It's my distinct honor to stand before you today on behalf of the really hundreds of individuals who represented both the creation of the National Emergency Telecritical Care Network and then ultimately deliver services to some of our most vulnerable hospitals and communities across the nation during our pandemic through the NETSIM. And certainly to be joined by the two individuals at my left here, Dr. Lilly and Dr. Scott, I think it's especially meaningful to me because Dr. Lilly was instrumental in my early career in telecritical care, and I think had he not been there for me at that time, then I probably wouldn't be here today. So thank you, sir, for your guidance and your wisdom. Overall – thank you, appreciate that – overall, we hope that today's discussion will really provide what we hope to be a nice bookend to what's been a years-long endeavor that is known as the National Telecritical Care – Emergency Telecritical Care Network project that surprisingly began as a strategic proposal to the Society of Critical Care Medicine in 2019. That was between Dr. Scott and Matt Getty that's in the audience and myself and a few others that were on the Telecritical Care Committee at that time, now the Telecritical Care Section for the Society, and it was picked up and approved as a white paper back in 2020 and then not very long after that, the same obviously spring, it got launched very rapidly into a national response system. So again, a long journey to get to where we are today. Really it's my purpose today to kind of provide a little bit of a background and then to hand it over to Dr. Scott and Dr. Lilly to provide their thoughts and insights for the project, how it was successful, and maybe some of the lessons learned and how we can move forward with a project like this as a nation. So these are our overall disclosures. I think for the sake of time, we decided to put them all in one location. There's no specific disclosures that we have related to this project or this presentation. We have obviously all received grants almost entirely from the federal government or from the military, and those both have helped this project and are instrumental in the rest of the work that we do. That's the overall overview of what we'll be doing and then for some background. So I don't think I need to spend a lot of time with this audience going over the problems with our healthcare system and how so many of them were really unmasked by the pandemic, but it is certainly worth highlighting some of the drivers that inspired the vision of the National Emergency Telecritical Care Network or NETCEN. First of all, large-scale disasters, whether they are man-made or natural, and certainly mass casualty events that unfortunately all too many of us are familiar with these days, stress our healthcare system. Most of our hospitals truly operate at or very near capacity on a routine basis, and this is because that's the most cost-efficient model, but it really leaves little room for resilience within our system. Furthermore, our healthcare system is, for many reasons, not distributed equally across the nation. Where there is a lack of infrastructure for subspecialty or specialty support, that lack of infrastructure usually also leads to a lack of expertise in those specialties, and it's clear that a lack of critical care beds leads to a lack of critical care expertise in a community, and therefore the primary response to obtain that resource or that expertise is to transfer either resources to that location or to transfer that patient to those resources, and these challenges that our healthcare system faces were really profoundly apparent during the pandemic, especially one that caused acute respiratory failure for so many. So it was with the intent to really address the scarcity of critical care expertise during high-volume surges in either critical illness or injured individuals, so trauma care was also the initial perspective behind this, but transitioned to the pandemic illness as the pandemic kicked off. We envisioned that really telecritical care could be a means to rapidly expand the capability and capacity of a hospital by delivering expertise to the point of need without having to move physical resources of either humans, experts, or patients to those experts, and it was in this kind of context that we imagined the same expertise that we, many of you understand, delivering as part of a tiered staffing model in which critical care experts, whether they're physicians, nurses, respiratory therapists, or pharmacists, you know, guide a team of non-critical care-trained clinicians to deliver services, the right care at the right time to a larger number of patients. We imagined that we could do this without a physical person on-premises, and we could do that virtually wherever that support might be needed. Ultimately, that vision turned into what became a funding opportunity through both the military and what was then the Assistant Secretary for Preparedness and Response, a slightly older slide now. Now obviously that's the Administration for Strategic Preparedness and Response, and this was to, you know, to rapidly form these clinical technical teams that you see before you to deliver the capability that was NETS. You know, one question that people might have is why was the military interested in this? For the sake of time today, we're not going to get into a lot of that. That could potentially be a question at the end of the day. But there are certainly overlaps between large pandemic patient volumes and large-scale combat operations and large-scale numbers of patients or casualties. I think it's also worthwhile just to describe some of the differences between what is NETS and what is maybe considered more traditional or common telecritical care. Certainly one of the most important ones is that NETS was always imagined to be a temporary solution, right? It was designed to go in to a hospital, stand up rapidly, be there for a period of time, and then leave. It was never intended to be an enduring capability, and in that context, that presents certain constraints to the way that you would deploy a system, but also to certain expectations that you might have from both the service provider and also the customer that's receiving that service, an example of which might be, you know, integration into the electronic medical record. You know, even though every hospital might have an Epic or a Cerner deployment of an EMR, those EMRs and their back end are not all identical, right? And there requires integration with the third-party system to work with those electronic medical records on premises, and there's no possible way to do that in a speed of relevance during a pandemic or any other type of disaster. So there's things that you can do, and there's things that you probably can't do on an ad hoc basis. Some of the other really kind of important things, I think, that are differentiating between NETS and kind of normal telecritical care is there's no negotiation about what services you're going to get. We came with a plate of services, and this is what you get. If you don't want more, we're not going to be able to provide a tool that we do not otherwise have, and that became some negotiating challenges with some of our deployments. The other thing, surprisingly, as you might imagine, that, you know, no cost for services you'd think would be great. There are a variety of folks that are out there, especially CEOs in some of these hospitals that see free as being concerning. Maybe free wasn't well-designed, or maybe free wasn't, you know, validated, or a lot of other issues that are associated with free, and we had to get over some of those concerns. I'll just highlight the software solutions for these two systems are not terribly different. They all have the right cybersecurity, HIPAA compliance, et cetera. I would say that most traditional telecritical care software solutions have a few more bells and whistles to them. Hardware, however, was significantly different. Our primary hardware solution was a mobile device, right? No deployed hardware associated with NetSend. We weren't putting cameras in people's rooms or microphones, just mobile devices. And then the way that we managed data was significantly different. So all those clinical technical teams that you saw before had a standardized interoperable data standard across the vendors, and most of the telecritical care platforms in normal use have proprietary data structures. And then the model of telecritical care delivery is not dissimilar to what most people would understand or see or recognize as telecritical care in the community today. In the end, most of what we were doing was reactive model of telecritical care for a variety of reasons. These were the core functions of the NetSend applications. I'll only touch on a couple of them. Again, it was mobile device centric. It could be Apple iOS or Android iOS. We didn't have others in the pandemic. Team collaboration was key. Communication was key through both asynchronous methods as well as voice and video. There were elements of care management, keeping patients coordinated wherever they may be. So if you were in a gym or a hotel, these platforms could deploy and keep track of where the patients were in those types of environments. We had push survey data capture, so if you had questions about what was going on at the edge, we could ask some of those questions. And then what we called documentation was really what you might call light documentation. It wasn't all of the documentation for billing purposes that what you might have in our normal electronic medical records. These were really communication tools for documentation, what do you need to know when you need to know it. And then finally, I just want to kind of go over our general timeline for how the portfolio played out. You can see the first six months of work from the time the emergency declaration was kind of made for the nation, obtaining funding, doing contract, et cetera, was at light speed for the government. So within six months, we were actually to start to deliver services on a relatively small basis, but our initial pilots were within six months of the initial kind of concept ideation here. We did eight requests and seven live sites in the first several months of deployment. This was under military funding, and then during the alpha kind of wave is when we transitioned over to ASPR funding, and that was kind of a contracting phase, and we provided almost no services. That picked up again, obviously, during Delta and Omicron, and you can see the kind of numbers here. Overall, we have received 131 requests from a variety of states. Ben will show some of that data. We're doing live and a little under half of them with a large percentage of being in some of our most at-risk communities, 35 critical access hospitals, one EMS system, and one clinic. And then just because this slide is here right now, and I think it just picks this challenge very graphically and it's easy to see, you know, request doesn't mean start service on day one, and you can see for both Omicron and Delta, you know, the request volume went up right as the waves were starting to peak, right? They were going into the waves, and people recognized there was going to be problems. But the going live, the red lines here, so black line peak here, red line below, was the going live dates, and they were always delayed from the request, right? In fact, the last go live request, go live for the Delta wave was really after the Delta wave was over, right? And we got a little bit better at doing that. Ben will show some of that data for the go lives during Omicron, but, you know, this is just, it shows, speaks to some of the complexities and the challenges of actually doing this, and I think this was just a good graphic for people to be aware of. So I'll turn that over to Ben now for his comments. All right, thank you, Jeremy. So I'm going to make the case that Netson was successful. I'm going to focus on a few different things. I think there's something to be said, which may not be impressive to other people, but for everybody that spent a lot of time working on this, that we just successfully demonstrated a new concept and a new model of care. We actually got this thing up and running. I think probably most importantly, the program, I think, was very successful in improving access to care. The people who use Netson in terms of the patients and the customers, the customers being providers, as I think almost as importantly as patients, were people who were in rural areas, very vulnerable, socially vulnerable areas and underserved areas. I think you can make a strong case, and I think a lot of folks, if you have been involved in telecritical care over time, I think we all know this, that one of the first things you have to try to do is demonstrate that there's some return or value on the investment, and that's hard to do in terms of outcomes. But I think we can make a case that the sort of concept of having backup, of having a safety blanket has some value in itself, and certainly was experienced that way by people during the pandemic. So the load balancing feature, the providing patient care where there wasn't any, and in particular, as I said, supporting clinicians at the bedside during a period that was very stressful and uncertain, I think actually had a very tangible value, even if it's hard to quantify in any kind of outcomes or financial term. And then I think also very important was that we learned a whole lot of lessons about how to hopefully do this better, faster, more efficiently and more successfully in the future. So as I said, really the main lesson is that this can be done, and I'm going to go through a couple, I think, important details about our deployments and the activity that Netsyn did. So I think first of all, and I'll come back to this, 58% of the sites that went live with the Netsyn platform were critical access hospitals. We were active in small communities. If you look at the city population, the median of the total deployment population was 7,364 people. So this is in very rural parts of the country, obviously without much access to higher levels of care, and I'll talk about that a little more in a minute. Just to see this, there were basically COVID hospitalization rates were similar to regular other places that did not receive Netsyn and between different sites here. I'll show a graph that shows this more clearly in a minute, but in terms of the kind of social vulnerability, most of the sites would score by various systems as being very highly socially vulnerable. The median bed capacity for the hospitals that received services was 25, so these are all small places. That's the hospital beds, right? Not the ICU beds. The median ICU beds was zero, the median number of intensivists was zero, and the median number of ICU nurses at these places was zero. So I think you can make this a strong case that we were providing a service that was needed in a place where it wasn't available. A couple other things to point out here, the 60 sites ultimately were active over the two waves that we're talking about here. We had different teams. This was a competitive selection process for the teams that ultimately provided care, and so there were some different care models involved, and so both sort of proactive and reactive models were used. Total days of coverage in the end was 1,890 coverage days. There were total unique patients, 1,064 patients, and total encounters was 5,653. So I think if you think about the nation, those numbers are tiny, but I think they do represent a pretty significant intervention, and I think if you extrapolate those and think about scaling, which I'll talk about in a second, then they're meaningful. These are just some pictures of some of the places where NETCEN was deployed. This picture over here of the map is the NETCEN Central Command Center, which was an attempt to kind of graphically show where we were active and working, and sort of also link out to some different reports and kind of a command hub. But you can see we were in quite a few different parts of the country, including in some of the outlying territories of the U.S., Puerto Rico and Guam. It's important to point out these patients were critically ill, so just if you look at kind of the acuity scores for the patients, 84% were scored as high acuity, so these were critically ill. At our other talk the other day, Jerome Lee talked about how a lot of their work has turned out to be a lot of kind of primary care stuff, but at least for us in NETCEN during COVID, the patients were, in fact, critically ill. This map, this is a heat map just sort of showing the activity level, and Colonel Pamplin already alluded to the fact that unfortunately a lot of times we were a little bit behind the wave, and I think that impacted our numbers. But the only point here is that if you look in the middle of this graph, we did have some sort of peak days where we were ready, we were up and running, and the wave was sort of cresting, and so we did end up with fairly large numbers, which I think is just important as kind of an indication of what this could be, again, if we scaled. Money really depends on, that's interesting, Dr. Goldman, you showed up in the middle of the slide. Money is all relative, right, so in some ways you could argue this is an expensive program. That didn't show up on any of our other views of this, it's a ghost in the machine. Anyway, that's a plug for, yeah. So total clinical costs of the healthcare that was delivered by Netsan was about $7,000,000, $6.9 million. That theoretically was what could be billed for, but that was sort of the valuation the care provided, and the infrastructure to deliver these services was about $7 million. So the total budget for the care we provided was about $13.9 million. If you kind of do very simple calculations, that comes out to about $300 an hour for both a nurse and a doctor to provide care. I have two slides just to sort of put this in perspective. If you look at the fiscal year 2024 budget of Health and Human Services, there's $20 billion in mandatory funding to increase preparedness for pandemics and other biological threats, a billion dollars to BARDA, almost a billion dollars to the Strategic National Stockpile, $400 million in flexible funding for ASPR to invest in capabilities that enable rapid response to future threats, and some vaccine programs. So I don't begrudge any of those other line items their money. I think most of us who are working in this area feel very strongly that all this stuff should be funded. So the point is not to say that they should get less, but I think in context, this whole Netsan project starts to look quite cheap. The other thing to think about is to compare it to the existing NDMS model. So it's estimated that to deploy a national disaster medical system boots on the ground team, so a medical response team that goes to the point of care, costs around $250,000 to as much as a million dollars per week. And so if you think about that, that's around $1,500 an hour for each site, whereas we're talking about $300 an hour for Netsan. If you even just covered the 36 critical care access hospitals that we covered with Netsan, that would be about $53,000 per hour. If you extrapolate that to the over 1,300 critical access hospitals that exist in the US, obviously that's billions of dollars. So I think it's important to think about what if we could scale up. So Netsan treated about nine patients per site over an average of 61 days per site. So that's pretty tiny little numbers, right, 0.15 patients per day per site. But with the bandwidth that we had available, we could have actually covered most of the critical access hospitals because we had enough people in place to do this. And at that scale, that would be about 200 patients a day. It's estimated that that would potentially increase the kind of bed capacity, ICU bed capacity of the US around 2%, which is not insignificant. Even as a limited pilot for a short amount of time, we were able to monitor 30 patients at home who didn't end up requiring admission. Only five of those patients ultimately ended up coming into the hospital, and three of them went back home after less than 48 hours. So again, these are tiny little numbers and don't intend to pretend that that's an outcome, but I think it just shows you the potential. So the pilot itself, you could argue, was expensive, but expanded care at scale would not be. I think we had a signal, at least, that we could reduce transfers, reduce admissions, and multiply the workforce, very similar to the arguments that have been made for the general power of telecritical care. So again, I said, if Netson was available to all critical access hospitals in the US, you could theoretically provide a 2% increase in critical care beds. And the NDMS model, while, again, I'm not arguing for replacement, I think that's obviously a crucial and important service. But if you had a telecritical care wing or deployment model, you could reach places that are functionally or technically not really reachable by our current system. So what that means is that I think we have a significant opportunity to improve access to care and provide more equitable care, and I think we can show a little bit that we already did that. CDC has measures of social vulnerability that you can look at. They have an interactive map on the CDC ATSDR site. And basically, every county in the US is scored for the level of social vulnerability, and that includes things like economic status, housing costs, education levels, age, disability rates, all kinds of stuff, right? So it's a pretty broad measure of kind of where, how counties are situated in terms of the overall level of resources and the social and health vulnerabilities and stresses in those communities. If you look at the map, you can see that the, especially the south, and I think it's a lot of, a lot of this is also rural, it's more vulnerable. So for all sites that Netson took care of, the median SVI was, SVI is basically just a scaled score. It's probably just sort of a rank percentile, but the SVI was around 0.4694. So that in their scale system is around middle, you know, moderate vulnerability. But if you look at, because of the way Netson played out, we deployed to some states, specifically Vermont, Minnesota, and Wisconsin, which actually overall as states have very low social vulnerability indexes, so good for them, but I think a little bit, probably a combination of factors that are, you know, that have to do with demographics and state budgets and priorities and all kinds of things. But in any case, if you remove those three states, then the SVI for the Netson deployments was 0.6646, which is moderate to high vulnerability. In 15 of our deployments, so, you know, almost half were in highly vulnerable areas, including a few that scored in literally the highest social vulnerability that you can have in the U.S. So again, these locations, I think, are very hard to reach, and I think we were able to reach some places that otherwise wouldn't have been able to have these services at all. So then the last thing to say is I think we learned a lot of lessons that hopefully can be applied, and, you know, it's obviously, if I spend lessons learned as a reason we were successful, that's maybe a little bit, whatever, disingenuous. But I think that this was of great value to us going forward. So just, some of you may have heard this if you were at my talk the other day, but one of the deployments that we did was the state of Vermont reached out to Netson through the Regional Disaster Health Response System. Vermont is in Region 1, which is the New England area, and they asked for help from the Regional Disaster Health Response System. And Region 1 had already been working with us on some of our Netson projects and planning, and so they said, hey, well, why don't you guys request help from Netson? They had the full support of the Vermont Department of Health and the Vermont Health and Hospital Administration to go ahead with kind of a statewide on-demand deployment. And so we really felt like this was an optimal scenario. You know, Vermont is a small state, relatively small population, a relatively small number of hospitals. We had the program up and ready to go, and we had, you know, as much as you could, coordinated buy-in from state and local leadership, including, you know, some of the hospital, each hospital basically involved. So we deployed, and unfortunately, the thing that we learned was that it still took us forever. The fastest that we were able to deploy in one of those hospitals was seven days, and the median time from their request to deployment was 27 days. So, you know, Colonel Pamplin alluded to this, but basically, the surge was sort of subsiding by the time we got up and running, so we kind of missed our window. And I think there's a couple things to be said about this. The first is that it's kind of hard to sort out exactly why we were so slow. I think it varied a little bit by hospital. Some of the hospitals just hadn't really gone through this emergency credentialing process before. Some of them, even though everybody said yes, did still have some concerns. took a few days. So the lesson, I think, there is that these things work. And they can't, you know, our fastest deployment in all of Netzen was two hours, right? So we had a request, and we're up and running within two hours at one site. And so obviously, that's not realistic, but that's possible. And I think the lesson is that if these systems are in place and somebody is invested in them ahead of time and knows they're there and knows how to use them, we could deploy in a remarkably quick amount of time. So, you know, I think going back to this, I think, you know, how do you demonstrate that this was valuable? I think, you know, we were ready fast. We did, we're able to live up to some of the, some of the kind of promises, right? We had patients online quickly. We had clinicians ready. We had a lot of support from clinicians right away. We did log thousands of video messages and communications. We did fill in some gaps. We had one case where we actually diagnosed pneumothorax virtually when nobody else was around and were able to provide service. We did cover nights and weekends and provide some kind of documented, you know, burnout reduction for some of these places. We monitored places at home, I mean, patients at home, sorry, we reduced hospital admissions in that cohort that I already talked about. And we actually had one situation where Netzen stayed live and the local hospital's IT system went out and went down. So those are obviously anecdotal, but I think they're real potential benefits. We did get a little bit faster as we went. So this is just compares from sort of earlier on in the timeframe to later, our days from request to go live did go down, even though it never went to where we wanted it. And I think, you know, probably as important as anything is that we laid a foundation that has continued, I think, to generate benefit. We built a real strong community of people around the country. So there's been, you know, consistent support from thought leaders and experts and practitioners of telecritical care who have continued to show up. They're still showing up and asking us kind of how they can help and what's next for this program. And this has led to some specific spinoff programs. There's been an effort to do some ECMO regionalization in Texas using some network, Netson platform ideas. There have been real world deployments in Ukraine by SCCM supported projects that kind of, at least the teams assembled during the Netson effort. And I think we've established a clear model for multidisciplinary telepresence. So there's efforts going on in burn care and sort of remote palliative care and monitoring vaccine clinics and all kinds of other things. And I think all of us have recognized that it's, if we develop the platform, it's got a wide range of uses well beyond critical care. We did learn a little bit about successful and unsuccessful deployments. So successful deployments are the most successful if there's an identified need that's recognized by everybody. If you have effective leadership that really engages the key stakeholders in the places you're trying to reach, you have to have IT support. This stuff, even though we have a sort of ready to go system it still requires quite a bit of work and people who understand things like networks and IT security. Privileging and credentialing obviously really require or are much easier if you have an experienced team that knows what they're doing. And as it's gone through this before, we recognize that in some cases there were kind of misaligned ideas about what we were offering or what was available. And so you have to try to sort of figure out how to make sure that your service you can provide is aligned with what people are hoping for. There were a couple of cases where the administrative apparatus of a hospital or health system said yes and the clinicians kind of said no. So you really need buy-in from all levels. And then I think there's some areas of uncertainty that we didn't answer that still are worth some thinking about. One is we deployed both proactive and reactive models. One of the models used kind of a nurse navigator to start out and route and triage. The other model was direct to expert and we don't have enough data to say much that's meaningful about which one of those was better but it's an interesting thing. Still a lot of things about liability, about indemnification of providers, about how orders will be placed and who's sort of responsible for care are unexamined or still open to a lot of discussion. And then kind of we lived basically thrived on volunteerism during COVID and I think that's actually also what's happened for example in the Ukraine deployment is that people are willing to put their time and effort into things when they think it's important but obviously that's probably not a sustainable all hazards kind of approach and so we still have a lot of uncertainty about how compensation for this care can happen. I'll just leave you with this. You can just read these but I think we had quite a few users of the service who thanked us for it and described the benefits we provided and obviously it's hard to put a number on any one of these things but I do think we made a difference for a lot of people. Thank you. Well, I see many friends and respected colleagues in the audience today. And I think that I just want to take a moment to thank you for your contributions to telemedicine and the background that really made this success possible. You guys did it. I need to directly compliment Jeremy and Ben for doing what was hard rather than what was easy. I can just tell you from my experiences every April 15th on just giving money to the government that doing this kind of a project is really amazing. And so to stand this up in the time they did, I think is really fantastic. I also wanted to thank Corinne for inviting me to give the easiest con presentation that I've ever been invited to do. And I would simply point out that it's widely accepted that during COVID there was increased critical care need and that the individuals, incredibly talented and dedicated individuals that volunteered in essence, were very good, but they weren't perfect. And the systems that they worked in are really far from perfect. And therefore, it's self-evident that the network could have done better. But I will go on and give you a little bit more drill down about this, a little perspective about things that I think going forward that we learned from this that informed us about what we should be doing and a little bit how we should do it so we can do it better, quicker, and faster. When we measure effectiveness, you can take a look, as Jeremy had done, some of his data will be in here. The total critical care need, if you subtract out the critical care needs that are not addressed by any TCCN and you subtract out the nets and inefficiencies or harms, that's an index of overall effectiveness. In the analyses that I've done, the quantitative analysis that I'll present to you, I'm going to ignore any inefficiencies. I'm going to assume, even though I'll show you some data that it might not be the case, that the NETCCN is equally effective to other forms of critical care, such as the continuous model. I'm indebted to Dr. Geiling, who authored the planning and organization chapters in our emergency, in our intensive care textbook. I think it's the single best resource if you're a non-professional disaster responder to get up to speed. He loaned this slide to me. In addition to the patient-facing materials put out by the CDC and a variety of review papers, this being a particularly well-written and recent one, there's general agreement that when you go to respond to a disaster that it requires, you can bring resources in terms of space, stuff, and staff. Now the NETCCN intervention really focuses mostly on staff. It does address indirectly space, but not so much stuff. Because it's really a staff-focused response, it's not as robust as necessarily is required to really optimally deal with disasters. We talk about telemedicine support. There are several things that we can do that can really be helpful and bring value. Those of us that work behind the camera have done all these things. One of the things is we can help recognize an evolving emergency. The earlier we recognize that the patient is starting to become physiologically unstable, the easier it is to deal with the situation. The longer you wait, the easier it is to recognize it, but the harder it is to deal with. So recognition is important. And I'll give you some examples where the continuous monitoring approach may be a little bit better than the on-demand approach in that regard. One of the things we can do is arrange evacuation. This isn't always possible, but one of the key concepts here is are we going to take Muhammad to the mountain, which is arranging evacuation, or are we going to take the mountain to Muhammad, which is things like transitioning to palliative care and a critical care intervention at the current site of care. If you're going to do the take the mountain to Muhammad, and a little bit even if you're going to just arrange evacuation, you still have to create and resource teams on the fly. And so one of the key things that the Netson folks and the continuous monitoring folks were doing is they're taking people who maybe don't practice critical care all the time or aren't comfortable doing so and creating conditions where they can be effective and comfortable serving their patients. So one of the things about activation that matters are several lessons that came from the Hurricane Katrina disaster. So this photograph of this young boy here was taken four hours after the storm had cleared. He's sitting in his house. He has his only remaining position, his teddy bear, in front of him. And he's emotionally overwrought. And so many of our frontline providers, when they're faced with the possibility of an unexpected death or more patients than they can take care of, they feel not all that differently than this little boy feels. Now about this time, there were several interviews of people that had survived Hurricane Katrina. One of them that I remember was on ABC News. And it was a woman that was, her house was destroyed, but it wasn't completely unlivable. And it was several days after the disaster. And they were asking what things that the management associations were doing that really helped her and what didn't. And she said, you know, sometimes when people come around, they ask me, what do I want to eat for dinner tonight, I just don't, you know, I just, it's just a burden to try to figure that out. Why don't they just bring me a pizza, because they can see that I'm hungry. So as we look at this little boy, you can tell that the little boy is hungry. You can tell that he's thirsty and that he's going to get cold. But does he have what it takes to reach out and to ask the photographer to have, to share some of their water with him? So one of the problems that we found early on is that we had done some qualitative research about recognizing instability in our ICUs, and we found some surprising stuff. I think this has evolved over time. This is older, but the fundamentals are still true. And it's not all that divorced from observations around Hurricane Katrina. So in our ICUs, we had about 6.8 true positive alarms a day. The bedside staff were on top of five of them, but that was 1.8 times a day when there was an emergency that was evolving that the staff hadn't responded to. And about every other day, that happened when the intensive care team was actually rounding on the unit. And it's not an accident, because when the ICU team's on the unit, there's sort of an intense focus on one patient at a time, or the sickest patient. And it creates a situation where you, like, have a 400-square-foot rug in an 800-square-foot room. You're moving that rug around, but it can't be everywhere all at the same time. And some of those patients are left uncovered because the resources have been pulled away from them. The qualitative analysis that we did is we just counted up, because we knew how many phone calls people made, how many times they pushed the button to activate the system, and the continuously monitoring paradigm. And we recorded roughly 25,000 interventions. Of those, 24,426 were initiated by the off-site team, and 483 were the on-site team asking for help. So it isn't that they necessarily didn't know they needed help. It's just that in their workflow, taking the time to call for help wasn't as important as doing their other tasks. Translated, what this means is that for every time that the on-demand system can recognize an opportunity to make a difference, there's 49 times when it misses them, because the on-site team simply can't activate the system. And I want to drill down. I normally don't tell anecdotes. I spent a long time in my career not doing this, but I decided today I really needed to do this. This is a case that was—Theresa might remember this case—it was a case that we served when she was—we were lucky enough to have her helping us out. This is a case of a 58-year-old, 400-pound man. And an alert came across our system that he was hypoxemic and tachycardic, and we turned on the camera, and we realized that the bedside intensivists and respiratory therapists were struggling to try to get him intubated. We had evolving respiratory distress, low oxygen saturations. This was in the setting of status asthmaticus. So one of the questions that I bring out—that I bring to you guys is, how can an on-demand service engage when there's no one available to make the request? Now, as it turns out—oops. As it turns out, the intensivist was somebody who we had trained before, so I knew him well. And I knew that he was a skilled intubator and a world-class bronchoscopist. So before I said anything, anything unhelpful like, how can I help you? Or even worse, you know, do you want me to get somebody up here that knows how to intubate or something along those lines? The first thing I did is I decided not to speak. I called down to our OR staff and arranged for them to deliver a video laryngoscope to the ICU, including setting it up. And then I clicked on my microphone, I said, good evening, this is Dr. Lilly, your telemedicine support physician. In case you would find a video laryngoscope to be helpful, I've arranged for our OR staff to deliver one and to set it up for you. Would you like me to see if another experienced intubator is available to support your efforts? So here, this is the equivalent of giving the thirsty kid the water bottle and then asking him, is there anything else that you need? Because you've communicated that you understand their situation and that you're there to help. It turned out, possibly because I knew that I had a relationship with the intensivist, that he was more than willing to have someone come up and help him because by the time I turned the camera on, he was already, you know, sweating. So I speed dialed the OR desk, I found out that the in-house anesthesiologist was going to be in the OR for at least 60 minutes. So I asked him, do you have a backup? And they said, yes, we do. Our chief anesthesia, who's our best intubator, is available. Why don't you give them a call, give her a call? So I called her at her home and she is so good at intubating that she almost never uses a bronchoscope, but she was the best intubator of the group and she said she could be there in 20 minutes. So I asked the OR staff to bring a bronchoscope up to the ICU before the anesthesia chief arrived. It took 52 minutes with the anesthesia chief manipulating the video laryngoscope and the intensivist manipulating the bronchoscope until that airway was secured and he was ventilated. And I can tell you from looking at their scrubs, they were sweating and there was a big sigh of relief when everyone was convinced that the airway was secure. So let's take a look at the two models. So in the on-demand model, you have to learn from the bedside what's going on with the patient. In the off-site model, you have an electronic summary. You know his weight, you know his major diagnosis, and you know the history of his, you can look at the flow sheet and see what's been going on with his vital signs. In the on-demand model, the bedside provider has to tell you what they need. On the off-site model, because you have these other ways to know, you have ways to understand what the situation is and they don't have to communicate that. In the on-demand model, a telemedicine provider calls the hospital operator to get the OR number. That takes a delay. And when they finally do get them on the phone, they find that the anesthesiologist is not available and don't necessarily have the relationship or the understanding to say, oh, there's also a backup person available that can come in. In addition to being able to reduce the time to airway security for this patient, knowing the other patients in the ICU, the continuous monitoring team can say, oh, I've pulled the only RT out of this 10-bed ICU. There's a number of other patients in there who are unstable and need RT services. I'm going to get one of the RTs that's on the floor to come in and cover during the emergency. So I just think that when you look at the on-demand versus continuous monitoring model, that there's a lot of reasons that the continuous model is more effective to dealing with acute emergencies. So Jeremy had nicely shown that there were 4,560 hours of incremental critical care that this team provided, and that is amazing, absolutely amazing, and it's a great accomplishment. I think really he lived up to the commitments he made to council here at SCCM, and my hat's off to him for doing that. But I did publish that it was a rather small fraction of the total work that was done relative to meeting the emergency. So I think that this is something that Netzen definitely deserves a lot of credit for, but there are other people in the telemedicine community who stepped up and also contributed. So I want to make an analogy here about what we really learned from the COVID disaster. So what did we learn from the RMS Titanic? So this is an artist rendition of the Titanic going down, and the main message was that prevention was not enough. You had to be prepared. That is, that focus on hull design and iceberg detection were not enough. You also had to have enough icebergs. So on the bottom left-hand corner, you can see the individuals that designed the Titanic, and you can see a rendering on the right-hand side, you can see the office where the engineers actually did the design. Below the left shoulder of the main engineer there, you can see the picture of the RMS Titanic hull design that was reviewed when they went back and said, well, how come it sunk and what could we have done different? On the right shoulder is a picture of the lifeboats. So I wanted to just share with you that when they went over the hull design, they discovered there was a couple of things that they might have taken care of and done a little bit differently. But the lifeboats, they didn't need to redesign them. There wasn't a single lifeboat that failed. The lifeboats actually were kept in the harbor, and White Star Line didn't get rid of the lifeboats. They deployed them to the other sister ships of the RMS Titanic, because if they didn't have enough lifeboats on them, nobody would go and go on those ships. So the equivalents here in COVID are the hull design is the equivalent of a focus on vaccines that are going to wipe out the pandemic, and the boats here represent doctors, nurses, and frontline critical care providers. So if we ask, what did the pandemic teach us about critical care? Did we learn that we need better support for intensivists, pharmacists, nurse practitioners, physician assistants, respiratory therapists, nutrition service professionals, and nurses? Or did we learn that the only thing we need to invest a lot of money in is better public health measures? And so I ask you, in these pictures at the bottom, you can see Dr. Fauci's effective here. You can even get U.S. presidents to wear a mask if he works at it hard enough. If you look at the bottom of this picture, this is public health. Where is critical care and health? How come Tim Buckman, or better yet, Jeff Drazen, who was the editor-in-chief of the New England Journal when this all went down and once told me that he was one of the five physicians in the country that could get the president on the phone, how come they're not at these conferences? And if they had been, would they have been saying things like, this ventilator reserve package that we have is more than enough to deal with the crisis because all we need is stuff? Would they have said that we just need more money for ASPR or for BARDA, which is what the government funded? Because I'll tell you, not a single one of my critical care nurses think that more ASPR BARDA funding is what is required to better deal with these disasters. So what do we learn from the NET-CCN experience? One important thing was that setting these things up is really hard. And even when everyone wants to do it, it takes longer than it should. So one of the technologies that we now have is this eConnect technology. I was in a foreign country with a team that went in and they were talking to the C-suite and I couldn't have the language skills to understand. And while they were doing that, they installed this in the ICU. And when that conference was done, they had taken an ICU workstation, all stuff that they already owned, and they had set up a monitoring center in that amount of time. And that was a little less than what Ben had presented. I think that a policy that required all hospitals to have 10 percent of their licensed beds monitored with a network connected biomedical monitor that included a camera, a microphone, and a speaker would expedite the emergent deployment of telemedicine support where and where it needs to go. And this is something that could be done at almost no cost to the government, incrementally over time, and can be done at very low cost. And why are we not doing that? AI-driven monitoring solutions are important. They're important because they reduce the number of false positive alerts. I recently published an article that's going to come out in Chess in just a couple of weeks that demonstrates that with 78 intensivists, 78 nurses, and 78 pharmacists, you could cover the entire country 24-7. Analyses from the monitor can provide actionable items and real-time updates to the emergency response centers. And I think that rather than sitting around a table and saying, well, what's going on in the neuro-ICU today, you'd have real data about acuity and involving patient need. Our telemedicine pharmacists, they need to be managing national drug supply stores. We got a billion dollars for, like, stuff we need. And how much money do we have to deal with drug shortages? Maybe we're not using our national resources the way we should. And I think that the sort of folks that support our critical care teams every day have the skill set that's required to both establish and to manage those resources. And at least in my hospital, they'd be used every day. And the worst time to run out of a standardized medication is when you have junior and inexperienced people managing your ICU. And so why are we doing that when we don't need to? We need to do critical care better. The Federal Disaster Management Agencies have focused on an American Red Cross restorative disaster relief model. And they sunsetted their support for the NEDSR. And this is literally the equivalent of taking the lifeboats off the RMS Titanic and burning them rather than redeploying them where they need to be. I'm convinced that it's not going to be possible, either for the Department of Defense or for the ASPR organization, to efficiently manage the mobilization of these kinds of resources. I think the center that needs to do this is the National Institutes of Health, primarily because they've successfully coordinated between the key governmental agencies, including the Department of Defense and CMS in the past. I just wanted to conclude by, again, thanking each of you for your contributions to telemedicine and to tell you, I think, that what you do every day really makes a difference. Thank you.

NETCCN

remote critical care

pandemic support

hospital capacity

rapid response teams

telemedicine

AI-driven monitoring

disaster preparedness

equitable healthcare