Current Status and Future Current Status and Future Direction of Telemedicine ICU Direction of Telemedicine ICU

Consultation (Tele-ICU) in Consultation (Tele-ICU) in KenyaKenya

Wangari Waweru-SiikaWangari Waweru-SiikaMBChB, MMed(Anaes), FRCA(UK)MBChB, MMed(Anaes), FRCA(UK)

Consultant Anaesthetist and Paediatric IntensivistConsultant Anaesthetist and Paediatric IntensivistApril 2015April 2015

OBJECTIVESOBJECTIVES

• To define telemedicine and tele-ICUTo define telemedicine and tele-ICU

• To outline the potential benefits of tele-ICU in a To outline the potential benefits of tele-ICU in a resource-limited country such as Kenyaresource-limited country such as Kenya

• To describe the current limitations of tele-ICU To describe the current limitations of tele-ICU efforts in Kenya and chart the way forwardefforts in Kenya and chart the way forward

Case ReportCase Report

• A young woman was admitted to MTRH ICU with septic A young woman was admitted to MTRH ICU with septic shock and Adult Respiratory Distress Syndrome (ARDS). shock and Adult Respiratory Distress Syndrome (ARDS).

• After initiation of mechanical ventilation, her chest X-ray After initiation of mechanical ventilation, her chest X-ray was e-mailed to an ICU consultant in the US. was e-mailed to an ICU consultant in the US.

• Using Skype® via a wireless internet connection Using Skype® via a wireless internet connection (Safaricom®), the ICU consultant and the Kenyan medical (Safaricom®), the ICU consultant and the Kenyan medical officer:officer:• reviewed the patient reviewed the patient • optimised ventilation using ARDSnet guidelinesoptimised ventilation using ARDSnet guidelines• initiated sepsis management using the sepsis bundle. initiated sepsis management using the sepsis bundle.

The scope of the problemThe scope of the problem

• Sub-Saharan Africa bears 24% of the global burden of Sub-Saharan Africa bears 24% of the global burden of disease.disease.

• Only 3% of the world’s healthcare workers serve Sub-Only 3% of the world’s healthcare workers serve Sub-Saharan AfricaSaharan Africa

• Kenya has only 18 physicians/100,000 populationKenya has only 18 physicians/100,000 population– USA 254 physicians/100,000 USA 254 physicians/100,000 – Brazil 170 physicians/100,000Brazil 170 physicians/100,000– India 60 physicians/100,000India 60 physicians/100,000

WHO 2010 World health statistics WHO 2010 World health statistics

WHO 2006 Working together for health; the World Health ReportWHO 2006 Working together for health; the World Health Report

TelemedicineTelemedicine

““The use of electronic information and The use of electronic information and communication technology to provide communication technology to provide health care health care when distance separates when distance separates the participantsthe participants”. ”.

Institute of Medicine. Telemedicine: A Guide to Assessing Institute of Medicine. Telemedicine: A Guide to Assessing Telecommunications in Health Care. Field MJ, ed. Washington, Telecommunications in Health Care. Field MJ, ed. Washington,

DC: National Academy Press; 1996DC: National Academy Press; 1996..

Telemedicine icu Telemedicine icu consultation (Tele-ICU)consultation (Tele-ICU)

• ‘‘The use of computers and audiovisual communication The use of computers and audiovisual communication systems to link an ICU patient and the ICU team with a systems to link an ICU patient and the ICU team with a remotely-based critical care teamremotely-based critical care team’. ’.

• Surveillance and support provided for a large number of Surveillance and support provided for a large number of ICU patients in a variety of geographical locations.ICU patients in a variety of geographical locations.

• Remote monitoring of physiological variables possible in Remote monitoring of physiological variables possible in active systems.active systems.

• Also referred to as “virtual ICU,” “remote ICU,” or “eICU” Also referred to as “virtual ICU,” “remote ICU,” or “eICU”

Tele-ICU equipmentTele-ICU equipment

Tele-ICU equipmentTele-ICU equipment

The case for Tele-ICUThe case for Tele-ICU

• Outcomes of critically ill patients are improved by the Outcomes of critically ill patients are improved by the 24-hour presence of intensivists.24-hour presence of intensivists.

• The first large scale study in 2000 demonstrated a The first large scale study in 2000 demonstrated a 60% reduction in severity-adjusted ICU mortality60% reduction in severity-adjusted ICU mortality

• Tele-ICU fueled by the shortage of trained Tele-ICU fueled by the shortage of trained intensivists. intensivists.

Rosenfeld BA, Dorman T, Breslow MJ, et al: Intensive care unit telemedicine: Alternate paradigm for providing continuous intensivist care. Crit Care Med

2000; 28:3925–3931

Meta-Analysis of Mortality Meta-Analysis of Mortality with Tele-ICUwith Tele-ICU

Crit Care. 2012 Jul 18;16(4):R127. doi: 10.1186/cc11429.

TELE-ICU AND ICU LENGTH TELE-ICU AND ICU LENGTH OF STAYOF STAY

Critical Care in KenyaCritical Care in Kenya

• There are a limited number of adult intensivists There are a limited number of adult intensivists in Kenyain Kenya

• There are even fewer paediatric intensivistsThere are even fewer paediatric intensivists

• ICUs in Kenya are manned by anesthesiologistsICUs in Kenya are manned by anesthesiologists

• Kenya has 148 anesthesiologists registered with Kenya has 148 anesthesiologists registered with the KMPDBthe KMPDB

• MTRH has only 7 anesthesiologists who cover MTRH has only 7 anesthesiologists who cover both theatre and ICU.both theatre and ICU.

Tele-ICU in KenyaTele-ICU in Kenya

• The Ministry of Health plans to have ICUs in two hospitals The Ministry of Health plans to have ICUs in two hospitals in each of the 47 counties by the end of May 2015, at a in each of the 47 counties by the end of May 2015, at a cost of equipment of KShs 3.3 billion.cost of equipment of KShs 3.3 billion.

• Tele-ICU consultation between these ICUs, the two Tele-ICU consultation between these ICUs, the two national referral hospitals and external partners could be national referral hospitals and external partners could be a key component of realising this goal.a key component of realising this goal.

• Tele-ICU in Kenya would provide consultant support in Tele-ICU in Kenya would provide consultant support in ICUs that would otherwise not be able to support this ICUs that would otherwise not be able to support this level of staffing. level of staffing.

Benefits of tele-ICUBenefits of tele-ICU

• Provides support to anesthesiologists with heavy Provides support to anesthesiologists with heavy clinical obligations. clinical obligations.

• Improves morale of ICU staff.Improves morale of ICU staff.

• Allows access to specialists and sub-specialists in Allows access to specialists and sub-specialists in short supply. short supply.

• Potential reduction in ICU transfers from other Potential reduction in ICU transfers from other hospitalshospitals

• Improved pre-transfer resuscitation and Improved pre-transfer resuscitation and stabilisation. stabilisation.

Limitations of tele-ICU Limitations of tele-ICU in Kenyain Kenya

• Limitations due to current internet connectivity:Limitations due to current internet connectivity:• Quality, stability and cost Quality, stability and cost

• Limitations of Skype® as a platform for tele-ICULimitations of Skype® as a platform for tele-ICU

• Time-zone differences when clinicians overseas Time-zone differences when clinicians overseas need to be consulted need to be consulted

• Legal issues of data protection and patient Legal issues of data protection and patient confidentiality. confidentiality.

Future directions for tele-Future directions for tele-ICU in KenyaICU in Kenya

• Improved informatics infrastructure. Improved informatics infrastructure.

• Research to define optimal tele-ICU configuration Research to define optimal tele-ICU configuration for a resource limited settingfor a resource limited setting

• Regulatory and confidentiality issues regarding Regulatory and confidentiality issues regarding transmission of protected health information.transmission of protected health information.

• Development of tele-ICU consultation and triageDevelopment of tele-ICU consultation and triage

SUMMARYSUMMARY

• The critical care setting is an important arena to The critical care setting is an important arena to develop telemedicine in Kenyadevelop telemedicine in Kenya

• Tele-ICU in Kenya has the potential to provide Tele-ICU in Kenya has the potential to provide remote support to ICU patients and staff, and to remote support to ICU patients and staff, and to improve patient outcomesimprove patient outcomes

• There are limitations that need to be overcome There are limitations that need to be overcome for tele-ICU to be successfully adopted in Kenya. for tele-ICU to be successfully adopted in Kenya.

Thank youThank you