), collegiality
between the client and consulting sites was improved (Al-Kadi et al., 2009; Dyer et al., 2008;
Westbrook et al., 2008), and up to 92% of providers were satisfied or very satisfied with a
teletrauma interaction (Al-Kadi et al., 2009). Teletrauma services for rural environments are
also reportedly life-saving (Ricci et al., 2003; Rogers et al., 2001; Rottger et al., 1997). In two
cases, a rural clinician was guided through an unfamiliar emergency procedure by an expert
consultant, saving the life of the patient: Rogers et al. (2001) described a successful emergency
cricothyroidotomy by a community hospital surgeon who had not performed the procedure in
more than 20 years; Rottger et al. (1997) mentioned that a craniotomy, a procedure that

31

normally would have been conducted by a neurosurgeon, was successfully performed by a rural
physician not trained on the procedure. In both cases, teletrauma adequately facilitated safe
and appropriate management. Thus, ‘acceptability’ of teletrauma services can be considered an
umbrella term that includes satisfaction, usability, and perceived value. Of these concepts,
satisfaction was frequently used to capture patient or provider perspectives of teletrauma
systems (n=7) reflecting acceptability of the service. However, while satisfaction with
teletrauma services was generally positive, the full scope of benefits can be difficult to measure
(Latifi et al., 2009) and thus the concept of acceptability should not be limited only to
satisfaction as a proxy measure.
2.3.7 Feasibility. Across literature identified, teletrauma was noted as being feasible;
five articles explicitly mention the service as being feasible (Dyer et al., 2008; Ehrlich et al.,
2007; Marcin et al., 2004; Ricci et al., 2003; Wibbenmeyer et al., 2016). However, the concept
of feasibility was measured in distinct ways across the various studies. Some examples of
teletrauma feasibility include: effective and reliable clinical ultrasound exam performance (Dyer
et al., 2008); reliable use of satellite communication to support remote doctors (Ehrlich et al.,
2007); accurate burn size estimation (Wibbenmeyer et al., 2016); decreased overall hospital
costs (Duchesne et al., 2008), and; lesser costs for videoconferencing as compared to telephone
when considering transfer decisions (Yang et al., 2015a). Therefore, ‘feasibility’ can be further
categorized into clinical feasibility (i.e. accurate diagnosis), economic feasibility (i.e. cost
saving), and technical feasibility (i.e. reliable technology). Clinical feasibility was most
commonly described in terms of therapeutic management or quality of care received (n=17).
For example, Dharmar et al. (2013) reported more changes in diagnosis and therapeutic

32

interventions for patients who had teletrauma as compared to those with telephone
consultations, resulting in a higher quality of care for teletrauma patients (5.60 [95% CI, 5.425.79] vs. 5.20 [95% CI, 5.07-5.34], p<0.05, as measured on a 7-point scale). The authors
attributed the changes in diagnostic and therapeutic interventions to the specialists’ ability to
visualize the patient, family, and bedside equipment. The frequency of changes may also reflect
the specialists level of involvement in the care process. However, the authors noted that
further study is needed to delineate how the number of changes in care affects clinical
outcomes. Teletrauma also facilitates the rapid identification and transfer of more severely
injured rural patients, improving care (Duchesne et al., 2008). In both cases, the teletrauma
systems were judged as being feasible. However, it may be useful for future research to adopt a
common definition of feasibility in the context of teletrauma to facilitate program evaluation
and comparison.
Considering the large number of clinically feasible telehealth services identified in the
literature, feasibility can be expected to increase further. In particular, improvements in
teletrauma feasibility may first take place in the form of technological feasibility as technology
continues to advance. Clinical and economic feasibility may then increase as the medical system
integrates teletrauma into existing health delivery services.
2.3.8.0 Factors associated with teletrauma use. Associated factors can be categorized
as being either antecedent (identifiable prior to the telehealth event) or as outcomes
(identifiable after the telehealth event). These can be further subdivided into clinical or
organizational factors (Figure 5). This classification system supports a targeted approach to
teletrauma utilization where the system is activated only for those patients who may benefit

33

most, identified and selected based on certain clinical and organizational criteria. Whereas
some articles examined factors antecedent to individual teletrauma encounters and may
therefore be used to screen patients, other studies cited reasons for adopting the teletrauma
service as a whole.

Factors associated with teletrauma use

Antecedent factors

Clinical
-Patient age
-Injury severity
-Injury type

Outcome factors

Organizational
-Rurality
-Distance to
trauma center

Clinical
-Mortality
-Length of stay

Organizational
-Cost
-Transfer rate

Figure 5: Classification of Factors Associated with Teletrauma Use with Examples
2.3.8.1 Antecedent factors. Antecedent clinical factors included injury or trauma
severity scales (Duchesne et al., 2008; Marcin et al., 2004; Mohr et al., 2017; Ricci et al., 2003;
Rogers et al., 2001; Yang et al., 2015a), limb injury location (Brebner et al., 2004; Elkaim et al.,
2012; Lambrecht, 1997), mechanism of injury (Duchesne et al., 2008; Latifi et al., 2009; Mohr et
al., 2017), and patient age (Dharmar et al., 2013; Franken et al., 1997; Marcin et al., 2004; Yang
et al., 2015a; Yang et al., 2015b).
Several clinical factors were found to be significantly associated with use of a teletrauma
service. Scales were frequently used to evaluate the severity of injuries in trauma patients,
including the Injury Severity Score (Baker, O’Neill, Haddon, & Long, 1974) or Revised Trauma
34

Score (Champion et al., 1989). The Injury Severity Score assesses injuries from multiple body
regions and sums them to generate a composite anatomically-based severity score (Baker et al.,
1974). The scores range from 3-75, with higher scores correlating with increased mortality and
morbidity. The Revised Trauma Score, on the other hand, uses a physiologic scoring system that
relies on three physiologic measures (Glasgow Coma Scale, systolic blood pressure, and
respiratory rate) to describe severity of injury. The scores range from 0-12, with lower scores
indicating increased severity. The scales were used in several studies to quantify injury severity
and examine association with teletrauma use. It has been found that severely injured patients
were more likely to receive a teletrauma consultation. Duchesne et al. (2008), for example,
compared a cohort of patients who did not have teletrauma (n=351) to a group of patients that
received teletrauma (n=51) to evaluate outcomes for rural patients. The authors found that
teletrauma patients had an Injury Severity Score of 18 compared to 10 for those patients who
did not receive teletrauma (p < 0.001). The authors also mentioned that they were able to
select more severely injured patients, resulting in more aggressive treatment early on in the
care management process. Similarly, Mohr et al. (2017) found that, as compared to patients
with minor injuries, those with severe injuries were 70% more likely to receive a teletrauma
consultation (unadjusted OR 1.70, 95% CI 1.13 – 2.56). This finding is echoed by several other
studies reporting on injury severity or physiological illness (Duchesne et al., 2008; Marcin et al.,
2004; Ricci et al., 2003; Rogers et al., 2001; Yang et al., 2015a). Specific symptoms and
mechanisms of injury have also been examined. Mohr et al. (2017) found that patients
presenting with hypotension, penetrating injury, tachycardia, and burns were more likely to
receive teletrauma, while Duchesne et al. (2008) identified hypotension, penetrating injury,

35

higher initial base deficit, and the need for more blood transfusions as being associated with
teletrauma use. Although one study (Latifi et al., 2009) found that more patients with blunt as
opposed to penetrating injury used teletrauma (91% versus 9% respectively), the small sample
size and lack of a more in-depth statistical analysis reduces confidence in this unique finding.
Younger patient age was also found to be significantly associated with teletrauma use in a
number of studies (Dharmar et al., 2013; Franken et al., 1997; Marcin et al., 2004; Yang et al.,
2015a; Yang et al., 2015b); Marcin et al. (2004) reported a mean age of 5.5 years for teletrauma
patients versus 13.3 years for non-teletrauma patients (p < 0.01). Similar results in an adult
population were demonstrated by Mohr et al. (2018) who found that, as compared to younger
patients, adults aged 65 years and older were 4.7 times less likely to receive teletrauma (risk
difference -4.7, 95% CI -8.6 – -0.8).
Antecedent organizational and hospital-level factors were also examined in 14 of the
captured literature (Al-Kadi et al., 2009; Ashkenazi et al., 2007; Dharmar et al., 2013; Duchesne
et al., 2008; Dyer et al., 2008; Ehrlich et al., 2007; Jacobs et al., 2015; Mohr et al., 2016; Roccia
et al., 2005; Rottget et al., 1997; Saffle et al., 2009; Syed-Abdul et al., 2012; Westbrook et al.,
2008; Wibbenmeyer et al., 2016). Antecedent organizational factors included access to
specialist knowledge or services (Ashkenazi et al., 2007; Duchesne et al., 2008; Dyer et al., 2008;
Ehrlich et al., 2007; Roccia et al., 2005; Saffle et al., 2009; Syed-Abdul et al., 2012; Westbrook et
al., 2008), number of unnecessary transfers (Ashkenazi et al., 2007; Jacobs et al., 2015), clinical
experience of local health professionals (Dharmar et al., 2013; Al-Kadi et al., 2009; Rottger et
al., 1997; Wibbenmeyer et al., 2016), and hospital-level factors included rurality, number of
trauma cases, and distance to a facility with a higher level of care (Mohr et al., 2016).

36

Mohr et al. (2016) found that geographic factors such as rurality and distance to a
facility with a higher level of care did not significantly explain variability in teletrauma use.
However, the authors mentioned that the rural facilities all had similar capabilities resulting in a
lack of variation of usage after teletrauma was adopted. Access to specialist knowledge or
services was a commonly cited reason to adopt and use teletrauma (n=7). Saffle et al. (2009)
mentioned that untimely subspecialist involvement was a challenge overcome through the
deployment of a teletrauma system. Physician confidence with therapeutic management and
clinical experience were also factors identified in the literature; a lack of physician experience
or familiarity with certain clinical situations have been noted as justification to adopt a
teletrauma system (Al-Kadi et al., 2009; Wibbenmeyer et al., 2016). Similarly, physicians were
reportedly more likely to initiate a teletrauma consultation if they were uncertain of the
diagnosis or clinical management of a patient (Dharmar et al., 2013).
2.3.8.2. Outcome factors. Clinical outcome factors associated with teletrauma use were
frequently reported by studies (n=14), including mortality (Duchesne et al., 2008), length of stay
(Mohr et al., 2018; Westbrook et al., 2008), and perceived quality of care received (Dharmar et
al., 2013; Ehrlich et al., 2007; Latifi et al., 2009; Marcin et al., 2004). For example, Duchesne et
al. (2008) noted that despite teletrauma being used for more severely injured patients,
mortality did not change (17 [4.8%] pre-teletrauma vs. 4 [7.8%] post-teletrauma, p>0.05). On
the other hand, the authors noted that the length of stay in the emergency department
increased. The availability of teletrauma was associated with an increase in length of stay for
transferred patients (12.6 minutes, 95% CI 0.6–24.6) and non-transferred patients (15.6
minutes, 95% CI 9.7–21.4).

37

Organizational outcome factors were also studied, and included transfer rate or status
(Brebner et al, 2004; Ehrlich et al., 2007; Jacobs et al., 2015; Lambrecht, 1997; Latifi et al., 2009;
Mohr et al., 2017; Mohr et al., 2018; Roccia et al., 2005; Westbrook et al., 2008; Yang et al.,
2015a; Yang et al., 2015b) and cost (Duchesne et al., 2008; Latifi et al., 2009; Saffle et al., 2009;
Yang et al., 2015b). Roccia et al. (2005), for example, noted a 50% reduction in the number of
transfers to a specialist center as a result of teletrauma use. Cost reduction was also often
associated with reduced transfers; Latifi et al. (2009) noted that 29% (n=17) of transfers were
prevented, saving an estimated $104,852 in transfer costs. Lesser costs as a result of
implementing teletrauma was consistently mentioned in the literature (Duchesne et al., 2008;
Latifi et al., 2009; Saffle et al., 2009; Yang et al., 2015b).
2.4 Discussion
The 28 articles included in this review provide insight into how teletrauma functions
within rural geographies and the effects of teletrauma on population health, patients,
providers, and the health care system. Outcomes were frequently reported in the literature and
the benefits were well-recognized; numerous articles explicitly mentioned the utility of
teletrauma for rural areas (Al-Kadi et al., 2009; Duchesne et al., 2008; Dyer et al., 2008; Ricci et
al., 2003; Rogers et al., 2001; Rottger et al., 1997; Syed-Abdul et al., 2012). As well, several
antecedent factors associated with teletrauma utilization were delineated. These factors were
categorized as being either clinical (i.e. demographics, signs and symptoms, medical
interventions) or organizational (i.e. staff clinical experience, hospital rurality). Classifying these
factors aided in understanding how various aspects of the care system can be used to target
patients for teletrauma consultation. Although several elements, such as lack of access to

38

timely specialist involvement and lack of physician familiarity with or confidence during major
trauma, can be used to identify and select sites that may benefit from teletrauma, this falls
outside the scope of this thesis. Other elements, however, can be used develop a selective
strategy for individual teletrauma encounters. Mohr et al. (2018) explicitly call for a targeted
approach to teletrauma utilization. Uncovering the factors significantly associated with
teletrauma use may lead to more judicious use of teletrauma resources in rural areas by
identifying and selecting those patients who may benefit most.
Studies included in this review investigated and reported on a variety of factors
associated with use of a teletrauma system. Few articles (Duchesne et al., 2008; Mohr et al.,
2017) examined signs and symptoms of patients, in addition to other clinical and demographic
information. Although specific physiological signs (base deficit, tachycardia) may be used to
select patients for future teletrauma use, further study is needed before this information can
be clinically useful. For example, Brebner et al. (2004) noted that of the 1,322 injuries evaluated
through a teletrauma consultation, 94% were of the upper and lower limbs, 80% of which were
fractures or suspected fractures. Because of the high prevalence of limb injuries in trauma
cases, use of ‘upper or lower limb injury’ as a selection criterion for teletrauma may be too
broad to be immediately useful without further study. On the other hand, several articles
reported on clinical factors, identifiable prior to a teletrauma encounter, that are generalizable
to and useful for future trauma cases. Across the literature, it was consistently found that
younger patient age (Dharmar et al., 2013; Franken et al., 1997; Marcin et al., 2004; Mohr et al.,
2017; Mohr et al., 2018; Yang et al., 2015a; Yang et al., 2015b) penetrating injury (Duchesne et
al., 2008; Mohr et al., 2017), and high severity of illness or injury (Duchense et al., 2008; Marcin

39

et al., 2004; Ricci et al., 2003; Rogers et al., 2001) were significantly associated with teletrauma
use. These findings can be used to support the development of criteria to select patients for
targeted teletrauma use. Other factors mentioned but not yet studied by other research
included the need for more blood transfusions, radiograph consultation, higher initial base
deficit, fractures of upper or lower limbs, injuries in primary dentition, injuries after hours
(Monday to Friday, 1800h – 0800h), burns, tachycardia, ambulance transport, and endotracheal
intubation; future research investigating these factors may support the continued development
of teletrauma selection criteria.
For use within this thesis, findings provide guidance on the selection of individual factors
and variables to be explored. However, none of the studies have specifically explored the
experiences of physicians using teletrauma, and other stakeholders engaged in the planning
and delivery of healthcare services. Understanding these perspectives are much needed and
essential to developing a comprehensive understanding of teletrauma services within a rural
setting. As well as contributing to the current study, this review identifies gaps in current
teletrauma research and highlights areas for further clinical and health services research.

40

3.0 Methods
Teletrauma represents an important service option for rural care. Teletrauma connects
clinicians to the necessary resources to enable timely and appropriate care for rural patients.
Thus, various components of the health care system may be affected along the care continuum.
This section will provide an overview of the theoretical orientation and methods for the current
study. In addition, this section will begin with an overview of the research question and
objectives.
3.1 Objectives
The objectives of the proposed study are to a) describe the Robson Valley teletrauma
program, b) identify factors associated with teletrauma service utilization, and c) explore the
perspectives of physicians who have used teletrauma or who have practiced rurally. To address
these objectives, this study will examine the question: What factors are associated with the use
of teletrauma in northern British Columbia?
First, the current Robson Valley teletrauma program in northern BC will be described in
detail. This will enable a thorough understanding of its current functioning, utility, and
outcomes, and provides the general context for the following two objectives. Second, factors
associated with teletrauma service utilization will then be identified through interviews with
physicians who have used teletrauma. This includes physicians who have used a teletrauma
system or who have practiced rurally and may have had exposure to trauma. Identification of
associated factors will provide information as to which aspects of the health care system
(patient type, physician characteristics, environmental factors, etc.) are associated with
teletrauma service use. Third, perspectives of teletrauma users will be explored to better

41

understand the use of teletrauma in a rural context and how it functions as a part of the trauma
system. The knowledge gained by this study may provide insight into the establishment of
teletrauma as an integral component to a high functioning regionalized trauma system.
3.2 Theoretical orientation
The interrelations between rurality, illness-related factors, and general population
characteristics are complex (Hartley, 2004). For the rural population in Canada, the effects of
physical environment on health service delivery cannot be simply described in terms of spatial
isolation from larger centers. The design and evaluation of rural health systems requires
consideration of associated economic factors, societal norms and cultural beliefs, demographic
factors, and local resources, among others. The individual must be viewed as an integrated
component of their unique environment existing and actively functioning within in a health care
system. To examine and evaluate health care delivery systems, it is necessary to engage a
theoretical perspective that appreciates the dynamic relationships between place, individual,
and society. To facilitate understanding between these components within the context of
teletrauma service deployment and utilization, Andersen and Newman’s (1973) theoretical
Health Service Utilization framework was used (Figure 6). The framework provides insight into
how the use of teletrauma is influenced by, for example, geographical distribution of resources,
individuals within a community, and technology. Use of the framework may also uncover
mutable factors to be leveraged to enhance equitable access to appropriate care while
accounting for potential effects across the whole health system.
Three main components are specified including a) societal determinants, b) health services
system, and c) individual determinants (Andersen & Newman, 1973). Each of the three main

42

components consist of dimensions, or sub-components, as outlined in Figure 6. The subcomponents provide a means of operationalizing the major factors to make assumptions about
how changes in one area may affect health service utilization. For example, Andersen and
Newman (1973) postulate that accessibility (falling under the organization of health services
system category) is assumed to increase as government health expenditures increase and
waiting times for medical care decrease, thus altering service utilization. The authors also
describe how the unit of analysis for health services utilization can shift the relative importance
of major determinants. For example, when examining the volume of services delivered as
Societal Determinants

Health Services System

•Technology
•Norms

•Resources
•Organization

Individual Determinants
•Predisposing
•Enabling
•Illness Level

Health Services
Utilization
Figure 6: Health Service Utilization Framework (Andersen & Newman, 1973)
opposed to studying initial provider contact, physician characteristics may be more important
than individual determinants (Andersen & Newman, 1973).
Thus, the model can be used to gain a better understanding of trends and patterns in
service utilization while remaining sensitive to the local context and unit of analysis. For rural

43

teletrauma, the health service utilization model helps to delineate the interrelations between
major determinants of health and provide a deeper understanding of how the various
components influence use. More specifically, the model can explain unwanted variation in
teletrauma utilization and may uncover which variables are most responsible and susceptible to
change. To guide targeted teletrauma program uptake, for example, the model can enhance
understanding of the relative value and impact of the various health system components within
a rural context; the adoption of teletrauma programs according to patient characteristics
(individual determinants) or clinician characteristics (health system services), and whether
technology plays a role (societal determinants), could play a role in determining which
communities may benefit the most from teletrauma. Therefore, it is possible to influence
service use outcomes by leveraging context-specific determinants based on identified
mutability and relative importance. The model adequately captures the modern perspective of
health care as being complex and holistic with dynamic context-dependent relationships
between variables. Andersen and Newman’s (1973) model thus provides theoretical guidance,
and was used to inform the collection and analysis of data, provide a lens through which to
understand the research findings, and contextualize implications of the study within a dynamic,
comprehensive view of the health care system.
Although Andersen and Newman’s (1973) model was used to provide an overarching
perspective of how determinants are linked and operate within the context of rural teletrauma
use, the components of the model served as sensitizing concepts to guide the analysis of the
study data. The notion of a sensitizing concept was first delineated by Blumer (1954) and has
evolved to become an important interpretive device in social research which may “deepen

44

perception [and] provide starting points for building analysis” (Charmaz, 2003, p. 259).
Sensitizing concepts act as a jumping-off point for the development of themes and patterns
while remaining grounded in the data and flexible to new directions in analysis. Sensitizing
concepts support an inductive process and guides the creation of concepts throughout analysis
whether or not they are included in the final work (Bowen, 2006). This is in contrast to
definitive concepts which may prescribe themes or patterns prior to data collection and
analysis; "sensitizing concepts merely suggest directions along which to look” (Blumer, 1954, p.
7). Concepts may be indicated by the data, revealing new and insightful directions in analysis
and allowing for flexibility as themes and patterns emerge. This conceptual framework was
embedded within an overall inductive process to discover and generate findings.
In addition to the Andersen and Newman’s (1973) model, this research also
incorporated an interpretive approach. Rooted in the naturalistic paradigm, the interpretive
approach utilizes inductive analysis to generate knowledge that is grounded in the data. As
opposed to deductive methodology, whereupon a theory is constructed a priori and tested
through observation, inductive approaches build theory grounded in instances of empirical
observation. As put by Patton (1980), “inductive analysis means that the patterns, themes, and
categories of analysis come from the data; they emerge out of the data rather than being
imposed on them prior to data collection and analysis” (p.306). Thus, sensitizing concepts and
the inductive approach are complementary and fitting for this study; findings remained
grounded in the data and free from prescriptive analysis, suiting the exploration of teletrauma
user experiences within an appropriate theoretical perspective.

45

3.3 Research Design
Data was gathered from key stakeholder interviews on teletrauma while following the
principles of Thorne et al.’s (1997) interpretive description methodology. This research
approach originated with the purpose to develop knowledge surrounding complex phenomena
in the applied sciences (Thorne et al., 1997) and intends to reveal “the kind of knowledge that
sits somewhere between fact and conjecture” (Thorne, 2008, p. 15). Use of interpretive
description provides insight into and generates knowledge about the health experience with
methodological and theoretical integrity (Thorne et al., 1997).
From an epistemological and ontological standpoint, interpretive description is
underpinned by a constructivist lens, through which there is the belief that human experience is
socially constructed and that multiple realities exist (Thorne, 2016). When considering the
nature of the applied sciences, this method is conceptually fitting; health care also spans both
scientific objectivity and the subjectivity of patient care. Although interpretive description
originated with the intent to address clinical questions in the nursing field, it has expanded to
include other applied disciplines. A primary component of the method is that knowledge
generated should have practical implications and have the potential to contribute towards
applied or disciplinary knowledge (Thorne, Kirkham, & O’Flynn-Magee, 2004). Thus, many
health professions have used interpretive description as a way to explore complex phenomena
and develop knowledge that is clinically useful. This has an included:
•

An examination of patient preferences for physician behaviors during end-of-life
communication (Abdul-Razzak, You, Sherifali, Simon, & Brazil, 2014);

46

•

Understanding the challenges of rural occupational therapists and physiotherapists
in northern British Columbia (Roots, Brown, Bainbridge, & Li, 2014); and,

•

An exploration of physician perspectives towards cancer survivors’ work integration
issues (Morrison, Thomas, & Guitard, 2015).

Interpretive description capitalizes on the flexibility of data sources, data collection
methods, and analytical methods to produce findings that are driven by the interpretive
dynamic between data and researcher. Although interviews are a common way to generate
data, interpretive description also allows for diverse sources of data including theoretical
explorations, narratives, and case studies. The inductive approach advocated by interpretive
description relies on the researcher’s interpretation of data to yield truths built out of the data.
These truths are constructed from within the research design presenting a logically coherent,
conceptual description (Thorne et al., 2004). As a logic-based method, interpretive description
accurately captures the individuality of the lived experience with methodological integrity by
making explicit the decisions made throughout the research design. By doing so, the audience
has access to the logic behind each decision made by the researcher, permitting outside
evaluation of the credibility of findings.
When developing this research, other more traditional qualitative methods were
considered including phenomenology and qualitative description. While several different school
of phenomenology exist, each with distinct theoretical and philosophical foundations (Dowling,
2007), phenomenology is generally considered to be both a philosophy and methodology that
attempts to uncover the essential meaning of a phenomenon (van Manen, 1990). To reveal the
deeper meaning of human experience, the phenomenologist must suspend all preconceived

47

notions, worldviews, and prior knowledge of the experience (‘bracketing’) (Kleiman, 2004).
Doing so permits a naïve, pure description of the phenomenon as lived and experienced by the
individual. Interpretive description, on the other hand, is not so tightly bound by rigid
philosophical tenets and theory, but is instead highly focused on logic to inform and produce
findings that are clinically relevant and practical (Thorne et al., 2004). The flexibility afforded by
interpretive description is more fitting of the purposes of this study. Additionally, the
methodological complexity and philosophical proficiency required for phenomenological
research would significantly add to the duration of this study.
Qualitative description was also considered as an approach to inquiry. Qualitative
description is a naturalistic form of inquiry (Sandelowski, 2000) that is often used in health care
research. This approach is less theoretically-bound than phenomenology and does not require
bracketing of preconceptions (Gearing, 2004). While qualitative description is closely linked to
interpretive description, qualitative description aims to ensure descriptive validity; one goal of
the qualitative descriptive method is that it produces a valid summary of events that remain
close to the words of the participants, rather than findings which are highly interpretive in
nature (Sandelowski, 2000). This is attained in part through transparency of researcher
presuppositions and positionality. Because the emphasis remains on presenting a valid account
of the lived experience in the subjects’ own words, qualitative description is less fitting for this
study; interpretive description aims to move beyond a descriptive account as “investigators are
rarely satisfied with description alone and are always exploring meanings and explanations that
may yield application implications” (Thorne et al., 2004, p. 3). Interpretive description still
recognizes the reciprocal-interpretive relationship between researcher and subject but instead

48

emphasizes logic and transparency as a means of dealing with researcher presuppositions,
positionality, and biases. Additionally, interpretive description aims to produce findings that are
relevant to disciplinary knowledge and directly applicable to practice. As such, interpretive
description was selected as the most appropriate method for this study. The approach is fitting
given the complex, experiential phenomenon of teletrauma use while adhering to rigorous
methods needed for the creation and application in the clinical setting.
3.4.0 Sample and recruitment
3.4.1 Study setting. The Robson Valley geography and health care delivery was briefly
described in chapter one. Physicians in the Robson Valley have identified a lack of access to
timely care and lack of access to necessary resources as being challenges of health care delivery
in the area (University of British Columbia, 2018). To overcome these challenges, a virtual care
program was implemented. The system consisted of synchronous and asynchronous service
delivery, including an on-demand, real-time videoconferencing service and a secure textmessaging service. The system was comprised of several user endpoints. These included a
mobile teletrauma cart in the emergency room of the Valemount hospital, a desktop computer
in the home of a physician, a videoconference system in a separate room of the hospital, and a
fixed-unit screen and camera in the trauma bay at the University Hospital of Northern British
Columbia in Prince George, BC Canada.
When a physician was not present in one of the communities, the teletrauma program
enabled a virtual connection to be established between McBride and Valemount. This
permitted remote evaluation and consultation between the communities. Physicians were able
to contact the University Hospital of Northern British Columbia in Prince George when

49

consulting on a case or preparing a transfer. When physicians wanted to initiate a call with the
University Hospital of Northern British Columbia in Prince George, the rural physician in the
Robson Valley had to log in to the system, select the site they wished to call, and then wait for
the consulting clinician to answer the call. A similar process was in place for consultations
within the Robson Valley. The system was also capable of connecting with a larger center (i.e.
Vancouver General Hospital).
The teletrauma service was used by nurses, physicians, and specialists. In the Robson
Valley, it was typically a nurse contacting a physician, or a physician contacting a physician.
Between the Robson Valley and Prince George, a rural physician would often consult another
physician or a specialist. For the purpose of this thesis, ‘teletrauma user’ refers to nurses,
physicians, or specialists who used the system to consult with other health care professionals,
including nurses, physicians, or specialists. While it was suggested that several different
specialists have been consulted using the system, the term ‘specialist’ most often refers to
emergency room physicians.
3.4.2 Sampling approach. Purposive sampling was initially used to identify participants.
This process includes a purposive selection of participants, based on the judgement of the
researcher, as a means of gaining access to knowledge or experiences (Cresswell & Plano Clark,
2011). As noted by Patton (2002), cases are selected for the purpose of being information-rich.
That is, the technique allows for the identification of those who would provide data most
relevant to the investigation (Morse, 1995; Thorne et al., 1997). In addition, this also permits
efficient use of resources while remaining focused on the phenomenon of interest. In contrast
to quantitative techniques which emphasize generalizability and aim to broaden understanding,

50

purposive sampling intends to facilitate an in-depth and comprehensive understanding of an
experience or phenomenon (Patton, 2002). Thus, a sample is generated with the intention of
accessing knowledge that only a particular group of individuals hold. Given the context and
purpose of this study, purposive sampling is fitting. Following this approach, snowball sampling
was then used as a means of gaining further access to this difficult-to-reach population. The use
of snowball sampling can help to enrich the sample and access new participants through social
networks (Noy, 2008). By asking participants to identify other individuals whom they may
consider to have valuable knowledge or insight, the sample size can be increased while
remaining focused on the topic under study. Considering the established relationships between
rural practicing clinicians, this sampling technique was an effective way of accessing more
teletrauma knowledge-holders despite the population being small and difficult to access.
3.4.3 Participant recruitment. Capitalizing on existing relationships, the researcher (TW)
worked with stakeholders to identify and recruit participants. As the Northern Health Authority
is engaged in the development of the Robson Valley teletrauma program, and telehealth
programs more broadly, the use of existing relationships was an effective means of accessing
this population and purposively sampling the participants. As described in the background
section, the Northern Health Authority region is predominantly rural and remote, and the
number of health care providers is limited. Thus, it was necessary to utilize social networks and
intraorganizational communication networks to recruit relevant knowledge-holders. This
included social networks between physicians, and existing relationships with the Northern
Health Authority stakeholders and individuals at the Rural Coordination Center of British
Columbia.

51

It was estimated a potential sample size of 5-8 participants would be needed for this
study. This was based upon consideration of the small pool of potential participants from which
to select and the desire to achieve theoretical saturation. Saturation, according to Sandelowski
(1995), is a theoretical point whereupon no new information emerges from the data. That is,
the researcher continues to sample until no new substantive information is identified from
participants; no new patterns or themes in data analysis arise. Based on findings from
interviews conducted with teletrauma users previously, saturation was assumed to be reached
at six participants. Although this theoretical saturation limit was identified previously and this
was used to guide sample size selection, it was not a requirement to cease sampling and
exclude potential participants; each participant is expected to bring information that is new and
valuable. In this study, saturation was reached at five participants.
3.5 Data collection
Primary data were generated from six semi-structured interviews with physicians who
have used a teletrauma service or who have experience practicing in rural areas. The semistructured nature of the interviews allows openness and spontaneity in conversation, while
keeping the interview focused on the central concepts. Several variables thought to be
associated with teletrauma use were selected and were integrated into the interview
questions. The interview schedule was also reviewed and tested with clinical experts, including
an emergency department physician with expertise in pre-hospital medicine and trauma
(Appendix C). To link the data collection to the theoretical framework, a model was created
adopted from Andersen and Newman’s (1973) original framework (Figure 7). The example
includes several variables selected from and adopted into the ‘individual determinants’

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component of health service utilization. Additional factors at the health service level included
number of uses of telehealth, duration of use, and transfer status. The framework was used to
guide the selection of variables to be discussed during the interviews and aided in the
visualization of how variables are interrelated. However, participants were open to speak
freely.

Predisposing

Enabling

Illness Level

Patient demographics
• age
• sex
• past illness

Family
• health insurance

Social structure
• race
• ethnicity

Community
• staffing levels

Evaluated
• diseases
• comorbid conditions
• injury type
• symptoms

Figure 7: Individual Determinants of Health Adopted from Andersen and Newman (1973)
Participants were provided with a comprehensive information sheet and consent form
and were able to contact the researcher to obtain further information or express their
willingness to participate while maintaining confidentiality. Snowball sampling was then used to
recruit additional participants; interviewees were asked to identify and contact other potential
participants who may be interested and were asked to distribute the study documents and
contact information of the researcher. After written or verbal consent was obtained, telephone
or in-person interviews were conducted using open-ended questions. These were digitally
recorded and transcribed verbatim, allowing the researcher (TW) to repeatedly return to the
primary data source as a means of immersion in data to facilitate and enhance analysis.

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Interview questions were created and developed iteratively over time. As interviews
progressed, questions were revised and adapted to best uncover the experiences and insights
of participants. Questions were developed as to not be leading or to include slang or other
medical jargon (Rubin & Rubin, 2011). Interview questions were initially reviewed by the
committee and it was agreed that questions would evolve with ongoing data collection to focus
on emerging themes and areas of interest. The interviews were designed based on Spradely’s
(1979) approach to asking descriptive questions. Grand tour questions involve asking
participants about a general sequence of events or locale and typically illicit rich descriptions,
whereas mini tour questions inquire about specific events or examples (Spradley, 1979). Grand
tour questions and mini tour questions were used at different points throughout the interview
to ensure richness and depth of responses. Probes were used to gain further insight if answers
were short or superficial, and to help guide participants if they were unsure how to answer.
Interviews began with open conversation and general questions to allow the researcher to
learn about the participant and their context of practice, and to build rapport. The end of the
interviews also included open conversation as a way of debriefing participants.
Eight interviews with key stakeholders were conducted previously which included
physicians, administrators, and Northern Health Authority executives involved with teletrauma.
These were part of a larger internal quality initiative for telehealth within the Northern Health
Authority. Since these included other relevant stakeholders, a secondary analysis of these
interviews was undertaken for the purpose of understanding teletrauma use from a variety of
perspectives within the health system. Interview data from the previous study helped to
uncover deeper meaning of teletrauma in this context of the present study and provided

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additional insight from unique perspectives. In total, 14 interviews were analyzed; six
interviews were conducted to generate primary data and transcriptions from eight previously
conducted interviews were re-analyzed for use within this project.
3.6 Data analysis
Data analysis followed the principles of the interpretive descriptive method which takes
a constructivist approach to knowledge creation (Thorne, 2008). That is, knowledge produced
are not facts but truths; the end product is a conceptual description that is meaningful and
relevant to practice (Thorne et al., 2004). As data are transformed into knowledge through
analysis, the researcher must engage an approach that emphasizes logic, transparency, and
flexibility (Thorne et al., 2004). Instead of providing rigid steps for analysis, Thorne et al. (2004)
advocates for creativity within a setting of transparency. The responsibility to ensure that the
reader is able to follow the cognitive analytic process lies entirely with the researcher. By doing
so, the interpretations can be said to have analytic logic producing truths that are viable and
inform disciplinary knowledge.
To produce such knowledge, analysis occurred concurrently with data collection. By
creating meaning from the data and postulating relationships and themes, the researcher
makes a commitment to the interpretations and has the responsibility to make explicit this
process (Thorne et al., 2004). As such, the reader has access to the interior logic behind
analytical decisions and can make credibility judgements about posited interpretations. Several
strategies were used to ensure a transparent and logical knowledge creation process. One
technique involved becoming immersed in the data. This immersion facilitates what Thorne
(2008) considers to be the most difficult aspect of an interpretive descriptive study: to create

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knowledge out of data through interpretation. This begins with close reading of the transcripts.
As the researcher becomes engaged with and organizes data, themes and patterns emerge
driven by personal interpretation. This sorting and immersion in the data enhances critical
thinking and supports the researcher’s ability to reflect on patterns and themes, creating new
avenues for knowledge creation. Immersion in the data was attained by listening to digital
recordings for transcription accuracy, and then reading and re-reading transcripts several times.
Close reading of transcripts occurred during and following completion of the data collection
phase.
To manage the data, NVIVO software was used. Using a software package permits the
“effective archiving, management and storage of the vast quantities of raw data generated
through the qualitative research process” (Banner & Albarran, 2009, p. 25). The software
facilitates data organization and theory-building by providing a visual framework on which to
hang concepts and themes. For the purposes of this study, NVIVO was used to generate initial
codes, while manual mapping techniques were used to visually explore the linkages in the data
and eventual themes.
Once data were organized and mapped, the researcher (TW) examined the data for key
words, ideas, or quotes. These were flagged with concepts thought to be applicable and
relevant. Codes are ideas or labels that provide insight into and are reflective of the
phenomenon of interest (Graneheim & Lundman, 2004). These codes were then compared to
other transcripts and evolved over time to reveal threads across interview data. Codes were
then systematical organized and arranged into broad categories which were used to support
the identification of themes. The process of applying codes and concept development was

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based on Bowen’s (2006) sensitizing concepts. The sensitizing concepts approach supports the
inductive analytic process and is in alignment with the flexibility of interpretive description;
codes were not assigned a priori, but were instead used to guide knowledge development
whether or not they were to be included in the findings (Bowen, 2006).
In line with Thorne’s (2004) techniques for analysis, emphasis was put on intellectual
inquiry and transparency of the cognitive processes to guide interpretations. As such, fields
notes were taken during and after interviews, and a reflexive journal was kept throughout the
entire process. Reflective journaling aided critical thinking, cultivated the interpretive dynamic
relationship between the researcher and data, and provided a means for identifying and
exploring new insights as data were encountered. Field notes supplemented understanding of
the data and helped to contextualize data in terms of individual interviews and as a cluster of
interviews. These techniques also present the reasoning process behind analytic decisions
which aligns with Thorne’s (2004) commitment to a transparent, logical process of knowledge
creation. Transparency during analysis allows the reader to follow the cognitive processes and
use of reasoning to create knowledge. This makes explicit the reasoning behind decisions made
and aids in the accruement of credibility and trustworthiness of study findings (Carcary, 2009).
To further enhance the inductive analytic process, a constant comparative method was used.
Analysis occurred while other interviews were being conducted and the researcher alternated
between new data and prior interviews, analyzing themes and ideas as they became apparent.
This permitted a view of the interview data as being linked and aided in the identification of
patterns and commonalities. Visually mapping the data became a useful tool during this
process. Overall, this method supported an organic exploration of key themes and patterns as

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data emerged, permitting flexibility in researcher interpretation while remaining focused on the
phenomenon of interest.
Additionally, a main focus of analysis remained on producing findings that could support
disciplinary knowledge. Put by Thorne et al. (2004), the study should “[generate] an interpretive
description capable of informing clinical understanding” (p. 3). As a means of maximizing logical
coherence and establishing credibility of the findings, data analysis was an iterative,
transparent process with an “explicit awareness of the investigator as interpreter” (Thorne et
al., 2004, p. 6). Thus, the research remained cognizant of positionality, gender, power
complexes, biases, judgments, and social constructs subscribed to, as they all inevitably
influence how data is perceived. This awareness of self was maintained through reflexive
journaling, a concept discussed in the following section.
3.7 Rigor
Lincoln and Guba (1985) proposed a quality framework to judge the authenticity and
quality of a research product that is generally accepted by the research community (Thorne,
2008). To evaluate the credibility of findings and establish qualitative work as being
trustworthy, several criteria were posited by Lincoln and Guba (1985) including: credibility,
transferability, dependability, and confirmability. Conceptually, the philosophical underpinnings
of Lincoln and Guba’s (1985) naturalistic inquiry are in alignment with interpretive description:
there are multiple realities which are contextual and subjective; the researcher and object of
study influence one another; and, no truths developed a priori can account for or predict the
realities to be encountered (Lincoln & Guba, 1985). Thorne’s (1997) methodology appreciates
the subjectivity of the lived experience and allows for the possibility of shared realities by

58

acknowledging the researcher as a key component of the constructed truths. Given the
philosophical alignment with interpretive description, Lincoln and Guba’s (1985) framework will
be used to assess quality and authenticity of findings.
Credibility refers to the degree of agreeableness or ‘fit’ between the subjects’ truths and
the researcher’s representation of those truths (Schwandt, 2001). In essence, it is the link
between the researcher’s findings and reality, demonstrating the internal validity of the study.
To build and demonstrate credibility of findings, several techniques were used. These included
prolonged engagement and constant comparison of the data. As data and findings became
available, feedback was sought from the researcher’s committee members to ensure that
findings were accurate, logical, and validly represented participants’ descriptions. This process
of peer review aids novice researchers to “synthesize and see patterns in their data… and
assists with the development of internal validity” (Morse, 2015, p. 1215). It is noted that validity
should not depend on consensus (Morse, 1998); it is something earned and demonstrated
through analytic integrity. As a means of producing findings that are closely linked to reality and
participants’ description of a phenomenon, a lot of time was spent with participants during the
data collection phase. The development of trust and intimacy between the researcher and the
participant helps to enable a clear, valid account of the phenomenon through thick, rich
description (Morse, 2015). Thick description of the data facilitates credibility by providing
sufficient data to demonstrate themes and patterns (Morse, 1995). The constant comparison
method (Glaser, 1965) was another strategy used; secondary analysis of stakeholder data
provided diverse perspectives. The process included systematically analyzing and comparing
data to previously collected and analyzed data. This method facilitates analysis of new

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perspectives through examination of the similarities and differences between perceptions
(Glaser, 1965). Thus, a deeper understanding of teletrauma is jointly constructed through a
diverse group of stakeholders, exhausting all viewpoints of a phenomenon.
Transferability refers to the potential for findings to be used in different contexts; that
is, the researcher “[provides] the data base that makes transferability judgements possible on
the part of potential appliers” (Lincoln & Guba, 1985, p. 315). For study results to be applicable
to other situations, thick description was used. This included a detailed description of the
context in which interviews occurred. Whether interviews were conducted while participants
were at work, over the phone or in person, whether or not they were rushed, and the
surrounding social or cultural environment helps readers to judge the transferability of findings.
A detailed, rich description derived from field notes and an audit trail aided in the
establishment transferability. This technique is necessary for outside readers to be able to
transfer the findings to different contexts or individuals (Guba & Lincoln, 1989).
Dependability establishes findings as being repeatable and consistent over time. As one
important means of ensuring trustworthiness, dependability helps to confirm that findings are
accurate and supported by the data (Morse, 2015). Similar methods of triangulation were used
to help establish dependability; the researcher’s committee examined codes applied to help
ensure consistency and accuracy throughout the development of study results. Committee
oversight regarding the conduct of the study, decisions made throughout study design, and
analytic logic helped to develop dependability. Use of an audit trail also helps to ensure findings
are dependable; accurate, comprehensive documentation ensures to readers that the research
process is logical and traceable (Schwandt, 2001).

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Confirmability helps to assess the accuracy of findings. The use of an audit trail and
reflexivity are important techniques to demonstrate confirmability (Morse, 2015; Tobin &
Begley, 2004). This concept provides the reader with confidence that findings were derived
from the data and participant narratives rather than researcher biases or preconceived ideas. A
reflexive journal was kept to remain cognizant of how personal influences can alter
interpretations of the data, to permit insight and self-reflection, and to keep track of the
rationale behind analytical decisions made. Reflexivity as an attitude supports the interpretivereciprocal relationship between researcher and data, and recognizes the influence of the
researcher on every aspect of the study design. Providing a transparent, self-critical account of
the research design and analysis makes explicit the ‘how’ and ‘why’ of decisions made to
readers, aiding in the accruement of trustworthiness of findings. For this study, examination of
how personal positionality, interests, and values affected every aspect of the research process
was central to authenticating credibility.
3.8 Ethical considerations
This study complies with the requirements for ethical research involving humans as set
out by the Tri-Council Policy Statement – 2 (TCPS-2). Ethical approval for minimal-risk clinical
study was granted by the University of Northern British Columbia Research Ethics Board in a
harmonized review process involving the Northern Health Authority (REB H19-02054). Ethics
approval to analyze secondary data was granted by the Research Ethics Board of University of
Northern British Columbia for use within this thesis (Ethics Application E2017.1204.084.00H).
Potential participants were provided with an information sheet and consent form after
expressing interest in the study. Individuals were then given the opportunity to ask questions

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about the study. Verbal or written consent was obtained from each participant prior to the
start of the interviews and participants were made aware that they were free to stop the
interview, decline to answer any question, or withdraw consent at any time. Although
anonymity cannot be guaranteed due to the small study population, participants were assured
that every effort would be made to keep their information confidential. Participants also agreed
to digital recording of interviews to facilitate analysis at a later date. While no risks were
expected from study involvement, participants were aware that discussing clinical events or
professional practice could be distressing. To minimize the potential for discomfort during
interviews, questions were asked in a sensitive manner and the concluding questions were
designed to debrief participants. Data is stored on a password protected computer on a
secured network with anonymized participant names; only the researcher (TW) has access to
the computer. Data will be stored for five years in accordance with the University of British
Columbia data storage policies and will then be destroyed. Participants are aware they are able
to have a copy of the findings emailed to them upon conclusion of the study.
3.9 Knowledge translation
Generating applied and relevant knowledge was a key aim from the outset of this study.
The target audiences include participants, the public, health system professionals, and
academics. As such, upon completion of the thesis, the researcher (TW) will share findings in
the following ways: participants who expressed interest in study findings will receive a
summary of the research; a presentation will be created and delivered at the Brown Bag Lunch
series (a joint initiative between the Northern Health Authority and University of Northern
British Columbia to promote health research in the north); a one-page executive summary will

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be created and shared with the Northern Health Authority and the University of Northern
British Columbia to be distributed online; chapters of the thesis will be published in academic
journals; and, findings will be taken to relevant conferences.

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4.0 Findings
4.1.0 Introduction
This study explored factors associated with the use of teletrauma in a rural setting.
Andersen and Newman’s (1973) framework was used to guided inquiry and sensitized the
researcher to look for individual, health system, clinician, and geographic factors. Three
overarching objectives directed the study:
1. Describe and understand the Robson Valley virtual care program
2. Identify factors associated with teletrauma service utilization
3. Explore the perspectives of clinicians who use or have been exposed to teletrauma
In total, fourteen interviews with participants familiar with or playing a key role in
teletrauma use or development were analyzed. Primary analysis included six interviews with
physicians involved in rural practice or teletrauma, conducted between December 2019 and
February 2020. Eight interviews were conducted previously, between July 2018 and August
2018, with physicians, administrators, and executives. These interviews underwent secondary
analysis, whereupon transcripts were coded and reanalyzed for use within this study. The
interview questions with physicians (n=6) were designed to explore perspectives on teletrauma
for rural contexts, the functioning of a teletrauma program, and how certain patient, clinician,
organizational, and geographic factors influence use of teletrauma.
Following analysis of the study data, as guided by the interpretive description (Thorne et
al., 1997) approach, four themes emerged as shared their experiences, feelings, and insights
into teletrauma for northern rural settings. These included: teletrauma in a northern rural
context; factors associated with teletrauma use; teletrauma as a tool to foster team-based care;

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and, interconnectedness of the health care system. The following section will provide an
overview of the key demographic characteristics of the study participants, followed by an
overview of the findings.
4.1.1 Participants. All six physician participants newly interviewed specifically for this
thesis have practiced in rural settings in the past or present. Years of experience practicing in
rural areas ranged from two years to more than 20 years. Five physicians were family
practitioners, while one was an emergency physician. Three physicians worked in the Robson
Valley at the time of writing this thesis. The remaining three worked in urban centers but still
spent a portion of their time practicing in rural environments, although not in the Robson Valley
specifically. Other rural sites included Fort Saint James, Burns Lake, and Fort Saint John (Figure
3). Physicians were familiar with teletrauma systems, or have had to use telehealth for an acute
care situation, whereas three physicians had extensive direct experience with the teletrauma
program in the Robson Valley.
Of the previous interviewees (n=8), two were physicians in the Robson Valley, one an
administrator involved in the set up and deployment of the Robson Valley teletrauma program,
one a regional trauma lead, one a health services administrator, one a regional director, one a
researcher that evaluated the Robson Valley teletrauma program, and one a Northern Health
Authority executive. This group of interviewees had varying levels of familiarity and
involvement with the Robson Valley teletrauma program. However, all of the participants (n=8)
worked within the Northern Health Authority region and had knowledge of the local context. A
list of the roles and locations of focus for primary and secondary participants is shown in Table
1.

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Primary
Participants (n=6)

Role

Location of Focus

P1

Family physician

Client site

P2

Family physician

Consulting site

P3

Emergency physician and
trauma team leader

Client and consulting sites

P4

Family physician

Client site

P5

Family physician

Client site

P6

Family and emergency physician

Client and consulting sites

Secondary
Participants (n=8)

Role

Location of Focus

S1

Trauma and Emergency Lead

Northern Health Authority region

S2

Family physician

Client site

S3

Family physician

Client site

S4

Project Manager

Northern Health Authority region

S5

Health Services Administrator

Client sites

S6

Regional Director

Northern Health Authority region

S7

Researcher

Northern Health Authority region

S8

Health Executive

Northern Health Authority region

Table 1: Roles and Locations of Focus for Primary and Secondary Participants (N=14)
4.1.2 Interviews. Individual in-depth interviews (n=6) were conducted with physicians
over the phone with the exception of one which was conducted in person. All interviews took
place during the day or early in the evening. Interviews lasted between 26 and 60 minutes and
averaged 29 minutes. All interviews followed the protocol as described in section 5. Interviews

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were often deep and rich, supported by the personal experiences and feelings of physicians.
The narratives provided by participants provided insight into the underlying attitudes and
perceptions of teletrauma, rural practice, and telehealth in general. However, several
participants noted that they had work-related time-constraints, or had just worked a long shift.
Fluidity of the conversation fostered genuine interaction between the researcher and
participant, and allowed for spontaneity and intimacy when sharing experiences. This was
evidenced by the sharing of many personal stories and feelings. To protect the identities of
participants and to make a distinction between primary (n=6) and secondary (n=8) interview
data, a labeling system of P1 (Primary 1) through P6 and S1 (Secondary 1) through S8 is used.
4.1.3 Structure of findings. The findings from this study are presented under four
themes to answer the research question and present new ideas that emerged. Throughout the
interviews, participants (n=6) were asked specific and broad questions regarding the function of
teletrauma, factors associated with system activation, and their personal experiences of
practicing in rural settings. For example, participants were asked to describe their experiences
using teletrauma, and to identify specific situations when they found teletrauma most
beneficial. The questions elicited rich accounts of rural teletrauma utilization, revealed the
nuances of rural practice, and provided insight into the role of telehealth for rural sites in the
context of trauma. Data collection and analysis occurred iteratively, each informing the other,
to aid in the development of an integrated, deep understanding of physician perspectives.
These findings were compared and contrasted with pervious interviews (n=8) to enhance
understanding from unique perspectives and different levels within the same health system.

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Four major themes emerged throughout the analytic process. The first describes how
teletrauma is used in a northern context in addition to barriers and facilitators to use, and
factors associated with increased teletrauma utilization. The second is factors associated with
teletrauma use. The third is that teletrauma is a tool to foster team-based care built on strong
interprofessional relationships; teletrauma is more than just the technology being deployed.
The fourth is the concept of interconnectedness as the unifying concept that binds rural
clinicians, teletrauma, and team-based care, and how clinicians are vital to successful
teletrauma models. That is, technological solutions to rural health care delivery should be
clinically-driven and clinician-led to best reflect the nature of rural health care delivery. The
themes are discussed below to provide insight into physician perspectives, the role of
teletrauma in a northern rural context, and telehealth more generally.
4.2.0 Teletrauma in a northern rural context
4.2.1 The Robson Valley teletrauma program. Teletrauma in the Robson Valley was
initially implemented for emergency room use. Telehealth carts were placed in the remote
emergency room and had to be plugged into a wall outlet. Clinicians would have to log in to the
system, phone the consulting site to ensure their system was powered on, place a call, and then
have the call accepted by the consulting site. Once activated, the cart would be connected
directly to a fixed wall unit in the trauma bay at Prince George’s hospital. Physicians in the
Robson Valley also had access to the system from their homes. When connecting directly with
specialists in Prince George, only physicians would use the service. When used locally between
McBride and Valemount, nurses, medical students, and physicians would use the service to
communicate with one another.

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The system was used during several trauma and emergency cases since it was deployed.
As mentioned by one participant,
We had a severe major trauma patient that presented [to the Robson Valley] and we
were able to help McBride run that case to provide I guess resuscitation and had that
patient go in the back of the ambulance with the physician and make it to Prince George
and continue on the care, so it worked fantastic. (S1)
Another participant (P5) described a scenario in which the system was successfully used to
perform a cardioversion with the help of a remote specialist. While teletrauma may be used to
accurately triage and rapidly transfer patients, there were several instances where the service
was used to provide local early management of a trauma case prior to transfer. This participant
also reported their use of teletrauma to stabilize a trauma patient by performing a
thoracentesis and inserting a chest tube on the advice of a remote specialist. Thus, triaging,
patient stabilization for transfer, and early clinical management of trauma patients have been
notable uses of teletrauma in the Robson Valley as identified by participants.
4.2.2 Facilitators to teletrauma use. The facilitators that were helpful to use
teletrauma, were typically identified in the context of how teletrauma had evolved in the
Robson Valley, as the system was adapted to facilitate use. Facilitators of teletrauma use
included the specific characteristics of the technology and the relationships between the
clinicians using the service. The seamlessness of the technology was a factor mentioned by
three participants, a characteristic not attributed to the older teletrauma carts. That is, the
process of activation and functionality during a call was simple and effortless. One participant
stated,

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Your applications and the way that you call people, it needs to be simple, simple,
simple… and, you know we’ve changed that whole process… so you don’t have to do a
phone call anymore to get somebody in. You just now click a name on the screen and it
goes through to that doctor immediately. So it’s as simple as that. (P5)
This is in contrast to older inefficient systems that would require the user to “log in and enter a
billion passwords and set up a meeting” (P1). Or, for fixed-unit systems, the cart may become
unplugged, moved, or powered off, hindering timely activation. The efficiency and simplicity of
the activation and consultation process were key aspects facilitating teletrauma use.
Participants often used the analogy of a telephone to exemplify simplicity of a teletrauma
system: “[teletrauma has] got to be as reliable, easy, and simple as the phone… and the closer
we can get to those with that video enhanced option, I think then we’ll start to get adoption in
a more meaningful way” (P1). Another, comparing teletrauma to the ease of use and familiarity
of telephone, mentioned “the reason smartphones work so well is because people use them
hundreds of times a day… so in our case, [teletrauma is] very normalized so that nurses activate
it, you know, in a very methodical way” (P2). Thus, when the technology is familiar, it is easier
to use thereby facilitating effective system utilization. Comparing teletrauma carts to iPads, one
rural physician stated, “the issue [with teletrauma carts] was that it was not user friendly at all…
so with iPads, everybody is kind of well aware of the technology, you know, and it’s simple,
easy to use” (P5). These technological developments have facilitated teletrauma use by making
the consultation process seamless and effortless.
Flexibility of the technology to receive clinical input was also important. These included
mobility of the system, multi-caller capabilities, and resource accessibility. One participant used

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an example of holding the camera to view diagnostic results or images: “if they want to see an
ECG, we again just move the iPad to see the ECG… and then if we do, like, an ultrasound… we
just move the iPad so they can see the screen of the ultrasound” (P5). Camera mobility is
particularly useful during trauma cases, enhancing accurate assessment and effective
management. As noted by a consulting site emergency physician, “a better usage of this
teletrauma would be, you know, visualize. Somebody having a camera and going around and
saying, ‘okay, here's the monitor, here's what the patient looks like, here's the wound’” (P3).
The ability to access necessary resources in a timely manner was also mentioned. One
participant stated the reason they chose one app over another was for its ability to easily select
and involve multiple individuals on one call (P4). Another made a distinction between
telehealth carts and iPads emphasizing the ability of iPads to effortlessly involve multiple callers
(P5). Because trauma cases often require teams of clinicians and specialists to adequately
manage the patient, multi-caller ability is an important characteristic of teletrauma technology.
Another major concept identified by participants that facilitated use of teletrauma was
interprofessional relationships. Participants frequently mentioned the importance of
relationships, trust, and mutual understanding of site capabilities as being vital to teletrauma
utilization. Rural physicians have expressed their hesitation calling a consulting clinician
“because you don’t want to waste their time” (S2). But, when rural physicians “know [the
consulting clinicians] by name, you know their faces and you know that they’re fine accepting
your calls whenever, then it makes it so much easier to push that button” (S2). The ability to
simply visualize the patient, rural and consulting clinician, was noted as being a determining
factor for a positive teletrauma encounter; “it is more likely that you're going to get a negative

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encounter when someone's got less riding on it; they don't see your face, they don't see the
patient's face, they don't see what you're dealing with” (P6). That is, apprehension to call a
consulting clinician was reduced when teletrauma users were familiar with one another and
have an established interprofessional relationship. The visual component to teletrauma also
helps to develop a mutual understanding of site resources and capabilities. Put by one rural
physician, “they don’t always realize what we’re dealing with here… but if I can go, ‘let’s
livestream with the patient and I will show you what I’m seeing,’ I feel like it will be often more
receptive” (P6). Another reported that “understanding of context” and “having the expertise
[rural physicians] need” (S3) were desirable qualities of the consulting site clinicians. Locally,
relationships between clinicians were noted as being key to delivering care remotely; “I need to
know the person that's on the other end of the phone. If I don't know that person, if I haven't
worked with them, if I haven't met them face to face, it's far more difficult” (P1). Three other
participants echoed this finding. This mutual understanding of resources and capacity may help
to share the responsibility of care between sites resulting in rural clinicians feeling more
supported.
Participants identified several facilitators to teletrauma use including technological
aspects and characteristics of teletrauma users. Most notably, participants mentioned the
importance of seamlessness and simplicity of the consultation process, and flexibility of the
technology to accomplish clinical means. It was also identified that strong interprofessional
relationships between those using the service facilitate teletrauma use.
4.2.3 Barriers to teletrauma use. During the interviews, participants were asked to
reflect upon the barriers of teletrauma use in their field of work. Reported barriers included

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ease of use, familiarity with the technology, and workflow changes at the consulting site.
Within the Robson Valley virtual care program, various aspects of the technology presented
challenges to teletrauma users, particularly with the older teletrauma carts that were initially
deployed. For those located in the Robson Valley, the arduousness of the teletrauma cart was
identified as a key barrier to its use. One participant commented:
[If] you needed to plug something else in and forgot to plug it back in… or [clinicians]
needed the space to hang something else for whatever reason and so then the carts had
to be moved and things took a little bit longer to set up, then it might not be their go-to,
they might choose the phone for some things. (S4)
These issues were echoed by a rural practicing physician who stated “when we used those old
carts, if we tried to do a video call, everybody ran away because they knew how difficult it
was... [and] the cart was connected to a land port, so you couldn't move it around” (P5). Lack of
simplicity of the system was frequently cited as a reason to abandon teletrauma during a realtime case; “I've been in situations where I fumbled with technology… [and] very quickly
abandoned the video option… because of the fact that we needed timely connectivity and it
wasn't happening with the with the technology” (P1). Thus, the lack of portability and simplicity
of the system was a major barrier to teletrauma use and often resulted in participants using
alternative modes of communication.
Workflow changes at the consulting site was an issue consistently reported by
physicians, administrators, and others. A consulting site physician noted that “it's pretty tough
for us on this end to commit ourselves to utilizing [teletrauma] while we have a really busy
department with a three, four hour wait constantly” (P3). The physician then elaborated on the

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potential burden that multiple peripheral sites using teletrauma could place on consulting
physicians: “we only have one main hospital… and probably 8 peripheral hospitals, right? So if
every department had [teletrauma] and they get to using it then that would put a lot of
pressure on our department” (P3). A researcher described the potential workflow challenges as
increasing “overcrowding virtually” (S7) of the consulting emergency department, whereupon
virtual consults may increase the workload of consulting sites that are already overcrowded.
Lack of familiarity with the technology was another barrier to use. As stated by a rural
practicing physician, “when you have other pieces of equipment that you don't utilize as much,
you tend to have to re-familiarize yourself with it… it’s not intuitive… it’s not automatic” (P2). If
the system is not regularly used, the activation process and use during a trauma case may
become less timely, resulting in increased stress on the physician while they are attempting
manage often life-threatening medical situations. One administrator noted the impracticality of
having to read an instruction sheet during high-stress clinical situations when “you’re not used
to using [the technology] and when you’re in a panic or your adrenaline is high” (S4). As a
result, many rural physicians have dismissed the teletrauma system and reverted to the
familiar, such as telephone. In summary, a variety of barriers were identified and these relate to
the practicality, portability, and usability of the system within the context of real-time clinical
trauma care.
4.2.4.0 Effects and outcomes of teletrauma. Several notable effects of teletrauma were
identified, including the potential for organizational cost savings, increased local management
of patients, improved health outcomes, and enhanced confidence for clinicians. These were
categorized according to Bodenheimer and Sinsky’s (2014) Quadruple Aim: cost optimization,

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patient experience, provider experience, and population health. A rural physician (P4) and a
Northern Health Authority executive (S8) noted the importance of the Quadruple Aim
(Bodenheimer & Sinsky, 2014) when examining the effects of teletrauma across the health
system. Responses to the teletrauma survey administered to participants are also reported.
4.2.4.1 Teletrauma survey responses. As a part of the interviews, participants were
asked to rate their experiences using teletrauma on a five-point Likert scale (Figure 8). Overall,

Statements
I was able to communicate
clearly and effectively using the
teletrauma technology (n=4)
Use of tele trauma has changed
my clinical management plan
(n=5)
Use of tele trauma facilitated
timely access to appropriate
care (n=5)
I believe teletrauma to be
helpful in the provision of high
quality trauma care (n=5)
Teletrauma is beneficial for
patients (n=5)
Teletrauma is beneficial for
providers (n=5)
When in-person evaluation is
not available, teletrauma is an
acceptable alternative (n=5)
Overall, I am satisfied with the
teletrauma service (n=4)

Strongly
agree (%)

Agree (%)

75%

Neutral
(%)

Disagree
(%)

Strongly
disagree
(%)

25%

40%

60%

80%

20%

80%

20%

100%

80%

20%

60%

40%

50%

25%

25%

Figure 8: Participant Responses to Teletrauma Survey (N=5)
five of the six participants responded to the survey questions. One participant declined to
answer any of the questions due to a perceived lack of experience using teletrauma. Some of

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the participants refused to answer a particular question because of limited experience or
relevance to their teletrauma encounters.
All respondents strongly agreed that teletrauma is beneficial for patients. Eighty percent
(n=4) strongly agreed and 20% (n=1) agreed that teletrauma is beneficial for providers, helps in
the provision of high quality care, and facilitates timely access to appropriate care. When asked
about the acceptability of teletrauma when face-to-face is not available, 60% (n=3) strongly
agreed and 40% (n=2) agreed. All respondents (n=5) strongly agreed or agreed that use of
teletrauma changed their clinical management plan, however the proportion of those who
strongly agreed (40%) was notably less than for other statements. The most dispersed set of
responses were for the statement regarding satisfaction with teletrauma; 50% (n=3) of
respondents strongly agreed, 25% (n=1) agreed, and one responded with ‘neutral.’ Seventy-five
percent (n=3) strongly agreed that they were able to communicate effectively using teletrauma,
with one neutral response.
4.2.4.2 Cost optimization. No participants reported actual instances of cost savings for
the health system that had occurred as a result of using teletrauma. Four participants noted the
potential cost savings of the teletrauma system. For example, one physician remarked on the
lower prices of new technology as compared to the previous teletrauma equipment in the
Robson Valley (S2). Another described how increased local management of patients could
decrease costs by reducing the number of emergency room visits and cost of travel (P4).
However, one participant said that cost savings should not be the objective of teletrauma:
If it’s just about saving money, there may or may not be a good outcome to the
organization. So for instance, the cheapest outcome for a trauma is if the patient dies,

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just to be fairly blunt. Because then they don’t get into hospital, they don’t get to ICU or
whatever, so that’s cheap, that’s a good [return on investment]. (S3)
On the other hand, one administrator highlighted the importance of examining redundancies
during care management as a result of using teletrauma (S6). That is, if the consulting clinician
directed the rural physician to perform diagnostic tests during the teletrauma consult, would
these tests then be repeated again at the larger facility after the patient arrives thereby
increasing organizational cost.
4.2.4.3 Patient experience. Teletrauma had many notable effects on the patient
experience, including increased satisfaction and decreased costs associated with travel.
Teletrauma may enable patients to remain in the community for treatment thereby saving
travel costs and resulting in satisfaction with the health event. A health administrator gave an
example of a case where transfer was avoided through the use of teletrauma and the patient
was able to be discharged locally (S1). The participant went on to characterize this situation as
“[bringing] the care to the patient” (S1). A physician corroborated this finding, describing the
situation as “a real win-win” when they could manage patients locally and prevent transfer (P2).
Participants also identified that patients using the teletrauma system saved money that
otherwise would have been spent on travel. However, it was mentioned that the family or
support system would typically have to absorb the cost of travel; “in a trauma situation, it’s not
just the cost to the patient, it’s the cost to all the family and support providers… people have to
stay in hotels and they have to catch airplanes… it’s a huge burden” (S5). The cost savings also
extended to non-trauma patients. As one physician explained,

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There are also huge cost savings involved… typically if you are to get an appointment for
cardiology, it would take about three months to get an appointment. And, you know,
then the patient needs to travel down to Kelowna, which is a 500 kilometer drive, and
then spend a night or two in a hotel, and then they see the doctor for 10 minutes, you
know, then they come back… So those kinds of cases are really helpful to just have
access to somebody immediately. (P5)
A researcher had a similar response, giving an example of when telehealth is not available and a
transferred patient has to miss work for an extended period of time, arrange childcare, and find
a means of transportation back home (S7). As a result of remaining in the community, thereby
saving money and reducing travel risk, patients were reportedly satisfied with their health
events. One physician stated that patients have had very positive experiences with teletrauma
(S2). Furthermore, satisfaction with the health service encounter extended to the family as
well, particularly in trauma situations; “if you have a big case where we have to resuscitate…
the family thinks you probably didn't do everything you could. But if there's a specialist in the
room [virtually], they immediately feel much more comfortable… like everything was done”
(P5). Thus in trauma settings, cost savings and satisfaction with health care were not isolated to
the patient. It was consistently identified that the family or support unit benefited from
teletrauma.
4.2.4.4 Population health. Participants frequently discussed effects of teletrauma
related to the population health domain. It was identified that teletrauma improved care
outcomes, enabled more appropriate transfers, and increased diagnostic accuracy. Three
participants explicitly mentioned that teletrauma use saved lives and enhanced patient safety.

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One physician stated, “I've heard stories across the province where a physician has told me
that, you know, without [teletrauma], the patient would be dead” (P1). This was echoed by a
rural practicing physician who stated, “hands-down, there's no way telehealth does not 100
percent improve patient care,” particularly for traumatically injured patients (P6). Multiple
participants also provided examples where, as a result of teletrauma support, patients were
able to be appropriately stabilized prior to transfer, reducing the risk of adverse outcomes
during transport.
In addition to safe patient transfers, teletrauma also facilitated transfers that were more
appropriate. One physician noted, “our biggest issue here in rural towns is to get patients out
that need to go out” (S2). This was echoed by an administrator who stated, “ultimately a
transfer may be needed, but it’s that being able to maximize when a transfer is appropriate and
maximize the preparation for a transfer” (S7). For patients in the Robson Valley, teletrauma
helped to identify those who needed to be transferred and reduced unnecessary transfer. One
rural physician mentioned that this also applied locally:
Now you can see the patient via video link and you can already decide ‘do I have to get
this patient to travel this way or is it something that can be dealt with locally?’ And we
had several cases where patients did not have to travel just because we had direct
access and we could decide, make a better decision. (S2)
When discussing transfers, participants also referred to the appropriateness of the consulting
site. One participant elaborated on appropriate transfers as “[diverting] to a better center
based on earliest or earlier specialist involvement” (P1). Thus, patients who needed to be

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transferred were identified more rapidly as a result of specialist involvement and unnecessary
transfers were reduced.
Diagnostic accuracy was enhanced through the use of teletrauma. Particularly in
situations when rural clinicians were uncomfortable, teletrauma facilitated accurate diagnosis
and proper care. It has been noted that the use of teletrauma changed the clinical management
of several patients. One physician in the Robson Valley recounted an emergency case
whereupon early specialist involvement via teletrauma changed the clinical management of a
pediatric case, preventing an adverse outcome (P4). The physician went on to describe that if
the clinical management plan had not changed, the outcome “would have been not good” (P4).
Another physician in the Robson Valley noted that as a result of the change in care, “we've had
cases that I think had really good outcomes because of the fact that we had early intervention
from specialists that guided us” (P5).
4.2.4.5 Provider experience. A notable impact of teletrauma was increased support for
rural clinicians professionally and personally. The importance of this outcome was put into
perspective by on rural physician:
Obviously [teletrauma] helps patient care. It can help improve outcomes. It can save
lives. It can reduce costs. Those are all kind of the typical ones. But I but I would say, as
importantly or more importantly, it improves the quality of life of the nurse on the
ground. So instead of them working in isolation and being super stressed, their stress
goes down because they're well supported. (P2)
This finding was evident in nearly all interviews with participants. Physicians typically talked
about the anxiety associated with rural practice particularly when faced with difficult or

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unfamiliar situations. Rural physicians felt more supported, experienced less anxiety, and were
more confident providing care when using teletrauma; “for the physician that needs to manage
these cases, it decreases your level of anxiety significantly to just have somebody else there
that can share decision making and responsibility” (P5). Another stated “we deal with very
difficult situations sometimes that we don’t have daily experience with and it really decreases
my levels of anxiety significantly if I know I have somebody that can back me up in a difficult
situation” (S2).
Teletrauma also enabled professional development, making rural clinicians more
confident when faced with similar patient presentations in the future. That is, clinicians were
more confident independently providing care in cases they had previously managed using
teletrauma; “what I found in my experience is you do a few difficult cases with a specialist on
the other side and then you have enough confidence to do the next one on your own” (S2). One
physician in the Robson Valley remarked that as a result of teletrauma use, “there's a lot of
patients that we would have sent out previously that we're now comfortable dealing with
locally” (P5). Thus, participating in the care of patients who otherwise would have been
immediately transferred provides learning opportunities for rural clinicians and supports
professional development.
Furthermore, teletrauma facilitated the mutual understanding of context between sites.
For example, rural clinicians felt more supported when they knew that the consulting site
understood their capabilities and resource limitations. One rural physician explained that as a
result of using teletrauma, “[consulting clinicians] actually have a better understanding of what
services we can do and can’t do in Valemount” (S3). An administrator reported a similar effect

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of teletrauma: “I think too there will be an appreciation of what sites have and what sites don’t
have and what maybe even regional sites can offer” (S1). This insight into rural practice
afforded by teletrauma also affects emergency medicine more broadly. One researcher noted
these far reaching effects:
One of the things that I thought was notable was how [the development of mutual
understanding] then informs people that may be teaching in teaching hospitals or
through the Faculty of Medicine, through the emergency department, Department of
Emergency Medicine, how that enriches the faculty members to be able to speak to
emergency practice not just in urban or regional sites, but what that’s like across the
province in rural and remote areas. (S7)
Through teletrauma, a clearer picture is uncovered of what emergency medicine looks like for
northern BC, not being isolated from urban centers. Consulting sites may then be more aware
of the needs of rural sites and more receptive to providing timely support.
As a result of increased clinician support and mutual understanding, teletrauma
improved the quality and efficiency of care delivered by rural clinicians. One physician noted, “if
I feel supported, I’m likely to give better care. Because if I’m not feeling frantic, I’m going to be
calmer, make clearer decisions and be more confident about the decisions I make” (P6). More
confident decision-making in the rural emergency room also allows for optimization of
workflow. The same physician noted how the confident clinical management of a patient
allowed her to move on to subsequent cases:
If I know that, you know, that the splint is appropriate and that this is appropriate, it
also gives me a certain amount of freedom to carry on to my next case. I can carry on

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with the next patient without having to panic running backwards and forwards to have
to go check the ankle pulse or the tie. (P6)
The optimization of care processes also extended to patient transfers, enabling more timely
transfers between facilities. One participant remarked on the optimization of transfers as a
result of teletrauma; “now you can get a specialist on the line who can actually see the patient
and see the situation that you’re in and we’ve definitely experienced that is easier to get those
patients transferred out” (S2). The same participant elaborated that previously, a transfer
would take two hours to arrange and then would often get declined. However, the use of
teletrauma has optimized the transfer process, creating “a much easier situation” (S2).
4.3.0 Factors associated with teletrauma use
During the interviews, the participants identified numerous factors that were associated
with teletrauma utilization, and telehealth more broadly, were identified. Upon analyzing the
data, these were organized into individual determinants and health services system factors,
guided by Andersen and Newman’s (1973) framework. Individual determinants are comprised
of patient-specific and illness factors, whereas the health services system category includes
organizational factors, clinician characteristics, and the physical environment.
4.3.1 Individual determinants. Across the interviews, specific signs and symptoms,
injury types, or interventions were found to not drive teletrauma use. While several
participants described clinical cases in which teletrauma was useful, participants did not
associate patient demographics or specific physiological markers with increased likelihood of
using the system. Put by a rural physician with more than 10 years of experience using
telehealth for emergency situations,

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So whatever the emergency is, is what we use it for. So we've done cardioversions.
We've done joint dislocation that need to be reduced. We've packed, you know, serious
nosebleeds. We've treated pre-term labor. We've treated sepsis, sick kids, sick elders,
broken bones. I mean, the list is endless. (P2)
When asked whether or not there were specific patient profiles within the trauma category for
which they would activate the teletrauma system, participants responded with several
examples. These included neurosurgical patients, motor vehicle accidents, and major trauma.
However, considering the wide range of situations reported by participants in this regard,
patient characteristics were not found to be associated with increased teletrauma use. One
participant highlighted this finding: “I think [teletrauma use] depends on the cases, you know,
so it depends on what comes in our emergency door. I don't think there's a specific patient that
we deal with… so it varies considerably” (P5). Another had a similar response regarding
teletrauma, stating that “telehealth is used for, you know, to treat emergencies. And so
whatever the emergency is, is what we use it for” (P2). Particularly in small sites where
clinicians are not exposed to a large number of trauma or emergency cases, patient
characteristics were not identified as driving teletrauma use.
4.3.2 Health Services System. Clinician characteristics were the most commonly cited
reasons for activating teletrauma, particularly when clinicians were unfamiliar or
uncomfortable with clinical management. One mentioned that it is those cases which cause
anxiety and fear when teletrauma is especially helpful and may be activated more often (P5).
This finding was echoed by several other participants. A rural clinician in the Robson Valley
stated, “I think we kind of use [teletrauma] when we think we're going to potentially run out of

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ideas in our plans, then we just use it… if I feel incapable of managing this on my own, I phone
these guys” (P5). Another physician, practicing outside of the Robson Valley, commented on
clinicians’ comfort level as being associated with teletrauma use:
I think anything that makes nurses uncomfortable dealing with [acute patients] in
isolation is what’s most useful. So I wouldn’t focus on the medical problem. I would
focus on the challenges on the local care team on the ground. So making their life
better, if they're super stressed out about- and obviously, the sicker the patient they
have in front of them, the more stressed out they're going to be, because they work in
isolation. That’s where I see the most value. (P2)
This finding was also relevant at the local level. One physician described how it is the nurse’s
comfort level with a clinical situation that ultimately determines their willingness to use
telehealth between McBride and Valemount (P1). The interdisciplinary aspect of the care team
may also be a driving factor; speaking of the necessity of team-based care by including
northern-trained nurses, P3 mentioned that “[health organizations] have to start utilizing and
maximizing the cognitive potential of the other professionals that work with the situation.” He
went on to describe that many emergency rooms are “nurse-run departments” where “a lot of
the procedures are done by the nurse [and] decision-making is shared.” Another physician
mentioned how often nurses reach out to physicians using telehealth: “I don't think there's a
day that goes by when the nurse doesn't reach out to one of the docs on call” (P2).
The rural setting was another reason cited as contributing to clinician anxiety and
subsequent activation of teletrauma. One consulting site specialist noted that the wide range of
clinical situations that rural clinicians have to be prepared for contributes to anxiety when

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practicing rurally (P3). Put by another, “what typically happens with the rural [physician] is we
don’t deal with [trauma] cases often enough to get really good at it” (P5). Thus, clinician
characteristics, shaped by the environment and clinical context in which they practice,
influences the threshold to use teletrauma.
Three participants described how organizational factors may be associated with
teletrauma utilization. These included local resources and volume of exposure to clinical cases.
For those sites that see trauma infrequently, clinicians may be more likely to activate the
system. As described by one physician, “if you have a very low volume site for trauma, a very
low volume site, they are the sites that will likely use [teletrauma] more” (P3). That is, less
trauma exposure contributes to a lack of familiarity with clinical management, decreasing
clinician comfort which then lowers the threshold to use teletrauma. A physician in the Robson
Valley also mentioned site resources as contributing to a higher likelihood of activating
teletrauma, particularly for “those [patients] whose immediate medical needs are beyond the
facility that’s dealing with them” (P1). One specified that the lack of immediate access to a
neurosurgical specialist contributed to teletrauma utilization (P6), whereas another identified a
lack of general surgeons (P3). Thus, site resources and case volumes play a role in the rural
clinicians’ decision to use teletrauma, although these factors were less reported by participants.
Aspects of the environment also influenced teletrauma utilization, including weather
and physical location. Poor weather, for example, often forces rural clinicians to treat the
patient locally in the event that they are unable to be transferred. One rural physician explicitly
mentioned the low threshold to use teletrauma during poor weather conditions (P4). During

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time-sensitive situations, extended local management caused increased stress on clinicians. A
case was highlighted by another physician from the Robson Valley:
For instance, if we have somebody with a myocardial infarction, if the weather allows,
those people can be out within an hour by plane. But if the weather does not allow, you
know, and the roads are bad, those patients often end up staying our emergency room
for up to seven, eight hours. And then, you know, the [physician] needs to deal with all
the complications and stuff that might come. And it's been very helpful to have an
intensivist that can again guide you through all these things. (P5)
For trauma patients, teletrauma utilization when patient transfer is delayed is vital to safe
patient care and appropriate management. The same physician noted that during extensive
trauma cases, the situation may be exacerbated due to the timeliness of care required; “you
end up having to look after those patients for an extended period of time, you know, without
the real training and the capability of doing that. So [teletrauma] is an awesome way of dealing
with these cases” (P5). This finding was echoed by a consulting site physician who commented
on the utility of teletrauma for stabilizing patients prior to transfer, so that patients have less
risk of deteriorating when weather impedes timely transport (P6).
The location of the communities also plays a role in exposure to risks and the potential
of needing to use teletrauma. Because the Robson Valley is located on long stretches of
highway, there is a risk associated with travel. One participant from the Robson Valley gave an
example of a patient who was referred for diagnostic imaging and died along the highway after
being involved in a motor vehicle accident (P5). Another physician confirmed this finding: “we
have had people travel on roads and communities for something that's minor and routine and

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die because of being in a road accident... probably one person a year the last two or three
years” (P4). Thus, geographical factors such as inclement weather and large distances between
sites, particularly in the context of travel risk, affect rural clinicians’ threshold to use
teletrauma.
Across interviews with participants, organizational factors, clinician characteristics, and
geographical factors were drivers of teletrauma utilization. These included poor weather and
travel risk, lack of clinician confidence or comfort, lack of local resources and the need for a
higher level of care, and decreased case volume. Specific patient factors were not reported by
participants as being associated with teletrauma use.
4.4.0 Teletrauma as a tool to foster team-based care
Teletrauma was consistently discussed in terms of its reliance upon strong
interprofessional relationships and suitability for the rural context. The technological
component of teletrauma was noted as being important yet not a vital piece of program
success. Although the technology is one aspect to consider, the impetus of teletrauma is its
ability to connect clinicians and establish an effective team-based model of care. Thus,
teletrauma moves beyond the technology it utilizes and instead is viewed as a tool by which to
enhance communication and build relationships.
4.4.1 Teletrauma is more than the technology. Technology continues to play an
important role in successful teletrauma deployment and utilization. Participants identified
several technological aspects that were fitting for the rural trauma setting. These included a
“camera that would either be wearable or… that you just hold” (S4), the ability to “get multiple
people in [on the call]” (P4), and seamless activation; “it’s not going to be something where you

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need to log in and enter a billion passwords and set up a meeting” (P1). These characteristics
suit the trauma context given the timeliness required for treatment, involvement of several
parties simultaneously, and the need to examine injuries or diagnostics images up close and
from different angles. However, technology alone is not key to successful teletrauma
consultation. As noted by one participant, “the technology can make [teletrauma] better. Don't
get me wrong. But, you know, the technology isn't the solution. It's just a part of the solution”
(P1).
Across the interviews, it was consistently noted that the potential of teletrauma is being
limited to the characteristics of the individuals using it. When talking about the ideal
technological components, participants frequently mentioned caveats to successful teletrauma
use including user attitudes, mutual understanding of site resources and capabilities, and
rapport with the other user. That is, even if the teletrauma system had been designed with the
ideal technology, poor attitudes and anonymous users may limit the capabilities of teletrauma.
As put by one rural physician,
If you can build those relationships with the doctors, you know them by name, you
know their faces and you know that they’re fine accepting your calls whenever then it
makes it so much easier to push that button and say ‘listen I just need a quick answer on
this question, please help me.’ (S2)
Another mentioned that “you want someone nice, when I say nice, someone who wants to be
there, wants to be helpful, who understands the context” (S3). Thus, the effectiveness of
teletrauma can be limited by the attitudes of the individuals who are using the service. While
technology can support or detract from the effectiveness of teletrauma, participants identified

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that it is not the major driving force of successful service utilization. One participant, speaking
with regards to a successfully deployed teletrauma program, stated that “ninety-five percent of
what made [the teletrauma program] fantastic was the attitude in the group of specialists
supporting it. It was not the technology. The technology was five percent of it” (P1). This
perspective was echoed by three additional participants. Another stated that “relationships are
always the pivotal piece. The technology supports the relationships, but it doesn’t define them”
(P2). He went on to describe how successful teletrauma programs need to be relationshipbased; “if it's an anonymous program by, that is, anonymous people, anonymous technology, I
think that that's less likely to be of value to the average rural physician and patient” (P2). Thus,
while teletrauma can be supported through appropriate technology that aligns with clinicians’
needs, relationships are the main driver of successful teletrauma use. As put by one participant,
“if I can leave one impression in your ear, it’s that I really do think technology is wonderful, but
it’s really about the relationships and the people” (P1).
Beyond the technology, teletrauma is a tool through which to foster interprofessional
relationships and support effective team-based care. One participant gave an example of acting
as a secondary provider during high-acuity situations and the resultant effect on the psyche of
the treating physician:
So when I do anesthesia and I'm called into, for example, I'm called into a difficult
airway, the primary provider is very nervous because they're there alone, right? And
whereas I can be the secondary provider and I am not nervous because it's not primarily
my case. Yet, I'm there to help. So the psychology of trauma is different if you're the

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secondary provider, right? So that is the biggest benefit to any communication, is that
the secondary provider can have a different psychological point of view. (P3)
In situations when rural clinicians feel vulnerable or uncomfortable, teletrauma supports a
team-based model of care by facilitating secondary provider involvement. The technology
facilitates this interaction but does not define it. As a result, clinicians feel more supported
particularly in high-stress situations; “and, I mean, it's a huge help… when I'm taking care of
something that I'm having difficulty with but I know that my colleague just walked in… and
often, my heart rate goes down if they just kind of walk in and say ‘hey [P3], can I help?’ It's like,
‘thank God you're here’” (P3). Successful teletrauma use therefore relies on existing
relationships and simultaneously enables the development of these relationships to reach the
goal of effective team-based care.
4.4.2 Teletrauma as a dynamic, fluid service. Teletrauma is dynamic and evolves from
within the rural context and as driven by clinicians who use the service. That is, after a
teletrauma program is established, the system can be used in different ways as clinicians
discover situations in which it is useful. Additionally, technological components may be altered
or adapted. Despite being deployed for use within a particular set of circumstances, teletrauma
may be adapted by clinicians and based on clinician need and local context.
Over time, clinicians developed uses for the service outside the context of trauma and
emergency care. One participant described using the service to manage a simple laceration: “I
actually had a relatively simple laceration that I had a medical student sew up in Valemount
when I was in McBride. So that was done over video” (P1). Another mentioned that the service
had become a part of a weekly routine for clinicians in the Robson Valley to meet and discuss

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cases (P4). Thus, while the initial focus of the program was emergency care support, the service
had evolved into use for minor cases, group meetings, and ward rounds to suit the local context
of care delivery. Put by a practicing rural physician, “the clinicians on the ground, how they see
this tool being helpful to them and their patients changes over time the more they use it” (P2).
Teletrauma extended to the pre-hospital setting, used as proactive communication for
high-risk situations and community events, streamlining access to emergency services. A
participant described how nurses began using video calls during mountain bike races to
remotely connect with physicians, “and if there’s an injury, they just call in on the same video
system and they show us the injury and they say ‘we’re sending this patient down in the
ambulance, get ready for this’” (P5). The service has also been used to remotely triage minor
cases within the Robson Valley and decide whether or not an in-person consults was necessary
by traveling between the two communities. As described by the individual who set up the
program,
So if the McBride doc was covering Valemount, he could stay in McBride and the nurses
could run the system and he could call in from his house and do a quick consult to see
whether he needed to go into the clinic or if they needed to send them through to
Prince George or if they could return the next day in regular business hours. (S4)
A physician in the Robson Valley elaborated on this particular use of the service, stating that
they could remotely view the case and decide whether or not to travel to the other community
to see the patient in-person; “so sometimes it's something simple that can wait till the next day
or, you know, a possible fracture. That's not going to change your management by waiting
another day or so. So it's really helpful to sort those things out” (P5)

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Duration of use varied by clinical context as well. Because complex cases were often
managed with the help of specialists at the Prince George site, call duration was longer for
more severe cases. Calls for patients managed locally were often shorter because the cases
were minor. Reported length of use ranged from “maybe five, 10 minutes” for minor cases, to
“maybe 20 minutes, 40 minutes” for more complex cases (P4). Another stated that for local
cases, “that might be a 10-minute or a 15-minute call” and for “big emergency cases where we
got specialists into those cases, it might be for an hour” (P5). Frequency of use also varied by
intended use. Put by one participant, “we used it probably at least once a month, sometimes
twice… that’s for specifically with a specialist in Prince George. But we used it much more often
locally (P5). Another, referring to local use of the system, stated “we actually use it every
Wednesday morning. I just call in and check in with the group. So every morning they do a
morning huddle at 8:30 in the morning” (P1). Despite the intended purpose for the program
when implemented, clinicians have adapted use of teletrauma resources to suit their local
needs. Adaptability of the service, whether it was originally intended or not, has led to
successful use in several unique circumstances that reflect the context of rural health care
delivery.
Malleability of telehealth programs is important as clinicians and care context ultimately
determine the technology; technology does not drive care. Even though programs may be
deployed with a narrow clinical focus, as in teletrauma, clinicians and the local context shape
the purpose, design, and use of the system. In the Robson Valley, for example, previous
experience with teletrauma has driven technological adaptations and the procurement of new
technology to best support the local context. Although the technological components of the

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telehealth cart could not be modified, clinicians’ experience using the system provided insight
into which technologies would work best for future systems. After the Robson Valley virtual
care program, clinicians began using simple, mobile technology with multi-caller capability and
seamless activation. This included an iPad between emergency rooms and an online application
to support videoconferencing on iPads. Drawing a distinction between the activation process of
the older telehealth carts and newer technology, one participant stated,
Simplicity of the system is so important. If it’s easy, then it’s easy for people to buy into
that and to use the system. But if it’s a long drawn out process to contact somebody
then, in an emergency situation time is of the essence [and] you don’t have time to go
through those kind of procedures. (S2)
Another participant reflected on the importance of technological adaptions as being clinicianled and driven by the clinical interface; “so it’s not what somebody thinks might be a good idea,
who has no connection with the clinical service. But it’s driven by people who are delivering the
care which I think is really good” (S3). Use of teletrauma beyond the intended purpose of the
system was also highlighted by a consulting site physician: “I think [teletrauma] could be used
for anything critical care wise or really any clinical question that the peripheral site has. So it’s
role isn’t really that understood. It’s certainly underutilized, like grossly underutilized” (P3).
Thus, technological development and ‘off-label’ uses of teletrauma are inevitable and are
determined by the needs of rural clinicians.
4.4.3 Goals of teletrauma. Several goals of teletrauma for a northern rural context were
identified. These included characteristics of the technological design and function of the
service.

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For service design, it was consistently noted that rural clinicians want a teletrauma
service that is adaptable at the point of care. That is, clinicians want technology that adequately
reflects the context in which they practice and has the ability to adapt to the situations they
encounter. The underlying principles identified were versatility and usability of the service. Put
by one participant,
Once people gain experience with what [teletrauma] looks like, the technology, how
they manage patients using it, they start to develop new ideas in their mind about, oh, I
could actually use this for something else too, or that. So that kind of stretching of the
opportunities for the technology in the context which that rural physician works is
undoubtedly shaped by the experience they initially start with. And then you just go
from there. So in other words, they have no idea where it's going to take them. The
important part is to start and then they start to see all sorts of new opportunities that
they can't see at the beginning. (P2)
Although teletrauma programs may be initially deployed for a particular set of clinical uses,
participants highlighted the importance of clinical versatility. As mentioned by one rural
clinician, “especially if you're a provider in a small community with a doctor, you're a provider
of many things not just an 8 hour shift in [emergency]” (P3). To support a versatile service, it is
vital that use of the technology is not restricted to accomplishing only a clinically-narrow set of
tasks. Instead, it was found that the technology should be adaptable and driven by the care that
rural clinicians deliver. One participant explained, “a lot of people think they have [teletrauma]
all figured out at the beginning. Administrators and I.T. people… make this classic mistake
because they don't deliver the care” (P2). He went on to describe how it is the care that rural

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clinicians deliver and “how they see this tool being helpful to them” (P2) that should drive the
technology. This finding was echoed by an administrator who stated “it really has to meet the
needs of the individuals who are going to be using it. Because in the past we have brought in
telehealth equipment in one of my sites and it was never used” (S5). Thus, the technology
deployed should have the ability to accommodate the variety of clinical uses as led by clinicians,
appropriately reflecting rural practice. This is reinforced by the flexible ways that communities
used and adapted technology in their everyday practice, as stated in the previous section.
Regarding technological characteristics, several clinicians used an example of the
telephone to emphasize the need for reliability and familiarity of teletrauma technology.
Speaking of the differences between existing telehealth technology (MedEx) and the telephone,
one participant explained,
You know, as much as technology is a wonderful thing, it is not as reliable as the
telephone. So I know how to work MedEx. I work with MedEx all the time. And I have
failed at MedEx many times. And I don't know why. And, you know, when I pick up my
phone and I dial my phone, that never happens. So technology still is a barrier in terms
of its consistency and reliability. (P1)
Many others mentioned that the reliability and ubiquity of the telephone should be future goals
of teletrauma. Put by a rural clinician, “there's a telephone in every rural emergency room,
right? So there needs to be a virtual care setup in every rural emergency room. And virtual
health is really just a telephone call with video, right? So that's all it is” (P2). Another stated that
it would be ideal for everyone to have teletrauma (P3). Furthermore, when asked about having
criteria for when to activate the system, rural clinicians consistently responded negatively. It

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was reported that having specific activation criteria does not fit with the nature of rural health
care delivery. One participant described how the use of clinical judgement should determine
teletrauma activation:
In rural medicine, I think it's the clinical judgment. I mean, if it's used from bigger
centers, that might change a little bit, you know, and I accept that. But I think for us, it's
what you're comfortable with dealing with. You know, there's so many different things
that comes in our emergency room doors. (P5)
Another participant again made a comparison to the telephone, stating “it’s like calling a friend,
right? I mean, do you have criteria when you call a friend? So no, please, no. I would discourage
that. That’d be the death nail in telehealth” (P2). He went on to describe how clinicians do not
have criteria as to who they reach out to for help in the hospital and in the same way,
teletrauma should not have criteria;
Virtual care is no different. And so thinking that it is, is a misstep. So, yeah, there should
be no criteria. People should [if] they've got a thought they want to bounce off
somebody, they've got a sick patient they need help with. Like wherever it is, the
technology just supports those [interactions]. It's a way to support communication
between people who trust one another. (P2)
Thus, the role of activation criteria is not fitting for the rural context and should instead be left
to clinical judgement. The likening of teletrauma to the telephone also underscores the
perceived role of teletrauma as an enhanced communication modality to support clinicians.

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4.5.0 Interconnectedness of the healthcare system
The concept of interconnectedness applies to the main aspects of teletrauma care in the
Robson Valley (clinicians, teletrauma, and team-based care) and the linkages between them.
For example, rural clinicians feel connected as a result of using teletrauma, team-based care
can be supported by and foster connectedness through teletrauma, and the level of
connectedness between rural and urban clinicians can improve care. The degree of
interconnectedness between the healthcare system also determines the quality and efficacy of
care that can be provided to rural trauma patients. Across the data, interconnectedness was
identified as an underlying concept that binds rural clinicians, teletrauma programs, and teambased care models, and functions individually within each aspect.
4.5.1 Teletrauma facilitates connected, compassionate care. Many rural clinicians have
reported feelings of professional isolation and a lack of clinical support as a result of geographic
separation. One participant noted that many Canadian medical graduates are dissuaded from
practicing rurally because of a perceived lack of support (P3). These feelings can adversely
affect the care that clinicians deliver and negatively impact rural clinicians’ quality of life,
preventing an effective team-based approach to care delivery. One participant described caring
for sick patients in the rural context as being “a very isolating experience” (P2). He went on to
note that reduced feelings of isolation and stress of rural clinicians improves patient outcomes
and saves lives. A rural physician reported similar experiences: “if I feel supported, I’m likely to
give better care… I’m going to be calmer, make clearer decisions, and be more confident” (P6).
Across the interviews, it was found that connected care as a result of teletrauma
negates the isolation and lack of support felt by rural clinicians. That is, teletrauma reinforces

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the view of rural health care delivery as a collective task, as opposed to being the sole
responsibility of rural clinicians. Several attributes of connectedness between clinicians were
identified including trust, mutual understanding, and a willingness to help. One participant
mentioned that rural clinicians should be trusted to have “the competence… to know when to
ask for help” (P1). A physician noted trust as a being vital precondition to effective
communication between clinicians (P2), whereas an administrator highlighted the trust and
confidence that develops by “[seeing] someone face-to-face” (S1). Mutual understanding
between sites was another factor identified. By creating an awareness of site capabilities,
resources, and unique context, empathy is developed. Beyond the practicality of understanding
which services can or cannot be provided at a site, empathy cultivates feelings of support and
comfort for rural clinicians, facilitating connected care. During a face-to-face interview, one
physician used an example of her children being present to describe how the ability to visualize
and understand context affects attitudes:
It's the same scenario as right now: my kids don't feel like I'm taking anything away from
them. But if you and I were sitting on the phone right now, they'd be telling me I don't
have time for them because they can't see what I'm distracted with. But them visually
having an idea that mom is right here but she's doing something, that doesn't make
them feel like I'm taking time away from them. I mean, that's just in life. So it's the same
there, like I said, it's maybe subconscious, but no matter what, the physician will feel
supported. (P6)
In other words, consulting site clinicians may be more empathic and more willing to help when
they can visualize and understand the context of rural clinicians, leading to increased feelings of

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support. Willingness to help also contributed towards the development of connectedness by
creating cohesiveness between teletrauma users and a mentality of ‘shared care.’ Rural
clinicians are then able to rely on consulting clinicians without worrying about “[wasting] their
time” (S2). Another stated that the consulting clinician should be “someone who wants to be
there, wants to be helpful” (S3). This reliance on one another without fear of rejection may help
to foster an attitude of collectivism, negating the ‘us versus them’ mentality that several
participants expressed. One mentioned cases as ‘belonging’ to a site, with one site being
entirely responsible: “if you're flat out… and there's only two of you staffing the emergency
room, then you're probably not going to really want to spend a whole time dealing with
somebody else's problems” (P4). Another talked about the obligation to their own site,
potentially at the cost of not providing help to a rural site that is in need (P3). Thus, the sharing
of patients and relationship-building between clinicians, based on principles of trust, empathy,
and a willingness to help, support team-based care. This reinforces the view of rural trauma
care as a network of connected care and not being isolated to individual sites. Teletrauma
strengthens these linkages by facilitating meaningful collaboration and cultivating
interprofessional relationships. Therefore, interconnectedness between rural clinicians via
teletrauma may contribute towards the establishment of rural trauma care from a network
perspective.
4.5.2 Clinicians as vital to rural telehealth models. The team-based model of care does
not just apply to teletrauma. Participants often spoke of the need for general-use telehealth
programs that cross multiple disciplines, as broad services more closely align with the rural

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context. One participant elaborated on the challenges that arise in rural sites when narrowfocused telehealth programs are deployed:
I would have concerns about a very focused program because you'll end up with
multiple siloed programs and we already wrestle a lot with that… so oncology is a great
example, which is already up and running. It works well for the oncologists because they
have their own little routine and their own little box. But when you're at the other end
and you have to deal with virtual care for oncology, plus palliative care, plus trauma,
plus emergency, plus home care, plus internal medicine, plus cardiology, plus general
surgery, plus orthopedics, and you have a different app or way of doing it for each one
of those things, that's becomes pretty much impossible. So my feeling would be kind of
a general use thing that's supported ubiquitously across the province, a tool that the
various kind of groups and models can use, can afford, whatever service they're looking
at. (P4)
As such, the concept of interconnectedness extends to telehealth more generally and
appropriately reflects the rural context by emphasizing relationships instead of technology. For
trauma, broad programs allow rural sites to become established as key players in a regionalized
trauma system while also enabling rural clinicians to attend to a variety of clinical situations.
Noted by one participant, “I think [telehealth will] help with morale. I think it’ll produce better
team effort. I think it’s also going to start to help us establish our emergency trauma network
with all the 26 sites” (S1). Another mentioned the utility rural sites play in trauma cases,
particularly in performing the primary and secondary surveys of the patient (P3). To develop

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broad programs responsive to rural settings, it was identified that use of telehealth should be
driven by clinician experiences. As one participant suggested,
I think if we leave [telehealth] open, we’ll find the tweaks… So I think site by site you'd
have to start using it and go “OK for the first three months everybody use it at their
discretion.” And then do a synopsis of what were the issues, what did the specialists
like, what did they not like, did they feel like they were getting over telehealth, and if so,
which were the cases that were the problematic ones? From a physician perspective in
the emerge, it would be like “how easy did we find it to use it, you know, and then what
did we learn? What did it change in all behaviors? And, you know, where was it useful?
Where was it not useful?” And tweak it that way. Again, running a telehealth system like
this is not that difficult. (P6)
Thus, broad, interconnected telehealth programs that are clinician-led contribute to the
development of integrated networks of trauma care for rural areas.
4.6 Summary of findings
This section described the Robson Valley teletrauma program and explored perspectives
on teletrauma use in a northern rural setting. Analysis of the interview data yielded four major
themes. The first described the function, uses, and outcomes of teletrauma in the north. The
second explored factors associated with teletrauma utilization. The third explained how
teletrauma is more than just a technology, it is a tool to foster interprofessional relationship
through enhanced communication. The fourth described the concept of interconnectedness as
the binding force between rural clinicians, teletrauma, and team-based care.

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The concepts discussed and findings identified are closely related and serve an
overarching purpose within the context of rural trauma care (Figure 9). These aspects outline a

es
dn

ne

dn

Int
er
co
n

cte

es
s

Clinicians

- Do-it-all programs
- Technological flexibility
and versatility
- Clinically-driven

ne

cte

- Interprofessional
relationships
- Connected,
supported
care

n
co
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Int

s

Team-based
care

Interconnectedness

Teletrauma

- Clinician-led programs
- Adaptable technology
- Enhanced communication
modality

Figure 9: Interconnectedness as a Unifying Concept
model of care that incorporates the role of technology, principles and goals of rural health care,
and clinician needs. This balanced model integrates the network of regionalized trauma care,
enabling the provision of the best and most accessible care possible for the patient, despite
their location.

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5.0 Discussion and Interpretation
5.1.0 Interpretation of findings
Interpretations of findings were organized into four overarching themes: teletrauma
affects the healthcare system; teletrauma creates a network of care built on interprofessional
relationships; the reasons why clinicians use teletrauma are multifaceted and interrelated; and,
interconnectedness of the healthcare system. Findings are discussed in relation to current
research.
5.1.1 Teletrauma affects the healthcare system. The outcomes of Robson Valley
teletrauma program were organized according to the Quadruple Aim (Bodenheimer & Sinsky,
2014) to aid in understanding which aspects of health care teletrauma affects and to what
degree. As identified in the literature review, cost optimization and patient experience were
studied the least, whereas provider experience and population health were most common. This
finding was reflected across interviews with participants, who expressed less interest with cost
optimization and patient experience, and more interest towards population health and provider
experience.
Few participants noted instances of cost savings for the organization. Of those who did,
some remarked that cost reduction should not be a goal of teletrauma. However, it was
identified that teletrauma has the potential to reduce costs for the health care system by
reducing emergency room visits and patient transfers to a larger center. This finding is
consistent with the literature; after deployment of a teletrauma system, Duchesne et al. (2008)
reported an 85% reduction in hospital costs as a result of decreased transfers. Cost savings for
both the consulting and client sites is a consistently reported outcome of telehealth

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(Demaerschalk et al., 2013; Natafgi et al., 2018; Wibbenmeyer et al., 2016; Yang et al., 2015b).
For clinicians in the Robson Valley, the realities of rural practice and the potential to save lives
via teletrauma may outweigh the possible financial costs to the organization. Several instances
of death during travel were reported, which may have been potentially avoided with
teletrauma. While organizational cost savings was mentioned as a potential effect of
teletrauma, clinicians in the Robson Valley did not see this as an important outcome when
faced with the benefits of teletrauma, such as preventable deaths from unnecessary travel.
Therefore, initiatives to promote the use of teletrauma within rural settings should not rely on a
promise of cost saving, but instead focus on other factors, such as provider experience and
quality of patient care.
For those in the Robson Valley, the most pronounced outcomes of teletrauma were
related to the population health domain and included improved care outcomes, more
appropriate patient transfers, and increasesd diagnostic accuracy. Although remote
communities may not be equipped with the appropriate resources necessary to manage
complex trauma patients (Latifi et al., 2009), teletrauma is a recognized solution that facilitates
timely access in regionalized trauma systems (Hameed et al., 2010). Rural clinicians may be able
to more effectively triage patients and decide who needs a higher level of care more rapidly by
including specialists at the outset. This was experienced by clinicians in the Robson Valley who
were able to rapidly identify and transfer patients in need of a higher level of care. A similar
finding was reported by Duchesne et al. (2008) who demonstrated that teletrauma enabled the
identification of more severely injured patients thereby facilitating timely, appropriate
transfers.

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Participants identified that use of teletrauma changed clinical management, resulting in
improved outcomes for patients. In one instance, a child had inhaled an object and presented
to a clinician in the Robson Valley with difficulty breathing. After a teletrauma consultation, the
rural clinician and specialist decided not to try to retrieve the object, and instead immediately
transferred the patient. The clinician recalled that the change in clinical management may have
saved the life of the patient. It has been commonly cited in the literature that improved patient
outcomes results from teletrauma use. One study evaluating teletrauma for a pediatric
population noted that physicians using teletrauma reported more changes in diagnosis and
intervention as compared to telephone, resulting in a higher quality of care (Dharmar et al.,
2013). Several other studies have mentioned improved patient care due to teletrauma use
(Duchesne et al., 2008; Ehrlich et al., 2007; Mohr et al., 2018; Ricci et al., 2003; Rogers et al.,
2001; Syed-Abdul et al., 2012). For example, Duchesne et al. (2008) noted that patients were
treated more aggressively with packed red blood cell transfusions, significantly improving the
evaluation and management of trauma patients. Thus, changes in clinical management,
facilitated by teletrauma, leads to improved patient outcomes.
The large geographical distances between facilities in the Robson Valley and larger
centers, as well as unpredictable weather, increase the likelihood of adverse health events
during patient transport including death. Teletrauma circumvents this issue by ensuring
appropriate stabilization and initial management prior to transfer. In one case, a pediatric head
trauma patient was able to be appropriately stabilized with the help of a remote specialist
before being transferred, saving his life (Rottger et al., 1997). Additional articles have reported
teletrauma as being life-saving in rural settings (Ricci et al., 2003; Rogers et al., 2001). As

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evidenced in this research exploring the Robson Valley, teletrauma has the ability to connect
facilities that are otherwise spatially isolated, reducing the geographic barriers to appropriate
and timely care.
Rural clinicians have consistently highlighted the many positive effects of teletrauma on
the provider experience. By connecting clinicians at a distance, teletrauma reduces feelings of
anxiety and professional disconnect experienced by clinicians who practice in rural settings. The
ability for a secondary clinician to be virtually present provides clinical support and enables a
sharing of responsibility during care delivery. This was consistent with other literature
identified. In one study, satellite communication was used to facilitate remote consultation of
injured patients, resulting in increased clinical support for rural clinicians (Ehrlich et al., 2007).
Another study reported greater support for remote clinicians as a result of a teletrauma system
(Westbrook et al., 2008). By enabling the sharing of responsibility and facilitating remote
support during trauma cases, teletrauma also has the benefit of strengthening relationships
between clinicians. This was consistently mentioned by participants. In the literature,
collegiality between the client and consulting site was reportedly increased through the remote
guidance and advice provided to rural clinicians during difficult cases (Dyer et al., 2008). In
another study that evaluated clinician perceptions of teletrauma, 92% of respondents reported
improved collegiality and feelings of appreciation between sites (Al-Kadi et al., 2009). Although
not formally analyzed, the teletrauma consultations included medical trainees and physicians at
the client site and consultant site working together to care for multiple patients simultaneously.
This may have enhanced team-based care and feelings of cohesiveness between members of
the team.

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Furthermore, workflow is optimized. Because clinicians can be confident with the
decisions made when remote support is available, they are able to move on to the next case
without second-guessing or re-checking the previous patient case. This finding was also
demonstrated in the literature. In one study, a senior physician was busy caring for multiple
patients whereupon a trainee was able to use teletrauma to evaluate an additional patient,
allowing the senior physician to attend to a greater number of cases (Al-Kadi et al., 2009).
However, it was noted that teletrauma may increase workload on consulting sites. A study
evaluating the effects of teletrauma on clinicians’ work demonstrated a perceived increase in
workload for specialists and feelings of greater responsibility for the remote patient
(Westbrook et al., 2008). Across the interviews, however, this appeared to be more
apprehension than reality; none of the participants reported actual instances of increased
workload, only the potential effect that several teletrauma programs could have on a single
consulting site. Professional development was another notable outcome of teletrauma for the
provider experience domain. That is, after clinicians had managed a particular case using
teletrauma, they then felt more confident independently managing the same case in the future.
Similarly, Syed-Abdul et al. (2012) noted that the remote management of burn patients
permitted facilitated continuing medical education for the client site clinicians. Thus,
teletrauma provides learning opportunities for clinicians who otherwise would not be as
involved in the care of complex or unfamiliar cases.
5.1.2 Teletrauma enables a network of care built on interprofessional relationships.
Teletrauma is more than the technology being deployed. Clinicians adapt the technology
according to the setting in which it is implemented, driven by the needs of clinicians. In the

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Robson Valley, participants explained how the teletrauma program evolved from a telehealth
cart for use during emergency cases, to using iPads and cellphones to provide primary care,
follow-ups, regular hospital rounds, pre-hospital care, and trauma management. Given the
nature of rural medicine and the variety of clinical cases encountered, teletrauma technology
must be sensitive and adaptable to the needs of clinicians. As such, teletrauma does not
determine the care that is provided. Rather, it is the clinician who defines the care provided,
and teletrauma is a tool to enable enhanced communication between users.
Participants described teletrauma consultations as creating a ‘virtual presence’ of the
consulting clinician, increasing rural clinicians’ feelings of support and connectedness. The
ability to foster relationships during a teletrauma encounter hinges on the theory of social
presence (Short, Williams, & Christie, 1976). Originally used to describe teleconferencing, social
presence is the feeling that others are involved in the communication exchange. The degree of
social presence is determined by the mode of communication; that is, with fewer ‘channels’
available in a medium, users pay less attention to other participants (Walther, 1995). In the
case of teletrauma, video enhances the degree of social presence by including a visual
component, which may support the development of mutual trust and empathy during remote
consultations. This was in alignment with the findings from this research. Participants identified
that teletrauma aided in the personalization of clinical encounters primarily because of the
ability to visualize the other user. Similarly, it has been suggested that during teleconsultations,
impersonal exchanges result from decreased feelings of social presence (Walther, 1995). In this
way, teletrauma is seen as an enhanced modality of communication with the potential to foster
relationships and develop a sense of connectedness between users at a distance.

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It was identified that technology plays a role in successful teletrauma encounters. To
maximize consultation effectiveness, the purpose, design, and function of the technology must
revolve around the clinician. Participants compared teletrauma to the telephone to express
their desire for a service that is ubiquitous, clinically versatile, easy to use, reliable, and familiar.
The discussion of the ‘ideal’ system was not limited to a particular clinical use or scenario.
Rather, value of the system was seen in the ability for teletrauma to be used by and for the
clinician at the point of care, regardless of the clinical situation. In this way, teletrauma is not
viewed as a modality of care, but a tool to support clinicians. Participants also emphasized that
with the telephone, clinicians retain their autonomy over when and how to use it. Thus, when
teletrauma is deployed as a communication tool in a similar manner to the telephone, clinicians
may feel more control over the care they give while remaining sensitive to the demands of rural
practice. Similarly, Permwonguswa et al. (2018) found that telehealth is empowering to
clinicians, resulting in increased provider satisfaction and efficient treatment of patients.
Empowerment refers to the process of individuals gaining control over a situation and having
the ability to influence decisions that affect their lives (Zimmerman, 1995). This highlights the
ability for teletrauma to empower clinicians where they practice. As a modality of
communication, teletrauma enables clinicians to deliver high-quality trauma care in the face of
a lack of resources and support.
Teletrauma drives team-based care by connecting clinicians and fostering relationships.
As revealed in the analysis of the findings of this study, feelings of trust, empathy, and a
willingness to help are necessary components for successful teletrauma use. In the context of
collaborative care, these principles embody compassion between clinicians. These findings are

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corroborated by Atkins and Parker (2012), who identified that compassion leads to positive
organizational outcomes and quality relationships. Several aspects associated with compassion
were also identified, including helping, trust, support, and cooperation. Similarly, West Eckert,
Collins, and Chowla (2017) noted that compassion between members of a health organization
supports cooperativity and collaboration. The authors went on to describe how effective
teamworking relies on individuals’ recognition of the needs and value of others, and their
interdependence on one another to accomplish organizational goals (West et al., 2017). A
collective mindset between teams or members of a team helps to establish an effective
collaborative care model, a finding also reported by participants in this study. The crossdisciplinary cooperation between remote clinicians, as supported by teletrauma, facilitates
team-based care. Thus, teletrauma is foundational to the development and effective
functioning of team-based care in rural areas, viewed as an enhanced communication tool to
support clinicians.
5.1.3.0 Reasons clinicians use teletrauma are multifaceted and interrelated.
5.1.3.1 The role of technology. Considering that traumas often involve multiple injuries
and may require immediate input from several other clinicians, stationary telehealth carts with
inefficient activation procedures may not be functional. This is especially true in time-sensitive
situations where complicated activation processes dissuade clinicians from using the system.
For example, it has been noted that technical complexity and clinician discomfort engaging with
a pediatric emergency telehealth system impeded use (Uscher-Pines & Khan, 2014). This finding
was echoed by several participants in this study, emphasizing that complicated technology in
time-sensitive situations often leads clinicians to resort to traditional telephone consults. Thus,

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seamlessness of the system is an important technological attribute that facilitates timely,
effective teletrauma utilization; clinicians may be more willing to use teletrauma when the
technology is seamless and easy to use.
In this study, mobility of the teletrauma system to view injuries, along with multi-caller
capabilities, were other functional attributes that suit the trauma context and facilitate
teletrauma consults. These findings were also consistent with those in a few studies (Joseph,
Hadeed, Sadoun, Rhee, & Weinstein, 2012; Zangbar et al., 2014). For example, in programs
where telehealth robots that have been deployed, users found that mobility of the system was
an issue, as was visualization of the patient due to a fixed camera (Marttos et al., 2013). Similar
findings were reported by participants during interviews, who identified space allocation for
fixed-units and camera mobility as barriers to teletrauma use during emergency cases. In
contrast, most of the identified teletrauma literature mentioned the use of mounted cameras
with remote control capabilities (Duchesne et al., 2008; Ricci et al., 2003; Rogers et al., 2001;
Yang et al., 2015a; Yang et al., 2015b), as opposed to cameras that were fully mobile.
Connectivity is an important aspect as trauma case can rapidly change and procedures are
often performed under clinical time-constraints. Connectivity was mentioned in the interviews
as being a necessary precondition to telehealth use. Similarly, Duchesne et al. (2008) reported
that insufficient bandwidth can create technical difficulties during telehealth consults. Lag time
in video connection, for example, could delay or impede the care provided by a remote
clinician, which could then be detrimental to the care of the patient. As such, connectivity is a
vital consideration in rural areas that may not have the infrastructure to support the high-speed

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internet required for continuous, quality audiovisual connection. This highlights appropriate
infrastructure as being foundational to successful teletrauma use.
Because initial trauma management requires significant time commitment for clinicians
(Grossman, Schwab, Chu-Rodgers, & Kestner, 1999), time spent away from the patient should
be minimized. Therefore, the ability to immediately access necessary resources at the point of
care is particularly important to facilitate high quality, timely trauma care. Many interview
participants reported the ability to virtually access call lists of specialists and care documents
from a single screen as being a notable facilitator to teletrauma consults. To reduce barriers to
teletrauma use, technology must suit the trauma care context and must be supported by the
appropriate infrastructure.
5.1.3.2 The role of individual characteristics. Participants in this study did not identify
specific patient profiles or characteristics as the driving factor to determine teletrauma use.
Instead, clinician characteristics, geographic and organizational factors appeared to be the main
determinants. Despite the implementation of a program with a well-defined clinical purpose,
system adaptations were shaped by the users and clinical context. For rural clinicians in the
Robson Valley, a wide variety of cases are encountered. When a case presents that is not a
‘teletrauma’ case, the technology is adapted to meet the immediate needs of the clinician. This
was contrary to current literature which suggests that increased teletrauma use is associated
with younger patient age (Dharmar et al., 2013; Franken et al., 1997; Marcin et al., 2004; Mohr
et al., 2017; Mohr et al., 2018; Yang et al., 2015a; Yang et al., 2015b), penetrating injury
(Duchesne et al., 2008; Mohr et al., 2017), and high severity of illness or injury (Duchense et al.,
2008; Marcin et al., 2004; Ricci et al., 2003; Rogers et al., 2001). One reason why patient factors

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were identified in the literature and not the present study may be that the datasets were often
large enough to perform the necessary statistical analyses. In the Robson Valley, on the other
hand, low volumes of trauma patients and a lack of quantitative data preclude robust statistical
analysis. That is, as patients continue to use teletrauma and more data accumulates,
quantitative analysis of specific patient factors may become possible.
5.1.3.3 The role of user attitudes and relationships. Teletrauma use is dependent on
interprofessional relationships and user attitudes, as demonstrated in the findings of this
research. Across the interviews, it was found that when rural clinicians perceive that
consultants want to help, clinicians are less hesitant to initiate a teletrauma call. In a study by
Tachakra, Sivakumar, Everard, Mullett, and Freij (1996), it was noted that assessment of user
attitudes was a key consideration when designing teletrauma systems. Similar results were also
found by Sikka et al. (2016), who highlighted the importance of favorable attitudes and
opinions towards mobile technologies as a driver of innovation in acute wound telehealth. This
exemplifies the concept of teamwork during teletrauma consultations and outlines individual
attitudes and cooperativeness as prerequisites to effective team functioning. The leveraging of
existing interprofessional relationships was seen as vital to successful teletrauma consultations.
As well, Copley et al. (2017) noted that the effectiveness of telehealth consultations depends on
the relationships between those involved. Relationships between clinicians have also been
mentioned as a key component to effective, collaborative care (Berendsen, Benneker,
Meyboom-de Jong, Klazinga, & Schuling, 2007; Sampson, Barbour, & Wilson, 2016).
Examination of this study’s findings suggest that care processes have been improved as
a result of strong teamwork. For example, transfer times in the Robson Valley were reportedly

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reduced when clinicians had an existing relationship with consulting clinicians. The literature
also supported this finding: Butler et al. (2019) found that stronger teamwork predicted faster
time to defibrillation during simulated pediatric resuscitation. While successful teletrauma
depends on the attitudes and relationships between users, teletrauma also facilitates
relationship-building, acting as a tool to enhance the interaction between clinicians. Westbrook
et al. (2008) mentioned improved interhospital relationships and increase understanding
between staff as a result of using a teletrauma service. Participants in this study also reported
enhanced interprofessional relationships and collegiality as an outcome of teletrauma use.
Other literature supported this finding (Al-Kadi et al., 2009; Dyer et al., 2008).
5.1.3.4 The role of geography and organizational factors. Although it was noted in the
interviews that complex and severely injured patients may be more likely to receive teletrauma,
this was conditional on the comfort level of clinicians. That is, clinicians’ familiarity with the
presentation or level of comfort with clinical management ultimately determines use. Similar
findings were reported by Dharmar et al. (2013), who found that physicians were more likely to
initiate a teletrauma call if they were uncertain regarding clinical management. Another
described the activation and use of teletrauma to perform an unfamiliar procedure (Rottger et
al., 1997). Several other teletrauma programs were adopted as a means of overcoming a lack of
clinician experience and confidence in managing trauma cases (Al-Kadi et al., 2009;
Wibbenmeyer et al., 2016).
Access to resources and geographic factors also play a role in a clinicians’ decision to
activate teletrauma. For those in the Robson Valley, immediate access to necessary resources,
such as specialty care, is limited. When a patient’s condition is complex or requires increased

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resources, rural clinicians are likely to use teletrauma as a means of facilitating access. In the
literature, Saffle et al., (2009) noted a lack of timely subspecialist involvement and vast
geographical distance as reason to use a teletrauma service. The authors found that despite
“extremely limited medical subspecialty” (p. 361) coverage in the area, teletrauma facilitated
appropriate critical care, highlighting access to burn care as justification for program adoption.
Poor weather and large physical distance influence the threshold to use teletrauma.
When inclement weather prevents the transfer a patient to a larger facility, rural clinicians are
forced to manage patients locally, often for an extended period of time. In such cases,
teletrauma is more likely to be used. These findings were not demonstrated in the literature;
one study found that rurality and distance to a facility with a higher level of care were not
associated with teletrauma use (Mohr et al., 2016). However, characteristics of the rural
hospitals were cited as reasons for the lack of variability of teletrauma use. Thus, geography,
clinician characteristics, and organizational factors determine utilization of teletrauma.
5.1.3.5 Interrelatedness between the determinants of teletrauma use. When
examining the role of technology, patient characteristics, organizational and geographical
factors through the lens of Andersen and Newman’s (1973) Health Service Utilization
framework, the interrelatedness between them is apparent. Under Andersen and Newman’s
(1973) model, societal determinants influence individual determinants directly and indirectly
through the healthcare system, whereupon individual determinants (such as symptoms or
diagnoses) would then strongly influence health service utilization (Figure 6). However, the
context of teletrauma may alter the degree of influence that individual determinants have over
service utilization. For example, when a trauma patient is encountered in a rural area,

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geographic isolation and clinician discomfort may be more important than patient
demographics when deciding to use trauma resources. This shift is reflected in the findings of
this study, as trauma service use in the Robson Valley is reportedly more strongly influenced by
clinician, organizational, and geographical factors as opposed to specific patient-level
characteristics; participants did not identify that patient characteristics altered the threshold to
use the teletrauma service. Teletrauma appears to limit the degree to which individual patient
factors determine service utilization.
Thus, trauma service use in the Robson Valley may be best explained by the influence
that teletrauma has on societal determinants and the health services system. For example,
augmenting technology, supporting a virtual care culture, and focusing on clinicians and the
relationships between them may maximize access to appropriate trauma care in rural areas. As
virtual care becomes more culturally accepted and embedded into societal values, this
relationship may shift again, emphasizing instead the role of the normative component.
5.1.4 Interconnectedness of the healthcare system. The delivery of rural trauma care is
complex, having many interacting and interdependent parts. While aspects of the healthcare
system can be identified and understood separately, effective functioning relies on the
interworking of the parts. Plsek (2001) mentioned that the power of the system lies in the
number and strength of interconnections between the elements. As such, rural teletrauma
examination may necessitate a complex systems view of health care that appreciates the
relationships between components, as opposed to a fragmented view that appraises each
element individually. Noted by Widmer, Swanson, Zink, and Pines (2018), complex systems
thinking is particularly suited to emergency medicine when designing interventions and

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overcoming challenges, by moving beyond distinct processes and reductionism.
Interconnectedness is one way to envision how the different parts of rural teletrauma care
relate to one another and evolve to create value, influencing patient care.
Findings from this study support the view of rural trauma care as being interconnected.
While the various components of the health delivery system are identifiable, guided by the
findings and Andersen and Newman’s (1973) Health Service Utilization framework, the
relationships between them are dynamic. For care delivered in the Robson Valley,
interconnectedness is the concept that binds rural clinicians, teletrauma, and effective teambased care (Figure 9). At the center of collaborative care models is the care that is delivered to
the patient (Lorenz, Mauksch, & Gawinski, 1999), unifying the parts of the system under one
superordinate goal. The degree of connectedness between the healthcare system may affect
the care that is provided and may explain variations in trauma service utilization.
Clinicians, for example, share the care of trauma patients in the Robson Valley when
consulting remote clinicians via teletrauma. This sharing of clinical responsibility and fostering
of interprofessional relationships typifies connectedness between clinicians, teletrauma, and
team-based care. On the other hand, the breakdown of the connections between these parts
(poor communication, lack of interprofessional relationships, or ill-suited teletrauma
technology) can negatively affect patient care, as demonstrated in the findings of this study. To
augment the care provided to patients, it may be of use to focus on the interrelations between
the system factors, rather than examining the pieces in isolation. This approach to thinking
about the healthcare system was also recognized by Stange (2009), who described that
understanding system components as being related and connected can foster care that is less

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fragmented and of higher value. Similarly, Widmer et al. (2018) mentioned that complex
systems thinking is well-suited for optimizing health care interactions and understanding
system behavior. Furthermore, teletrauma may be seen as a part of a larger system of
connected telehealth programs more broadly. This perspective recognizes telehealth as a
clinician-centric solution to streamlined patient care access via a virtual network, as opposed to
being an isolated commodity. As identified by participants in this study, the deployment of
telehealth systems that act on and are designed for clinicians emphasizes relationships instead
of siloed clinical scenarios. This approach to telehealth is fitting for collaborative care models
and views telehealth as operating within a complex healthcare system having many interrelated
parts.
Interconnectedness provides the perspective and the tools necessary to appropriately
examine teletrauma care in the Robson Valley, assess challenges and opportunities, and design
interventions. The delivery of optimal trauma care in the Robson Valley relies on the effective
functioning of clinicians, teletrauma, and team-based care in a dynamic, interconnected model
of care. Interconnectedness in the Robson Valley is exemplified through the sharing of clinical
responsibility between rural and consulting clinicians, the necessity of interprofessional
relationships as a prerequisite to effective teletrauma use, and the establishment of the Robson
Valley as a vital component to the trauma network of care. This balanced model appreciates
the interdependence of the parts of the system and integrates the network of regionalized
trauma care to enable the best and most accessible care for patients, regardless of their
location. Insights from this study highlight the importance of a complex systems perspective of

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trauma care in rural areas and the need for interventions that are focused on clinicians and the
relationships between them.
5.2.0 Implications and recommendations
This study has direct implications for practice and policy while filling an identified
knowledge gap in the current teletrauma literature. Implications and recommendations are
summarized below (Figure 10).

Implications
• Clinician-focused programs may reduce barriers to teletrauma use
• Strengthening interprofessional relationships may empowered to
manage trauma patients
• Teletrauma facilitates the establishment of rural sites as vital
components in the trauma network
• Regional teletrauma policies are necessary to guide strategic
teletrauma design and implementation in other rural areas
• Clinician-centric policies enhance program sustainability
Recommendations
• Future research should engage a complex systems perspective that
recognizes the interconnectedness between system components
• Investing in local solutions may drive innovation for rural health care
delivery
• Medical education and training should adopt an interdisciplinary
approach that appreciates the context of rural trauma care

Figure 10: Summary of Implications and Recommendations

5.2.1 Clinical implications. Exploring factors associated with teletrauma utilization in
northern BC permits a deeper understanding of the functioning of the teletrauma program

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within the local context and how it operates within the regionalized trauma network.
Understanding teletrauma in northern BC may help clinicians to view teletrauma as a
communication tool, serving the broader network of care. By allowing rural clinicians to decide
which technology best suits their context, and how and when to use it, clinicians may feel more
empowered. Knowledge from the study facilitates the development of team-based care and
enables rural providers to establish their sites as key components in the trauma network.
Specifically, rural sites are better able to effectively stabilize and manage trauma patients,
contributing to integration of the trauma network.
This provides knowledge about when, how, and for whom teletrauma is being used.
Opportunities may be identified to facilitate more efficient use of teletrauma by identifying
situations when it is required most, enhancing effectiveness of the service and maximizing
benefits for northern BC patients in need of trauma care. In addition, analysis of associated
individual, clinician, and system level factors highlights in greater detail the degree of
teletrauma accessibility and between-provider variability in service use. Rural clinicians using
the service may also gain a better understanding of how certain organizational and geographic
characteristics influence their use of teletrauma. Being more aware of how and why they use
teletrauma may enable clinicians to more effectively use the system while remaining confident
that teletrauma is making a difference for the patients they are treating.
5.2.2 Policy implications. Understanding how teletrauma operates as a key component
of a high-functioning, complex regionalized trauma system provides insight into how telehealth
may be integrated into rural settings more broadly. Being aware of how teletrauma influences
the role of rural facilities within the larger system of care is integral to designing and

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implementing additional telehealth services; understanding the functioning of teletrauma may
help guide the leveraging of other telehealth programs to fill gaps in rural health care delivery.
Knowledge gained through this project may also contribute towards strategic adoption of
telehealth with a systems perspective. At the systems level, this study provides some of the
groundwork necessary to design and use standardized implementation policies to create robust
telehealth networks across the health region. As telehealth moves towards becoming
structurally integrated into heath delivery systems, patients and clinicians can be more
confident in the long-term reliability of telehealth as a standard for health care in remote areas.
This study outlines an integrated model of care that includes virtual and traditional care,
normalizing the use of telehealth in the health care system.
To facilitate expansion of telehealth services and guide policy creation, the use of
standardized language is necessary. From the insight provided by key stakeholders during
consultation, a regional definition of teletrauma can be delineated. This supports the adoption
of consistent language regarding teletrauma and may drive telehealth policy that is more fitting
for the nuances of rural care. Thus, guidelines can be adapted that support rural clinicians and
are reflective of rural practice.
It may be of use to create policies that permit flexible, clinician-led technological
innovation and utilization. While innovations may not always be successful, giving clinicians the
freedom to experiment with technology is in line with the identified need for clinician-led and
clinically-driven solutions to rural health care delivery. To create the conditions necessary for
innovation, West et al. (2017) mentioned that clinicians must have the autonomy to discover
and experiment with new ways to deliver care. Creating the space for innovation in policies

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requires that rural clinicians are recognized as the experts where they practice; empowering
them to decide what works best for them in their unique context is in alignment with a systems
perspective of rural health care delivery and may contribute towards sustainable services. The
design of teletrauma services by and for clinicians may foster feelings of ownership over the
program, leading to enhanced sustainability. Practice-driven and clinician-centric policies may
therefore contribute towards sustainable programs and may facilitate effective adaptations to
existing programs that are sensitive to evolving clinical contexts in rural areas.
5.2.3 Recommendations. This study provides unique insight into future teletrauma
research with particular regards to the dynamic relationships between various health care
components. Because teletrauma functions within a complex system having many
interdependent parts, researchers should adopt a systems perspective. That is, research should
be reflective of the interconnectedness between healthcare system pieces instead of isolating
components to be studied individually. More specifically, connectedness between teletrauma
(or telehealth more broadly) and clinicians implies that research should include the clinicians
and the relationships between them; teletrauma research needs to occur with the same
systems perspective within which teletrauma operates. For example, examination of
teletrauma technology should take into consideration the needs of rural clinicians, the rural
context in which they practice, how the technology operates to support or hinder
interprofessional relationships, and the interoperability of teletrauma with other telehealth
programs.
To support future research and the advancement of integrated regionalized trauma
networks, organizations should invest in solutions focused on linking clinicians and resources.

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As opposed to isolating the technology and studying its effects on care processes, research
should be clinician-centric, emphasizing the important role of interprofessional relationships
embedded within networks of care. The design of teletrauma programs or other interventions
should engage a similar approach. Investing in local solutions means giving rural clinicians the
freedom to drive innovative solutions to local health care delivery. This recognizes the
practicing clinician as the one who best knows the resources and local context and facilitates
the design of interventions that are non-prescriptive and locally-relevant.
Knowledge from this study may also affect medical education, broadening the
perspective of emergency medicine. This research highlights the heterogeneity in the way that
emergency medicine is delivered. Rural trauma care differs from the care delivered in urban
centers, owing to the unique challenges related to geography, rural institutions, and the
clinicians that practice rurally. Education on emergency medicine should expand to include the
nuances of rural health delivery, emphasizing the challenges of rural medicine, appropriate
medical training, and the utility of alternate methods of delivering care at a distance. Education
that includes this perspective may contribute towards rural-specific training and enhance the
recruitment and retention of a rural workforce. Furthermore, interdisciplinary training of
clinicians may be of use. Because clinicians in rural areas typically work in small teams with
other professions, an interdisciplinary approach may help to solidify the principles of crossboundary collaboration that are necessary for rural health delivery. For a summary of the
implications and recommendations, see Figure 10.

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5.3 Strengths and limitations
A qualitative interpretive description study was undertaken using interview data from
fourteen teletrauma stakeholders to better understand teletrauma utilization in northern BC.
The study had several strengths. The research approach was fitting for the research question
and objectives of the study. The study also generated rich data from a variety of perspectives of
teletrauma, permitting deep insight into the role and function of teletrauma in a rural setting.
Prolonged engagement with the data and ongoing reflexivity supported the rigor of the
research. A reflexive journal, kept throughout the study, aided in analysis and helped the
researcher to remain aware of biases and how these affect the research design. Reflexive
journaling also enabled transparency of the logic behind the themes and interpretations that
emerged while remaining grounded in the data, facilitating the accruement of credibility.
Findings from this research address knowledge gaps in literature by focusing on clinician
perspectives of teletrauma in a rural setting, and how teletrauma operates within an existing
regionalized trauma system. Given the diverse set of perspectives that were examined,
knowledge from this study also has implications for rural practice, policy development,
healthcare system design, and future research.
There are several limitations to the study. First, the sample size may be considered
small. However, this sample size is consistent with qualitative studies, which are performed to
prioritize inductive analysis and depth, as opposed to breadth (Morse, 1995). While study
participants practiced in a variety of rural settings and had a diverse range of experiences using
teletrauma, the researcher recognizes that findings may not be representative of all rural
practicing physicians. Additionally, it is notable that the pool of potential participants identified

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for the study was particularly limited due to the small number of rural physicians who had
experience with teletrauma and participants were sampled to generate information-rich cases.
Despite these potential limitations, saturation in the analysis was achieved. Likewise, the focus
of this study was limited to the Robson Valley in northern BC and may not be generalizable to
other clinical settings. However, it is important to note that this research has focused on an
under-researched context and as such, the findings will be transferrable to other centers with
similar contexts and population. Second, interviews with participants were often limited due to
the time constraints and busy schedules of the participants. Work demands shortened
interview time for several participants, however, the researcher worked to prioritize key data
that was most relevant to teletrauma within this context and avoid focusing on more general
data. In future research, it may be beneficial to conduct repeat interviews with participants to
yield different insights and richer data.
5.4 Conclusions
Teletrauma has the potential to overcome barriers to care in rural and remote areas and
may enhance appropriate and timely access to care in rural contexts. This research examined
the perspectives and experiences of teletrauma stakeholders to better understand rural
teletrauma use in northern rural BC. Patients, clinicians, the population, and the health care
system benefited from availability and use of the teletrauma program. Teletrauma was not
isolated solely to trauma care, but enhanced further the system of care by enabling clinicians to
attend to a variety of non-trauma situations. Teletrauma supports rural sites to participate in
the trauma network by supporting rural clinicians to be connected in real-time to appropriate
resources. The establishment of relationships between teletrauma users was vital to the

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success of teletrauma. Rural clinicians were more likely to activate teletrauma if they felt the
consulting clinician would be willing to help them in clinical management. Interprofessional
relationships enabled and facilitated effective teletrauma interactions, whereas communication
breakdown resulted from a lack of established relationships. The fundamental underlying
concept that brought together rural clinicians, teletrauma, and team-based care in the Robson
Valley teletrauma program was interconnectedness. This model of interconnected care
empowers rural clinicians and establishes rural sites as vital components in the trauma
network, expanding high quality trauma care to Canadians living in rural areas.
Based on findings from this research, it may be of use for future teletrauma research to
fully recognize the complexity and interdependence of healthcare system factors; teletrauma
was closely linked to all components of the healthcare system and affect each in unique ways.
As rural health care advances and virtual care becomes increasingly integrated, understanding
how teletrauma functions in the overall healthcare system will be pivotal to designing effective
regionalized trauma systems. Knowledge from this study may be used to guide the
development of regional policies, including a standardized regional definition of teletrauma,
and strategies to design and implement teletrauma in rural areas.

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142

FACTORS ASSOCIATED WITH THE USE OF TELETRAUMA

143

Appendix A
Search Strategy by Database using Keywords and Subject Headings

Search
Syntax

PsycINFO

EconLit

((telemedicine OR telemetry
OR "remote consultation" OR
telepathology OR telepathology OR teleradiology
OR videoconferencing OR
telenursing OR
telecommunications OR
telehealth OR tele-health OR
ehealth OR mhealth OR
telecare OR tele-care OR
teleconsultation OR "mobile
health" OR "online health" OR
"on-line health" OR teledermatolog* OR
teledermatolog* OR telepsychiatry OR telepsychiatry
OR telesurgery OR telesurgery OR teleconsult* OR
tele-consult* OR telecardio*
OR tele-cardio* OR
teleophthalmology OR teleophthalmology OR teleoncology OR teleoncology OR
tele-radiology OR
teleneurology OR teleneurology OR "telemental
health" OR "tele-mental
health" OR "e-mental health"

(telemedicine OR telemetry
OR "remote consultation" OR
telepathology OR telepathology OR teleradiology
OR videoconferencing OR
telenursing OR
telecommunications OR
telehealth OR tele-health OR
ehealth OR mhealth OR
telecare OR tele-care OR
teleconsultation OR "mobile
health" OR "online health" OR
"on-line health" OR teledermatolog* OR
teledermatolog* OR telepsychiatry OR telepsychiatry
OR telesurgery OR telesurgery OR teleconsult* OR
tele-consult* OR telecardio*
OR tele-cardio* OR
teleophthalmology OR teleophthalmology OR teleoncology OR teleoncology OR
tele-radiology OR
teleneurology OR teleneurology OR "telemental
health" OR "tele-mental
health" OR "e-mental health"

143

Biomedical Reference
Collection: Comprehensive
(telemedicine OR telemetry
OR "remote consultation" OR
telepathology OR telepathology OR teleradiology
OR videoconferencing OR
telenursing OR
telecommunications OR
telehealth OR tele-health OR
ehealth OR mhealth OR
telecare OR tele-care OR
teleconsultation OR "mobile
health" OR "online health" OR
"on-line health" OR teledermatolog* OR
teledermatolog* OR telepsychiatry OR telepsychiatry
OR telesurgery OR telesurgery OR teleconsult* OR
tele-consult* OR telecardio*
OR tele-cardio* OR
teleophthalmology OR teleophthalmology OR teleoncology OR teleoncology OR
tele-radiology OR
teleneurology OR teleneurology OR "telemental
health" OR "tele-mental
health" OR "e-mental health"

CINAHL

PubMed

((telemedicine OR telemetry
OR "remote consultation" OR
telepathology OR telepathology OR teleradiology
OR videoconferencing OR
telenursing OR
telecommunications OR
telehealth OR tele-health OR
ehealth OR mhealth OR
telecare OR tele-care OR
teleconsultation OR "mobile
health" OR "online health" OR
"on-line health" OR teledermatolog* OR
teledermatolog* OR telepsychiatry OR telepsychiatry
OR telesurgery OR telesurgery OR teleconsult* OR
tele-consult* OR telecardio*
OR tele-cardio* OR
teleophthalmology OR teleophthalmology OR teleoncology OR teleoncology OR
tele-radiology OR
teleneurology OR teleneurology OR "telemental
health" OR "tele-mental
health" OR "e-mental health"

(telemedicine OR telemetry
OR remote consultation OR
telepathology OR telepathology OR teleradiology
OR videoconferencing OR
telenursing OR
telecommunications OR
telehealth OR tele-health OR
ehealth OR mhealth OR
telecare OR tele-care OR
teleconsultation OR mobile
health OR online health OR
on-line health OR teledermatolog* OR
teledermatolog* OR telepsychiatry OR telepsychiatry
OR telesurgery OR telesurgery OR teleconsult* OR
tele-consult* OR telecardio*
OR tele-cardio* OR
teleophthalmology OR teleophthalmology OR teleoncology OR teleoncology OR
tele-radiology OR
teleneurology OR teleneurology OR telemental
health OR tele-mental health
OR e-mental health OR

FACTORS ASSOCIATED WITH THE USE OF TELETRAUMA
OR telegeriatric* OR telegeriatric* OR teledialysis OR
tele-dialysis OR
telerehabilitation OR telerehabilitation OR teleconferenc* OR teleconferenc*
OR "video conferenc*" OR
"virtual care" OR telerenal OR
telediabetes OR
teleemegency OR
telemergency OR teleemergency OR teletrauma OR
telemonitor* OR telestroke)
OR (MM "Telemedicine" OR
MM "Teleconferencing" OR
MM "Online Therapy" OR MM
"Teleconsultation" OR MM
"Telepsychiatry" OR MM
"Telepsychology" OR MM
"Telerehabilitation")) AND
((rural OR rural area* OR rural
communit* OR remote OR
small town*) OR (MM "Rural
Environments")) AND
((trauma* OR injur* OR acute
OR emergent OR urgent OR
emergenc* OR ed OR er) OR
((MM "Emergency Medicine"
OR MM "Emergency Services"
OR MM "Crisis Intervention
Services") OR (MM "Injuries"
OR MM "Birth Injuries" OR
MM "Burns" OR MM
"Electrical Injuries" OR MM
"Head Injuries" OR MM

OR telegeriatric* OR telegeriatric* OR teledialysis OR
tele-dialysis OR
telerehabilitation OR telerehabilitation OR teleconferenc* OR teleconferenc*
OR "video conferenc*" OR
"virtual care" OR telerenal OR
telediabetes OR
teleemegency OR
telemergency OR teleemergency OR teletrauma OR
telemonitor* OR telestroke)
AND (rural OR rural area* OR
rural communit* OR remote
OR small town*) AND
(trauma* OR injur* OR acute
OR emergent OR urgent OR
emergenc* OR ed OR er)

144

144
OR telegeriatric* OR telegeriatric* OR teledialysis OR
tele-dialysis OR
telerehabilitation OR telerehabilitation OR teleconferenc* OR teleconferenc*
OR "video conferenc*" OR
"virtual care" OR telerenal OR
telediabetes OR
teleemegency OR
telemergency OR teleemergency OR teletrauma OR
telemonitor* OR telestroke)
AND (rural OR rural area* OR
rural communit* OR remote
OR small town*) AND
(trauma* OR injur* OR acute
OR emergent OR urgent OR
emergenc* OR ed OR er)

OR telegeriatric* OR telegeriatric* OR teledialysis OR
tele-dialysis OR
telerehabilitation OR telerehabilitation OR teleconferenc* OR teleconferenc*
OR "video conferenc*" OR
"virtual care" OR telerenal OR
telediabetes OR
teleemegency OR
telemergency OR teleemergency OR teletrauma OR
telemonitor* OR telestroke)
OR ((MM "Telemedicine+")
OR (MM "Telehealth+") OR
(MM "Telepsychiatry") OR
(MM "Telerehabilitation")))
AND ((rural OR rural area* OR
rural communit* OR remote
OR small town* ) OR ((MM
"Rural Areas") OR (MM "Rural
Health") OR (MM "Hospitals,
Rural") OR (MM "Rural
Population") OR (MM "Rural
Health Services") OR (MM
"Rural Health Nursing") OR
(MM "Rural Health Centers")
OR (MM "Rural Health
Personnel"))) AND ((trauma*
OR injur* OR acute OR
emergent OR urgent OR
emergenc* OR ed OR er) OR
((MM "Emergency Service+")
OR (MM "Emergency
Patients") OR (MM
"Emergencies+")))

telegeriatric* OR teledialysis
OR tele-dialysis OR
telerehabilitation OR telerehabilitation OR teleconferenc* OR teleconferenc*
OR video conferenc* OR
virtual care OR telediabetes
OR telemergency OR teleemergency OR teletrauma OR
telemonitor* OR telestroke)
AND (rural OR rural area OR
rural communit* OR remote
OR small town) AND (trauma*
OR emergent OR urgent OR
emergenc*)

FACTORS ASSOCIATED WITH THE USE OF TELETRAUMA

Initial
Results
Limiters
Results
after
Limiters

145

"Spinal Cord Injuries" OR MM
"Wounds")))
384 articles

26 articles

178 articles

903 articles

898 articles

English language, academic
articles
341 articles

English language, academic
articles
11 articles

English language, academic
articles
160 articles

English language, academic
articles
643 articles

English language, human
subjects
622 articles

Note: ‘MM’ denotes Subject Heading for a given database

145

FACTORS ASSOCIATED WITH THE USE OF TELETRAUMA

146

Appendix B
Summary of Teletrauma Studies Included in the Review (N=28, article date range 1997-2018)
Reference

Year

Study
location

Study type

Study
objectives

Patient
group

Sample size
N (teletrauma
subgroup n)

Telehealth
technology and
function

Al-Kadi et
al.

2009

Alberta,
Canada

Pilot study
descriptive
evaluation

“In order to
evaluate the
acceptability
of
[telesonograp
-hy], we
surveyed the
clinical users
regarding
their
perceptions
of the teleultraound
system” (p.
251)

Trauma
patients

N=14

Telesonography
via real-time
bidirectional
videoconferenci
ng to conduct
Focused
Assessment
with
Sonography for
Trauma (FAST)
and Extended
FAST
examinations
for
pneumothoraxe
s during acute
trauma
resuscitations

146

Factors
Associated
with
telehealth
activation
Lack of
operator
experience to
produce
clinicallymeaningful
information
Lack of
familiarity
with major
trauma

Evaluation
aim*

Communicatio
n network

Main findings

Provider
experience

Rural
community
hospital
(physicians,
nurses,
residents,
medical
students)
consulting a
quaternary
level trauma
care center
(emergency
physicians,
trauma
surgeons)

The majority of
users were
either satisfied
or very satisfied
with the service
and agreed or
strongly agreed
it could benefit
injured patients
in northern
Canada
92% of
respondents
reported
improved
collegiality
between the
client and
consulting sites

FACTORS ASSOCIATED WITH THE USE OF TELETRAUMA
Ashkenazi
et al.

Brebner et
al.

2007

2004

Israel

Scotland

Retrospective
descriptive
analysis

Evaluation and
retrospective
review of a
telemedicine
service

“To assess
the effect of
teleradiology
upon the
need for
transfer of
head injured
victims
requiring
hospitalisatio
n but
referred
initially to a
rural Level 2
trauma
centre
without
neurosurgical
capacity” (p.
550)
To
“[evaluate]
the
teleconsultations
during a 12month
period” (p.
17)

147

Trauma - All
ages
included (<1
year - >65
years)

N=209
(n=83
teletrauma)

Accident
and emergency patients
(mean age
40 years)

N=1322

Teleradiology
via an online
consultation to
evaluate
pathological
head and neck
CT scans

Lack of timely
neurosurgical
access

Population
health

Rural general
hospital
(senior trauma
surgeon)
consulting a
Level 1 trauma
center
(neurosurgeon
)

Reliable, around
the clock
teleradiology can
facilitate the
safe
management of
head trauma
patients in a
Level 2 trauma
center

Teleconsultatio
n for injured
patients via a
videoconferenc
e system and
document
camera

Radiograph
consultation

Population
health

Upper and
lower limb
injuries;
fractures or
suspected
fractures

Provider
experience

Fourteen
community
hospitals
(emergency
nurses)
consulting a
larger hospital
(doctor or
specialist)

High levels of
satisfaction with
the service

Avoidance of
unnecessary
inter-hospital
transfer

“The majority of
teleconsultations
related to
fractures or
suspected
fractures of the
limbs” (p. 19)
Teleconsultation
reduced travel
distance by
increasing local
management

147

FACTORS ASSOCIATED WITH THE USE OF TELETRAUMA
Dharmar et
al.

2013

California,
USA

Retrospective
chart review
with
concurrent
surveys

“To compare
the quality of
care
delivered to
critically ill
and injured
children
receiving
telemedicine,
telephone, or
no
consultation
in rural
emergency
departments
” (p. 2388)

Trauma Children
older than 1
day and
younger
than 17
years

148
N=320
(n=58
teletrauma)

Telemedicine
consultations
via bidirectional
videoconferenci
ng system for
children
presenting in
the highest
triage category;
that is,
“seriously ill or
injured with life
or limb
threatening
emergencies
requiring
immediate
physician
assessment and
treatment” (p.
2389)

“ED
physicians
may be more
likely to
request
consultation
when they
are less
certain of
their
diagnosis or
treatment
plan” (p.
2394)
Telemedicine
was used for
younger
patients

Patient/
family
experience
Provider
experience
Population
health

Five rural
emergency
departments
(physicians
and nurses)
consulting an
academic
children’s
hospital
(pediatric
critical care
physician)

Compared to no
consultation and
telephone
consultation,
quality of care
was highest for
patients
receiving
telemedicine
consultation
Compared to
telephone
consultation,
physicians more
frequently
reported
changes in
diagnosis and
therapeutic
interventions
with
telemedicine
consultation
Physician and
parent
satisfaction was
higher for
telemedicine
consultation
than for
telephone

148

FACTORS ASSOCIATED WITH THE USE OF TELETRAUMA
Duchesne
et al.

Dyer et al.

2008

2008

Mississippi,
USA

Alberta,
Canada

retrospective
chart review
and analysis

Descriptive
analysis of
pilot project

To “analyze
outcomes
before (preTM) and after
(post-TM)
implementati
on of
telemedicine
in the
management
of rural
trauma
patients
initially
treated at
local
community
hospitals
(LCH) before
trauma
center (TC)
transfer” (p.
92)

Trauma - All
ages
included
(mean age
33 years)

“describe the
development
of a pilot
project to
communicate
real-time
resuscitative
EFAST
examinations
between a
rural referral
center and a
tertiary care
receiving

Trauma - All
adults >18
years

149

149
N=402
(n=51
teletrauma)

N=23

Trauma
telemedicine
via two-way
audio-visual
videoconferenci
ng system
during trauma
cases

Teleultrasound
via a real-time
bidirectional
videoconferenci
ng system
during acute
trauma
resuscitation

Lack of access
to quality
emergency
care
Higher Injury
Severity
Score, higher
initial base
deficit, lower
initial systolic
blood
pressure, less
blunt trauma
and more
penetrating
injuries, and
the need for
more units of
packed red
blood cells
for
transfusion
Lack of access
to expert
trauma care
and
specialists
Lack of access
to highly
experienced
ultrasonographers

Population
health
Cost
optimization

Seven rural
community
hospitals (ED
physicians or
nurse
practitioners)
consulting a
Level 1 trauma
center
(emergency
physician)

Telemedicine
improves
evaluation and
management of
rural trauma
patients; more
severely injured
patients are
identified and
more rapidly
transferred
Decreased
hospital costs
associated with
telemedicine use
without changes
in mortality
Telemedicine
improved care

Provider
experience
Population
health

Rural
community
hospital
(emergency
physicians)
consulting a
quaternary
level trauma
care center
(emergency
physicians and
trauma
surgeons)

General
satisfaction with
the technology
and the
perception that
it would be
useful in remote
communities
Improved
feelings of
collegiality
between the

FACTORS ASSOCIATED WITH THE USE OF TELETRAUMA

150

center” (p.
1210)

Ehrlich et
al.

Elkaim et
al.

2007

2012

Chechen
Republic,
Russia

France

Descriptive
analysis

Case series
and
retrospective
analysis

Describe a
telemedicine
service

“to assess
remote
diagnosis and
treatment
recommenda
tion of
orthopedic
trauma... and
the
usefulness of
image
transfer” (p.
296)

client and
consulting site

All ages
included
(age range 2
weeks-56
years)

Pediatric
patients
(mean age
9.2 years,
age range 216 years

150

N=64

N=20

Teleconsultatio
ns for injured
and ill patients
via real-time
videoconferenc
e or
asynchronous
e-mail

Lack of
specialist
support

Teleconsultatio
n for traumatic
orthopedic
pediatric
injuries via xray image
transfer
through a
mobile camera
phone

Fractures of
the upper
limbs

Population
health

Population
health

Remote
children’s
hospital
(doctors)
consulting a
larger
Pediatric and
Children’s
Surgical
hospital
(doctors,
specialists)
Local hospital
(physician) to
a larger
central
hospital
(orthopedic
surgeon)

Technical and
clinical feasibility
of remote
ultrasound
during acute
trauma
resuscitations
Use of satellite
communication
is technically
feasible and
provides clinical
support to
remote doctors
Improved quality
of care and
reduced the
need for
transport
Teleconsultation
using cellphones
is useful for
diagnosis,
treatment
initiation, or for
decision to
transfer in
emergency
orthopedic cases

FACTORS ASSOCIATED WITH THE USE OF TELETRAUMA
Franken et
al.

Jacobs et
al.

1997

2015

Iowa, USA

Netherland
s

“observational
… with a
control
population
to indicate the
differing
nature of
requests by
primary
care
physicians for
teleradiology
consultation”
(p. 495)
Retrospective,
descriptive,
observational
before and
after study

To
quantitatively
document
“how
teleradiology
was used for
contemporaneous
consultation
with a
radiologist by
physicians at
a small rural
hospital” (p.
492)
“what is the
influence of
the
introduction
of an x-ray
facility in a
remote
[general
practitioner]
practice on
accurately
diagnosed
fractures,
hospital
visits,
number of xrays and
treatment”
(p. 2)

All patients
with
radiological
consultation
(age range 0
- >65 years)

All patients
with
traumatic
orthopedic
injury

151

151
N=937
(n=519
teletrauma)

N=794
(n=482
teletrauma)

Teleradiology
system with
real-time
bilinear
interpolated
zoom, pan, and
windowing to
transmit images
to a referring
radiologist

Younger
patient age

Teleradiology
via digital
transmission of
radiographs
and phone
follow-up for
orthopedic
injuries

Reduce
unnecessary
referrals
(trips to the
central
hospital)

Population
health

Spine
examinations
Abdominal
radiographs

Population
health

A rural
hospital
(attending
physicians)
consulting a
remote private
radiology
practice
(radiologists)

Teleradiology is
more likely to be
used in acute
cases,
particularly spine
and abdominal
and in those
involving infants

Two rural
general
practices
(general
practitioners)
consulting a
central
hospital
(radiologists,
surgeons)

The introduction
of teleradiology
increased
demand for xrays

Teleradiology
improves
timeliness of
care

Teleradiology
reduces missed
fractures,
unnecessary
travel, and
increases local
treatment

FACTORS ASSOCIATED WITH THE USE OF TELETRAUMA
Lambrecht

Latifi et al.

Lienert et
al.

1997

2009

2010

North
Dakota,
USA

Arizona,
USA

Switzerland

Descriptive
study

Retrospective
chart review
of a pilot
program

Retrospective
analysis

“to study the
role of
telemedicine
in the
delivery of
trauma care
to rural
providers on
a
telemedicine
network” (p.
265)

Trauma
patients
(mean age
32.3 years,
range 2 – 93
years)

“to report
the initial
experience
with a
telemedicine
program
connecting 5
rural
hospitals with
a level I
trauma
center” (p.
905)

Trauma
(mean age
34.3 years,
age range
1.5-80
years)

“to assess the
occurrence of
phone calls
related to

Dental
trauma
(mean age
8.6 years,

152

152
N=100

N=35

N=672

Trauma
teleconsults via
two-way
interactive
video
conferencing to
transmit
images, patient
information,
radiographs,
and
electrocardiogr
ams for trauma
patients

Extremity
and pelvic
injuries

Teletrauma via
real-time
transmission of
video, audio,
and vital signs
during trauma
and emergency
resuscitations

Blunt trauma
(orthopedic
or close head
injuries)

Telemedicine
via telephone
triage to
provide

Patients
classified as
‘urgent care’

Provider
experience
Population
health

Provider
experience
Population
health
Cost
optimization

After hours
(Monday to
Friday 6pm –
8am)

Population
health

3 rural
hospitals
(general
practitioner,
family
practitioner,
internist,
physician
assistants)
consulting a
Level 2 trauma
center
(orthopedic
surgeons,
emergency
physicians,
radiologists,
neurosurgeons
)
5 rural
hospitals
(physician,
nurse
practitioner)
consulting a
university
hospital
trauma center
(trauma
surgeon)

Patients
directly
consulting a
large

Trauma
teleconsultation
has the ability to
reduce trauma
center transfers
There are no
adverse
outcomes for
patients who
received a
trauma
teleconsult
Isolation of
primary care
providers was
reduced
Teletrauma is
potentially costsaving by
reducing
unnecessary
transfers
Continual staff
training is
needed for
providing
teletrauma care
Quality of care
was enhanced
“In rural areas,
the proportion
of those calling
for dental

FACTORS ASSOCIATED WITH THE USE OF TELETRAUMA

Marcin et
al.

McKerrow
et al.

2004

2017

California,
USA

Australia

Nonconcurrent
cohort design

Retrospective
review

dental
trauma… and
to collect
information
regarding
patient
profiles,
geographic
region, time
of calling, and
assumed type
of injury” (p.
224)
“to describe a
pilot
telemedicine
project that
allows
remote
trauma
center’s adult
intensive care
unit to obtain
nontrauma,
nonsurgicalrelated
pediatric
critical care
consultations
for acutely
injured
children” (p.
251)
“to analyze
the
proportion of
operative and
non-

153

age range 06 years)

Pediatric
trauma
patients less
than 16
years

All ages of
patients
with clavicle
fracture
(median age

153

diagnoses and
propose
treatment
options for
traumatic
dental injuries

N=97
(n=17
teletrauma)

N=150
(n=50
teletrauma)

telemedical
center
(physicians)

Injuries in
primary
dentition

Telemedicine
consultation via
a live,
interactive,
two-way
audiovisual
connection to
review the
history, vital
signs, lab work,
radiographs,
monitoring and
therapeutic
devices, and to
perform a
physical exam

Higher Injury
Severity
Score

Telehealth via
teleconferencin
g to consult on
patients with
clavicle fracture

N/A

Younger age

Population
health
Provider
experience
Patient/
family
experience

Population
health

Rural Level 2
trauma center
(nurses,
trauma
surgeons,
neurosurgeons
, adult
intensivists)
consulting a
Level 1 trauma
center and
university
children’s
hospital
(pediatric
critical care
physicians)

Various rural
clinics or
hospitals
consulting a

trauma was
higher than in
urban areas” (p.
226);
telemedical
centers can
improve
emergency
management
after trauma to
patients with
limited access to
dental care
Telemedicine
consultation for
remote, critically
injured pediatric
patients is
feasible and
maintains care
quality
Parents and
clinicians were
satisfied with the
consultation and
care received

Telehealth
patients were
managed more
conservatively
(reflecting access

FACTORS ASSOCIATED WITH THE USE OF TELETRAUMA

Mohr et al.

2016

North
Dakota,
USA

Observational
cohort study

operative
treatment
methods for
clavicle
fracture in
the
[telehealth
clinic] and
[tertiary level
hospital] and
to compare
patient
outcomes”
(p. 856)
“to describe
hospital and
geographical
factors that
contribute to
increased
telemedicine
utilization in
ED trauma”
(p. 1)

154

20.5 years,
age range 582 years)

Trauma - All
adults >18
years

154

tertiary level
hospital

to orthopedic
services)
Similar patient
outcomes in the
conservative
(telehealth)
group and
operative group
(tertiary care)

N=3,309
(n=361
teletrauma)

Teletrauma via
a two-way highdefinition
audio-visual
connection
during trauma
cases

“no hospitallevel factors
were
associated
with
telemedicine
use” (p. 3)

Population
health

Small rural
hospital
(physician or
nurse)
consulting
remote
experienced
emergency
physicians

Hospital-level or
geographic
factors do not
influence
telemedicine
penetration or
use
Once established
as a standard
practice,
telemedicine use
remains
consistent over
time

FACTORS ASSOCIATED WITH THE USE OF TELETRAUMA
Mohr et al.

Mohr et al.

2017

2018

North
Dakota,
USA

North
Dakota,
USA

Observational
cohort study

Observational
cohort study

“Describe
patient-level
factors
associated
with
telemedicine
consultation
in North
Dakota
critical-access
hospital
(CAH)
emergency
departments
(EDs) and to
measure the
association
between
telemedicine
consultation
and
interhospital
transfer” (p.
177)
“The
objective of
this study is
to evaluate
the impact of
a
rural
telemedicine
network on
trauma
process of
care and
clinical
outcomes in

Trauma - All
adults >18
years

Trauma - All
adults >18
years

155

155
N=2,837
(n=301
teletrauma)

N=7,500
(n=291
teletrauma)

Teletrauma via
a two-way highdefinition
audio-visual
connection
during trauma
cases

Teletrauma via
a two-way highdefinition
audio-visual
connection
during trauma
cases

More severe
injuries
(higher Injury
Severity
Score),
penetrating
injuries,
burns,
hypotension,
tachycardia,
and
ambulance
transport

Population
health

Endotracheal
intubation

Population
health

Small rural
hospital
(physician or
nurse)
consulting
remote
experienced
emergency
physicians

“Telemedicine is
activated for the
most severely
injured and for
those who are
likely to require
interhospital
transfer” (p. 183)

Small rural
hospital
(physician or
nurse)
consulting
remote
experienced
emergency
physicians

The availability
of telemedicine
increases the
proportion of
transfers, length
of stay, and
diagnostic
imaging

telemedicine did
not change the
transfer rate

Telemedicine
availability
improves trauma
care and may
improve

FACTORS ASSOCIATED WITH THE USE OF TELETRAUMA

Ricci et al.

Roccia et
al.

2003

2005

Vermont
and New
York, USA

Italy

Description
and analysis of
a teletrauma
program

Description of
a telemedicine
system

North
Dakota” (p.
195)
Describe the
teletrauma
system and
evaluate
“clinical
outcomes
and
participant
acceptability”
(p. 6)

“The purpose
of this article
is to review
the 2-year
experience
with
PATATRAC in
managing
patients with
cranial
maxillofacial
trauma” (P.
1101)

156
timeliness of
tertiary care

Trauma - All
major
trauma
cases (mean
age 34
years, age
range 14-81
years)

All patients
needing
maxillofacial
treatment
(median
34.8 years,
age range
16-81 years)

156

N=397
(n=41
teletrauma)

N=18

Interactive,
two-way
audiovisual
communication
system for
trauma
consultations

Teleconsultatio
n via a monitor
and dedicated
data
transmission
line to transmit
patient
information
and radiologic
images

More
severely
injured
patients;
higher Injury
Severity
Score

Lack of access
to specialized
support

Population
health
Provider
experience

Population
health

4 rural
hospitals
(physicians
and surgeons)
consulting a
Level 1 trauma
center
(trauma
surgeons)

35 rural
regional
hospitals
(emergency
physicians)
consulting a
specialized
center
(specialists)

The teletrauma
system was
judged to be
acceptable and
easy to use, and
was thought to
improve patient
care
Reliability and
usability are
necessary
features for
teletrauma
technology
Teletrauma is
feasible and
potentially lifesaving for rural
trauma care
Telemedicine
reduces the time
to specialist
intervention,
enhances
therapeutic
participation,
and reduces
unnecessary
transfers

FACTORS ASSOCIATED WITH THE USE OF TELETRAUMA
Rogers et
al.

Rottger et
al.

2001

1997

Vermont
and New
York, USA

Alberta,
Canada

Description
and analysis of
a teletrauma
program

Case report

“In this study,
it was
hypothesized
that
[teletrauma]
during the
initial
evaluation
and
resuscitation
of the trauma
patient
between
trauma
surgeons and
the
community
hospital
providers
could
improve
community
hospital
trauma care”
(p. 1037)
“the
following
account gives
a dramatic
example of
how
telephone
consultation
in
combination
with a fax
message was
used in an

157

Trauma - All
major
trauma
cases (mean
age 34
years, age
range 14-81
years)

N=842
(n=26
teletrauma)

Critically
injured 12
year old
patient

N=1

157

Interactive,
two-way
audiovisual
communication
system for
trauma
consultations

Higher Injury
Severity
Score

C-Band radio,
cellular and
standard
telephone and
fax to consult a
remote
neurosurgeon
for the clinical
management of
a trauma case

Lack of
physician
experience
with a
procedure

Lower
Revised
Trauma
Score;
patients who
are “more
physiologicall
y deranged”
(p. 1038)

Patient
transfer
unsafe

Population
health
Provider
experience

Population
health

4 rural
hospitals
(physicians
and surgeons)
consulting a
Level 1 trauma
center
(trauma
surgeons)

Teletrauma
improves rural
trauma care and
should be
expanded to
other rural areas

A rural
community
hospital
(physician)
consulting a
large pediatric
hospital
(neurosurgeon
)

Teletrauma
facilitated local
management
and stabilization
prior to patient
transport

Providers felt
that the
teletrauma
system improved
care and was
life-saving in
some cases

Strong
relationships
between the
rural physicians
and the
specialist was

FACTORS ASSOCIATED WITH THE USE OF TELETRAUMA

Saffle et al.

Syed-Abdul
et al.

2009

2012

USA

Sao Tome
and
Principe
Islands,
and Taiwan

Description
and
comparative
analysis of a
telemedicine
program

Case study of
a telemedicine
burn program

acute trauma
case” (p. 59)
“to evaluate
the feasibility
and value of
telemedicinebased
evaluation of
acutely
burned
patients” (p.
359)

To “report on
the utilization
of
telemedicine
to support
the
management
of the burns
treatment”
(p. 207)

Acutely
burned
patients
(median age
30 years,
interquartile
range 33
years)

Acutely
burned
patients
(both
patients 7
years old)

158

158

N=108
(n=80
teletrauma)

N=2

Telemedicine
via portable
televideo carts
with a video
camera and
handheld
macro camera
for burn wound
evaluation and
consultation

Telemedicine
via
videoconferenci
ng and email to
consult on and
manage burn
patients and to
allow patients
to
communicate
with family
members

Lack of access
to timely
subspecialty
involvement

Population
health
Provider
experience
Patient
experience
Cost
optimization

Lack of access
to specialist
advice,
knowledge,
and surgical
intervention

Population
health

3 regional
remote
hospitals
(emergency
physicians,
nurses)
consulting a
burn center
(attending
surgeons,
physicians)

A remote
hospital
(medical
team)
consulting a
university
hospital
(medical
specialists)

the key to
success
“telemedicine
evaluation
helped speed
provision of
appropriate
critical care and
justify the
expense and
risks of air
transport” (p.
361)
Providers and
patients were
satisfied with the
technology and
the telemedicine
experience, and
felt that it
enhanced local
management
Telemedicine
facilitated
continuing
medical
education for
remote doctors
Telemedicine
“improved care
management
throughout the
entire patient
pathway” (p.
211)

Westbrook
et al.

FACTORS ASSOCIATED WITH THE USE OF TELETRAUMA

159

2008

Telemedicine
helped to
establish and
maintain the
doctor-patient
relationship
Teletrauma
facilitates
triaging of
patients by
identifying those
not requiring
further care

Australia

Before and
after study

“to evaluate
whether
introduction
of an
emergency
department
(ED)
telemedicine
system
changed
patient
management
and outcome
indicators
and to
investigate
clinicians’
perceptions
of the impact
of the system
on care
provided and
on their
work” (p.
704)

All acutely ill
patients
requiring
urgent care
(age range 0
years - >75
years)

159

N=350
(n=181
teletrauma)

Virtual Critical
Care Unit using
an
ultrabroadband
connection for
real-time
audiovisual
communication
during acute
care cases

Lack of an
ICU and
access to
specialist
expertise

Provider
experience
Population
health

A district
hospital
(nurses,
physicians)
consulting a
large teaching
hospital
(specialists)

Teletrauma
resulted in
improved
understanding
between the
sites but
increased
workload and
feelings of
responsibility at
the consulting
site

FACTORS ASSOCIATED WITH THE USE OF TELETRAUMA
Wibbenmeyer et
al.

Yang et al.

2016

2015
a

Iowa, USA

California,
USA

Prospective
cohort study

Retrospective
cohort study

To determine
the
“feasibility,
acceptability,
accuracy, and
educational
impact” (p.
532) of a
burn
telemedicine
program

Acutely
burned
patients
(mean age
25.2 ± 20.9
years)

“To compare
the
appropriaten
ess of
hospital
admission in
eight rural
emergency
departments
among a
cohort of
acutely ill and
injured
children who
receive
telemedicine
consultations
from
pediatric
critical care
physicians to

Trauma Children
older than 1
day and
younger
than 17
years

160

160
N=282
(n=78
teletrauma)

N=138
(n=74
teletrauma)

Telemedicine
via store-andforward and
conference
calling
whereupon
video images
are uploaded to
a web-based
portal for burn
size estimation
and clinical
management

Lack of burn
experience

Live,
interactive,
audiovisual
communication
s system for
acutely ill and
injured children
assigned to the
highest triage
category

Younger
children

Population
health
Provider
experience

Lower
Revised
Pediatric
Emergency
Assessment
Tool score

Population
health

9 rural
hospitals
(referring
staff)
consulting a
Level 1 trauma
center (nurses
and
physicians)

8 rural
emergency
departments
(physicians
and nurses)
consulting an
academic
children’s
hospital
(pediatric
critical care
physician)

“visual
telemedicine has
facilitated the
proper mode of
transport” (p.
536), assisted
triage decisions,
and facilitated
care of the
patient
Telemedicine
improved burn
size estimation
and fluid
management
decisions
Telemedicine
was associated
with fewer
admissions and
transfers as
compared to
telephone
consultations
Telemedicine
may reduce
unnecessary
transfers and
enhances the
accuracy of
patient
disposition
decisions

FACTORS ASSOCIATED WITH THE USE OF TELETRAUMA

Yang et al.

161

a cohort of
similar
children who
receive
telephone
consultations
from the
same group
of physicians”
(p. e59)
2015 California,
Retrospective
“to estimate
Trauma N=135
Live,
Younger
Cost
8 rural
Telemedicine
b
USA
review and
the cost,
Children
(n=71
interactive,
children
optimization emergency
reduces
economic
effectiveness, younger
teletrauma) audiovisual
departments
interfacility
analysis
and return on than 18
communication
(physicians
transfers and
investment
years
s system for
and nurses)
reduces health
(ROI) of
acutely ill and
consulting an
care costs
telemedicine
injured children
academic
consultations
assigned to the
children’s
The
provided to
highest triage
hospital
telemedicine
health care
category
(pediatric
program is more
providers of
critical care
effective than
acutely ill and
physician)
telephone
injured
consultation
children in
rural EDs
compared
with
telephone
consultations
from a health
care payer
prospective”
(p. 773)
*Note: The Quadruple Aim (Bodenheimer & Sinsky, 2014), adapted from Berwick, Nolan, and Whittington’s (2008) original Triple Aim framework for health
care system optimization, was used to categorize the evaluation aim of each study into four domains: patient experience, provider experience, population
health, and cost optimization

161

FACTORS ASSOCIATED WITH THE USE OF TELETRAUMA

Appendix C
Preliminary Teletrauma Interview Script
Ø Collect demographic data
Ø Introduction, project overview, and explanation of interview process
Ø Option to ask questions about the project or the interview
Ø Verbal consent to audio record interview
Ø Begin interview:
1. Tell me about your role in the community that you serve
2. Describe your experience using teletrauma in northern BC
3. Describe the general process for using the teletrauma system
a. As the patient comes in, how it is activated, communication between
providers, ending the call, outcomes, etc.
b. Can you provide me with an example of how you have used this service?
4. Since the program began, how frequently have you used the teletrauma service?
a. Per week/per month
5. When you have used the service, how long do you use it for on average?
a. How does the duration of use vary by context or patient situation?
6. In which situations do you find teletrauma most beneficial?
a. How is this beneficial for you as a provider?
b. How is this beneficial for the patient?
7. Describe the types of patients who often access teletrauma
a. Demographics
b. Illness or injury type
c. Symptoms or clinical profile
8. Are there other patients you think may benefit from the service?
9. In which situations would you find the service useful? For example, unfamiliar
clinical case, lack of immediate specialist access, multiple traumas at the same
time…
162

162

FACTORS ASSOCIATED WITH THE USE OF TELETRAUMA
a.
b.
c.
d.

163

Clinician factors (level of expertise)
Patient factors (complex cases, need for referral)
Organizational factors (staffing levels, availability of specialists by phone)
Environmental factors (weather conditions during a potential transfer)

10. What factors may lead to a patient being considered a ‘trauma patient’?
a. When you first see or learn of a patient who is coming in, how do you know
to label them a ‘trauma’ patient?
b. Injury Severity Score?
c. Level of complexity?
d. Mechanism of injury?
11. How does the organization define a trauma case and does this differ from your
perspective of trauma?
a. Are there guidelines or policies that help you to identify a trauma patient?
b. For which patients do policies and procedures activate a trauma code?
12. In your experience, what are some clinical outcomes of using teletrauma?
a. Transfer
b. Local management
c. Death
13. For the following statements, please respond with the answer that most
appropriately describes your experiences and beliefs using teletrauma (strongly
agree, agree, neutral, disagree, strongly disagree):
a. I was able to communicate clearly and effectively using the teletrauma
technology
b. Use of teletrauma changed my clinical management plan
c. Use of teletrauma facilitated timely access to appropriate care
d. I believe teletrauma to be helpful in the provision of high quality trauma care
e. Teletrauma is beneficial for patients
f. Teletrauma is beneficial for providers
g. When in-person evaluation is not available, teletrauma is an acceptable
alternative
h. Overall, I am satisfied with the teletrauma service
14. Is there anything that I haven’t asked you about that you think is relevant or would
like to share?
Ø Option to provide additional comments or ask questions
Ø Explanation of the sampling process and inquire about potential participants known to
the interviewee
163

FACTORS ASSOCIATED WITH THE USE OF TELETRAUMA

Ø Ask if interviewee would like a brief report of findings emailed to them
Ø Conclude interview
*Questions are preliminary and will evolve in response to emerging data

164

164

FACTORS ASSOCIATED WITH THE USE OF TELETRAUMA

165

Appendix D
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Archives Canada non-exclusive license to reproduce theses which also extends to its agents such as ProQuest
.

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FACTORS ASSOCIATED WITH THE USE OF TELETRAUMA
Ministry of Citizens’
Services

BRITISH

COLUMBIA

Technology, Innovation.
Procurement and Supply

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Intellectual Property Program
PO Box 9452 Stn Prov Govt
Victoria BC V8W 0C5

.

Copyright Permission Request Form
The following credit line is to be included:
Copyright (c) Province of British Columbia. All rights reserved. Reproduced with permission of the Province of British Columbia.
Should you have any questions, please contact the Intellectual Property Program by telephone at (250) 216-0935 or by email at
QPPPCopyright®gov.bc.ca

Director
Intellectual Property Program
Ministry of Citizens' Services

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FACTORS ASSOCIATED WITH THE USE OF TELETRAUMA
Copyright Permission for Figure 2 – Geography of British Columbia by Population Density
From: Diane Bralthwalte jbraith @ uvic.ca
Subject: RE: copyright permission
Date: June 3, 2019 at 9:16 AM
To: Timothy Wood twoodO @ unbc.ca

Hello Timothy. You have permission to use this figure in your thesis, with appropriate credit. All the best!
Diane
Diane Braith waite
Publication Assistant
Canadian Western Geographical Series

—Original Message—
From: Timothy Wood fmaiIto:twoodO @ unbe.cal
Sent: June-02-19 12:08 PM
To: Diane Braithwaite <dbraith@ uvicca>
Subject: copyright permission

Hello,
I am writing to inquire about copyright permission for your figure about population densities across BC. I would love to be able to put
this into my Master’s thesis which will be a non-commercial publication. My thesis examines factors associated with telehealth use in

northern regions of BC .

Digging around i have not been able to find the original source through BC Stats - 1 have contacted them and they confirmed they are
not able to grant copyright permission because the map appears to have been 'created' by a third party (albeit with their statistics, I’m
assuming). Am i able to use this figure for my thesis citing the secondary source (BC atlas - Foster et al.)?
Your insight would be greatly appreciated,
Timothy Wood

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FACTORS ASSOCIATED WITH THE USE OF TELETRAUMA

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Copyright Permission for Figure 3 - Map of McBride, Valemount, and Prince George within the Northern Health Authority (Comprised of Three
Health Service Delivery Areas)

RE: Copyright use
Haggerstone, James
Wed 2019 07- 31 10:30 AM

.

To Innovation & Development Commons < idc @northernhealth.ca >; Wood Timothy < Timothy.Wood@northernhealth.ca >;

@i 1 attachment
2011 - Northern Map FAQ.pdf;

Thanks for passing this along Diana!

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Hi Mr. Tim wc produce our materials with public funding and in the public interest, so please feel free to use the maps and graphics that we produce.
An acknowledgement of Northern Health as the source for the images would be appropriate.
lust to let you know that we another more detailed Northern Communities map available.

This is a piece of my work and was last updated in 2011

you should be able to cut and paste as needed

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- an FAQ is attached