Chad Hodge Roosan Islam Casey Rommel Nicole Ruiz Diane Walker

TELEMEDICINE IN THE ICU

What is telemedicine?

The delivery of healthcare from a distance using

electronic information and technology.

Literally, “Healing at a distance.”

What units qualify as an ICU?

All critical care areas, such as surgical, cardiac,

medical, pediatric, neurology, neonatal, burn,

and other postoperative.

What is an eICU?

Nurses and physicians located at a remote command

center providing care to patients in multiple,

scattered intensive care units via computer and

telecommunication technology.

DEFINITION

ICUs treat 4.5 million annually (10% of all

patients). Expected to rise as the population

ages.

$107 billion annually (4% of total healthcare

costs).

ICUs are coalescing.

Fewer than 6000 intensivists.

ICU mortality rate is 10-20% and is

responsible for 500,000 deaths annually.

eICUs are estimated to reduce that number by

50,000 (10%) per year.

THE NEED

Fewer than 15% of hospitals meet the Leapfrog Group intensivist staffi ng model. Return page within 5 minutes 95% of time.

Or arrange for alternate staff to respond.

THE NEED CONTINUED

ADEs in ICUs are 2x the national average (19/1000 patients) because of the high number of drugs ordered.

Responsibilities of the hub intensivist

can vary from treating emergent

situations, with all other care managed

by the admitting physician (open ICU

model), to complete intensivist

management, with only notification of

treatments given to the patient’s

physician (closed ICU model).

 A well-supported intensivist may staff

approximately 50 to 100 remote ICU

beds.

EICU MODEL

Having an ICU physician rapidly available.

Having an intensivist available more hours of the day.

Having rapid access to all forms of clinical data through improved ITS.

Having an ICU physician available allows for more rapid interventions in case of problems.

Length of stay and resource utilization may also be affected by commencing care as soon it is warranted (eg, ventilator weaning begun during the nighttime).

ADVANTAGES

Potentially putting a layer of technology

between the patient and the physician.

Significant upfront and maintenance costs.

Subject to malfunction and downtime.

Physicians are typically cited as the greatest

barrier to implementation.

Physicians perceive that a lack of direct

interaction, eye contact, and other sensory

input with the patient may cause them to

miss critical diagnostic cues.

DISADVANTAGES

TELE-ICU IMPROVES PATIENT OUTCOMES

Preintervention Tele-ICU InterventionBedside monitor alarms Physiological trend alerts

Abnormal laboratory value alerts

Review of response to alerts

Off-site team rounds

Daily goal sheet Electronic detection of nonadherence

Real-time auditing

Nurse manager audits

Team audits

Telephone case review initiated by house staff or affiliate practitioner

Workstation review initiated by intensivist includes electronic medical record, imaging studies, interactive audio and video of patient, interaction with nurse and respiratory therapist, and assessment of response to therapy

TABLE 1. COMPARISON OF INTENSIVE CARE UNIT (ICU) PROCESSES BEFORE AND AFTER TELE-ICU INTERVENTION

MORTALITY AND LENGTH OF STAY OUTCOMES

BEST PRACTICE AND COMPLICATION MEASURES

Improves 3 areas of quality of

care:

Improved patient outcomes

Access to care

Cost savings

Technology is ubiquitous. Still…

Only 10% of hospitals have teleICU

services.

Only 4900 adult ICU beds

supported by teleICU.

1 million patients monitored by

teleICU.

WHY IS TELEMEDICINE THE SOLUTION?

Digital Video Transport System System to send and receive

digital streaming videos over broadband internet.

H.323 Video Conferencing Solution The H.323 protocol is a

recommendation from the International Telecommunication Union.

Vidyo Vidyo provides high quality

video conferencing from a range of technologies.

EMERGING TECHNOLOGIES

Financial costs $6-8 million initial startup. $1-2 million operating costs

yearly. Maintenance and/or Upgrades Licensure Staffing

Limited or no patient reimbursement/billing.

Shortages of specialists results in “poaching.” ICU clinician shortage >

Intensivist shortage.Staff and patient acceptance.

BARRIERS TO ADOPTION

Image- http://blogs.bmj.com/bjsm/2011/07/20/educating-all-medical-specialists-to-support-exercise-as-the-fifth-vital-sign-dr-danica-bonello-spiteri-comments/

Looked at the difference between using standard system of paging ICU physician versus robotic telepresence (RTP) intervention.

Focused on neurocritical care patients: Traumatic Brain Injuries Brain tumor Ischemic stroke

Hypothesized that physician face-to-face response time to patient would significantly decrease.

CASE STUDY 1: ROBOTICS

Image- http://www.robots-and-androids.com/robotic-syringes.html

Standard Model: Nurse detects

change in patient’s condition.

Pages ICU physician.

Physician calls the nurse and gives instructions over the phone.

Robotic Telepresence Model: Nurse sends text

message to physician or can walk up to robot if session is in progress.

Physician conducts rounds from offi ce.

Examine patients by driving robot next to bed and speaking to patient directly or instruct nurse to perform exam.

CASE STUDY 1: ROBOTICS

Vespa et al, 2007.

VISN (Veterans Integrated Service Network) 19 Covers areas including

Montana, Utah, Colorado, Wyoming, Idaho, Nevada, Kansas and Nebraska.

Developed tele-ICU model to improve access to critical care services in rural facilities by combining tele-ICU technology with expanded critical care nursing services.

First of its kind in the VA system.

CASE STUDY 2: VA HOSPITAL

Model: Operated entirely by nurses. One experienced CCRN-certified

nurse manages system 24/7. Nurses from different facilities

report on patients at start of shift. Available for immediate

consultation. Virtual rounds.

Results: Cost savings. Increase in collaboration between

healthcare facilities. Increase in number of nurses

becoming CCRN-certified.

CASE STUDY 2: VA HOSPITAL

Legal Issues The physician’s liability in case of

malpractice. The patient has to be protected, and cyber

physicians must be able to quantify their risk.

The relationship between physicians and insurance companies may need to be modified.

The roles of electronic decision support systems, medical software, and data collection systems in determining responsibility need to be clarified.

Reimbursement USA lacks unified healthcare system and

regulations need to adapt with the changing industry.

States need to be proactive in their regulation.

FUTURE CHALLENGES

Image- http://www.democracy4stoke.co.uk/archives/604

We are happy to answer any of your questions.

THANK YOU

Cummings et. al. Intensive Care Unit Telemedicine: Review and Consensus Recommendations. American Journal of Medical Quality 2007 22: 239. http://www.ncbi.nlm.nih.gov/pubmed/17656728

MD Andersen Cancer Center, University of Texas, Glossary of terms, http://www.mdanderson.org/patient-and-cancer-information/cancer-information/glossary-of-cancer-terms/t.html

Lil ly, C. M., Cody, S., Zhao, H., Landry, K., Baker, S. P., McIlwaine, J . , Chandler, M. W., et al. (2011). Hospital mortality, length of stay, and preventable complications among critical ly i l l patients before and after tele-ICU reengineering of crit ical care processes. JAMA : the journal of the American Medical Association, 305(21), 2175–83. http://www.ncbi.nlm.nih.gov/pubmed/21576622

Nielsen, M., & Saracino, J . (2012). Telemedicine in the intensive care unit. Critical care nursing cl inics of North America, 24(3), 491–500. doi:10.1016/j.ccell .2012.06.002

Venditti , A., Ronk, C., Kopenhaver, T., & Fetterman, S. (2012). Tele-ICU “myth busters”. AACN advanced critical care, 23(3), 302–11. doi:10.1097/NCI.0b013e31825dfee2

Young, L. B., Chan, P. S., & Cram, P. (2011). Staff acceptance of tele-ICU coverage: a systematic review. Chest , 139(2), 279–88. doi:10.1378/chest.10-1795

CITATIONS

Hawkins, C. L. (2012). Virtual rapid response: the next evolution of tele-ICU. AACN advanced critical care , 23(3), 337–40. doi:10.1097/NCI.0b013e31825dff 69

Vespa, P. M., Mil ler, C., Hu, X., Nenov, V., Buxey, F., & Martin, N. a. (2007). Intensive care unit robotic telepresence faci l itates rapid physician response to unstable patients and decreased cost in neurointensive care. Surgical neurology , 67(4), 331–7. doi:10.1016/j.surneu.2006.12.042

Chan, M., Esteve, D., Escriba, C., & Campo, E. (2008). A review of smart homes- present state and future challenges. Comput Methods Programs Biomed, 91 (1), 55-81. doi: 10.1016/j.cmpb.2008.02.001

Cao, M. D., Shimizu, S., Antoku, Y., Torata, N., Kudo, K., Okamura, K.,Tanaka, M. (2012). Emerging technologies for telemedicine. Korean J Radiol, 13 Suppl 1 , S21-30. doi: 10.3348/kjr.2012.13.S1.S21

CITATIONS CONTINUED

User Needs, Acceptability and Satisfaction Consider the subjects needs who are sick, disable and

elderly. The subjects immediate surrounding including

caregivers ease of use and delivery of care. The manufacturers, as well as the commercial

providers, should customize products based on needs.Reliability and effi ciency of sensory systems and data processing software.

Have a reliable algorithm for evaluating the patient’s “lifestyle.”

Trigger an alarm in case of danger. Correctly interpret the vital signs through automated

software or a competent medical professional, so that deficient function can be recognized.

FUTURE CHALLENGES AND POSSIBLE SOLUTIONS

Image- http://wc.k12.mo.us/TWarner/Med%20Term/Chapter1.html