How tele-ICU is revolutionizing access to life-saving care
A patient in a remote area of Vermont lies in bed at a small, rural hospital with a critical lung condition that the clinician on site has never before treated. Instead of waiting for a med-flight to transfer the patient to another location, the care team sets up a virtual visit with a clinician in Chicago for the patient’s immediate care. They’re able to work through the details of the needed treatment without him ever leaving the area.
The notion that critical care medicine could be provided virtually began to take shape more than 20 years ago as the U.S. looked for ways to combat a growing shortage of critical care physicians. Unfortunately, the pandemic exacerbated the situation. The past three years have resulted in high rates of burnout among physicians—especially those in critical care, who saw the bulk of hospitalized COVID-19 patients.
A critical need
“The shortfall of critical care physicians is only expected to worsen,” says Konrad L. Davis, M.D., FCCP, FCCM, Captain (Ret.) in the U.S. Navy, Chief of the Division of Pulmonary & Critical Care at Scripps Memorial Hospital La Jolla, and Clinical Professor of Medicine in the Scripps Clinic Medical Group. “By leveraging technology with tele-critical care (also called tele-ICU), you can allow a smaller number of physicians to extend that care expertise to a larger number of (potentially) geographically dispersed patients.”
Dr. Davis, who recently retired from the U.S. Navy after 21 years, started the Military Health System tele-critical care program in 2012. Now practicing in-person critical care at Scripps, he’s working with the health system as it explores tele-ICU.
While many health systems have incorporated telemedicine as a standard way to deliver healthcare, tele-critical care is an emerging category that more hospitals and health systems like Scripps are beginning to seriously consider. The tele-ICU solution enables specialized physicians to manage care for seriously ill patients located in parts of the country where it is difficult to find critical care expertise. The U.S. military, Department of Veterans Affairs, Banner Health and Mercy Virtual are among the early adopters effectively operating tele-ICU programs based on their patient populations’ needs.
How tele-ICU works
The patient is located at what’s known as the originating site, which is usually a hospital. The critical care provider is located at what’s called the distant site. “At the originating site, remote support can be provided round-the-clock, partial or as-needed,” Dr. Davis explains. At the distant site, there are different models for providing care. “A hub-and-spoke model is where a centralized group of providers support multiple facilities that are part of a health system. A decentralized model means the critical care providers could be located just about anywhere.”
Communication and information technology advancements like continuous remote monitoring allow critical care providers to manage up to 150 patients in a tele-ICU setting, rather than 10 to 15 patients in person. Healthcare professionals like advanced practice providers (APPs) and anesthesiologists handle procedures in the absence of a critical care physician provider on site.
“Because medicine is becoming more and more digitized, it can be practiced increasingly through virtual tools and care models. It doesn’t always need to be hands on,” says Dr. Davis. “A nurse can place a digital stethoscope on the patient’s chest and the intensivist can listen remotely.”
Barriers to adoption
Reimbursement for tele-ICU had been lower than in-person services and was temporarily increased during the pandemic. “If reimbursement reverts to pre-COVID levels, some tele-ICU practices may not be as profitable,” suggests Dr. Davis. In addition, it can be challenging to practice tele-critical care across state lines, since providers must have state licensure in each state and privileges at each hospital where they provide services. “Some systems allow for privileges by proxy for a telemedicine program. For those exploring this initiative, make sure this is included as part of your services agreement,” he adds.
How patients & communities benefit
The greatest opportunity for tele-ICU benefit is in rural areas with low-density populations. Tele-ICU enables hospitals that don’t see enough volume to staff round-the-clock critical care physicians to provide life-saving care to patients with conditions like sepsis, pneumonia and overdoses. It also makes it possible for these hospitals to provide consultation in subspecialties like neurocritical care, surgical critical care, trauma and cardiac critical care.
Many studies show that, if implemented correctly, tele-ICU patients receive a higher level of care than they do with in-person care. “It is resulting in shorter length of stays, improved quality and lowered costs,” adds Dr. Davis.
Konrad Davis, M.D., FCCP, FCCM, Chief of the Division of Pulmonary & Critical Care at Scripps Memorial Hospital La Jolla, and Clinical Professor of Medicine at Scripps Clinic Medical Group, offers the following considerations to providers exploring the addition of tele-critical care services within their health systems.
- Start with the why. Clearly identify the problems you are working to solve with tele-critical care ahead of time. It’s not a panacea, but it can be effective in solving some issues such as inadequate staffing, less than 24/7 coverage and lack of standardized care across a healthcare system.
- View tele-ICU from a systems standpoint. If you are a tele-critical care physician, caring for 100 to 150 patients spread across 20 different hospitals, it’s very challenging, especially if every hospital has a different way of managing vent-weaning and other clinical situations. Standardizing the administrative parts of care across hospitals improves quality of care, decreases confusion and makes physicians more efficient.
- Make tele-ICU part of a larger digital health strategy. A 5- or 10-year strategy for digitization should involve understanding the movement of patients and what they need at different stages of their journey to attract and retain them, and how to provide high-quality care at a lower cost.
- Assemble a multidisciplinary team. Implementing tele-critical care is not just a clinical initiative. It also needs to include administration, information management and other disciplines to support the process. The team should have both physician and nurse champions, as well as an executive champion to help clear administrative red tape and to be actively engaged in the planning process.
- Establish trust. Tele-ICU will not work unless there is trust among team members at the spoke-and-hub sites. Leaders should physically meet with staff, listen to their concerns and answer any questions that they may have.
- Implement robust education and training to help teams feel comfortable. Before going live, conduct exercises that involve simulated patients with teams going through standard interactions between the hub site and spoke sites. This helps people get used to the technology and systems.
