SCCM Resource Library-Tele-Health Explosion: What We Learned During the Pandemic

Tele-Health Explosion: What We Learned During the Pandemic

Video Transcription

Good afternoon, everyone, and welcome to the Telehealth Explosion, what we learned during the pandemic session.  I've had the privilege over the past year to serve as the chair for the Telecareer Committee, and I'm going to serve as the moderator for this session.  I'm going to introduce the topics. The first topic is a silver lining in the COVID-19 cloud, humanizing the ICU experience  through telecritical care, compliments to the core, a multi-professional approach to telecritical care and the impact during COVID-19.  This will be from a nurse perspective, a pharmacist perspective, and a respiratory therapist perspective.  The learning objectives for this session include describe novel patient and family-centric telecritical care delivery during a pandemic and future applications, and also to discuss  the rapid escalation of telecritical care use in hospitals, staffing model considerations, lessons learned, and opportunities for the future based on the experiences during the  COVID-19 epidemic from four disciplines. Good afternoon, everybody. My name is Chris Palmer.  I'm an assistant professor of emergency medicine and critical care at Washington University in St. Louis, Missouri, and I'm a co-medical director for our tele-ICU program.  My lecture today is on humanizing the ICU experience through telecritical care and what I like to look at as the silver lining in the COVID-19 cloud.  From a disclosure standpoint, I am on the medical advisory board for a telehealth startup company called Omnicure, but I'm not going to be speaking about that today.  My only other disclosure is that I'm an absolute fanatic and I have a deep love affair with telemedicine that I will be talking about today, and probably to a fault is my love  affair with telemedicine, and I won't be apologizing for that. I figured since I'm going to be talking about humanizing critical care, and a lot of that  has to do with burnout, I figured I'd give everybody their daily non-COVID-19 moment for some burnout relief, which oftentimes involves kittens, puppies, or babies.  I'm a first-time dad, and this is my daughter, Clara, and she always puts a smile on my face, so hopefully she can put a smile on yours as well, and you can escape your COVID-19  burden for the day with that picture. The outline for my lecture today is really just kind of discussing humanizing the ICU  experience, and what has the impact of COVID-19 been on humanizing the ICU experience, usually  to its negative, and what role can telecritical care play, both at present and in the future, in this concept?  I think it's important to think about the definition of humanizing critical care, and  critical care, and before we go any further, and I don't think there's one particular definition  that encapsulates humanization, but at the same time, I think there's some pillars that we can be guided by, and that is step one is that everything that has been done to promote  and protect health, cure diseases, and guarantee an environment that favors a healthy and harmonious life on a physical, emotional, social, and spiritual level in people.  The second pillar would be it demands intrinsic dignity of every human being.  The third, from a humanizing standpoint, would be individualizing care, and really paying attention to what patients and families need.  And the fourth is to not forget about us as healthcare professionals, and that we're fallible and vulnerable, and need to be taken care of as well.  So if I think about humanizing in this fashion, it makes sense to me.  But at the same time, I really think it's important to always go back and start with the why, so that it really resonates with people.  And I can just tell everybody that it's important to humanize your ICU and the patient's ICU experience, and I don't think a lot of people would disagree with that, but why should  we be doing that? And for me, it's different for everybody, but to be quite honest, for me, it was the  moment that I became a family member of a critically ill patient and really saw all the flaws in our current ICU care delivery model.  This is a picture of my dad, with his permission, when he was in a ICU for two weeks in rural upstate New York. We thought he was having a stroke.  He ended up having a subdural and needed to have a hemicrane, and really just had a prolonged ICU course.  There was no intensivist there, just kind of complication after complication. It was frustrating for my family, and I was trying my best to help out here from St. Louis.  At some point, I had to actually go there and take him off the five antibiotics that he was on that he didn't need and get him on DVT prophylaxis, all the kind of some  of the basic stuff like dopamine and beta blockers at the same time. It was just crazy.  So it was a very frustrating experience.  He did come out of the ICU, and then when he did, I asked him, hey, can you just write down some of your experiences while you were in the ICU so that maybe I can learn from  that and be a better doctor?  I'll read what he wrote here. He said that, I wasn't aware at this point. Every 10 minutes, I would be awakened for vitals and pills and IVs for the next two weeks.  I have to admit, I was frightened and embarrassed of my condition. Mind you, this is coming from a doctor's father, and he should kind of know all this, I would think.  But he said, I became convinced I would never be myself again, and I loved who I used to be. My cognitive skills seemed terribly diminished. I couldn't say the alphabet.  I would be told by everybody that it would come back, but I just didn't believe it. I was depressed for the first time in my life, stuck in a very dark place.  I felt I would be a burden to my wife. I wouldn't take visitors. I just was annoyed that the doctor who saved my life spent less than 30 seconds once a day with me.  I couldn't talk fast enough or well enough to ask him questions, and knowing he's an incredibly busy man was frustrating.  So that kind of experience really shaped my life and my perception of how we deliver critical care.  And I had a serendipitous moment at SSEM 2020 in Orlando where I was just kind of like, I think we've all been there. It's nice out. We weren't wearing masks.  You know, it's like, hey, let's go to the pool. Like, the conference is kind of winding down.  But, you know, I saw a lecture in a program that I was just kind of really struck by and moved by, and I was like, oh, this could be, you know, a great thing to go to.  And so I went to the lecture, the plenary speaker lecture by Dr. Nicholas Nin on humanizing  intensive care, and was just absolutely blown away by what he and others are doing in terms of this movement of humanizing intensive care, and I learned so much that I had never  even heard of that others were doing. Just kind of revolves around this movement and research project that started back in  2014 to really create a more friendly and human-centered model of critical care that's focused on these kind of eight pillars of improvement and research that would hopefully  lead to a paradigm shift in the healthcare model.  And we'll go through these here in just a few moments. And so as I was sitting here and in the lecture auditorium, at least now it's virtual, it  will be virtual this year, you know, I just had this idea. You know, I'm always thinking telehealth first. How can I incorporate telehealth into this?  And I was just kind of like, this makes perfect sense to me. Like, everything he's talking about, albeit one, you know, the humanizing the architecture  and infrastructure of the hospital. I believe that telehealth, you know, could improve upon this and really be a way to help  humanize the intensive care experience for patients and their families and would help in ways that I was really struggling when my father was in the ICU.  And so I remember right after that lecture, I kind of went up to some people and I was like, guys, like I want to humanize, you know, the ICU through telemedicine.  And it was just kind of like a lot of laughs, you know, because like in people's minds, they're like, wait a minute, you're going to humanize the patient's experience through  technology, you know, and they have this picture of robots in their head. And it's just like, I don't know, it just, it didn't sit well with a lot of people.  But I still had conviction that we could make this work. And mind you, though, this is pre-COVID.  And well, not pre-COVID, just like a month or two before it all got real for all of us. And then, you know, obviously, this thing called COVID hit and we were all kind of faced  with it at that time. And I think we all stepped up to the plate. And we're like, hey, like, you know, you know, this is challenging. We're not going to let this crisis go to waste.  We're going to get better. We're going to improve. And I love this quote, you know, that there are decades where nothing happens. And then there are weeks where decades happen.  And that was March, April, May for all of us due to COVID-19. And specifically, you know, with telemedicine just kind of like just exploding during that  timeframe and people's need and desire for it. So if you already had a telehealth program established, you had a huge head start.  And so at that time, I was like, okay, this is the chance to really kind of like put these concepts into play.  And so the first kind of pillar that they talk about for humanizing the ICU experiences through an open ICU visiting policy, which makes sense.  And I think most of us would agree here that, you know, if we had open ICU visiting policies, it's better for patients and families.  There is research on this, but it's hard, you know, in terms to study this and trial designs and what are the right outcomes to study for delirium or should we be looking  at family outcomes versus patients? Like it's a mixed bag. But there is research on this. And overall, it's just the reason we have traditional typical ICU policies is really  just due to more historical context. And that's what they used to do. And we've carried it forward.  And so a typical ICU visiting policy is really just like I say, it's the wall of art, you know, get well soon, the balloons and static pictures.  And hey, you know, at seven o'clock, we're closed. The announcement comes on. There's never any kids in the ICU.  Now as a new dad, if you told me I couldn't see my daughter for like a week or two, like it would drive me nuts. And so that seems wrong. And then there's COVID.  And then, you know, people are basically like trying to break down our doors to get in to see their family members, which I completely understand why.  Because patients are literally just dying alone in our COVID ICUs. And that's terrible for everybody.  And so from a telecritical care standpoint, why don't we just invoke the virtual ICU door policy where at this point in time, you know, visitors really, we want them to focus on  them being as partners in care. We turn wall art into more dynamic video chats like you see here on the right where, you  know, you're just kind of, you're talking to your loved ones, seeing your kids and hopefully like improving your mood if you're able to do this and you're not intubated, obviously.  And so that's what we did. We said, hey, let's institute this open virtual ICU door policy.  Our nurses, our APPs, our docs in our core would use our technology to kind of link families into patients' rooms.  This is an example here of just a family member just kind of chatting with their loved one, being able just to talk with them, not just stare at a picture on a wall and just have  those meaningful conversations. And so I think that, you know, an open virtual ICU door policy can also augment having a more open ICU door policy in real.  I also think that another pillar here is presence and participation of relatives in the ICU. You know, this kind of lumps into, I think, the ICU visiting policy.  You know, we certainly can't have family members like helping patients eat and drink and participate  in physical therapy via telemedicine, you know, like physically, but we can have their presence.  And I had this picture of a lady who wouldn't get out of bed and participate in PT, but as soon as I was able to get her family on via our mobile cart and she spoke Russian  and they were encouraging her, she's like, okay, I'll get out of bed and she participated.  And so like these kinds of things are meaningful for patients and I believe that ultimately they'll improve outcomes.  And so telepresence and participation of relatives, I think, is a no brainer. From a communication standpoint, communication is key. It's everything.  All the lawsuits and issues and problems that we have in a hospital always, you know, come down to poor communication.  And the typical communication is really just kind of like a very siloed program. We basically have, it's a frustrating experience for all of us.  It's trying hard to get the information that we need. I'd say during COVID, you just kind of felt completely isolated.  You know, patients would have dropped off in the COVID ICU and be like, who is this patient? Why are they on BiPAP? Why are, you know, what's the sign out for here?  So I think many people experienced that and it was terrible. Same thing from a family perspective during COVID. You know, many families were in the dark.  Our rotation schedule for physicians was just off. You know, we weren't sure when the family last was communicated with, so it was just challenging.  And so with telecommunication, we decided, hey, like, you know, let's make this more grand central station.  Let's bring in all the communication through the tele-ICU, a central hub so that we can then really use that spoken hub model that we deployed to its full effect and we can  hopefully just congregate the information so we improve our ability to hand off, sign out, and have a more structured view of that.  And so I really believe that telemedicine and tele-ICU can help from a communication standpoint.  And not only just use the hub and spoke model, but when the spokes should actually be able to talk to each other. Why keep all the telehealth technology at the core?  You know, bring it to the bedside and let them use it to interact with patients and consultants. And that's what we did.  So we just spent a lot of time bringing our software out to the bedside, installing it across all of our ICUs across the system so that now respiratory therapy and our consultants  can communicate with each other and be present on rounds and be more efficient in their consults.  At the same time, allowing our nurses and bedside providers to communicate with family members and prevent having to go into rooms and just be a more integrated, holistic system.  And certainly there was no communication from the bedside using our cameras prior to March and then now you can see even as of November, 500 hours is being used by the bedside with  the tele-ICU software between different providers to help improve patient outcomes and really  improve communication and decrease errors and the lack of communication I think is prevalent in our system beforehand.  The next pillar I'd say or research motive for the humanizing project would be the well-being of the patient.  And so I think of this as kind of the ABCDEF liberation bundle, which is just so critical  and kind of making sure that we're doing everything we can to liberate patients and get them out of the ICU as quickly as possible.  I think from a COVID standpoint, I think of the early days of COVID, March, April, especially is just almost like a horror story.  I'd walk in here and be like, at our institution, we're a good institution. Patients are getting pressure ulcers. They're not getting turned.  They haven't seen their consultants because they weren't allowed in the COVID unit. We're not talking to families. They're still on the vent two, four weeks later.  It's just like a bad situation. And so at that point, we're like, okay, that's terrible. We can't continue this.  And it really has pushed me to kind of make the telecritical care station more of that care traffic control center and say, hey, just because we're doing something this way  at our main hospital, we should still be able to do these things at all of our satellite hospitals and have this very unified, homogeneous program of high quality critical care.  And so that's what we're working on now is kind of using telemedicine to kind of institute  the ABCDF liberation bundle across the system and having the teleICU be more of the fact checker to kind of say, hey, you've completed your bundle.  You're doing all these right things for the patient. If you haven't, let's provide real-time feedback to them to say, why haven't you done it?  What can we do to get that accomplished? And I would say at the same time, it's not just about, hey, you've gotten them off the  vent, but kind of really taking that holistic approach and saying, hey, the lights are down. The sound is low. Spiritual care has been involved.  We can do this even from the core involving palliative care and spiritual care via the telemedicine to really help promote the wellness of patients through telemedicine.  Number five would be burnout, which I certainly believe is a huge problem. It was a huge problem before COVID, and it's an even bigger problem after COVID.  And we've been very focused on this in the past few years, and rightfully so. And COVID has taken this to the next level, given the stresses and the hours and the death  and the PPE donning and doffing, just the worry between us and for our family members, it's really taken burnout to the next level.  Now, not to kind of say that the tele-ICU is like this posh place to work, and it's not stressful at times, but I work in the tele-ICU, and I can certainly say that when  I work in the tele-ICU, there's just a different level of stress that I have compared to the bedside. And this picture here is a guy wearing jeans. Maybe it's casual Friday.  I don't know, but legs are crossed. And I've had some very stressful days in the tele-ICU, but as a whole, I'd say that I have  a new frame of reference and a different outlook when I come to the core and I'm taking care of patients virtually.  And I think it helps me to be a better bedside physician, and it gives me a little bit of a break from bedside care.  And I don't know about you, but at least in our core, we have a little bit of an exercise center.  I'd like to even institute some yoga classes a few times a week just to, again, to promote wellness within our staff.  And if you have faculty that kind of rotate through, I think that's to the benefit of the whole program. And also, I'm coining this term. It's called a workcation.  So the next time you see this, you've heard it here first. But the tele-ICU, I believe now with the fact that we're all working from home or can work from home.  Again, Emory started this years ago. Now they do tele-ICU from Perth in Australia. I plan to set up a core in New Zealand, my favorite place of all time.  But you can work from anywhere. You can do tele-ICU from anywhere in the world. And I think that that kind of also could be this really neat way of decreasing burnout  because you work in New Zealand and then you go play in New Zealand and you're just a much more happier individual, I would guess.  Moving on, I'll talk about post-intensive care syndrome, which is an important part of humanizing the ICU experience.  Post-intensive care syndrome is really just the physical, cognitive, and mental impairments that ICU survivors and their families face. It's still a new concept.  It's pretty poorly understood. About 50% of patients may have these symptoms. And there's very few recovery centers in the United States for patients to get help with  these symptoms. COVID may make PICS even worse. These patients, again, the liberation bundle was disrupted, heavy sedation, paralysis,  not seeing their family members, longer time on the ventilator, just all this stuff that may kind of lead to more unique features of PICS in COVID patients.  And so how is telemedicine going to fit into this? Well, I believe it's the part of healthcare that we haven't really tackled yet.  And it's not just when they're in the ICU, but it's even after they leave the ICU that we still need to be taking care of them. And so we were awarded a grant to kind of study this.  And we've set up a research feasibility study called the COVID-19 Virtual Post-intensive Care Syndrome Clinic, or COVE-PICS for short, which is Modern, Convenient, and Practical  Recovery Care, which is our hypothesis is that a virtual outpatient PICS clinic focused on COVID survivors is feasible, and it's going to improve their physical, cognitive,  and mental health. And so we just have decided to design and implement a virtual clinic. We're trying to evaluate the utilization, satisfaction, and challenges that the clinic  presents and also assess for those unique post-COVID features of patients.  And this is an example here of the COVE-PICS clinic, where it's really just on Zoom. We have pharmacists, social workers, PT, OT, dietitian, and intensivist.  You can do this from anywhere. The patient can do it from anywhere. And so as long as they have access to technology and, you know, a computer or mobile phone,  they can check in and get some information about PICS that they never had before. We can kind of make sure that we have this well-coordinated response for their care,  even after they've left the ICU. We're not just leaving them alone and to follow up with a primary care doctor who knows nothing  about their intensive care experience and what they went through. And so I think that this is going to be a huge thing, and I do believe that telemedicine leads the way.  And also to tie this back into burnout, I'll tell you the happiest I've been—well, I'm not going to say that because my daughter was just born this year, but maybe the second  happiest I've been this year was when I was able to take care of a patient that I helped transfer from the tele—you know, they were in an outside hospital.  Through the tele-ICU, I was able to transfer them to our main academic center. I then took care of her and extubated her after she came off ECMO when I was the COVID-ICU  intensivist. And then I saw her in the COVID-19 tele-PICS clinic afterwards, a few months later, doing  well and just, you know, having some minor issues that we were able to kind of help try to get her teed up for.  And so that, I think from a burnout perspective, is just a huge way to kind of, you know, improve  the way that you practice medicine because you see how these patients turn out. And also you are able to celebrate the wins and then at the same time learn from some  of the losses and understand why—how patients do after they're discharged from the ICU because their experience isn't over for them, even though it may be for you.  Starting to wrap up, you know, I said I'm going to skip number seven, the kind of infrastructure part because I don't believe the tele-ICU can really impact that.  But it's a very important—I think we'd all agree that it's important to have an end-of-life palliative care model within your ICU so that we can improve the quality  of life for patients towards the end of their life. And palliative care is just such a huge resource for us at our Washington University and Barnes Hospital.  And there is research to kind of show that early involvement of palliative care is great for patients.  And then maybe it should just be almost automatic or just be trigger-based, you know, so that you don't have to remember to call them.  It's just like, hey, if they meet certain criteria, palliative care should be involved to really help kind of move the patients through their ICU course and make sure everybody's  aligned with their goals of care. But, you know, certainly during COVID, that was almost non-existent.  Our palliative care folks weren't allowed in the COVID ICU and so it was just, you know, patients, again, family members weren't there.  It's really hard to have these goals of care discussions when nobody's around or, you know, you just also don't have the time because normally you rely on some palliative care  specialists who that's what they focus on and they're so good at. And so we said, hey, similar to kind of the communication perspective, but also from a  consultant perspective, hey, let's make sure that our palliative care folks, spiritual care, chaplaincy is hooked up with our software so that they can help us camera in, talk to  patients, even if the patient is intubated, they can still have virtual chats with family members, you know, if they want to, or they can just be in a separate breakout room and  just kind of really talk about goals of care, include the intensivist as needed as well, just to make sure that we're all aligned.  And, you know, it really helps to be able to have patients care progress forward when you're actually able to see them.  And you know what we're talking about when we say they're on life support and pressers and all these machines, including dialysis.  It just, I think it really just brings it home for the patient's family members. And hopefully, you know, we can align ourselves with the patient's, you know, overall goals of care.  So wrapping up, I think that, you know, we're certainly, we're undergoing a digital health revolution. You really make no mistake about that.  It's really just COVID just advanced this timeline, I'd say by about a decade or more. And everyone here is on the forefront of that revolution, which is really cool.  And I think, you know, our interest in telemedicine will help lead the way here. You know, there is absolutely no going back. The proverbial genie is out of the bottle.  And I, but I believe this will really allow us to realize the value and the potential and the efficiency of telemedicine.  And this will really allow us to put the patient back into the center of everything that we do. And we can use technology to build out from there and then augment our abilities and  capabilities and use telecritical care as really an adjunct to humanizing the intensive care experience for patients.  Finishing up, I'd just like to take a moment to wrap up about the story about my dad. And just remind everybody, the patient's journey isn't over once they leave the ICU.  It could just be beginning, even though it's the end for all of us. And this is also true for their family members.  My mom said, hey, you know, the hospital gave me paperwork on his meds and incision care, but I was not prepared at all for the emotional side of caring for a TBI person.  The seizure med side effects really tested me. It changed his personality in a way I wasn't expecting. He was agitated, anxious, confused.  His short-term memory was good, so it was bad, foggy, short-tempered, and just he wasn't himself. I sometimes have trouble falling asleep.  Some of those bad days from the hospital creep into my head. I just need to look over and see Jack, my dad, sleeping, and I can relax.  And it hurts to see your husband hurting, and I felt helpless some days. A caregiver really needs support as well.  And I think that, you know, that's a really powerful and important thing to remember, and I think the only thing that I would change or modify that, knowing what I know now, is  that it's really the entire care team that needs support.  And, you know, I really believe that it's our mission now to use telecritical care in order to achieve a more humanized experience for patients and their family members, and  I'm excited to do that moving forward. Thank you very much.  Good morning, everybody. I'm so glad to be here.  I am Fiona Winterbottom. I'm a clinical nurse specialist at Oshina Medical Center in New Orleans, and I'm here  to talk to you about telecritical care, the impact during COVID-19 from a nursing perspective.  I have nothing to disclose, and I really just am going to talk about our program and then a little bit about how we used and are still using telecritical care.  So our program went live in March of 2012, and we had a staged implementation over about six months where we supported seven critical care units across the kind of greater New  Orleans, Baton Rouge areas.  Since then, this program is now supporting 12 critical care units and was covering 230 beds.  There's an average daily census of around 160 throughout the Oshina system, and our staffing model is a 24-7 nursing model with every nurse having about 40 patients per nurse.  And then we have a board-certified intensivist at nighttime, usually 7P to 7A, and they cover about 150-ish patients.  So most of you will be familiar with this graphic from the Johns Hopkins site that really shows the ICU occupancy over time, and you can see where the heaviest areas are.  In Louisiana, we were hit fairly early on, so March 2020 was really when we had the pandemic crisis.  It was right after Mardi Gras. We weren't really expecting it, and we went from zero patients in our hospital to 350 COVID patients in about 10 days. So it was pretty significant.  We grouped everybody together. The ICUs obviously had to meet the demand, although our med-surge areas felt it first, and then we felt it a little bit later.  Staff protection was an issue, as it was for everybody, because we weren't expecting the surge, and we really didn't know much about the disease altogether.  And so everybody had to create surge plans fairly quickly.  This graphic really just shows you the facility where I work, and it's a large academic center. It has about 600 beds, plus, minus a few, because it seems to change frequently.  Our teams have published some articles that show the way that the virus affected people  in Orleans and Jefferson Parish. So if you're familiar with those, they kind of sit either side of us, and we sit on the banks of the Mississippi, right outside New Orleans proper.  So with regard to our telecritical care surge support, there was a huge need for suddenly a lot of ICU beds and coverage, both for people and equipment.  As most of you know, getting equipment is not easy in a surge or a pandemic either. So we had to manage those issues and mitigate those issues too.  We needed to get, improve our response time to all of our patients across the hospital. We needed to make sure that it was safe for patients and families and staff,  most of all, in the hospital.  So this gives you an idea of our rapid ICU census growth. You can see that right there at the beginning of March and April, that was our biggest months.  And those numbers are up to the 300s in that time period.  Early on, we did probably what most people did, and we intubated most of our critically ill patients, people on high-risk beds,  critically ill patients, people on high oxygen, with high oxygen requirements. That number right there is 124. I think we got to right around 130  was our max ventilator usage at one time. We used tier one, tier two, and tier three types of equipment. So we had different ventilators, different pack machines.  We had a variety of different things that we used to make sure that we could deliver. We never ran out. We just used different equipment.  You can see the telecritical care growth here and how quickly that happened. Basically, in the first two weeks of the pandemic hitting the New Orleans area,  the bed increase was 42% increase with a total of 127 beds. With regard to equipment deployment, as I said earlier, it's a challenge to even get things like headphones and cameras.  So we really utilized every resource that we had available to us. And we had several because we had been piloting several different types of equipment over time.  So we really gathered together all of our leaders, service lines, biomed facilities, and all our vendors to really help us meet the emergent need, which was a two-week timeline,  and then the urgent, which was a two-month timeline.  So we pulled all the stakeholders together. There were lots of meetings happening, trying to figure out how to deploy, where to deploy,  what to deploy, and how we would actually mobilize that equipment to get there. There were training tips put together for staff that have never used telemedicine before.  Our ICU staff had used it in some ways, but not in the way we were asking them to use it because we placed telemedicine on all of our bedside computers  so staff could actually access the patients from outside the rooms rather than being in the rooms. And then probably like most of you, we had staff deployed from clinics and ORs  and other places in the hospital. So we also had to train them on the general use of the equipment and on the general use of the technology.  So this is kind of a summary slide and I'll show you some pictures really of what we did across some of the system.  Mid-March to April was our highest utilization time. We hardwired many rooms and adapted them. We had some airflow changes and things like that  that were all part and parcel of how we adapted our rooms. Luckily, we actually had already built out some floors in one of our facilities that allowed us to have  a hundred negative pressure rooms that we could outfit. And in one of our other facilities, we were about to open another ICU. So that gave us additional ICU space.  So we were in a good position to flex, even though it took a lot of building, we were able to flex and move a lot of equipment and people fast.  So this was our Kenner location. They were already building an ICU. So they were actually able to open two ICUs, keep that old one open and open this beautiful new one,  which of course then needed to expedite all the telemedicine and everything else, as well as building out the rooms.  This is our academic center and these were really outfitted.  They were shells at the beginning, which is where you see this picture up in the top corner. They were a shell really when the pandemic started  and very quickly outfitted to be not necessarily like our other ICUs with lots of office space, but the patient rooms were all outfitted with telemedicine and everything else  so that they could be fully functional for patients. So we were able to scale that by June, July, three of those floors were able to be opened,  which was 34 beds a unit, so 102 beds.  This is another example of how we used our telecritical care clinical support. So that's me in a overall, close to the beginning of the crisis, I think.  We already have, our tele-ICU already documents our procedures and things like that. They do timeouts, they make sure credentials are all organized, they put in our LDAs.  That was just something that was so super helpful during this time where there were people that don't usually work in the ICU that were there. So they were actually able to help  and coach with that too.  With proning, when we needed lots of people, that was another thing that they were able to kind of be, surveil the equipment, make sure that ventilators were safe  and tubes were safe and things like that. So that was really helpful.  We use some communication technologies for patients, for families, and for staff. So that's a picture of a modality, a tablet modality where we were conferencing  in a family with a patient who was not able to communicate, and then the top corner with the red light is where the patient was actually able to communicate in some ways  and interact with family. Because if you remember, and I'm sure some of you are already doing this also, we had periods where no family members were allowed into the hospital,  which is pretty devastating when your patient's family member is in critical care.  This is a picture that shows our virtual nurse program. So that was at our Kenner location that was already in place. So we were able to use that to monitor patients  in med surgery areas. So again, just scaling what we already had.  We had some other tablets that we were able to utilize with our rapid response team. So they were able to really use stands and things. We could do a drop-in or a call.  So it worked both for dropping in and leaving equipment in the room to monitor patients where there was no hardwired technology. And it also helped if the nurses themselves  needed to almost consult a provider so that they could communicate and you could actually visualize the patient. So maybe one person was in the room and not four.  Again, for trying to protect the staff.  This is kind of where we were and where we are now. So from 205 beds to 466, and you can see the geographical locations that we cover. So the state of, it's pretty much  the whole state of Louisiana. We have some coverage across the state.  These are the numbers as of the beginning of January, 2021. And as you can see, the numbers are climbing. The top number is the hospitalized patients.  And then the yellow is the number of ventilated patients. We have stopped intubating people early. So our numbers, where they were very high at the beginning of March, April, 2020,  I suspect will be a lot less. This again is that same ventilator utilization chart that you saw earlier, but you can see we have much less utilization  where we were close to 130, we're in the 80s.  This is the facility that I spoke about where I work, where we have most of our academic center. And again, just showing that we have  most of our academic center. And again, just showing that we are not through with this, even though we're all getting our vaccines. We hope to be through soon,  but we do have this spike that's coming. And so hopefully we'll be able to use all of the equipment and technology that we put in place in the early months in March and April  to be better prepared now here in the beginning of 2021.  So what do we learn? We learned that we can leverage technology in multiple ways.  We have been very flexible  during these disaster response time. Telecritical care has benefited us greatly during this time.  We've had huge increases in the use of that technology. And I'm sure there are other things that we've thought about and could still use as we move forward.  And then we were able to increase service to patients in other specialties, not just the ICU, so well outside the ICU. Our hospital medicine team has a telemedicine program.  Many of our medical and surgical specialties are non-critical care units. So our critical care kind of without walls and our rapid response team. And we really did identify  that we feel like there are some places where hard wiring is important, but the use of carts has been phenomenal. We've been able to change ORs and PACUs  and places where we don't usually have monitoring endoscopy into ICUs.  So I just want to finally thank and acknowledge everyone who's participated in getting our telemedicine program to everywhere it was needed. So the names of our key team members  who deployed all of our equipment and help us move everything when we needed it are up there in the corner. And then there's pictures of our staff  from across our state who have all participated in taking care of our patients and trying to keep them safe. Thank you for your time today.  Good afternoon. My name is Sonya Everhart and I'm a critical care clinical pharmacy specialist at Atrium Health. I split my time between the bedside  at our second largest facility in virtual critical care. And I'm here today to share our telecritical care pharmacist perspective and impact during COVID-19.  I have nothing to disclose.  My objectives today are to define telepharmacy and telecritical care pharmacists, describe Atrium Health's virtual critical care program,  discuss the division of pharmacy's response to COVID-19, and finally review the telecritical care pharmacist impact on critically ill COVID-19 patients care.  The following definitions will help ground my discussion. Telehealth uses electronic information and telecommunication technologies to support long distance clinical healthcare.  With the growth of telehealthcare, telepharmacy has expanded as well. National pharmacy organizations define telepharmacy as oversight of pharmacy operations  for patient care services via telecommunications technology. Several studies have looked at the role of the telecritical care pharmacist and have shown similar results to bedside  or decentralized critical care pharmacist in providing remote order verification, clinical interventions and drug information along with helping standardized care.  Virtual critical care or VCC at Atrium Health was established in 2013. It is a hub and spoke model serving more than 300 ICU beds at 12 hospitals.  The VCC is a multi-professional team consisting of physicians, nurses, pharmacists, respiratory therapists and various support staff.  In 2015, pharmacy services were established at VCC. Originally staffing was established during second shift hours to coincide with the initial physician shift at that time.  Two full-time pharmacist staff Monday through Friday on alternate weeks. They perform chart reviews based on clinical alerts  for new admissions. In 2017, we were fortunate to add day shift coverage on Mondays, Wednesdays and Fridays from 7 a.m. to 12 noon with an associate professor  at Wendt University School of Pharmacy. A day shift pharmacist reviews each ICU status patient chart at select facilities and also virtually rounds with three rural facilities  who do not have a critical care trained pharmacist on staff. As COVID-19 cases were emerging in other parts of the U.S., the Division of Pharmacy at Atrium  began preparations for our expected surge. Operations and clinical pharmacists worked diligently to create tools and guidance for the system. Inventory tracking tools were key,  especially for the critically ill as we were learning from colleagues in other states just how much analgesia and sedation these patients required. Guidance documents were developed  by the critical care pharmacist to help non-ICU trained pharmacists feel more comfortable managing these patients. In addition, the VCC pharmacists  were available during a time of limited resources. To provide social distancing in each physical pharmacy location, pharmacists were asked to work remotely.  The two VCC pharmacists set up homework stations and were provided an additional monitor to ensure dual screen setup. Throughout the initial surge, the summer low  and now our fall and winter surge, communication has been crucial. Corporate incident communication Corporate incident command provides ongoing updates  for the system while daily touch points in each department provide information about local issues, views and needs.  Inventory management tools were crucial for helping manage our patients. A special location on our internal SharePoint site was created for the division of pharmacy  and accessible by all pharmacists.  Inventory tracking documents help each pharmacist know how many doses of critical medications  are on hand daily, as well as how many patients we can treat.  For managing the critically ill, the ventilator support medication tracking sheet was invaluable. As shown here, it provides the quantity on hand,  projects how many days we can support a specific number of ventilated patients.  Centralization of certain medications ensure the most accurate count per day supply and simplified distribution to all facilities.  Shortly after we began seeing our first patients, the division of pharmacy clinical leadership worked with medical staff leadership and critical care and incident command  to enact emergency prescribing protocol for the critical care trained pharmacists in the system. From reports across the country, we knew that the critically ill COVID-19 patients  were going to need the greatest support. In addition to the protocol, seven day per week coverage was provided. The two BCC pharmacists remained staffing  Monday through Friday to maintain clinical practice at the second largest ICU in the system. During this time period, these pharmacists focused on the critically ill  mechanically ventilated COVID-19 patients providing a complete medication therapy review. They also clustered medication administrations  to minimize PPE use and thereby reducing nursing exposure. Additional resources such as daily statistics and dispensing reports were provided to aid with identification  and management of these patients.  Technology also played a large role. The pharmacists at Atrium Health Cabarrus began using BCC technology to virtually participate in multi-professional rounds  as seen by the images on the right-hand side of the screen. Pharmacists at other facilities utilized Microsoft Teams or phone calls to complete rounds.  These methods minimized pharmacist exposure and need for PPE as well as limiting team size to help with social distancing. Statistics on the number of tests performed  as well as the number of positive cases along with ICU and mechanically ventilated patients were updated and emailed twice daily providing a quick snapshot for the system.  This data helped each critical care pharmacist with their daily workflow. A daily report from the automated dispensing cabinets along with inventory tracking  helped the pharmacists with their chart reviews. These chart reviews resulted in discussions with the bedside provider to guide conversion to alternate therapy  including oral or per-tube administration, switching to an alternate agent versus ultimate discontinuation. The critical care pharmacist also created a medication guidance document  for the division's SharePoint site. Since the critical care pharmacists were not available 24-7, this information was available for all pharmacists in the system.  As seen here, this document provides dosing and titration parameters for the most common agents used for mechanically ventilated patients including in the table  for the neuromuscular blocking agents is dosing, our system standard concentration, advantages, disadvantages, and clinical pearls. Additional pearls for managing the critically ill  were included below each section and contained guidance for goal RAS, VTE prophylaxis, as well as ocular lubricant information for corneal abrasion prophylaxis  related to neuromuscular blockade. When the critical care pharmacist emergency protocol went into effect, it granted expanded practice privileges  like collaborative practice agreements in the ambulatory care setting. These are known as clinical pharmacist practitioners in the state of North Carolina.  This protocol allows the critical care pharmacist  in collaboration with the local critical care provider to automatically order, discontinue, or adjust certain medications per protocol. Once medication orders are placed,  the pharmacist writes a progress note to be co-signed by the provider. Focus on medication administration with once-daily versus twice-daily medications  by using proton pump inhibitors versus H2RAs, an oxyparin in place of sub-Q heparin, and timing electrolyte replacements when the RN would enter the known room next,  and finally scheduling finger sticks at the same time as other medication administration will help to cluster care, thus minimizing nursing exposure and PPE use.  Initially, no changes were made to the VCC pharmacist hours. We prioritized patients on second shift the same as day shift. Once the seven-day-per-week schedule was halted,  we realized our schedule needed to be altered to provide greater assistance to the bedside teams.  In addition, VCC carts were deployed to our three Georgia facilities. The VCC pharmacist obtained their temporary Georgia licensure, received training on three new EMRs,  so we would be a resource for the VCC providers.  How did this emergency protocol work for the VCC pharmacist? While many of our daily processes remain the same, such as the EMR-generated clinical alert triggering a chart review,  prior to the emergency protocol, as seen in the top line, we would place our medication therapy change request on the triage board and await approval by the provider,  followed by order entry and a progress note and documentation of an intervention. Now, between the hours of 1 p.m. and 3 p.m., we collaborate with the bedside providers  at our rural facilities for medication therapy changes. To do this, we utilize the EMR alert to focus our chart review.  We then use a secure messaging platform to provide our recommended changes to the bedside clinician. If they agree, we then complete the orders,  write a progress note, and document our intervention. Between 3 p.m. and 9 p.m., given our established rapport with the VCC providers, we implement the medication therapy changes,  write our progress note, and document our intervention, then notify the provider via the triage board  so they can countersign our progress note.  Shown here is an example of our notification to the VCC provider, as highlighted with the lime green in the middle of the screen, along with notification to the nurse at the VCC  that our intervention has been completed.  A standard progress note template was designed, as seen here, with the help from our informatics team.  Our VCC EMR work list generates alerts based on abnormal laboratory values, such as glucose, changes in serum creatinine, electrolytes, along with triglyceride  and the use of propofol with triglyceride. Between April 1st and October 31st, 2020,  our EMR generated more than 31,000 alerts that were reviewed.  Based on the alert generated, along with any medication therapy changes, we document an intervention in one of these overarching categories. These categories include code sepsis,  as shown by the light blue bar on the far left, glucose management in red, electrolyte management in green, stress ulcer prophylaxis in purple,  medication management in the teal bar, along with clinical consults and VTE prophylaxis  rounding out the bars on the graph here. This data is reported regularly to VCC leadership as well as the Division of Pharmacy leadership.  In addition to reporting by facility, we also look at the number of interventions per shift. The blue bars represent day shift interventions, while green is second shift.  The solid green bars represent facilities only covered by second shift, since there are critical care trained pharmacists available on day shift there.  In the pie chart on the left, nearly 50% of day shift interventions involve medication management, just dose optimization, medication discontinuations, adding medications as needed,  along with changing route or formulation. These interventions are most often identified by chart review. If you look at the pie chart on the right,  you will see that second shifts interventions are nearly equal parts medication management and glucose management. These interventions are more likely often linked to alerts  since additional facilities are covered.  This graph shows the total interventions completed monthly for the past four years. In this graph, 2020 is represented by the purple bars. As you can see, during March 2020,  our total intervention numbers increased due to a combination of increasing COVID positive patients plus implementation of the pharmacist prescribing protocol.  And as you can see, October took a huge jump to nearly 900 interventions.  In addition to reviewing charts, we are also a drug information resource and answer various questions from different providers, such as the VCC physician, the bedside physician,  any advanced practice providers, other pharmacists and nurses. Some examples of the types of questions we have answered include reviewing antiretroviral regimens,  treatment of agitation, reviewing renal replacement therapy with citrate anticoagulation.  Given that we review hundreds of charts monthly, several alerts help us guide our review for potential adverse drug events and intervene for avoidance.  A total of 272 interventions were documented between April and October of 2020. Examples of the self-identified adverse drug events avoided include adjusting sedation and analgesia  while the patient is on neuromuscular blockade, suspending long acting insulins when patients are NPO for falling blood glucose values, halting or stopping antihypertensives  while the patients are on vasopressors.  In addition, ensuring appropriate prophylaxis for our COVID-19 patients, adding ocular lubricant, changing VTE prophylaxis to enhance therapy  are among several that we've completed.  Pharmacists are an integral part of the multi-professional team, especially at the bedside as well as through telecritical care. The Division of Pharmacy, Inventory Management  and Patient Identification Resources made managing these patients easier. In addition, the prescribing protocol expanded the scope of practice  for all critical care pharmacists at Atrium Health with the hope that this collaborative practice agreement will become a permanent part of our workflow.  The VCC pharmacist use of the prescribing protocol allowed the providers more time to focus on higher level interventions  while optimizing patient care and minimizing patient harm, as well as leveraging limited resources to provide care to our many smaller facilities.  Thank you.  Well, thank you all. Those were wonderful and informative talks. We have quite a few questions that have come through for our faculty Q&A. Some of them are directed specifically  to individual faculty, and some are generic for everybody.  So I'll start with one of the generic questions,  which was asked, what are the best outcomes from a process perspective as it will help sustainability, and where will compensation for providers' time  head from insurance reimbursement? They noted the documentation I do for telecritical care is it's a much less than my normal critical care billing.  Chris, would you like to take that one?  I think you can hear me now. I was probably on mute.  Yeah, from a process perspective,  to make sure we have sustainability, I think that we need to focus on the processes where both the hospital system as well as the clinicians are seeing impactful results  for their patients that make them believe in the technology and the processes that we're doing. So I believe in terms of from getting patients  off the vent quicker through liberation bundle compliance  and having that be documented, I think that drives change. I think all things related to best practice and seeing quantitatively and with daily and monthly reports  that your compliance with best practice is improving, and then ultimately length of stay and mortality is improving, that drives adoption and sustainability. For our community ICUs,  processes that ensure that they're keeping sicker patients there in their rural hospitals that, and if they are hopefully maybe not transferring as many patients, but then as well,  that all of their processes that are in place for improving care are moving in the right direction. Complications are lowering. I think that's important.  So those are some of the things I think, if I'm understanding the question correctly, that I think would drive sustainability. And in terms of documentation and billing,  I think this is a golden time that we're in, in terms of being able with the disaster privileging to be able to bill. That was something we instituted very early,  as soon as it was allowed, as a lot of the rural restrictions for billing were removed. And I'm very nervous about that, to be honest, moving forward that many of the hospitals  where we do our most impactful work, like especially in the community, we're not in a rural setting. And if those laws go back to where they were,  we wouldn't be able to bill in those areas. But through my emergency medicine side, I have worked through different interest groups to advocate with Congress that what we're doing  in the community, regardless of its geographic location, is critical care. Being able to provide lifesaving measures and resuscitation and support to a hospital system  just a few miles away that's still in an urban location is 100% critical care. And I'm advocating for that strongly so that we will be able to continue to be paid  for our services appropriately. And I think that's a huge challenge that we face in the coming year or so, hopefully once this pandemic fades to some degree  and we may have to face new laws and regulations. Okay, a follow-up to that question. Which of these processes that were put in place for COVID  or other things that you've learned during this COVID period or things that were catalyzed by COVID, which of these things have you retained for general routine standard of care?  And which of these things do you think  were mostly relevant for the pandemic?  Is that to me or I can let- Anybody can step in.  Let's see. Fiona, do you wanna take that? Or I'll also, I have a couple of things as well. Yeah, I can take some of the things. I think that we had some things pre-COVID  that we would do in procedures, code leadership, those kinds of things. I think things that we didn't have previously, really similar to your talk, Chris,  are the family things, the family visitation. I think that's an opportunity that will sustain. I think we've, like you said, we've probably moved five years ahead,  five to 10 years ahead of where we were with that.  And hopefully that's a sticking point. We were able to actually communicate with people in different countries when their families were on ECMO and different things,  which, I mean, realistically, we probably wouldn't have thought about doing some of the things that we did. So I'm hoping that in terms of our specialty services,  even though we had a tele-ICU,  kind of, we call it a bunker, but I don't think everybody was using telehealth. So hospital medicine was not using it in the way. So we have virtual services  just to manage the volume of patients that we had alone. I think your points about the ICU to home, I think that's gonna be something that can stick around the post-ICU clinics.  So I think there's a lot of things that will stay. I think one of the things we'll probably do is we kind of threw things together because we had to.  So I think the next years are gonna be trying to figure out how to do it in a more sustainable and repeatable fashion.  Okay. All righty. I'm going to ask, bring one of the other questions. Telepresence takes available technology.  Is this a barrier in your own institution? Were you able to work with what you had or did you have to compile and acquire new pieces of technology?  Well, we were lucky to have software and telehealth equipment already available to us. We had to work very hard to really bring it to the bedside  and kind of change or adapt to our standard model.  This is not present throughout the hospital though. We also work in the emergency department. We have no telehealth capabilities down there.  So we did have to purchase equipment on the floors and in the emergency department, and then incorporate some of what we were doing in the tele-ICU into those different areas.  So it was a little bit of a mix, but at least from the tele-ICU side, we did have already available equipment. We did buy some new equipment from a mobile perspective  to kind of ramp up that particular component of it, but we already had contracts in place with vendors and we had a relationship already established there.  So that made it a little bit easier on our side, I'd say.  And I would say the same thing for us. We had the same, we had some infrastructure, we did purchase some things. And then the other thing is we repurposed things.  So we had a lot of things like tablets and things that have been used for kind of a bedside service that we never had fully implemented.  So we were able to take those and repurpose them. So a lot of that. Actually, that's another question that has come through for you, Fiona, specifically to iPads.  Let me see what that question is.  Yeah, sorry, I didn't mean to use a brand name, but we use multiple, it wasn't even just one type. Like we use all kinds of tablets for different things.  So we used it for, as a platform, we have a lot of capability on our cell phones that we're able to use. I think, you know, I can pick up my phone  and I can communicate with a drop-in on a patient, which is great.  So we were able to do that. And like I say, we had a lot of things that were set up through our EMR already  to be repurposed. And then we used, anything we could get our hands on that was a remote application and we could repurpose it, we did.  Mm-hmm. Were there any issues with security that came up if you were using like non-traditional technology?  Most of it, no, because it had already been configured. So that was where it was useful to repurpose because it had one HIPAA compliant application  that we were able to kind of use in a different way. So I will say that we did have some barriers that I think we can look to in the future that were related to the recipient.  So if it was a family member, they, some of our elderly family members struggled with how do you get that application on your phone if they had to load a new app  and things like that. So I think there's opportunity there for the customers or the, you know, the recipients, but we heavily, heavily use that for families.  And we made a point of contacting families daily because that was one thing. I too had a family member in the ICU in a different country and that we communicated. Mm-hmm. Okay.  I have one question that has come through for you, Dr. Everhart. One of the biggest benefits of having our ICU pharmacists on rounds is the education that they provide  to the prescribing practitioner. Obviously by your results, this is needed on the second shift as well. Did this education occur with tele-ICU  or were messages often left with the nurses?  For us with second shift, the messages are often left with the tele-ICU nurses and or to the bedside. Now, if it was something that is, you know, really, really important,  if we could reach the bedside provider and do that communication, we would. So that's one advantage with us shifting our hours  from full second shift to more day shift hours, we were able to provide that education to those bedside providers and work with them much more closely for that education component.  Okay. Okay. There's additional questions coming in regarding surrounding billing. It says, what is your experience with billing for tele-ICU time? Are you able to capture billing  and is it impactful toward your program overhead?  Absolutely.  I don't have the figures right off the top of my head, but we have been charting them for the past few,  or multiple months now that we've been billing. We bill equivalent to just being at the bedside. So with the relaxed rules and regulations for many of our outside hospitals,  especially in our community hospitals where we are the intensivist at night, there is no onsite provider. We are the sole provider for those hospitals.  We bill just as if we were at the bedside and we've looked at our collections from private payers, Medicare, Medicaid, and they have been on par with what that has been  for just bedside billing. So I do think that it really helps with sustaining your program. In addition, I believe to proving that you are,  proving the ROI and proving that you're decreasing complications, you're decreasing length of stay and those important metrics. I also think it's helpful to then have revenue  and not just be a cost center per se, and really try and change that dynamic.  I was looking very hard to do that pre-COVID and with the geographic restrictions, it was a challenge. And so everything just kind of caught fire and timing was right with COVID.  And I'm advocating very strongly, as I stated before,  through any contact that I have with legislation to continue the current model of care because I think it benefits patients and also allows us to expand.  And it would allow other centers to develop a telehealth program if there's actually, if they're able to generate revenue.  Okay.  Let's see, there's another interesting question here. Are there any ways that medical education or interdisciplinary education could be improved? And if you didn't have all  of your typical multidisciplinary team members with you  in the tele-ICU that you're accustomed to having in bedside, did you have any times where you worked without pharmacists or worked without your other team members?  I'll start at least with that.  Wait, the first question was,  remind me again on the first one. Medical education for interdisciplinary groups. I'm, I think that is just like, it's the next frontier. I think really doing virtual simulations  is an incredibly exciting opportunity. We've started to undertake that. And so we have opportunity, all of our fellows rotate out through the tele-ICU  and then through the Department of Emergency Medicine, we're starting to incorporate virtual simulations where we just have them kind of take care  of critically ill patients as if they're, just kind of an offsite, maybe not an intensivist, but either emergency medicine or kind of a critical care provider.  So I think from that perspective, telemedicine education is going to be mandatory moving forward because your website manner,  not your bedside manner is going to be critically important just in this next, in the oncoming decades as we move towards this digital health revolution,  you have to understand how to provide care over a camera and you can't touch patients, your sensory mechanisms that you're used to are just all off.  So I think that it's gonna be critically important. And yes, I, from what I'm lacking, I mean, both on the ground at the bedside, as well as, our court, we are not set up  where we have ERTs and e-pharmacists, we're moving towards that, we hope rapidly, but I was completely, I felt naked at the bedside without my pharmacist,  without all my multidisciplinary team members care, what was definitely to the detriment,  without our multidisciplinary team members. And I think a EICU or tele-ICU core with those providers  that we eventually established once we figured out how to do it, improved the care. So when our pharmacists rejoined rounds and when everybody was able to rejoin round virtually,  care, just everything became normal again. And so that is just, it was an eye-opening experience  and something I think is critical for us moving forward. Yeah, the multidisciplinary team needs to be everywhere that critical care is delivered.  There's a question that's come through regarding  how did things go with the end users or the customers that were not part of your professional circle beforehand? How did you, how did they receive the telecritical care?  People who were, I guess they were not accustomed to telecritical care and they came into this during this time, how did they respond and what were some of the things that you did  to facilitate success?  I can speak from our perspective that they, I mean, they're very used to technology. So the uptake was rapid and any way that people could find to communicate.  I think what we learned is we do a lot of communication and perhaps we don't realize how much we do and how much we go in and out of rooms,  whatever floor you're on, whether you're in the ICU, whether you're on a med search floor, it doesn't matter. And suddenly when that's not there,  it seems crazy because you can't get anything done. So I think that we learned a lot. The uptake was fast. I think we put telecritical care on our bedside monitors  outside the room because we kind of have pods. And so all the rooms are private rooms. And so, you know, at the beginning, we didn't know about how the virus spread.  We didn't know about what PPE we could and couldn't use. We didn't have, you know, negative pressure rooms. We were using, you know, all kinds of mechanical ventilation  and non-invasive ventilation. So everything was unknown, right, in those early days. And that's when we put the telemedicine  within the first two weeks, like I said in the presentation, was outside the room. So we had a limited access for the nurses. You couldn't do everything  that the tele ICU nurses could do. The nurses outside the room could communicate inside the room and look at things and check pumps and check IV.  And then we move things out into the hallways. And so there was a lot of adaptation, but the uptake was rapid. Like I find it difficult to believe  that in a two-week period, it was a 10-day period, we went from zero to, you know, 350 patients. And we managed to suddenly use technology in ways we've never used it before.  That's wonderful.  I want to ask a question. Now, did you see that, okay, we don't have all of the ancillary departments and we don't have regular communication  with social workers or chaplains or physical therapists or any of the other members that we would normally have those resources. Did you find that the nurses were being called upon  to be the communicator or the liaison or the person that would field all of those things  more so than they were accustomed to?  I would say that the nurses end up fielding the most calls from families. That's where that technology, that patient family technology was key  because our nurses were getting, you know, were getting slammed with phone calls because families couldn't visit for the first two months at all, like nobody in the building.  How did you triage the calls? I mean, the nurses triaged them well, I think. And we tried to, so that's where I think our mechanism for, we're going to round in the morning  if there are any updates that are critical, then they will be at the time that something critical needs to be communicated. Otherwise, know that somebody from the team  will contact the designated decision maker  by the evening shift, like in the afternoons. I know that some of our hospital medicine partners had medical students calling with a script  so that they made sure that families were communicated with. And I will say at the end of life, families were allowed in.  Like if there were end-of-life situations, then our families were in either by in-person or they were by some kind of communicative device. So they were able to be present. Okay.  A new question. Do you think that hospitals partnering with private sector companies would enhance provision  of remote healthcare, like addressing PICs following ICU stay, especially in rural areas where people may not have access to Wi-Fi?  In parentheses, the VA has partnered with Walmart to help connect vets living in remote rural areas with clinicians. Absolutely. I believe, you know, just technology is advancing.  I know that, like, with 5G and also with a lot of satellite technology coming down the pipeline soon where all of our phones will be able to, you know, receive internet  access just with, you know, satellite technology. This is really going to open up opportunities for patients in rural areas.  But in the meantime, yes, I think any partnership that will improve our access to patients is so important.  I really believe that, you know, critical care has advanced so far in the past, really, I mean, many decades.  But for many disease processes, we've kind of, I think, started to plateau maybe even a little bit with sepsis or ARDS.  And so when these patients now are going home and they're having complications, the post-intensive  care realm is really, we haven't even touched that space yet because we are all focused on caring for patients in the hospital.  And with our research grant for our COVID-19 PICS clinic, it has opened my eyes to just the amount of suffering that patients have after they leave the ICU, the barriers to  care that they face, you know, they are discharged with medicines, they didn't get any of their  medicines, they can't get into their primary care doctor, their primary care doctor doesn't know what a ventilator is, doesn't know anything about their stay.  And so it's really changed my outlook for what these patients experience, what my family and my father and my mom went through as well.  And so any partnership that will improve our access to these patients is important. And I also think that related back to a prior question, from an outcome perspective and  a process perspective, this is what hospitals care about. They care about readmissions. And so part of the goal of this is to decrease readmissions, and then you'll immediately  get buy-in from your telehealth program perspective that you're doing something to decrease readmissions. And then also from a billing perspective, these visits are billable.  And so now, again, you've changed your center into, you know, no longer just a cost center, as now many virtual visits are, again, just are billable.  And this is done more in Europe than it is in the United States, in terms of these virtual post-intensive care clinics, for various reasons they haven't caught on.  But it's mostly because the ability for patients to go to their visits is challenging. I mean, they're weak.  I just saw a patient today in a virtual PICS visit who was unable to drive, and just really like the hardest part of his day was just kind of getting out of bed.  But he was able to pull up his phone and was able to see our team on his phone. And we were going to be trying to, you know, coordinate home health to his home to get  his strength back. And so this is the future of medicine and critical care. And even though they are not in the hospital, we, I believe, are still responsible for their  care and taking care of them. And I think any partnership with a private company that can help with that would be incredible. Yeah, I would second that.  My mom ended up in an intensive care unit for five weeks in England, and it was very, very challenging, both for her, for my father, and for my mom when she came home, just to  even get the least thing done. Because we're in a time where we're not even operating as we would normally outside the hospital.  So I think, to your point, Chris, that was one of the things, like, if you would have usually been even able to go to your family clinic, you couldn't go there because it's  not open for business. So I think that ICU to home is critical. We did set up some palliative care, you know, some palliative care telehealth program also  that I think was very beneficial. It didn't quite do what you're doing. But I do think that that's another huge opportunity, because if we could send some of our patients  that really, quite frankly, want to die at home and don't want to die in the hospital, leaving them out there to fend for themselves, like my 80-year-old father can't manage my,  you know, then dying ICU, you know, mother, I mean, that's not feasible. So how do we help them and give some provision of care that might even be just how do you empty a bedpan?  Like, it might be as simple as that, right, help them. I totally agree with that. And we see this all the time in the emergency department where patients are on hospice and  their family member, they're dying at home, but they're too scared of those final moments.  They don't know how to administer some sublingual medication or do some basic kind of care need for the patient. And so they revoke the hospice and bring them into the ER.  And, you know, the whole point of the process is ruined there. But again, if you had a virtual coach to then just tell you, hey, it's going to be okay,  their breathing pattern is normal, provide them the morphine in this manner, do said intervention to help them and just kind of give them reassurance.  I think that the end-of-life palliative care virtual aspect of this is completely under recognized.  And I think it's something that we have to move towards and it will improve the logistics for the whole hospital system as well as the ICUs are at max capacity.  We have to find ways to get patients out of the ICU who are not going to survive and would prefer to die at home with dignity and in the manner that they choose.  So I'm keeping patients out of the hospital. At my place, they also took care of patients that were discharged, ICU patients discharged  home, you know, to try and help facilitate, you know, monitoring them and, you know, helping them along at home through the telecritical care environment.  And as a routine standard of care, we actually have telepharmacists that once patients are discharged, if they're on home health, they will meet with the home health person and  they'll meet with the patient and they'll go over the medications and really patients, you know, when they get home, they're like, what did they say about that medication?  So they're doing like a med rec, med teaching, you know, with the family and the patient at home.  And that is like a major help to keep people, you know, healthy and at home to have the telepharmacists, you know, going into the home as well.  Sonia, has that been done in your practice? From our telecritical care perspective? No, it has not.  But with Atrium, we actually established a virtual hospital, you know, during the pandemic and it actually has kind of two levels to it.  So there's like you're fairly healthy, still ambulatory, not quite needing hospital care basic level.  And then there's a second level that they're tutoring on, they might need to come in so they get a little more advanced help from like the paramedics and other nursing people  in the community. And we do have our ambulatory care pharmacists who are participating in that virtual hospital  and reviewing the medications and helping with those patients and that from that perspective.  So it is being done just not from the telecritical care from the pharmacist's perspective in the in the ICU, but certainly something that we could could see doing in the future.  We need a few more of us. Yeah, similar to what Chris was saying. The post-acute illness care is as important as the critical care.  And you know how cardiac surgery patients have their cardiac rehab program or stroke patients have their particular, you know, post-acute illness program.  It sounds like critical care people are going to have the advantage of having a post-critical care kind of program to help them recover the best that they can.  And tele can do it, I guess. Well, I almost believe that, you know, the tele ICU, tele critical care is one of the  only people that can do it because many clinics have failed because intensivists are busy and they don't want to have an outpatient clinic that they can only go to one day a  week or and then the patients have to find time. Like as we're doing right now, you know, if you have an intensivist on 24 hours a day,  then patients can literally book an appointment every single day with a awake and rested and available intensivist there to see them. And it doesn't require continuity of care.  You can read the chart prior to the visit, read a survey that they respond to saying what they're having issues with and everything through your EMR can be coordinated with their  primary care doctor. So having just one day a week of clinics is why these post-intensive care clinics fail  in addition to the fact that patients are unable to actually physically come to them. So I do believe that this will change the post-intensive care world for patients and  lead to better outcomes, absolutely. And I think that the tele ICU is one of the only ways to make them sustainable and hopefully  it would be also something that can be profitable for the center itself.  Let's see if we've had any more questions come through.  Dr. Palmer, we have one for you.  Were you exclusively assigned to the telemedicine ICU or were you simultaneously caring for your other clinical obligations?  Similar, I'm sure, to everybody else. Those months were incredibly busy. So no, I was not dedicated to the tele ICU, kind of just wearing multiple hats at the  time, either working clinically or then, you know, just doing tele ICU projects.  Every moment I wasn't working clinically, had some tele ICU shifts. So life is getting back a little bit towards more normal now, kind of pre-COVID with standard  shifts and stuff, but there's just so much still to do. So I was still dabbling in both at the time.  Okay, another question for you, Dr. Palmer. Did you receive the same welcome from your physicians working in the ICU in community  versus university affiliated hospitals when you initiated tele ICU?  It depends. I think that that's something that when you're going out into the community hospitals, it is all about a one team approach and concept.  And, you know, even though you are a consultant, you know, trying to really, you know, organize and rally around that one team approach that you're just trying to help the patient.  There are some, I think, either hospitalists, it just depends on who's at the bedside that are more prideful than others and have some more critical care experience than others.  But if you approach people, you know, in a non-judgmental, non-condescending way, and  your sole focus is really on just delivering better outcomes for the patient, there's more buying.  And now after COVID and during COVID, the acceptance rate, I think, as Fiona mentioned, is just like, it's through the roof.  When you're helping them be like, well, wait, we've never prone before, but now proning is easy and we can do it without a problem.  And, you know, the tele ICU through the kind of hub and spoke model has helped teach us how to do that. And now it's just become part of our standard of care and many other things.  It's just kind of like, well, this is incredible. And wow, we're managing sick ARDS patients and we're not transferring them and they're doing okay.  It's powerful. And so there's been a lot of buy-in and acceptance of the telecritical care model because of COVID.  For all the bad that COVID has brought, telehealth has been, you know, just an incredible winner  from this as everybody sees that you can provide high quality care just through two-way audio visual interaction.  And I would just add to that, the use of, you know, we've used the hardwired technology, but I think we probably use the mobile technologies more than we've ever used them.  Like carts, we've had a lot of projects where we've tried to introduce carts to pull into ED rooms or, you know, other places that were not, so it was a passive kind of, oh, it's  not enough room in there, you know, for this cart to be present. And suddenly, miraculously, wow, these carts actually really can work, right?  Like the OR and the, I say OR, really recovery areas where you don't have a lot of monitoring. I mean, we repurposed all kinds of spaces to be ICU, you know, to deliver ICU or high  acuity care that we didn't have before. And, you know, just the ability or even the sense of relief to know that you could call  somebody, even if it didn't connect right away, here's the phone number that's on the thing that might be able to connect you to somebody who can see what your problem is.  Like, it's like a helpline, right? So I do think that that was very, very valuable. And one of the other things that we did do that I was not involved in really, but was  from the outpatient and internal medicine family practice, we have an on-call system, which I'm sure a lot of other places do.  And so they were able to monitor people using telemedicine, you know, just with pulse oximeters and things like that to keep people at home who really didn't want to be in the  hospital. And we didn't necessarily want them to be in the hospital because we didn't have any other space to put them.  And they were probably better served being at home to a point, but they had regular check-ins. And so now we have devices that can really connect.  You know, we have stethoscopes that connect. We have all of these other things that can connect to our telemedicine devices. It's like a world of opportunities.  The home will become the hospital in the next, you know, few years, few five to 10 years, you know, all the care you get in the hospital for a lot of it can be done at home.  And also through mobile integrated health and through a lot of these connected devices, there will be easy, you'll be able to get labs done at home.  And, you know, if you can stay home, most people would prefer to do that. And I truly believe that, you know, just the revolution we're undergoing right now is very  excited about it.  I think that public health has great opportunities as well to rejuvenate, not just be like the  MPHs or epidemiologists, but public health that can actually go and take care of patients  in the real world and try to keep people well on the outside.  I would love to see a resurgence of that. But anyway, if anyone has any last questions or last comments from our faculty that you would like to contribute.  I'm actually going to circle back to the medical education piece and talk a little bit about  how fortunate we are at Atrium with our telecritical care program to have a faculty member from a local school of pharmacy who actually brings her fourth year pharmacy students to  the telecritical care program for a rotation and introduces them early on in their career  for the telepresence. So it's a really nice benefit for us to get the pharmacy students introduced to this  teleworld that we all live in now early in their career.  Yeah, and I think that could be a benefit to nursing because I think one thing that,  you know, for people that have sat on the other side of the camera, we spend a lot of time when we're in the units being busy and running around and answering phone calls.  And the cognitive load is huge, adding all these extra alerts and alarms and things like that. But now we have this opportunity when you sit back, you have less distractions while  you're in the bunker or your core or whatever you call your center.  It's different, but there's so much opportunity to learn, even if I can just imagine having a nurse sitting next to you and, you know, pointing out like missed opportunities or  what we could do here and how we can prevent clinical deterioration and all these other  opportunities that are really cognitive more than the actual physical, you know, application skills that we're learning.  And I think to your point, Chris, what you were talking about with the ability to communicate,  I think teamwork and communication is another huge learning opportunity through tele-ICU because it's a different set.  Absolutely. I mean, and what I love about technology that we're harnessing is that, again, it just  really, it augments our ability to put the patient back at the center of everything.  And so if you have additional tools and technology to help you be able just to focus on the patient,  talk to the patient, take care of the patient at that moment, but you know in the background  that there is AI and data and maybe a telehealth center kind of watching over things, helping you with alerts and documentation.  It just lets you focus and talk to the patient, which is why what they remember at the end of the day is, hey, the nurse and the doctor talked to me. They spent time with me.  Like my father said, like they, you know, he had more than 30 seconds to talk to me that I'm actually going to speak again, you know, after my subdural.  So, I mean, those are the things that patients care about and technology, even though it sounds weird, but it will actually help us to be better nurses and doctors and pharmacists  because we'll just be able to focus on the patient and let the technology augment our intelligence and efficiency in the background.  Okay, I haven't found any more questions that have come through.  So, if any last questions, if not, we can probably move forward to closing question and answer section.  If anyone wants to add one last question in. Okay, Sonia, Fiona, Chris, Katie, everyone, thank you so much for facilitating this wonderful  session on telecritical care.  We're all big proponents, and I hope that we're able to continue with a lot of these good efforts.  Thank you very much for having us. Appreciate it. Thank you. Thank you so much.

Video Summary

The video discussed the impact of telecritical care and telemedicine during the COVID-19 pandemic. It highlighted the importance of humanizing the ICU experience and how telemedicine can help achieve this. The session focused on the perspectives of nursing, pharmacy, and emergency medicine. It emphasized the need for patient and family-centric telecritical care delivery during a pandemic and discussed future applications.<br /><br />The speakers shared personal stories and experiences to demonstrate the positive impact of telecritical care on patients and families. They discussed how telemedicine technology can improve communication between patients, families, and healthcare professionals, and improve the overall ICU experience. The importance of open ICU visiting policies, individualized care, and involving palliative care and spiritual care in the telecritical care process was highlighted.<br /><br />The speakers also discussed the role of telemedicine in reducing burnout among healthcare professionals by providing a change of environment and allowing for flexible work arrangements. They emphasized the potential for telemedicine to improve the patient experience in the ICU and provide more patient-centered care.<br /><br />The session also addressed the use of telemedicine in critical care settings, such as the tele-ICU or telecritical care. It discussed how telemedicine technology allowed for remote monitoring and treatment of critically ill patients, reducing the need for in-person contact and conserving personal protective equipment. Pharmacists played a crucial role in medication management, and telemedicine facilitated collaboration between multidisciplinary teams. The session also highlighted the challenges and opportunities associated with telemedicine, including access to technology and billing reimbursement for telemedicine services.<br /><br />Overall, the video emphasized the positive impact of telecritical care and telemedicine during the COVID-19 pandemic and discussed the potential for further integration of telemedicine in critical care settings in the future.

Asset Subtitle

Administration, Crisis Management, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Learning Objectives
Describe novel patient- and family-centric tele-critical care delivery during the COVID-19 pandemic and future state applications
Discuss the rapid escalation of tele-critical care use in hospitals, staffing model consideration, lessons learned, and opportunities for the future based on COVID-19 experiences from four disciplines

A Silver Lining in the COVID-19 Cloud: Humanizing the ICU Experience Through Tele-Critical Care
Chris Palmer

Complements to the Core: A Multiprofessional Approach to Tele-Critical Care and the Impact During COVID-19
Fiona Winterbottom

Complements to the Core: A Multiprofessional Approach to Tele-Critical Care and the Impact During COVID-19
Sonia S. Everhart

Meta Tag

Content Type Presentation

Knowledge Area Administration

Knowledge Area Crisis Management

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Telemedicine eICU

Tag COVID-19

Tag Communication

Year 2021

Keywords

telecritical care

telemedicine

COVID-19 pandemic

ICU experience

nursing

pharmacy

emergency medicine

patient-centric care

communication

burnout reduction

remote monitoring

personal protective equipment

medication management

integration

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