Literature relevant to telemedicine in emergency and critical care.

Telecritical Care Clinical and Operational Strategies in Response to COVID-19

Jaspal Singh; Michael B. Green; Scott Lindblom; Michael S. Lindblom; Michael S. Reif

Background The cororavirus disease 19 (COVID-19) pandemic has strained intensive care unit (ICU) material and human resources to global crisis levels. The risks of staffing challenges and clinician exposure are of significant concern. One resource, telecritical care (TCC), has the potential to optimize efficiency, maximize safety, and improve quality of care provided amid large-scale disruptions, but its role in pandemic situations is only loosely defined.

Planning and Preparation Phase We propose strategic initiatives by which TCC may act as a force multiplier for pandemic preparedness in response to COVID-19, utilizing a tiered approach for increasing surge capacity needs. The goals involved usage of TCC to augment ICU capacity, optimize safety, minimize personal protective equipment (PPE) use, improve efficiencies, and enhance knowledge of managing pandemic response.

Implementation Phase A phased approach utilizing TCC would involve implementing remote capabilities across the enterprise to accomplish the goals outlined. The hardware and software needed for initial expansion to cover 275 beds included $956,670 for mobile carts and $173,106 for home workstations. Team role deployment and bedside clinical care centering around TCC as critical care capacity expand beyond 275 beds. Surge capacity was not reached during early phases of the pandemic in the region, allowing refinement of TCC during subsequent pandemic phases.

Conclusions Leveraging TCC facilitated pandemic surge planning but required redefinition of typical ICU staffing models. The design was meant to workforce efficiencies, reduce PPE use, and minimize health care worker exposure risk, all while maintaining quality care standards through an intensivist-led model. As health care operations resumed and states reopened, TCC is being used to support shifts in volume and critical care personnel during the pandemic evolution. The lessons applied may help health care systems through variable phases of the pandemic.

The US Strategic National Stockpile Ventilators in Coronavirus Disease 2019

Rich Branson, MSc; Jeffrey R. Dichter, MD; Henry Feldman, MD; Ryan C. Maves, MD; Niranjan “Tex” Kissoon, MB; Lewis Rubinson, MD, PhD; Show all authors

Background Early in the coronavirus disease 2019 (COVID-19) pandemic, there was serious concern that the United States would encounter a shortfall of mechanical ventilators. In response, the US government, using the Defense Production Act, ordered the development of 200,000 ventilators from 11 different manufacturers. These ventilators have different capabilities, and whether all are able to support COVID-19 patients is not evident. Research Question Evaluate ventilator requirements for affected COVID-19 patients, assess the clinical performance of current US Strategic National Stockpile (SNS) ventilators employed during the pandemic, and finally, compare ordered ventilators’ functionality based on COVID-19 patient needs. Study Design and Methods Current published literature, publicly available documents, and lay press articles were reviewed by a diverse team of disaster experts. Data were assembled into tabular format, which formed the basis for analysis and future recommendations. Results COVID-19 patients often develop severe hypoxemic acute respiratory failure and adult respiratory defense syndrome (ARDS), requiring high levels of ventilator support. Current SNS ventilators were unable to fully support all COVID-19 patients, and only approximately half of newly ordered ventilators have the capacity to support the most severely affected patients; ventilators with less capacity for providing high-level support are still of significant value in caring for many patients. Interpretation Current SNS ventilators and those on order are capable of supporting most but not all COVID-19 patients. Technologic, logistic, and educational challenges encountered from current SNS ventilators are summarized, with potential next-generation SNS ventilator updates offered.

Tele-ICU: Efficacy and Cost-Effectiveness Approach of Remotely Managing the Critical Care

Sajeesh Kumar | Shezana Merchant | Rebecca Reynolds Department of Health Informatics & Information Management, University of Tennessee Health Science Center,920 Madison Avenue Suite 518, Memphis, Tennessee 38163, USA

Tele-ICU has an off-site command center in which a critical care team (intensivists and critical care nurses) is connected with patients in distance intensive care units (ICUs) through a real-time audio, visual and electronic means and health information is exchanged. The aim of this paper is to review literature to explore the available studies related to efficacy and cost effectiveness of Tele-ICU applications and to study the possible barriers to broader adoption. While studies draw conclusions on cost based on the mortality and Length of Stay (LOS), actual cost was not reported. Another problem in the studies was the lack of consistent measurement, reporting and adjustment for patient severity. From the data available, Tele-ICU seems to be a promising path, especially in the United States where there is a limited number of board-certified intensivists.

A Business Case for Tele-intensive Care Units

Alberto Coustasse, DrPH, MD, MBA, MPH; Stacie Deslich, MA, MS; Deanna Bailey, MS; Alesia Hairston, MS; David Paul, DDS, PhDD

Objectives: A tele-intensive care unit (tele-ICU) uses telemedicine in an intensive care unit (ICU) setting, applying technology to provide care to critically ill patients by off-site clinical resources. The purpose of this review was to examine the implementation, adoption, and utilization of tele-ICU systems by hospitals to determine their efficiency and efficacy as identified by cost savings and patient outcomes. Methods: This literature review examined a large number of studies of implementation of tele-ICU systems in hospitals. Results: The evidence supporting cost savings was mixed. Implementation of a tele-ICU system was associated with cost savings, shorter lengths of stay, and decreased mortality. However, two studies suggested increased hospital cost after implementation of tele-ICUs is initially expensive but eventually results in cost savings and better clinical outcomes. Conclusions: Intensivists working these systems are able to more effectively treat ICU patients, providing better clinical outcomes for patients at lower costs compared with hospitals without a tele-ICU.

Selected Use of Telemedicine in Intensive Care Units Based on Severity of Illness Improves Cost-Effectiveness

Byung-Kwang Yoo, Minchul Kim, Tomoko Sasaki, Jeffrey S. Hoch, and James P. Marcin

Background: Telemedicine in the intensive care unit (tele-ICU) is expected to address geographic health disparities through more efficient resource allocation. Our previous economic evaluation demonstrated tele-ICU to be cost-effective in most cases and cost saving in some cases, compared to conventional intensive care unit (ICU) care without adequate intensivist coverage. Introduction: This study’s objective is to examine how to optimize the cost-effectiveness of tele-ICU use by selecting highest risk (i.e., both highest mortality and highest cost) subpopulations. We also explore potential cost savings. Materials and Methods: We conducted simulation analyses among a hypothetical adult ICU patient cohort defined by the literature, distinguishing four types of hospitals: urban tertiary (primary analysis), urban community, rural tertiary, and rural community. The selected tele-ICU use was assumed to affect per-patient ICU cost and hospital mortality among highest risk subpopulations (10–100% of all ICU patients), defined by an established illness-severity measure. Results: We found a U-shaped relationship between the economic efficiency and selected tele-ICU use among all 4 hospital types. Optimal cost-effectiveness was achieved when tele-ICU was applied to the 30–40% highest risk patients among all ICU patients (incremental cost-effectiveness ratio = $25,392 [2014 U.S. dollars] per extending a quality-adjusted life year) in urban tertiary hospitals (primary analysis). Our break-even analyses indicated that cost saving seems more feasible when reducing ICU medical care cost, rather than lowering the cost to operate telemedicine alone. Discussion and Conclusions: A selected use of tele-ICU based on severity of illness is likely to improve tele-ICU cost-effectiveness. To achieve cost saving, tele-ICU must reduce more than just telemedicine-related cost.

Tele-ICUs for Covid-19: A Look at National Prevalence and Characteristics of Hospitals Providing Teleintensive Care

Dunc Williams Jr. PhD, John Lawrence MS, Young-Rock Hong PhD, Aaron Winn PhD

Purpose Amidst the COVID-19 outbreak, the use of intensive care unit telemedicine (tele-ICUs) may be one mechanism to provide patient care, particularly in rural parts of the United States. The purpose of this research was to inform hospital decision makers considering tele-ICUs, policy makers weighing immediate and longer-term funding and reimbursement decisions relative to tele-ICU care, and researchers conducting future work evaluating tele-ICUs. Methods We compared hospitals that reported providing teleintensive care to hospitals that reported not providing teleintensive care in the 2018 American Hospital Association Annual Survey (AHAAS). Differences between groups were tested using Pearson’s chi-square (categorical variables) and t-tests (continuous variables) using 0.05 as the probability of Type 1 error. The study sample included all US short-term, acute care hospitals that responded to the AHAAS in 2018. Our key variable of interest was whether a hospital reported having any tele-ICU capabilities in the 2018 AHAAS. Other factors evaluated were ownership, region, beds, ICU beds, outpatient visits, emergency department visits, full-time employees, and whether a hospital was rural, a critical access hospital, a major teaching hospital, or part of a health system. Findings Larger, not-for-profit, nonrural, noncritical access, teaching hospitals that were part of a health system, particularly in the Midwest, were more likely to have tele-ICUs. Over one-third of hospital referral regions (HRRs) had zero hospitals with tele-ICUs, 4 had all hospitals with tele-ICU, and the median percent of hospitals with tele-ICU by HRR, weighted by outpatient visits, was 11.3%. Conclusions and Implications We found wide variation in the prevalence of tele-ICUs across HRRs and states. Future work should continue the evaluation of tele-ICU effectiveness and, if favorable, explore the variation we identified for improved access to teleintensive care.

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