What once seemed a remote possibility, is now an accelerating reality. Learn more about remote monitoring in the ICU critical care setting through Tele-ICU models, aimed at addressing the serious sub-specialty skills shortage of intensivists by allowing ICUs to have around the clock and instant access to critical care expertise…
What once seemed a remote possibility…?
In April 1924, Radio News jokingly suggested that a “radio doctor” may one day bring virtual medical care directly to patients 1. This seemed to be a crazy notion at the time, in a decade where house calls were common and twice-daily hospital rounds were a mainstay of patient evaluation and treatment- a very remote possibility indeed!
…Is now becoming a new found reality
With the increasing need for high-quality sub-specialty care, together with advances in telecommunication technology, the prescient fantasy of 1924 has become an achievable and increasingly common approach in recent decades to providing relevant and fast expertise to patients. Telemedicine, the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status, 2 has been incorporated into various fields of medicine. However, it has become a central focus of development in the intensive care unit (ICU).
Why the rapid uptake of remote care in ICU?
Well, in the face of rising ICU demand and costs for the care of critically ill patients 4, a rapidly aging population increasing the number of elderly sick patients, as well as a critical shortage of on-hand intensivists in the ICU, has fueled the popularity of Telemedicine technology (Tele-ICU). The critical shortage of on-hand intensivists, estimated by COMPACCS trial as a 22 percent shortfall is predicted to increase to 35 percent by 2030 5. Leaving us with a no-longer remote possibility but rather a serious reality of a substantial sub-specialty critical care skills shortage.
A well-implemented Tele-ICU program is a solution for this skills shortage and insufficient staffing, especially during nights and weekends, by providing rapidly available expertise 24-7 independent of geographical location. Various models have been implemented, including centralized and decentralized care. Tele-ICU can provide patient care by a centralized critical care team (often based in a remote location) via a constant 2-way interaction with the bedside ICU team and patients using audiovisual communication and computer systems. A decentralized model also exists, whereby intensivists can be located at any geographical location, and using various modes of technology can communicate directly with remote hospitals.
The wide-ranging benefits of tele-ICU
Staff and hospitals
Tele-ICU offers a means of leveraging intensivist coverage over more ICU beds. One physician and four nurses in one command center can oversee the care of up to 150 patients in distant ICUs 6. Clinicians are assisted by specialized decision support systems that track patients’ clinical values and give an alert when signs indicate a negative trend or when a change in treatment is scheduled according to protocol. In the case of Tele-ICUs, local ICUs need not be staffed with dedicated critical care specialists, rather hospital physicians or advanced practitioners who have the necessary procedural skills and can be guided by the remote consultative support of the intensivist6. This is one way that health systems counteract the severe skills shortage facing ICUs.
Well-implemented Tele-ICU programs also provide numerous benefits to both ICU staff and patients. On-site ICU staff are better supported in providing immediate management of patients and the all-hours coverage gives them a sense of security and confidence to handle complex patient problems 7. This technology can also lessen the workload of bedside staff and minimize the number of phone calls to consultants during off hours 7. The result is greater staff satisfaction and reduced turn-over and burnout rates.
Residents in training
Tele-ICU also has a positive impact on the clinical experience and education of medical residents, enabling them to discuss the status of their patients with consultants and benefit from more in-depth reasoning on clinical decision-making 7. Access to such oversight helps maintain consistency of practice with trainees.
Patients may benefit from a substantially shortened response-time where an audio-video Tele-ICU virtual connection can be established in a matter of seconds to minutes 9. Patient safety practices are also improved by the ability to standardize and achieve high adherence rates of best-practice processes through this real-time collaboration 8,10.
Improved ICU patient outcomes
The rapid and easily accessible remote specialist support of Tele-ICU programs to on-site staff may have a significant impact on ICU patient outcomes 8. The increasing use of this technology has resulted in a plethora of research studies investigating the effect of Tele-ICU implementation on several relevant outcomes to understand its applicability, utility, impact, and cost-effectiveness. For example, Chen and colleagues recently carried out a systematic review and meta-analysis of nineteen out of 1035 reviewed controlled trials and observational studies to evaluate the impact of Tele-ICU programs on mortality rates and hospital length of stay, and to summarize the available data on the implementation costs of Tele-ICU programs 11. Their findings showed significant reductions in ICU mortality, hospital mortality, and lengths of ICU stays. However, Tele-ICU programs were not found to be associated with decreased lengths of hospital stays. Moreover, their study implied that approximately US$50 000 to US$100 000 is needed per Tele-ICU bed to implement Tele-ICU programs in the first year. However, the costs per patient after applying Tele-ICU varied between hospitals from a US$2600 reduction to a US$5600 increase 11. The long-term return on investment therefore seems to be unclear. Although Tele-ICU implementation incurs substantial costs, the setting where it may be most cost-effective is when the intensity of care is high and patients are more ill 7.
Tailoring the program to the hospital without disrupting workflow may be the best model of care
For Tele-ICU to have a positive impact on patient outcomes, it should be well accepted by the bedside clinical staff and must be easily adopted and integrated into a system without disrupting the workflow pattern 12. The existing evidence base indicates that Tele-ICU programs are most effective if they are thoughtfully implemented and tailored to the specific hospital and ICU coverage needs, and if there is close integration between the Tele-ICU team and bedside staff 13.
Barriers and challenges
There are several barriers to broader use. Firstly, the substantial capital costs of constructing and installing a new Tele-ICU platform, and training staff in implementing the new program. There are also ongoing annual operating costs. Reimbursement for TeleICU intensivists’ fees is an additional issue since they are not currently reimbursed by insurers and must be paid for as part of hospital operating expenses 6. Although the TeleICU market has grown, it has now plateaued due to the cost constraints and many programs being shuttered. However, the potential to increase the physician/patient and nurse/patient ratio using new, advanced monitoring technologies and TeleICU rounding strategies could have a dramatic impact on reducing the costs of TeleICU care.
Engaging with the ICU staff and getting buy in from the early stages is critical for adoption of digital health technologies in the ICU. In order for a true transformation to come about, there needs to be more than simply a digital and technological innovation. Staff needs to be trained in digital literacy, and lack of awareness and trust in novel digital technologies or fear of them, need to be addressed 14 In addition, lack of trust in clinical decision support systems (CDSS) based on artificial intelligence can hinder the early detection of complications such as sepsis, respiratory failure, or bleeding. 14 This is despite the fact that the principle of predictive analytics in clinical decision support systems is relatively simple: The combination of several parameters and the automatic recognition of specific patterns allow for earlier detection of adverse events, than the classical parallel monitoring of single parameters. 15
Future studies should therefore answer how to apply telemedicine in the most effective and cost-effective manner, and to investigate the success of a model incorporating ICU staff upskilling and training together with Tele-ICU technology implementation and CDSS systems. Additional research efforts should also investigate which are the highest impact clinical settings for Tele-ICU programs with minimal adverse consequences.
Tele-ICU medicine is now a reality …
So, to sum it all up, despite the need for further investigation into the cost-effectiveness of Tele-ICU programs, and the apparent lag in user acceptance, current evidence indicates that Tele ICUs provide many benefits to both larger and smaller hospitals and to more critically ill patients 7,8. Apart from the important acute care interventions, Tele-ICUs also add value through objective, data-driven population management and can improve adherence to best clinical practices and clinical protocols, in addition to standardizing evidence-based clinical care approaches 13.
Our challenge is to increase adoption and sustainability of Tele-ICU in the coming years, making this long-held remote dream a reality to expand our delivery of optimal critical care.
- Gernsback H, Gernsback S, Dermott RW. The radio doctor – maybe. Radio News 1924;1406.
- Voran D. Telemedicine and beyond. Mo Med. 2015;112(2):129–135.
- Reynolds HN, Bander JJ. Options for tele-intensive care unit design: centralized versus decentralized and other considerations: it is not just a “another black sedan”. Crit Care Clin. 2015;31(2):335-50.
- Lindemark F, Haaland ØA, Kvåle R, Flaatten H, Norheim OF, Johansson KA. Costs and expected gain in lifetime health from intensive care versus general ward care of 30,712 individual patients: a distribution-weighted cost-effectiveness analysis. Crit Care. 2017 Aug 21;21(1):220.
- Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J, Jr, Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS) Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA. 2000;284(21):2762–2770.
- New England Healthcare Institute, Massachusetts Technology Collaborative, Health Technology Center. Tele-ICUs: Remote Management in Intensive Care Units. March 2007
- Venkataraman R, Ramakrishnan N. Outcomes related to telemedicine in the intensive care unit: what we know and would like to know. Crit Care Clin. 2015;31(2):225-237.
- Fuhrman SA, Lilly CM. ICU Telemedicine Solutions. Clin Chest Med. 2015;36(3):401-407.
- Eric Wicklund. Telemedicine in the ICU: How One Hospital Improved Care Management. Telehealth News. Available at: https://mhealthintelligence.com/news/telemedicine-in-the-icu-how-one-hospital-improved-care-management. Accessed on 19/12/2019.
- Lilly CM, McLaughlin JM, Zhao H, et al. A multicenter study of ICU telemedicine reengineering of adult critical care. Chest 2014; 145:500–7.
- Chen J, Sun D, Yang W, Liu M, Zhang S, Peng J, Ren C. Clinical and Economic Outcomes of Telemedicine Programs in the Intensive Care Unit: A Systematic Review and Meta-Analysis. J Intensive Care Med. 2018;33(7):383-393.
- Kahn JM, Hill NS, Lilly CM, et al. The research agenda in ICU telemedicine: a statement from the Critical Care Societies Collaborative. Chest 2011; 140:230–8.
- Becker C, Frishman WH, Scurlock C. Telemedicine and Tele-ICU: The Evolution and Differentiation of a New Medical Field. Am J Med. 2016;129(12):e333-e334.
- Poncette A-S, Spies C, Mosch L, Schieler M, Weber-Carstens S, Krampe H, Balzer F. Clinical Requirements of Future Patient Monitoring in the Intensive Care Unit: Qualitative Study. JMIR Med Inform 2019;7(2): e13064
- Mouchard F. Hemodynamic monitoring in the era of digital health. Intensive Care (2016) 6:15 DOI 10.1186/s13613-016-0119-7