Telemedicine in the intensive care unit: its role in emergencies and disaster management

Focusing on experts: Expectations of healthcare professionals regarding the use of telemedicine in intensive care units

Objectives

Telemedical applications are solutions to challenges in the healthcare system. However, it is unclear what intensive care unit healthcare professionals expect from such solutions. This study investigated the expectations and concerns of nurses and physicians when implementing telemedicine tools in intensive care units (tele-ICU).

Methods

The study was conducted in intensive care units in 2020 during the second wave of the COVID-19 pandemic. It used a mixed-methods approach targeted at physicians and nurses and involved 14 qualitative interviews and 63 quantitative questionnaires.

Results

The qualitative and quantitative data showed that both nurses and physicians were willing to use tele-ICU. Nurses recognised the advantages of real-time access to expertise offered by tele-ICU, but feared this would reduce physicians' on-site patient time. Physicians, in turn, were concerned that they would be expected to be continuously on call. The majority in both groups agreed that any tele-ICU solution must be simple to use and integrate easily into existing organisational structures, networks, and work routines. Additionally, COVID-19 significantly influenced expectations: those who reported having more personal health concerns during the pandemic were more predisposed to favour the use of tele-ICU.

Conclusions

Overall, tele-ICU supports better care, but a successful implementation depends on its ease of use and context-sensitive approaches. Effectively integrating tele-ICU solutions into daily clinical routines requires input from nurses and physicians and their involvement in the implementation process from the outset, as well as consideration of existing organisational structures. Such measures will vastly increase the chance of acceptance and successful adoption of telemedical solutions in clinical practice.

Telemedicine to Expand Access to Critical Care Around the World

This multiauthored communication gives a state-of-the-art global perspective on the increasing adoption of tele-critical care. Exponentially increasing sophistication in the deployment of Computers, Information, and Communication Technology has ensured extending the reach of limited intensivists virtually and reaching the unreached. Natural disasters, COVID-19 pandemic, and wars have made tele-intensive care a reality. Concerns and regulatory issues are being sorted out, cross-border cost-effective tele-critical care is steadily increasing Components to set up a tele-intensive care unit, and overcoming barriers is discussed. Importance of developing best practice guidelines and retraining is emphasized.

Tele-consent using mixed reality glasses (NREAL) in pediatric inguinal herniorrhaphy: a preliminary study

There is an increasing demand and need for patients and caregivers to actively participate in the treatment process. However, when there are unexpected findings during pediatrics surgery, access restrictions in the operating room may lead to a lack of understanding of the medical condition, as the caregivers are forced to indirectly hear about it. To overcome this, we designed a tele-consent system that operates through a specially constructed mixed reality (MR) environment during surgery. We enrolled 11 patients with unilateral inguinal hernia and their caregivers among the patients undergoing laparoscopic inguinal herniorrhaphy between January through February 2021. The caregivers were informed of the intraoperative findings in real-time through MR glasses outside the operating room. After surgery, we conducted questionnaire surveys to evaluate the satisfaction and usefulness of tele-consent. We identified contralateral patent processus vaginalis in seven out of 11 patients, and then additionally performed surgery on the contralateral side with tele-consent from their caregivers. Most caregivers and surgeons answered positively about the satisfaction and usefulness of tele-consent. This study found that tele-consent with caregivers using MR glasses not only increased the satisfaction of caregivers and surgeons, but also helped to accommodate real-time findings by adapting surgical plan through the tele-consent.

Health System Resiliency and the COVID-19 Pandemic: A Case Study of a New Nationwide Contingency Staffing Program

When COVID-19 emerged, the U.S. Veterans Health Administration (VA) was in the process of implementing a national contingency staffing program called Clinical Resource Hubs (CRHs). CRHs were intended to provide regional contingency staffing for primary and mental health clinics experiencing staffing shortages primarily through telehealth. Long-term plans (year 2) included emergency management support. Early in the implementation, we conducted semi-structured interviews with CRH directors and national program leaders (n = 26) and used a rapid analysis approach to identify actions taken by CRHs to support the resiliency of the VA healthcare system during the pandemic. We found that the CRH program was flexible and nimble enough to allow VA to leverage providers at hubs to better respond to the demands of COVID-19. Actions taken at hubs to sustain patient access and staff resiliency during the pandemic included supporting call centers and training VA providers on virtual care delivery. Factors that facilitated CRH’s emergency response included hub staff expertise in telehealth and the increased acceptability of virtual care among key stakeholders. We conclude that hub providers serving as contingency staff, as well as specialization in delivering virtual outpatient and inpatient care, enabled VA health system resiliency and recovery during the COVID-19 pandemic.

Comparison of smartphone application-based visual acuity with traditional visual acuity chart for use in tele-ophthalmology

PURPOSE:

The aim of this study was to compare the visual acuity (VA) by smartphone-based applications – EyeChart and the Peek Acuity to the standard Snellen chart to explore the possibility of using them as an alternative in tele-ophthalmology in the current COVID-19 pandemic.

MATERIALS AND METHODS:

An analytical type of observational study was done on 360 eyes of 184 patients above 18 years of age. Patients with VA <6/60 and gross ocular pathology were excluded from the study. VA measured by these three methods was converted to logMAR scale for ease of statistical analysis. One-way analysis of variance with post Tukey HSD was used to compare the VA measured by these three methods.

RESULTS:

There was no statistically significant difference between VA measured using the smartphone-based apps (EyeChart and Peek Acuity) and the Snellen chart (F = 2.5411, P = 0.7925) in 360 eyes assessed. VA measured by Peek Acuity (P = 0.5225) was more comparable to Snellen chart than EyeChart (P = 0.4730). Intraclass correlation coefficient (ICC) demonstrated a strong positive correlation for EyeChart (ICC: 0.982, P < 0.001) and Peek Acuity (ICC: 0.980, P < 0.001) with Snellen chart. A Bland–Altman difference plot showed good limits of agreement for both EyeChart and Peek Acuity with Snellen chart. In subgroup analysis, VA measured by Peek Acuity was not statistically different from Snellen in any subgroups, but in EyeChart, it was statistically different in emmetropes.

CONCLUSION:

VA measured by smartphone apps (EyeChart and Peek Acuity) was comparable with traditional Snellen chart and can be used as an effective, reliable, and feasible alternative to assess VA in tele-ophthalmology.

National Estimates of Workplace Telehealth Use Among Emergency Nurses and All Registered Nurses in the United States

INTRODUCTION

The goal of this research was to quantify the baseline status of prepandemic workplace emergency nursing telehealth as a key consideration for ongoing telehealth growth and sustainable emergency nursing care model planning. The purpose of this research was to: (1) generate national estimates of prepandemic workplace telehealth use among emergency and other inpatient hospital nurses and (2) map the geographic distribution of prepandemic workplace emergency nurse telehealth use by state of nurse residence.

METHODS

We generated national estimates using data from the 2018 National Sample Survey of Registered Nurses. Data were analyzed using jack-knife estimation procedures coherent with the complex sampling design selected as representative of the population and requiring analysis with survey weights.

RESULTS

Weighted estimates of the 161 865 emergency nurses, compared with 1 191 287 other inpatient nurses revealed more reported telehealth in the workplace setting (49% vs 34%) and individual clinical practice telehealth use (36% vs 15%) among emergency nurses. The geographic distribution of individual clinical practice emergency nurse telehealth use indicates greatest adoption per 10 000 state residents in Maine, Alaska, and Missouri with more states in the Midwest demonstrating emergency nurse adoption of telehealth into clinical practice per population than other regions in the United States.

DISCUSSION

By quantifying prepandemic national telehealth use, the results provide corroborating evidence to the potential long-term adoptability and sustainability of telenursing in the emergency nursing specialty. The results also implicate the need to proactively define emergency nursing telehealth care model standards of practice, nurse competencies, and reimbursement.

Telehealth in emergency medicine: A consensus conference to map the intersection of telehealth and emergency medicine

INTRODUCTION

Telehealth has the potential to significantly change the specialty of emergency medicine (EM) and has rapidly expanded in EM during the COVID pandemic; however, it is unclear how EM should intersect with telehealth. The field lacks a unified research agenda with priorities for scientific questions on telehealth in EM.

METHODS

Through the 2020 Society for Academic Emergency Medicine's annual consensus conference, experts in EM and telehealth created a research agenda for the topic. The multiyear process used a modified Delphi technique to develop research questions related to telehealth in EM. Research questions were excluded from the final research agenda if they did not meet a threshold of at least 80% of votes indicating "important" or "very important."

RESULTS

Round 1 of voting included 94 research questions, expanded to 103 questions in round 2 and refined to 36 questions for the final vote. Consensus occurred with a final set of 24 important research questions spanning five breakout group topics. Each breakout group domain was represented in the final set of questions. Examples of the questions include: "Among underserved populations, what are mechanisms by which disparities in emergency care delivery may be exacerbated or ameliorated by telehealth" (health care access) and "In what situations should the quality and safety of telehealth be compared to in-person care and in what situations should it be compared to no care" (quality and safety).

CONCLUSION

The primary finding from the process was the breadth of gaps in the evidence for telehealth in EM and telehealth in general. Our consensus process identified priority research questions for the use of and evaluation of telehealth in EM to fill the current knowledge gaps. Support should be provided to answer the research questions to guide the evidenced-based development of telehealth in EM.

Telemedicine Use in Disasters: A Scoping Review

Disasters have many deleterious effects and are becoming more frequent. From a health-care perspective, disasters may cause periods of stress for hospitals and health-care systems. Telemedicine is a rapidly growing technology that has been used to improve access to health-care during disasters. Telemedicine applied in disasters is referred to as disaster telemedicine. Our objective was to conduct a scoping literature review on current use of disaster telemedicine to develop recommendations addressing the most common barriers to implementation of a telemedicine system for regional disaster health response in the United States. Publications on telemedicine in disasters were collected from online databases. This included both publications in English and those translated into English. Predesigned inclusion/exclusion criteria and a PRISMA flow diagram were applied. The PRISMA flow diagram was used on the basis that it would help streamline the available literature. Literature that met the criteria was scored by 2 reviewers who rated relevance to commonly identified disaster telemedicine implementation barriers, as well as how disaster telemedicine systems were implemented. We also identified other frequently mentioned themes and briefly summarized recommendations for those topics. Literature scoring resulted in the following topics: telemedicine usage (42 publications), system design and operating models (43 publications), as well as difficulties with credentialing (5 publications), licensure (6 publications), liability (4 publications), reimbursement (5 publications), and technology (24 publications). Recommendations from each category were qualitatively summarized.

Efficacy of endoscopic triage during the Covid-19 outbreak and infective risk

OBJECTIVE

SARS-CoV-2 outbreak is spreading worldwide. As a consequence of the new circumstances, almost all endoscopic units underwent in-depth reorganization involving patients' selection. We analyzed the efficacy of the newly adopted endoscopic triage.

METHODS

In March 2020, we monitored endoscopies to evaluate the effects of the novel selective triage aimed to reduce the number of investigations and viral spread/contagions. Clinical-demographic data of the patients, indications, type of endoscopy, endoscopic findings (subtyped in major and minor), finding rates (major and minor) and diagnostic yields (major findings) have been analyzed and compared to the endoscopic procedures performed in March 2019. Furthermore, patients were called at least 21 days after the endoscopy to evaluate the possibility of a Covid-19 onset.

RESULTS

Accordingly to the novel triage, the number of procedures dropped from 530 to 91 (-84%). The finding rates and diagnostic yields were 83% (74-89) vs 71% (66-73) (P 0.015) and 56% (46-65) vs 43% (38-47) (P 0.03) on March 2020 and March 2019, respectively. A significant increase of operative procedures has been reported in 2020, 34% vs 22% in March 2019. All the patients were recalled and neither cases of onset of Covid-19 like symptoms nor positive nasopharyngeal swabs PCR have been evidenced.

CONCLUSION

The novel endoscopic triage significantly reduced the number of procedures and increased finding rates and diagnostic yields. However, a careful schedule of canceled procedures should be applied to avoid to miss relevant pathologies. No Covid-19 onset or infection has been noted after endoscopies.

Endoscopy during the Covid-19 outbreak: experience and recommendations from a single center in a high-incidence scenario

A dramatic SARS-Cov-2 outbreak is hitting Italy hard. To face the new scenario all the hospitals have been re-organised in order to reduce all the outpatient services and to devote almost all their personnel and resources to the management of Covid-19 patients. As a matter of fact, all the services have undergone a deep re-organization guided by: the necessity to reduce exams, to create an environment that helps reduce the virus spread, and to preserve the medical personnel from infection. In these days a re-organization of the endoscopic unit, sited in a high-incidence area, has been adopted, with changes to logistics, work organization and patients selection. With the present manuscript, we want to support gastroenterologists and endoscopists in the organization of a "new" endoscopy unit that responds to the "new" scenario, while remaining fully aware that resources, availability and local circumstances may extremely vary from unit to unit.

Using Telemedicine in Mass Casualty Disasters

OBJECTIVES

The goal of this study is to test an implementation and examine users' perceptions about the usefulness of telemedicine in mass casualty and disaster settings and to provide recommendations for using telemedicine in these settings.

METHODS

Ninety-two US Army Forward Surgical Team (FST) members participated in a high-fidelity mass casualty simulation at the Army Trauma Training Center (ATTC). Telemedicine was implemented into this simulation.

RESULTS

Only 10.9% of participants chose to use telemedicine. The most common users were surgeons and nurses. Participants believed it somewhat improved patient care, attainment of expert resources, decision-making, and adaptation, but not the timeliness of patient care. Participants reported several barriers to using telemedicine in the mass casualty setting, including (1) confusion around team roles, (2) time constraints, and (3) difficultly using in the mass casualty setting (eg, due to noise and other conditions).

CONCLUSIONS

There appear to be barriers to the use and usefulness of telemedicine in mass casualty and disaster contexts. Recommendations include designating a member to lead the use of telemedicine, providing telemedical resources whose benefits outweigh the perceived cost in lost time, and ensuring telemedicine systems are designed for the conditions inherent to mass casualty and disaster settings.

The Importance of Telemedicine during COVID-19 Pandemic: A Focus on Diabetic Retinopathy

Recently, telemedicine has become remarkably important, due to increased deployment and development of digital technologies. National and international guidelines should consider its inclusion in their updates. During the COVID-19 pandemic, mandatory social distancing and the lack of effective treatments has made telemedicine the safest interactive system between patients, both infected and uninfected, and clinicians. A few potential evidence-based scenarios for the application of telemedicine have been hypothesized. In particular, its use in diabetes and complication monitoring has been remarkably increasing, due to the high risk of poor prognosis. New evidence and technological improvements in telemedicine application in diabetic retinopathy (DR) have demonstrated efficacy and usefulness in screening. Moreover, despite an initial increase for devices and training costs, teleophthalmology demonstrated a good cost-to-efficacy ratio; however, no national screening program has yet focused on DR prevention and diagnosis. Lack of data during the COVID-19 pandemic strongly limits the possibility of tracing the real management of the disease, which is only conceivable from past evidence in normal conditions. The pandemic further stressed the importance of remote monitoring. However, the deployment of device and digital application used to increase screening of individuals and monitor progression of retinal disease needs to be easily accessible to general practitioners.

Breaking Barriers to Reach Farther: A Call for Urgent Action on Tele-ICU Services

How to cite this article: Ramakrishnan N, Vijayaraghavan BKT, Venkataraman R. Breaking Barriers to Reach Farther: A Call for Urgent Action on Tele-ICU Services. Indian J Crit Care Med 2020;24(6):393–397.

Hurricane Impact on Emergency Services and Use of Telehealth to Support Prehospital Care

The impact of hurricanes on emergency services is well-known. Recent history demonstrates the need for prehospital and emergency department coordination to serve communities during evacuation, storm duration, and cleanup. The use of telehealth applications may enhance this coordination while lessening the impact on health-care systems. These applications can address triage, stabilization, and diversion and may be provided in collaboration with state and local emergency management operations through various shelters, as well as during other emergency medical responses.

Criteria for Critical Care Infants and Children: PICU Admission, Discharge, and Triage Practice Statement and Levels of Care Guidance

OBJECTIVES

To update the American Academy of Pediatrics and Society of Critical Care Medicine's 2004 Guidelines and levels of care for PICU.

DESIGN

A task force was appointed by the American College of Critical Care Medicine to follow a standardized and systematic review of the literature using an evidence-based approach. The 2004 Admission, Discharge and Triage Guidelines served as the starting point, and searches in Medline (Ovid), Embase (Ovid), and PubMed resulted in 329 articles published from 2004 to 2016. Only 21 pediatric studies evaluating outcomes related to pediatric level of care, specialized PICU, patient volume, or personnel. Of these, 13 studies were large retrospective registry data analyses, six small single-center studies, and two multicenter survey analyses. Limited high-quality evidence was found, and therefore, a modified Delphi process was used. Liaisons from the American Academy of Pediatrics were included in the panel representing critical care, surgical, and hospital medicine expertise for the development of this practice guidance. The title was amended to "practice statement" and "guidance" because Grading of Recommendations, Assessment, Development, and Evaluation methodology was not possible in this administrative work and to align with requirements put forth by the American Academy of Pediatrics.

METHODS

The panel consisted of two groups: a voting group and a writing group. The panel used an iterative collaborative approach to formulate statements on the basis of the literature review and common practice of the pediatric critical care bedside experts and administrators on the task force. Statements were then formulated and presented via an online anonymous voting tool to a voting group using a three-cycle interactive forecasting Delphi method. With each cycle of voting, statements were refined on the basis of votes received and on comments. Voting was conducted between the months of January 2017 and March 2017. The consensus was deemed achieved once 80% or higher scores from the voting group were recorded on any given statement or where there was consensus upon review of comments provided by voters. The Voting Panel was required to vote in all three forecasting events for the final evaluation of the data and inclusion in this work. The writing panel developed admission recommendations by level of care on the basis of voting results.

RESULTS

The panel voted on 30 statements, five of which were multicomponent statements addressing characteristics specific to PICU level of care including team structure, technology, education and training, academic pursuits, and indications for transfer to tertiary or quaternary PICU. Of the remaining 25 statements, 17 reached consensus cutoff score. Following a review of the Delphi results and consensus, the recommendations were written.

CONCLUSIONS

This practice statement and level of care guidance manuscript addresses important specifications for each PICU level of care, including the team structure and resources, technology and equipment, education and training, quality metrics, admission and discharge criteria, and indications for transfer to a higher level of care. The sparse high-quality evidence led the panel to use a modified Delphi process to seek expert opinion to develop consensus-based recommendations where gaps in the evidence exist. Despite this limitation, the members of the Task Force believe that these recommendations will provide guidance to practitioners in making informed decisions regarding pediatric admission or transfer to the appropriate level of care to achieve best outcomes.

Augmenting Critical Care Capacity in a Disaster

A health care facility must develop a comprehensive disaster plan that has a provision for critical care services. Mass critical care requires surge capacity: augmentation of critical care services during a disaster. Surge capacity involves staff, supplies, space, and structure. Measures to increase critical care staff include recalling essential personnel, using noncritical care staff, and emergency credentialing of volunteers. Having an adequate supply chain and a cache of critical care supplies is essential. Virtual critical care or tele-critical care can augment critical care capacity by assisting with patient monitoring, specialized consultation, and in pandemics reduces staff exposure.

Access to Continuing Education for Critical Care Nurses in Rural or Remote Settings

Caring for the critically ill does not occur solely in large medical centers or urban areas. Nurses practicing in rural or remote settings practice as nurse generalists, caring for a wide range of patients, including those needing critical care. As a nurse generalist, the need for a wide variety of skill sets challenges nurses in rural areas to maintain current practice through continuing education across many content areas. They also may not come in contact with critically ill patients or emergent situations as often as their urban counterparts, which can make remaining comfortable with more advanced skills difficult. Because nurses working in rural or remote areas may care for critically ill patients less often, the need to remain vigilant in pursuit of continuing education is increased; however, access to continuing education can be problematic because of geographic isolation, difficulty getting time off from work, limited financial resources, and perceived lack of applicable topics. With advances in technology, critical care nurses working in rural areas have more options for continuing education, which is crucial for maintaining a skilled nursing workforce in rural health care facilities. This article addresses challenges critical care nurses working in remote or rural areas face in pursuing continuing education and provides information about available educational opportunities.

The Promise of Direct-to-Consumer Telehealth for Disaster Response and Recovery

Telehealth has great promise to improve and even revolutionize emergency response and recovery. Yet telehealth in general, and direct-to-consumer (DTC) telehealth in particular, are underutilized in disasters. Direct-to-consumer telehealth services allow patients to request virtual visits with health care providers, in real-time, via phone or video conferencing (online video or mobile phone applications). Although DTC services for routine primary care are growing rapidly, there is no published literature on the potential application of DTC telehealth to disaster response and recovery because these services are so new. This report presents several potential uses of DTC telehealth across multiple disaster phases (acute response, subacute response, and recovery) while noting the logistical, legal, and policy challenges that must be addressed to allow for expanded use. Uscher-Pines L , Fischer S , Chari R . The promise of direct-to-consumer telehealth for disaster response and recovery. Prehosp Disaster Med. 2016;31(4):454-456.

Telemedicine: Potential applications in epidemic situations

Background

Telemedicine has several applications regarding different medical specialties or clinical situations. However, telemedicine as a potential tool during epidemics is not as well considered.

Methods

In this paper, the application of telemedicine is conceptualised using five possible evidence-based epidemic situations.

Results

The first situation corresponds to asymptomatic individuals, mainly home-based, living in an epidemic-affected location. The application of telemedicine would be through the use of teleconsultation for emergency medical dispatching and would occur when suspicious symptoms are detected by an individual. The second situation for the application of telemedicine is principally home-based and corresponds to the follow-up telemonitoring of asymptomatic individuals identified as case contacts. Concrete applications of these concepts were used during the Ebola virus disease outbreak in Africa since 2014. The third situation links to symptomatic cases in need of isolation. Examples include patients isolated in Taiwan during SARS epidemic in 2003 and H1N1 pandemic influenza in 2009, as well as H7N9 influenza infected patients in 2013 in China. The fourth situation involves tele-expertise when local medical resources do not have the technical expertise for the diagnosis or treatment of a patient and support is required from reference centres. The fifth situation corresponds to a healthcare facility under quarantine that would use telemedicine to keep taking care of patients that cannot access the facility, as it was the case in June 2015 in Seoul during the Middle East Respiratory Syndrome Coronavirus epidemic.

Conclusion

The use of telemedicine in epidemic situations has a high potential in improving epidemiological investigations, disease control, and clinical case management. However, since it is a recent application, further research would be needed to gain an improved understanding of how telemedicine could be applied in epidemic situations.