Should Critical Care Training Programs Start Offering Formal Training in Tele-ICU?

2014 - 5 October – 44th Critical Care Congress Advance Program
Erik Vakil, MD; Marc T. Zubrow, MD, FCCM
Two experts discuss the efficacy of tele-ICU training.

The Society of Critical Care Medicine (SCCM) In-Training Section is dedicated to assisting and guiding trainees as they progress through training into independent practice. It also aims to foster career development following this transition. To further this mission, members will contribute articles addressing emerging issues in critical care training and career development authored by in-training professionals under the guidance of a mentor. For additional information about the In-Training Section or this project, please e-mail SCCM In-Training Section Chair Utpal Bhalala, MD, at ubhalal1@jhmi.edu or Member-at-Large Erik Vakil, MD, at erikvakil@hotmail.com.

Telemedicine in the intensive care unit (tele-ICU) is the use of remote monitoring and communication systems to connect intensive care units (ICUs) with expert critical care practitioners in different geographic locations. While telemedicine has been practiced for decades by connecting practitioners over the telephone, a modern definition has emerged as a result of advancements in hardware and sophisticated software.

The first deployment of a comprehensive tele-ICU program was a joint venture between Sentara Healthcare and VISICU in 2000.(1) Since then, approximately 50 tele-ICU centers have been established -- a growth that has fueled rapid development of tele-ICU technologies and even created opportunities for privatized tele-ICU provider groups. The impetus for growth has mainly been ICU staffing shortages across the country, particularly in smaller hospitals or rural locations. The demand for intensivists is increasing because of an aging U.S. population requiring higher acuity of care and data showing that intensivist-led or co-managed ICU care improves patient outcomes.(2-4) In 2000, a report by the Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS) showed that only about one-third of patients in ICUs were being managed by intensivists,(5) well short of the suggested two-thirds advised by The Leapfrog Group, a leading advocacy organization for increased intensivist staffing in ICUs. A 2006 report by the U.S. Department of Health and Human Services examined the growing pressure to increase intensivist staffing levels and projected significant shortages until at least 2020.(6)

Evidence is mounting that tele-ICUs can ameliorate the staffing shortages and improve outcomes in much the same way as employing in-house intensivists.(3,4,7-10) However, implementing tele-ICU systems can be challenging due to such factors as a high level of capital investment, high maintenance and operation costs, resistance to change, cross-state licensure issues, and undefined reimbursement schedules. Nevertheless, pressure to increase staffing levels and projected shortages in board-certified intensivists are likely to drive many hospitals to consider tele-ICU systems.

The critical care curriculum, particularly at the fellowship level, has already had to undergo changes as medical technology advances. The latest example is the emphasis on point-of-care ultrasonography for an increasing variety of situations in the ICU. Programs have had to adapt quickly to provide this training, and fellows working at institutions where ultrasound training is well established are at an advantage. Because the tele-ICU is likely to emerge as an extension of current critical care practice, programs that include the appropriate training in their curricula early stand to position themselves as leaders in the field.

Several organizations have begun developing guidelines and standardized competency benchmarks for tele-ICU care. The American Telemedicine Association (ATA) recently drafted guidance for the use of telecommunication technologies in the ICU(11); final guidelines are to be released later this year. The American Association of Critical-Care Nurses (AACN) has published nursing practice guidelines that aim to define essential components of tele-ICU nursing, identify areas for improvement and support healthcare organizations seeking to implement tele-ICU systems.(12)  No competency benchmarks for critical care fellows have been developed, and no curriculum has included the use of emerging telecommunication technologies. Not all training centers are equipped to offer such training, but larger health centers, especially those that already have tele-ICU hubs, could begin to offer structured exposure to this model of care (in the form of a one-month rotation, for example).

Programs that offer such training will not only help to distinguish their graduates but also begin to develop a network of tele-ICU-ready practitioners who can offer expertise to an emerging field. Since many ICUs across the country will be looking to open tele-ICUs or align with one to deliver critical care, finding qualified practitioners will be challenging. The opportunity to address this upcoming need is at hand, and programs best positioned to provide tele-ICU training should strongly consider implementing formal training as soon as possible.

References:

1. Celi LA, Hassan E, Marquardt C, Breslow M, Rosenfeld B. The eICU: it's not just telemedicine. Crit Care Med. 2001;29(8 Suppl):N183-189.
2. Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002;288(17):2151-2162.
3. Wilcox ME, Chong CA, Niven DJ, et al. Do intensivist staffing patterns influence hospital mortality following ICU admission? A systematic review and meta-analyses. Crit Care Med. 2013;41(10):2253-2274.
4. Wilcox ME, Adhikari NK. The effect of telemedicine in critically ill patients: systematic review and meta-analysis. Crit Care. 2012;16(4):R127.
5. Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J Jr. Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA. 2000;284(21):2762-2770.
6. Duke EM. The critical care workforce: a study of the supply and demand of critical care physicians. 2006. http://bhpr.hrsa.gov/healthworkforce/reports/studycriticalcarephys.pdf. Accessed September 10, 2014.
7. Young L, Chan PS, Lu X, Nallamothu BK, Sasson C, Cram PM. Impact of telemedicine intensive care unit coverage on patient outcomes: a systematic review and meta-analysis. Arch Intern Med. 2011;171(6):498-506.
8. Willmitch B, Golembeski S, Kim SS, Nelson LD, Gidel L. Clinical outcomes after telemedicine intensive care unit implementation. Crit Care Med. 2012;40(2):450-454.
9. Lilly CM, Cody S, Zhao H, et al. Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes. JAMA. 2011;305(21):2175-2183.
10. Lilly CM, Thomas EJ. Tele-ICU: experience to date. J Intensive Care Med. 2010;25(1):16-22.
11. American Telemedicine Association. Guidelines for TeleICU Operations. 2014. http://www.americantelemed.org/docs/default-source/standards/teleicu-final-draft-for-public-comment.pdf?sfvrsn=2. Accessed May 25, 2014.
12. American Association of Critical-Care Nurses. AACN Tele-ICU Nursing Practice Guidelines. 2013. http://www.aacn.org/wd/practice/docs/tele-icu-guidelines.pdf. Accessed May 25, 2014.