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Telemedicine in the ICU. Chad Hodge Roosan Islam Casey Rommel Nicole Ruiz Diane Walker. Definition . What is telemedicine? The delivery of healthcare from a distance using electronic information and technology. Literally, “Healing at a distance.” What units qualify as an ICU? - PowerPoint PPT Presentation
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Chad Hodge Roosan Islam Casey Rommel Nicole Ruiz Diane Walker
TELEMEDICINE IN THE ICU
What is telemedicine? The delivery of healthcare from a distance using
electronic information and technology. Literally, “Healing at a distance.”
What units qualify as an ICU? All critical care areas, such as surgical, cardiac,
medical, pediatric, neurology, neonatal, burn, and other postoperative.
What is an eICU? Nurses and physicians located at a remote command
center providing care to patients in multiple, scattered intensive care units via computer and telecommunication technology.
DEFINITION
ICUs treat 4.5 million annually (10% of all patients). Expected to rise as the population ages.
$107 billion annually (4% of total healthcare costs).
ICUs are coalescing.Fewer than 6000 intensivists.ICU mortality rate is 10-20% and is
responsible for 500,000 deaths annually.eICUs are estimated to reduce that number by 50,000 (10%) per year.
THE NEED
Fewer than 15% of hospitals meet the Leapfrog Group intensivist staffing model. Return page within 5 minutes 95% of time. Or arrange for alternate staff to respond.
THE NEED CONTINUED
ADEs in ICUs are 2x the national average (19/1000 patients) because of the high number of drugs ordered.
Responsibilities of the hub intensivist can vary from treating emergent situations, with all other care managed by the admitting physician (open ICU model), to complete intensivist management, with only notification of treatments given to the patient’s physician (closed ICU model).
A well-supported intensivist may staff approximately 50 to 100 remote ICU beds.
EICU MODEL
Having an ICU physician rapidly available. Having an intensivist available more hours of
the day.Having rapid access to all forms of clinical data
through improved ITS.Having an ICU physician available allows for
more rapid interventions in case of problems. Length of stay and resource utilization may
also be affected by commencing care as soon it is warranted (eg, ventilator weaning begun during the nighttime).
ADVANTAGES
Potentially putting a layer of technology between the patient and the physician.
Significant upfront and maintenance costs.Subject to malfunction and downtime. Physicians are typically cited as the greatest
barrier to implementation.Physicians perceive that a lack of direct
interaction, eye contact, and other sensory input with the patient may cause them to miss critical diagnostic cues.
DISADVANTAGES
TELE-ICU IMPROVES PATIENT OUTCOMES
Preintervention Tele-ICU InterventionBedside monitor alarms Physiological trend alerts
Abnormal laboratory value alerts Review of response to alerts Off-site team rounds
Daily goal sheet Electronic detection of nonadherence Real-time auditing Nurse manager audits Team audits
Telephone case review initiated by house staff or affiliate practitioner
Workstation review initiated by intensivist includes electronic medical record, imaging studies, interactive audio and video of patient, interaction with nurse and respiratory therapist, and assessment of response to therapy
TABLE 1. COMPARISON OF INTENSIVE CARE UNIT (ICU) PROCESSES BEFORE AND AFTER TELE-ICU INTERVENTION
MORTALITY AND LENGTH OF STAY OUTCOMES
BEST PRACTICE AND COMPLICATION MEASURES
Improves 3 areas of quality of care: Improved patient outcomes Access to care Cost savings
Technology is ubiquitous. Still… Only 10% of hospitals have teleICU
services. Only 4900 adult ICU beds supported
by teleICU. 1 million patients monitored by
teleICU.
WHY IS TELEMEDICINE THE SOLUTION?
Digital Video Transport System System to send and receive
digital streaming videos over broadband internet.
H.323 Video Conferencing Solution The H.323 protocol is a
recommendation from the International Telecommunication Union.
Vidyo Vidyo provides high quality
video conferencing from a range of technologies.
EMERGING TECHNOLOGIES
Financial costs $6-8 million initial startup. $1-2 million operating costs
yearly. Maintenance and/or Upgrades Licensure Staffing
Limited or no patient reimbursement/billing.
Shortages of specialists results in “poaching.” ICU clinician shortage >
Intensivist shortage.Staff and patient acceptance.
BARRIERS TO ADOPTION
Image- http://blogs.bmj.com/bjsm/2011/07/20/educating-all-medical-specialists-to-support-exercise-as-the-fifth-vital-sign-dr-danica-bonello-spiteri-comments/
Looked at the difference between using standard system of paging ICU physician versus robotic telepresence (RTP) intervention.
Focused on neurocritical care patients: Traumatic Brain Injuries Brain tumor Ischemic stroke
Hypothesized that physician face-to-face response time to patient would significantly decrease.
CASE STUDY 1: ROBOTICS
Image- http://www.robots-and-androids.com/robotic-syringes.html
Standard Model: Nurse detects
change in patient’s condition.
Pages ICU physician.
Physician calls the nurse and gives instructions over the phone.
Robotic Telepresence Model: Nurse sends text
message to physician or can walk up to robot if session is in progress.
Physician conducts rounds from office.
Examine patients by driving robot next to bed and speaking to patient directly or instruct nurse to perform exam.
CASE STUDY 1: ROBOTICS
Vespa et al, 2007.
VISN (Veterans Integrated Service Network) 19 Covers areas including
Montana, Utah, Colorado, Wyoming, Idaho, Nevada, Kansas and Nebraska.
Developed tele-ICU model to improve access to critical care services in rural facilities by combining tele-ICU technology with expanded critical care nursing services.
First of its kind in the VA system.
CASE STUDY 2: VA HOSPITAL
Model: Operated entirely by nurses. One experienced CCRN-certified
nurse manages system 24/7. Nurses from different facilities
report on patients at start of shift. Available for immediate
consultation. Virtual rounds.
Results: Cost savings. Increase in collaboration between
healthcare facilities. Increase in number of nurses
becoming CCRN-certified.
CASE STUDY 2: VA HOSPITAL
Legal Issues The physician’s liability in case of
malpractice. The patient has to be protected, and cyber
physicians must be able to quantify their risk.
The relationship between physicians and insurance companies may need to be modified.
The roles of electronic decision support systems, medical software, and data collection systems in determining responsibility need to be clarified.
Reimbursement USA lacks unified healthcare system and
regulations need to adapt with the changing industry.
States need to be proactive in their regulation.
FUTURE CHALLENGES
Image- http://www.democracy4stoke.co.uk/archives/604
We are happy to answer any of your questions.
THANK YOU
Cummings et. al. Intensive Care Unit Telemedicine: Review and Consensus Recommendations. American Journal of Medical Quality 2007 22: 239. http://www.ncbi.nlm.nih.gov/pubmed/17656728
MD Andersen Cancer Center, University of Texas, Glossary of terms, http://www.mdanderson.org/patient-and-cancer-information/cancer-information/glossary-of-cancer-terms/t.html
Lil ly, C. M., Cody, S., Zhao, H., Landry, K., Baker, S. P., McIlwaine, J . , Chandler, M. W., et al. (2011). Hospital mortal ity, length of stay, and preventable complications among crit ical ly i l l patients before and after tele-ICU reengineering of crit ical care processes. JAMA : the journal of the American Medical Association, 305(21), 2175–83. http://www.ncbi.nlm.nih.gov/pubmed/21576622
Nielsen, M., & Saracino, J . (2012). Telemedicine in the intensive care unit. Critical care nursing cl inics of North America, 24(3), 491–500. doi:10.1016/j.ccell .2012.06.002
Venditti , A., Ronk, C., Kopenhaver, T., & Fetterman, S. (2012). Tele-ICU “myth busters”. AACN advanced critical care, 23(3), 302–11. doi:10.1097/NCI.0b013e31825dfee2
Young, L. B., Chan, P. S., & Cram, P. (2011). Staff acceptance of tele-ICU coverage: a systematic review. Chest , 139(2), 279–88. doi:10.1378/chest.10-1795
CITATIONS
Hawkins, C. L. (2012). Virtual rapid response: the next evolution of tele-ICU. AACN advanced critical care , 23(3), 337–40. doi:10.1097/NCI.0b013e31825dff69
Vespa, P. M., Mil ler, C., Hu, X., Nenov, V., Buxey, F., & Martin, N. a. (2007). Intensive care unit robotic telepresence faci l itates rapid physician response to unstable patients and decreased cost in neurointensive care. Surgical neurology , 67(4), 331–7. doi:10.1016/j.surneu.2006.12.042
Chan, M., Esteve, D., Escriba, C., & Campo, E. (2008). A review of smart homes- present state and future challenges. Comput Methods Programs Biomed, 91 (1), 55-81. doi: 10.1016/j.cmpb.2008.02.001
Cao, M. D., Shimizu, S., Antoku, Y., Torata, N., Kudo, K., Okamura, K.,Tanaka, M. (2012). Emerging technologies for telemedicine. Korean J Radiol, 13 Suppl 1 , S21-30. doi: 10.3348/kjr.2012.13.S1.S21
CITATIONS CONTINUED
User Needs, Acceptability and Satisfaction Consider the subjects needs who are sick, disable and
elderly. The subjects immediate surrounding including
caregivers ease of use and delivery of care. The manufacturers, as well as the commercial
providers, should customize products based on needs.Reliability and efficiency of sensory systems and data processing software.
Have a reliable algorithm for evaluating the patient’s “lifestyle.”
Trigger an alarm in case of danger. Correctly interpret the vital signs through automated
software or a competent medical professional, so that deficient function can be recognized.
FUTURE CHALLENGES AND POSSIBLE SOLUTIONS
Image- http://wc.k12.mo.us/TWarner/Med%20Term/Chapter1.html