Integrating a Virtual ICU with Cardiac and Cardiovascular ICUs: Managing the Needs of a Complex and High-Acuity Specialty ICU Cohort.

A long-standing shortage of critical care intensivists and nurses, exacerbated by the coronavirus disease (COVID-19) pandemic, has led to an accelerated adoption of tele-critical care in the United States (US). Due to their complex and high-acuity nature, cardiac, cardiovascular, and cardiothoracic intensive care units (ICUs) have generally been limited in their ability to leverage tele-critical care resources. In early 2020, Houston Methodist Hospital (HMH) launched its tele-critical care program called Virtual ICU, or vICU, to improve its ICU staffing efficiency while providing high-quality, continuous access to in-person and virtual intensivists and critical care nurses. This article provides a roadmap with prescriptive specifications for planning, launching, and integrating vICU services within cardiac and cardiovascular ICUs-one of the first such integrations among the leading academic US hospitals. The success of integrating vICU depends upon the (1) recruitment of intensivists and RNs with expertise in managing cardiac and cardiovascular patients on the vICU staff as well as concerted efforts to promote mutual trust and confidence between in-person and virtual providers, (2) consultations with the bedside clinicians to secure their buy-in on the merits of vICU resources, and (3) collaborative approaches to improve workflow protocols and communications. Integration of vICU has resulted in the reduction of monthly night-call requirements for the in-person intensivists and an increase in work satisfaction. Data also show that support of the vICU is associated with a significant reduction in the rate of Code Blue events (denoting a situation where a patient requires immediate resuscitation, typically due to a cardiac or respiratory arrest). As the providers become more comfortable with the advances in artificial intelligence and big data-driven technology, the Cardiac ICU Cohort continues to improve methods to predict and track patient trends in the ICUs.

ICU Telemedicine Implementation and Risk-Adjusted Mortality Differences Between Daytime and Nighttime Coverage.

BACKGROUND: ICU telemedicine augmentation has been associated with improvements in clinical and financial outcomes in many cases, but not all. Understanding this discrepancy is of interest given the clinical impact and intervention cost. A recent meta-analysis noted an association with mortality reduction and standardized mortality ratio (SMR) before ICU telemedicine implementation of > 1. RESEARCH QUESTION: Does ICU telemedicine implementation affect adjusted mortality outcomes? If so, in what context? STUDY DESIGN AND METHODS: We performed a retrospective pre-post analysis comparing before vs after ICU telemedicine implementation on the outcome of risk-adjusted ICU mortality during am vs pm admissions as well as other objective measures of ICU telemedicine involvement. RESULTS: One thousand five hundred eighty-one patient-stays and 14,584 patient-stays were available for analysis in the implementation period before vs after ICU telemedicine implementation, respectively. The average Acute Physiology and Chronic Health Evaluation (APACHE) IVa score was 46.6 vs 54.8 (P < .01) in the am group before ICU telemedicine implementation vs the am group after ICU telemedicine implementation, respectively. The average APACHE IVa score was 47.2 vs 56.3 (P < .01) in the pm group before ICU telemedicine implementation vs the pm group after ICU telemedicine implementation, respectively. Overall, the risk-adjusted ICU mortality was 8.7% before ICU telemedicine implementation vs 6.5% (P < .01) after implementation. When stratified by am and pm admission groups, no significant difference in risk-adjusted ICU mortality was seen in the am stratum. In the pm stratum, risk-adjusted mortality was 10.8% before ICU telemedicine implementation vs 7.0% (P < .01) after ICU telemedicine implementation. The preimplementation SMR in the am admission stratum was 0.95 vs 1.30 in the pm stratum. INTERPRETATION: We found a reduction in risk-adjusted ICU mortality with implementation of ICU telemedicine driven predominantly within the pm admission group. The pm admission SMR was 1.30, which may suggest an association with SMR of > 1 before ICU telemedicine implementation and mortality reduction. Future studies should seek to confirm this finding and should explore other important ICU telemedicine outcomes in the context of observed-to-expected ratios.

Effects of Telemedicine ICU Intervention on Care Standardization and Patient Outcomes: An Observational Study.

OBJECTIVES: Given the numerous recent changes in ICU practices and protocols, we sought to confirm whether favorable effects of telemedicine ICU interventions on ICU mortality and length of stay can be replicated by a more recent telemedicine ICU intervention. DESIGN SETTING AND PATIENTS: Observational before-after telemedicine ICU intervention study in seven adult ICUs in two hospitals. The study included 1,403 patients in the preintervention period (October 2014 to September 2015) and 14,874 patients in the postintervention period (January 2016 to December 2018). INTERVENTION: Telemedicine ICU implementation. MEASUREMENTS AND MAIN RESULTS: ICU and hospital mortality and length of stay, best practice adherence rates, and telemedicine ICU performance metrics. Unadjusted ICU and hospital mortality and lengths of stay were not statistically significantly different. Adjustment for Acute Physiology and Chronic Health Evaluation Version IVa score, ICU type, and ICU admission time via logistic regression yielded significantly lower ICU and hospital mortality odds ratios of 0.58 (95% CI, 0.45-0.74) and 0.66 (95% CI, 0.54-0.80), respectively. When adjusting for acuity by comparing observed-over-expected length of stay ratios through Acute Physiology and Chronic Health Evaluation IVa methodology, we found significantly lower ICU and hospital length of stay in the postintervention group. ICU mortality improvements were driven by nighttime ICU admissions (odds ratio 0.45 [95% CI, 0.33-0.61]) as compared to daytime ICU admissions (odds ratio 0.81 [95% CI, 0.55-1.20]), whereas hospital mortality improvements were seen in both subgroups but more prominently in nighttime ICU admissions (odds ratio 0.57 [95% CI, 0.44-0.74]) as compared to daytime ICU admissions (odds ratio 0.73 [95% CI, 0.55-0.97]), suggesting that telemedicine ICU intervention can effectively supplement low intensity bedside staffing hours (nighttime). CONCLUSIONS: In this pre-post observational study, telemedicine ICU intervention was associated with improvements in care standardization and decreases in ICU and hospital mortality and length of stay. The mortality benefits were mediated in part through telemedicine ICU supplementation of low intensity bedside staffing hours.

Telemedicine in the ICU: clinical outcomes, economic aspects, and trainee education.

PURPOSE OF REVIEW: The evidence base for telemedicine in the ICU (tele-ICU) is rapidly expanding. The last 2 years have seen important additions to our understanding of when, where, and how telemedicine in the ICU adds value. RECENT FINDINGS: Recent publications and a recent meta-analysis confirm that tele-ICU improves core clinical outcomes for ICU patients. Recent evidence further demonstrates that comprehensive tele-ICU programs have the potential to quickly recuperate their implementation and operational costs and significantly increase case volumes and direct contribution margins particularly if additional logistics and care standardization functions are embedded to optimize ICU bed utilization and reduce complications. Even though the adoption of tele-ICU is increasing and the vast majority of today's medical graduates will regularly use some form of telemedicine and/or tele-ICU, telemedicine modules have not consistently found their way into educational curricula yet. Tele-ICU can be used very effectively to standardize supervision of medical trainees in bedside procedures or point-of-care ultrasound exams, especially during off-hours. Lastly, tele-ICUs routinely generate rich operational data, as well as risk-adjusted acuity and outcome data across the spectrum of critically ill patients, which can be utilized to support important clinical research and quality improvement projects. SUMMARY: The value of tele-ICU to improve patient outcomes, optimize ICU bed utilization, increase financial performance and enhance educational opportunities for the next generation of providers has become more evident and differentiated in the last 2 years.

Evaluating Tele-ICU Implementation Based on Observed and Predicted ICU Mortality: A Systematic Review and Meta-Analysis.

OBJECTIVES: Past studies have examined numerous components of tele-ICU care to decipher which elements increase patient and institutional benefit. These factors include review of the patient chart within 1 hour, frequent collaborative data reviews, mechanisms for rapid laboratory/alert review, and interdisciplinary rounds. Previous meta-analyses have found an overall ICU mortality benefit implementing tele-ICU, however, subgroup analyses found few differences. The purpose of this systematic review and meta-analysis was to explore the effect of tele-ICU implementation with regard to ICU mortality and explore subgroup differences via observed and predicted mortality. DATA SOURCES: We searched PubMed, Cochrane Library, Embase, and European Society of Intensive Care Medicine for articles related to tele-ICU from inception to September 18, 2018. STUDY SELECTION: We included all trials meeting inclusion criteria which looked at the effect of tele-ICU implementation on ICU mortality. DATA EXTRACTION: We abstracted study characteristics, patient characteristics, severity of illness scores, and ICU mortality rates. DATA SYNTHESIS: We included 13 studies from 2,766 abstracts identified from our search strategy. The before-after tele-ICU implementation pooled odds ratio for overall ICU mortality was 0.75 (95% CI, 0.65-0.88; p < 0.001). In subgroup analysis, the pooled odds ratio for ICU mortality between the greater than 1 versus less than 1 observed to predicted mortality ratios was 0.64 (95% CI, 0.52-0.77; p < 0.001) and 0.98 (95% CI, 0.81-1.18; p = 0.81), respectively. Test for interaction was significant (p = 0.002). CONCLUSIONS: After evaluating all included studies, tele-ICU implementation was associated with an overall reduction in ICU mortality. Subgroup analysis suggests that publications exhibiting observed to predicted ICU mortality ratios of greater than 1 before tele-ICU implementation was associated with a reduction in ICU mortality after tele-ICU implementation. No significant ICU mortality reduction was noted in the subgroup of observed to predicted ICU mortality ratio less than 1 before tele-ICU implementation. Future studies should confirm this finding using patient-level data.

International teleconsultation on conjoined twins leading to a successful separation: a case report.

Conjoined twins are identical twins that have incompletely separated in utero. The prognosis for conjoined twins is poor and management in a skilled tertiary care centre is paramount for definitive care. We describe our experience with a telemedical consultation on conjoined twins in The Dominican Republic from our eHealth centre in Valhalla, NY. The patients were two month old, female, pygopagus conjoined twins. A multidisciplinary teleconference was initiated with the patients, their family, the referring paediatrician and our team. Based on this teleconsultation, the team felt as though the twins may be amenable to a surgical separation. They presented to our centre in Valhalla, NY, for a detailed physical examination and series of imaging studies. Soon after, the patients underwent a successful 21 h separation procedure and were discharged 12 weeks later. To our knowledge, this is one of the first reports of an international teleconsultation leading to a successful conjoined twin separation procedure.

Restrictive versus liberal red blood cell transfusion strategy after hip surgery: a decision model analysis of healthcare costs.

BACKGROUND: Red blood cell transfusion related to select surgical procedures accounts for approximately 2.8 million transfusions in the United States yearly and occurs commonly after hip fracture surgeries. Randomized controlled trials have demonstrated lack of clinical benefit with higher versus lower transfusion thresholds in postoperative hip fracture repair patients with cardiac disease or risk factors for cardiac disease. The economic implications of a higher versus lower hemoglobin (Hb) threshold have not yet been investigated. STUDY DESIGN AND METHODS: A decision tree analysis was constructed to estimate differences in healthcare costs and charges between a Hb transfusion threshold strategy of 8 g/dL versus 10 g/dL from the perspective of both Centers for Medicare and Medicaid Services (CMS) as well as hospitals. Secondary outcome measures included differences in transfusion-related adverse events. RESULTS: Among the 133,697 Medicare beneficiaries undergoing hip fracture repair in 2012, we estimated that 45,457 patients would be anemic and at risk for transfusion. CMS would save an estimated $11.3 million to $24.3 million in payments, while hospitals would reduce charges by an estimated $52.7 million to $93.6 million if the restrictive transfusion strategy were to be implemented nationally. Additionally, rates of transfusion-associated circulatory overload, transfusion-related acute lung injury, acute transfusion reactions, length of stay, and mortality would be reduced. CONCLUSIONS: This model suggests that the uniform adoption of a restrictive transfusion strategy among patients with cardiac disease and risk factors for cardiac disease undergoing hip fracture repair would result in significant reductions in clinically important outcomes with significant cost savings.