SCCM Resource Library-Telesimulation and Tele-Critical Care Interface

Video Transcription

Thank you so much for logging in and choosing to listen to this presentation. My name is Christina Uranimakis, I'm a bedside critical care nurse and the lead telecritical  care nurse at Madigan Army Medical Center. And I'm absolutely honored to be presenting to you today about the interface of telecritical care and telesimulation.  I have no conflicts of interest to disclose, and since I work for the U.S. government, the information presented are my views and not that of my employer.  Before the pandemic, it's estimated that 15% of all adult ICU beds had hardwired telecritical care support in the United States.  The pandemic has changed our delivery of telecritical care to novel solutions such as mobile cards and smartphone applications.  Initially, we used this technology to help address staffing shortages, either from attrition or from patient surges, but the benefits of telecritical care remains unchanged.  Through the adherence to evidence-based practices and clinical practice guidelines, we have  an improvement in compliance to standards of care with reductions in morbidity and mortality.  The military provides 24-7 telecritical care support through a collaboration between the Army and the Navy known as the Joint Telecritical Care Network.  Through our three hub sites, we offer both physician and nursing support to 16 military treatment facilities with plans to expand to all of our adult ICU beds.  But unlike our civilian counterparts, we need to be prepared to expand our focus based on a range of needs from national defense conflicts to the pandemic.  The military has leveraged this technology to provide expert consultation to soldiers with battlefield injuries and during simulated field training exercises.  The Jetson has been tasked with disaster responses, which include COVID relief missions. The big question is how can we prepare for these potential threats while simultaneously  testing our network function and effectiveness? There's some challenges that we really need to keep in mind, and the first is that during  peacetime, preparation is dependent on the ability to perform training exercises. And two, military who have deployed may have limited exposure to telecritical care.  And the most important point is that each disaster and conflict is unique. So how do we feasibly offer different iterations of training events to be prepared for the unpredictable?  The answer lies in telesimulation. Telesimulation has demonstrated to be a feasible way to maintain medical readiness skills.  Telesimulation can be defined as the ability to provide education, training, and assessment to learners at an offsite location.  The pandemic has shown us that training normally done in person can be facilitated remotely  because one of the most important parts of simulation occurs at the end with the debriefing,  which helps the learner to reinforce the objectives through honest self-reflection and direct feedback from the instructor.  I'm going to break up my talk about telesimulation into two different categories, procedural and non-procedural skills.  I will start by going over procedural skills to address topics such as broad knowledge assessment, surgical procedures, and device implementation.  An example from over 20 years ago highlights a transcontinental telesimulation. In this scenario, the human patient simulator was located at the distant learner site of  a Puerto Rico Naval Hospital, but operated by remote instructors in Ann Arbor, Michigan. The emergency medical personnel in Puerto Rico volunteered to be what I would describe  as a speed-dating telesimulation. They were five scenarios carried out over five minutes, followed by a five-minute debriefing.  The objective was to assess the perceived preparedness of the following medical emergencies.  We had near-drowning, ventricular fibrillation, lung trauma with pneumothorax, rapid sequence intubation, and shock.  The participants reported that they felt better prepared to medically manage these emergencies because of their telesimulation experience.  The goal of damage control resuscitation is to limit the amount of blood loss and prevent coagulopathy through permissive hypotension and minimal fluid administration, and to give  blood product with a ratio of 1 to 1 to 1, that is, 1 RBC to 1 FFP to 1 platelet. And the last component of damage control resuscitation is damage control surgery, which  is to temporize the bleeding until stabilization can be achieved at a higher level of care.  In this example of procedurals-filled development using telesimulation, we have surgically-naive  first responders performing damage control laparotomies with wound packing due to exsanguinating liver injuries that mimic battlefield injuries.  Volunteers were randomized into two groups. The first was the remote tele-mentored group that wore a two-way headset and head-mounted  camera that communicated and displayed images to an off-site instructor, and the second was the non-tele-mentored group.  The simulated surgery was performed using a high-fidelity cut suit that was modified to measure both volume and velocity of fluid loss.  The results indicate that the remote tele-mentored group reported the use of telesimulation in  damage control surgeries, improved the operators' confidence, and enhanced their learning experience.  In our last example, there was a collaboration with the early medics who were able to test the application of a novel wound clamp to stop extremity exsanguination.  The Innovative Technology, or IT, clamp is a single-use, disposable, self-locking clamp that seals the wound using mechanically-assisted direct pressure.  The volunteers were broken up into two groups. The first group was taught how to use the clamp before the training, and the second  group learned how to use the device during the telesimulation by being tele-mentored by instructors in Calgary.  And although both groups were able to apply the IT clamp and stop extremity exsanguination, it's important that I reinforce the point that one group received the training during  the exercise. And this is important for the military because new devices and technology may be released  during an act of conflict, and that using video telecommunication, we can train remote end-users for immediate use of the device or technology.  Telesimulation is a feasible way for performing MassCal training exercises using state-of-the-art technology.  The individual pictured on the left is wearing the Google Glass device and has the application EyeSight to create a virtual reality of MassCal training events.  In a transcontinental study, students in an EMS course from Irvine, California, and English-speaking healthcare personnel from two universities in Saudi Arabia participated.  The objective was to offer a transcontinental MassCasualty training course and assess the feasibility and effectiveness of performing this training.  This scenario is using virtual reality technology to immerse learners directly as if they were in-person.  As they demonstrated in providing the same experience in-person, what could be done by experts over 100 miles away or to a broader audience to increase the access to this education,  thus eliminating geographic barriers to learning and experiential knowledge. As in-person learning transitioned to remote learning during the pandemic, we've been able  to utilize telesimulation to develop non-procedural skills, for example, teamwork. Bandura's social cognitive theory states that teams that train together perform better  together and telesimulation is a team building experience or exercise. So whether you are performing the scenarios as a team off-site or in individual locations,  you're still working and collaborating for the same objective. We're also able to utilize telesimulation to develop leadership skills.  In our own anecdote at Madigan, we had a very shy active duty soldier with very strong informal leadership skills, and we used a telesimulation event to highlight her formal  leadership skills and capabilities. Due to the fact that we're performing medical procedures, it requires critical thinking  as we decide what our next choice of action is going to be and intervention, as well as time-sensitive decision-making.  Our medical interventions and patient management and care needs to be performed on a timely manner because failure to respond can result in the patient or human patient simulator  deteriorating. Military efforts are expanding the use of telecritical care beyond the bedside to include meeting the diverse needs for our military medical readiness.  In the following slides, I'm going to demonstrate to you how we integrated telecritical care with telesimulation to train tomorrow's soldiers today.  We were able to successfully demonstrate the utilization of telecritical care and telehealth. In the 2019 Joint Warfighter Assessment, a simulated traumatic brain injury patient was  received at the Battalion Aid Station after sustaining a head injury in the battlefield. Here the general surgeons needed guidance with performing a decompressive craniectomy,  but the trauma surgeon was over 50 miles away in the combat support hospital. Communications was available between the two aid stations and the expert trauma surgeon  was able to tele-mentor the surgical residents using synchronous video telecommunication capabilities.  As you can see on the picture on the left, he was able to talk the surgical residents on performing this procedure.  There was a telecritical care physician and nurse at the main hospital over 100 miles away on standby for additional consultation during the procedure and for medical and nursing  management of the patient after the cranie. In a simulated remote area of Africa, an active duty soldier comes to the clinic complaining  of shortness of breath and quickly develops increasing oxygen needs. The inexperienced nurses are still providing care within their scope of practice stateside  and they recognize that this patient needs to be medically evacuated, but cannot because of increased enemy activity in the area.  So these nurses reach out to critical care physicians using the National Emergency Telecritical Care Network app, also known as Omnicare.  The critical care physicians help with securing a definitive airway and after the patient develops a pneumothorax, providing procedural tele-mentoring of a needle decompression with  subsequent chest de-placement. The interventions, the needle decompression and the chest de-placement, those instructions  were actually sent by Omnicare just in case communication was lost between the remote users and the distant or offsite instructors.  In this case, we're thinking of the critical care physicians. One of the things to think about is that the far forward environment is incredibly challenging.  We have limited resources. We have limited knowledge, skills and abilities of the caregivers who are providing these  interventions that having an on-demand resource is an invaluable asset to the safe medical management of high acuity traumatic injuries.  The most recent example of the military utilizing telecritical care occurred in the 2021 Pacific  Defender Army Training Exercise, which was designed to operationalize the National Defense Strategy.  Here, we tested the feasibility of a deployable physiological monitoring device with a two-way audio communication and one-way video transmission. Think battlefield to stateside.  With the anticipated loss of the golden hour in future conflicts, today's deployable units, which are smaller and more geographically dispersed, need to be prepared for providing  prolonged field care with limited resources. The Tempest Probe, pictured on the right, has 12 lead EKG capabilities, invasive and  non-invasive blood pressure reports, SpO2 monitoring, respiratory rate monitoring, as well as ultrasound and laryngoscopy capabilities.  To demonstrate the utility of such technology, nurses deployed to Indonesia were not only able to communicate with providers in San Diego, but they were also able to display  images to the virtual medical operations center as well. This technology is changing the delivery of care in deployable settings to increase the  accuracy and efficacy of battlefield interventions. Telecritical care improves patient outcomes through the adherence of evidence-based practices,  as well as clinical practice guidelines, overall reducing the ICU length of stay and risk of morbidity and mortality.  Telesimulation can be an extension of telecritical care to improve the knowledge, skills, and abilities of our deployable caregivers.  We can integrate telesimulation with our telecritical care technology to train our soldiers, whether  they're in the battlefield or at higher levels of care, for skill development, for new devices, or even in real time for procedural telementoring of surgical interventions.  We're working to leverage these remote technologies to advance our critical care training without any regards to our geographical barriers. Thank you so much for your time.  I sincerely hope that you enjoyed this presentation. Please feel free to email me if you have any questions.

Video Summary

Christina Uranimakis, a bedside critical care nurse, discusses the interface of telecritical care and telesimulation. Before the pandemic, 15% of adult ICU beds had telecritical care support in the US, but the pandemic has led to the use of mobile cards and smartphone applications to address staffing shortages. Telecritical care has improved compliance to standards of care and reduced morbidity and mortality. The military provides 24/7 telecritical care support through the Joint Telecritical Care Network, and they have leveraged telecritical care for expert consultation and training exercises. Telesimulation is a feasible way to maintain medical readiness skills, and it can be used for both procedural and non-procedural skills. Telecritical care and telesimulation can be integrated to train soldiers for skill development and surgical telementoring.

Asset Subtitle

Professional Development and Education, 2022

Asset Caption

COVID-19 affected undergraduate and graduate medical education for all trainees in all disciplines, including clinical bedside experiences, knowledge assessments in high-stakes certification examination administration, and case volume decrement for procedural and operative disciplines. Traditional in-person simulations of small and large scale were affected by the paucity of personal protective equipment and the risk of clinicians congregating in groups. Variation in ability and resources to deliver simulation in person warranted rapid expansion of telesimulation and creative solutions to close the experience and knowledge gap, which continued for several months during the pandemic.

Meta Tag

Content Type Presentation

Knowledge Area Professional Development and Education

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Telemedicine eICU

Tag Innovation

Tag Simulation

Year 2022

Keywords

telecritical care

telesimulation

mobile cards

smartphone applications

staffing shortages

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