Theme Section: Computers in the ICU Revisited: An Expert Roundtable, April 2005, Chicago, IL
Remote ICU care programs: Current status

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Abstract

The desire to provide continuous intensivist management for all intensive care unit (ICU) patients in the face of a massive shortfall of available intensivists prompted the introduction of remote ICU care programs in 1999. The past several years have seen a dramatic increase in the number of health systems adopting this care model. These health systems have increased our understanding of both the ability of this new care model to improve clinical outcomes and the clinical processes that are required to achieve program quality goals. Health systems have begun to expand the scope of activities of the remote care team, capitalizing on the potential of this new operational and technology platform to leverage scarce personnel and achieve increases in both clinical effectiveness and provider efficiency. This review summarizes the current state of remote ICU care programs in the United States.

Introduction

Proper care of the critically ill requires extensive resources, specially trained personnel, and well-defined processes to ensure that all tasks are performed correctly and on time. Telemedicine offers the potential to bring the knowledge of specialized practitioners to all locations, without regard to time of day or the local availability of these practitioners. It also, through the networks that can be supported by this technology, creates opportunities for centralizing key activities to achieve increases in efficiency and effectiveness. The history of telemedicine in critical care dates back to the mid-1980s; however, the past 5 years have seen dramatic increases in the number of patients receiving some aspects of their care from remote care providers. At the same time, the nature of the services provided has evolved markedly as more sites have experimented with novel uses of the technology. This review describes the current state of telemedicine in critical care.

Section snippets

Background

In the 1980s, Grundy et al reported on the use of telemedicine for intermittent, consultative support of remote facilities lacking physicians with special expertise in this new specialty [1]. This project demonstrated the technical feasibility of bringing intensivist knowledge to remote sites. Although the investigators believed that the telemedicine services provided value to the patients (and providers) in the remote site, the project was short-lived. Almost 15 years later, Rosenfeld et al

Conceptual framework

In many ways, the evolution of remote care programs has paralleled that of ICU care in general. The initial focus was on duplicating the continuous monitoring/oversight encompassed in the dedicated intensivist care model. Early efforts centered on creating the necessary technology components, defining the optimal staffing mix and work flows, and ensuring the consistency of the service provided by the remote team. More recently, as critical care has recognized the importance of practice

Program structure

The preponderance of remote care programs have been implemented by multihospital systems (3-30 hospitals in size). This predominantly reflects their ability to create large networks of ICU/high-acuity beds because the staffing and infrastructure costs argue against remote care programs involving less than 50 to 60 ICU beds. These multihospital systems generally link all their ICUs (and in some cases, other high-acuity beds) into a centralized remote care center and provide all staffing for the

Operational considerations

As discussed above, remote care programs are becoming an integral part of how ICU care is delivered across the health system. Although there is variability in how tasks are allocated, based on differences in on-site staffing and other local factors, there are several core features that must be in place to achieve quality goals. First, each patient must have a comprehensive daily care plan that addresses all clinical issues (eg, ventilator weaning, nutrition, risk assessment, analgesic therapy,

Technology components

Table 3 lists the major components of the remote care technology platform installed at every VISICU site.

Performance data

The introduction of any new care model generates many important questions. First and foremost, does the new model change clinical outcomes? Are the benefits similar in different types of ICUs and hospitals? Why do outcomes improve, and what are the human and operational determinants of clinical efficacy? What are the costs of the new model and the economic impact on the hospital? What effect does the program have on provider morale? How do we train individuals to practice in this new care model

Success factors

Successful implementation of a remote care program requires major changes in how ICU care is organized and executed. Establishing a highly functional remote care team, although a considerable undertaking, is usually accomplished without difficulty. Getting physicians (and nurses) who admit to and/or work in the ICU to accept a new care model based on broad collaboration, consistent communication, and practice standardization is equally important. In ICUs without dedicated intensivists, where

Future outlook

The 30+ health systems that have implemented remote care programs are expanding the number of covered ICU beds. Many are experimenting with novel uses of the program, including using mobile units to provide remote support to rapid response teams on medical-surgical floors, assisting with off-hours management of patients in the postanesthesia care unit, and providing tele–stroke support to patients in community hospital emergency departments. The remote ICU team also has become an integral part

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    Effect of a multi-site intensive care unit telemedicine program on clinical and economic outcomes: an alternate paradigm for intensivist staffing

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There are more references available in the full text version of this article.

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The author is an employee and officer of VISICU, Inc, and a stockholder in the company.

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