Objectives: 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. Design: Before‐and‐after study of use of the Virtual Critical Care Unit (ViCCU), which uses an ultrabroadband connection allowing real‐time audiovisual communication between clinicians at distant sites. Semi‐structured interviews were conducted with medical and nursing staff at the end of the study. Participants and setting: The ViCCU intervention commenced on 1 January 2004. Our study was conducted in the EDs of an 85‐bed district hospital and a 420‐bed metropolitan tertiary hospital. It involved all acutely ill patients requiring urgent care (defined by triage category and grouped into critical care, major trauma and moderate trauma) who were treated during the 12 months before (n = 169) and 18 months after (n = 181) the intervention at the district hospital. Thirty‐one of 33 clinicians (doctors and nurses) participating at the two hospitals took part in interviews at the end of the study. Main outcome measures: Changes in patterns of management (disposition [admission, discharge or transfer], treatment times, number of procedures) and outcomes (rapid acute physiology scores, hours on ventilation or in intensive care, length of stay). Results: Patient disposition remained unaltered for major trauma patients. For critical care patients, admissions fell significantly (54% to 30%), transfers increased (21% to 39%), and more procedures were performed. For moderate trauma patients, discharges increased significantly (45% to 63%), transfers decreased (48% to 25%) and treatment times were longer. No significant changes were found in outcome indicators. Clinicians reported that the ViCCU allowed greater support to remote clinicians. Specialists reported increased workloads and feelings of greater responsibility for patients at the district hospital. Nurses at the district site reported reduced stress, but district doctors reported some loss of autonomy. Conclusions: The ViCCU appears most effective for moderate trauma patients, with associated reductions in admissions and transfers. Large‐scale trials of telemedicine systems that include measurements of both patient care and impact on clinicians’ work are required.

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Median dose for analgesia was comparable with other studies; dose for sedation was less than reported elsewhere. Intubation rate for patients receiving prehospital ketamine was 17%. Further study is recommended to assess the ED course of the non-intubated group of patients, and consideration should be given to non-weight-based methods of dose selection.

A broadband telehealth system has been developed for supporting critical care services between a major referral hospital and a rural hospital by transmitting very high-quality, realtime multimedia information, including images, audio and real-time video, over an Internet Protocol (IP)-based network. The technical design team took an iterative and user-centred approach toward the system design. Usability tests with scenario analysis were incorporated into the development process to produce a system that operates seamlessly in the critical care environment. Careful analysis of the reliability of the system was incorporated into the clinical protocols for integration into existing work practices. The use of high-quality multimedia data, consideration of human factors early in the design process, and incorporation of proper development approaches were critical for the success of the system design.

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