Current Status and Future Directions of Telemedicine ICU Consultation (Tele-ICU)
in Kenya
Lilian Lukoko1, Wangari Waweru-Siika, FRCA1, P.K. Werunga4, Anne Mills Mathews, MD2, 3
Kristin Corey, BA2, 3, Peter S. Kussin, MD2, 3
1
2
Moi Teaching and Referral Hospital, Department of Anesthesia, Eldoret, KE.
Duke University School of Medicine Department of Medicine, Division of Pulmonary
and Critical Care
3 Academic Model Providing Access to Healthcare (AMPATH) Eldoret, Kenya
4 Moi University, College of Health Sciences, School of Medicine
Corresponding author: Wangari Waweru- Siika, FRCA
Objectives:
The objectives of this paper are: 1. Define telemedicine and tele-ICU. 2. Review the
background and history of tele-ICU globally and in Kenya. 3. Describe a clinical scenario
highlighting our experience with tele-ICU consultation. 4. Discuss the global evidence of benefit
for tele-ICU as it pertains to Kenya. 5. Enumerate lessons learnt, challenges and future directions
for tele-ICU in Kenya.
Background and History of Tele-ICU:
Telemedicine is defined as the “the use of electronic information and communications
technologies to provide and support health care when distance separates the participants”. 1
Critical care has long been regarded as an important arena to develop tele-medicine capability.
Enthusiasm for telemedicine consultation and management (tele-ICU) has been fueled by the
evidence that intensive care patient care outcomes are improved by 24 hour per day presence of
intensivists2. The growth of tele-ICU in the United States has been fueled by the increasing
demand for real-time critical care services, and limitations in the supply of trained intensivists.
The obvious appeal of tele-ICU abroad and in Kenya lies in the ability to provide real-time
consultant presence in small ICUs that would otherwise not be able to support this level of
staffing. Since the introduction of telemedicine in the 1990’s, improvements in technology and
infrastructure have greatly outdistanced proof of benefit on patient outcomes in resource rich
settings. This dichotomy is no more evident than in the area of tele-ICU. The precise magnitude
of the benefit of tele-ICU is not known. While systematic reviews have shown that tele-ICU is
associated with lower ICU and hospital mortality3 but the authors warned that “the optimal
telemedicine configuration and dose tailored to ICU organization and case mix remains unclear”.
A recent consensus statement outlines the agenda for high quality research in tele-ICU to answer
these questions. 4
Ideally, Kenya would be the ideal venue to develop telemedicine applications. While SubSaharan Africa carries 24% of the burden of the world’s disease, it is served by only 3% of the
world’s healthworkers.5 In Kenya there are 18 physicians/100,000 population compared to 254
physicians/100,000 in the United States.5 These statistics compare unfavorably to countries such
as India ( 60/100,000 and Brazil 170/100,000).6 In view of this critical shortage, increased
telemedicine efforts for Kenya are being promoted.7 To date, most efforts have focused on the
use of Short Message Services (SMS) and other mobile applications, to promote adherence to
anti-retroviral therapy and assist rural clinical officers in protocol-driven care of chronic disease.
Recently, the government of Kenya announced that by the end of May 2015 at least two
hospitals in each of the 47 counties should have intensive care units at a cost for equipment of
Sh3.3 billion.8 Tele-ICU consultation between these ICUs and the two national referral hospitals
could be a key component of realizing this goal while improving triage, patient care and referral.
However, to our knowledge, tele-ICU has not been implemented in Kenya to link ICUs either
within the country or to consultants abroad. We report on the use of available wireless
technology and social media to link an ICU staff in Kenya to an intensivist from the United
States. Since the initial experience, the ICU at our Kenyan institution has conducted regular teleICU rounds with this intensivist colleague in the United States.
Clinical Scenario:
A young woman was admitted to a public hospital ICU with a 2-day history of headache,
dyspnea and emesis. On admission, the patient had severe respiratory distress, persistent
hypotension and fever. Laboratory evaluation showed leukopenia, thrombocytopenia,
pyuria, hypoxemia and metabolic acidosis. HIV and malaria testing were negative. Chest
radiograph demonstrated diffuse bilateral infiltrates. The clinical picture was consistent
with Adult Respiratory Distress Syndrome (ARDS) with septic shock. After intubation and
initiation of mechanical ventilation, the chest radiograph was sent to an ICU consultant
(PSK) in the US via e-mail. Using a wireless internet connection (Safaricom®) and
Skype®, the US consultant (PSK) and the Kenyan medical officer (LL): reviewed the
patient, optimized ventilation using ARDSnet guidelines and initiated sepsis management
using a sepsis bundle. Unfortunately, the patient died due to refractory septic shock and
ARDS.
History and Benefits of Tele-ICU:
Beginning in the late 1960’s advances in computerized monitoring of critically ill patients could
be extended to include remote monitoring of physiological variables.9 This process was
accelerated by the successes of NASA in monitoring astronauts’ physiologic variables from
space.10 In 1980’s the first reports of telemedicine consultation of the ICU were published but
the first large scale study comparing outcomes of a telemedicine consultation service to
historical controls was published in 2000. 11 In what was termed “an alternate paradigm” for ICU
staffing, this 16 week study of 24 hour continuous remote ICU care demonstrated a 60%
reduction in severity adjusted ICU mortality. The subsequent expansion of tele-ICU medicine
was undoubtedly fueled by rapid progress in the development of comprehensive computerized
medical record systems and the growing consensus that continuous intensivist coverage of
critical care units was associated with improved quality of care.12 Predictably, the introduction
of multiple platforms, the commercialization of tele-ICU technologies and varied approaches to
tele-ICU have complicated the landscape of clinical practice and research thereby complicating
the task of understanding the true impact of tele-ICU.13
Can the use of tele-ICU improve outcomes of critically ill patients globally and in Kenya? The
answer to both questions, based on recent systematic reviews and the authors’ experience, is a
qualified yes.8,14 Globally, a recent meta-analysis of available studies showed that tele-ICU
lowered ICU and hospital mortality.8 This systematic review included 11 before and after
observation studies involving over 49,000 patients and found that tele-ICU telemedicine reduced
ICU mortality (RR, 0.79; 95% CI, 0.65 to 0.96; P = 0.02) and hospital mortality (RR, 0.83; 95%
CI, 0.73 to 0.94; P = 0.004). However, there is uncertainty as to which interventions reduce
mortality, given the heterogeneity of methodologies included under the rubric of tele-ICU. Highintensity comprehensive monitoring and management (so-called active systems) were not
superior to consultation-only passive systems. It is suggested that the mortality benefit was
related to better adherence to protocols of “best practice” in ventilator management, infection
control and sedation practice. Quality improvement interventions focused on adoption of “best
practice” have been cited in several studies as being critical factors in improved outcomes in the
arena of critical care where adherence to evidence based care guidelines has been suboptimal.15
In addition, better staff education and mentoring, increased attention to patient evaluation and
treatment during the first hour of critical care and enhanced involvement of hospital leadership in
quality improvement efforts in support of the ICU are postulated. Despite the existing
uncertainties and limitations of previous studies, these potential “mechanisms of action” of teleICU are directly applicable to current and future needs of critical care in Kenya.
Lessons Learnt and Future Directions: Using a passive system model of tele-ICU
consultation with readily available wireless internet connectivity and free social media, we
highlight feasibility of Tele-ICU and are able to identify the following actual and potential
benefits of real-time consultation via telemedicine: 1. The ICU staff supported the initiative and
perceived benefit from the consultations which translated into improved morale. 2. The US
consultant provides support for Kenyan colleagues who must balance heavy teaching and clinical
obligations. 3. Prompt access to sub-specialists including neurologists, endocrinologists and
thoracic radiologists who are in critical short supply in Kenya. 4. Potential reduction in ICU
transfers from smaller hospitals and 5. Better pre-transfer resuscitation and stabilization.
We can identify several limitations and barriers to the dissemination of tele-ICU in Kenya. These
include: 1. Cost, quality and stability of current internet connections 2. Limitations of Skype®
in supporting real-time transmission of radiographic and ultrasound images. 3. Time-zone
differences hampering 24/7 access to consultants abroad and 4. Legal issues of data protection
and patient confidentiality. Future directions for tele-ICU in Kenya should include: 1.
Development and financial support for tele-ICU consultation and triage within Kenya linking
existing and planned ICUs to consultants in national referral hospitals. 2. Improved internet
infrastructure to expand real-time sharing of data and images. 3. Research to define optimal
configuration, cost and effectiveness of tele-ICU in Kenya and 4. Clearer understanding and
consensus regarding regulatory and confidentiality issues related to transmission of protected
health information.
Conflicts of Interest: None identified
Acknowledgements: The authors from Duke University gratefully acknowledge the support of
the Hubert Yeargan Institute for Global Health, Duke University Department of Medicine
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