Successful Implementation of Low-Cost Tele-Critical Care Solution by the U.S. Navy: Initial Experience and Recommendations.

Abstract

Intensivist physician involvement has been shown to improve outcomes for critically ill patients. Unfortunately, the number of Intensivists nationally is unable to meet the current demand. Similar to the civilian community, the Navy critical care workforce is limited by available resources. Tele-critical care (TCC) has recently been shown to improve outcomes for critically ill patients, and has been suggested as a suitable means of extending Intensivist expertise. Naval Hospital Camp Pendleton (NHCP) is a small community hospital located 41 miles north of Naval Medical Center San Diego (NMCSD). NHCP operates a relatively low-volume six-bed medical-surgical intensive care unit. The Intensivist staffing of NHCP has been variable, ranging from 3 Intensivists to periods of time with no on-site Intensivists. This intermittent staffing has led to (1) network disengagements, (2) unnecessary transfers to NMCSD, and (3) adverse outcomes for critically ill patients cared for at NHCP without Intensivist involvement. In early 2014, NMCSD established a TCC system to address this staffing challenge. Through the TCC program, the tele-Intensivist at NMCSD provides 24/7 coverage for patients located at NHCP using low-cost, off-the-shelf, synchronous high-definition video-teleconferencing equipment, and remote access to electronic medical record, imaging studies, and laboratory data. The tele-Intensivist also participates in multidisciplinary teaching rounds with the NHCP house staff. Several medical protocols have also been developed and implemented as part of the TCC program. When comparing the 12 months before implementation with the 19 months following implementation, we found (1) a trend toward increase volume of admissions per month (22.9 ± 7.5 vs. 27 ± 6.6, p = 0.11), (2) a decrease in total number of avoidable disengagements (12 ± 0.9 vs. 0, p = 0.0008), (3) increased maximum Acute Physiology and Chronic Health Evaluation II score per month (17.22 ± 2.2 vs. 21.8 ± 5.5, p = 0.018), and no adverse outcomes related to the TCC system. This reduction in disengagements correlated with a savings in out-of-network expenditures of $1.3 million over the 19 months of program operation. There was no change in either the patients' length of stay or the number of patients transferred to NMCSD. TCC improves readiness by increasing the volume and acuity of critical care patient encounters at the spoke hospital. TCC can also enhance Graduate Medical Education by providing Intensivist teaching, and supports the concept of "Regionalized Care" by improving the integration of care between hospitals. The quality of care is improved through the more rapid transfer of patients who require a higher level of care, standardization of care through protocols, and the Intensivist expertise that is applied to patients kept at the smaller facility. The value of care increased through both enhanced quality, and the cost savings associated with decreasing network disengagements. Leveraging new technology to provide remote care for our sickest beneficiaries has been proven a successful solution to the dilemma of limited Intensivist staffing. Leadership should consider TCC as a tool to extend Intensivist expertise to all of our small hospitals, and should explore the application of synchronous telehealth within the operational environment where similar staffing challenges exist.