In 2014, the Tele-ICU Committee of Society of Critical Care Medicine (SCCM) published a review of tele-ICU services (1) and now provides updates on its evolution. Today, clinicians use tele-ICU technologies and services in ways not previously considered. Consequently, the committee recommends a new term to describe technology-enabled critical care services to replace existing terms such as tele-ICU, ICU telemedicine, and others—tele-critical care (TCC). This term accommodates the concept that TCC services can be provided to locations beyond the physical confines of an ICU, or even a hospital. This article provides insight into TCC’s evolving prevalence, functions, emerging trends, technologies, new applications, outcomes, and barriers. To clarify terminology, the entity providing TCC services is referred to as the “remote site,” and the connected services recipient where care is physically provided as the “local site,” regardless of geographic proximity.
EMERGING TRENDS IN TELE-CRITICAL CARE STRUCTURE
TCC has evolved along three technologic and administrative structures according to health system needs and investment capabilities. However, impact of the different structures on staff satisfaction, acceptability, and patient outcomes have not been comparatively evaluated nor has there been study to validate the prevalence of these administrative structures. Nevertheless, we describe them here so the reader may understand their differences.
Centralized Hub-and-Spoke Program Structure
Hub-and-spoke, the predominant TCC structure, uses a single remote center (hub) in a fixed location to provide TCC services to multiple local locations (spokes) simultaneously. Continuous patient monitoring at multiple locations is a hallmark (Fig. 1). The hub has dedicated staff with only occasional (if any) staffing responsibilities at local sites (2). Technology support typically involves a dedicated, vendor-supplied telecommunication and software solution providing the TCC team with real-time remote access to patients’ electronic medical records, with video-teleconferencing to patient’s rooms (2,3). Software platforms provide computer-generated alerts, notifications, and clinical-support algorithms (4). One example is a hub located in a large academic, flagship hospital providing TCC services to smaller hospital spokes in the same healthcare system, or to unaffiliated regional hospitals.
A variant is the hub-node-spoke structure used by the Veterans Affairs (VA) Administration, Military Health System, and some large civilian TCC programs (Fig. 2). A single centralized hub provides administrative oversight (call schedules, policies, guidelines) and technical support (software licenses, network, and cloud servers) to multiple remote nodes (satellite centers) providing TCC clinician services to multiple local spokes. Nodes share coverage responsibility for multiple ICUs across the system and may be co-located in the same city as the recipient units or in a different city, state, country, or continent. Advantages to hub-spoke models are continuous patient monitoring, integration of patient-specific data, and proactive care ability, while disadvantages are high technical, human resource, and administrative expenditures (4).
Decentralized Program Structure
In this TCC structure, also called a “point-to-point system,” a remote intensivist virtually reviews one patient at a time at a local location. This generally involves audio-video connectivity between the provider and the local site using individual computers or mobile devices (4). Providers connect from any area of convenience (e.g., office, home) appropriate for maintaining patient privacy and information protection (2). Telecommunication between providers and local sites is encrypted, open architecture via the internet (usually requiring broadband access) (3). Patients are not monitored continuously but on an episodic or consultative basis. For example, local intensivists pool resources to contract out TCC services but are never responsible for onsite presence. A decentralized structure can support units in a country different from the TCC provider (5). Because of its mobility and lighter infrastructure, this model suits critical care provision in disaster scenarios. The ability to deliver immediate care at a lower cost must be weighed against its reactive and consultative nature, with lesser data acquisition, integration, and analytics (4).
Hybrid Program Structure
The hybrid structure starts with the centralized continuous oversight model, but layers in point-to-point reactive consultations for expert specialty care as needed (4). One example is a centralized TCC intermittently connecting to a specialist for an unanticipated obstetric emergency, psychiatric evaluation, or acute neurologic event (4).
Tele-Critical Care Staffing Structures
TCC program staffing models originally involved physicians and nurses situated at the remote location. TCC physicians may be either employed or contracted for services by the remote entities. Recently, advanced practice providers (APPs) have been added to support TCC staffing. In some instances, APPs may perform patient screening and escalate cases as needed to co-located intensivists. Using APPs in TCC adds additional perspective to multidisciplinary TCC team and facilitates training, standardization, and consistency at both remote and local sites. Research comparing models involving only physicians versus a tiered system incorporating APPs is emerging (6).
TELE-CRITICAL CARE AND CRITICAL CARE ORGANIZATIONS
Critical care organizations (CCOs) assemble multiple ICUs within a single healthcare system under one leadership structure with defined accountability to consistently deliver safe, efficient, cost-effective, high-quality care, and assist in organizational development and congruence (7). Since CCO goals are the same as those of effective TCC services, TCCs can be central in the process of creating and sustaining CCOs, driving resource stewardship and standardization.
Inherent to integrated CCO function is the assumption of fiscal and resource stewardship, with appropriate ICU resource allocation using a robust triage system. Evidence suggests that a significant percentage of ICU patients might not require high-intensity or invasive interventions that characterize critical care (8). TCC programs incorporating a logistics or operation center overseeing critical care resources across a system of hospitals or ICUs optimize ICU resource allocation (8). TCC also offers new paradigms for bed management such as “reverse triage,” where the higher-acuity medical centers offload less acute patients to community ICUs in exchange for high-acuity patients without delay (9).
TCC also drives CCO care standardization. Although proactive versus reactive TCC care delivery warrants further study, some proactive systems elements appear to confer benefits. TCC teams functioning as extensions of the bedside care team provide consistency within and across CCOs by standardizing and monitoring best practices adherence (10). For example, TCC-driven ventilator rounds improved adherence to lung-protective mechanical ventilation practices and ventilator liberation, and were associated with sustainable decreased ventilator days and reduced ICU mortality (11,12). Such TCC-driven standardization processes, when efficiently implemented across multiple units, impacts many patients.
TELE-CRITICAL CARE OUTCOMES AND NEWER APPLICATIONS
Published accounts of TCC outcomes are impacted by the quality of pre- and post-cohort designs, technology variations, TCC process complexity, and nuances in process implementation (1,8). It is important to note that technology itself cannot, on its own, change outcomes and TCC must also be considered in the context of how each center uses technology to impact clinical decisions and care (13, 14), thus partially explaining variations in reported TCC outcomes. In 2016, Kahn et al (15) compared case hospitals adopting TCC to control hospitals and found a small but statistically significant reduction in 90-day mortality odds for case hospitals (odds ratio, 0.96; 95% CI, 0.95–0.98; p < 0.001), a finding consistent with other research (8,16). However, only 12% of case hospitals experienced significant mortality reductions, and these were urban hospitals with high admission volumes (> 1,000/yr), which runs counter to the expectation that TCC most benefits small rural hospitals where critical care expertise is limited or absent.
Evolving TCC Applications
One newer application for TCC is in improving sepsis care (17). Capability of an emergency department to place central lines and access TCC services has been independently associated with 30% lower odds of sepsis transfers to another hospital (18). TCC-enabled automated sepsis compliance monitoring has also enhanced sepsis detection and bundle compliance (19,20). Yet, another application is the increasing function of TCC centers as logistic centers coordinating and facilitating patient transfers to appropriate care levels. Although TCC implementation might help retain patients at local sites because of available virtual expertise, one study showed a reverse effect unexplained by illness severity (21). Conversely, a study of 500,000 VA patients admitted to ICUs with and without TCC demonstrated a significant decrease in inter-hospital transfers with TCC (relative risk, 0.79; 95% CI, 0.71–0.87) (22).
TCC is emerging as a facilitator for end-of-life care planning. An informal survey by SCCM’s membership suggested that nearly 40% of programs use TCC to initiate end-of-life discussions. A process for incorporating end-of-life discussions into TCC routine has not yet been developed or evaluated, but tele-ethics consultation is feasible (23). Last, a newer application of TCC is its extension to support patients and care teams in non-ICU settings where critical care expertise is emergently needed, such as hospital wards without on-site rapid response teams (24), war zones (5,25–27), and in response to disease outbreaks (17). In these settings, TCC providers immediately project expertise to the point of need, well before and sometimes in the absence of, moving patients to critical care resources. In low-resource areas, the use of cellular or satellite technology or even telephones, with or without low-definition video (e.g., from a web camera or cellphone), or photographs sent asynchronously via end-to-end encrypted email may still provide needed critical care to patients in disaster settings (5,26,27). Such rapidly deployable TCC models must still adhere to data privacy and security according to HIPAA (5,26,28).
BARRIERS TO TELE-CRITICAL CARE ADOPTION AND EFFECTIVENESS
Costs and Return on Investment
Cost significantly hinders TCC adoption (1). Lack of defined reimbursement models, unclear financial incentives, and human factors challenge TCC expansion (29). Kumar et al (30) estimated program costs of $50,000 to $100,000 per ICU bed in the first year. A cost-effectiveness analysis by Yoo et al (31) projected that TCC extended quality-adjusted life-years by 0.011 with an incremental cost of $516 per patient compared with critical care without TCC, resulting in a cost-effectiveness ratio of $46,909 ($516/0.011) per additional quality-adjusted life-year.
A cost analysis by Lilly et al (9) found that a comprehensively integrated TCC system improved annual contribution margins by $37,668,512 to $60,586,397, attributable to improved efficiency, increased case volume, and access to high-quality critical care (9). Nevertheless, not all studies demonstrate savings (32,33). In one systematic review, Chen et al (34) reported costs ranging from a savings of $2,600 to an increase of $5,600 per patient, proposing that variation was likely related to how TCC was used in each site, health system size, and the TCC-ICU interface model, suggesting that factors beyond technology impact local efficacy and return on TCC investment (35).
Organizational and Human Factors Impacting Tele-Critical Care Effectiveness
The 2016 study by Kahn et al (15) showed that, although TCC-adopting hospitals demonstrated a mortality benefit, there was a wide variation (12% decreased mortality, 81% no change, 6% increased mortality). Since technology varied little between programs, they suggested that TCC organizational structure, admission volume, and human factors, attitudes, and expectations surrounding TCC use impacted effectiveness. Whereas using TCC to promote best practices and improved communication might improve outcomes, TCC may also disrupt local communication or diffuse responsibility, resulting in negligence (15). A focused ethnographic evaluation by the same authors revealed three domains influencing TCC effectiveness—leadership (decisions related to the role of TCC, conflict resolution, relationship building); perceived value (expectations of availability and impact, staff satisfaction, understanding of operations); and organizational characteristics (staffing models, allowed involvement of the local unit, new-hire orientation) (36). More research regarding these modifiable organizational and human factors on TCC effectiveness is needed (36–39).
Licensure and Credentialing Barriers to Tele-Critical Care
TCC adoption barriers include varying requirements for clinician licensure, credentialing, and privileging, which are governed by inconsistent federal and state laws, medical staff bylaws, and American Medical Association guidelines (40). Lack of a standard definition for TCC makes the application of laws and guidelines difficult.
The U.S. Centers for Medicare and Medicaid Services (CMS) requires that medical professionals be licensed in the state and credentialed and privileged by the hospital where the patient is physically located (40,41). CMS guidelines require written agreements between local hospitals and telemedicine providers, and documentation granting privileges. Recently improved interstate cooperation on professional licensure facilitates TCC delivery (42), but interstate licensure compacts currently exist in only 21 states for physicians (43,44), 29 states for nurses (45,46), and in none for pharmacists.
Credentialing requirements also affect TCC. The CMS Conditions of Participation permits a streamlined process for credentialing telemedicine-based entities without the full administrative burden of the traditional process. Credentialing by proxy (CBP) permits local hospitals to accept the remote site’s credentialing decisions (47). However, the Joint Commission requires that both sites be accredited by the Joint Commission (a requirement not imposed by CMS), potentially curtailing CBP use (48,49). A clear, streamlined process of obtaining licensure, credentials, and privileges for TCC helps avoid legal and reimbursement concerns.
TCC clinicians should be specifically trained and experienced in critical care and ideally maintain some bedside practice to preserve situational awareness of bedside context. Specialty certifications (e.g., Fundamental Critical Support, Advanced Cardiac Life Support, Board Certified Critical Care Pharmacist, Critical Care Registered Nurse [CCRN], CCRN-E) are recommended. TCC pharmacists should complete at least 2 years of employment experience (50,51). Competence in communication, teamwork, conflict resolution, and leadership are essential to TCC effectiveness (36).
Legislative Updates Related to Tele-Critical Care
Regulations impacting TCC are ongoing at federal (52) and state (53) levels. As of this writing, the 115th U.S. Congress considered 61 items of telemedicine-related legislation. Seven bills were passed into law, of which four were related to the VA. Two bills becoming law—H.R.2 and H.R.3354—address telemedicine within the context of rural development, and several more under consideration have rural health impact (H.R.2291 and H.R.3565). S.870 and S.1016/H.R.2556 under consideration, relate to use (and Medicare support) of telemedicine technologies to expand care access. Several bills relating to broadband coverage carry associated telemedicine impact (H.R.4308, H.R.3994, H.R.5213, S.3346, and H.R.800) (54).
At the state level, the VA permits telemedicine care delivery by VA providers irrespective of the location. Outside the VA system, significant barriers to telemedicine provision and reimbursement within and across states remain. Only 24 states have policies for live video transmission, 14 with store-and-forward policies (acquisition and storing of clinical information then forwarded to, or retrieved by, another site for clinical evaluation), and six with remote monitoring policies (55). Only one state (Mississippi) reimburses all three transmission types, while 47 have Medicaid policies regarding live video transmission, 37 regarding store-and-forward, and 20 regarding remote monitoring. Only 13 states require that live video transmission be reimbursed by Medicaid at the same level as in-person services. Consistent and uniform policies will greatly enable and streamline TCC delivery.
EMERGING TECHNOLOGIES FOR TELE-CRITICAL CARE
Historically, TCC requires a dedicated, secure, rapidly responsive, and reliable communication link with high-definition audiovisual interface with readily available on-call technology support. However, the evolution of other technologies, such as broadband wireless connectivity also provides reliable, high-quality communications (e.g., 3G, 4G, Long-Term Evolution, and Wi-Fi) and extends the range and access of TCC platforms (56–58). Many new telemedicine platforms allow evaluations using mobile devices and extend services beyond hospitals into prehospital and home environments (59).
A SNAPSHOT OF CURRENT TCC USAGE
To provide a snapshot of current TCC usage among its membership, the SCCM Tele-ICU Committee developed and disseminated a voluntary survey to its membership in 2017. The geographic and professional distribution of the valid responses is shown in Table 1, and of the 561 unique center responses, 35% had formal TCC programs and 65% used technology outside a formal program. Also, a variety of TCC platforms were reported. Table 2 shows the functions, activities, and technologies of the formal TCC programs. Most reported using TCC to identify emerging patient problems, and half provided continuous monitoring of patient progress, facilitated care team communication, and provided rapid response support. Less than a third reported TCC being used to educate, provide population management and performance improvement, or multidisciplinary rounds, and only a quarter practiced daily care planning or mentorship. Only two-thirds could actively intervene in emergencies, and half actively implemented best practices or provided ICU services when no physician was available locally. Use of supplemental technology by the formal TCC programs is also shown in Table 2, Of the responding centers without formal TCC programs (Table 3), the majority used tele-radiology (67%) and, to a lesser degree, phone-based communication with photo exchange (44%), tele-electroencephalogram (31%), tele-stroke (26%), and tele-electrocardiogram (26%) support tools. Notwithstanding its limitations, this snapshot suggests that TCC programs actively engage remote and local sites in continuous monitoring and identification of emerging problems and fostering and implementing best practices, but intervening in emergencies is still not universal, and the full potential for multidisciplinary engagement, collaborative care planning, and mentorship seems underutilized. Also, most respondents reported using technologic connectivity outside of formal programs, a trend expected to expand.
The ability of TCC to project critical care expertise into multiple and unconventional nontraditional—even war-torn—clinical contexts highlights its flexibility and adaptability (5). However, significant barriers to TCC adoption exist, and we suggest the following to advance further TCC evolution.
- 1) Legal and administrative barriers still inhibit efficient credentialing, licensure and privileging for TCC clinicians especially across state lines, and improvement is needed.
- 2) Industry and medical professionals should partner to develop more cost-effective TCC solutions to support adoption. Research is needed to investigate the minimum effective audio and video fidelity and network connections for optimal safety, efficiency, and outcomes, and whether mobile devices, voice-enabled assistants, and other technologies provide similar capabilities at less cost (60).
- 3) Rigorous comparative research is needed to support best practices for TCC staffing, clinical responsibilities, workflow, and decentralized and hybrid TCC models evaluation.
- 4) In this era of machine learning (61,62), explore whether big data gathered from TCC acquisition platforms could enable development and application of algorithms for critical care decision support provided patient privacy is upheld.
We would like to acknowledge contributions to the article provided by Craig M. Lilly, MD, FCCM, FCCP, FACP (Departments of Medicine, Anesthesiology, and Surgery, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, MA); Majdi Hamarshi, MD (Department of Critical Care Medicine, Saint Luke’s Health System, Kansas City, MO); Marc T. Zubrow, MD, FACP, FCCP, FCCM (Department of Medicine, University of Maryland School of Medicine, Baltimore, MD); Crystal L. Jenkins, RN, MHI (Arizona State University, Phoenix, AZ); Kenneth M. Kempner, MS (Bethesda, MD); Desiree Kosmisky, PharmD, BCCCP (Atrium Health, Charlotte, NC); Kamana E. Mbekeani, MD, MBA, MJ, FACS (Masonic Medical Center, Chicago, IL); Evert A. Eriksson, MD (Department of Surgery, Medical University of South Carolina Medical Center, Charleston, SC); Ahmed E. Badr MD, FACS (Bon Secours Medical Group, Norfolk, VA); Dominick A. Rascona, MD, FACP, FCCP (Department of Anesthesiology, West Penn Allegheny, Pittsburg, PA); Mark J. McDonald, MD (Department of Pediatrics, University of Louisville, Louisville, KY); and Lori Harmon (Society of Critical Care Medicine, Mount Prospect, IL).
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