The Utility of Teleultrasound to Guide Acute Patient Management

Integrating a Virtual ICU with Cardiac and Cardiovascular ICUs: Managing the Needs of a Complex and High-Acuity Specialty ICU Cohort

A long-standing shortage of critical care intensivists and nurses, exacerbated by the coronavirus disease (COVID-19) pandemic, has led to an accelerated adoption of tele-critical care in the United States (US). Due to their complex and high-acuity nature, cardiac, cardiovascular, and cardiothoracic intensive care units (ICUs) have generally been limited in their ability to leverage tele-critical care resources. In early 2020, Houston Methodist Hospital (HMH) launched its tele-critical care program called Virtual ICU, or vICU, to improve its ICU staffing efficiency while providing high-quality, continuous access to in-person and virtual intensivists and critical care nurses. This article provides a roadmap with prescriptive specifications for planning, launching, and integrating vICU services within cardiac and cardiovascular ICUs-one of the first such integrations among the leading academic US hospitals. The success of integrating vICU depends upon the (1) recruitment of intensivists and RNs with expertise in managing cardiac and cardiovascular patients on the vICU staff as well as concerted efforts to promote mutual trust and confidence between in-person and virtual providers, (2) consultations with the bedside clinicians to secure their buy-in on the merits of vICU resources, and (3) collaborative approaches to improve workflow protocols and communications. Integration of vICU has resulted in the reduction of monthly night-call requirements for the in-person intensivists and an increase in work satisfaction. Data also show that support of the vICU is associated with a significant reduction in the rate of Code Blue events (denoting a situation where a patient requires immediate resuscitation, typically due to a cardiac or respiratory arrest). As the providers become more comfortable with the advances in artificial intelligence and big data-driven technology, the Cardiac ICU Cohort continues to improve methods to predict and track patient trends in the ICUs.

Small Animal Teleultrasound

Teleradiology is well established in many small animal practices, whereas teleultrasound is slowly gaining prominence. The demand for teleultrasound services in the veterinary profession has increased substantially because access to ultrasound to general practitioners increases faster than the number of imaging specialists and Point of Care Ultrasound (POCUS) becomes part of the standard of care. Two main methods of teleultrasound currently exist: asynchronous (eg, "store-and-forward") and synchronous (eg, real-time) interpretations. Few standardized protocols for teleultrasound in small animals are available. Similarly, there are no standardized training programs for sonographic examination acquisition and interpretation outside of the traditional diagnostic imaging residency under the purview of the American College of Veterinary Radiology. The success of a telesonographic evaluation largely depends on the relationship between the veterinarian requesting remote assistance and the expert providing support.

Point-of-Care Teleultrasound: A Systematic Review

Background: Telemedicine and point-of-care ultrasound have merged to create a field known as teleultrasound (TUS). Real-time TUS involves the transmission of bedside ultrasound (US) images with direct feedback from an US expert. In this review, we summarize the current uses of real-time TUS and discuss its potential future uses. Methods: We performed a literature search (PubMed and EMBase) to assess articles related to real-time TUS. Data were extracted using a standardized collection form, and relevant articles were separated into feasibility or clinical studies. Results: Our search yielded 45 articles, with most of the reports taking place in resource-constrained settings. A large portion of the studies discussed the use of the focused assessment with sonography in trauma exam. Others included musculoskeletal, vascular, and echocardiography. Conclusion: Real-time TUS allows for rapid access to diagnostic imaging in various clinical settings. This technology is poised to expand with many uses on the horizon.

Global health, global surgery and mass casualties: II. Mass casualty centre resources, equipment and implementation

Trauma/stroke centres optimise acute 24/7/365 surgical/critical care in high-income countries (HICs). Concepts from low-income and middle-income countries (LMICs) offer additional cost-effective healthcare strategies for limited-resource settings when combined with the trauma/stroke centre concept. Mass casualty centres (MCCs) integrate resources for both routine and emergency care-from prevention to acute care to rehabilitation. Integration of the various healthcare systems-governmental, non-governmental and military-is key to avoid both duplication and gaps. With input from LMIC and HIC personnel of various backgrounds-trauma and subspecialty surgery, nursing, information technology and telemedicine, and healthcare administration-creative solutions to the challenges of expanding care (both daily and disaster) are developed. MCCs are evolving initially in Chile and Pakistan. Technologies for cost-effective healthcare in LMICs include smartphone apps (enhance prehospital care) to electronic data collection and analysis (quality improvement) to telemedicine and drones/robots (support of remote regions and resource optimisation during both daily care and disasters) to resilient, mobile medical/surgical facilities (eg, battery-operated CT scanners). The co-ordination of personnel (within LMICs, and between LMICs and HICs) and the integration of cost-effective advanced technology are features of MCCs. Providing quality, cost-effective care 24/7/365 to the 5 billion who lack it presently makes MCCs an appealing means to achieve the healthcare-related United Nations Sustainable Development Goals for 2030.

Mobile Health Technologies in Cardiopulmonary Disease

Mobile health (mHealth) technologies are modernizing medicine by affording greater patient engagement, monitoring, outreach, and health-care delivery. The cardiopulmonary fields have led the integration of mHealth into clinical practice and research. mHealth technologies in these areas include smartphone applications, wearable devices, and handheld devices, among others, and provide real-time monitoring of numerous important physiological measurements and other key parameters. Use of mHealth-compatible devices has increased in recent years, and age and socioeconomic gaps of ownership are narrowing. These tools provide physicians and researchers with a better understanding of an individual's health and well-being. mHealth interventions have shown utility in the prevention, monitoring, and management of atrial fibrillation, heart failure, and myocardial infarction. With the growing prevalence of cardiopulmonary disease, mHealth technologies may become a more essential element of care within and outside of traditional health-care settings. mHealth is continuously developing as a result of technologic advancements and better understandings of mHealth utility. However, there is little regulation on the mHealth platforms available for commercial use and even fewer guidelines on implementing evidence-based practices into mHealth technologies. Online security is another challenge and necessitates development in data collection infrastructure to manage the extraordinary volume of patient data. Continued research on long-term implications of mHealth technology and the integration of effective interventions into clinical practice is required.

Legal Perspectives on Telemedicine Part 2: Telemedicine in the Intensive Care Unit and Medicolegal Risk

Tele-intensive care unit (tele-ICU) implementation has been shown to improve clinical and financial outcomes. The expansion of this new care delivery model has outpaced the development of its accompanying regulatory framework. In the first part of this commentary we discussed legal and regulatory issues of telemedicine in general and expanded on tele-ICU implementation in particular. Major legal and regulatory barriers to expansion remain, including uncertainty regarding license portability and reimbursement. In this second part we discuss the effects of telemedicine implementation on the various aspects of medicolegal risk and risk mitigation, with a particular focus on tele-ICU. There is a paucity of legal data regarding the effect of tele-ICU implementation on medicolegal risk. We will therefore systematically discuss the effects of tele-ICU on the various root causes of medical error. Given the substantial capital and operational investment that must be undertaken to build and run a tele-ICU, any reduction in risk adds to the financial return on investment and further decreases barriers to implementation.

Telemedicine in the ICU: clinical outcomes, economic aspects, and trainee education

PURPOSE OF REVIEW

The evidence base for telemedicine in the ICU (tele-ICU) is rapidly expanding. The last 2 years have seen important additions to our understanding of when, where, and how telemedicine in the ICU adds value.

RECENT FINDINGS

Recent publications and a recent meta-analysis confirm that tele-ICU improves core clinical outcomes for ICU patients. Recent evidence further demonstrates that comprehensive tele-ICU programs have the potential to quickly recuperate their implementation and operational costs and significantly increase case volumes and direct contribution margins particularly if additional logistics and care standardization functions are embedded to optimize ICU bed utilization and reduce complications. Even though the adoption of tele-ICU is increasing and the vast majority of today's medical graduates will regularly use some form of telemedicine and/or tele-ICU, telemedicine modules have not consistently found their way into educational curricula yet. Tele-ICU can be used very effectively to standardize supervision of medical trainees in bedside procedures or point-of-care ultrasound exams, especially during off-hours. Lastly, tele-ICUs routinely generate rich operational data, as well as risk-adjusted acuity and outcome data across the spectrum of critically ill patients, which can be utilized to support important clinical research and quality improvement projects.

SUMMARY

The value of tele-ICU to improve patient outcomes, optimize ICU bed utilization, increase financial performance and enhance educational opportunities for the next generation of providers has become more evident and differentiated in the last 2 years.