Telemedicine in the Intensive Care Unit

As the U.S. population has been aging, the risk of mortality has been falling. In 1950, the total percentage of the U.S. population older than the age of 65 was approximately 8%; the percentage increased to 12.5% in 2009 and it is projected to be 20% by 2050.⁴ In addition, the composition of the U.S. population is becoming more diverse. This is impacting health care needs and challenges health care planning because of differences between racial and ethnic groups and their access to health care services and health insurances.^4,5

Approximately 500,000 intensive care unit (ICU) patients in the United States die each year. It is estimated if each hospital implemented intensivist physician staffing, approximately 55,000 lives and $4.3 billion dollars could be saved in the United States.^6,7 Research suggests the quality of care in ICUs varies and better outcomes are achieved in ICUs staffed by intensivists versus an attending physician.^7–9 However, there is a limited supply of new critical care specialists as teaching hospitals have decreased the size of critical care programs for financial reasons. It is predicted by 2020, there will be a 35% shortfall of intensivists and pulmonologists, and this will increase to 46% by 2030.¹⁰

The ongoing shortage in experienced nurses who specialize in intensive care is due to numerous factors. There is a shortage of nursing faculty, which limits nursing school enrollments. Fewer young adults are entering the nursing profession (ICUs historically attract younger nurses), and the current RN workforce is aging, with the average age around 44.5 years. Staffing on nursing units is insufficient, resulting in increased stress levels that lead to job dissatisfaction and nurses leaving the profession. Finally, it is taking 7% longer to staff a critical care vacancy.¹¹

Within a remote command center, each eICU RN sits at a workstation. A workstation typically contains two computers that have been configured to three or four display monitors each. A multiline telephone is available along with earpiece and microphone. There is a high-resolution remote camera that can be used to visually access a patient. A ringing bell within the patient’s room might be used so bedside staff are aware when the camera has been activated. The eICU RN would then provide his or her name and state the purpose for turning on the camera.^15,16

A basic principle of the tele-ICU is routine rounding and attention to evidence-based practices to help prevent complications. The eICU RN conducts rounds anywhere from every hour to every 4 hours depending on the acuity of the patient. During rounds, patient orders, the plan of care, laboratory results, radiology, and other tests are reviewed. The eICU RN then applies his or her critical care thinking skills to assess how the patient is doing. Throughout a shift, any alerts that appear on the computer screen would be addressed. An eICU system interfaces with bedside monitoring systems, and the decision support system built into eICU system can help to identify subtle changes and trends in the patient’s laboratory studies and physiologic parameters (eg, vital signs, urine output). The alerts may be color coded based on severity. The eICU RN would then review the patient’s data and hemodynamic information to troubleshoot the alert. If unable to determine the cause, the remote camera would be turned on to visualize the patient and ICU room to see if the bedside nurse is with the patient and aware of any alarms. If the alert is valid and the bedside RN is not aware, the eICU RN would phone appropriate bedside staff and could make suggestions for an assessment or intervention.^13,15,16

When the ePhysican is on duty, she or he may only round on high-acuity patients or those patients who have deteriorating trends in vital signs. The ePhysician can read and interpret test results, provide consultation, and may write orders as indicated. Other duties for eICU staff might include assisting with new admissions, supervising procedures, responding to emergencies, or serving as a resource when called upon. Staff within an eICU command center work together as a team. They respect and support each and often depend on each other to help answer questions that might come from bedside staff.^15,16

Robotic devices are a newer approach for a tele-ICU, and their use is growing as these devices can have lower equipment costs. The robot is about 6 feet tall and equipped with two cameras, a display monitor, and microphone. It uses an Internet connection and video conferencing for real-time two-way audio–video communications, along with robotic control software that allows multidirectional movement. Access is achieved via the hospital’s secure intranet, or via an encrypted virtual private network.¹⁷ The robot can move from one patient to the next. There is the ability to capture video images of the patient and to communicate directly with the bedside caregivers, the patient, and his or her family. The robot would not replace daily intensivist rounding. Use of such a device has an advantage of allowing many members of the multidisciplinary critical care team to observe rounds from a location outside of the patient’s room such as a conference room. There can be limitations to these devices if there are wireless connectivity issues, and the range for obtaining video images is lower compared to that of wall-mounted cameras that can be utilized with a remote tele-ICU command center.^14,17

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