Treating from Afar: The New, Digital Face of Intensive Care
by COLIN STAYTON
Late one night, a worried mother calls her family physician. Her young child is suffering from fever, nausea and shallow breathing, and the mom needs to know right away what she should do.
After hearing the symptoms, the physician makes a diagnosis and suggests a treatment. This may seem like an uncommon occurrence, but thanks to emerging digital technologies, this scenario is being played out in new ways in ICUs across the country.
Today it’s called telemedicine, but the idea of delivering healthcare from a remote location has been around for centuries. Prior to the 19th century, a sick person who couldn’t travel might send a family member on horseback to a neighboring town to seek medical advice. During the Civil War, telegraphs were often sent from the battlefield to communicate casualty lists and order medical supplies. With the advent of the telephone in the late 19th and 20th centuries, telemedicine was successfully applied to the primary care setting with over-the-phone consultations like the one described above.
Today, telemedicine comes in three forms:
- Send-and-store, wherein a medical entity sends information (i.e. x-rays, blood work, etc.) to another medical entity digitally. Once sent, the information is stored for reference at a later time. Since both parties don’t have to be present for the exchange to occur, send-and-store isn’t considered a simultaneous or “real-time” form of telemedicine.
- Video conferencing, which has been implemented in health care settings for the past 20 years or so. New mobile technologies such as laptops, smartphones and tablet devices have added a level of sophistication previously unknown to this form of telemedicine.
- Continuous monitoring, which combines send-and-store and video conferencing for a more comprehensive exchange of health information. As its name suggests, continuous monitoring happens around the clock, in real time, using remote visual and data observation to monitor patients.
A Ripe Time
Enabled by continuous monitoring, telemedicine is finding a novel use in an unexpected place: the ICU.
“Naturally, the most common application for remote continuous monitoring is in the acute care setting, where information exchanges can’t be planned ahead of time,” says Mary Jo Gorman, MD, MBA, chief executive officer and co-founder of Advanced ICU Care in St. Louis, Mo. “So far, telemedicine is being implemented in approximately one in 10 ICUs in the United States, and that number is growing.”
The demand for ICU services in the United States has risen steadily over the past 30 years. The reason is threefold: 1) The average life expectancy has increased. 2) The baby boomer generation, which makes up more than a quarter of the U.S. population, is getting older. As they age, the geriatric population is expected to grow to twice its current size by 2030, bringing a higher demand for critical care and management of chronic illness. 3) There is a critical shortage of intensivists in the U.S.
“In an overcrowded, understaffed ICU, best practices are not always followed. By closing the ratio of patients to intensivists, telemedicine is already achieving such positive outcomes.”
— Mary Jo Gorman, MD, MBA, ceo and co-founder of Advanced ICU Care in St. Louis, Mo.
In 2008, the Leapfrog Group identified key benchmarks for improving quality care in the face of nationwide aging. One recommendation was to increase staffing in ICUs. In fact, the Leapfrog Group estimated that 53,000 lives could be saved each year through better ICU staffing. But with a shortage of intensivists in the U.S., meeting this quality measure will continue to be a growing challenge.
Adding to this challenge is the problem of uneven distribution. Of the roughly 10,000 intensivists currently practicing in the U.S., most are concentrated in larger metropolitan areas, leaving a noticeable deficit in rural and mid-sized communities.
“There are simply not enough intensivists to go around,” Dr. Gorman says. “This shortage is what’s driving the rapid growth of telemedicine.”
Dr. Gorman, who works through Advanced ICU Care to help set up tele-ICU programs in community hospitals across the country, says these smaller hospitals can use telemedicine to leverage their services against larger, full-service hospitals in nearby cities. For patients, the draw of tele-ICU is the ability to stay close to home.
“Hospitals in denser urban areas have the upper hand, because the demand for ICU care is much greater,” Dr. Gorman says. “Hospitals in less dense areas can’t sustain a robust ICU program when local residents migrate to the big cities for intensive care, and that leaves them at risk for losing other crucial service lines, as well. Tele-ICU provides a terrific opportunity for these hospitals to retain, stabilize, and gradually increase their ICU traffic.”
Filling a New Role
According to Dr. Gorman, the hospital best suited for tele-ICU is one that has between 15 to 40 ICU beds. The typical Advanced ICU Care client is a hospital that offers higher-end services—such as trauma, cardiology, neurosurgery, etc.—but that can’t staff intensivists in a financially viable way. Rather than staffing intensivists, these hospitals contract with intensivists in the metropolitan areas to fill a new position, known as a tele-intensivist.
These physicians collaborate with the physician or nurse on staff at the hospital to provide their expertise remotely. In this scenario, hospital staff members become liaisons to manage acute care patients and administer treatment under the direction of the tele-intensivist. The tele-intensivist’s job is to remotely monitor and interpret patients’ visual cues, vital signs, physiologic data, medications, and lab results.
“These tele-intensivists are facilitating first-class intensive care in hospitals that don’t have a full-service ICU,” Dr. Gorman says.
By the Numbers
The greatest objection to bringing telemedicine into the ICU is the potential for decreased quality outcomes. Without the intensivist being in the room with the patient, some argue crucial aspects of acute care might be lost in translation, leading to inappropriate care in a setting where “getting it right” the first time can be a matter of life and death. But the numbers seem to disagree. Though still early out of the gate, studies actually show tele-ICU is improving critical care outcomes.
One landmark study out of the University of Massachusetts Medical School in Worcester followed 6,290 tele-ICU patients between April 2005 and September 2007. The findings show that:
- Hospital-wide mortality rate decreased from 13.6 to 11.8 percent following tele-ICU implementation.
- ICU mortality rate fell from 10.7 percent to 8.6 percent for the tele-ICU group.
- Average length of stay in the ICU dropped from 6.4 days to 4.5 days.
The research also associates tele-ICU intervention with closer adherence to best practices and lower rates of hospital-related pneumonia and bloodstream infections.
Advanced ICU Care has culled even more impressive data from its own hospital clientele. Dr. Gorman cites a 17 percent increase in ICU patient volume among Advanced ICU Care’s clients in the first year of tele-ICU implementation. The hospitals see a 40 percent decrease in ICU mortality rate on average, with average length of stay shortening by 25 percent.
“In an overcrowded, understaffed ICU, best practices are not always followed,” Dr. Gorman says. “We’re not surprised to find that, by closing the ratio of patients to intensivists, telemedicine is already achieving such positive outcomes.”
Making Telemedicine Work
In order for telemedicine to be applied successfully to the ICU, some key components must be in place. For one, tele-ICUs must provide around-the-clock tele-intensivist presence, not just intermittent care when an emergent episode arises. Hospitals must also seek to integrate their tele-ICU program into their existing information systems, such as EMR and CPOE. Lastly, a successful tele-ICU will hinge largely on whether or not the hospital’s physicians and nurses accept, understand, and use the required technologies. Historically, changes in the structure of healthcare delivery, especially when contingent upon digital platforms, have been met with some resistance. But with telemedicine use growing at a rate of 20 percent per year internationally, integration of telemedicine is not a question ofif, but when.
To learn more about Advanced ICU Care, visit icumedicine.com.
