Describing advanced practice provider roles within critical care teams with Tele-ICUs: Exemplars from seven US health systems

Best Practices in Telecritical Care: Expert Consensus Recommendations From the Telecritical Care Collaborative Network

OBJECTIVES

Telecritical care (TCC) refers to the delivery of critical care using telehealth technologies. Despite increasing utilization, significant practice variation exists and literature regarding efficacy remains sparse. The Telecritical Care Collaborative Network sought to provide expert, consensus-based best practice recommendations for the design and delivery of TCC.

DESIGN

We used a modified Delphi methodology. Following literature review, an oversight panel identified core domains and developed declarative statements for review by an expert voting panel. During three voting rounds, voters agreed or disagreed with statements and provided open-ended feedback, which the oversight panel used to revise statements. Statements met criteria for consensus when accepted by greater than or equal to 85% of voters.

SETTING/SUBJECTS

The oversight panel included 18 multidisciplinary members of the TCC Collaborative Network, and the voting panel included 32 invited experts in TCC, emphasizing diversity of discipline, care delivery models, and geography.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified ten core domains: definitions/terminology; care delivery models; staffing and coverage models; technological considerations; ergonomics and workplace safety; licensing, credentialing, and certification; trust and relationship building; quality, safety, and efficiency, research agenda; and advocacy, leading to 79 practice statements. Of 79 original statements, 67 were accepted in round 1. After revision, nine were accepted in round 2 and two in round 3 (two statements were merged). In total, 78 practice statements achieved expert consensus.

CONCLUSIONS

These expert consensus recommendations cover a broad range of topics relevant to delivery of TCC. Experts agreed that TCC is most effective when delivered by care teams with specific expertise and by programs with explicit protocols focusing on effective communication, technical reliability, and real-time availability. Interventions should be tailored to local conditions. Although further research is needed to guide future best practice statements, these results provide valuable and actionable recommendations for the delivery of high-quality TCC.

The Lived Experiences of Telemedicine Intensive Care Unit Nurses

BACKGROUND

Although nurses are the primary clinicians in telemedicine intensive care units (tele-ICUs), their experiences remain underresearched.

OBJECTIVE

To describe and interpret the lived experiences of tele-ICU nurses.

METHODS

A qualitative, hermeneutical, phenomenological approach based on van Manen's methodology was used to collect and interpret interview data. In-depth interviews were conducted with 11 tele-ICU nurses affiliated with a health system in the northeastern United States. The interviews were intended to elicit direct reports of specific incidents to capture the phenomenological experience. Field observations of the practice setting were conducted to enhance data richness.

RESULTS

The participants were primarily female, aged 34 to 67 years, with 11 to 45 years of nursing experience. The following 4 major themes and 12 subthemes were identified: (1) watching intensively and panoptically, with subthemes (a) affirming unremitting diligence, (b) uncovering virtual knowing, and (c) easing perceptions of intrusion; (2) transcending complex boundaries, with subthemes (a) building trustful collaboration, (b) discerning vigilant interventions, and (c) exercising skillful investigation; (3) transforming nursing practice, with subthemes (a) mastering tact, (b) delineating the critical wholeness, and (c) augmenting safety and quality of care; and (4) developing an e-identity, with subthemes (a) tempering feelings of working in shadows, (b) evolving to the enhanced specialist role, and (c) achieving professional gratification.

CONCLUSIONS

Tele-ICU nurses play a transformative role in nursing practice. These findings have implications for nursing practice, education, health policy, enhancement of the current American Association of Critical-Care Nurses (AACN) Tele-ICU Nursing Practice Model, and future research on ICU telemedicine.

Innovation in Nurse Staffing Models: Implementing a Tele-Critical Care Nurse Program in a Pediatric Cardiac Intensive Care Unit

A pediatric tele-critical care nursing program provides an extra layer of surveillance for patients and alerts bedside nurses of abnormal trends to mitigate adverse events. Although workforce turnover combined with patient complexity and acuity in a pediatric cardiac intensive care unit strains the sustainability of a healthy work environment, these variables have also opened the door to an innovative approach to tele-critical care nursing care delivery. In addition to virtual surveillance, a clinical bedside intervention was developed to provide hands-on assistance to bedside nurses. This article describes the evolution of this novel technique for enhancing nursing care delivery.

Acute Care Advanced Practice Providers' Use of Telehealth During the COVID-19 Pandemic

Advanced practice registered nurses and physician assistants, collectively termed advanced practice providers (APPs), have been part of telehealth for many years. During the COVID-19 pandemic, APPs experienced the growth in roles, responsibilities, and tools used for telehealth care delivery. This article uses examples from 3 health systems to highlight the ways in which telehealth use was expanded due to the pandemic, how APP roles were altered across the United States during and after the pandemic, and implications for future practice.

Innovations in Tele-Critical Care Nursing During the COVID-19 Pandemic

For decades, tele-critical care (TCC) programs have provided expert population surveillance with standardized clinical interventions for critically ill patients. The COVID-19 pandemic created massive strains on critical care resources. For this report, standard questions were used to solicit COVID-19 pandemic workflow and service modifications from a network of TCC leaders to describe the rapid expansion of TCC-supported services during the pandemic. In this article, leaders from 7 TCC programs report on the effective use of services to support changing hospital needs during the pandemic in areas such as clinical education, personal protective equipment stewardship, expansion of virtual care, and creative staffing models, among others.

Rise of the Virtual Nurse

As the process of providing health care becomes increasingly complex and the foundation of the nursing profession changes, nursing leaders will need to think differently about how to support their colleagues more efficiently and effectively. The role of the virtual nurse is expanding as part of the effort to address these complexities and develop innovative solutions. Although more work is necessary to define best practices in the variations of virtual nursing, current examples have had a positive impact on nursing and patient care. This article describes the ways in which virtual nursing has grown over the years and how it continues to adapt to support the nursing profession.

Developing Cardiothoracic Surgical Critical Care Intensivists: A Case for Distinct Training

Cardiothoracic surgical critical care medicine is practiced by a diverse group of physicians including surgeons, anesthesiologists, pulmonologists, and cardiologists. With a wide array of specialties involved, the training of cardiothoracic surgical intensivists lacks standardization, creating significant variation in practice. Additionally, it results in siloed physicians who are less likely to collaborate and advocate for the cardiothoracic surgical critical care subspeciality. Moreover, the current model creates credentialing dilemmas, as experienced by some cardiothoracic surgeons. Through the lens of critical care anesthesiologists, this article addresses the shortcomings of the contemporary cardiothoracic surgical intensivist training standards. First, we describe the present state of practice, summarize past initiatives concerning specific training, outline why standardized education is needed, provide goals of such training standardization, and offer a list of desirable competencies that a trainee should develop to become a successful cardiothoracic surgical intensivist.

Pilot of rapid implementation of the advanced practice provider in the workflow of an existing tele-critical care program

Incorporating the advanced practice provider (APP) in the delivery of tele critical care medicine (teleCCM) addresses the critical care provider shortage. However, the current literature lacks details of potential workflows, deployment difficulties and implementation outcomes while suggesting that expanding teleCCM service may be difficult. Here, we demonstrate the implementation of a telemedicine APP (eAPP) pilot service within an existing teleCCM program with the objective of determining the feasibility and ease of deployment. The goal is to augment an existing tele-ICU system with a balanced APP service to assess the feasibility and potential impact on the ICU performance in several hospitals affiliated within a large academic center. A REDCap survey was used to assess eAPP workflows, expediency of interventions, duration of tasks, and types of assignments within different service locations. Between 02/01/2021 and 08/31/2021, 204 interventions (across 133 12-h shift) were recorded by eAPP (n_routine = 109 (53.4%); n_urgent = 82 (40.2%); n_emergent = 13 (6.4%). The average task duration was 10.9 ± 6.22 min, but there was a significant difference based on the expediency of the task (F [2; 202] = 3.89; p < 0.022) and type of tasks (F [7; 220] = 6.69; p < 0.001). Furthermore, the eAPP task type and expediency varied depending upon the unit engaged and timeframe since implementation. The eAPP interventions were effectively communicated with bedside staff with only 0.5% of suggestions rejected. Only in 2% cases did the eAPP report distress. In summary, the eAPP can be rapidly deployed in existing teleCCM settings, providing adaptable and valuable care that addresses the specific needs of different ICUs while simultaneously enhancing the delivery of ICU care. Further studies are needed to quantify the input more robustly.

Implementation of an emergency department virtual follow-up care process in a community-based hospital: a quality improvement initiative

During the COVID-19 pandemic, patients were apprehensive to seek acute care resulting in delayed diagnoses of serious conditions and reduction in emergency room (ER) visits by 50% in the Fraser Health Authority. Patients who did present to the ER left prior to their results being available and some refused admission and critical treatments.

At the Chilliwack General Hospital ER, a virtual care clinic was established to follow-up on patients after their initial ER visit, providing test results and ensuring patients are not clinically deteriorating at home. Specific criteria were created for safe referral to virtual follow-up. For 2 hours daily, an ER physician contacts selected patients by telephone to provide a virtual follow-up based on the patients’ needs.

Through the emergency department virtual care (EVC) pilot project, from May 14 to August 31, 2020, on average 58 telehealth visits were conducted weekly, with 19% of visits reaching unattached patients without a regular primary care provider. A patient survey revealed that 75% of respondents were very satisfied or satisfied with telephone virtual care as a follow-up to their emergency department (ED) visit, while 95% would like to continue to receive telephone follow-up care. Additionally, based on a physician survey, 80% of providers were satisfied or very satisfied with the overall EVC experience. The majority (80%) would like to continue to provide the service. One patient was referred for a virtual care follow-up for imaging results that did not meet the referral criteria; the patient was diagnosed with a perforated appendicitis. They had an atypical presentation of abdominal pain and their care was delayed by several hours than if they were to present to the ED for in-person follow-up. The process and referral criteria may require minor modification and must be followed strictly to ensure safety and efficiency in providing telehealth follow-up in the acute care setting.

Optimizing the Potential for Telehealth in Cardiovascular Care (in the Era of COVID-19): Time Will Tell

Before the coronavirus disease 2019 (COVID-19) pandemic, use of telehealth services had been limited in cardiovascular care. Potential benefits of telehealth include improved access to care, more efficient care management, reduced costs, the ability to assess patients within their homes while involving key caretakers in medical decisions, maintaining social distance, and increased patient satisfaction. Challenges include changes in payment models, issues with data security and privacy, potential depersonalization of the patient-clinician relationship, limitations in the use of digital health technologies, and the potential impact on disparities, including socioeconomic, gender, and age-related issues and access to technology and broadband. Implementation and expansion of telehealth from a policy and reimbursement practice standpoint are filled with difficult decisions, yet addressing these are critical to the future of health care.

2019 John M. Eisenberg Patient Safety and Quality Awards: A Model Cell for Transformational Redesign of Sepsis Identification and Treatment: Aligning Digital Tools with Innovative Workflows

BACKGROUND

Readmission after hospitalization, increased morbidity, and high levels of mortality are not uncommon in patients diagnosed with sepsis. Sepsis bundles designed to mitigate the deleterious effects have been recommended for nearly a decade. Despite this, mortality remains high, sepsis bundle requirements controversial, and bundle compliance low.

METHODS

A health system implemented a multidisciplinary project to decrease the mortality rate of sepsis. A Model Cell mental model was adopted. Data on mortality and compliance were gathered from four acute care hospitals in the system and analyzed. The observed mortality data were compared to predictive data based on comparable acute care facilities.

RESULTS

Regression analysis showed significant increases in bundle compliance rates at each site (p < 0.05), reflecting the continuous use of the methods described above. Mortality systemwide decreased significantly in response to increased bundle compliance (r = 0.80, r² = 0.64, p < 0.001), with compliance alone accounting for nearly two thirds of the variance in the linear model. The observed results revealed a median mortality rate of 5.7% (95% confidence interval [CI] = 5.1%-7.3%, n = 23), 1.9 percentage points lower than predicted when compared to similar institutions. When using only the final 12 months of the project, the median mortality drops further to 5.3% (95% CI = 3.9%-5.6%, n = 12), 2.5 percentage points less than predicted.

CONCLUSION

The Model Cell intervention was successful in increasing bundle compliance, which then decreased mortality. This model can be enhanced as technology improves and is well positioned for artificial intelligence to help drive further success.

Impact of rurality on melanoma diagnosis in Utah

Aim

To analyze trends in Utah melanoma diagnosis and study the impact of rurality.

Patients & methods

State-wide melanoma incidence was calculated using Surveillance, Epidemiology, and End Results data (2005-2013). A subset of 5199 patients treated in an integrated healthcare system was further stratified for urban or rural residence.

Results

Early-stage tumors accounted for most of the increase in melanoma incidence over time. Age-adjusted melanoma incidence rate was higher in rural counties (46.7 vs 39.4). Anatomic site and stage did not differ between rural and urban patients. Rural patients were more commonly diagnosed by a local primary care provider.

Conclusion

Rurality had an impact on melanoma diagnosis in the specialty and location of the diagnosing provider.

COVID-19 and telehealth: Issues facing healthcare in a pandemic

ABSTRACT

Providing safe nonemergent care during the coronavirus disease 2019 (COVID-19) pandemic has been challenging for NPs. This article, the first of a three-part series, will overview telehealth and telemedicine and provide a brief history of the two. The benefits, challenges, and temporary changes due to COVID-19 will also be addressed.