TELEMEDICINE IN THE
ICU
Chad Hodge
Roosan Islam
Casey Rommel
Nicole Ruiz
Diane Walker
DEFINITION
 What is telemedicine?
 The delivery of healthcare from a distance using electronic
information and technology.
 Literally, “Healing at a distance.”
 What units qualify as an ICU?
 All critical care areas, such as surgical, cardiac, medical,
pediatric, neurology, neonatal, burn, and other postoperative.
 What is an eICU?
 Nurses and physicians located at a remote command center
providing care to patients in multiple, scattered intensive care
units via computer and telecommunication technology.
THE NEED
 ICUs treat 4.5 million annually (10% of all patients).
Expected to rise as the population ages.
 $107 billion annually (4% of total healthcare costs ).
 ICUs are coalescing.
 Fewer than 6000 intensivists.
 ICU mortality rate is 10-20% and is responsible for
500,000 deaths annually.
 eICUs are estimated to reduce that number by
50,000 (10%) per year.
THE NEED CONTINUED
Fewer than 15% of hospitals meet the
Leapfrog Group intensivist staffing model.
 Return page within 5 minutes 95% of time.
 Or arrange for alternate staff to respond.
 ADEs in ICUs are 2x the national average
(19/1000 patients) because of the high
number of drugs ordered.
EICU MODEL
 Responsibilities of the hub intensivist can
vary from treating emergent situations,
with all other care managed by the
admitting physician (open ICU model), to
complete intensivist management, with
only notification of treatments given to
the patient’s physician (closed ICU
model).
 A well-supported intensivist may staff
approximately 50 to 100 remote ICU
beds.
ADVANTAGES
 Having an ICU physician rapidly available.
 Having an intensivist available more hours of the
day.
 Having rapid access to all forms of clinical data
through improved ITS.
 Having an ICU physician available allows for more
rapid interventions in case of problems.
 Length of stay and resource utilization may also be
affected by commencing care as soon it is warranted
(eg, ventilator weaning begun during the nighttime).
DISADVANTAGES
 Potentially putting a layer of technology between the
patient and the physician.
 Significant upfront and maintenance costs.
 Subject to malfunction and downtime.
 Physicians are typically cited as the greatest barrier
to implementation.
 Physicians perceive that a lack of direct interaction,
eye contact, and other sensory input with the patient
may cause them to miss critical diagnostic cues.
TELE-ICU IMPROVES PATIENT OUTCOMES
TA BLE 1 . C OM PA RISON OF I N T E NSI VE CA RE UN I T ( I C U)
P ROC E SSES BE FORE A N D A F T ER T E LE - I C U I N T E RVENTI ON
Preintervention
Tele-ICU Intervention
Bedside monitor alarms
Physiological trend alerts
Abnormal laboratory value alerts
Review of response to alerts
Off-site team rounds
Daily goal sheet
Electronic detection of nonadherence
Real-time auditing
Nurse manager audits
Team audits
Telephone case review initiated by house staff or
affiliate practitioner
Workstation review initiated by intensivist includes
electronic medical record, imaging studies,
interactive audio and video of patient, interaction
with nurse and respiratory therapist, and
assessment of response to therapy
MORTALIT Y AND LENGTH OF STAY
OUTCOMES
BEST PRACTICE AND COMPLICATION
MEASURES
WHY IS TELEMEDICINE THE SOLUTION?
 Improves 3 areas of quality of care:
 Improved patient outcomes
 Access to care
 Cost savings
 Technology is ubiquitous. Still…
 Only 10% of hospitals have teleICU
services.
 Only 4900 adult ICU beds supported
by teleICU.
 1 million patients monitored by
teleICU.
EMERGING TECHNOLOGIES
 Digital Video Transport System
 System to send and receive digital
streaming videos over broadband
internet.
 H.323 Video Conferencing Solution
 The H.323 protocol is a
recommendation from the
International Telecommunication
Union.
 Vidyo
 Vidyo provides high quality video
conferencing from a range of
technologies.
BARRIERS TO ADOPTION
 Financial costs
 $6-8 million initial startup.
 $1-2 million operating costs yearly.
 Maintenance and/or Upgrades
 Licensure
 Staffing
 Limited or no patient
reimbursement/billing.
 Shortages of specialists results in
“poaching.”
 ICU clinician shortage > Intensivist
shortage.
 Staff and patient acceptance.
Image- http://blogs.bmj.com/bjsm/2011/07/20/educating-all-medical-specialists-to-support-exercise-as-the-fifth-vital-sign-dr-danica-bonello-spiteri-comments/
CASE STUDY 1: ROBOTICS
 Looked at the difference
between using standard system
of paging ICU physician versus
robotic telepresence (RTP)
intervention.
 Focused on neurocritical care
patients:
 Traumatic Brain Injuries
 Brain tumor
 Ischemic stroke
 Hypothesized that physician
face-to-face response time to
patient would significantly
decrease.
Image- http://www.robots-and-androids.com/robotic-syringes.html
CASE STUDY 1: ROBOTICS
 Standard Model:
 Nurse detects change in
patient’s condition.
 Pages ICU physician.
 Physician calls the nurse
and gives instructions
over the phone.
Vespa et al, 2007.
 Robotic Telepresence
Model:
 Nurse sends text
message to physician or
can walk up to robot if
session is in progress.
 Physician conducts
rounds from office.
 Examine patients by
driving robot next to bed
and speaking to patient
directly or instruct nurse
to perform exam.
CASE STUDY 2: VA HOSPITAL
 VISN (Veterans
Integrated Service
Network) 19
 Covers areas including
Montana, Utah, Colorado,
Wyoming, Idaho, Nevada,
Kansas and Nebraska.
 Developed tele-ICU
model to improve access
to critical care services
in rural facilities by
combining tele-ICU
technology with
expanded critical care
nursing services.
 First of its kind in the VA
system.
CASE STUDY 2: VA HOSPITAL
 Model:
 Operated entirely by nurses.
 One experienced CCRN-certified nurse
manages system 24/7.
 Nurses from different facilities report
on patients at start of shift.
 Available for immediate consultation.
 Virtual rounds.
 Results:
 Cost savings.
 Increase in collaboration between
healthcare facilities.
 Increase in number of nurses becoming
CCRN-certified.
FUTURE CHALLENGES
 Legal Issues
 The physician’s liability in case of
malpractice.
 The patient has to be protected, and cyber
physicians must be able to quantify their
risk.
 The relationship between physicians and
insurance companies may need to be
modified.
 The roles of electronic decision support
systems, medical software, and data
collection systems in determining
responsibility need to be clarified.
 Reimbursement
 USA lacks unified healthcare system and
regulations need to adapt with the
changing industry.
 States need to be proactive in their
regulation.
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THANK YOU
We are happy to answer any of your questions.
CITATIONS
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FUTURE CHALLENGES AND POSSIBLE
SOLUTIONS
 User Needs, Acceptability and Satisfaction
 Consider the subjects needs who are sick, disable and
elderly.
 The subjects immediate surrounding including caregivers
ease of use and delivery of care.
 The manufacturers, as well as the commercial providers,
should customize products based on needs.
 Reliability and ef ficiency of sensory systems and
data processing software.
 Have a reliable algorithm for evaluating the patient’s
“lifestyle.”
 Trigger an alarm in case of danger.
 Correctly interpret the vital signs through automated
software
or a competent medical professional, so that deficient
function can be recognized.
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