Thalea- round table meeting · 11.10 Telenursing in the Intensive Care Unit - Merja Meriläinen, Oulu University Hospital 11.30 Thalea Call for Tender - Timo Alalääkkölä, Thalea

Round table meeting

October 30th/31st 2014

Agenda 10.00 Coffee and introductions

10.10 Welcome – Timo Alalääkkölä, Thalea project

10.20 Telemedicine in the Intensive Care Unit – Tero Ala-Kokko, Oulu University Hospital

10.50 Requirement identification using content validity assessment - Simo Larinkari, Oulu University, Faculty of medicine

11.10 Telenursing in the Intensive Care Unit - Merja Meriläinen, Oulu University Hospital

11.30 Thalea Call for Tender - Timo Alalääkkölä, Thalea Project

-demand, aims, budget, time line, contracts

12.15 Discussion, Networking

13.00 End of the session

Welcome Timo Alalääkkölä, M.Sc. (Econ.)

Project Manager, Oulu University Hospital

30.10.2014

European demand of a…

Telemonitoring and Telemedicine for

Hospitals

Assisted by ICT for

Life saving co-morbid patients in

Europe

As part of a Patient personalised care

program of the EU

Who‘s behind

1. University Hospital Aachen (coordination) (Germany)

2. German Ministry of Innovation, Science and Research

(Germany)

3. Maastricht University Medical Centre+ (Netherlands)

4. NL, Agency, Ministry of Economic Affairs (Netherlands)

5. ParcTauli Sabadell University Hospital (Spain)

6. Catalan Agency for Health Information, Assessment

and Quality (Spain)

7. Hospital East Limburg (Belgium)

8. Northern Ostrobothnia Hospital District (Finland)

PCP from demand

to product

Product idea Solution

design

Prototype First test

products

TELEMEDICINE IN THE ICU:

A clinicians view

THALEA Info Session in Oulu 2014

Tero Ala-Kokko, MD, PhD, EDICM

Chief of ICU

Professor in Intensive Care Medicine

Oulu University Hospital

Oulu University Medical Faculty, Insitute of Clinical Medicine

Tero Ala-Kokko, MD, PhD, EDICM, Chief of ICU, Professor in Intensive Care Medicine

Oulu University Hospital 30.10.2014

Content

• Current and future challenges in critical

care

• Expectations from teleICU

• Own experience

• Effect of teleICU implementation on care

process and patient outcome

• Conclusions



Current and future

challenges • Number of patients needing critical care are increasing

– Ageing population and increasing life expectancy

– Increasing healthcare expectations

– Advancing cancer treatment, transplantation and high risk surgery for the elderly population

– Pandemics

• Financial burden and decreasing ability to pay

– Skilled specialists for decision making to target the critical care resources to those most likely to benefit and to achieve best outcomes

• Increasing need for critical care services faces decreasing physician and nursing workforce

– Critical care patients need specialized care takers with high competence level

– Critical care is a human resource intensive therapy (P/N 1:1)

– Already today limited intensivist coverage in smaller hospitals and rural regions

• Critical care services are increasingly needed outside the ICU walls

– Patients with critical illness may be found throughout the hospitals

– Need for remote monitoring techniques to identify those at risk earlier



Patient outcomes and

treatment costs depend on • Dedicated 24/7 intensivist and ICU nursing staff

• Volume of the case flow necessitating regionalized or centralized care

• Skilled interdiciplinary team work (incl. eg. pharmacists, physiotherapists)

• Compliance to evidence based treatment protocols

• Rapid identification of the at risk patient with prompt initiation of treatment also outside the ICU (e.g. Medical Emergency Teams)

• Patient management after the ICU stay (e.g. ICU outreach teams)



How could telemedicine

help?

• Improve quality of care and increase productivity of intensivists and ICU nurses

– Maximize resources and expertice for larger regional critical care patient population

– Immediate access to experienced ICU nurse or intensivists

– Allow remote monitoring, advice and support of bed side caretakers (intensivists and nurses) between units and hospitals

– Regional coordination and guidance of treatment processes

– Provide real-time education (via camera)

• Provide earlier identification of patients at risk and treatment initiation in all areas of the hospital

• Interaction with patients and families and local care takers during crisis and difficult discussions

• Check for compliance with best practices

• Provide tools for quality improvement by gathering information for benchmarking and best practices

• Provide tools for national and international collaboration

– Khunlertkit et al. J Crit Care 2013: 28: 315



Who Needs a Doctor When There's a Robot in the

Hospital Keeping the Sickest Patients Safer!

Scientific American, Dec. 2008 J Contin Educ Nurs 2012



Examples of telemedicine

utilization in OYS-OUH ICU • ICU multidiciplinary morning rounds through remote

monitoring: – Doctors, nurses and pharmacists are gathered to ”command

center” where they analyze patient data, discuss the cases and make treatment plan

– No bedside walking rounds

– Real-time patient data is projected to big screen for all participants to review

• electronic medical records

• laboratory results

• physiological parameters (incl. real time ECG and EEG)

• critical care information system

• medication

• imaging data

• nursing notes



Tele-consultation

• To a remote central hospital when needed (300 km distance between hospitals): – Direct and secure connection between two ICUs

• similar patient data management systems between hospitals

– Interactive telemedicine solution provides all relevant information for the consulting intensivist better support for colleagues and information for better decisions

– Multi-disciplinary university hospital level support available in a single session

– Fewer patient transfers needed between hospitals



Challenges of the current

system • Many separate patient data systems in use

plenty of switching between systems

• No visual video connection currently available • photos available when needed

• Support is given by telephone

• Tele consultation available only on demand

• Vendor lock in

• Teleconsultation system is platform dependent • In Oulu University Hospital district ICU data

management systems are equal between 5 hospitals but there are 3 different systems for electronic health records, radiology and laboratory



Global challenges in the

implementation of IT tech in ICU • Significant regional differences between countries in the

use of IT in healthcare – from computerized display of laboratory and radiology results

and electronic patient records to fully dedicated critical care clinical information management systems with physician ordering notes, clinical decision support features and mobile remote working stations

• Requires investments in the infrastructure and in the operational costs of the electronic systems – Totally electronic health record

– Secure information channels

– Cost effectiveness unclear

• Need for interoperable, a user friendly and intelligent global decision supporting system that can be customized for local needs



Telemedicine improves ICU

outcomes; a meta-analysis

• 15667 pre-intervention and 25797 post-intervention patients

• Statistically significant 20 % decrease in ICU mortality (OR 0.8, CI 0.66-0.97, p=0.02)

• Decrease in hospital mortality (OR 0.82, CI 0.65-1.03, p=0.08)

• Statistically significant decrease in the ICU length of stay (mean difference 1.26 days; CI -2.2—0.3, p=0.01)

• Decrease in the length of hospital stay (mean difference 0.64 days; CI -1.52-0.25, p=.16) – Brendan L at al. Arch Intern Med 2011; 171: 498-506



Telemedicine improves the process

of care in a multicenter study

• 11 558 controls and 107 432 intervention patients

• Teleintervention lead to 16 % decrease in standardized mortality ratio and 20 % decrease in ICU length of stay as well as 15 % decrease in hospital length of stay

• This was achieved by: – More rapid availability of an intensivist consultation

– Timely use of performance data

– Better adherence to ICU best practices

– Quicker alert response times

– Regular multidiciplinary patient rounds • Lilly CM ym. CHEST 2014:145: 500-7



Improves adherence to lung

protective ventilatory management

• In a US multicenter retrospective analysis implementation of teleICU – Increased the compliance of adhering to safe

ventilatory management (29.5 % to 52 %, p<0.001) during a two year follow up period

– The standardized APACHEIV predicted ventilatory duration rate was significatly reduced

– The standardized APACHEIV mortality ratio decresed significantly

• Kalb T et al. J Crit Care 2014: 29: a head of print



Single center studies

• In a US community-based non academic hospital teleICU intervention lead to significant decrease in hospital mortality (7.9 % vs. 3.8 %) – Sadaka ym. Crit Care Res Pract 2013: ahead of print

• In a single US academic medical center was associated with significant increase in the adherence of best clinical practice guidelines and significantly reduced the rate of preventable complications (13 % vs. 1.6 %) and significantly reduced the hospital length of stay (13.3 vs. 9.8 days) as well as significant reduction in mortality – Lilly CM at al. JAMA 2011; 21: 2175-83.



Adoption of ICU telemedicine in

the US

• Number of US hospitals with teleICU increased from 16 (0.4 %) in 2003 to 213 (4.6 %) in 2010

• The number of ICU beds covered by telemedicine increased from 598 (0.4 %) in 2003 to 5799 (7.9 %) in 2010

• Hospitals with teleICU were more likely to be large teaching hospitals in large metropolitan areas – Kahn J et al. CCM 2014: 42: 362-368

• In the US formal tele ICU programs support 11 % of critically ill patients – Lilly G et al. CCM 2014, a head of press



Conclusions

• Telemedicine in critical care is associated in significant reduction in mortality, length of stay and increase in patient safety in observational studies – Provides expert multi and interdiciplinary support of

remote ICU´s and improves the process of care

– Reduces the variation in clinical practice and improves the adherence to best practice guidelines

• TeleICU must have complete access to all patient related information for good care decisions also with video assisted personal contact from the cockpit to the bed side care takers as well as the patient and the family

• Wide staff acceptance of the concept is required



Be prepared! They are watching

over us and trying to take over!!!



http://www.google.fi/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&docid=3mHelKPwWPX68M&tbnid=gtq9yn_s99i2JM:&ved=0CAUQjRw&url=http://www.boston.com/yourtown/news/melrose/2012/02/melrose-wakefield_hospital_one_1.html&ei=eIcDU4jHHeam4gTikoEg&bvm=bv.61535280,d.bGE&psig=AFQjCNGMxNyXyN_nentzrDVpr4ObDLpadQ&ust=1392826355609986

Requirement

identification using

content validity

assessment

M.Sc, B.M., Simo Larinkari

30.10.2014



Background

• Research to gain insight over clinicians

expectations for tele-ICU system for

European healthcare environment

• Done under Thalea project

– Linked to request for tender process

– Sent to clinicians through participating

hospitals

– Conducted January – March 2014



Methods

• Online cross-sectional structured focus group survey

• 50 function statements (eg. ”System should display all patient medication and drug infusion rates”) – Formed by multidisciplinary team

– Divided to 4 sections: single patient, unit, ”command center” and user interface

– 4 step scale from ”not relevant” to ”highly relevant”

– ranking of 3 top functionalities per section

– Possibility to leave open ended comments and additions



Methods

• Second round of questionnaire with 18

statements

– Sent to 1st round respondents

– Same sections as in 1st round

– Only relevancy was estimated

– Included new function statements from open

ended questions and those with unclear of

content/language or unclear relevancy



Results

• 1st round had 26 respondents – Mostly M.D with high experience level

– 4 nationalities

• 2nd round had 18 respondents

• From each statement: – Item level content validity (I-CVI)

– Weighted ranking (WRP)

• Statistically significant correlation of I-CVI and WRP



Summarized statements of high

relevancy 1/2 • Single patient level

– Current and historical data of all measurements, flows and equipment settings should be presented

– All relevant information and alarms from other patient systems/equipment should be brought into the system

– Audiovisual connection to individual patient bed should be supported

• Unit Level – Overall status of every patient with possible special conditions,

risks and alarms of each patient should be visualized by unit

– Both staff and patient resources and flows should be presented

– System should include unit level alarms for eg. lack of resources or unattended patient alarms



Summarized statements of high

relevancy 2/2 • Command center Level

– There should be possibility to initiate audio visual connection from cockpit to give consultation

– Data from district area should be anonymized but the ability to see more detailed data on unit and patient level should be possible at will

• User Interface – Information security is of topmost importance and data should

only be accessible by authorized users

– The layout and graphics should be consistent throughout the system and data should be presented in structured form

– There is a need for cockpit view for consultation, meetings and management of patients and resources

– System should accessible wirelessly



Discussion / Remarks

• Results used in requirement prioritization

• Represents clinicians point of view, other

user groups were not included in the

study

• Pre-implementation view

• Division to levels (patient/unit/command

center) conceptual, not to be taken as

ideal for system in use



Thank you!



Telenursing in the Intensive Care Unit

Chief Nursing Officer, OUH

Merja Meriläinen, RN, PhD

[email protected]

Merja Meriläinen, RN, PhD, Chief nursing officer


mailto:[email protected]

http://www.google.fi/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&docid=r7uaRSG8rhi7WM&tbnid=d8WMGTkQPL3_cM:&ved=0CAUQjRw&url=http://missyrosse.blogspot.com/2012/03/telenursing-helps.html&ei=zy-OU6jdLLLS4QTqkoCQAg&bvm=bv.68191837,d.bGQ&psig=AFQjCNFIOYpBk7BhWvPmt77nyf7Vs3CuhQ&ust=1401913400978255

Daily challenge in ICU

Rapidly changing healthcare

Decreasing resources

Healthcare innovations

Patients and families

expectations



Tele-ICU

• Is the arena where informatics and telecommunication technology, coupled with telemedicine and telenursing, are bought together to affect the care of critically ill patients

• It provides expert-driven, evidence-based, cutting-edge services for the monitoring and treatment of critically ill patients

• It supports the bedside health care team through collaborations between the tele-ICU nurse and the bedside team

(www.americantelemed.org., Stafford et al. Working in an eICU unit: life in the box. Crit Care Nurs Clin 2008; 20.)



http://www.americantelemed.org/

Outcomes

• Reductions in ICU mortality

• Shorter stays in the ICU and the hospital

• Increased compliance with evidence-based best practice (e.g. screening for sepsis)

• Experienced ICU nurses and intensivist physicians help to monitor and treat critically ill patients and provide an additional layer of safety

• Decreased cost of patient care (Kohl et al. 2007, Zwada et al. 2009, Dickhaus et.al. 2006, King et al. )



The role of the tele-ICU nurse

• Make rounds via camera and patient database

• Assess patients via database – Verification of continuous infusions

– Follow-up of laboratory values

• Video assessment of patients´ physical appearance

• Equipment safety check

• Verbal interactions with patients, their families and staff



The role of the tele-ICU nurse

• Acts as a resource for the bedside nurses

(second set of eyes and ears)

• Ensures that best practice is adhered to

• Responds to questions and requests from

bedside staff

• Teleintensivist and telenurses can educate

bedside novice physicians and nurses by

walking them through unfamiliar procedures (Williams et al. 2012, Reis M 2009)



Tele-ICU nursing interventions

• Williams et al. 2012

– N=594

– 477 (80%) independent nursing interventions

• Assistance

• Brainstorming

• Overall collaboration

• Rescue interventions

• Prevention

Increased patient safety



Tele-ICU nursing: what is it not?

• It does not replace bedside nursing or the

bedside team

• It does not replace direct patient contact

• It is not a way of decreasing staff

numbers



What hopes do we have for

telenursing?

• Online, real time communication

between ICU experts

• Shared knowledge

• Expert-driven, evidence-based treatment

for critically ill patients



What does tele-ICU nursing

require?

• Clarity in roles between bedside team

and tele nursing team

• Functional and easy-to-use system

• Monitor view that provides an easy-to-

understand holistic picture of a patient’s

situation



What next?

• More interactive?

• Higher speed?

• More intelligent solutions?

• Extra staff?

• Do we really understand what we could request from these solutions?

• Can we move from crisis management and problem-solving to real innovations?



http://www.google.fi/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&docid=r7uaRSG8rhi7WM&tbnid=d8WMGTkQPL3_cM:&ved=0CAUQjRw&url=http://www.nursing-informatics.com/revealing/network.html&ei=nDOOU4T_C87T4QTo9ICQCA&bvm=bv.68191837,d.bGQ&psig=AFQjCNE0_sh1jfmOsDqbOfTTgtWLXXmUdQ&ust=1401914286672054

Thank you!



http://www.google.fi/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&docid=Z7HPp0v2tNdWNM&tbnid=eKnpeIHBDWIccM:&ved=0CAUQjRw&url=http://publications.mcgill.ca/headway/2011/09/13/health-care-from-afar/&ei=RTCOU-mDOYHh4QTvnIGIBQ&bvm=bv.68191837,d.bGQ&psig=AFQjCNFIOYpBk7BhWvPmt77nyf7Vs3CuhQ&ust=1401913400978255

Call for Tender

The past

Project time line

ICT Proposers

Day Warsaw

Building of consortia

Submission of THALEA proposal

Evaluation report 14

points

Negotiations with EC

Kick-off meeting in Brussels

Evaluation of tender

documents by EC

26th Sep ’12 11th Dec ’12 Jan ’13 April ‘13 May ‘13 4th Nov ‘13 June ‘14

Institutions & people

1. UKA (Coordination) (D)

2. MIWF (D)

3. AZM (NL)

4. NL Ag (NL)

5. FPT (ES)

6. AIAQS (ES)

7. ZOL (BE)

8. NOHD (FIN)

Project time line

Evaluation of tender

documents

Call for tender

published

Collection of tenderers

Submission Oral

presentation Phase I

Evaluation of Phase I

results

June’14 11th Dec ’12 CURRENT 25th Nov ‘14 Jan ‘15

Open Market consultation I

Aim

– Market research

– Insight in market and state of the art

Duration

– 20.12.2013 – 31.03.2014

– Online questionnaire till 28th of February

Open Market consultation II

Results

– 23 interested companies from 5 different

countries

– 52% are e-specified companies

– 25% are PDMS manufacturers

– 82% of companies are familiar with data-

safety and security

– Strong interest in forming of consortia

The present

PCP process has been

started

1. Prior information notice

2. Functional description

3. Open procedure with bidding competition

4. Call for tender

5. Development and evalution of products

during three phases

The reasons and procedures

Pre Commercial Procurement (PCP)

PCP to steer the development of solutions towards

concrete public sector needs, whilst

comparing/validating alternative solution

approaches from various vendors

Public Procurement for Innovation (PPI)

PPI to act as launching customer / early adopter / first

buyer of innovative commercial end-solutions newly

arriving on the market

PCP overview:

From demand to product

Budget

IPR

• Ownership rights of IPRs generated by a Tenderer during the PCP contract will be assigned to that Tenderer

– The THALEA Consortium will be assigned a free licence to use the R&D results for internal use.

• A call-back provision: IPRs that are not exploited within 3 years after the PCP project will return to the THALEA Consortium

Project Timeline

Consortium established in 2012

Project start: November 1st 2013

Open Market Consultation: from Dec 20th 2013 to Feb 28th 2014

Call for tender: from Oct 9th to Nov 25th 2014

Indicative time schedule: PCP Phase 1: February - May 2015

PCP Phase 2: August 2015 – July 2016

PCP Phase 3: October 2016 – March 2017

Identified demand

• Lack of a highly interoparable platform

for telemedicine in ICU

• Capability to extract data in near real

time from existing Patient Data

Management Systems [PDMS]

• Offering decision support in telemedicine

centres

Objectives • Develop a new technical platform to create a

technologically advanced ICU-cockpit

• Enable establishment and operation of regional or national ICU telemedicine centres – improve the care of critically ill patients treated in ICUs.

– detection of ICU-patients at increased risk

• Develop a solution for data management – Gather the information

– Data integration

– Data analysis

– Data presentation

– Export of anonymized data

Focus Areas • Compatibility with patient data management

systems that are already in use in ICUs

• High level of interoperability - Patient data integration from various sources

• Scalability

• Manufacturer independency

• Enabling remote consultation regionally with telemedicine solutions

• Early detection of ICU patients at increased risk

• Effective resource utilization and real-time resource management

System Schematic Overview

Solution

Call for tender

launched on October 9th 2014

open untill November 25th 2014

To find on:

www.evergabe.nrw.de (german tender-site)

or

http://ted.europa.eu (EU-tender-site)

Call for tender:

Important legal information

The Tender won't take place under the

regulations of the Directive 2004/18/EC.

It is excluded under the regulation of Art.

16 lit. f) and under the German

procurement law under the regulation of

§ 100 (2) lit. n) GWB.

It will take place as a PCP-Procedure.

Call for tender - Documents

All necessary documents are ready to

download on www.evergabe.nrw.de

It is possible to participate as single

bidder, but it‘s possible to participate as a

consortium of bidders as well!

Call for tender – Phase 1

To enter phase 1 we expect only a

sustainable solution design for the

problem.

The proposal shopuld be accompanied by

several certificats which are clearly

marked in the tender documents.

Call for tender – Phase 1

The tender has to be accompanied by:

1.THALEA PCP Tender Form

2.the UKA Fair Payment Charter

3.the UKA Anti-Bribery Code of Conduct

4.the UKA Anti-Fraud Code of Conduct

5.the UKA Anti-Bankruptcy Statement

6.the UKA Declaration of gender equality and women’s

promotion

7.Signature page Declaration of exclusion criteria

Call for tender

Submitting the tender

All tenders must be sent to UKA in a marked and

sealed envelope

The date of submission is

November 25th 2014 at 13:00 CET

Tenders who arrive later will be excluded!

We provide a „Read me“ and a Red sticker to

mark the envelope with the tender docs.

Call for tender

Submitting the tender Postal address:

Universitätsklinikum Aachen AöR

GB Recht vs-PCP-MB-2014

Sekretariat / Fr. Jansen

Pauwelsstraße 30

52074 Aachen

Street address:

Universitätsklinikum Aachen AöR

GB Recht vs-PCP-MB-2014

Sekretariat / Fr. Jansen

Kullenhofstr. 50, 4th floor, Room 404

52074 Aachen

Call for tender


Please send your Tender in a separate

sealed envelope and mark the envelope

with the red sticker which can be

generated by printing the document

“Kennzeichnung Angebotsabgabe”.

Call for tender


Call for tender

End of phase 1

After submission date:

the sealed envelopes will be opened by

Thalea consortium (4-eyes-rule!)

The formal necessarities of the tenders

will be checked

The tenders will be assessed by the

Thalea-consortium and the experts

The following phases

You‘ll find a description of the following

phases in the tender documents!

How to find

the tender documents?

You can download all tender documents

from the german procurement site

www.evergabe.nrw.de

Registration is mandatory to use the site

Registration is free

Registration on

www.evergabe.nrw.de

1. Go to http://www.evergabe.nrw.de/VMPCenter/

Registration on

www.evergabe.nrw.de

2. Click “Registrierung” on the left side of the page

Registration on

www.evergabe.nrw.de

3. General Information page (Information): – Fill in the application form. Fields with * are mandatory;

– Email confirmation: After completion of application you will receive Login

details and password;

– Finish registration:

Registration process is finished after

first login.

Please click on “weiter”

Registration on

www.evergabe.nrw.de

4. Company details (Daten des Unternehmens): Fill in

company details. Click “weiter”

Registration on

www.evergabe.nrw.de

5. Industry (Branche):

Choose an industry by clicking on “Kategorie(n)

bearbeiten”.This step is NOT MANDATORY. Click

on “weiter”

Registration on

www.evergabe.nrw.de

6. Personal details (Eigene Daten):

Fill in personal details. Click “weiter”

Registration on

www.evergabe.nrw.de

7. Confirmation (Bestätigung): Check your application.

Check the general terms of condition (“ich akzeptiere die

AGB”). Click “Registrierung abschließen”.

Registration on

www.evergabe.nrw.de

8. How to get the call for tender documents?

- After finishing registration, you will receive a confirmation email

- Click on link to the vergabe platform.

- You can log in (by clicking “Anmelden" on the left side of the

page) with your created account details.

- After that you will be able to download all tender documents in

English by typing THALEA into the search.

Communication

Web page: www.thalea-pcp.eu

Call for tender:

– www.evergabe.nrw.de

– http://ted.europa.eu

All communication during the bidding process

has to be made by using the communication-

modul on www.evergabe.nrw.de!

The future

PPI

At this moment it is being discussed to

start a following project on PPI for Thalea.

So be aware about ongoing actions and

information!

Thank you for your attention

and

good luck during

the PCP-process!

Contact:

Timo Alalääkkölä

[email protected]

+358 40 561 4390