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.

Centralized monitoring and virtual consultant models of tele-ICU care: a systematic review.

BACKGROUND: Increasing intensivist shortages and demand coupled with the escalating cost of care have created enthusiasm for intensive care unit (ICU)-based telemedicine ("tele-ICU"). This systematic literature review compares the Centralized Monitoring and Virtual Consultant tele-ICU Models. MATERIALS AND METHODS: With an experienced medical reference librarian, we identified all language publications addressing the employment and efficacy of the centralized monitoring and virtual consultant tele-ICU systems through PubMed, CINAHL, and Web of Science. We performed quantitative and qualitative reviews of documents regarding financial sustainability, clinical outcomes, and ICU staff workflow and acceptance. RESULTS: Of 1,468 documents identified, 1,371 documents were excluded, with the remaining 91 documents addressing clinical outcomes (46 documents [enhanced guideline compliance, 5; mortality and length of stay, 28; and feasibility, 13]), financial sustainability (9 documents), and ICU staff workflow and acceptance (36 documents). Quantitative review showed that studies evaluating the Centralized Monitoring Model were twice as frequent, with a mean of 4,891 patients in an average of six ICUs; Virtual Consultant Model studies enrolled a mean of 372 patients in an average of one ICU. Ninety-two percent of feasibility studies evaluated the Virtual Consultant Model, of which 50% were in the last 3 years. Qualitative review largely confirmed findings in previous studies of centralized monitoring systems. Both the Centralized Monitoring and Virtual Consultant Models showed clinical practice adherence improvement. Although definitive evaluation was not possible given lack of data, the Virtual Consultant Model generally indicated lean absolute cost profile in contrast to centralized monitoring systems. CONCLUSIONS: Compared with the Virtual Consultant tele-ICU Model, studies addressing the Centralized Monitoring Model of tele-ICU care were greater in quantity and sample size, with qualitative conclusions of clinical outcomes, staff satisfaction and workload, and financial sustainability largely consistent with past systematic reviews. Attention should be focused on performing more high-quality studies to allow for equitable comparisons between both models.

Centralized monitoring and virtual consultant models of tele-ICU care: a side-by-side review.

BACKGROUND: Telemedicine-based "tele-intensive care unit" ("tele-ICU") solutions represent an increasingly popular hospital platform to provide ICU specialist expertise while remaining sensitive to healthcare costs. This side-by-side review directly compares the Centralized Monitoring and Virtual Consultant tele-ICU Models. MATERIALS AND METHODS: We identified all publications in any language addressing the use and efficacy of centralized monitoring and virtual consultant tele-ICU systems through reviews of the PubMed, CINAHL, and Web of Science Web sites, corporate documents, corporate Internet sites, and discussions with corporate representatives. Of the 1,468 documents identified, 1,371 documents were excluded, with the 91 included documents addressing the following: clinical outcomes, 46 documents (enhanced guideline compliance, 5; mortality and length of stay, 28; and feasibility, 13); financial sustainability, 9 documents; and ICU staff workflow and acceptance, 36 documents. We performed qualitative comparative reviews of documents addressing technology, financial sustainability, clinical outcomes, and ICU staff workflow and acceptance. RESULTS: The Centralized Monitoring tele-ICU Model showed improved mortality and/or length of stay and staff acceptance, particularly in rural or specific patient populations, likely because of the presence of integrated clinical information systems and analytics. However, there are high costs and unclear savings. The Virtual Consultant Model could not be adequately evaluated for effects on clinical outcomes or staff acceptance given minimal data. This model can be both portable and implemented at a lower cost profile but cannot integrate different data streams. Improved compliance with clinical practice guidelines was seen in both models. CONCLUSIONS: Further study is required to adequately compare these tele-ICU models with regard to clinical outcomes and financial sustainability. With respect to tele-ICU effects on mortality and length of stay improvements and on-site staff acceptance, existing evidence favors the Centralized Monitoring Model. Studies addressing the Virtual Consultant Model are growing in number and are necessary before proper comparisons can be made.

Implementation and Impact of Critical Care Pharmacist Addition to a Telecritical Care Network.

Critical care pharmacists when incorporated into the ICU team, have been shown to improve outcomes in critically ill patients by decreasing mortality, improving morbidity and reducing cost. As telehealth continues to evolve, the incorporation of a critical care pharmacist into a comprehensive telecritical care (TCC) service will allow increased comprehensive pharmacotherapeutic care for those in smaller, community or rural hospitals. OBJECTIVES: To describe the implementation of a TCC pharmacist into an established TCC network, classify interventions performed, and quantify cost avoidance generated through pharmacist interventions. DESIGN: Multicenter, observational cohort study and retrospective return on investment, performed between December 2019 and December 2021. SETTING AND PARTICIPANTS: Critically ill adult patients, admitted to an ICU located in any of our eight community hospitals (50 ICU beds) within a large, 25-hospital integrated healthcare system (563 ICU beds total) in the United States. MAIN OUTCOMES AND MEASURES: The TCC pharmacist service was implemented in 8-hour shifts, initially available 5 days per week, then expanded to 7 days per week. Critical care pharmacist interventions were categorized by clinical type established utilizing American Society of Health-System Pharmacists benchmarking standards and the latest cost avoidance data. RESULTS: During the 2-year analysis period, TCC pharmacists documented 2,838 interventions generating $1,664,254 of gross cost avoidance and a return on investment of 4.5:1. CONCLUSIONS AND RELEVANCE: It is feasible to implement a TCC pharmacist within an established TCC network. Our experience showed enhanced comprehensive care of critically ill patients located in community hospitals within a large, integrated healthcare system, demonstrated significant cost avoidance, and has led to other initiatives, including a collaborative clinical/operational partnership with Life Flight.

Awakening and Breathing Coordination: A Mixed-Methods Analysis of Determinants of Implementation.

Rationale: Routine spontaneous awakening and breathing trial coordination (SAT/SBT) improves outcomes for mechanically ventilated patients, but adherence varies. Understanding barriers to and facilitators of consistent daily use of SAT/SBT (implementation determinants) can guide the development of implementation strategies to increase adherence to these evidence-based interventions. Objectives: We conducted an explanatory, sequential mixed-methods study to measure variation in the routine daily use of SAT/SBT and to identify implementation determinants that might explain variation in SAT/SBT use across 15 intensive care units (ICUs) in urban and rural locations within an integrated, community-based health system. Methods: We described the patient population and measured adherence to daily use of coordinated SAT/SBT from January to June 2021, selecting four sites with varied adherence levels for semistructured field interviews. We conducted key informant interviews with critical care nurses, respiratory therapists, and physicians/advanced practice clinicians (n = 55) from these four sites between October and December 2021 and performed content analysis to identify implementation determinants of SAT/SBT use. Results: The 15 sites had 1,901 ICU admissions receiving invasive mechanical ventilation (IMV) for ⩾24 hours during the measurement period. The mean IMV patient age was 58 years, and the median IMV duration was 5.3 days (interquartile range, 2.5-11.9). Coordinated SAT/SBT adherence (within 2 h) was estimated at 21% systemwide (site range, 9-68%). ICU clinicians were generally familiar with SAT/SBT but varied in their knowledge and beliefs about what constituted an evidence-based SAT/SBT. Clinicians reported that SAT/SBT coordination was difficult in the context of existing ICU workflows, and existing protocols did not explicitly define how coordination should be performed. The lack of an agreed-upon system-level measure for tracking daily use of SAT/SBT led to uncertainty regarding what constituted adherence. The effects of the COVID-19 pandemic increased clinician workloads, impacting performance. Conclusions: Coordinated SAT/SBT adherence varied substantially across 15 ICUs within an integrated, community-based health system. Implementation strategies that address barriers identified by this study, including knowledge deficits, challenges regarding workflow coordination, and the lack of performance measurement, should be tested in future hybrid implementation-effectiveness trials to increase adherence to daily use of coordinated SAT/SBT and minimize harm related to the prolonged use of mechanical ventilation and sedation.

Physician and Trainee Perceptions of Telecritical Care Practice and Education: Results of a Programmatic Survey.

Background: Telecritical care (TCC) as a telehealth modality seeks to remedy contemporary shortfalls in staffing and experience at the bedside. Physician and physician trainee perceptions of TCC practice and education can help inform programmatic and curricular decisions. The perceptions of TCC and a formalized structured TCC rotation from faculty and trainees are unknown. Objective: To evaluate perceptions of TCC practice and education among participating physicians and trainees. Methods: Survey of physicians and trainees participating in the Emory Critical Care Center's TCC unit from 2017 to 2021 was conducted, after implementation of a structured TCC educational curriculum. Items were developed with a 5-point Likert scale. Results: The overall response rate was 71% (43 of 61). Most respondents felt their knowledge was used appropriately and that their recommendations were well received at the bedside. The majority perceived that the TCC program improved continuity, quality, and safety of patient care. More than half of respondents would practice TCC in the future, and most would advocate for it. Most fellows were comfortable providing patient care remotely after their rotation. The majority of respondents felt TCC did not add to their level of burnout. Conclusions: This programmatic evaluation identified perceived improvements in patient care. Implementation of a TCC rotation does not seem to negatively impact the educational experience of trainees.