SCCM Resource Library-Almost Anything Is Virtually Possible: How Rapid Changes in Virtual Abilities During the Pandemic Have Improved Access to Critical Care

Video Transcription

Good afternoon. My name is Jayshree Rykelker. As a part of the series related to telemedicine and critical illness, today I'll be talking  about how rapid changes in our virtual abilities have improved access to critical care during the pandemic and how almost anything can be virtually possible. So let's get started.  I have nothing to disclose.  As objectives for this talk, I'll be discussing large-scale telecritical care adaptations during the pandemic.  This includes what large organizations have done to accommodate the additional health care burden.  In particular, the steps taken by the Veterans Health Administration, or their C5 program, and the Defense Health Agency, including their NETSIN program.  Also we'll take a look at telecritical care collaboration of smaller systems and what lessons have been learned.  We will also touch on the factors that make telecritical care more cost-effective. And finally, some newer technology in critical care that may improve access in the future.  Large-scale telecritical care adaptation. The Veterans Health Administration is America's largest integrated health care system, providing  health care to 9 million veterans annually. Prior to the pandemic, approximately 43 of the 110 VA hospitals with ICUs were affiliated  with the existing VA telecritical care programs, namely East and West, providing an overall capacity to serve approximately 532 beds across the nation.  As you can see, this was not nearly enough to service the health care burden at the individual  ICU level during a COVID wave, and there was limited ability to expand capacity during a surge. For this, the COVID-19 Critical Care Cooperative Community, or C5, was developed.  Essentially, this is a rapidly deployable telehealth critical care response that could be activated when the capacity of a VA ICU has been met.  The mission of C5 is to provide a national nexus of critical care practitioners who can provide episodic telehealth critical care to COVID hotspots that are experiencing the  greatest demands for critical care services during the COVID-19 pandemic. To prepare and fortify critical care resources, the Veterans Health Administration leveraged  its telecritical care hubs, well-established telehealth infrastructure, with existing national VA critical care staff to ensure telecritical care support to any site in the  VA enterprise. The goals of C5 is to provide VA bedside practitioners 24 hours a day, 7 days a week, continuous  access to episodic telecritical care consultation, and also to maintain critical care management  during possible disruptions in critical care coverage due to quarantine or illness of bedside practitioners at that site.  To implement C5, the VA Deputy Undersecretary of Health for Operations and Management issued a series of memorandums, the first of which called upon each VA facility with an ICU not  affiliated with existing telecritical care programs to establish at least one temporary video-capable device for every 10 ICU beds.  This included iPads, computer on wheels, and workstation on wheels.  The next memorandum was related to emergency credentialing and privileging, establishing  processes for shared privileging between facilities or privileging by proxy, to provide telehealth  consultation between VA facilities and obliviate the need to credential and privilege each provider at every affiliated hospital.  By May 2020, the federal rule was finalized, allowing physicians and nurses to provide care via telehealth across state borders or anywhere to anywhere.  The third memorandum requested each regional network or VISN in the VA system to nominate at least one critical care provider to assist with C5 staffing.  With C5, the facility is dynamic and changes as the pandemic evolves and the facility needs change.  The capacity is directly proportional to the recruitment of intensivists nationally, so intensivists at less affected sites are able to assist more affected sites.  Connectivity is provided by VA Video Connect, and doctors and nurses have access to local EMR. The C5 program is activated by a call to a toll-free number.  It is answered by a C5 triage nurse who collects clinical information regarding the consult and sends it to the C5 intensivist.  The C5 intensivist has easy access to all relevant information, including the contact information of bedside providers.  In this way, the intensivist can provide timely consult and recommendations and documentation in the patient's chart. With that being said, within six weeks, C5 was developed.  It united a diffuse consortium of departments, many of which had not worked together previously,  leveraging existing telehealth technologies, equipment, emergency management processes for recruitment, training, credentialing, and privileging.  Another large-scale adaptation is the formation of the National Emergency Telecritical Care Network, or NETCN.  This is a federally funded temporary support for civilian hospitals and health care systems requiring help managing COVID-19 and other disaster surges.  It provides critical care support, as well as other specialty support, to facilities that may lack it.  Frontline clinicians are linked to critical care experts using secure HIPAA-compliant applications on mobile devices.  Due to its simplicity, it can be used in field hospitals, rural ICUs, and at home. It is designed for e-consult, relief coverage, remote home monitoring, and palliative care.  I wanted to talk a bit about telecritical care interprogram collaboration, how two programs might be able to support each other during disasters.  Chandra et al. explored this in a paper regarding collaboration between two tele-ICU programs during the COVID-19 pandemic.  They implemented a network between two programs to support staffing and round during the first wave of the pandemic in March 2020.  Northwell Health in New York State had a tele-ICU program that covered approximately 176 beds.  They collaborated with Providence St. Joseph's Health in Washington State, enabling intensivists in Washington to round virtually at Northwell Health.  They laid down the infrastructure to provide connectivity between two programs. This included standardization of clinical responsibilities, expediting credentialing  and privileging, accepting out-of-state medical licensure, implementation of mobile cards, and access to local EMR.  With that, they developed a model that allowed virtual rounding on an additional 40 to 60 beds per day, thus allowing connectivity between two programs supporting non-intensivist  teams with critical care physicians. This also allowed for reduced staffing requirements at the site where the surge was occurring.  So really, the keys to success, or lessons learned, appears to be the formation of prior partnerships and pathways, as we've seen with Northwell Health and St. Joe's Health.  At the federal level, a three-pronged partnership is underway. NETSAN and the Joint Telecritical Care Network, which is the telecritical care program supporting  military hospitals, are in talks with the Veterans Health Administration to create a single federally funded telecritical care network capable of providing telecritical  care support to any of the 1,700 VA or 400 Department of Defense ICU beds in the nation. Now let's talk about some of the financial aspects of telecritical care, and specifically  the factors that would make it more cost effective. The desired financial equation related to telecritical care is capital costs, these  are upfront costs of the hardware, software, training, etc., plus operating costs, should be less than the revenue of reimbursement plus the cost savings attained.  The examples of cost savings could be a reduction in length of stay, which creates the ability to care for more ICU patients per day.  The model of telecritical care significantly impacts capital costs. The centralized hub and spoke structure, as seen on the left, consists of a single remote  hub that provides telecritical care services to multiple locations, or the spokes. This has significant upfront capital costs, operation costs, but can provide continuous  patient monitoring. The decentralized structure on the right consists of a remote intensivist consulting on one  patient at a time with AV connectivity between provider and the site using a individual computer or mobile device.  There is increased flexibility as the provider is at home or in the office. With this model, there is a significantly reduced upfront capital cost, but the low  cost must be weighted against its reactionary and consultative nature, and lesser data acquisition. The second factor related to cost effectiveness is the degree of engagement.  We know that teleICUs that have more interactions with their client sites tend to be more cost  effective by having more revenue for reimbursement and improving key metrics, such as length of stay, thus resulting in cost savings. The third factor is patient acuity.  We know that teleICUs covering higher acuity units tend to be more cost effective. If the teleICU provides a mortality reduction, teleICU interventions appear to be more cost  effective in the sickest of patients.  And finally, I wanted to talk about some of the newer technology in critical care that would possibly enhance access to patients remotely in the future.  The first is robotic IV catheter insertion. This is a robotic-assisted central and peripheral vein puncture device that minimizes time and the attempts made at IV insertion.  The second is robotic-assisted echography. It has numerous applications in critical care, including central cannulization, diagnosis  of lung pathology like pneumothoraces, and echocardiography. Robotic-assisted echography has been studied for more than 20 years. It still strongly relies on operator skill.  However, a robot can overcome these limitations to provide improved accuracy, probe positioning, and image analysis.  These devices appear to be on the horizon to help improve access. This concludes my talk, How Rapid Changes in Virtual Abilities Have Improved Access to Critical Care. Thank you.  I appreciate your time. Please email me with any questions you may have.

Video Summary

In this video, Jayshree Rykelker discusses how rapid changes in virtual abilities have improved access to critical care during the pandemic. She discusses the large-scale telecritical care adaptations made by the Veterans Health Administration and the Defense Health Agency, as well as the formation of the COVID-19 Critical Care Cooperative Community and the National Emergency Telecritical Care Network. She also explores the collaboration between tele-ICU programs during the pandemic and the factors that make telecritical care more cost-effective. Lastly, she mentions some newer technologies in critical care that may enhance access to patients remotely in the future, such as robotic IV catheter insertion and robotic-assisted echography.

Asset Subtitle

Quality and Patient Safety, Professional Development and Education, 2022

Asset Caption

The COVID-19 pandemic has been the catalyst that changed our critical care world. This session will review how rapid changes in implementing telemedicine technology has improved education, management, and outcomes in critical care, especially in resource-limited regions. Speakers will show how, even with novel critical conditions, telemedicine has been shown to improve care without inducing negative financial impacts in underserved areas of healthcare. Speakers will show how to utilize diverse multiprofessional personnel to efficiently manage ICUs in multiple states while improving all aspects of critical care, including pharmacy, respiratory therapy, and specialty care.

Meta Tag

Content Type Presentation

Knowledge Area Quality and Patient Safety

Knowledge Area Professional Development and Education

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Quality and Patient Safety

Tag Telemedicine eICU

Year 2022

Keywords

virtual abilities

critical care

telecritical care

pandemic

cost-effective

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