A Second Set of Eyes: An Introduction to Tele-ICU

Abstract

The purpose of the tele-ICU is not to replace bedside clinicians or bedside care, but to provide improved safety and enhance outcomes through standardization.Telemedicine, defined as “the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status” is not a novel approach to patient care.1 It has been more than 25 years since Grundy et al2 first described the use of intermittent remote telemedicine consultation to improve the delivery of health services to 395 patients in an intensive care unit (ICU) at a 100-bed hospital. Although the project demonstrated that television consultation had a “greater clinical and educational impact” than telephone consultation, Grundy et al concluded that further research was necessary to optimize use of the technology. Historically, other models of ICU tele-consultation have also demonstrated clinical benefits; a reduction in length of stay for infants of very low birth weight in neonatal ICUs,3 improved management and transfer of trauma patients,4 and improved consultations for pediatric critical care inpatients.5In the year 2000, Sentara Health-care, in partnership with VISICU, Inc (a Baltimore-based health care solutions company), implemented the first continuous, multisite telemedi-cine program. At 1 year after implementation, Sentara reported a reduction in hospital mortality of 27% when compared with the preceding year.6 According to today’s estimates, approximately 45 to 50 tele-ICU programs are supporting care in several hundred ICUs nationwide. The US market has 1 dominant vendor for tele-ICU systems, Philips-VISICU (Baltimore, Maryland), and 2 additional vendors, Cerner (Kansas City, Missouri) and iMDSoft (Need-ham, Massachusetts).The terms “tele-ICU,” “virtual ICU,” “remote ICU,” and “eICU” all refer to the same care concept; a centralized or remotely based critical care team is networked with the bedside ICU team and patient via state-of-the-art audiovisual communication and computer systems. The tele-ICU team can provide surveillance and support for a large number of ICU patients in disparate geographical locations for multiple hospitals.The ICU environment continuously assails clinicians with distractions, alarms, and interruptions that produce alarm fatigue and the potential for increased error rates. While addressing the needs of 1 patient, a busy nurse or physician may be unaware of a second patient’s change in status that requires immediate attention. The tele-ICU is that “second set of eyes” that provides additional clinical surveillance and support. By collaborating with the bedside team, the tele-ICU can support care without distraction and deliver timely interventions when minutes may make the difference. The purpose of the system is not to replace bedside clinicians or bedside care, but to provide improved safety through redundancy and enhance outcomes through standardization.There is no doubt that we are living in challenging times that promise to become increasing complex. The health care system will experience a surge in demand for services as more than 70 million “baby boomers,” many with chronic health conditions, continue to age.7,8 The volume and severity of cases treated in ICUs will increase dramatically with the aging population. To meet this expanding demand, hospitals will be required to increase the critical care capacity at great cost and simultaneously increase the volume of staff. Unfortunately, this surge will collide with the significant shortage of critical care nurses and physicians.The lack of human resources could adversely affect patients’ outcomes. Suboptimal staffing of ICU nurses has been linked to medication errors,9 increased risk of pneumonia and reintubation,10 and increased lengths of stay with higher complication rates.11 Physician staffing is also a concern; data12–14 strongly suggest that the best clinical outcomes occur when ICUs are managed by intensivists, specialists in critical care with advanced certification, who are directly involved with patient care. In its 2000 baseline analysis, the Leapfrog Group, an association of Fortune 500 companies, concluded that by having full-time intensivist staffing in metropolitan areas, 53 850 lives could be saved annually.15 However, given the current and projected shortage of intensivists, few hospitals are able to meet this mandate. Today fewer than 15% of ICUs are able to provide intensivist care; it is unlikely that future resources will be adequate to meet the population surge.16 The Leapfrog Group, recognizing the challenge in meeting this directive, has acknowledged that the tele-ICU may play an important role in attaining this quality objective.17,18The designation “tele-ICU” implies the presence of telemedicine technology in the delivery of care to ICU patients. The technology platform includes various vendor-specific components of hardware and software and affects both the tele-ICU and bedside teams. The tele-ICU team requires the same access as the bedside team to data elements related to patient care (eg, vital signs, results of laboratory tests, radiologic images, orders, and notes) to assess patients’ status accurately and identify actualand/or potential issues related to patient care. By using sophisticated alert systems, subtle changes in a patient’s condition are assessed for the purposes of early intervention and prevention of a crisis for the patient. High-resolution zoom cameras, microphones, and speakers are mounted in each ICU patient’s room (Figure 1), providing the tele-ICU 1-way or 2-way video/audio assessment capability and bedside communication. The VISICU vendor also provides an in-room button (Figure 2) that the bedside team can activate when requesting tele-ICU support. The complex technology (Table 1)19,20 is designed to support and enhance the care process while improving efficiency and effectiveness.Although the technology is relatively consistent from one tele-ICU system to another, program staffing models vary according to the needs of the hospitals within the system and the availability of resources. The “typical” tele-ICU operates 24 hours a day, 7 days a week and is staffed with critical care nurses and support staff with the intensivist on site 15 to 20 hours a day.21 In some programs, the intensivist works only the off-shift hours when on-site physicians have signed out to the on-call system. Replacement of tele-ICU registered nurses (eRNs) by midlevels such as nurse practitioners or physician assistants is another option for the model (Shawn Cody, VISICU operations director, oral communication, monthly teleconference, August 2007). The mean ratio is about 60 to 125 patients to 1 tele-intensivist, 30 to 40 patients to 1 eRN, and 50 to125 patients to 1 clerical assistant.22 Currently no data suggest a particular model as the most effective way of achieving the best outcomes. As the collective tele-ICU experience increases, patterns may emerge that enable us to indentify more specifically the efficacy of staffing models and processes.Tele-ICU physicians (ePhysicians) are board-certified/board-eligible intensivists, privileged and credentialed in each participating hospital, who provide oversight and intervention as appropriate for patient safety or as requested by the attending physician. A few programs employ a full-time ePhysician, but most programs have physician rotation schedules. When a program has more than 125 patients, the need for additional ePhysicians may need to be revisited.22 Challenged by the shortage of intensivists, some programs provide additional coverage with specialists such as cardiologists or with hospitalists under the guidance of the ePhysician (a VISICU operations director, oral communication, monthly teleconference, August 2007). Staffing needs are driven by the availability of on-site intensivists, the organization’s use of house staff, hospital resource utilization, and program goals.When the ePhysician arrives, the eRN or physician from the previous shift provides an overview of patient issues and concerns. Acute needs are prioritized and addressed before the initiation of routine “virtual” rounds. During rounds, each patient’s status is evaluated with the aid of vital signs, results of laboratory tests, progress notes, radiology reports, and other patient data. The acuity level of the patient determines the frequency of rounds, but most patients are reassessed every 1 to 4 hours according to acuity or as needs emerge. As patient care conditions are identified, changes to the plan of care are discussed directly with the bedside team. As needed, the ePhysician enters orders into the system software, or if available, directly into the hospital’s order entry system. The ePhysicians provide a variety of services, which may include performing multidisciplinary rounds via the camera, discussing weaning options with respiratory therapists, identifying potential patients for transfer, or entering the orders for bundle compliance. Software alerts provide a visual cue that allows the physician to respond proactively to emerging problems.The tele-ICU’s medical director is accountable for the medical care provided by the tele-ICU, but providing patient care is only 1 aspect of the tele-ICU work. Teamwork, essential to a culture of safety, is crucial to the success of the tele-ICU program. The tele-ICU environment encourages and supports excellence in ongoing collaboration between the tele-ICU team and the ICU. The tele-ICU’s medical director must demonstrate strong leadership skills in order to build and strengthen the working relationships if the transformation of care is to be accomplished.23The tele-ICU’s RN (eRN) often monitors the ICU patients 24 hours a day, 7 days a week. Many tele-ICU centers have highly experienced staff with 15 years or more of bedside experience in critical care. Some eRNs are attracted to the tele-ICU to mitigate the significant physical and emotional demands of full-time bedside care. Others are drawn to the challenge of providing patient care in a new setting and enjoy being on the cutting edge of change. Although programs vary, Table 2 highlights the baseline requirements for an eRN position. Excellence in communication is the most essential skill required for the eRN position. Computer and workflow skills can be obtained through orientation and experience, but poor communication and customer service skills are counterproductive and deleterious to the goals of the program.As with the ePhysician staffing, the eRN models vary among programs. Some tele-ICUs may employ only dedicated eRNs, whereas others contain a combination of dedicated and “shared” positions. The staff with shared positions have a secondary position in the tele-ICU and a primary position in the ICU; dedicated eRNs work only in the tele-ICU. Each model has pros and cons. Shared positions have the potential to enhance collaboration and acceptance of the tele-ICU program in the “home” ICU and provides for continued clinical competence for the eRN. However, shared positions can also increase the requirements for attendance at staff and committee meetings, competency demonstration, and performance evaluations. Because shared staff may report to 2 or more managers and units, the scheduling of vacation, shift rotation, and weekend and sick time coverage is more complex as staff respond to the needs of both work locations. Significant ongoing communication must occur between the director of the tele-ICU and the directors/managers of the ICU to secure staffing for both units.Shared positions may also be more challenging for staff who are less professionally mature. Critical care nurses often attain status and identity from their role in the ICU; they are required to have the ICU knowledge and skills to function in a new role but are not in the ICU. There is a transition not only to a new location and team, but to a new role with considerable ambiguity remaining in its definition. The desire for their tele-ICU contributions to be valued and recognized by their ICU counterparts is part of finding the new identity. For some, conflict with ICU peers or confusion about loyalty issues becomes overwhelming and the RN will decide to leave 1 of the 2 positions. For others, however, this combination role provides significant satisfaction and balance, which may actually extend the nurse’s critical care career.24In programs with only dedicated positions, eRNs work full time in the tele-ICU. This simplifies scheduling, evaluation, and identity issues and contributes to team stability and staff satisfaction.25 However, ICU staff often voice concerns about the eRN’s ability to maintain clinical competence when not providing care at the bedside (Elaine Comeau, CNE, VISICU, oral communication, VISICU 2008 User Conference, November 2008).To enhance the role of team, eRNs should participate in the candidate interview, selection, and orientation process. The transition from bedside nurse to eRN is neither intuitive nor easy. Even for experienced critical care nurses, the idea of “providing care” for 30 ICU patients is overwhelming and feels “unsafe.” A new definition of providing care must be developed and accepted for tele-ICU staff to be satisfied. Orientation should focus not only on managing the tele-ICU software and technology, but on strategies to enhance the tele-ICU identity. Tele-ICU competency standards have been determined via consensus among many tele-ICU programs, but they still must be validated through the research process.The variance found in tele-ICU programs due to vendor selection or program goals may produce subtle differences in work flows, but similarities in patient assessment and virtual rounding exist. Table 321,22,26 highlights the various components of virtual rounds. RN rounds, like the ePhysician counterparts, are prioritized on the basis of patient acuity and occur every 1 to 4 hours. During the rounding process, the eRN also responds to requests for assistance from the ICU team. Requested assistance may include but is not limited to the following: paging necessary personnel, verifying high-risk medications, reporting results of laboratory tests, or nursing consultation on patient care issues. The eRN is also evaluating alert notifications that can be dismissed after review or reset as the clinical condition warrants.26 During the hours in which the tele-intensivist is not on site, the eRNs must be able to direct requests for tele-physician consultation to the appropriate resource as determined by the individual program’s policies.Other members of the tele-ICU team often include support staff, who are instrumental in data entry, phone management, and quality monitoring. Support staff may have a variety of backgrounds, including previous experience as a unit secretary, nursing assistant, or as a nursing student seeking part-time employment. As with the eRN staff, the commitment to excellence in customer service is vital to the success of the role. Support personnel must be competent in the management of various computer software systems and demonstrate accuracy in data entry as the data may be used to support clinical decision making.A key component of the success of the tele-ICU program is the partnership between the clinical staff and the system’s information services department. Platform, network, interface development, connectivity, and desktop management are all components within the information services department that must be attuned to the technology needs and goals of the program. Program growth and maintenance can occur only with the understanding and support of the team from the information services department. The ability of the clinical staff to articulate their needs to the information services team in a way that promotes shared understanding takes time and energy but is vital to the success of technology integration. Each tele-ICU program requires a clear simple-to-use structure for problem reporting that clarifies the roles and responsibilities of the individual hospital’s information services team, and the tele-ICU’s information services team. It is vital for ICU and tele-ICU staff to understand to whom and how to report technical issues so that clinical time remains focused on patient care.As new and creative uses of the technology emerge, new positions such as pharmacists, clinical nurse specialists, case managers, and quality analysts are being added to the tele-ICU teams. The expertise of each of these roles can be leveraged to develop system standards of care or provide consultations that can improve both patient and system outcomes. Examples of standardization may include sedation and delirium management, prevention and treatment of pressure ulcers, and identification and measurement of quality indicators.Visitors to the tele-ICU are often surprised by the environment. They envision a hectic environment with hundreds of electrocardiography tracings and as many camera images on display, with alarms sounding compounded by the usual ringing of the phones. Many anticipate a realization of Orwell’s famous novel, 1984, with constant camera surveillance, a loss of ICU control, and increasing encroachment on the rights of the attending physician.The reality of the tele-ICU environment is often different than imagined. A site visit by the ICU team can be paramount in the acceptance of the remote team and program. Whether the tele-ICU is located within a hospital facility, or in a business park, they are similar in function. The typical workstation houses 5 to 7 computer screens for data display (Figure 3). Although, many assume the tele-ICU is “watching” with the cameras “on” all the time, only 1 camera at each workstation can be activated at a time; so if the tele-ICU has 4 workstations, only 4 patients can be viewed at once. Having the immediate access to patients’ data, including real-time vital signs and waveforms, allows patients’ changes to be evaluated without always activating the in-room camera. However, if the tele-ICU is extremely busy, the tele-ICU staff may camera in and out of several patient rooms in a short time to meet multiple demands.The waveform interface allows access to all patients’ waveforms, but often only the patients in the most unstable condition are continuously monitored. Other waveforms become visible with a single click of the mouse. The tele-RN or tele-physician can focus on each patient without the various disruptions that can plague bedside care.Placing ICU nurses and physicians at computer workstations to work for up to 12 hours when they are used to a very physically demanding pace provides its own ergonomic challenges. Computer monitors may require adjustment to accommodate the various vision needs of the users. Many tele-ICUs have electronic work tables that adjust the height of the desk from 26 inches (66 cm) high to 46 inches (117 cm) high, enabling staff to work in either a sitting or standing position. When building or initiating a tele-ICU program, consultation with an ergonomic specialist is a valuable and cost-effective strategy to prevent repetitive work injuries. Tele-ICU staff are encouraged to take frequent breaks from the computer screens to reduce eye strain, and many tele-ICU centers boast a variety of exercise equipment to discourage the risks of a sedentary position.The concept of allowing a remote team to join the bedside patient care team in providing care can be either reassuring or threatening, depending on the culture of the ICU and the transparency of the program’s goals. An organization’s ability to realize improved clinical outcomes from investment in the tele-ICU program, however, depends largely on the acceptance of the bedside team.Success starts with visionary leadership and direction at the organization level. Zapotochny-Rufo25 describes the importance of organizational vision for virtual ICU utilization:Pexton, coauthor of Improving Healthcare Quality and Cost With Six Sigma, points out in her article, “Overcoming Organizational Barriers to Change in Healthcare”27 that there is “often an inverse correlation between expectations and end results.” Pexton further identifies the most common barriers to successful change initiatives and strongly encourages the development of a management plan to address each potential barrier.Each of the barriers as noted by Pexton may be present as a system implements a tele-ICU program. Competing organizational priorities may make effective communication and leadership support more difficult and time consuming. Myers,21 Ries,22 Zapotochny-Rufo,25 and Sapirstein et al28 emphasize the importance of both organizational leadership support and local nursing and physician champions to achieve program integration and acceptance. Sapirstein et al further emphasize that tremendous organization and cultural changes are required and must appear if clinical transformation is to be accomplished with tele-ICU implementation. The roles of the tele-ICU nursing and medical directors are also key factors in this transformation. Behaviors such as acceptance, patience, support, reassurance, and good judgment must be modeled by the tele-ICU leadership22 and recognized and rewarded in integration efforts.Tele-ICU programs use a variety of strategies to build the communication skills and collaborative environment for integration success (Table 4). A focus on the AACN’s standards for a healthy work environment becomes a powerful foundation upon which to build the tele-ICU/ICU relationship and desired behaviors.29 Sharing outcome metrics such as length of stay, mortality rates, and compliance with best practice measures with both the ICU and tele-ICU staffs provides an additional opportunity to support the common goal of improved patient care.Given the current economic constraints, hospital executives and clinical leaders are requesting tele-ICU data demonstrating improved outcomes and return on investment. An analysis of severity-adjusted data from 185 464 patients from 2006 to 2007 in 156 hospital ICUs supported by the VISICU eICU programs shows actual hospital mortality rates of 9.6% versus the national average of 13.6%. These data were collected in a mix of rural, community, urban, and academic centers. The 29% reduction in mortality for this sample translates into an additional 7233 saved lives.30Aggregate and individual system outcomes are also being reported in a variety of professional publications and conference venues (Table 5).26,31–35 Currently, success is predicated on meeting the individual program goals such as a decrease in hospital mortality, reduction in ICU length of stay, or improved compliance with best practice recommendations. However, other specific markers of success may include return on investment data or other clinical outcomes specific to the use of the tele-ICU program.Interest in the use of telemedicine for improvement in the care of acutely or critically ill patients continues to expand. Mobile units capable of providing data to the tele-ICU team outside of the traditional ICU setting are being used by rapid response teams, or in emergency departments, postanesthesia care units, critical access facilities, and long-term acute care hospitals.Tele-ICU, eICU, virtual ICU, or remote ICU centers are affecting ICU patient care and clinicians in 28 states, more than 40 health care systems, and more than 200 hospitals.19 The concept of a remote ICU team providing care remains foreign to some, whereas others remain skeptical of the cost-to-benefit ratio. However, with the expansion of the various programs and the publication of clinical and fiscal outcomes, tele-ICUs are becoming more mainstream and transforming clinical care. Controversies and challenges will continue as the tele-ICU programs grapple with reimbursement issues, cultural resistance, and interoperability of information technologies.The tele-ICU concept expands the care team to include a “second set of eyes,” not to control or intrude, but to support and enhance current care. It is imperative to critically ill patients and their families that ICU and tele-ICU teams continue to share experiences, collaborate to find solutions, build respect and understanding of the role of the tele-ICU, and learn how together the teams can improve patient care.