SCCM Resource Library-Implementation and Management of a Multiprofessional Tele-Critical Care Program: Rapid Improvement in Access to Intensive Care Among Underserved Populations

Video Transcription

Hello, my name is Nehal Tucker. I'm a pulmonary critical care physician at Atrium Health in Charlotte and the medical director of the virtual critical care program here.  Today I'll be talking about implementation and management of a multiprofessional telecritical  care program focusing on rapid improvement and access to intensive care among underserved populations. I have no disclosures. The objectives for the talk today are listed below.  Number one, demonstrate the framework for a large telecritical care program. Our program has been in place since 2013 and has grown significantly.  I'll discuss some of the building blocks of our telecritical care program. Number two, emphasize the importance of a multiprofessional telecritical care team to  provide care standardization. I'll speak through the various components of our team. And number three, highlight the ability to scale rapidly and expand to provide telecritical  care services to an underserved population. This obviously became very important throughout the COVID pandemic over the last two years.  Our telecritical care program is referred to as virtual critical care or VCC. The map here highlights the facilities that we cover.  The majority of facilities are located around the Charlotte metro region. And recently we have added additional facilities heading towards the coast of North Carolina  towards the east. We also now have additional facilities in Georgia through our partnership with Navison Health. We cover Navison Health Baldwin.  And during the COVID response, we added on the medical center of Peach County and Monroe County Hospital. Both of these are critical access hospitals.  I have highlighted Monroe County Hospital as the case presentation that I will discuss next was located at this facility.  So the case presentation that I have today will help highlight the role of our virtual critical care program in providing critical care services to a critical access hospital.  The case presentation is as follows. Again, the patient was located in Monroe County Hospital, which is in Forsyth, Georgia.  A critical access hospital, which has a total of 25 beds, no ICU beds. And it's staffed by one emergency room physician 24-7.  And then one family practice physician who staffs the inpatient service during the daytime and takes call at night.  Our patient is a 29-year-old obese male who presented to the hospital in September 2021 with complaints of shortness of breath, fevers, weakness, and a cough.  He tested positive for COVID-19. Chest x-ray showed fairly typical multifocal bilateral peripheral ground glass opacities.  The patient was started on supplemental oxygen, steroids, and remdesivir. He was admitted to the medical telemetry unit for further management.  Over the next 48 hours, the patient had increasing oxygen requirements and worsening respiratory distress.  He was transported back to the emergency room, intubated, placed on mechanical inhalation and sedation. At this time, virtual critical care assistance was requested.  Over the upcoming portion of the talk, we will speak to how we initiated the program as part of the COVID response at Monroe County Hospital.  The timeline here demonstrates our implementation and growth of the program over the years. We began in 2012 with the formation of the Atrium Health Critical Care Network, which  really focused on aligning the pulmonary and critical care practices around the region. As part of that, the virtual critical care program was implemented and went live in May  of 2013. We started with five facilities located here in the Charlotte region, which had variable coverage models of critical care at the bedside.  Some of the facilities were covered 24-7 by hospitalists who were up-trained to provide critical care services.  Some of the other facilities had daytime intensivist coverage at the bedside who would then take call in the evenings and night from home.  As we went live with these facilities, we took over all of the cross-cover calls and provided support to these facilities.  Over the years, we have had additional services grow out of the VCC program. I will mention a few of these.  The first one that I will mention is our critical care pharmacy program or e-pharmacy. We have three critical care trained pharmacists embedded within the VCC.  They provide support to all of our VCC facilities, again, an extremely valuable and limited resource  that now all of our facilities have access to, which otherwise they would not have had this resource available.  Moving towards the right side of the timeline, you can see we have a more robust presence in all of our emergency rooms.  This was highlighted during the pandemic as there was increased need with patients that were boarding in the emergency rooms.  We now have mobile carts in all of our EDs, including all of our freestanding EDs around the region.  And moving towards the bottom right of the timeline, we have developed our quarterback program, which is embedded in the VCC, and that really is our VCC physicians, our critical  care trained physicians, providing oversight and management of all ICU transfers that are  happening within the system or transfers that are requested from outside of our system coming into one of our facilities.  Our VCC physicians will provide management and coordination of all of these patients to provide more efficient transfers and optimal utilization of ICU beds.  And also, you can see in the bottom right, the last two years were really focused quite a bit on COVID-19 support, obviously, and I will talk further about that upcoming, especially  as we talk about our patient at Monroe Hospital that I presented earlier. As we discuss the framework and building blocks of our virtual critical care program, I do  want to highlight our current staffing that we have. In the top left, you can see we have 33 virtual critical care nurses. They are all CCRN certified.  Most have upwards of 14 years of experience in critical care. In the bottom left, you can see, again, our three critical care pharmacists that I mentioned earlier.  We also have three virtual respiratory therapists embedded within our program. They have been an extremely valuable resource in helping provide support to the bedside  respiratory therapist in managing complex ventilatory issues. In the bottom right, you can see our operations department, and in the top right, you can  see our provider pool, which is now over 100 providers that we have working with the VCC. We have 46 atrium-employed physicians such as myself.  There are a variety of pulmonary medical critical care, surgical anesthesia, and ED critical care.  I will mention that we have a fairly good number of surgical critical care physicians working with us, which has been extremely helpful in understanding the care and standardizing  management of the surgical ICU population across our region. We now have 20 atrium critical care APPs, nurse practitioners and physicians assistants.  Again, we are growing out this program as well. We have 25 physicians that work with Remote ICU, a third-party staffing company. They are located overseas.  They are all board-certified in critical care, licensed and credentialed here in the U.S. They trained here in the U.S. and now live in their home countries.  This has been an extremely valuable resource and great partnership as well. Again, they provide our nighttime coverage with the benefit being that it is their daytime.  We have 10 Flexpool physicians. These are physicians located in various locations throughout the United States, such as Tennessee, New Hampshire, Alabama, and Colorado.  We have one physician working with us from Navisant Health through our partnership with them with additional physicians planned to come on board.  We have five physicians working out of a location in Charleston as part of Charleston Pulmonary Associates.  Again, I do want to highlight this broad pool of providers, and it is a large pool, but the largest benefit being this is what has allowed us to scale up quickly and expand  our services quickly, and this became very evident during the COVID response. The map here demonstrates where many of our providers are located.  As I said earlier, we have physicians located overseas. They are in countries such as the Philippines, Pakistan, India, Israel, France.  And then on the left side of the map, you can see where our physicians are located around the United States as well, again, with the majority of them located here in the Charlotte  region. I highlight this map mostly to demonstrate that really the location of the provider doesn't matter. Geography doesn't matter.  As we have expanded our virtual critical care program, really it has been about access to providers to help take care of patients no matter where they are located and no matter  where the provider is located. A lot of our workflows over the years have been developed around making sure that any  member of our team, no matter where they are located, can work with the rest of the team to really focus on optimal management of that patient that's located in Georgia or somewhere  in North Carolina, wherever they may be. Again, as we highlight the multi-professional components of the telecritical care team,  I have listed again the services that we have, again, 24-7 nursing support from our BCC nurses. They really are our eyes and ears to what's happening at the bedside.  As requests come from the bedside nurses and the bedside team, they help bring those to our attention.  And then as we develop the plan of care with them, they help communicate that back to the bedside and make sure everything is moving along efficiently in caring for that patient.  The physician pool, I mentioned earlier in terms of the critical care physicians that we have of various disciplines, surgical, medical, anesthesia, ED.  And throughout this process, we've also been able to bring in consultative services, especially  during the COVID pandemic, we provided access to really all of our services throughout the system to have virtual access to all of our patients in the ICU, whether it was infectious  disease, neurology, and telestroke services, cardiology, renal, and palliative care became quite important as well, needing their services to be done remotely as well, wherever the  patient was located and wherever the provider was located. I mentioned the advanced practice providers. We're expanding that pool as well.  Again, a core group of well-trained critical care EPPs, nurse practitioners and physician's assistants that have worked at the bedside for at least one year now are providing their  services through the virtual critical care program as well. The e-pharmacist and the virtual respiratory therapist, I already highlighted the importance of both of those services.  Again, I mentioned all of these services because I really think these are the building blocks  of the multi-professional telecritical care team providing access to these services, again, wherever that patient may be located.  The previous slides focused on the framework of our telecritical care program and the staffing that we have in place.  These next few slides I'm going to discuss taking those components that we have built over the years and using those resources to scale quickly, especially as we are in the  COVID pandemic. This graphic that you see here is from an article we published back in 2021, which really discussed our surge preparation.  At that time, we were unsure of what volume of numbers we would be dealing with, so we had various levels of staffing.  Initially, you can see up to 275 critical care beds added and then all the way up to 900 beds added. I'll just highlight a few of the components of this.  On the left part, you can see consistent with future direction, regardless of the surge and preparation and early surge, again, these are processes that were already in motion  as part of our virtual critical care program. Many of these were accelerated due to the COVID pandemic.  The first one there is probably the most important, expand virtual cart numbers and utility.  Again, many of our rooms are hardwired already for virtual critical care coverage that we had been providing over the years, but as the need expanded quickly and rapidly for  the COVID pandemic due to the surge, we purchased a large number of carts and started deploying  those to all of our facilities, both in the ICUs if they needed additional carts or in surge units and then, as I mentioned before, in our emergency rooms.  We quickly expanded our virtual intensivist pool.  Again, we had a fairly large number of intensivists and APPs who were already providing virtual  critical care, but we expanded that pool quickly, again, getting them through the credentialing process under emergency conditions very quickly.  We also provided home setups to all of our critical care physicians and APPs, even if they had not previously worked in the VCC, so they would be able to provide virtual services  as quickly as needed, depending on the numbers and the requirements. We were fortunate that Atrium Health had significant buy-in towards the concept of telemedicine.  Again, as I mentioned, many other services quickly increased their telemedicine services, whether it was cardiology, the hospitalist, even surgical services, other consultants,  and the health system was in support of this. As listed there, you can see the home workstation expansion was a large part of this, again,  procuring equipment and giving that to the provider so they could work from home, even if they were not on service or if they had COVID, they could still be able to assist  the bedside teams. In the middle, you can see, as part of our preparation, if we were to get up to 275 additional  critical care beds added, I'll just highlight a few of those components. Again, expanding the virtual services to those surge beds, whether it may be in a PACU or  other areas of the hospital that may not be ICU areas, making sure we had carts deployed to all of those places to allow for remote access by providers.  The third bullet point there in the middle, you can see, as I mentioned, the quarterback program coordinating interfacility transfer requests throughout the healthcare system.  As beds became extremely limited, this program became more and more valuable, again, speaking towards the regional management of all ICU transfers, managing all of the ICU beds as  a whole from within the VCC with our VCC physicians and nurses coordinating the transfers and overseeing that process was extremely valuable.  And to the right side, you can see our preparation. If we got to the point where we needed to add upwards of 900 additional ICU beds, fortunately,  we did not, but we were prepared to do so, again, at that point, really utilizing a team concept where there may be oversight by a virtual intensivist overseeing bedside critical  care teams, which may have expanded to include hospitalists and other services to really try to manage a large population of patients.  And I think that last bullet point on the bottom right is important, greater coordination of remote team-based care, again, utilizing the team concept with oversight by a virtual  intensivist to oversee a larger population than normally they would, but utilizing the efficiencies of telemedicine to provide those services.  This graphic here, again, just demonstrates what I was discussing earlier in terms of preparation for a significant increase in the number of patients, up to 900 additional  ICU patients. Fortunately, we did not reach those levels in any of the surges. On the left, you can see, again, focusing on team-based care led by an intensivist  giving oversight to the on-site team and then additional resources that I had mentioned before, the VCC pharmacist, respiratory therapist overseeing the bedside intensivist and APPs  and providing virtual support. And then to the right, if numbers got really high up into the 600 to 900 range, really  having the virtual critical care physician be a team leader over many non-critical care providers such as hospitalists, CRNAs, et cetera, again, utilizing the resources of  the pharmacist and respiratory therapist efficiently to provide care to as many patients as possible in as many locations as possible.  I mentioned this in the previous slide as we talk about access, especially in underserved areas. Given the framework that we had in place for the program leading up to the pandemic,  this allowed us to scale rapidly, to increase our staffing pool fairly quickly, and to allow  us to provide access and care to those underserved areas that we partnered with as well, given the previous example of our patient at Monroe County Hospital.  Again, I think a lot of this was because a lot of the building blocks and framework were already in place that allowed us to expand fairly quickly to cover these facilities as  well that really needed our help during the COVID surge. I do want to discuss important operational considerations that arose during the COVID  response in providing rapid access to telecritical care services. Number one, the technological considerations, obviously.  At the critical access hospitals that I mentioned, Monroe County and Peach Hospital, we were  able to rapidly deploy mobile carts to allow for access to our telecritical care services.  Again, as many of you are aware, during the COVID pandemic, procurement of equipment became extremely difficult and limited.  Things such as monitors, headsets, cameras, microphones, cart equipment, etc. was extremely difficult to come by.  However, we were able to procure enough equipment to allow for deployment to these critical access facilities.  Also, on the provider side, we were able to procure enough equipment in terms of laptops,  monitors, to provide to each one of our physicians and APPs to allow for them to work from home.  All of our providers, all the physicians, APPs, and nurses needed network and systems access at the local facility, so EMR access, making sure we had access to the vitals.  Our IS team was instrumental in this in moving this along, efficiency, and then again, as I said, making sure all of our physicians, nurses, and APPs had the ability to work  from home as we decentralized from our hubs, our VCC bunkers that we had traditionally worked from for the most part.  Licensing and credentialing was a big part of this, again, making sure each one of our  providers had appropriate licensing and credentialing to provide services to our critical access facilities in Georgia.  We utilized the Emergency Georgia licensing process, and then again, emergency credentialing  at these facilities was completed fairly efficiently for all 80 of our providers working with the local medical staff services, again, just a monumental challenge that despite those  challenges proceeded fairly quickly and efficiently, again, to get us access and allow us to provide care to these patients in the underserved area in the critical access hospitals.  The third bullet point obviously is a big one, the cost, the cost of implementation. Again, a lot of this cost had been incorporated into the long-term plans of the VCC rollout,  especially at Navisant Health Baldwin, however, at Monroe County Hospital in Peach, this was additional cost that was not planned, but again, a valuable service that needed to be  provided. I will mention that one of the facilities we went live with there, Baldwin, again, we had the COVID response for about almost a year, over a year, and then we incorporated  sort of the routine model of VCC 24-7 coverage, which had been planned, but over that time  of about two years, they did see a significant increase in contribution margin as they were able to keep many of these patients at their facility instead of transferring them out  without, which would not have been possible without our VCC services, so again, some of the cost was offset by the increase in the contribution margin based on being able to  keep those patients at that local facility. And then the last bullet point I put there, ICU triage, I mentioned it as part of our  quarterback program, but again, it became evident during the COVID pandemic that these smaller facilities needed help with triage, again, as there were no beds really throughout  the entire state of Georgia, they did rely on our services, on our physicians to help try to triage at least the one or two that were most acute, and to help facilitate those  transfers as we did, we were able to help facilitate some of these transfers to the larger center located in Macon, Georgia.  So again, not a planned process, but sort of organically grown as part of this to help  the emergency room physicians and family practice physicians in these critical access hospitals of who to transfer and triage accordingly based on acuity.  So I come back to our case presentation of our 29-year-old gentleman with COVID pneumonia  and acute respiratory failure requiring intubation who was transported back to the emergency room at our critical access facility in Monroe County, Georgia.  We were able to help manage this patient for about 48 hours in the emergency room, and then we were able to help facilitate transfer to the larger medical center in Macon, Georgia  after helping coordinate the transfer process and help with local management, trying to stabilize the patient as best as possible before transport.  In follow-up, we were able to follow the patient and found out that he actually did fairly well, had a fairly prolonged hospital course at the larger medical center in Macon with  a tracheostomy and PEG-2 placement, but was ultimately discharged to a local rehab facility for ongoing rehab.  So again, really, the goal of this talk was really to highlight the framework of a fairly large and robust telecritical care program that has been well-integrated over the last  eight years, and then really highlight the need to accelerate and expand services during the COVID pandemic and during the surges to allow access for our telecritical care services,  physician, nursing, APP, pharmacy, respiratory therapy, to be able to provide those services  to critical access hospitals, to underserved patients in areas that may not otherwise have access to these services, and clearly there was a need, which was highly pronounced during  the COVID pandemic and may be ongoing as well. So I will end with that. I appreciate your time today, and thank you.

Video Summary

Dr. Nehal Tucker, a pulmonary critical care physician, discusses the implementation and management of a multiprofessional telecritical care program. He emphasizes the importance of a telecritical care team in providing standardized care and highlights the ability to rapidly scale and expand telecritical care services to underserved populations during the COVID-19 pandemic. Dr. Tucker presents a case study of a 29-year-old COVID-19 patient who required critical care services at a critical access hospital. He discusses the framework and building blocks of their telecritical care program, including staffing, technology considerations, licensing, credentialing, and cost. Dr. Tucker also mentions the operational considerations they faced during the pandemic, such as ICU triage and coordination of interfacility transfers. He concludes by highlighting the benefits of their telecritical care program in providing access to critical care services regardless of geographical location.

Asset Subtitle

Professional Development and Education, Administration, 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 Professional Development and Education

Knowledge Area Administration

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Innovation

Tag Telemedicine eICU

Year 2022

Keywords

telecritical care program

COVID-19 pandemic

underserved populations

case study

staffing

geographical location

	Society of Critical Care Medicine 500 Midway Drive Mount Prospect, IL 60056 USA Phone: +1 847 827-6888 Fax: +1 847 439-7226 Email: support@sccm.org	Contact Us About SCCM Newsroom Advertising & Sponsorship DONATE	MySCCM LearnICU Patients & Families Surviving Sepsis Campaign Critical Care Societies Collaborative	GET OUR NEWSLETTER
© Society of Critical Care Medicine. All rights reserved. \| Privacy Statement \| Terms & Conditions The Society of Critical Care Medicine, SCCM, and Critical Care Congress are registered trademarks of the Society of Critical Care Medicine.