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DEPARTMENTS: Legal and Ethical

Tele-Critical Care

Reducing Risk and Expanding Care to the Critically Ill Patient Everywhere

Paulson, Shirley DNP, MPA, RN, NEA-BC; Dover, Jeffrey MSN, RN, CCRN, CNL; Shipley, Samantha MHA; Scruth, Elizabeth Ann PhD, MPH, CNS, CCRN-K, FCCM, FCNS, CPHQ

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doi: 10.1097/NUR.0000000000000667
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The coronavirus (COVID-19) pandemic overwhelmed the US healthcare systems resulting in a need to quickly add additional intensive care unit (ICU) capacity.1 The United States has one of the highest numbers of ICU beds per capita in the world,2 with approximately 20% of nonfederal adult ICU beds supported by some form of tele-ICU coverage.3 The ICU beds are not evenly distributed, with most of them in nonrural areas, leaving rural areas of the country with limited ICU capacity. During the COVID-19 pandemic, it became very apparent that solutions needed to be implemented to facilitate high-quality care in all parts of the country because of the scarcity of ICU beds, limiting the transfer of critically ill patients, increasing the complexity and vulnerability of rural critical care patients who are at increased risk of having a severe COVID-19 response due to their age and comorbidities, and because of the insufficient numbers of intensivist physicians.4

The use of intensive care unit telemedicine (tele-ICUs or tele-critical care [TCC] units) during the COVID-19 pandemic has enabled care to be delivered by intensivists (TCC MDs) and critical care nurses (TCC RNs) from remote centers to rural areas that do not have enough intensivists for the increased ICU census.4 Even with the addition of TCC services, there is a wide variation in the prevalence of TCC units across hospital referral centers and states.4 A study exploring national prevalence and characteristics of hospitals providing TCC demonstrated inequity across geographic regions.4 Teaching hospitals, which were part of a healthcare system and larger, not-for-profit, noncritical care access, and nonrural hospitals in the Midwest were more likely to have TCC coverage.4 The disparities continued—Alabama had the lowest number of hospitals with TCC coverage (0%), whereas Utah had the highest (more than 50% of its hospitals have TCC coverage). Six states had no TCC coverage among rural hospitals, and most states had less than 10% TCC coverage.4 COVID-19 has also led to the enormous expansion of federal and state reimbursement for telemedicine.5 It is important to continue to evaluate the effectiveness of TCC units as rural hospitals explore additional services and/or continue existing services.

LEGAL PERSPECTIVES ON TELE-CRITICAL CARE: REDUCING RISK AND ERRORS

Tele-critical care consists of a team of remote TCC MDs and TCC RNs using sophisticated interconnected software and technology to allow for viewing patients and entering electronic medical records. Hundreds of ICU patients can be cared for, and different types of technology at the receiving hospitals can enable the TCC clinician to either check the patient via a camera in the room or a cart brought to the bedside, or provide consultation over the phone. Because of the advanced technology, patients from many different states can be cared for at the same time.

Tele-critical care has been demonstrated to reduce medicolegal risk. Reductions in malpractice claims at sites serviced by TCC were shown in a study of 450 ICU beds covering 5 states.6 Common root causes of latent errors according to the Agency for Healthcare Research and Quality include the following: institutional and regulatory, organizational and management, work environment, team environment, task-related, staffing, and patient characteristics.7 In the ICU setting, problems with communication between clinical providers are frequent causes of human error—often related to the work and team environment.

Tele-critical care is ideally equipped to reduce risk related to the common root causes of latent errors in the following ways:

  1. Institutional and Regulatory: For example, a patient on an anticoagulant is reviewed by the TCC RN who proactively reviews all patients assigned to him/her. The TCC RN notices that the patient is prescribed a medication that can potentially interact with the anticoagulant. The TCC RN notifies the TCC MD who intervenes to correct the issue. Both the TCC RN and TCC MD have time to review all the patients, providing a second set of eyes for the patient and clinicians in the ICU. A regulatory issue is compliance with Centers for Medicare and Medicaid Services and Joint Commission survey preparedness. The TCC team can ensure that protocols are followed and become standard work.
  2. Organizational and management: Technology in the ICU is often very advanced and constantly changing. The ICU nurse is presented with numerous alarms and alerts in one shift, all at various levels of sound to ensure that they are acted upon. When performing their proactive rounding, the TCC RN reviews all alarms and parameters, including those that are turned off or have parameters set wide to prevent alarm notification. During the review, the TCC RN can assess the validity of the alarm parameters and can determine if they need to be adjusted to meet the patient's clinical condition. The clinical oversight that the TCC RN brings to support management oversight of patient care allows the ICU RN to address gaps in patient management within that shift. This reinforces timelier interventions and more comprehensive patient care, especially when there are competing clinical priorities, such as COVID-19.
  3. Work Environment: Tele-critical care brings a high level of clinical technology and human expertise to the bedside, allowing the TCC RN and TCC MD a direct visual to the care of the ICU patient. According to the Society of Critical Care Medicine, TCC is defined as “critical care services delivered using communication technologies from anywhere to anywhere.”8 Although the technology may vary depending on the hospital, the basic equipment allows the remote clinician to assess the patient's status, and the human experts—the remote TCC RN and TCC MD—can provide proactive assessment and collaborate with the bedside caregivers to prevent untoward trends from developing into adverse outcomes. The work environment becomes a combination of on-site and off-site clinical expertise supporting the patient. Using this combination, the environment can be transformed into one that allows everyone to speak up—a safe space for meaningful dialogue and consensus building.
  4. Team Environment: Tele-critical care allows the bedside ICU RN or respiratory therapist to have almost immediate connection with the TCC RN and/or TCC intensivist to consult, identify a plan of care, and request orders as needed. Providing a closed-loop approach for communication with an experienced intensivist or TCC RN prevents delays in care and is another layer of support for the bedside RN and hospitalist. Instead of waiting for the morning rounds to begin weaning to extubate the ventilated patients, weaning can readily occur through the night, with the guidance of a TCC MD, leading to reduced times on ventilators and earlier discharge from the ICU.
  5. Task related: Tele-critical care supports the organizational transfer of knowledge through the standardization of practices and support of bedside practitioners. If a bedside ICU RN is inexperienced with a specific device or ICU equipment, such as a blood warmer, the nurse can contact the TCC RN to request a procedural review of the device. A culture of open communication, standard policy and procedure references, and strong clinical knowledge by the TCC RN promotes safe and reliable task completion.
  6. Staffing: The TCC RN can serve as a second set of eyes to sign off medications, can doublecheck blood products, and/or can participate as a scribe during codes and other emergencies.
  7. Patient Characteristics: Tele-critical care operations perform comprehensive evaluations on all new patients admitted to the ICU, allowing real-time assessment of the patient's cardiac rhythm and electronic medical record, and using predictive algorithms, the TCC RN and or TCC MD is able to intervene early to prevent deterioration.

COMPLEX ISSUES IN LICENSING, OVERSIGHT, AND LIABILITY PROTECTIONS

Current licensure requirements for practicing telemedicine, including TCC across state lines, vary from state to state. The TCC RN must be licensed in the state where the patient is in, regardless of the state where the TCC RN is physically located. The following states allow physicians to practice telehealth from another state: Alabama, Louisiana, Maine, Minnesota, New Mexico, Ohio, Oregon, Tennessee, and Texas.9 Other states do not have specific laws around TCC and telemedicine; instead, they issue temporary licenses, as long as the states' licensing conditions have been met. There have been failed attempts at federal legislation to address the cross-state licensure barrier.

Regulatory challenges are one issue, legal concerns are a significant second challenge. Malpractice liability does not always cover multiple states. Most specify which area the coverage for claims will encompass. Although TCC has advanced during the COVID-19 crisis, the legal and regulatory laws have not. All TCC clinicians must be aware of what their liability coverage protects.

THE FUTURE AHEAD

Expanding the TCC model can improve the consistency of patient care and can increase both rural and urban access for patients given the intensivist shortages throughout the United States. The future of TCC can be optimized while its current medicolegal risks can be mitigated by addressing at minimum the following3,8:

  • Licensing portability: professional cross-state licensing for all clinicians working in TCCs, as patients are cared for all over the world and not just in the state or country the clinician is in.
  • Establishment of a uniform standard of care for TCCs: developing consistent guidelines that define responsibilities and workflows among its remote and on-site teams can mitigate cultural barriers and reduce risk.
  • Enactment of regulations: formalizing TCC as providing a heightened standard of care in malpractice cases against healthcare providers with telemedicine.
  • Education and training: providing physicians and nurses with a consistent tele-critical care curriculum to fully educate and integrate the next generation of practitioners to the telemedicine-incorporated practice.
  • Increasing research funding: advancing the field of TCC through dedicated research and developing evidence-based workflows and implementation practices.
  • Issues around confidentiality and both patient and staff privacy: proactively taking measures to protect patient privacy, such as preventing videotaping on cameras, which promotes higher trust with on-site clinicians.
  • Finally, executive support for both the implementation and the ongoing operation of TCC is essential for long-term success. Navigating the system hierarchy and overcoming cultural and organizational barriers are critical to mitigating risk and promoting successful patient outcomes using TCC.

THE CLINICAL NURSE SPECIALIST AND TCC-LEADING DURING TIMES OF UNCERTAINTY

The clinical nurse specialist (CNS) who demonstrates consistent and masterful use of CNS competencies can lead a TCC unit to be a high performing unit and one that engages in teamwork on a regular basis to ensure that there is effective delivering of messages and consensus building. Although there are many unknowns for the TCC environment in terms of regulatory and legal perspectives, the clinical component and supporting clinicians in the ICU do not change, and there are always opportunities for performance improvement.

References

1. Douin DJ, Ward MJ, Linsdell CJ, et al. ICU bed utilization during the coronavirus disease 2019 pandemic in a multistate analysis—March to June 2020. Crit Care Explor. 2021;3(3):1–13.
2. Prin M, Wunsch H. International comparisons of intensive care: informing outcomes and improving standards. Curr Opin Crit Care. 2012;18(6):700–706.
3. Becker C, Dandy K, Gaujean M, Fusaro M, Scurlock C. Legal perspectives on telemedicine part 1: legal and regulatory issues, part 2: telemedicine in the intensive care unit and medicolegal risk. Perm J. 2019;23:18–293. doi:10.7812/TPP/18.293.
4. Williams D Jr., Lawrence J, Hong YR, Winn A. Tele-ICUs for COVID-19: a look at national prevalence and characteristics of hospitals providing teleintensive care. J Rural Health. 2021;37(1):133–141.
5. CARES Act, HR 748 (2020). Congress.gov. Public Law No: 116-136 (03/27/2020).
6. Lily CM, Zubrow MT, Kempner KM, et al; Society of Critical Care Medicine Tele-ICU Committee. Critical care telemedicine: evolution and state of the art. Crit Care Med. 2014;42(11):2429–2436.
7. Agency for Health Care Research and Quality. Root cause analysis. https://psnet.ahrq.gov/primer/root-cause-analysis. Published September 7, 2019. Accessed December 29, 2021.
8. Adzhigiery L, Raikhelkar J, Panos R, et al. Building a case for tele-critical care to improve quality. SCCM. 2019. Critical Connections Archives. https://www.sccm.org/Communications/Critical-Connections/Archives/2019/Building-a-Case-for-Tele-Critical-Care-to-Improve. Accessed January 10, 2022.
9. State Telehealth Policies. National Conference of State Legislatures. https://www.ncsl.org/research/health/state-coverage-for-telehealth-services.aspx.
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