#31 Tele-Critical Care Drs. Bill Beninati and David Guidry
Tele-health is blowing up in 2024 and that is as true for critical care as it is for other fields of medicine! On this episode of Critical Care Time, Nick and Cyrus interview Drs. Bill Beninati and David Guidry: Two experts in the world of tele critical care. We cover all the in’s and out’s of delivering critical care service from afar with a focus on implementation, logistics, benefits and challenges. Give this a listen and let us know what you think!
Show Notes:
What is Tele-Critical Care?
Telecritical care is a model for providing critical care services to patients who are remote from the location of the caregiver team.
Nomenclature: The term telecritical care is preferred over terms like tele-ICU or eICU. Those are proprietary/brand names for products that deliver telecritical care. (Like Bandaid)
Currently, 15% of ICU beds in the US are managed using tele-medicine. The number of ICU beds managed/co-managed using tele-critical care rose rapidly during the pandemic and is expected to continue to increase.
Goals of tele-critical care: increase access to critical care specialists, improve clinical outcomes, manage ICU capacity and resources across a larger area
Tele-critical care is good for smaller primary hospitals that benefit from intensivist consultation and transferring sick patients, but is it also benefit larger quaternary hospitals that receive patients. It can also help coordinate across different phases of care (ED, small regional hospital ICU, larger specialized ICU, etc) and improve the efficiency of resource allocation.
Telecritical care teams provide proactive care, rounding on patients and making recommendations to the bedside teams. It may not be possible to synchronize rounding with the boots on the ground, but the remote teams will make rounds and provide recommendations relating to critical care interventions.
Telecritical care programs can be organized in different models:
Care models:
Continuous care: 24/7 coverage
Episodic care: intermittent, pre-defined
Responsive care: “on-call” - alerted via alarm of some sort
Structure Models:
Centralized “hub & spoke” - most common, care team in a central location overseeing multiple sites
Decentralized: point-to-point, on demand care, easiest to set up and portable
Hybrid
At most programs there is central hub, or a few centralized hubs – i.e. mission control(s) and numerous “spokes” which represent the end users (i.e. hospitals utilizing telecritical care services.)
Operationalizing Tele-Critical Care
Communication: “I see I Think I Wonder” & Other Strategies
Effective communication and teamwork are crucial in telecritical care.
The “I see, I think, I wonder” approach can help address issues and build trust. You may not have all the information the boots on the ground team has and so, rather than calling a team out for doing something you don’t agree with, as a remote consultant it may be helpful to say something like: “I see you are treating community acquired pneumonia with meropenem. I was wondering what I’m missing here… What are your thoughts on switching to ABC? In similar situations I’ve seen, that has been helpful.”
Telecritical care is an iterative process that requires ongoing collaboration and relationship-building with the bedside teams. Avoid conflicts in the chart and communicate directly with healthcare providers to resolve issues.
Do not use the bedside nurse as a message taker, make the effort to contact healthcare providers directly.
Human factors:
Personnel in a basic telecritical care program include senior RNs, transfer specialists, and specialists in various areas of critical care. Together, this multidisciplinary critical care team and offer expert insights and provide tremendous value to the primary team and to hospitals that do not have on-site critical care professionals.
Invest in the necessary licenses and credentials for telecritical care. This must be done to ensure practices are all “above board.” This may be onerous but is absolutely necessary… perhaps even critical!
Misconceptions about telecritical care include the idea that it is invasive and takes over local care, but it is a value-added and collaborative approach. Telecritical care professionals are merely consultants who endeavor to inform and enhance the decision making of the primary physician care team who is with the patient.
Technical factors:
A telecritical care command center requires audio access to medical records, telephony, and good communication with hospitals. Do not discount the importance of good infrastructure. The tech matters!
Realtime 2-way video is becoming defacto standard.
High reliability, high redundancy systems is more important that features.
Remember that having the right team and building trust through good communication practices is more important than having the best tech stack!
Benefits of Tele-Critical Care Programs
Telecritical care programs can reduce unnecessary transfers and improve outcomes for patients. For example, this could allow a patient in extremis to be near their family and not need to endure a risky transfer while still receiving the standard of care despite being distant from a larger or more robust hospital center.
Evidence for improved outcomes with tele-critical care
One Meta-analysis of 11 observational studies demonstrated lower ICU and hospital mortality (RR 0.79 and 0.83 respectively).
Pitfalls & Challenges
Pitfalls of telecritical care include the cost and time required for licensing and credentialing, but efficient processes can help manage these challenges. Additionally, if there is not complete institutional buy in, conflict can arise which will erode the effectiveness of telecritical care support. Also, the lack of interoperability between electronic medical records remains a significant challenge in telecritical care.
AI is being explored in telecritical care, particularly in areas such as ambient listening and patient safety. A pitfall here is the potential for the primary physician team to feel a “big brother” phenomenon. Thus, rules of engagement and best practices must be clearly defined.
Audio
Video
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Irwin and Rippe's Intensive Care Medicine: Chapter 31 on Telecritical Care by Guidry et al.
Becker CD et al Effects of Telemedicine ICU Intervention on Care Standardization and Patient Outcomes: An Observational Study. Crit Care Explorations 2020
Cucchi EW, Kopec SE, Lilly CM. COVID-19 and the Transformation of Intensive Care Unit Telemedicine. Clin Chest Med. 2022
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Undifferentiated Shock
Cardiac Arrest