Telementored ultrasonography: a narrative review

Duarte, Marcio Luis; dos Santos, Lucas Ribeiro; Iared, Wagner; Peccin, Maria Stella

doi:10.1590/1516-3180.2020.0607.R2.15092021

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Sao Paulo Medical Journal

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Sumário

NARRATIVE REVIEW • Sao Paulo Med. J. 140 (2) • 2022 • https://doi.org/10.1590/1516-3180.2020.0607.R2.15092021 copy

Telementored ultrasonography: a narrative review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

BACKGROUND:

Teleradiology consists of electronic transmission of radiological images from one location to another, including between countries, for interpretation and/or consultation. It is one of the most successful applications of telemedicine. Combining this methodology with ultrasound (called telesonography) can accelerate the process of making diagnoses. Despite this rationale, the quality of the evidence about the effectiveness and accuracy of teleradiology remains unknown.

OBJECTIVE:

To review the literature on the evidence that exists regarding use of telemedicine for ultrasound in situations of synchronous transmission.

DESIGN AND SETTING:

Narrative review conducted within the evidence-based health program at a federal university in São Paulo (SP), Brazil.

METHODS:

A search of the literature was carried out in April 2020, in the online databases MEDLINE, EMBASE, Cochrane Library, Tripdatabase, CINAHL and LILACS, for original publications in all languages. The reference lists of the studies included and the main reviews on the subject were also evaluated.

RESULTS:

We included ten studies that assessed procedures performed by different healthcare professionals, always with a doctor experienced in ultrasound as a distant mentor. Among these, only one study assessed disease diagnoses in relation to real patients.

CONCLUSIONS:

Despite the promising position of telesonography within telemedicine, no studies with reasonable methodological quality have yet been conducted to demonstrate its effectiveness.

KEY WORDS (MeSH terms):
Ultrasonography; Teleradiology; Telemedicine

AUTHORS’ KEY WORDS:
Remote consultation; Teleultrasound; Telesonography; Telementoring

Database	Search strategy	Filter	Results
MEDLINE (Medical literature analysis and retrieval system online)	#1: “Ultrasonography”[mesh] or (echotomography) or (diagnostic ultrasound) or (diagnostic ultrasounds) or (ultrasound, diagnostic) or (ultrasounds, diagnostic) or (sonography, medical) or (medical sonography) or (ultrasound imaging) or (imaging, ultrasound) or (imagings, ultrasound) or (ultrasound imagings) or (echography) or (ultrasonic imaging) or (imaging, ultrasonic) or (echotomography, computer) or (computer echotomography) or (tomography, ultrasonic) or (ultrasonic tomography) or (diagnosis, ultrasonic) or (diagnoses, ultrasonic) or (ultrasonic diagnoses) or (ultrasonic diagnosis)	Since 2010 Free full text Comparative study Controlled clinical trial Randomized clinical trial Observational study	6,841
	#2: “Teleradiology”[mesh]
	#3: “Telemedicine”[mesh] or (mobile health) or (health, mobile) or (health) or (telehealth) or (ehealth)
	#4: “Remote consultation”[mesh] or (consultation, remote) or (teleconsultation) or (teleconsultations)
	#5: #1 And #2 or #3 or #4
Cochrane library	#1: “Ultrasonography”[mesh]	Since 2010	2,722
	#2: “Teleradiology”[mesh]
	#3: “Telemedicine”[mesh]
	#4: “Remote consultation”[mesh]
	#5: #1 And #2 or #3 or #4
EMBASE (Excerpta Medica database)	#1: ‘Echography’/exp or ‘diagnostic ultrasonic examination’ or ‘diagnostic ultrasonic imaging’ or ‘diagnostic ultrasonic method’ or ‘diagnostic ultrasound’ or ‘doptone’ or ‘duplex echography’ or ‘echogram’ or ‘echographic evaluation’ or ‘echography’ or ‘echoscopy’ or ‘echosound’ or ‘high resolution echography’ or ‘scanning, ultrasonic’ or ‘sonogram’ or ‘sonographic examination’ or ‘sonographic screening’ or ‘sonography’ or ‘ultrasonic detection’ or ‘ultrasonic diagnosis’ or ‘ultrasonic echo’ or ‘ultrasonic examination’ or ‘ultrasonic scanning’ or ‘ultrasonic scintillation’ or ‘ultrasonogram’ or ‘ultrasonographic examination’ or ‘ultrasonographic screening’ or ‘ultrasonography’ or ‘ultrasound diagnosis’ or ‘ultrasound scanning’	Since 2010 Diagnosis Prospective study Diagnostic test accuracy study Observational study Cohort analysis Cross-sectional study Comparative study Controlled clinical trial	39
	#2: ‘Teleradiology’/exp or ‘tele-radiology’ or ‘teleradiology’
	#3: ‘Telemedicine’/exp or ‘tele medicine’ or ‘telemedicine’
	#4: ‘Teleconsultation’/exp or ‘remote consultation’ or ‘tele-consultation’ or ‘teleconsultation’ or ‘telephone consultation’)
	#5: #1 And #2 or #3 or #4
TRIPDATABASE	#1: “Ultrasonography”	Since 2010	08
	#2: “Teleradiology”
	#3: “Telemedicine”
	#4: “Remote consultation”
	#5: #1 And #2 or #3 or #4
CINAHL (Cumulative index to nursing and allied health literature)	#1: “Ultrasonography”	Since 2010	229
	#2: “Teleradiology”
	#3: “Telemedicine”
	#4: “Remote consultation”
	#5: #1 And #2 or #3 or #4
LILACS (Latin American and Caribbean health sciences literature)	#1: Mh:”ultrassonografia” or (ultrasonografía) or (ultrasonography) or (échographie)or (ecografia) or (ecotomografia computador) or (sonografia médica) or (ecografia médica) or (tomografia ultrassônica) or (diagnóstico ultrassom) or (imagem ultrassônica) or (imagem ultrassonográfica) or (imagem ultrassom) or (imagem ultrassom) or (ecotomografia) or (mh:e01.370.350.850$)	Since 2010 Diagnostic imaging Prospective study Diagnostic study Observational study Controlled clinical trial	04
	#2: Mh:”telerradiologia” or (teleradiology) or (telerradiología) or (téléradiologie) or (mh:e05.920.700$) Or (mh:h02.010.850.700$) Or (mh:h02.403.840.700$) Or (mh:l01.178.847.652.700$) Or (mh:n04.452.515.825.500$) Or (mh:n04.590.374.800.700$) Or (mh:sp2.021.167.010.090.210$) Or (mh:sp2.031.332.210$)		04
LILACS (Latin American and Caribbean health sciences literature)	#3: Mh:”telemedicina” or (telemedicine) or (telemedicina) or (télémédecine) or (ciber saúde) or (ciber-saúde) or (cibersaúde) or (disque saúde da mulher) or (medicina 2.0) Or (saúde 2.0) Or (saúde conectada) or (saúde digital) or (saúde eletrônica) or (saúde móvel) or (saúde onipresente) or (saúde pervasiva) or (saúde ubíqua) or (serviço de telemedicina) or (serviço de telessaúde) or (serviços de telemedicina) or (serviços de telessaúde) or (serviços de e-saúde) or (serviços de esaúde) or (serviços em telemedicina) or (tele-serviços em saúde) or (teleassistência) or (telecuidado) or (telecura) or (telessaúde) or (telesserviços de saúde) or (telesserviços em saúde) or (telesserviços na saúde) or (e-saúde) or (esaúde) or (msaúde) or (usaúde) or (mh:h02.403.840$) Or (mh:l01.178.847.652$) Or (mh:n04.590.374.800$) Or (mh:sp2.016.303$) Or (mh:sp2.021.167.010.090$) Or (mh:sp2.031.332$)
	#4: Mh: ”consulta remota” or (remote consultation) or (consulta remota) or (consultation à distance) or (consulta à distância) or (consultadoria remota) or (consultadoria à distância) or (consultoria remota) or (consultoria à distância) or (teleconsulta) or (teleconsulta assíncrona) or (teleconsulta clínica) or (teleconsulta eletiva) or (teleconsulta síncrona) or (teleconsulta urgente) or (teleconsulta para discussão de casos clínicos) or (teleconsultadoria) or (teleconsultadoria assíncrona) or (teleconsultadoria clínica) or (teleconsultadoria eletiva) or (teleconsultadoria síncrona) or (teleconsultadorias) or (teleconsultas) or (teleconsultoria) or (teleconsultoria assíncrona) or (teleconsultoria clínica) or (teleconsultoria eletiva) or (teleconsultoria síncrona) or (teleconsultoria em urgências) or (teleconsultorias) or (l01.178.847.652.550$) Or (n04.452.758.849.550$) Or (n04.590.374.800.550$) Or (sp2.021.167.010.090.010$) Or (sp2.031.332.010$)
	#5: #1 And #2 or #3 or #4

Study	Study design	Participants	Country	Objective	Results
Choo et al.³⁰30. Choo EKH, Chen R, Millington SJ, et al. Remote solutions for telementoring point-of-care ultrasound echocardiography: The RESOLUTE study. Can J Anaesth. 2017;64(10):1077-8. PMID: 28681268; https://doi.org/10.1007/s12630-017-0927-8. https://doi.org/10.1007/s12630-017-0927-...	Non-comparative cross-sectional.	33 Intensive care nurses with no training.	Canada	To identify cardiac pathological conditions using echocardiography in a simulator.	The mentor was able to identify cardiac pathological conditions in 32 out of 33 examinations.
Douglas et al.²⁹29. Douglas TM, Levine AR, Olivieri PP, et al. Brief training increases nurses’ comfort using tele-ultrasound: A feasibility study. Intensive Crit Care Nurs. 2019;51:45-9. PMID: 30514602; https://doi.org/10.1016/j.iccn.2018.11.004. https://doi.org/10.1016/j.iccn.2018.11.0...	Prospective cohort.	16 Non-medical healthcare professionals who had previously had classes on how ultrasound works.	United States	To analyze the comfort of non-medical healthcare professionals for performing ultrasound examinations on the internal jugular vein, apices and bases of the lungs, cardiac sub-xiphoid view and urinary bladder, on a healthy volunteer.	The professionals, regardless of the teaching group and with the aid of teleteaching by a doctor, felt comfortable performing ultrasound examinations.
Hurst et al.³³33. Hurst VW, Peterson S, Garcia K, et al. Concept of Operations Evaluation for Using Remote-Guidance Ultrasound for Exploration Spaceflight. Aerosp Med Hum Perform. 2015;86(12):1034-8. PMID: 26630050; https://doi.org/10.3357/AMHP.3244.2015. https://doi.org/10.3357/AMHP.3244.2015...	Randomized clinical trial.	30 Sonographers with no previous experience with ultrasound.	United States	To evaluate the quality of the images in the focused assessment with sonography in trauma examination, in a healthy volunteer.	The groups that received telementoring provided images with better quality.
Kim et al.⁴4. Kim C, Kang BS, Choi HJ, et al. Clinical application of real-time tele-ultrasonography in diagnosing pediatric acute appendicitis in the ED. Am J Emerg Med. 2015;33(10):1354-9. PMID: 26306436; https://doi.org/10.1016/j.ajem.2015.07.048. https://doi.org/10.1016/j.ajem.2015.07.0...	Prospective observational.	12 Emergency residents with one to two years of experience with ultrasound.	South Korea	To analyze the diagnosis of acute pediatric appendicitis in patients.	Ultrasound with telementoring between an inexperienced doctor and an experienced doctor as a mentor can be effectively used to diagnose acute pediatric appendicitis in an emergency clinic.
Kirkpatrick et al.³²32. Kirkpatrick AW, McKee I, McKee JL, et al. Remote just-in-time telementored trauma ultrasound: a double-factorial randomized controlled trial examining fluid detection and remote knobology control through an ultrasound graphic user interface display. Am J Surg. 2016;211(5):894-902.e1. PMID: 27020901; https://doi.org/10.1016/j.amjsurg.2016.01.018. https://doi.org/10.1016/j.amjsurg.2016.0...	Randomized clinical trial.	101 Firefighters with no previous experience with ultrasound.	Canada	To identify free liquid in the abdominal cavity in mannequins, comparing telementoring and no telementoring.	The group with telementoring presented diagnostic accuracy of 98.1%, While the group without telementoring obtained 95.8%.
Lee et al.³⁴34. Lee Y, Kim C, Choi HJ, et al. A Feasibility Study of Telementoring for Identifying the Appendix Using Smartphone-Based Telesonography. J Digit Imaging. 2017;30(2):148-55. PMID: 27826671; https://doi.org/10.1007/s10278-016-9921-x. https://doi.org/10.1007/s10278-016-9921-...	Prospective randomized crossover.	30 Novice sonographers.	South Korea	To identify the cecal appendix in actors, comparing the guidance from a remote experts with that of an onsite expert.	The difference between the remote expert’s guidance group and the onsite expert’s group was not significant.
Levine et al.³¹31. Levine AR, McCurdy MT, Zubrow MT, et al. Tele-intensivists can instruct non-physicians to acquire high-quality ultrasound images. J Crit Care. 2015;30(5):871-5. PMID: 26122274; https://doi.org/10.1016/j.jcrc.2015.05.030. https://doi.org/10.1016/j.jcrc.2015.05.0...	Cross-sectional.	11 Non-medical healthcare workers who had had a theoretical class of 20 minutes.	United States	To evaluate the quality of images from bedside ultrasound among patients.	91% Of the images had good quality, as assessed by a doctor at a distance.
Robertson et al.¹1. Robertson TE, Levine AR, Verceles AC, et al. Remote tele-mentored ultrasound for non-physician learners using FaceTime: A feasibility study in a low-income country. J Crit Care. 2017;40:145-8. PMID: 28402924; https://doi.org/10.1016/j.jcrc.2017.03.028. https://doi.org/10.1016/j.jcrc.2017.03.0...	Cross-sectional.	9 Non-physician healthcare workers with 20 minutes of training on basic ultrasound techniques.	United States and Haiti	To evaluate the quality of the images from point-of-care ultrasound on a volunteer.	The distant physician found that 90% of the images were of adequate quality.
Sheehan et al.⁶6. Sheehan FH, Ricci MA, Murtagh C, Clark H, Bolson EL. Expert visual guidance of ultrasound for telemedicine. J Telemed Telecare. 2010;16(2):77-82. PMID: 20139139; https://doi.org/10.1258/jtt.2009.090313. https://doi.org/10.1258/jtt.2009.090313...	Randomized clinical trial.	20 Second-year medical students without previous experience with ultrasound.	United States	To compare verbal and verbal plus visual guidance in identifying the abdominal aorta and right kidney through ultrasound on patients and normal volunteers.	The group that received visual guidance produced images of better quality.
Smith et al.²2. Smith A, Addison R, Rogers P, et al. Remote Mentoring of Point-of-Care Ultrasound Skills to Inexperienced Operators Using Multiple Telemedicine Platforms: Is a Cell Phone Good Enough? J Ultrasound Med. 2018;37(11):2517-25. PMID: 29577381; https://doi.org/10.1002/jum.14609. https://doi.org/10.1002/jum.14609...	Randomized clinical trial.	36 Medical students from the first three years of their course and paramedics. All of them were inexperienced in ultrasound.	Canada	To compare different types of telemedicine in ultrasound examinations on the right upper quadrant, on a volunteer.	The different types of telemedicine showed similar results. The group that watched the video did the examination faster than did the group that just received mentoring.

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[1] Address for correspondence: Márcio Luís Duarte Programa de Pós-Graduação em Saúde Baseada em Evidências, Universidade Federal de São Paulo (UNIFESP) R. Napoleão de Barros, 865 Vila Clementino — São Paulo (SP) — Brasil CEP 04024-002 Tel. (+55 11) 5576-4848 E-mail: marcioluisduarte@gmail.com