Tele-ICU is a form of telemedicine in which caregivers, called intensivists, serve as a second pair of eyes, using technology such as video monitors, 2-way cameras, and microphones. “Critically ill patients can receive rapid access to a critical care physician with the full range of electronic data immediately available, at the press of a button,” according to Dr. Bonello.
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Federal Practitioner: Please provide a brief description of the development of the Central VA ICU Telemedicine System.
Dr. Robert Bonello: There are actually 2 regional ICU Telemedicine systems in the VA, one centered in Minneapolis and managed by VISN 23, the other in Cincinnati, managed by VISN 10. Both programs were developed and continue to be managed primarily at the VISN level, as a tool for quality improvement and to meet needs identified at the facility level. With greatly increased interest across VA, both programs have evolved into regional Tele-ICU systems, with coordination and support from VA Telehealth Services and Office of Information Technology.
Looking back a bit, the first report of a community-based ICU telemedicine program was published in 2000 in Critical Care Medicine . It is estimated that about 10% of adult ICU patients in the U.S. are now monitored using some form of Tele-ICU. The VISN 23 program started operation in August of 2011. It was at that time both the first ICU telemedicine program centered in Minnesota, as well as the first program of its kind in VA.
There were 2 motivations that precipitated the VISN 23 program. The first was a request from the smallest rural facilities to the larger tertiary care centers in VISN 23 to provide tele-consultation by ICU specialists to support them in managing certain critically ill patients. The second motivation grew gradually out of a shared experience in a 2-year VISN-wide ICU quality improvement collaborative, focusing on bringing low-risk, high-yield evidence-based practices to the bedside, particularly around mechanical ventilation and prevention of hospital-acquired infections, daily multidisciplinary team rounds with physician participation at the bedside, and the use of a daily patient checklist on rounds to ensure a standardized approach to patient safety. A growing body of evidence demonstrated improved patient outcomes when there is a significant presence and active daily participation at the bedside by ICU physician specialists called intensivists.
As we worked closely together on shared goals, it became apparent that there were wide variations in how we practice ICU medicine at different sites in VA: wide variation in physician staffing patterns, overnight call, cross coverage and supervision of trainees, availability and access to intensivists, participation in daily team rounds, and quality improvement initiatives by ICU physicians. We then recognized that ICU telemedicine might provide particular opportunities both for increased access to intensivists as well as for enhanced standardization of evidence-based practice in an integrated health care system with a common electronic health record, resulting in a funded Network Strategic Initiative in 2007 to develop an implementation plan.
Since their inception in 2011 and 2012 the 2 programs have grown and together now serve several hundred ICU beds in 25 VA Medical Centers in 14 states and 6 VISNs. Another 9 VA sites are currently waiting to join.
FP: What electronic and VA systems and software make the Telemedicine System happen?
RB: The Tele-ICU programs in both VISN 23 and VISN 10 use a combination of VA-developed systems and software as well as commercial applications. The systems are best understood by defining the actions the Tele-ICU team is capable of making.
The primary element is quick remote access with the click of a button directly into the patient’s ICU room, like Skype or FaceTime. But the Tele-ICU system is much more versatile. Tele ICU interfaces with the VA’s electronic health record (CPRS), the bedside patient-monitoring web viewers with real-time hemodynamic waveforms, and the electronic ICU Clinical Information System (in VA parlance CIS), which most people refer to as the bedside ICU flow sheet. All of this is tightly organized in a concise format through a commercial application designed for ICU patient population management, which both programs use.
The Tele-ICU clinical staff, nurses, and physicians have full access to the CPRS at each site. Tele-ICU physicians are able to write orders at each site. Physicians are expected to leave progress notes, using a specific template designed for Tele-ICU in CPRS. Drop-down boxes in the note template when clicked on are linked to digital markers that can be stored and later retrieved to track various aspects of utilization. Additional interfaces allow access to the digital radiology picture archiving and communication system, or PACS.
With newer high-definition AV equipment, there has been a significant improvement in the amount of bandwidth that is required. The capacity of the equipment to auto-scale to bandwidth availability allows for better quality audio/video transmission and permits a larger system with more beds. The in-ICU room cameras are wall or ceiling mounted with a 360-degree sweep that can be controlled by the Tele-ICU clinician, with resolution high enough to check a pupillary light reflex, read settings on the ventilator, assess skin tone and respiratory excursions, for example. The in-room equipment includes a display screen with the Tele-ICU clinician’s name and title as well as real-time audio-visual images transmitted to the bedside, so just as the Tele-ICU can see and hear the patient or family or bedside staff, they can see and hear the Tele-ICU clinician. Improvements in audio/visual equipment in just the past several years allow us to use up to 4 times less bandwidth, with equal or improved speed and quality of audio/visual transmission.
Using these interfaces Tele-ICU nurses can support bedside staff, in some cases assist with charting, troubleshoot issues with the electronic clinical information system, participate with local staff as an integral member of the extended ICU clinical team, assist during codes—in some cases as the code team reporter and recorder—provide education for newer ICU staff, provide a second signature for blood transfusions, alert Tele-ICU physicians to changes in the patient’s condition based on physiologic alerts and algorithms and additional electronic data, and assist in simulation training events.
FP: What hospital personnel and preparations are involved?
RB: Preparation requires the engagement of multiple levels and elements of the organization. Because these were VISN-initiated programs, it has been up to the VISN-led teams to make that work. The interesting thing to me is the generally proactive, can-do, high level of collaboration that they’ve encountered in doing so, from their co-workers across the spectrum. Don’t get me wrong. It has not been without considerable challenges. I would not want to diminish the sort of blood sweat and tears these teams have expended. But the thing is that they have done it, overcoming a lot of what seemed like insurmountable bureaucratic and technical barriers and solving a lot of problems along the way, with help from their colleagues and co-workers at the facility and network level primarily.
In order for this endeavor to be successful, it requires teams at both the VISN and facility level. The personnel needed include biomedical engineering, information technology, engineering, facility leadership, surgical and medical service leadership, ICU leadership, and most important, frontline nurses and physicians who work in the ICU. HR, credentialing, privileging, and contracting are also very important to the success of the project. And to some extent, there needs to be coordination at the national level for IT and telehealth services.
Site preparation includes a site walk-through, evaluating the space, setting up the network infrastructure, setting up all of the necessary interfaces, installing the equipment and testing the interfaces and equipment, ensuring there are adequate data ports and that emergency power is available. The implementation process is reviewed, weekly meetings are started to keep the project on track, milestones are determined, and go-live dates are set.
Education of clinical and nonclinical staff is done throughout the implementation process and beyond, using both traditional classroom training and simulation. Clinical workflows are developed by staff at the patient care sites and the Tele-ICU support center. Both physicians and nurses are encouraged to participate. VA also has the advantage of privileging and credentialing for physician telehealth services from a single facility location, through a written business agreement between participating sites to define roles and responsibilities and the expectations of each party.
FP: Was it a challenge to build personal relationships between the virtual team and the bedside team?
RB: Yes. It was and still is. It is the central element for a successful enterprise.
This is a potentially disruptive technology. Every ICU is different. Everything depends on collaboration with the bedside clinicians, their level of acceptance of the program, whether they are willing to invite you into their workplace as colleagues and team members, to understand that you are there to help provide the best possible patient care and to work with you to find the right fit with their environment.
It is not just the introduction of a certain type of technology. It is a different clinical paradigm. If used improperly, it can be intrusive. We are just not accustomed to having disembodied heads and voices apparate Harry Potter-like into an ICU room. It requires a sometimes nuanced negotiation of roles and responsibilities, depending on the clinical situation, the individuals involved, the expectations, and the environment of care.
It is about virtual teamwork and collaboration. Bedside nurses are patient advocates, and they are the key to building a successful foundation for virtual teamwork. ICU care is team based. It is axiomatic that you cannot provide the highest level of care without a well-functioning multidisciplinary team in the ICU. The Tele-ICU is just another element of that team. Intensivist participation in that model is very important. Skilled ICU nursing is mandatory. Facility leadership is vital. But none of that will be successful without authentic frontline physician buy-in and acceptance. Or at least it won’t happen optimally.
We’ve learned a lot through experience. Camera presence is huge. This is true for both sides of the camera and for both physicians and nurses, but it is particularly important for the Tele-ICU physicians. How the physician appears on screen, how she or he interacts with bedside staff—their courtesy, the clarity and cadence of their speech—impact how they are perceived and received by the patient site. Personality traits can be magnified on camera. We find that how a clinician appears in person may not be reflected in how they come across on camera. This is really important for building trust and relationships, and it works both ways. We’ve learned that some of our colleagues will respond in surprising ways over the camera. That can be a challenge, but we are constantly learning how to be more effective. You really have to emphasize the interpersonal niceties and collegiality.
FP: Hasn’t there been a recent collaboration with the DoD?
RB: Yes. We started working in April with a team from the U.S. Air Force. The clinical lead for DoD is Colonel Marc Goldhagen, director of Medical Modernization for Air Combat Command. The collaboration will enable ICU specialists (intensivists) from the Central VA ICU Telemedicine System to continuously monitor and assist in the care of critically ill patients.
The Central VA ICU Telemedicine system includes ICU nurses and physicians working from the Tele-Medicine Intensive Care Unit at the Minneapolis VA Medical Center. It also includes intensivists working from 2 additional linked locations, one at the Iowa City VA and another at the Hines VA.
The plan calls for Tele-ICU to serve ICU patients in 5 Air Force Medical Treatment Facilities, located in Alaska, Mississippi, Nevada, Ohio, and Virginia, covering a total of 20 DoD ICU beds. An additional 40 VA ICU beds is also part of the initiative.
The collaborative effort is supported by the DoD-VA Health Care Sharing Incentive Fund, also known as the Joint Incentive Fund, authorized by Congress as part of the 2003 National Defense Authorization Act. The funding is designed to cover start-up and implementation costs during the initial 2-year financial support period. The intent of the fund is to facilitate mutually beneficial exchanges of health care resources between DoD and VA. The goal is improving access to high-quality and cost-effective health care.