Tele-Critical Care Support for Guam

As of: 18 Jun 2019LTC(P) Hipp, Sean/ [email protected] / 1-844-VMEDCEN Slide 1 of 42

“Medically Ready Force…Ready Medical Force”

Tele-Critical Care Support for Guam

J. Jonas Carmichael, MD, FCCMCDR MC USN

Associate Director, Joint Tele-Critical Care NetworkNaval Medical Center San Diego



Background

• Island of Guam

• US island territory in the Western Pacific: 1600 miles to Manila, Philippines; 3800 miles to Honolulu, HI

• Guam Memorial Hospital

• Only public hospital on the island

• 130 inpatient beds, a single 12-bed ICU, and limited Intensivist support

• Guam experienced a surge in COVID-19 associated sepsis and respiratory failure in early September 2020

• State declared a public health emergency, FEMA was asked to provide support, DISCA mission was generated for DOD



Leveraging information & audiovisual technology to extend expertise.

Joint Tele-Critical Care Network = JTCCN Currently provides support to 11 military

treatment facilities from 3 hub sites

Working to expand to operational space

Platform components Synchronous AV communication

EHR access (including labs, imaging, and notes)

Real-time data

Predictive analytics

What is TCC?



Supporting Literature in MHS

• NMCSD supporting NHCP• 2013 (before) vs 2014 (after)

• Increased volume & acuity of patient admissions

• Decreased disengagements to network

• Care was safe (actual vs predicted mortality)

• BCA identified ROI of 16%

• Increase number of surgical cases

• GLWACH• 2013 (before) vs 2014 (after)

• Increased volume & acuity of patient admissions

• Decreased disengagements to network

• $233K cost savings with ROI of 19%

• Care was safe (actual mortality vs predicted)

• Positive staff satisfaction scores

• Increased number of surgical cases

• NMCSD supporting NMCCL• 2015 (before) vs 2016 (after)

• Civilian Literature• Decrease LOS

• Decrease cost

• Decreased mortality

• Increased “best practice” adherence

Can TCC be used for Defense in Support of Civil Authorities (DISCA) missions?



TCC DISCA Model

Bedside hospitalists act as Intensivist extenders

Ward nurses can support critically ill patients with TCC nurse mentorship and support

Critical Care physician and nurse available 24/7

Remote electronic health record access (including imaging)

Definition of “Critically Ill” Invasive or non-invasive mechanical ventilation for acute respiratory failure

High flow oxygen (≥ 20 liters and ≥ 50%)

Shock (of any cause) with acute organ failures

Administration of vasopressors or antihypertensive infusions

Emergency privileging by hospital

TCC team check in at beginning of shift, and periodically throughout the day

TCC Team available for questions 24/7

6

Concept of Support with TCC

NETCCN

• Links remote expertise using secure asynchronous and

synchronous mobile communications to frontline nurses and

providers

• Provide flexible (up to 24/7) support to healthcare teams using

mobile devices (personal or locally furnished) through a cloud

based, HIPAA compliant, industry standard application

National Emergency Tele-Critical Care Network (NETCCN)

NETCCN TCC TeamsDeloitte Consulting with the DHA Tele-Critical Care Network

Avera Health

Expressions Network

The Geneva Foundation

Telemedicine and Advanced Technology Research CenterMedical Research and Development Command, US Army

In collaboration with the Society of Critical Care Medicine (SCCM) and the Assistant Secretary for Preparedness and Response

(ASPR), the Telemedicine and Advanced Technology Research Center (TATRC) is funded to support tele-critical care delivery at 4

locations utilizing NETCCN through OCT 2020.

As an RDTE project, TATRC will collect de-identified data from the applications about how they are used as well as survey

data from the end-users to determine best solutions from a technical standpoint and a workflow/staffing model.

COL Jeremy C. Pamplin, Director, [email protected], (3-7967) UNCLASSIFIED

NETCCN MTEC Proposal = Competition

9 Teams 6 Teams 4 Teams

Completed 10

Jul

~1 Sep –

31 Oct

22 Jul –

20 Aug

DoD Funded

ASPR FundedMore information at: https://www.tatrc.org/www/resources/covid-19.html

~1 Oct - Complete

COL Jeremy C. Pamplin, Director, [email protected], (3-7967) UNCLASSIFIED 7

https://www.tatrc.org/www/resources/covid-19.html



Most common physician calls for management of respiratory failure, mechanical ventilation, ABG interpretation, and/or vasopressors.

Most common nurse calls were for: questions regarding medication compatibility and administration, evaluation of patient agitation and ventilator dys-synchrony, and discussion of patient care plan.

Limitations of support exist.

Results

No adverse events associated with TCC support.

Several notable examples of positive impact by TCC team.

GMH requested telemedicine support after on-site personnel departed.

473

255

14

470

64

31 days

ICU Patient Days (total)

Length of Support (Reflected in this Table)

Calls for Physician Support

Calls for Nursing Support

Code Blue Events

Patient Days of Mechanical Ventilation



Buy-in of bedside personnel is critical! Need to establish roles and expectations for the whole healthcare team

Bedside staff will have to do procedures

Educational content ready to deploy

Plan for connectivity in advance Deployable options exist

Determinant of the models of care, efficiency, and efficacy of support

Framework and support for emergency privileging is necessary

Policy needs to be updated to reflect telemedicine capabilities and interoperability

TCC can reliably and effectively extend critical care expertise

Lessons Learned



Discussion

Documents

Tele-Critical Care Support for Guam