Intensive care patients require round-the-clock care, but high patient volumes and a shortage of intensivists can make that goal difficult. Tele-ICUs, or remote intensive care units, are changing the equation by providing an additional layer of care and physician support for the sickest patients wherever they may be.
“Tele-ICUs can enhance patient experience by providing an additional layer of monitoring and immediate access to an ICU provider,” Christina Canfield, clinical program director of Cleveland Clinic’s tele-ICU called eHospital tells Healthcare Dive.
The clinic’s program provides extra coverage of ICUs between 7 p.m. and 7 a.m. in nine community hospitals in the Cleveland Clinic Health system, including Cleveland Clinic Florida. The aim is to speed up the time between recognition of a problem and intervention, Canfield says.
“While the system was designed to be EMR agnostic, the current application leverages compatibility with the Clinic’s EMR,” she notes. The system, developed in-house, also allows protocols to be customized to specific patient populations.
Estimates of the number of hospitals currently offering tele-ICU range from 15% to 20%, according to Advanced ICU Care, one of several commercial companies offering the service. A 2009 recommendation by the Leapfrog Group calling for round-the-clock physician staffing of ICUs could create more demand for tele-ICUs, particularly in hospitals without in-house critical care physicians.
In a study published by HIMSS, the mean length of ICU stay dropped from 6.9 days pre-tele-ICU intervention to 4.2 days post-intervention and there was strong evidence of secondary outcomes, such as reduced overall hospital length of stay, ICU mortality and hospital mortality.
According to Global Market Insights, the global tele-ICU market will reach $5 billion in 2023, up from $1.2 billion in 2015. The U.S. share of that market was about 60% that year. Driving growth are an aging population and growing rates of chronic diseases like cancer and neurological disorders. Major players include Banner Health, Philips, Advanced ICU Care, inTouch Health and Inova.
“One distinction that drives differences in hospital utilization is the availability of intensivists at the bedside,” says Lou Silverman, CEO of Advanced ICU Care. “If intensivists are internally staffed by the hospital, tele-ICU provides a second set of eyes — an additional layer of patient safety in partnership with the bedside team."
"When intensivists are not readily present, tele-interventionists take a more active role directing patient care, including intervening in urgent situations.”
CEO, Advanced ICU Care
Silverman likens it to an air traffic controller being able to offer a different vantage point and connect the interrelated moving pieces to identify downward trends in a patient’s condition and prompt intervention before a crisis occurs.
Keeping patients in the community
At Intermountain Healthcare’s tele-ICU support center, a team of four critical care nurses and a board-certified critical care physician monitor patients 24/7 via a steady data stream from EMRs, two-way audio-visual connections and bedside monitors. Depending on the situation, tele-ICU physicians can write notes and order, start and stop treatment, order diagnostic tests, consult with families or decide to transfer a person to another hospital and how to do so safely.
“There’s a tremendous amount we can do from this location without out being literally present,” says Dr. William Beninati, medical director for telecritical care at the Utah-based health system.
Launched in 2014, Intermountain’s tele-ICU program is now in 12 of the system’s hospitals that have ICUs and five non-system hospitals. A pilot project is underway at two rural critical access hospitals without ICUs, and plans are to expand to five more rural hospitals. While the aim at larger hospitals is to support in-house ICU staff, the primary goal at CAC facilities is to help stabilize patients and prepare families for transport.
The two-year-old program succeeded on several levels. “One of our goals after high quality of care is to allow people to stay in their community when that’s possible,” Beninati tells Healthcare Dive. In an analysis of 3,300 patients before and 3,200 following tele-ICU implementation, community hospitals were able to significantly increase the complexity of patients who could stay in their community and reduced mortality by 33%, says Beninati.
Financial gains and reductions in length of stay have been noted as well.
“We are seeing a rapid return on investment on a roughly one-year timeframe.”
Dr. William Beninati
Medical Director for telecritical care, Intermountain Healthcare
An initial cost analysis showed a $4.4 million decrease in the cost of care provided and a $3.3 million decrease in reimbursement. “The insurance companies experienced a tremendous benefit … and we still experienced slightly more than a $1 million benefit,” Beninati says.
Anecdotal reports also suggest a positive effect on patient experience, according to Beninati, though that is harder to measure conclusively. Negative feedback have mostly concerned privacy issues and “we generally can address that at the time,” he says.
Intermountain is taking its telecritical care operation a step further and integrating it with its Life Flight transport function to ensure a rapid, seamless transition from referral center to ICU. With tele-ICU personnel coordinating the care protocols and procedures that will be used during transport, the transport team can focus on the patient and family, Beninati says.
Deciding to set up a tele-ICU and then running it successfully can be challenging. According to a 2013 retrospective literature review by AHIMA Foundation, many bedside doctors and nurses don’t understand how tele-ICU works and see it as interfering in their treatment of the patient. Some hospitals have activated tele-ICUs only to shut them down because of resistance to changes in patient management and having to share control of patients with off-site physicians.
Communication and making sure the culture in the hospital that’s getting tele-ICU support is ready for it is key, Beninati says. It’s a “big, big change” bringing remote clinicians into the ICU, and like any marriage of different cultures, it involves work. That means building personal relationships with bedside staff, patients and family members and, when necessary, smoothing ruffled feathers.
Canfield agrees. To enhance buy-in by on-site staff, the Clinic conducts robust education with routine site visits prior to implementing tele-ICU.
Another challenge is deciding between a commercial platform or a homegrown strategy. Inova’s eICU, for example, is a highly capable, well-refined program that allows systems to get up and running quickly, but it comes at a financial cost and a cost in flexibility, Beninati says. “We gained flexibility and we saved a tremendous amount of money by doing the homegrown system. It’s a big commitment, but we had the horsepower to see it through.”
Still, for organizations with smaller capital and operating budgets, outsourcing to a tele-ICU provider can offer a financially sustainable means to improve ICU outcomes. These models can be adapted to offer varying degrees of operational control, affordability, simplicity and staffing, making them within reach of hospitals and health systems of any size, says Silverman.
Canfield says privileging can also be a challenge. Physicians, nurses and other providers who work remotely require state licensure and clinical privileges at the hospitals they serve. In the Clinic’s case, more than 100 providers must maintain privileges with nine hospitals.