Hi, I'm Cheryl Hiddleston. I'm the director of the Emory EICU program at Emory Health Care in Atlanta, Georgia. I'm going to talk a little bit about staffing for telecritical care nurses and how to balance the schedule and work-life balance. I have no disclosures or relationships to report. When looking at staffing grids or scheduling guidelines for telecritical care, we're a relatively new practice, only been around for about 20 years, and there are no well-established best practice recommendations as there are for the inpatient setting. However, ATA published practice guidelines in 2014 recommending a ratio of one ERN, which is an electronic RN, to every 35 to 45 patients. Also, AACN published an expert consensus statement related to electronic ICU, progressive care, high acuity care guidelines for nursing. And one of the primary guidelines they added was to confirm that processes are in place to evaluate and impact decisions regarding tele-ICU workflow and staffing. Again, no real established number, but I am constantly evaluating, reviewing with my staff what works, what doesn't work, how we can ensure that we're providing the highest level of support and care to not only the patients at the bedside, but more importantly, the staff at the bedside. In doing so, we have created a couple of innovative ways to create the schedule, make sure that staffing is covered, and that our clinicians have the highest level of quality in their lives that they can have and a work-life balance as much as possible. So one of the areas we have focused on is how do we combat burnout? As everyone in a critical care environment of any type knows, burnout is an issue that we encounter frequently. It has become synonymous with critical care in the last few years. One of the other principles and recommendations that AACN included in their consensus statement was that we need to identify and address the unique ethical dilemmas and moral distress that can be encountered when working in the tele-ICU environment. One of those distressors is the fact that we have 24-7 care, much like the bedside staff. That leads to issues with psychological and physical outcomes for the clinicians. So we decided to come up with a way to try and mitigate those effects as much as possible. When looking at how to combat the nighttime work issues, we started thinking of a different type of team. Amar Gupta published a research study where they looked at 11 hypotheses that were tested in a controlled field experiment involving one co-located team where everyone was in the same work area and one distributed team where different people of the team were geographically dispersed to different areas. It was characterized by similar composition, tasks, and collaborative technologies. The results showed that the two teams differed in their use of technologies and the knowledge and the knowledge sharing process, but not in efficiency and quality of outcomes. This is one study that shows that having geographically dispersed teams has some differences involved, but in the end the efficiency and the quality of outcomes were maintained. So in order to fulfill that fourth aim of increasing joy and work, the geographically dispersed teams sounded like a good idea to us because they're possible technically and they're high performing. We developed a transcontinental telecritical care model in 2016 that allowed us to deliver care to Emory EICU patients in Atlanta from Australia. How we managed this was redivining our EICU team. We actually took one physician and one nurse and relocated them physically in Australia. That allowed them to cover the nighttime shift during the day's time in Australia. It allowed our program to reduce the number of nighttime shifts that had to be filled during nighttime hours. It also allowed our staff to explore another side of the world that they may not have been able to visit unless it was part of this program. We call it Design for Outcomes and Engineer for Joy. While our clinicians worked in Australia covering night shifts that are hard to fill in the U.S. because weekends and holidays are not easy to fill, we covered those by allowing the staff, as I said, to cover night shifts by working in the daytime. These are just a few pictures of our staff. Some took their families with them, some took friends with them, and they actually formed very close relationships with those they were working with over there, probably primarily because they were the only people they knew in the country, in the city. It allowed them to explore the land, the customs, the cultures, and work less night shifts. We also found that there was a change with COVID-19. We had a dramatic increase in the number of patients we were monitoring. We also had a high number of COVID patients that we were providing care to. Our average daily census in one month went from 104 to 151. That was a 50 percent increase in the number of patients we were taking care of, around 1.4 new patients in those beds each and every day. We had fixed beds and mobile carts that we deployed across the system to try and increase the support we could offer to bedside staff. Our census, even now, has maintained around 145, and this has been due to changes associated with the pandemic. The bedside staff also have tripled their requests for bedside assistance, and our nurses increased their camera session times, which is when we go into a room, we look and see what's going on, and we help out as best we can. From January of 2020 to September of 2021, those incidences, camera sessions, increased dramatically from 8,800 to 39,000. You can also see that the number of camera sessions really had the same ebb and flow as when we had surges with the pandemic. In response to COVID and all of the implications and issues that are related to it, we decided to create a work from home program. In this program, I developed a mobile workstation, workstation in a suitcase. I purchased laptops, a docking station, and monitors so people could take the equipment home and set up their own environment. All of the applications that run in our physical hub also run on these at-home workstations that people set up. The way this works is that a nurse takes the equipment home and works from home for a month, then comes into the hub for two months, and it's a rotation-based program. So each nurse gets an opportunity to work at home for a month, and then everyone also comes and works in the hub, and it helps to re-establish their relationships. And I feel it's important for people to work in both places, not have someone who's permanently working from home. But as you can see, everyone sets up their own environment in a way that makes them comfortable, and they even have their pets sometimes next to them, although the pets aren't on the camera. But it gives them a feeling, as I said, of comfort that they know their environment and they enjoy working there. So here are some outcomes that are associated with our work from home program since we implemented it in June of 2020. This was a voluntary program, and more than 70 percent of our ERNs are participating in work from home. Some still like to come to work, and that's fine. We still have the physical hub there, and actually have to have people in the physical hub as well as working from home. We also found that those hard-to-fill shifts and shifts where someone has had to call out were covered, are now covered, excuse me, 80 percent of the time. Before we implemented this program, we had a 15 to 20 percent coverage rate for late call outs and other issues of that type. That has increased dramatically. When people can work from home, they're much more likely to say, oh sure, I'll pick up the shift because it's easier for them and they know they don't have to physically drive to work. 58 percent of our shifts are now covered by those who are working from home. One of the big results we found was that when looking at Press Ganey scores for the last several quarters, we found that there was an overall increase of 15 percent in our resiliency scores. So that was a great finding. The efficiency of work has remained stable. We continue to monitor different metrics that we've always monitored in our area, and we've seen no change in efficiency of work or outcomes related to the beginning of this program. In conclusion, I just want to share a couple of things I've learned about resilient teams and trying to ensure that the schedule is covered and people are feeling good about their work-life balance and their quality of life when they're working. I have learned a lot of lessons in hiring, and I have a requirement of a minimum of five years experience in critical care, and all of my nurses are required to be CCRN certified. So I'm not so much looking at trying to teach someone critical care skills because they have to have those when I hire them. Their critical care, critical thinking skills are intact, and they have a lot of experience. What I try to hire for is attitude. You don't hire for skills, you hire for attitude. You can always teach someone skills. Simon Sinek said this, and I think it's true. I have found it to be true. Listen and seek to understand. This is something our staff and I discuss a lot at our meetings. If someone makes a statement and it's perceived one way by someone else, then for them that's real. So our staff work really hard to listen and to seek to understand each other. That's very important for me, but it's also very important for everyone who's on the team. My biggest takeaway is don't be afraid to innovate. We're constantly looking at ways where we can deliver quality care and support bedside staff the same way we always have, but do it in an innovative way so it also adds to the support and quality of life for our own staff. If the telecritical care team is more stressed out and having more moral distress just like the bedside team, it makes it more difficult to be supportive and to help them. So finding ways to make our team more resilient and have a better quality of life allows them to provide the most support and quality patient care they can for the teams at the bedsides. Thank you for listening. I hope you have a wonderful conference.

telecritical care nurses

work-life balance

geographically dispersed teams

burnout prevention

innovation mindset