SCCM Resource Library-Tele-ICU in the Age of Novel High-Acuity Conditions: Leveraging Technology in Earlier Management of Burns, Infections, and Respiratory Failure

Video Transcription

Welcome to the tele-ICU in the age of novel high-acuity conditions, leveraging technology in earlier management burns, infections, and respiratory failure. My name is Lizzie Skruth.  I am the Northern California Kaiser Permanente Regional Director for Clinical Quality Programs, Data Analytics, and Tele-Critical Care.  I have no financial or conflicts of interest to disclose. And in this session, we'll look at how expanding tele-ICU to new points of care to treat burns  patients, infectious diseases, and respiratory failure may possibly improve outcomes for this patient population, and how the potential improvement in outcomes may be able to reduce  disparities in critical care and overall improve cost-effectiveness for critically ill patients. So what is the current level of evidence for tele-critical care?  So in four systematic reviews over a period of years and meta-analysis, it did demonstrate shorter hospital and ICU length of stay and lower mortality.  Well, we've been practicing different models of tele-critical care for the past four decades,  and it's very difficult to compare apples to apples because we do have different practice models.  And if we look at disparities, so we know there are disparities in health care in the United States, and we know geographically there's bigger disparities.  Depending on where you live, you may or may not have access to an ICU bed when the demand is high, and specifically during a pandemic.  We also know from the literature that tele-ICUs are not in every state. For example, Utah has over 50% of the hospitals with tele-ICUs, while Alabama, Western Tennessee,  and West Texas have none. Data from 2020. So leveraging technology. So we know that burn patients require very specialized care, and out of the 120 burn  centers in the United States, 64 of them are certified. And traditionally, before COVID pandemic hit, there was two types of telemedicine, videoconferencing,  and then storing and forwarding through electronic means of the images for consultation with a specialist.  Then the pandemic hit, and all of a sudden, technology, technology, technology exploded. We had all this technology from very basic to advanced all of a sudden thrust upon us.  And then they could do three-way video calls via a link. So the link could be sent to anyone in the world, and that person could click on the  link and immediately be connected to the three-way video call, being able to see the patient, speak to the patient, and the providers that were with the patient as well.  So getting instant consult for a patient that was critically ill. And if we look at how Spain has done this for their burn care, they have developed a  very robust teleburns platform for the acute care burns patients. They have one big major center that's in Barcelona, but their Barcelona center really helps up  to 8.5 million people via their teleburns platform. So they provide assistance across Catalona, the islands listed here, and Andorra.  And you can see where that distance can be very vast. But the platform they developed offers distant diagnosis during emergencies so that patients  can be transferred if they need to be transferred. And if they don't need to be transferred, they can stay where they are so that there's  cost-effectiveness, increased quality of care for the patient, and immediate access to specialists if needed.  So the program has been going on for quite a while, way before the pandemic occurred. So it started in 2013.  And it's demonstrated that they've really reduced the need for transfers because they have expert consultation straight away when they need it.  And so patients that need to be transferred immediately, they can be. So it's improved the accuracy of the assessment of burns patients.  And then due to that success, there's future work to expand the use of the platform to other Catalan health institute hospitals.  So expanding out to even further reduce disparities that may be present. And then we look at telecritical care and early respiratory management.  So as you know, the ROCS index is SpO2 over FiO2 respiratory rate. And really what that has afforded is patients that have acute respiratory failure or pneumonia,  the ROCS index can identify them that are at lower risk for high-frequency nasocannular failure, failure in which therapy can be continued after 12 hours.  And assigning virtual respiratory therapists in a telecritical care hub, or wherever they may be situated, to patients pre and post intubation for monitoring, using the ROCS  index as well, can further reduce the need for patients to be up-transferred if they don't need to be, or they can be intervened very early if there's problems once the patient  gets extubated or intubated.  And then ventilator management. So at Advocate Health, Dr. Reese, and for our program in Northern California, we monitor the ventilator patients very carefully overnight.  So at Advocate Health, at 2 AM, their TCCRNs start reviewing the RAS scores. And appropriate RAS scores for SBT are facilitated by the TCCRNs.  So patients get to their goal, their RAS goal, much more quickly when the TCCRNs are evaluating  and overseeing these patients during the night, so that more patients that are ventilated can have their SAT and SBT completed in the AM.  So every ventilator patient's reviewed every night against the orders that the patient has. And then tidal volumes are reviewed every night, too, to ensure they meet the four to  eight mils per kilogram predicted body weight. So really ensuring that the ventilation management of the patient is really continuous 24-7 with  the same level of quality of care, no matter what the time of the day or night it is. And then we implemented telecritical care during COVID to reduce disparities when we  had a lot of patients that were suddenly filling up our ICUs with COVID and other conditions.  And we needed to have a little bit more oversight during the night so that these patients could get continuous high quality of care.  So we implemented in September 2019 two hospitals, 50 ICU beds, one hub. We did pause in 2020 during the height of the pandemic and then recommenced towards the middle of the year.  In 2021, we added six more hospitals, added one more hub. We have a supportive and consultative model. So we have proactive work and reactive work.  And currently, we have one to two physicians every night and about four nurses. So we have a nurse caring for 35 patients and our physicians about 88 patients.  Our hub is only open from 8 p.m. to 8 a.m. And we are continuing on our journey to get to all 21 hospitals by the end of 2022, which  will get us to capacity about 400 ICU beds recovering. So the proactive and reactive work that we do, we look at all the order sets that patients  are on every night and we look at those order sets for their appropriateness, particularly sedation orders and ensuring that patients that may have one or two sedatives, that the  RAS score is the same to reduce confusion for the nurses, the local nurses in the ICU. And any new order sets that the RNs at the local facilities may not be familiar with,  our nurses review with them. We also have huddles and safety rounds at the beginning of the shift and weekly.  And then we use the EPIC platform to identify high-risk patients that come up at the top of what we call the watch list.  We do have a scoring system for severity of illness, and we also have a LAPS and a COPS score, which we've developed through our predictive analytics system.  Our TCCRNs review all patients, regardless of their level of care in the ICU. They're listed as med-surg.  We still review every patient by cameraing in at the beginning of the shift and doing safety rounds to ensure there are no safety hazards in the room, and then quality rounds  to ensure that order sets are appropriate and that the nurse is comfortable in the room with what the patient is being administered. So we check IVs.  We check the infusion orders as well. And then our nurses enter everything into a separate database.  So we log all calls, the RN intervention, the MD intervention, and what the exact intervention  was so that we can have a list of all the calls every night that's tracked on a Tableau dashboard.  And the technology is eight screens at a station for the clinician, RN or MD. And on the right-hand side, on the far right, you'll see the camera and the screen that's  in our ICU rooms.  So you can see on the left-hand side here, our medical director looking at the screens. Again, it's the Epic platform, and one of our nurses down the bottom looking at the  screens of the patients she's caring for. And our hubs, we have two hubs. And in the middle of the hub on the right-hand side, in the middle, you'll see a screen.  That screen is so we can see physicians and nurses that are at the hub. The blue screens behind our clinicians are for privacy, for when they camera in the patient  or clinician at the other end, or the family cannot see anything behind our nurse or clinician that's camera-ing in. And this is our second hub, where there's 10 stations.  And then you can see the screen on the right-hand side, so each hub can see each other on a continual basis throughout the night.  These are our pilot results. So we have reduced hospital mortality for patients with an ICU encounter. We have reduced length of stay.  And we have reduced ICU length of stay, as well as hospital length of stay.  And you can see the days saved per year in terms of hospital days and ICU days.  And what's our next steps? So we have 21 hospitals in Northern California that we're implementing into the telecritical care program.  And our other region in California, Southern California, is currently embarking on a pilot phase. They have 19 hospitals that they will be involved in.  They will be enrolling in their program eventually. And our aim is to expand it to all five regions or markets of Kaiser Permanente across the USA.  We are currently building a hub task management system. We use MS Teams right now, and that's really not meeting our business needs.  And we've learned that over the years that we've had the program in place since 2019. We also realize there's electronic medical record enhancements that are needed for efficiency.  And we're going to reanalyze our program this year after the COVID pandemic and to see whether  we're still reducing mortality length of stay and other measures that we've been currently measuring in terms of lung protective strategies and our event management as well.  Thank you. And my email address there if you need to ask any questions or send me an email. Thanks very much.

Video Summary

In this video, Lizzie Skruth, the Northern California Kaiser Permanente Regional Director for Clinical Quality Programs, discusses the use of tele-ICU to treat high-acuity conditions such as burns, infections, and respiratory failure. She discusses the evidence supporting the use of tele-critical care, including shorter hospital stays and lower mortality rates. Skruth highlights the disparities in access to critical care in the United States and the potential benefits of tele-ICU in reducing these disparities. She also discusses specific examples of tele-ICU implementation, such as Spain's teleburns platform, and the use of technology in respiratory management, including the monitoring of ventilated patients. Skruth concludes by outlining future steps for expanding telecritical care within Kaiser Permanente.

Asset Subtitle

Professional Development and Education, 2022

Asset Caption

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

Meta Tag

Content Type Presentation

Knowledge Area Professional Development and Education

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Telemedicine eICU

Tag Innovation

Year 2022

Keywords

tele-ICU

high-acuity conditions

evidence

disparities in access

respiratory management

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