The Evolving Role of Intensive Care Unit Telemedicine

2016 - 1 February - Technological Game Changers
Marc T. Zubrow, MD, FCCM, FACP, FCCP; Craig M. Lilly, MD, FCCM
Two experts discuss the role of ICU telemedicine in the midst of technological advances.
 
Intensive care unit (ICU) telemedicine programs currently support more than 11% of nonfederal hospital adult ICU beds,(1) and formal programs are growing with the escalating needs for evaluation and management of critically ill and injured patients. The availability of off-site ICU team members has encouraged comparative analyses of how these incremental resources can best be used to meet the needs of our patients. Maturation of the technologies that are increasingly available and affordable have led to new methods of application based on local needs. Telemedicine support and co-management is increasingly available in the emergency department (ED) setting, and key management decisions for high-acuity patients with neurologic emergencies are now routinely made by specialists using audio and/or video connections to patients and their bedside providers. ICU telemedicine support for busy EDs is one way to mitigate increased mortality associated with prolonged ED stays when critically ill and injured patients are awaiting ICU transfer.
 
ICU telemedicine programs are also one way to meet the rising need for critical care management services. The increasing number of patients with life-threatening injuries and diseases who seek medical care coupled with a decreasing supply of critical care experts has led to a growing need for solutions to the problem of access to intensive care units (ICUs) and reduction of long ED stays. ICU telemedicine programs are able to mitigate geographic and temporal challenges by connecting patients, families, and noncritical care specialist providers to critical care professionals. In addition to management recommendations for patients with evolving physiologic instability and decreased time to intensivist care plan review, ICU telemedicine programs provide population management solutions that have been shown to increase adherence to best practices and reduce preventable complications that can drive up costs.(2,3)
 
Most ICU telemedicine programs have focused on critical care processes that impact patient safety or outcomes. Practices that can be impacted by ICU telemedicine programs and that are associated with shorter lengths of stay and lower mortality include shortening provider response times for abnormal laboratory values and alerts for physiologic instability, real-time reminders from the ICU telemedicine team when actual practice varies from ICU best practice, shorter times to intensivist case review, and near real-time review of performance reports by an effective ICU governance team.
 
ICU telemedicine programs can be expensive to implement and operate. These costs often generate intense scrutiny from the healthcare systems considering ICU telemedicine solutions. Financial considerations are particularly relevant for ICU telemedicine programs that are not able to shorten lengths of stay for their patients. More information about the financial effects of ICU telemedicine programs is now available from an economic valuation study by Yoo et al that took the perspective of the sponsoring healthcare system. The study reported that ICU telemedicine programs are cost-effective in most cases and cost saving in some cases.(4)
 
In accordance with its mandate to keep our leaders informed about changes in the ICU telemedicine landscape, our Society of Critical Care Medicine (SCCM) Tele-ICU Committee sought to better define the true penetration of ICU telemedicine into practice by surveying our membership. The survey found that telecommunication technologies are used to support ICU patients and their families more commonly than is suggested by usage estimates that are based on large program service areas. The survey results are consistent with an increasing number of reports that indicate that informal use of telemedicine tools is common and perceived as increasing practice efficiency.
 
Our Tele-ICU committee has identified recent extensions of telecommunication technologies into our ICUs and practices. One significant trend is the incorporation of personal electronics into existing telemedicine systems that that meet all current technological privacy and security requirements. While communication with non-healthcare individuals is easier to facilitate, Health Insurance Portability and Accountability Act (HIPAA) requirements must be satisfied through the use of double encryption systems and other technological safety measures. Healthcare-embedded telecommunications tools work for patients who are interactive and for the families and supporters of patients who are not able to communicate for themselves. The ability of critical care nurses to interact with family members who are at home or at work using tele-ICU systems has generated positive feedback. These same tools are used to foster better communication through the use of electronic “billboards” that identify family questions and concerns to rounding physician teams. Preemptive communication strategies include the use of integrated systems to allow family members to participate in multiprofessional rounds from wherever they are. 
 
Public interest in telemedicine has also translated into legislative action. One important legislative thread is the push for promoting proxy credentialing and privileging for telemedicine services. Detailed recommendations that allow for more efficient credentialing processes have been approved by the Centers for Medicare & Medicaid Services.
 
As we move into the future, there will be technological advances to allow for increased accessibility, interconnectivity and markedly improved functionality. This will improve patient evaluation and treatment without the need to be at the bedside. Advances in sensing technology will help identify the incompletely diagnosed or deteriorating patient sooner. Bedside ultrasound has revolutionized the evaluation of the critically injured patient and is rapidly replacing the stethoscope and many radiologic studies for the critically ill patient. A recent study has shown the feasibility of rapidly training bedside caregivers to obtain helpful images that are evaluated in real-time by an intensivist at a remote location.(5)
 
New telemedicine-related technologies are focused on more efficient critical care work flows that enable off-site patent management using reliable standardized protocols and oversight. The advent of multipath medical device integration enables therapies to be titrated to laboratory and physiologic parameters under the careful watch of off-site critical care professionals. Increased efficiency comes from standardized reduction of titratable therapies, including oxygen delivery, positive end-expiratory pressure, vasoactive medications, and continuous-infusion heparin by teams of ICU professionals who can provide titration services for a large number of patients. Studies of how ICU telemedicine support and data are used by critical care professionals suggest that its patient-centered benefits are greater than hazards created by chain-of-command issues or misuse of data.3 In addition, analyses of rates of malpractice claims and payouts suggest that concurrent ICU telemedicine case review provides substantial protection from malpractice-related financial losses.(1) 
 
ICU telemedicine holds the promise of improving care along with the experiences of critically ill patients and their loved ones through new ways of connecting with critical care professionals. Promoting optimal patient-centered use of the telecommunication and health information technology tools that enable the practice of telemedicine is another way that SCCM supports bringing the right care at the right time. 

References:

1 Lilly CM, Zubrow MT, Kempner KM, et al. Critical care telemedicine: evolution and state of the art. Crit Care Med. 2014 Nov;42(11):2429-2436.
2 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 Jun 1;305(21):2175-2183.
3 Lilly CM, McLaughlin JM, Zhao H, et al. A multicenter study of ICU telemedicine reengineering of adult critical care. Chest. 2014 Mar 1;145(3):500-507.
4 Yoo BK, Kim M, Sasaki T, Melnikow J, Marcin JP. Economic evaluation of telemedicine for patients in ICUs. Crit Care Med. 2016 Feb;44(2):265-274.
5. Levine AR, McCurdy MT, Zubrow MT, Papali A , Mallemat HA, Verceles AC. Tele-intensivists can instruct non-physicians to acquire high-quality ultrasound images. J Crit Care. 2015 Oct;30(5):871-875.