Digitally-enabled remote critical care: will it make problems of geography history?

The COVID-19 pandemic has rejuvenated interest in the possibility of using telemedicine as an approach to providing critical care services to patients in remote areas. Conceptual and governance considerations remain unaddressed. We summarise the first steps in a recent collaborative effort between key organisations in Australia, India, New Zealand, and the UK, and call for an international consensus on standards with due considerations to governance and regulation of this emerging clinical practice.

Implementation of Tele-Intensive Care Unit Services During the COVID-19 Pandemic: A Systematic Literature Review and Updated Experience from Shandong Province.

Background: While the use of telemedicine had been expanding before the initial outbreak of COVID-19, the pandemic has dramatically accelerated its implementation and expanded its usage in many hospitals. Tele-intensive care unit (ICU) is a specialized type of telemedicine that adapts available technologies to the unique needs of critically ill patients. We published an editorial in 2020 describing our initial experiences of Tele-ICU application in Shandong Province. Here, we update our insights gained over the past 2 years, and we provide a systematic review of the literature to compare our perspectives with those from other institutions. Methods: We performed a systematic literature review of publications describing the use of telemedicine in an ICU setting during COVID-19. The PubMed database was searched for studies published after January 1, 2020, which offered detailed descriptions of tele-ICU usage. Extracted data included details regarding tele-ICU technologies, descriptions of the institution, usage cases, assessments of tele-ICU effectiveness, and site-reported opinions (e.g., advantages, disadvantages). Results: We screened 162 studies resulting from the PubMed literature search, along with one expert recommendation. Of the 112 full-text articles retrieved, 11 were selected for inclusion in this qualitative summary. All were retrospective descriptions of tele-ICU experiences at a single site. Some pairs of included articles reported results from the same institution, with seven unique sites being described. Three sites employed centralized models of tele-ICU, while four allowed staff to participate from distant locations. Five sites collected user-reported feedback regarding tele-ICU. While the advantages and disadvantages described rarely overlapped directly between sites, many reported positive opinions of tele-ICU use overall. Conclusions: The potential applications of tele-ICU technologies vary widely, making them highly adaptable to the needs of individual institutions. Tele-ICU has proven invaluable to some hospitals during COVID-19 due to its effectiveness at aiding patient care while mitigating risk to health care workers.

Telemedicine to Expand Access to Critical Care Around the World.

This multiauthored communication gives a state-of-the-art global perspective on the increasing adoption of tele-critical care. Exponentially increasing sophistication in the deployment of Computers, Information, and Communication Technology has ensured extending the reach of limited intensivists virtually and reaching the unreached. Natural disasters, COVID-19 pandemic, and wars have made tele-intensive care a reality. Concerns and regulatory issues are being sorted out, cross-border cost-effective tele-critical care is steadily increasing Components to set up a tele-intensive care unit, and overcoming barriers is discussed. Importance of developing best practice guidelines and retraining is emphasized.

COVID-19 and the Transformation of Intensive Care Unit Telemedicine.

The concept of telecritical care has evolved over several decades. ICU Telemedicine providers using both the hub-and-spoke ICU telemedicine center and consultative service delivery models offered their services during the COVID-19 pandemic. Telemedicine center responses were more efficient, timely, and widely used than those of the consultative model. Bedside nurses, physicians, nurse practitioners, physician assistants, and respiratory therapists incorporated the use of ICU telemedicine tools into their practices and more frequently requested critical care specialist telemedicine support.

Designing a critical care solution using in-person and telemedicine approaches in the US-Mexico border area during COVID-19.

BACKGROUND: UC San Diego Health System (UCSDHS) is the largest academic medical center and integrated care network in US-Mexico border area of California contiguous to the Northern Baja region of Mexico. The COVID-19 pandemic compelled several UCSDHS and local communities to create awareness around best methods to promote regional health in this economically, socially, and politically important border area. PURPOSE: To improve understanding of optimal strategies to execute critical care collaborative programs between academic and community health centers facing public health emergencies during the COVID-19 pandemic, based on the experience of UCSDHS and several community hospitals (one US, two Mexican) in the US-Mexico border region. METHODS: After taking several preparatory steps, we developed a two-phase program that included 1) in-person activities to perform needs assessments, hands-on training and education, and morale building and 2) creation of a telemedicine-based (Tele-ICU) service for direct patient management and/or educational coaching experiences.Findings.A clinical and educational program between academic and community border hospitals was feasible, effective, and well received. CONCLUSION: We offer several policy-oriented recommendations steps for academic and community healthcare programs to build educational, collaborative partnerships to address COVID-19 and other cross-cultural, international public health emergencies.

Virtual Handover of Patients in the Pediatric Intensive Care Unit During the Covid-19 Crisis.

OBJECTIVE: A key measure to mitigate coronavirus disease 2019 (COVID-19) has been social distancing. Incorporating video-conferencing applications in the patient handover process between healthcare workers can enhance social distancing while maintaining handover elements. This study describes pediatric intensive care unit (PICU) physicians' experience using an online video-conferencing application for handover during the COVID-19 pandemic. DESIGN: Qualitative content analysis. SETTING: PICU at a university hospital in Riyadh, Saudi Arabia. SUBJECTS: PICU Physicians. INTERVENTIONS: Due to the pandemic, the hospital's PICU used Zoom® as a remote conferencing application instead of a face-to-face handover. Following institutional review board approval, data were collected over two weeks (1 Jul 2020 to 14 Jul 2020). MEASUREMENTS: An online survey was conducted using open-ended questions to capture demographic data and the perceived efficacy of remote handovers. Thematic framework analysis process included open coding, creating categories, and abstraction. MAIN RESULTS: All 37 PICU physicians who participated in the handover completed the survey. The participants comprised six attendings, nine specialists, and 22 residents. While 20 (54.1%) physicians reported attending 1-5 Zoom handovers by the time of the study, some (n. 6, 16.2%) had more than ten virtual handovers. They had variable previous teleconferencing experiences. Most physicians (78.4%) were comfortable conducting a remote handover. Most found that Situation-Background-Assessment-Recommendation handover elements were properly achieved through this remote handover process. The perceived advantages of online handover included fewer interruptions, time efficiency, and facilitation of social distancing. The perceived disadvantages were the paucity of nonverbal communication and teaching during virtual meetings. CONCLUSION: Video-conferencing applications for online handovers could supplement traditional face-to-face intensive care unit patient handover during outbreaks of infectious diseases. The use of video streaming and more emphasis on teaching should be encouraged to optimize the users' experience.

Collaboration Between Tele-ICU Programs Has the Potential to Rapidly Increase the Availability of Critical Care Physicians-Our Experience Was During Coronavirus Disease 2019 Nomenclature.

OBJECTIVES: Implement a connected network between two Tele-ICU programs to support staffing and rounding during the first wave of the coronavirus disease 2019 pandemic in the United States. DESIGN: Proof of Concept model. SETTING: Northwell Health; a 23 Hospital, 40 ICU (500 ICU beds) healthcare organization serving the downstate NY area. During the initial coronavirus disease 2019 pandemic, Northwell Health rapidly expanded to greater than 1,000 ICU beds. The surge in patients required redeployment of noncritical care providers to the ICU bedside. The Tele-ICU program expanded from covering 176 beds pre pandemic to assisting with care for patients in approximately 450 beds via deployment of Wi-Fi-enabled mobile telehealth carts to the newly formed ICUs. PATIENTS: Critically ill coronavirus disease 2019 patients hospitalized at Northwell Health, NY, at any point from March 2020 to June 2020. INTERVENTIONS: To offset the shortage of critical care physicians, Northwell Health established a collaboration with the Tele-ICU program of Providence, St. Joseph Health in the state of Washington, which enabled the critical care physicians of Providence, St. Joseph Health to participate in virtual rounding on critically ill coronavirus disease 2019 patients at Northwell Health. MAIN RESULTS: We developed an innovative hybrid model that allowed for virtual rounding on an additional 40-60 patients per day by a remote critical care physician at Providence, St. Joseph Health. This was accomplished in approximately 3 weeks and provided remote care to complex patients. CONCLUSIONS: Our findings demonstrate the proof of concept of establishing a network of connected Tele-ICU programs as a rapidly scalable and sustainable paradigm for the provision of support from critical care physicians for noncritical care teams at the bedside.

Tele-ICUs for COVID-19: A Look at National Prevalence and Characteristics of Hospitals Providing Teleintensive Care.

PURPOSE: Amidst the COVID-19 outbreak, the use of intensive care unit telemedicine (tele-ICUs) may be one mechanism to provide patient care, particularly in rural parts of the United States. The purpose of this research was to inform hospital decision makers considering tele-ICUs, policy makers weighing immediate and longer-term funding and reimbursement decisions relative to tele-ICU care, and researchers conducting future work evaluating tele-ICUs. METHODS: We compared hospitals that reported providing teleintensive care to hospitals that reported not providing teleintensive care in the 2018 American Hospital Association Annual Survey (AHAAS). Differences between groups were tested using Pearson's chi-square (categorical variables) and t-tests (continuous variables) using 0.05 as the probability of Type 1 error. The study sample included all US short-term, acute care hospitals that responded to the AHAAS in 2018. Our key variable of interest was whether a hospital reported having any tele-ICU capabilities in the 2018 AHAAS. Other factors evaluated were ownership, region, beds, ICU beds, outpatient visits, emergency department visits, full-time employees, and whether a hospital was rural, a critical access hospital, a major teaching hospital, or part of a health system. FINDINGS: Larger, not-for-profit, nonrural, noncritical access, teaching hospitals that were part of a health system, particularly in the Midwest, were more likely to have tele-ICUs. Over one-third of hospital referral regions (HRRs) had zero hospitals with tele-ICUs, 4 had all hospitals with tele-ICU, and the median percent of hospitals with tele-ICU by HRR, weighted by outpatient visits, was 11.3%. CONCLUSIONS AND IMPLICATIONS: We found wide variation in the prevalence of tele-ICUs across HRRs and states. Future work should continue the evaluation of tele-ICU effectiveness and, if favorable, explore the variation we identified for improved access to teleintensive care.

Telecritical Care Clinical and Operational Strategies in Response to COVID-19.

Background: The cororavirus disease 19 (COVID-19) pandemic has strained intensive care unit (ICU) material and human resources to global crisis levels. The risks of staffing challenges and clinician exposure are of significant concern. One resource, telecritical care (TCC), has the potential to optimize efficiency, maximize safety, and improve quality of care provided amid large-scale disruptions, but its role in pandemic situations is only loosely defined. Planning and Preparation Phase: We propose strategic initiatives by which TCC may act as a force multiplier for pandemic preparedness in response to COVID-19, utilizing a tiered approach for increasing surge capacity needs. The goals involved usage of TCC to augment ICU capacity, optimize safety, minimize personal protective equipment (PPE) use, improve efficiencies, and enhance knowledge of managing pandemic response. Implementation Phase: A phased approach utilizing TCC would involve implementing remote capabilities across the enterprise to accomplish the goals outlined. The hardware and software needed for initial expansion to cover 275 beds included $956,670 for mobile carts and $173,106 for home workstations. Team role deployment and bedside clinical care centering around TCC as critical care capacity expand beyond 275 beds. Surge capacity was not reached during early phases of the pandemic in the region, allowing refinement of TCC during subsequent pandemic phases. Conclusions: Leveraging TCC facilitated pandemic surge planning but required redefinition of typical ICU staffing models. The design was meant to workforce efficiencies, reduce PPE use, and minimize health care worker exposure risk, all while maintaining quality care standards through an intensivist-led model. As health care operations resumed and states reopened, TCC is being used to support shifts in volume and critical care personnel during the pandemic evolution. The lessons applied may help health care systems through variable phases of the pandemic.

Breaking Barriers to Reach Farther: A Call for Urgent Action on Tele-ICU Services.

How to cite this article: Ramakrishnan N, Vijayaraghavan BKT, Venkataraman R. Breaking Barriers to Reach Farther: A Call for Urgent Action on Tele-ICU Services. Indian J Crit Care Med 2020;24(6):393-397.