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Scott BK, Singh J, Hravnak M, Everhart SS, Armaignac DL, Davis TM, Goede MR, Haranath SP, Kordik CM, Laudanski K, Pappas PA, Patel S, Rincon TA, Scruth EA, Subramanian S, Villanueva I, Williams LM, Wilson R, Pamplin JC. Best Practices in Telecritical Care: Expert Consensus Recommendations From the Telecritical Care Collaborative Network. Crit Care Med 2024; 52:1750-1767. [PMID: 39417998 DOI: 10.1097/ccm.0000000000006418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2024]
Abstract
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.
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Affiliation(s)
| | - Jaspal Singh
- Atrium Health, Charlotte, North Carolina & Wake Forest School of Medicine, Winston-Salem, NC
| | | | | | | | - Theresa M Davis
- Inova Health System, High Reliability Center, Falls Church, VA
| | | | | | | | - Krzysztof Laudanski
- Department of Anesthesiology and Perioperative Care, Mayo Clinic, Rochester, MN
| | - Peter A Pappas
- University of Central Florida College of Medicine, Orlando, FL
| | | | - Teresa A Rincon
- Tan Chingfen Graduate School of Nursing, UMass Chan Medical School, Worcester MA and Blue Cirrus Consulting, Greenville, SC
| | - Elizabeth A Scruth
- Northern California Kaiser Permanente, Clinical Quality Programs, Data Analytics and Tele Critical Care, Oakland, CA
| | | | | | | | | | - Jeremy C Pamplin
- The Telemedicine and Advanced Technology Research Center, Fort Detrick, MD
- Department of Medicine, The Uniformed Services University, Bethesda, MD
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Vranas KC, Kahn JM. Evaluating Complex Technological Innovations in Critical Care-Current Challenges and Future Directions. JAMA 2024:2824933. [PMID: 39382229 DOI: 10.1001/jama.2024.19854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/10/2024]
Affiliation(s)
- Kelly C Vranas
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Division of Pulmonary, Allergy and Critical Care Medicine, Oregon Health & Science University, Portland
| | - Jeremy M Kahn
- Department of Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
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Juneja D, Nasa P, Chanchalani G, Cherian A, Jagiasi BG, Javeri Y, Kola VR, Kothekar AT, Kumar P, Maharaj M, Munjal M, Nandakumar SM, Nikalje A, Nongthombam R, Ray S, Sinha MK, Sodhi K, Myatra SN. The Indian Society of Critical Care Medicine Position Statement on the Management of Sepsis in Resource-limited Settings. Indian J Crit Care Med 2024; 28:S4-S19. [PMID: 39234230 PMCID: PMC11369916 DOI: 10.5005/jp-journals-10071-24682] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 03/25/2024] [Indexed: 09/06/2024] Open
Abstract
Sepsis poses a significant global health challenge in low- and middle-income countries (LMICs). Several aspects of sepsis management recommended in international guidelines are often difficult or impossible to implement in resource-limited settings (RLS) due to issues related to cost, infrastructure, or lack of trained healthcare workers. The Indian Society of Critical Care Medicine (ISCCM) drafted a position statement for the management of sepsis in RLS focusing on India, facilitated by a task force of 18 intensivists using a Delphi process, to achieve consensus on various aspects of sepsis management which are challenging to implement in RLS. The process involved a comprehensive literature review, controlled feedback, and four iterative surveys conducted between 21 August 2023 and 21 September 2023. The domains addressed in the Delphi process included the need for a position statement, challenges in sepsis management, considerations for diagnosis, patient management while awaiting an intensive care unit (ICU) bed, and treatment of sepsis and septic shock in RLS. Consensus was achieved when 70% or more of the task force members voted either for or against statements using a Likert scale or a multiple-choice question (MCQ). The Delphi process with 100% participation of Task Force members in all rounds, generated consensus in 32 statements (91%) from which 20 clinical practice statements were drafted for the management of sepsis in RLS. The clinical practice statements will complement the existing international guidelines for the management of sepsis and provide valuable insights into tailoring sepsis interventions in the context of RLS, contributing to the global discourse on sepsis management. Future international guidelines should address the management of sepsis in RLS. How to cite this article Juneja D, Nasa P, Chanchalani G, Cherian A, Jagiasi BG, Javeri Y, et al. The Indian Society of Critical Care Medicine Position Statement on the Management of Sepsis in Resource-limited Settings. Indian J Crit Care Med 2024;28(S2):S4-S19.
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Affiliation(s)
- Deven Juneja
- Department of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Prashant Nasa
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai, United Arab Emirates
| | - Gunjan Chanchalani
- Department of Critical Care Medicine, K.J. Somaiya Hospital & Research Center, Mumbai, Maharashtra, India
| | - Anusha Cherian
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
| | - Bharat G Jagiasi
- Department of Critical Care, Kokilaben Dhirubhai Ambani Hospital, Navi Mumbai, Maharashtra, India
| | - Yash Javeri
- Department of Critical Care and Emergency Medicine, Regency Super Speciality Hospital, Lucknow, Uttar Pradesh, India
| | - Venkat R Kola
- Department of Critical Care Medicine, Yashoda Hospitals, Hyderabad, Telangana, India
| | - Amol T Kothekar
- Department of Anesthesiology, Critical Care and Pain, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Prashant Kumar
- Department of Critical Care Medicine, Yatharth Hospital, Noida, Uttar Pradesh, India
| | - Mohan Maharaj
- Department of Critical Care, Medicover Hospitals, Visakhapatnam, Andhra Pradesh, India
| | - Manish Munjal
- Department of Critical Care, ManglamPlus Medicity Hospital, Jaipur, Rajasthan, India
| | - Sivakumar M Nandakumar
- Department of Critical Care Medicine, Royal Care Super Speciality Hospital, Coimbatore, Tamil Nadu, India
| | - Anand Nikalje
- Department of Medicine, Medical Centre and Research Institute (MCRI) ICU, MGM Medical College and Hospital, Aurangabad, Maharashtra, India
| | - Rakesh Nongthombam
- Department of Anaesthesiology and Intensive Care, J.N. Institute of Medical Sciences, Imphal, Manipur, India
| | - Sumit Ray
- Department of Critical Care Medicine, Holy Family Hospital, New Delhi, India
| | - Mahesh K Sinha
- Department of Critical Care Medicine, Ramkrishna CARE Hospitals, Raipur, Chhattisgarh, India
| | | | - Sheila N Myatra
- Department of Anesthesiology, Critical Care and Pain, Division of Critical Care Medicine, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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4
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Siner JM. Tele-Critical Care Support Outside the Intensive Care Unit. Crit Care Clin 2024; 40:599-608. [PMID: 38796230 DOI: 10.1016/j.ccc.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Tele-intensive care unit (ICU), or Tele Critical Care (TCC), has been in active use for 25 years and has expanded beyond the original model to support critically ill patients beyond the confines of the ICU. Here, the author reviews the role of TCC in supporting rapid response events, critical care in emergency departments, and disaster and pandemic responses. The ability to rapidly expand critical care services has important capacity and care quality implications. Moreover, as TCC infrastructure becomes less expensive, the opportunities to leverage this care modality also have potentially important financial benefits.
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Affiliation(s)
- Jonathan M Siner
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, 300 Cedar Street, P.O. Box 208057, New Haven, CT 06520-8057, USA.
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Hadler RA, Gao Y, Beck B, Moeckli J, Massarweh N, Mosher H, Vaughan-Sarrazin M. Palliative Care Utilization and Hospital Transfers in Veterans Treated in Telecritical Care-Supported Intensive Care Units Versus Non-Telecritical Care Intensive Care Units. J Palliat Med 2024; 27:756-762. [PMID: 38324007 DOI: 10.1089/jpm.2023.0548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024] Open
Abstract
Background: Although telecritical care (TCC) implementation is associated with reduced mortality and interhospital transfer rates, its impact on goal-concordant care delivery in critical illness is unknown. We hypothesized that implementation of TCC across the Veterans' Health Administration system resulted in increased palliative care consultation and goals of care evaluation, yielding reduced transfer rates. Methods: We included veterans admitted to intensive care units between 2008 and 2022. We compared palliative care consultation and transfer rates before and after TCC implementation with rates in facilities that never implemented TCC. We used generalized linear mixed multivariable models to assess the associations between TCC initiation, palliative care consultation, and transfer and subsequently used mediation analysis to evaluate potential causality in this relationship. Results: Overall, 1,020,901 veterans met inclusion criteria. Demographic characteristics of patients were largely comparable across groups, although TCC facilities served more rural veterans. Palliative care consultation rates increased substantially in both ever-TCC and never-TCC hospitals during the study period (2.3%-4.3%, and 1.6%-4.7%, p < 0.01). Admissions post-TCC implementation were associated with an increased likelihood of palliative care consultation (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.01-1.15). TCC implementation was also associated with a reduction in transfer rates (OR 0.90, 95% CI 0.84-0.95). Mediation analysis did not demonstrate a causal relationship between TCC implementation, palliative care consultation, and reductions in interhospital transfer rate. Conclusions: TCC is associated with increased palliative care engagement, while TCC and palliative care engagement are both independently related to reduced transfers.
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Affiliation(s)
- Rachel A Hadler
- VA Quality Scholars Fellow, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
- Department of Anesthesiology, Emory University, Atlanta, Georgia, USA
- Emory Critical Care Center, Emory University, Atlanta, Georgia, USA
- Division of Palliative Care, Department of Geriatrics and Extended Care, Atlanta Veterans Administration Health Care System, Decatur, Georgia, USA
| | - Yubo Gao
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Brice Beck
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Jane Moeckli
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Nader Massarweh
- Department of Surgery, Atlanta Veterans Administration Health Care System, Decatur, Georgia, USA
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Hilary Mosher
- Geriatric Research Education and Clinical Center, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - Mary Vaughan-Sarrazin
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
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Rao P, Mathur N, Kalyanpur A. Utilization of Teleradiology by Intensive Care Units: A Cohort Study. Indian J Crit Care Med 2024; 28:20-25. [PMID: 38510772 PMCID: PMC10949298 DOI: 10.5005/jp-journals-10071-24593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/29/2023] [Indexed: 03/22/2024] Open
Abstract
Aim and background Imaging is indispensable to the diagnostic and treatment process. By facilitating access to rapid timely image interpretation, teleradiology plays a prominent role in improving access, quality of critical care, and management of the patients in intensive care units (ICU). The aim of the study is to investigate the role of teleradiology in ICU patient care and management. Materials and methods In our study, a total of 22,081 studies of a cohort of 14,900 patients which had been transmitted from intensive care units of 80 hospitals located across the United States of America through a teleradiology reporting workflow, were interpreted by the American Board Certified Radiologists empanelled by a teleradiology service provider, located in India. Results Among all modalities, the highest percentage of studies performed were computed tomography scan (47%) followed by radiographs (37.22%). Out of 22,081 cases under the study, 16,582 cases were reported during nighttime with a mean turnaround time (TAT) of 46.66 minutes 95% CI (46.27-47.04) while 5,499 cases were reported during daytime with a mean TAT of 44.66 minutes 95% CI (45.40-43.92). Conclusion Setting up teleradiology service connectivity with a teleradiology service provider located in India, providing high-quality diagnostic interpretations and lower turnaround time with the ICUs in the US hospitals reduces the interval to intervention time and leads to efficient patient care management. Moreover, it also provides time advantage for US hospitals when on-site radiologists at night are unable to provide immediate coverage. Clinical significance The ICU teleradiology service model designed in the study would greatly help overcome the shortfall of radiologists in the hospitals, provide better patient management and care by quality reporting in short turnaround time, not only during daytime but also in the night hours or on holidays when on-site radiologists are unable to provide immediate coverage. How to cite this article Rao P, Mathur N, Kalyanpur A. Utilization of Teleradiology by Intensive Care Units: A Cohort Study. Indian J Crit Care Med 2024;28(1):20-25.
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Affiliation(s)
- Pallavi Rao
- Department of Clinical Research, Image Core Lab, Bengaluru, Karnataka, India
| | - Neetika Mathur
- Department of Clinical Research, Image Core Lab, Bengaluru, Karnataka, India
| | - Arjun Kalyanpur
- Department of Clinical Radiology, Teleradiology Solutions, Bengaluru, Karnataka, India
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Eitenberger M, Gerger G, Klomfar S, Gabriel MA, Kletecka-Pulker M, Schaden E, Atanasov AG, Maleczek M, Völkl-Kernstock S, Klager E. Focusing on experts: Expectations of healthcare professionals regarding the use of telemedicine in intensive care units. Digit Health 2024; 10:20552076241257042. [PMID: 38836049 PMCID: PMC11149446 DOI: 10.1177/20552076241257042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 05/08/2024] [Indexed: 06/06/2024] Open
Abstract
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.
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Affiliation(s)
- Magdalena Eitenberger
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
- Department of Political Science, University of Vienna, Vienna, Austria
| | - Gernot Gerger
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
| | - Sophie Klomfar
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
- Department of Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria
| | | | - Maria Kletecka-Pulker
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
- Institute for Ethics and Law in Medicine, University of Vienna, Vienna Austria
| | - Eva Schaden
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Atanas G Atanasov
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
- Institute of Genetics and Animal Biotechnology of the Polish Academy of Sciences, Jastrzebiec, Poland
| | - Mathias Maleczek
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Sabine Völkl-Kernstock
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
- Department of Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria
| | - Elisabeth Klager
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
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DeBolt CL, Rheuban KS, Harris D. Telehealth Services: Improving Equity in Pulmonary Health Outcomes. Clin Chest Med 2023; 44:651-660. [PMID: 37517842 DOI: 10.1016/j.ccm.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
Expansion of telehealth services has the potential to attenuate health inequities in pulmonary medicine, by improving access to care and health outcomes in patients with lung disease. These telehealth services include remote patient monitoring, synchronous telemedicine, and remote pulmonary rehabilitation. Currently, patients who are White, well-educated, wealthy, and from urban areas are the most likely to benefit from telehealth services. Without clear policy decisions and planning to overcome the "Digital Divide," telehealth services will only exacerbate existing disparities within the pulmonary disease. We describe the benefits and limitations of these new technologies and their impact on improving equity in pulmonary medicine.
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Affiliation(s)
| | - Karen S Rheuban
- Department of Pediatrics, University of Virginia, Center for Telehealth, Charlottesville, VA, USA
| | - Drew Harris
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
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Telemedicine to Expand Access to Critical Care Around the World. Crit Care Clin 2022; 38:809-826. [PMID: 36162912 DOI: 10.1016/j.ccc.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
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Laudanski K, Huffenberger AM, Scott MJ, Williams M, Wain J, Jablonski J, Hanson CW. Operation analysis of the tele-critical care service demonstrates value delivery, service adaptation over time, and distress among tele-providers. Front Med (Lausanne) 2022; 9:883126. [PMID: 35991667 PMCID: PMC9388902 DOI: 10.3389/fmed.2022.883126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/28/2022] [Indexed: 11/24/2022] Open
Abstract
Background Our study addresses the gaps in knowledge of the characterizations of operations by remote tele-critical care medicine (tele-CCM) service providers interacting with the bedside team. The duration of engagements, the evolution of the tele-CCM service over time, and the distress during interactions with the bedside team have not been characterized systematically. These characteristics are critical for planning the deployment of teleICU services and preventing burnout among remote teleICU providers. Methods REDCap self-reported activity logs collected engagement duration, triggers (emergency button, tele-CCM software platform, autonomous algorithm, asymmetrical communication platform, phone), expediency, nature (proactive rounding, predetermined task, response to medical needs), communication modes, and acceptance. Seven hospitals with 16 ICUs were overseen between 9/2020 and 9/2021 by teams consisting of telemedicine medical doctors (eMD), telemedicine registered nurses (eRN), and telemedicine respiratory therapists (eRT). Results 39,915 total engagements were registered. eMDs had a significantly higher percentage of emergent and urgent engagements (31.9%) vs. eRN (9.8%) or eRT (1.7%). The average tele-CCM intervention took 16.1 ± 10.39 min for eMD, 18.1 ± 16.23 for eRN, and 8.2 ± 4.98 min for eRT, significantly varied between engagement, and expediency, hospitals, and ICUs types. During the observation period, there was a shift in intervention triggers with an increase in autonomous algorithmic ARDS detection concomitant with predominant utilization of asynchronous communication, phone engagements, and the tele-CCM module of electronic medical records at the expense of the share of proactive rounding. eRT communicated more frequently with bedside staff (% MD = 37.8%; % RN = 36.8, % RT = 49.0%) but mostly with other eRTs. In contrast, the eMD communicated with all ICU stakeholders while the eRN communicated chiefly with other RN and house staff at the patient's bedside. The rate of distress reported by tele-CCM staff was 2% among all interactions, with the entity hospital being the dominant factor. Conclusions Delivery of tele-CCM services has to be tailored to the specific beneficiary of tele-CCM services to optimize care delivery and minimize distress. In addition, the duration of the average intervention must be considered while creating an efficient workflow.
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Affiliation(s)
- Krzysztof Laudanski
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
- Leonard Davis Institute for Healthcare Economics, Philadelphia, PA, United States
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
- *Correspondence: Krzysztof Laudanski
| | - Ann Marie Huffenberger
- Penn Medicine Center for Connected Care, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Michael J. Scott
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
- Penn Medicine Center for Connected Care, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Maria Williams
- Penn Medicine Center for Connected Care, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Justin Wain
- Campbell University School of Osteopathic Medicine, Lillington, NC, United States
| | - Juliane Jablonski
- University of Pennsylvania Health System, Philadelphia, PA, United States
| | - C. William Hanson
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
- Penn Medicine Center for Connected Care, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
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A Survey of Tele-Critical Care State and Needs in 2019 and 2020 Conducted among the Members of the Society of Critical Care Medicine. Healthcare (Basel) 2022; 10:healthcare10081445. [PMID: 36011102 PMCID: PMC9408319 DOI: 10.3390/healthcare10081445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 07/12/2022] [Accepted: 07/15/2022] [Indexed: 11/16/2022] Open
Abstract
The study’s objective was to assess facilitators and barriers of Tele-Critical Care (TCC) perceived by SCCM members. By utilizing a survey distributed to SCCM members, a cross-sectional study was developed to analyze survey results from December 2019 and July 2020. SCCM members responded to the survey (n = 15,502) with a 1.9% response rate for the first distribution and a 2.54% response rate for the second survey (n = 9985). Participants (n = 286 and n = 254) were almost equally distributed between non-users, providers, users, and potential users of TCC services. The care delivery models for TCC were similar across most participants. Some consumers of TCC services preferred algorithmic coverage and scheduled rounds, while reactive and on-demand models were less utilized. The surveys revealed that outcome-driven measures were the principal form of TCC performance evaluation. A 1:100 (provider: patients) ratio was reported to be optimal. Factors related to costs, perceived lack of need for services, and workflow challenges were described by those who terminated TCC services. Barriers to implementation revolved around lack of reimbursement and adequate training. Interpersonal communication was identified as an essential TCC provider skill. The second survey introduced after the onset pandemic demonstrated more frequent use of advanced practice providers and focus on performance measures. Priorities for effective TCC deployment include communication, knowledge, optimal operationalization, and outcomes measurement at the organizational level. The potential effect of COVID-19 during the early stages of the pandemic on survey responses was limited and focused on the need to demonstrate TCC value.
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Levine DM, Paz M, Burke K, Beaumont R, Boxer RB, Morris CA, Britton KA, Orav EJ, Schnipper JL. Remote vs In-home Physician Visits for Hospital-Level Care at Home: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2229067. [PMID: 36040741 PMCID: PMC9428739 DOI: 10.1001/jamanetworkopen.2022.29067] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
IMPORTANCE Home hospital care is the substitutive provision of home-based acute care services usually associated with a traditional inpatient hospital. Many home hospital models require a physician to see patients at home daily, which may hinder scalability. Whether remote physician visits can safely substitute for most in-home visits is unknown. OBJECTIVE To compare remote and in-home physician care. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial assessed 172 adult patients at an academic medical center and community hospital who required hospital-level care for select acute conditions, including infection, heart failure, chronic obstructive pulmonary disease, and asthma, between August 3, 2019, and March 26, 2020; follow-up ended April 26, 2020. INTERVENTIONS All patients received acute care at home, including in-home nurse or paramedic visits, intravenous medications, remote monitoring, and point-of-care testing. Patients were randomized to receive physician care remotely (initial in-home visit followed by daily video visit facilitated by the home hospital nurse) vs in-home care (daily in-home physician visit). In the remote care group, the physician could choose to see the patient at home beyond the first visit if it was felt to be medically necessary. MAIN OUTCOMES AND MEASURES The primary outcome was the number of adverse events, compared using multivariable Poisson regression at a noninferiority threshold of 10 events per 100 patients. Adverse events included a fall, pressure injury, and delirium. Secondary outcomes included the Picker Patient Experience Questionnaire 15 score (scale of 0-15, with 0 indicating worst patient experience and 15 indicating best patient experience) and 30-day readmission rates. RESULTS A total of 172 patients (84 receiving remote care and 88 receiving in-home physician care [control group]) were randomized; enrollment was terminated early because of COVID-19. The mean (SD) age was 69.3 (18.0) years, 97 patients (56.4%) were female, 77 (45.0%) were White, and 42 (24.4%) lived alone. Mean adjusted adverse event count was 6.8 per 100 patients for remote care patients vs 3.9 per 100 patients for control patients, for a difference of 2.8 (95% CI, -3.3 to 8.9), supporting noninferiority. For remote care vs control patients, the mean adjusted Picker Patient Experience Questionnaire 15 score difference was -0.22 (95% CI, -1.00 to 0.56), supporting noninferiority. The mean adjusted 30-day readmission absolute rate difference was 2.28% (95% CI, -3.23% to 7.79%), which was inconclusive. Of patients in the remote group, 16 (19.0%) required in-home visits beyond the first visit. CONCLUSIONS AND RELEVANCE In this study, remote physician visits were noninferior to in-home physician visits during home hospital care for adverse events and patient experience, although in-home physician care was necessary to support many patients receiving remote care. Our findings may allow for a more efficient, scalable home hospital approach but require further research. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04080570.
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Affiliation(s)
- David M. Levine
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Mary Paz
- MGH Institute of Health Professions, Boston, Massachusetts
| | | | - Ryan Beaumont
- Northeastern University Bouvé College of Health Sciences, Boston, Massachusetts
| | - Robert B. Boxer
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Charles A. Morris
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Kathryn A. Britton
- Harvard Medical School, Boston, Massachusetts
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - E. John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jeffrey L. Schnipper
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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13
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Peltan ID, Guidry D, Brown K, Kumar N, Beninati W, Brown SM. Telemedical Intensivist Consultation During In-Hospital Cardiac Arrest Resuscitation: A Simulation-Based, Randomized Controlled Trial. Chest 2022; 162:111-119. [PMID: 35063451 DOI: 10.1016/j.chest.2022.01.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/15/2021] [Accepted: 01/08/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND High-quality leadership improves resuscitation for in-hospital cardiac arrest (IHCA), but experienced resuscitation leaders are unavailable in many settings. RESEARCH QUESTION Does real-time telemedical intensivist consultation improve resuscitation quality for IHCA? STUDY DESIGN AND METHODS In this multicenter randomized controlled trial, standardized high-fidelity simulations of IHCA conducted between February 2017 and September 2018 on inpatient medicine and surgery units at seven hospitals were assigned randomly to consultation (intervention) or simulated observation (control) by a critical care physician via telemedicine. The primary outcome was the fraction of time without chest compressions (ie, no-flow fraction) during an approximately 4- to 6-min analysis window beginning with telemedicine activation. Secondary outcomes included other measures of chest compression quality, defibrillation and medication timing, resuscitation protocol adherence, nontechnical team performance, and participants' experience during resuscitation participation. RESULTS No-flow fraction did not differ between the 36 intervention group (0.22 ± 0.13) and the 35 control group (0.19 ± 0.10) resuscitation simulations included in the intention-to-treat analysis (P = .41). The etiology of the simulated cardiac arrest was identified more often during evaluable resuscitations supported by a telemedical intensivist consultant (22/32 [69%]) compared with control resuscitations (10/34 [29%]; P = .001), but other measures of resuscitation quality, resuscitation team performance, and participant experience did not differ between intervention groups. Problems with audio quality or the telemedicine connection affected 14 intervention group resuscitations (39%). INTERPRETATION Consultation by a telemedical intensivist physician did not improve resuscitation quality during simulated ward-based IHCA. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT03000829; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Ithan D Peltan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT; Telecritical Care Program, Intermountain Healthcare, Salt Lake City, UT.
| | - David Guidry
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, UT; Telecritical Care Program, Intermountain Healthcare, Salt Lake City, UT
| | - Katie Brown
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, UT
| | - Naresh Kumar
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, UT
| | - William Beninati
- Telehealth Program, Intermountain Healthcare, Salt Lake City, UT; Department of Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Samuel M Brown
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT; Telecritical Care Program, Intermountain Healthcare, Salt Lake City, UT
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14
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Abstract
Hospitals and health care systems with active critical care organizations (CCOs) that unified ICU units before the onset of the COVID-19 Pandemic were better positioned to adapt to the demands of the pandemic, due to their established standardization of care and integration of critical care within the larger structure of the hospital or health care system. CCOs should continue to make changes, based on the real experience of COVID-19 that would lead to improved care during the ongoing pandemic, and beyond.
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Affiliation(s)
- Samuel Rednor
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Jack D. Weiler Hospital, 1825 Eastchester Road, 4th Floor, Bronx, NY 10461, USA.
| | - Lewis A Eisen
- Division of Critical Care, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, 201 East 87th Street, Apartment 15c, Bronx, NY 10467, USA
| | - J Perren Cobb
- Surgical Critical Care, Department of Surgery, Critical Care Institute, Keck Medicine of USC, Health Care Consultation Center, 1510 San Pablo Street #514, Los Angeles, CA 90033, USA; Surgical Critical Care, Department of Anesthesiology, Critical Care Institute, Keck Medicine of USC, Health Care Consultation Center, 1510 San Pablo Street #514, Los Angeles, CA 90033, USA
| | - Laura Evans
- Pulmonary, Critical Care and Sleep Medicine, University of Washington, University of Washington Medical Center, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Craig M Coopersmith
- Department of Surgery, Emory Critical Care Center, 101 Woodruff Circle Suite WMB 5105, Atlanta, GA 30322, USA
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15
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Kang D, Charlton P, Applebury DE, Robinson EJ, Merkel MJ, Rowe S, Mohan V, Gold JA. Utilizing eye tracking to assess electronic health record use by pharmacists in the intensive care unit. Am J Health Syst Pharm 2022; 79:2018-2025. [PMID: 35671342 DOI: 10.1093/ajhp/zxac158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE A study was conducted using high-fidelity electronic health record (EHR)-based simulations with incorporated eye tracking to understand the workflow of critical care pharmacists within the EHR, with specific attention to the data elements most frequently viewed. METHODS Eight critical care pharmacists were given 25 minutes to review 3 simulated intensive care unit (ICU) charts deployed in the simulation instance of the EHR. Using monitor-based eye trackers, time spent reviewing screens, clinical information accessed, and screens used to access specific information were reviewed and quantified to look for trends. RESULTS Overall, pharmacists viewed 25.5 total and 15.1 unique EHR screens per case. The majority of time was spent looking at screens focused on medications, followed by screens displaying notes, laboratory values, and vital signs. With regard to medication data, the vast majority of screen visitations were to view information on opioids/sedatives and antibiotics. With regard to laboratory values, the majority of views were focused on basic chemistry and hematology data. While there was significant variance between pharmacists, individual navigation patterns remained constant across cases. CONCLUSION The study results suggest that in addition to medication information, laboratory data and clinical notes are key focuses of ICU pharmacist review of patient records and that navigation to multiple screens is required in order to view these data with the EHR. New pharmacy-specific EHR interfaces should consolidate these elements within a primary interface.
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Affiliation(s)
- Dean Kang
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Sciences University, Portland, OR, and United States Department of the Navy, USA
| | - Patrick Charlton
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Sciences University, Portland, OR, USA
| | - David E Applebury
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Sciences University, Portland, OR, USA
| | - Eric J Robinson
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Sciences University, Portland, OR, USA
| | - Matthias J Merkel
- OHSU Health, Portland, OR, and Department of Anesthesiology & Perioperative Medicine, Oregon Health and Sciences University, Portland, OR, USA
| | - Sandra Rowe
- OHSU Health, Portland, OR, and Department of Anesthesiology & Perioperative Medicine, Oregon Health and Sciences University, Portland, OR, USA
| | - Vishnu Mohan
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Sciences University, Portland, OR, USA
| | - Jeffrey A Gold
- Department of Medical Informatics and Clinical Epidemiology and Division of Pulmonary and Critical Care Medicine, Oregon Health and Sciences University, Portland, OR, USA
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16
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Mao JY, Zhang HM, Liu DW, Wang XT. Visual Rounds Based on Multiorgan Point-of-Care Ultrasound in the ICU. Front Med (Lausanne) 2022; 9:869958. [PMID: 35692540 PMCID: PMC9174546 DOI: 10.3389/fmed.2022.869958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 04/15/2022] [Indexed: 11/20/2022] Open
Abstract
Point-of-care ultrasonography (POCUS) is performed by a treating clinician at the patient's bedside, provides a acquisition, interpretation, and immediate clinical integration based on ultrasonographic imaging. The use of POCUS is not limited to one specialty, protocol, or organ system. POCUS provides the treating clinician with real-time diagnostic and monitoring information. Visual rounds based on multiorgan POCUS act as an initiative to improve clinical practice in the Intensive Care Unit and are urgently needed as part of routine clinical practice.
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Affiliation(s)
- Jia-Yu Mao
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Hong-Min Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Da-Wei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Xiao-Ting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
- Department of Health Care, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Xiao-Ting Wang
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17
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Guinemer C, Boeker M, Fürstenau D, Poncette AS, Weiss B, Mörgeli R, Balzer F. Telemedicine in Intensive Care Units: Scoping Review. J Med Internet Res 2021; 23:e32264. [PMID: 34730547 PMCID: PMC8600441 DOI: 10.2196/32264] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/03/2021] [Accepted: 09/18/2021] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The role of telemedicine in intensive care has been increasing steadily. Tele-intensive care unit (ICU) interventions are varied and can be used in different levels of treatment, often with direct implications for the intensive care processes. Although a substantial body of primary and secondary literature has been published on the topic, there is a need for broadening the understanding of the organizational factors influencing the effectiveness of telemedical interventions in the ICU. OBJECTIVE This scoping review aims to provide a map of existing evidence on tele-ICU interventions, focusing on the analysis of the implementation context and identifying areas for further technological research. METHODS A research protocol outlining the method has been published in JMIR Research Protocols. This review follows the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews). A core research team was assembled to provide feedback and discuss findings. RESULTS A total of 3019 results were retrieved. After screening, 25 studies were included in the final analysis. We were able to characterize the context of tele-ICU studies and identify three use cases for tele-ICU interventions. The first use case is extending coverage, which describes interventions aimed at extending the availability of intensive care capabilities. The second use case is improving compliance, which includes interventions targeted at improving patient safety, intensive care best practices, and quality of care. The third use case, facilitating transfer, describes telemedicine interventions targeted toward the management of patient transfers to or from the ICU. CONCLUSIONS The benefits of tele-ICU interventions have been well documented for centralized systems aimed at extending critical care capabilities in a community setting and improving care compliance in tertiary hospitals. No strong evidence has been found on the reduction of patient transfers following tele-ICU intervention. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/19695.
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Affiliation(s)
- Camille Guinemer
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Martin Boeker
- Intelligence and Informatics in Medicine, Medical Center rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Daniel Fürstenau
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Digitalization, Copenhagen Business School, Copenhagen, Denmark
| | - Akira-Sebastian Poncette
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Björn Weiss
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Rudolf Mörgeli
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Felix Balzer
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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18
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Teng CY, Davis BS, Kahn JM, Rosengart MR, Brown JB. Factors associated with potentially avoidable interhospital transfers in emergency general surgery-A call for quality improvement efforts. Surgery 2021; 170:1298-1307. [PMID: 34147261 PMCID: PMC8550996 DOI: 10.1016/j.surg.2021.05.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 05/09/2021] [Accepted: 05/11/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Emergency general surgery conditions are common, require urgent surgical evaluation, and are associated with high mortality and costs. Although appropriate interhospital transfers are critical to successful emergency general surgery care, the performance of emergency general surgery transfer systems remains unclear. We aimed to describe emergency general surgery transfer patterns and identify factors associated with potentially avoidable transfers. METHODS We performed a retrospective cohort study of emergency general surgery episodes in 8 US states using the 2016 Healthcare Cost and Utilization Project State Inpatient and Emergency Department Databases and the American Hospital Association Annual Surveys. We identified Emergency Department-to-Inpatient and Inpatient-to-Inpatient interhospital emergency general surgery transfers. Potentially avoidable transfers were defined as discharge within 72 hours after transfer without undergoing any procedure or operation at the destination hospital. We examined transfer incidence and characteristics. We performed multilevel regression examining patient-level and hospital-level factors associated with potentially avoidable transfers. RESULTS Of 514,410 adult emergency general surgery episodes, 26,281 (5.1%) involved interhospital transfers (Emergency Department-to-Inpatient: 65.0%, Inpatient-to-Inpatient: 35.1%). Over 1 in 4 transfers were potentially avoidable (7,188, 27.4%), with the majority occurring from the emergency department. Factors associated with increased odds of potentially avoidable transfers included self-pay (versus government insurance, odds ratio: 1.26, 95% confidence interval: 1.09-1.45, P = .002), level 1 trauma centers (versus non-trauma centers, odds ratio: 1.24, 95% confidence interval: 1.05-1.47, P = .01), and critical access hospitals (versus non-critical access, odds ratio: 1.30, 95% confidence interval: 1.15-1.47, P < .001). Hospital-level factors (size, trauma center, ownership, critical access, location) accounted for 36.1% of potentially avoidable transfers variability. CONCLUSION Over 1 in 4 emergency general surgery transfers are potentially avoidable. Understanding factors associated with potentially avoidable transfers can guide research, quality improvement, and infrastructure development to optimize emergency general surgery care.
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Affiliation(s)
- Cindy Y Teng
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Billie S Davis
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jeremy M Kahn
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh PA
| | - Matthew R Rosengart
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Joshua B Brown
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. https://twitter.com/joshua_b_brown
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19
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Greco FR, D’Onofrio G, Ciccone F, Giuliani F, Russo S, Villani S, Sancarlo D, Greco A. Virtual Round care model in a Covid-19 Geriatric sub intensive unit. Ment Health (Lond) 2021. [DOI: 10.32437/mhgcj.v4i2.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Introduction. Telepresence provides clinicians the ability to monitor patients as well to communicate with all the members of the healthcare staff. Covid-19 Units cope with high complexity in providing care and an integration amount the care team and the patients’ relatives should be carried out to obtained successful outcomes and preventing complication. Virtual rounding (VR) has been successfully applied to cope with this task in the last 2000 years in medical units. Covid-19 patients due to safety rules may be prone to isolation and lack of communication with their family.
Purpose. The aim of our study was to evaluate the effect of structured virtual round protocol in a geriatric Covid-19 unit on anxiety and depression for the patients and their relatives.
Methodology. All the patients admitted to the geriatric Covid-19 unit from 1 February 2021 to 30 April were studied. Inclusion criteria to the study were the followings: no severe cognitive impairment (MMSE =>24) or neuro sensorial deficits; informed consent to participate to the study. Forty-nine 49 (75% of patients) met the inclusion criteria. All the subject who were found to be eligible to the study underwent a VR standard protocol of care. VR was consisted with: 1) a video call with a tablet device conducted by a psychologist that established a cooperative communication between the health care staff (nurses and MD, their relatives) at the bed sides; 2) a video call with the patient’s relatives in which it was clearly explained the standard care and the role of each healthcare member was also included. Anxiety and depression levels were assessed for the patients at baseline after the end of the protocol by the Hospital Anxiety and Depression Scale (HADS). Patients’ relatives were investigated for depression at baseline and after the end of the protocol by the Beck Depression Inventory- Primary Care (BDI-PC). The Beck Depression Inventory for primary care has seven items with each item rated on a 4-point scale (0–3). It is scored by summing ratings for each item (range 0–21). Items are symptoms of sadness, pessimism, past failure, loss of pleasure, self-dislike, self-criticalness, and suicidal thoughts and wishes. The Hospital Anxiety and Depression Scale (HADS) is a self- assessment scale found to be a reliable instrument for detecting states of depression and anxiety. The anxiety and depressive sub-scales are also valid measures of severity of the emotional disorder. The questionnaire comprises seven questions for anxiety and seven questions for depression, and takes 2–5min to complete. For both scales, scores less than 7 indicate non- cases, 8-10 mild, 11-14 moderate, 15-21 severe. JMP software by SAS (v.16) was used for the statistical analysis.
Results. The present study included forty-nine 49 patients (67% male), mean age of 69.9 ±14.7 years with one relative for each patient. The average mean of the hospitalization for each patients was 17.6 ± 5.7 days The mean VR duration time was 60±5.5 minutes. VR showed a significant decrease in both Anxiety and depression for patients: (HADS Depression baseline 10.6 ±3.1 vs 6.9 ±2.7 end p<0.01) (HADS Anxiety baseline 10.2 ±3.4 vs 6.8 ±3.0 end p<0.01). VR has also reduced depression in the relatives of patients (BDI-PC 3.6 ±2.4 vs 1.9 ±1.9 p<0.01).
Discussion. VR has reduced anxiety and depression in patients hospitalized in a sub-intensive COVID 19 unit and it also has been found to be effective in decreasing depression in the relatives of these patients
Limitation. However, the study has some possible limitations considering its small size and that it was mono centric
Conclusions. Our data confirm the efficacy of VR in the sub-intensive care setting. This evidence supports the key role of a multidisciplinary team, focusing on the importance of social and psychological support during the hospital stay.
More studies will be consequently necessary to better validate the importance of VR as a standard care tool in intensive/sub- intensive care units for the elderly patients
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20
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Gibson NA, Arends R, Hendrickx L. Tele-U to Tele-ICU: Telehealth Nursing Education. Crit Care Nurse 2021; 41:34-39. [PMID: 34595491 DOI: 10.4037/ccn2021109] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND The use of telehealth technology in various health care settings continues to expand. Such technology allows intensive care units to monitor patients living in remote locations and to intervene early when a patient's condition declines or a critical event occurs. The use of telehealth can also support nurses and help meet staffing challenges, which have increased in intensive care units during the COVID-19 pandemic. Currently, however, there are no formal requirements for telehealth education in nursing education or for telehealth orientation in nursing practice. OBJECTIVE To develop a telehealth curriculum based on telehealth competencies that would be broad enough to encompass all educational levels of nursing students and to support the current nursing workforce. INTERVENTION A telehealth curriculum was designed that included an overview of telehealth, camera considerations, equipment, troubleshooting, reimbursement, legislation, and quality measures. These topics were then organized and developed into 6 online interactive video modules and simulation experiences. The curriculum topics pertinent to the tele-intensive care unit are discussed in this article. CONCLUSIONS Completion of the telehealth curriculum or a formal telehealth orientation session may provide nurses with an understanding of the principles of telehealth and the skills needed to provide high-quality patient care using telehealth best practices. As the use of telehealth continues to expand, nursing education and practice should work together to address the needs of the nursing workforce and staffing challenges, specifically in the intensive care unit setting.
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Affiliation(s)
- Nicole Ann Gibson
- Nicole Ann Gibson is a clinical assistant professor at South Dakota State University, Sioux Falls
| | - Robin Arends
- Robin Arends is a clinical associate professor at South Dakota State University
| | - Lori Hendrickx
- Lori Hendrickx is a professor and a clinical nurse leader/administrator track specialty coordinator at South Dakota State University. She practices as a registered nurse in an emergency department in Detroit Lakes, Minnesota
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Characteristics of U.S. Acute Care Hospitals That Have Implemented Telemedicine Critical Care. Crit Care Explor 2021; 3:e0468. [PMID: 34235456 PMCID: PMC8245115 DOI: 10.1097/cce.0000000000000468] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Supplemental Digital Content is available in the text. OBJECTIVES: Telemedicine critical care is associated with improved efficiency, quality, and cost-effectiveness. As of 2010, fewer than 5% of U.S. hospitals had telemedicine critical care, and fewer than 10% of ICU beds were covered. We evaluated recent telemedicine critical care implementation and bed coverage rates in the United States and compared characteristics of hospitals with and without telemedicine critical care. DESIGN: Cross-sectional study of 2018 American Hospital Association Annual Survey Database. SETTING: U.S. hospitals. PATIENTS: None. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We obtained data regarding telemedicine critical care implementation, ICU capability (defined as ≥ 1 ICU bed), other hospital characteristics, and the Herfindahl-Hirschman Index, a measure of ICU market competition based on hospital referral regions. Among 4,396 hospitals (response rate 71%), 788 (17.9%) had telemedicine critical care, providing potential coverage to 27,624 (28% of total) ICU beds. Among 306 hospital referral regions, 197 (64%) had a respondent hospital with telemedicine critical care. Telemedicine critical care implementation was associated with being a nonprofit (odds ratio, 7.75; 95% CI, 5.18–11.58) or public (odds ratio, 4.16 [2.57–6.73]) compared with for-profit hospital; membership in a health system (odds ratio, 3.83 [2.89–5.08]; stroke telemedicine presence (odds ratio, 6.87 [5.35–8.81]); ICU capability (odds ratio, 1.68 [1.25–2.26]); and more competitive ICU markets (odds ratio per 1,000-point decrease in Herfindahl-Hirschman Index 1.11 [1.01–1.22]). Notably, rural critical access hospitals had lower odds of telemedicine critical care implementation (odds ratio, 0.49 [0.34–0.70]). Teaching status, geographic region, and rurality were not associated with telemedicine critical care implementation. CONCLUSIONS: About one fifth of respondent hospitals had telemedicine critical care by 2018, providing potential coverage of nearly one third of reported ICU beds. This represents a substantial increase in telemedicine critical care implementation over the last decade. Future expansion to include more rural hospitals that could benefit most may be aided by addressing hospital financial and market barriers to telemedicine critical care implementation.
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Noritomi DT, Ranzani OT, Ferraz LJR, Dos Santos MC, Cordioli E, Albaladejo R, Serpa Neto A, Correa TD, Berwanger O, de Morais LC, Schettino G, Cavalcanti AB, Rosa RG, Biondi RS, Salluh JI, Azevedo LCP, Pereira AJ. TELE-critical Care verSus usual Care On ICU PErformance (TELESCOPE): protocol for a cluster-randomised clinical trial on adult general ICUs in Brazil. BMJ Open 2021; 11:e042302. [PMID: 34155070 PMCID: PMC8217943 DOI: 10.1136/bmjopen-2020-042302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Daily multidisciplinary rounds (DMRs) consist of systematic patient-centred discussions aiming to establish joint therapeutic goals for the next 24 hours of intensive care unit (ICU) care. The aim of the present study protocol is to evaluate whether an intervention consisting of guided DMRs, supported by a remote specialist and audit/feedback on care performance will reduce ICU length of stay compared with a control group. METHODS AND ANALYSIS A multicentre, controlled, cluster-randomised superiority trial including 30 ICUs in Brazil (15 intervention and 15 control), from August 2019 to June 2021. In a parallel assignment, ICUs are randomised to a complex-intervention composed by daily rounds carried out through Tele-ICU by a remote ICU physician; development of local quality indicators dashboards coupled with monthly meetings with local leadership; and dissemination of evidence-based clinical protocols versus usual care. Primary outcome is ICU length of stay. Secondary outcomes include classification of the unit according to the profiles defined by the standardised resource use and the standardised mortality rate, hospital mortality, incidence of healthcare-associated infections, ventilator-free days at 28 days, patient-days receiving oral or enteral feeding, patient-days under light sedation or alert and calm, rate of patients under normoxaemia. All adult patients admitted after the beginning of the study in each participant ICU will be enrolled. Inclusion criteria (clusters): public Brazilian ICUs with a minimum of 8 ICU beds interested/committed to participating in the study. Exclusion criteria (clusters): units with fully established DMRs by an intensivist, specialised or step-down units. ETHICS AND DISSEMINATION The study protocol was approved by the institutional review board (IRB) of the coordinator centre, and by IRBs of each enrolled hospital/ICU. Statistical analysis protocol is being prepared for submission before the end of patient's enrolment. Results will be disseminated through conferences, peer-reviewed journals and to each participating unit. TRIAL REGISTRATION NUMBER NCT03920501; Pre-results.
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Affiliation(s)
- Danilo Teixeira Noritomi
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
- Clinical Governance, DASA, Sao Paulo, Brazil
- Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Otavio T Ranzani
- Pulmonary Division, Heart Institute, Hospital das Clinicas, Universidade de Sao Paulo Faculdade de Medicina Hospital das Clinicas, Sao Paulo, SP, Brazil
- ISGlobal, Barcelona Institute for Global Health, Barcelona, Catalunya, Spain
| | | | - Maura C Dos Santos
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
- Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Eduardo Cordioli
- Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Ary Serpa Neto
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
- Brazilian Research in Intensive Care Network - BRICNET, São Paulo, SP, Brazil
| | - Thiago D Correa
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
- Brazilian Research in Intensive Care Network - BRICNET, São Paulo, SP, Brazil
| | - Otávio Berwanger
- Academic Research Organization, Hospital Israelita Albert Einstein, Sao Paulo, São Paulo, Brazil
| | - Lubia Caus de Morais
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
| | - Guilherme Schettino
- Institute of Social Responsibility, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Alexandre Biasi Cavalcanti
- Brazilian Research in Intensive Care Network - BRICNET, São Paulo, SP, Brazil
- HCor Research Institute, Sao Paulo, SP, Brazil
| | - Regis Goulart Rosa
- Brazilian Research in Intensive Care Network - BRICNET, São Paulo, SP, Brazil
- Intensive Care, HMV, Porto Alegre, Rio Grande do Sul, Brazil
| | - Rodrigo Santos Biondi
- Instituto de Cardiologia do Distrito Federal, Brasília, Distrito Federal, Brazil
- Hospital Brasília, Brasília, DF, Brazil
| | - Jorge If Salluh
- Brazilian Research in Intensive Care Network - BRICNET, São Paulo, SP, Brazil
- Department of Critical Care and Graduate Program in Translational Medicine, D'Or Institute for Research and Education, Rio de Janeiro, Brazil, Rio de Janeiro, Brazil
| | - Luciano Cesar Pontes Azevedo
- Brazilian Research in Intensive Care Network - BRICNET, São Paulo, SP, Brazil
- Intensive Care Unit, Hospital Sírio-Libanês, São Paulo, SP, Brazil
- Emergency Medicine Department, University of Sao Paulo, Sao Paulo, São Paulo, Brazil
| | - Adriano Jose Pereira
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
- Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Postgraduate Program of Health Sciences, Universidade Federal de Lavras, Lavras, MG, Brazil
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Krupp A, Di Martino M, Chung W, Chaiyachati K, Agarwal AK, Huffenberger AM, Laudanski K. Communication and role clarity inform TeleICU use: a qualitative analysis of opportunities and barriers in an established program using AACN framework. BMC Health Serv Res 2021; 21:277. [PMID: 33766010 PMCID: PMC7992609 DOI: 10.1186/s12913-021-06287-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 03/17/2021] [Indexed: 01/24/2023] Open
Abstract
Background Understanding the use of tele-intensive care unit (ICU) services is an essential component in evaluating current practice and informing future use as the adoption and application of teleICU services expands. We sought to explore if novel ways to utilize teleICU services can emerge within an established, consulting-style teleICU model considering the program’s flexible, provider-driven operation. Methods This was a qualitative study of one teleICU/hospital dyad using semi-structured interviews from a convenience sample of ICU (n = 19) and teleICU (n = 13) nurses. Interviews were analyzed using directed content analysis to identify themes that describe their experiences with teleICU using a deductive codebook developed from an expert consensus (American Association of Critical Care Nurses) AACN statement on teleICU nursing. Results Three themes were identified through the qualitative content analysis: [1] nurses described unique teleICU knowledge, including systems thinking and technological skills, [2] the teleICU partnership supported quality improvement initiatives, and [3] elements of the work environment influenced perceptions of teleICU and its use. When elements of the work environment, such as effective communication and role clarity, were not present, teleICU use was variable. Conclusions Flexible, provider-driven approaches for integrating teleICU services into daily practice may help define the future use of the teleICU model’s applicability. Future work should focus on the importance of effective communication and role clarity in integrating the emerging teleICU services into teleICU/ICU practice. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06287-6.
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Affiliation(s)
- Anna Krupp
- College of Nursing, University of Iowa, Iowa City, IA, 52242, USA
| | - Michael Di Martino
- College of Arts and Sciences, University of Pennsylvania, 249 South 36th St, Philadelphia, PA, 19104, USA
| | - Wesley Chung
- Department of Chemistry, College of Arts and Sciences, Drexel University, 3141 Chestnut St., Philadelphia, PA, 19104, USA
| | - Krisda Chaiyachati
- The Department of Medicine, The University of Pennsylvania Perelman School of Medicine, The Leonard Davis Institute for Health Economics at the University of Pennsylvania, Penn Medicine Center for Connected Care, Philadelphia, PA, 19104, USA
| | - Anish K Agarwal
- The Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, The Leonard Davis Institute for Health Economics at the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Ann Marie Huffenberger
- Penn Medicine Center for Connected Care, The Clinical Practices of the University of Pennsylvania Health System, Philadelphia, PA, 19104, USA
| | - Krzysztof Laudanski
- Department of Anesthesiology and Critical Care; University of Pennsylvania, JMB 127, 3620 Hamilton Walk, Philadelphia, PA, 19146, USA. .,Leonard Davis Institute for Healthcare Economics , JMB 127, 3620 Hamilton Walk, Philadelphia, PA, 19146, USA.
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24
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Guinemer C, Boeker M, Weiss B, Fuerstenau D, Balzer F, Poncette AS. Telemedicine in Intensive Care Units: Protocol for a Scoping Review. JMIR Res Protoc 2020; 9:e19695. [PMID: 33382040 PMCID: PMC7808887 DOI: 10.2196/19695] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/31/2020] [Accepted: 11/10/2020] [Indexed: 11/15/2022] Open
Abstract
Background Telemedicine has been deployed to address issues in intensive care delivery, as well as to improve outcome and quality of care. Implementation of this technology has been characterized by high variability. Tele-intensive care unit (ICU) interventions involve the combination of multiple technological and organizational components, as well as interconnections of key stakeholders inside the hospital organization. The extensive literature on the benefits of tele-ICUs has been characterized as heterogeneous. On one hand, positive clinical and economical outcomes have been shown in multiple studies. On the other hand, no tangible benefits could be detected in several cases. This could be due to the diverse forms of organizations and the fact that tele-ICU interventions are complex to evaluate. The implementation context of tele-ICUs has been shown to play an important role in the success of the technology. The benefits derived from tele-ICUs depend on the organization where it is deployed and how the telemedicine systems are applied. There is therefore value in analyzing the benefits of tele-ICUs in relation to the characteristics of the organization where it is deployed. To date, research on the topic has not provided a comprehensive overview of literature taking both the technology setup and implementation context into account. Objective We present a protocol for a scoping review of the literature on telemedicine in the ICU and its benefits in intensive care. The purpose of this review is to map out evidence about telemedicine in critical care in light of the implementation context. This review could represent a valuable contribution to support the development of tele-ICU technologies and offer perspectives on possible configurations, based on the implementation context and use case. Methods We have followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist and the recommendations of the Joanna Briggs Institute methodology for scoping reviews. The scoping review and subsequent systematic review will be completed by spring 2021. Results The preliminary search has been conducted. After removing all duplicates, we found 2530 results. The review can now be advanced to the next steps of the methodology, including literature database queries with appropriate keywords, retrieval of the results in a reference management tool, and screening of titles and abstracts. Conclusions The results of the search indicate that there is sufficient literature to complete the scoping review. Upon completion, the scoping review will provide a map of existing evidence on tele-ICU systems given the implementation context. Findings of this research could be used by researchers, clinicians, and implementation teams as they determine the appropriate setup of new or existing tele-ICU systems. The need for future research contributions and systematic reviews will be identified. International Registered Report Identifier (IRRID) DERR1-10.2196/19695
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Affiliation(s)
- Camille Guinemer
- Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Martin Boeker
- Faculty of Medicine, Institute of Medical Biometry and Statistics, University of Freiburg, Freiburg, Germany
| | - Bjoern Weiss
- Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Daniel Fuerstenau
- Copenhagen Business School, Copenhagen, Denmark.,School of Business & Economics, Freie Universität Berlin, Berlin, Germany.,Einstein Center Digital Future, Berlin, Germany
| | - Felix Balzer
- Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Akira-Sebastian Poncette
- Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Einstein Center Digital Future, Berlin, Germany
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25
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Vranas KC, Scott JY, Badawi O, Harhay MO, Slatore CG, Sullivan DR, Kerlin MP. The Association of ICU Acuity With Adherence to ICU Evidence-Based Processes of Care. Chest 2020; 158:579-587. [PMID: 32229228 PMCID: PMC7417378 DOI: 10.1016/j.chest.2020.02.061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 01/23/2020] [Accepted: 02/15/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Admission to high-acuity ICUs has been associated with improved outcomes compared with outcomes in low-acuity ICUs, although the mechanism for these findings is unclear. RESEARCH QUESTION The goal of this study was to determine if high-acuity ICUs more effectively implement evidence-based processes of care that have been associated with improved clinical outcomes. STUDY DESIGN AND METHODS This retrospective cohort study was performed in adult ICU patients admitted to 322 ICUs in 199 hospitals in the Philips ICU telemedicine database between 2010 and 2015. The primary exposure was ICU acuity, defined as the mean Acute Physiology and Chronic Health Evaluation IVa score of all admitted patients in a calendar year, stratified into quartiles. Multivariable logistic regression was used to examine relations of ICU acuity with adherence to evidence-based VTE and stress ulcer prophylaxis, and with the avoidance of potentially harmful events. These events included hypoglycemia, sustained hyperglycemia, and liberal transfusion practices (defined as RBC transfusions prescribed for nonbleeding patients with preceding hemoglobin levels ≥ 7 g/dL). RESULTS Among 1,058,510 ICU admissions, adherence to VTE and stress ulcer prophylaxis was high across acuity levels. In adjusted analyses, those admitted to low-acuity ICUs compared with the highest acuity ICUs were more likely to experience hypoglycemic events (adjusted OR [aOR], 1.12; 95% CI, 1.04-1.19), sustained hyperglycemia (aOR, 1.07; 95% CI, 1.04-1.10), and liberal transfusion practices (aOR, 1.55; 95% CI, 1.33-1.82). INTERPRETATION High-acuity ICUs were associated with better adherence to several evidence-based practices, which may be a marker of high-quality care. Future research should investigate how high-acuity ICUs approach ICU organization to identify targets for improving the quality of critical care across all ICU acuity levels.
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Affiliation(s)
- Kelly C Vranas
- Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, OR; Health Services Research & Development, VA Portland Health Care System, Portland, OR; Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA.
| | - Jennifer Y Scott
- Health Services Research & Development, VA Portland Health Care System, Portland, OR
| | - Omar Badawi
- Department of Research and Development, Philips Healthcare, Baltimore, MD; Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD; Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA
| | - Michael O Harhay
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA; Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA
| | - Christopher G Slatore
- Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, OR; Health Services Research & Development, VA Portland Health Care System, Portland, OR
| | - Donald R Sullivan
- Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, OR; Health Services Research & Development, VA Portland Health Care System, Portland, OR
| | - Meeta Prasad Kerlin
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA; Pulmonary, Allergy and Critical Care Division, University of Pennsylvania, Philadelphia, PA
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26
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Connecting the Docs: Telemedicine Support during In-Hospital Cardiac Arrest Resuscitation. Ann Am Thorac Soc 2020; 17:278-279. [PMID: 32108502 DOI: 10.1513/annalsats.201912-884ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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27
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Fadul N, Elsayem AF, Bruera E. Integration of palliative care into COVID-19 pandemic planning. BMJ Support Palliat Care 2020; 11:40-44. [DOI: 10.1136/bmjspcare-2020-002364] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/11/2020] [Accepted: 05/17/2020] [Indexed: 01/08/2023]
Abstract
The COVID-19 pandemic is expected to surpass the healthcare system’s capacity to provide intensive care to all patients who deteriorate as a result of the disease. This poses a unique challenge to healthcare teams of rationing care during pandemic when resources are scarce. Healthcare providers will need to acquire new skills in care decision making and effective symptom control for patients who do not receive life-saving measures. In this review, we describe some of the important palliative care considerations that need to be incorporated into COVID-19 pandemic planning. The main aspects to be considered include decision algorithms for rationing care, training on effective symptoms management, alternative delivery methods of palliative care services such as telemedicine and finally death and bereavement support for surviving family members who are likely to be isolated from their loved one at the moment of death.
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Acceptability and Perceived Utility of Telemedical Consultation during Cardiac Arrest Resuscitation. A Multicenter Survey. Ann Am Thorac Soc 2020; 17:321-328. [DOI: 10.1513/annalsats.201906-485oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
Intensive care unit (ICU) telemedicine is an established entity that has the ability to not only improve the effectiveness, efficiency, and safety of critical care, but to also serve as a tool to combat staffing shortages and resource-limited environments. Several areas for future innovation exist within the field, including the use of advanced practice providers, robust inclusion in medical education, and concurrent application of advanced machine learning. The globalization of critical care services will also likely be predominantly delivered by ICU telemedicine. Limitations faced by the field include technical issues, financial concerns, and organizational elements.
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Intensive Care Unit Telemedicine in the Era of Big Data, Artificial Intelligence, and Computer Clinical Decision Support Systems. Crit Care Clin 2019; 35:483-495. [PMID: 31076048 DOI: 10.1016/j.ccc.2019.02.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This article examines the history of the telemedicine intensive care unit (tele-ICU), the current state of clinical decision support systems (CDSS) in the tele-ICU, applications of machine learning (ML) algorithms to critical care, and opportunities to integrate ML with tele-ICU CDSS. The enormous quantities of data generated by tele-ICU systems is a major driver in the development of the large, comprehensive, heterogeneous, and granular data sets necessary to develop generalizable ML CDSS algorithms, and deidentification of these data sets expands opportunities for ML CDSS research.
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Abstract
This review outlines various care models used in tele-intensive care unit (tele-ICU) programs. They may be differentiated by personnel and approach to care. Low-intensity models, such as nocturnal coverage, may be adequate for some ICU practices. Others might benefit from a high-intensity model, especially those practices that desire a proactive approach to care. Also discussed is the incorporation of the education of trainees into tele-ICU models.
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Affiliation(s)
- Sean M Caples
- The Enhanced Critical Care Program, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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