Patients Benefit From ICU Telemedicine

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.