Chapter 80: Managing the ICU from Afar: Telemedicine

Telemedicine was developed in the 1960s and 1970s by the US military and aerospace sectors by using information and communication technologies to provide medical care in remote areas.¹ More recently, as telecommunication technologies have significantly advanced, telemedicine can help alleviate the shortage of physicians in certain specialties by allowing instant access to specialists who are not physically available at the location of the patient. Consequently, telemedicine, and in particular, tele-ICU, may help offset several well-known health care delivery challenges within the critical care community. These challenges include the following:

1. A large deficit of board-certified intensivists staffing intensive care units (ICUs) during the day and, especially, at night. It is estimated that currently only one-third of ICU patients are cared for by board-certified critical care physicians.^2,3 Halpern et al⁴ note that many intensivists are also certified in additional specialties and spend a portion of their time in those capacities, thereby reducing the time they spend in the ICU. Furthermore, staffing ICUs in smaller hospitals and those located in rural areas is very challenging. In smaller hospitals, the number of ICU beds is often not sufficient to support a dedicated on-site intensivist, and in rural hospitals, there may be limited access to critical care medicine (CCM) specialists due to issues related to commuting.

2. The aging population is increasing and although the number of trained critical physicians has increased in recent years, it is projected that by 2020 the demand for critical care physicians will exceed the supply.²

3. Another concern is the high cost of intensive care. Bartolini and King⁵ note that over six million of the sickest patients are treated in ICUs per year. This patient population has the highest rate of mortality and contributes the most in terms of the cost incurred in health care, consuming $107 billion dollars per year, which is 4.1% of the $2.6 trillion dollars spent on annual health care in the United States.

To the extent that these challenges exist, research has shown that having an intensivist manage the care of ICU patients has significantly reduced mortality and length of stay (LOS) in the ICU.^6,7 Furthermore, the Leapfrog Group, a voluntary employer-based coalition that advocates for improved quality, safety, and affordability in hospitals, notes that due to high mortality rates in ICUs, the quality of care in ICUs is of particular importance. The Leapfrog Group composed a safety standard indicating that intensivists (in particular those specifically trained in critical care medicine) should be present in the ICU during daytime hours and exclusively provide care to these patients and that when physicians are not in-house, the on-call doctor or tele-intensivist needs to return pages at least 95% of the time within 5 minutes and arrange for care to be delivered to a patient by a doctor, physician assistant (PA), nurse practitioner (NP), or registered nurse (RN) within 5 minutes. As of 2010, the Leapfrog Group noted that only 34.5% of the responding hospitals were compliant with this safety standard.

Tele-ICU programs offer one way to improve patient access to critical care specialists and address these issues. In specialized off-site command centers, critical care is delivered by CCM-trained doctors and nurses who provide coverage to patients in academic, community, rural, and critical access facilities. By using telemedicine, specialists can use their expertise to alter patient care plans while constantly monitoring patients with the help of the bedside RN and tele-RN.

Dr. Brian Rosenfeld and Dr. Michael Breslow, critical care physicians for over 20 years at the Johns Hopkins Hospital in Baltimore, developed the initial technology for the electronic ICU (eICU) in 1998. They utilized a physician-focused electronic medical record (EMR), coupled with clinical algorithms of best practices, an early vital sign warning system,⁷ and an audio-visual interface to deliver ICU care. The original tele-ICU program was adopted for use by a Virginia hospital system in 2000. As of late 2012, there were 54 tele-ICU monitoring centers utilized by government and civilian health care systems covering over 350 hospitals.⁵

In essence, the tele-intensivist can be thought of as a doctor who is reviewing patients in an office adjacent to the ICU with access to the entire EMR, ICU waveform monitor, and radiologic imaging and who can approach the bedside when alerted by the RN. At night, the tele-intensivist may be better equipped than the day doctor who is on-call from home and is awakened to discuss a patient; the tele-intensivist is awake and alert with all the relevant information in front of him or her in real time. The tele-intensivist, whose only responsibility during a shift is to monitor ICU-level patients using a remotely located eICU workstation, may also be in a better position to provide care when compared to an on-site non-CCM physician who has a number of other responsibilities in the hospital, including those outside the ICU.Tele-intensivists work in different time zones during daytime hours, providing night shift coverage at the location of the patient. For example, the authors of this chapter are located in Israel; they are part of a group of US board certified CCM physicians providing night coverage to ICUs in the United States while working during the day in Israel.

As in all areas of medical care delivery, the key to any successful tele-ICU is proper communication, interpersonal and telecommunication between on-site and off-site staff—whether they are from medical or ancillary services. This includes proper sign-out between the in-house and off-site physicians and nurses, medical consultants, ER and admitting staff, anesthesiologists, and surgeons, and most importantly between the tele-ICU doctor and bedside nurse. Timely and effective communication yields the best results for the patient and their families (Figure 80–1).

There are various types of tele-ICU models (Table 80–1). Some models offer continuous monitoring and management of ICUs during night shift hours or 24 hours a day, where physicians and nurses in a monitoring center work in 8 to 12 hour shifts. During the shift, the tele-ICU team is exclusively dedicated to the care of the patients in the ICUs of that hospital system. In the tele-ICU consultant model, an intensivist provides critical care consultations upon request and is not responsible for continuous monitoring of entire units. Generally, in this model, a mobile cart with audio-video capabilities or a robot is commonly used to gather information followed by treatment recommendations given by the consultant.

There are other hospitals that use their own “home-made” tele-ICU monitoring systems by using various EMR programs, with or without audio-video capabilities, for patient assessment. The level of involvement of the tele-intensivist in the care of these patients varies between hospital systems based on the clinical job definition determined by the medical officers of each hospital system.

Tele-ICU technology provides access to the hospital’s EMR, the radiology image archiving and communication system (PACS), and the ICU hemodynamic monitor, and is coupled with an audio-visual interface allowing the CCM physician to see and communicate with the patient, family, and hospital medical staff.

There are currently several vendors offering different types of ICU EMR systems. The Philips eICU system (Philips Healthcare, Andover, MA) is currently the most commonly used application by health systems that run large tele-ICU programs involving continuous care. This is the system that the authors of this chapter have used in various health systems. When using the Philips eICU system, the ICU rooms are outfitted with high-definition Pan Tilt and Zoom (PTZ) cameras and servers. There is also an option of using a mobile cart with a camera that can be used for patients outside the ICU, such as in an emergency room awaiting ICU admission or during rapid response calls on the wards.

Various EMRs provide the tele-ICU staff with alerts such as sepsis alerts and best practice alerts regarding glycemic control, and DVT and GI prophylaxis, which need to be reviewed. The Philips Tele-ICU software has specialized algorithms that provide alerts when adverse trends in vital signs are noted.

Since the tele-ICU team provides care for critically ill patients, it is crucial that the tele-ICU team is always immediately available for real-time communications and that connectivity with the remote staff is not lost due to technology failure. The tele-ICU center is generally connected to the hospital data center via redundant dedicated T1 lines. Back-up electricity with uninterrupted power supply (UPS) systems and electric generators is used as well to ensure continuous operation even during power failures. Full-time information technology (IT) support is required to address any technical problems that may arise.

Staff is divided between in-house and off-site personnel, and medical and ancillary services (Table 80–2). The hospital staff available varies from facility to facility and the duties of the tele-intensivist depend on the staff available for that particular ICU.

In-House Staff

Bedside Registered Nurse

The ICU nurse is present at bedside and provides most of the hands-on care to the patient. The bedside RN is the key provider with whom the tele-ICU staff interacts; they discuss any medical events that arise, such as a change in status, or hemodynamic or respiratory issues, and the care plan is delivered per recommendations and orders given by the tele-ICU physician.

Hospitalist/Managing Physician

In the majority of hospitals with tele-ICU programs, there is an in-house hospitalist available 24 hours a day. The hospitalist is often responsible for the care of patients admitted to the medical floor, the ICU, as well as any new patients admitted through the ER. In some institutions, there are private internists who are responsible for new admissions and the care of admitted patients; these physicians may not be present on-site all the time. Some hospitals do not employ an on-site hospitalist or internist during the night hours.

Respiratory Therapist

The respiratory therapist helps manage invasive and noninvasive respiratory support. At some facilities, the respiratory therapist is also certified in performing intubations for invasive ventilation. In recent years, some hospitals have expanded the role of the respiratory staff to include critical care procedures such as the placement of central IV access, arterial access, peripherally inserted central catheters (PICC), and conducting focused bedside echocardiography.

ER Physician

In many of the hospitals, there is an emergency medicine physician whose primary responsibility is the emergency room, but the physician can be called to help out on the floors and the ICU for codes, intubations, or other procedures.

Surgeons and Anesthesiologists

Hospitals generally have an anesthesiologist and surgeon on-call. Aside from working in the OR, the anesthesiologist or surgeon can be called to help manage an airway problem or perform other invasive ICU procedures.

Other Specialists

Specialists in other fields may be available for consultation; they generally round in the ICUs during the day and are on-call from home during the night. The types of specialists available vary from hospital to hospital; in some of the more rural facilities, there may not be access to specialists in certain fields of medicine.

Command Center/Tele-ICU Monitoring Site Staff

The off-site center may be located on the premises of one of the hospitals in the system or may be located off-site. The medical staff in these command centers has at their fingertips sophisticated EMR technologies, bedside ICU monitoring, PACS system for imaging, and audio-video access to the patient’s room (Figure 80–2). The tele-ICU has medical secretaries, critical care nurses, and critical care physicians. Some tele-ICUs also have acute care NPs. Each member of the medical and nonmedical staff should be oriented, before starting to work in the service, to their own respective roles and duties as well as the roles of the other staff to ensure a cohesive and efficiently run service.

Unit Clerk/Medical Secretary

The unit clerk or secretary triages phone calls from different hospitals and helps the medical staff communicate with on-site personnel such as the beside nurses, hospitalists, ER physicians, and other on-call specialists. They also ensure that patient data are properly entered into the EMR. When necessary, they also help identify potential or current technical problems in software or hardware that arise with the network and communicate with the IT team.

Tele-ICU RN

The tele-ICU RN has several roles; the most important is to support the bedside RN with any medical concerns that arise. The tele-ICU RN is assigned patients to follow and monitors vital signs, hemodynamics and other tracings, laboratory values and other tests, and can also visually assess the patient using video cameras located in the patient’s room. The tele-ICU RN is in close communication with the bedside RN and proactively involves the tele-intensivist with any problems or concerns that arise.

Another tele-ICU RN role is to monitor standards of care and the application of best practices. For instance, the off-site RN can confirm glycemic monitoring and control, GI and DVT prophylaxis, sepsis and delirium alerts, and the VAP bundle. The team is alerted to ensure appropriate protocol-driven care, which can help the hospital meet standards of care developed by national and international medical societies such as the Society of Critical Care Medicine, the American College of Chest Physicians, the American Association of Critical Care Nurses, The Joint Commission (TJC, formerly known as JCAHO), and the World Federation of Societies of Intensive and Critical Care Medicine.

The tele-ICU nursing team also includes a clinical manager, or team leader. The clinical manager, together with the medical director, models the workflow and assigns the specific tasks for the tele-ICU nursing team.

Tele-Intensivist

The tele-intensivist is a board-certified or board-eligible CCM physician who is licensed in the state(s) where the hospital(s) is located. The responsibilities of the tele-intensivist are similar to that of the bedside ICU attending physician. The tele-intensivist is available to triage all matters of medical concern such as electrolyte replacement, pain management, sedation, ventilator management, titration of vasoactive agents, coordination and follow-up with consultants, as well as treat hemodynamic instability and respiratory distress. The tele-intensivist is in close communication with the bedside RN, respiratory therapist, and when applicable, the hospitalist or ER physician. Entering notes into the medical chart is a prudent form of communication and legal recording. Even minor details are recorded in a short note so the bedside staff will know the care provided by the tele-ICU staff.

Nurse Practitioner

Some of the larger or busier tele-ICUs also have acute care NPs, state licensed with specialty certification from the American Association of Critical Care Nurses. The NP, assigned to patients in a fashion similar to the off-site doctor, is responsible for patient care and is in constant communication with the CCM physician. The NP will generally take calls for laboratory orders, medication orders, and radiology requests. The NP may be asked to assist a physician who is attending to other patient care matters. A clear job definition for the NP should be outlined by the medical chief of staff together with the chief of service of each hospital system.

IT Support

IT support is an important component of telemedicine, ensuring that all telecommunications lines, hardware, and software are working reliably and smoothly. IT staff should be available 24/7, in-house and off-site.

Monitoring critically ill patients can be labor intensive, especially when there are many high-intensity patients. It is incumbent on the medical chief of staff together with the chief of service and vice-president of nursing for each hospital, in conjunction with the medical director of the tele-ICU service, to find a safe ratio of medical personnel to patient load. The ratio for monitoring that has been recommended for an MD is between 50 and 120 patients, an NP is between 50 and 100 patients, and an RN between 35 and 45 patients.

The general workflow in the tele-ICU includes treating all active medical issues that arise and best-practice monitoring. Tele-ICU team involvement occurs when the bedside staff calls them, when they discover medical trends during proactive rounding, or when using the tele-ICU program algorithms.

In facilities without intensivist coverage, the tele-intensivist can play a crucial role in the day or night. In these facilities, the hospitalist or internist can review care plans of new admissions with the tele-intensivist by phone or via the audio-video interface from the patient’s room. In many hospitals, there are regular daily morning rounds with the tele-intensivist. During the night, the tele-intensivist can be called by the physician or bedside RN to help just as an on-call physician would be called at home. The tele-intensivist can also assist the surgeon in managing patients postoperatively.

The majority of hospitals with a tele-ICU program have an intensivist or a pulmonologist available for consultation to help manage the ICU patients; however, they are not in house all the time. There may be a dedicated intensivist group but without enough staff to allow for in-house night time coverage. Other hospitals have a CCM physician who consults on a daily basis but is not always available to the ICU due to other responsibilities. In those facilities where a dedicated intensivist rounds during the day, the main role of the tele-intensivist is during night-shift hours. Ideally, the managing intensivist will sign out his or her patients at the end of the day to the tele-intensivist just as he would sign out to an in-house night intensivist taking over continuity of care. In the morning, the tele-intensivist signs out major events that occurred over night to the day CCM physician. Should the need arise where the tele-intensivist feels that an intensivist is needed at the bedside, the on-call intensivist can be notified to return to the ICU. Alternatively, the hospitalist, ER physician, or an anesthesiologist, if available, can help at the bedside during the night as well. With more and more facilities having respiratory therapists who are certified in ICU procedures, the tele-intensivist is able, in most cases, to provide appropriate medical management without requiring the help of an on-site intensivist.

Some facilities that have 24-hour in-house intensivist coverage are part of a broader hospital system that utilizes the tele-ICU program. The tele-intensivist is available to assist upon request. This generally happens when the in-house intensivist is covering a large number of patients in a particular ICU or is covering patients in other care areas within the same hospital.

Tele-ICU is a relatively new practice in medicine. The greatest theoretical impact that CCM specialists can have is on medical facilities with a deficit of intensivist coverage, facilities with a high severity-adjusted mortality and long LOS, and to facilities located remotely where safe transfer of a critical patient to a higher level care center may not be feasible.⁸ Lilly et al⁹ reported that early intervention by a tele-intensivist was associated with lower mortality and LOS. Wilmitch et al¹⁰ in their recent 3-year retrospective study found a statistically significant decrease in severity-adjusted hospital LOS by 14.2% and a decreased ICU LOS by 12.6%. The Philips Healthcare company reports,¹¹ according to company tracking data, that there has been a 37% to 64% decrease in patient mortality, as well as an $8 million consumer savings attributed to reduced ICU days.

The main benefit to using a tele-ICU model is real-time access to a CCM specialist who may otherwise not be available to care for ICU patents. The bedside nurses caring for patients who may potentially deteriorate while awaiting a call back from a doctor get an immediate response from the tele-intensivist. The tele-intensivist provides immediate care as orders can be entered efficiently into the medical chart and unnecessary delay is avoided. Implicit in this model is that the nurse is at the bedside while communicating concerns with the tele-intensivist. The patients and their families who are at the bedside, some of whom may have arrived in the middle of the night, can also access a physician upon request. Other benefits include adherence to best practice measures and improved nursing productivity.

Prior to implementing a successful tele-ICU program, there are various issues with cost and culture that need to be addressed. These barriers can be divided into system-based challenges or those related to the CCM specialist. System-based barriers include initial cost to implement a telemedicine program and a smaller hospital’s difficulty in putting a program in place. The construction, installation, and training of staff can approach $5 million, while the annual operation of a command center can approach $1 to $2 million for staff, hardware, software, and technology licensing.⁸ Although the implementation and maintenance of such a program can be costly, the overall benefit to patients and the hospitals entrusted with their care is tangible.

Another important barrier to implementation is the lack of third-party payer reimbursement for tele-intensivist care. Regarding this, the Leapfrog Group³ recommends that health care purchasers should encourage hospitals to implement changes and meet their standard by providing marketplace incentives. They call for education of the consumer and purchaser to create a greater demand for care by bedside and tele-intensivists to care for the sickest patients. Such innovations can create financial savings in the health care sector when community hospitals, with the help of telemedicine, can care for critically ill patients in their facilities, as opposed to transferring the patient to a tertiary hospital (unless the community hospital does not have adequate resources, in which case it is appropriate and recommended to transfer care).

Other barriers include acceptance by the in-house CCM community who may be reluctant to have a tele-intensivist intervene in the care of their patients. The tele-ICU staff must be considered by the bedside staff as an integral part of the health care team in order for the system to work and to achieve its benefits.

Another limitation is the inability of the tele-intensivist to perform invasive bedside procedures (such as central access, arterial access, hemodialysis access, or tube thoracostomy) and the potential delay while waiting for another member of the in-house staff to complete these procedures in a timely fashion. Availability of certified staff to perform ICU procedures is an important factor that complements the benefit of having a tele-ICU program.

Maintenance of medical licensing throughout the different states where the tele-ICU service is used is necessary for each physician. This can be facilitated by a dedicated licensing and credentialing coordinator who can ensure continuity of certificates and hospital privileges.

As the use of focused bedside ultrasound and echocardiography grows in the world of critical care medicine, the tele-intensivist can also utilize this diagnostic modality. Specially trained respiratory therapists have conducted focused bedside transthoracic echocardiography while the tele-intensivist watches the real-time imaging on the high-definition/high-fidelity audio-visual interface, allowing early diagnosis of issues relating to the fluid status and other cardiac abnormalities. As the therapists become more comfortable with ultrasound, they can learn other ultrasound modalities such as lung, renal, and abdominal imaging, and can help diagnose dysfunction in these organ systems. In the future, intensivists may also be able to help stabilize patients being evacuated by mediflight, in dangerous battlefield situations, or conduct international consultations. They may also be able to work with other physicians, such as cardiothoracic surgeons or neurosurgeons, who have accepted patients onto their service from outside hospitals, and help optimize these critical patients in concert with the surgeons prior to or during transfer to the accepting hospital.