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Telemedicine in the ICU

Telemedicine in the ICU. Chad Hodge Roosan Islam Casey Rommel Nicole Ruiz Diane Walker. Definition . What is telemedicine? The delivery of healthcare from a distance using electronic information and technology. Literally, “Healing at a distance.” What units qualify as an ICU?

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Telemedicine in the ICU

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  1. Telemedicine in the ICU Chad Hodge Roosan Islam Casey Rommel Nicole Ruiz Diane Walker

  2. Definition • What is telemedicine? • The delivery of healthcare from a distance using electronic information and technology. • Literally, “Healing at a distance.” • What units qualify as an ICU? • All critical care areas, such as surgical, cardiac, medical, pediatric, neurology, neonatal, burn, and other postoperative. • What is an eICU? • Nurses and physicians located at a remote command center providing care to patients in multiple, scattered intensive care units via computer and telecommunication technology.

  3. The Need • ICUs treat 4.5 million annually (10% of all patients). Expected to rise as the population ages. • $107 billion annually (4% of total healthcare costs). • ICUs are coalescing. • Fewer than 6000 intensivists. • ICU mortality rate is 10-20% and is responsible for 500,000 deaths annually. • eICUsare estimated to reduce that number by 50,000 (10%) per year.

  4. The Need CONTINUED • Fewer than 15% of hospitals meet the Leapfrog Group intensivist staffing model. • Return page within 5 minutes 95% of time. • Or arrange for alternate staff to respond. • ADEs in ICUs are 2x the national average (19/1000 patients) because of the high number of drugs ordered.

  5. eICU model • Responsibilities of the hub intensivist can vary from treating emergent situations, with all other care managed by the admitting physician (open ICU model), to complete intensivist management, with only notification of treatments given to the patient’s physician (closed ICU model). • A well-supported intensivist may staff approximately 50 to 100 remote ICU beds.

  6. Advantages • Having an ICU physician rapidly available. • Having an intensivist available more hours of the day. • Having rapid access to all forms of clinical data through improved ITS. • Having an ICU physician available allows for more rapid interventions in case of problems. • Length of stay and resource utilization may also be affected by commencing care as soon it is warranted (eg, ventilator weaning begun during the nighttime).

  7. Disadvantages • Potentially putting a layer of technology between the patient and the physician. • Significant upfront and maintenance costs. • Subject to malfunction and downtime. • Physicians are typically cited as the greatest barrier to implementation. • Physicians perceive that a lack of direct interaction, eye contact, and other sensory input with the patient may cause them to miss critical diagnostic cues.

  8. tele-ICU improves patient outcomes

  9. Table 1. Comparison of Intensive Care Unit (ICU) Processes Before and After Tele-ICU Intervention

  10. Mortality and Length of Stay Outcomes

  11. Best practice and Complication Measures

  12. Why is telemedicine THE SOLUTION? • Improves 3 areas of quality of care: • Improved patient outcomes • Access to care • Cost savings • Technology is ubiquitous. Still… • Only 10% of hospitals have teleICU services. • Only 4900 adult ICU beds supported by teleICU. • 1 million patients monitored by teleICU.

  13. Emerging Technologies • Digital Video Transport System • System to send and receive digital streaming videos over broadband internet. • H.323 Video Conferencing Solution • The H.323 protocol is a recommendation from the International Telecommunication Union. • Vidyo • Vidyo provides high quality video conferencing from a range of technologies.

  14. Barriers to Adoption • Financial costs • $6-8 million initial startup. • $1-2 million operating costs yearly. • Maintenance and/or Upgrades • Licensure • Staffing • Limited or no patient reimbursement/billing. • Shortages of specialists results in “poaching.” • ICU clinician shortage > Intensivist shortage. • Staff and patient acceptance. Image- http://blogs.bmj.com/bjsm/2011/07/20/educating-all-medical-specialists-to-support-exercise-as-the-fifth-vital-sign-dr-danica-bonello-spiteri-comments/

  15. Case study 1: robotics • Looked at the difference between using standard system of paging ICU physician versus robotic telepresence (RTP) intervention. • Focused on neurocritical care patients: • Traumatic Brain Injuries • Brain tumor • Ischemic stroke • Hypothesized that physician face-to-face response time to patient would significantly decrease. Image- http://www.robots-and-androids.com/robotic-syringes.html

  16. Case study 1: robotics • Standard Model: • Nurse detects change in patient’s condition. • Pages ICU physician. • Physician calls the nurse and gives instructions over the phone. • Robotic Telepresence Model: • Nurse sends text message to physician or can walk up to robot if session is in progress. • Physician conducts rounds from office. • Examine patients by driving robot next to bed and speaking to patient directly or instruct nurse to perform exam. Vespa et al, 2007.

  17. Case study 2: va hospital • VISN (Veterans Integrated Service Network) 19 • Covers areas including Montana, Utah, Colorado, Wyoming, Idaho, Nevada, Kansas and Nebraska. • Developed tele-ICU model to improve access to critical care services in rural facilities by combining tele-ICU technology with expanded critical care nursing services. • First of its kind in the VA system.

  18. Case study 2: va hospital • Model: • Operated entirely by nurses. • One experienced CCRN-certified nurse manages system 24/7. • Nurses from different facilities report on patients at start of shift. • Available for immediate consultation. • Virtual rounds. • Results: • Cost savings. • Increase in collaboration between healthcare facilities. • Increase in number of nurses becoming CCRN-certified.

  19. Future challenges • Legal Issues • The physician’s liability in case of malpractice. • The patient has to be protected, and cyber physicians must be able to quantify their risk. • The relationship between physicians and insurance companies may need to be modified. • The roles of electronic decision support systems, medical software, and data collection systems in determining responsibility need to be clarified. • Reimbursement • USA lacks unified healthcare system and regulations need to adapt with the changing industry. • States need to be proactive in their regulation. Image- http://www.democracy4stoke.co.uk/archives/604

  20. THANK YOU We are happy to answer any of your questions.

  21. Citations • Cummings et. al. Intensive Care Unit Telemedicine: Review and Consensus Recommendations. American Journal of Medical Quality 2007 22: 239. http://www.ncbi.nlm.nih.gov/pubmed/17656728 • MD Andersen Cancer Center, University of Texas, Glossary of terms, http://www.mdanderson.org/patient-and-cancer-information/cancer-information/glossary-of-cancer-terms/t.html • Lilly, C. M., Cody, S., Zhao, H., Landry, K., Baker, S. P., McIlwaine, J., Chandler, M. W., et al. (2011). Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes. JAMA : the journal of the American Medical Association, 305(21), 2175–83. http://www.ncbi.nlm.nih.gov/pubmed/21576622 • Nielsen, M., & Saracino, J. (2012). Telemedicine in the intensive care unit. Critical care nursing clinics of North America, 24(3), 491–500. doi:10.1016/j.ccell.2012.06.002 • Venditti, A., Ronk, C., Kopenhaver, T., & Fetterman, S. (2012). Tele-ICU “myth busters”. AACN advanced critical care, 23(3), 302–11. doi:10.1097/NCI.0b013e31825dfee2 • Young, L. B., Chan, P. S., & Cram, P. (2011). Staff acceptance of tele-ICU coverage: a systematic review. Chest, 139(2), 279–88. doi:10.1378/chest.10-1795

  22. Citations CONTINUED • Hawkins, C. L. (2012). Virtual rapid response: the next evolution of tele-ICU. AACN advanced critical care, 23(3), 337–40. doi:10.1097/NCI.0b013e31825dff69 • Vespa, P. M., Miller, C., Hu, X., Nenov, V., Buxey, F., & Martin, N. a. (2007). Intensive care unit robotic telepresence facilitates rapid physician response to unstable patients and decreased cost in neurointensive care. Surgical neurology, 67(4), 331–7. doi:10.1016/j.surneu.2006.12.042 • Chan, M., Esteve, D., Escriba, C., & Campo, E. (2008). A review of smart homes- present state and future challenges. Comput Methods Programs Biomed, 91(1), 55-81. doi: 10.1016/j.cmpb.2008.02.001 • Cao, M. D., Shimizu, S., Antoku, Y., Torata, N., Kudo, K., Okamura, K.,Tanaka, M. (2012). Emerging technologies for telemedicine. Korean J Radiol, 13 Suppl 1, S21-30. doi: 10.3348/kjr.2012.13.S1.S21

  23. Future Challenges and possible solutions • User Needs, Acceptability and Satisfaction • Consider the subjects needs who are sick, disable and elderly. • The subjects immediate surrounding including caregivers ease of use and delivery of care. • The manufacturers, as well as the commercial providers, should customize products based on needs. • Reliability and efficiency of sensory systems and data processing software. • Have a reliable algorithm for evaluating the patient’s “lifestyle.” • Trigger an alarm in case of danger. • Correctly interpret the vital signs through automated software or a competent medical professional, so that deficient function can be recognized. Image- http://wc.k12.mo.us/TWarner/Med%20Term/Chapter1.html

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