Intensive Care Units (ICU) and Emergency Departments (ED) are usually busy departments in a hospital, and this has been especially aggravated due to Covid. Using telemedicine can be useful to address this and improve hospital capabilities and outcomes. A Tele-ICU (or ED), is a centralized model of care where remote providers monitor ICU (or ED) patients continuously, providing both structured consultations and reactive alerts. Touted by many as an obvious solution to chronic shortages of intensivists, the practice of Tele-ICU/ ED remained slow to take off until the Covid-19 pandemic. However, a number of barriers remain, for example, upfront costs to implement a tele-ICU can range between $50,000 and $100,000 per ICU bed.
Our discussion highlighted the continued supply and demand constraints between critical care patients and the physicians needed to care for them across the globe which demonstrates the importance of Tele-ICU and Tele-ED services.
Tele-ICU can solve for providing access to clinical expertise across a large geographic area and/or increasing ICU capacity at center(s) where there is acute pressure on skilled staff numbers. These are the two main problems Tele-ICU can address. In regards to Tele-ED, telemedicine support for stroke has been shown to be efficacious, tele-psych is a way to manage ED volumes and increase the speed of psych assessments where access to skilled psychiatrists is difficult. Additionally, a tele-ICU function within an ED department can provide support for patients as they transition between departments and improve outcomes.
A large part of Tele-ICU adoption is premised around workflow changes for professionals. This can be around physician preferences for work hours and resistance to change, through to guidelines such as GPICS v2 that suggest a physician to patient ratio that is not in line with the capabilities of a Tele-ICU model. While there is an upfront capital cost to set up a Tele-ICU service, the major costs and cost savings should be around staff costs. Systems with a minimum of 60 ICU beds, ideally 100-120 beds, with an ambition to grow are good candidates for tele-ICU. Along with this a larger geographic spread of clinical responsibility is a driver for adoption.
When considering a tech-enabled clinical service like Tele-ICU, there are a few elements to consider in regards to implementation.
Is the underlying software clinically appropriate, responsive and proactive in design?
Ensuring there is an underlying robust tech infrastructure to support the software. This is about ensuring cameras work all the time, there is no latency in connectivity or fidelity of data transfer. This is key in confidence building in a high pressure service
Are the clinical staff bought in? Do the bedside staff understand this is supportive and not competitive. Managing for egos and collaboration between local and remote staff is very important. Weighting for EQ on remote staff who are given to collaboration over direct instruction is a key consideration.
Having technical support around the service to quickly fix and keep operations working and evolving to local needs is a key element also.
While obvious interoperability with other systems in the hospital is critical - there is a major hesitancy to taking on the burden of integration within hospital IT teams. Beyond primary interoperability, linking the monitors and medical equipment around the patient to the system is an area of potential - be it for improved decision making by remote physicians or in the case of a pandemic, allowing physicians to monitor and adjust care, e.g. ventilators and infusion pumps, remotely.
While AI-enabled tools are attractive in this setting, much of the work to be done is on human work practices and change management. It is unlikely that a disruptive AI technology will circumvent the complex multidisciplinary team approach required in this high pressure hospital setting.