Sep 18 2020

What Is a Tele-ICU and How Does It Work?

When bedside and remote teams collaborate through tele-ICUs, the partnership elevates care and outcomes.

On their best days, as they work together to orchestrate and deliver tele-ICU care from different places, bedside and remote teams might feel akin to a symphony, says Dr. Sarah Pletcher, vice president and executive medical director of virtual care at Houston Methodist.

“Everyone has their part to play, and when everyone is on the same rhythm, it is a thing of beauty,” she says.

Around the country, tele-ICU programs ­— command centers staffed with intensivists and critical care nurses who electronically aid and deliver real-time information to frontline clinicians — have empowered busy hospitals during the COVID-19 pandemic by providing care for more patients while minimizing infection risk and the use of personal protective equipment.

Even beyond the current pandemic, tele-ICUs are a powerful way to augment limited resources in rural counties that lack critical care expertise and in urban areas facing temporary surges in traffic, says Dr. Benjamin Scott, an anesthesiologist at UCHealth in Colorado and the chair-elect of the Society of Critical Care Medicine’s Tele-ICU Committee.

“There’s always the risk that acuity or volume can outstrip your ability to care for all the patients in your hospital,” he says.

In tele-ICU settings, remote clinicians and their bedside colleagues leverage technology, expertise and intense collaboration to make sure that doesn’t happen.

Houston Methodist Gets a Head Start on Its Tele-ICU

The January opening of a new tele-ICU at Houston Methodist couldn’t have been timelier.

The operations center supports nearly 250 intensive care unit beds across three of the organization’s eight campuses — coverage that will soon expand to more than 300 beds. Bedside and operations center clinicians, together with intensivists based in New York, coordinate care within what Pletcher describes as “an ecosystem of technology.”

In patient rooms, teams collaborate via two-way audio and Sony high-definition, pan-tilt-zoom cameras. The latter tool provides a bird’s-eye view into each room, close enough for a clinician to see a pupil dilate or to read a medicine bottle.

In the operations center, which is outfitted with Dell monitors, Lenovo PC workstations and Cisco phone systems, teams have a wealth of data at their fingertips. An Intel-powered Sickbay platform pulls data from a variety of sources — including bedside monitoring, biodata and electronic health records — to identify trends, analyze risks and produce alerts.

When COVID-19 hit in March, mobile carts equipped with iPad devices extended tele-ICU support throughout the Houston Methodist premises by allowing remote teams to monitor patients who came to the emergency department and then transferred to another unit, with the goal of preventing escalation to the ICU.

The carts also helped remote teams consult on COVID-19 patients waiting for ICU beds. During a recent spike of cases in Texas, guidance from the New York partners — battle-tested from their own surge — was critical.

“Getting intensivist expertise to a patient as quickly as possible improves outcomes, so by extending that resource into an area outside the ICU, we’re getting a head start,” Pletcher says.

READ MORE: Learn how mobile tools and videoconferencing software help doctors perform virtual rounding duties.

Northwell Health Quickly Ramps Up Its Rollout

In New York, Northwell Health has relied on tele-ICU infrastructure in several ways during the public health crisis: supporting bedside nurses, providing critical care guidance to pop-up ICUs and quickly onboarding two more hospitals into the tele-ICU program.

Now 6 years old, Northwell’s tele-ICU covers about half of its 400-plus ICU beds across a 23-hospital system, with plans to cover up to 300 total beds by next year, says Iris Berman, the organization’s vice president of telehealth services.

The Syosset, N.Y.-based command center has a wide reach: With one nurse for every 40 beds and one intensivist for every 200 beds, the remote team relies on eight monitors, two CPUs (half for high-quality video and half for documentation systems), robust Phillips e-ICU software and, in patient rooms, HD PTZ cameras and two-way audio.

7,000

The number of remote connections into patient rooms via Houston Methodist’s tele-ICU technology between March 16 and May 11

Source: houstonmethodist.org

Before the pandemic, two Northwell hospitals had their ICU rooms outfitted with cameras but hadn’t yet completed tele-ICU onboarding. Every hospital is different, Berman notes, and time is needed for teams to adjust and align.

But in midspring, as the disease struck New York hard, there was no time for that.

“We got the call: ‘We’re getting slammed. We need help,’” says Berman. “We said, ‘OK, turn it on. We’ll at least have eyes on them.’”

Command center staff launched tele-ICU support for both Northwell hospitals, with remote nurses and intensivists providing cohesive guidance to support decision-making with bedside teams as the situation progressed.

Tele-ICU staff also conducted real-time documentation, communicated patient conditions to help nurses bundle care and minimize PPE use, and served as a safety net when frontline staffers were overwhelmed.

“We could alert them when there was a patient in trouble because we could see the trend — sometimes more quickly than you would at the bedside — because of the amount of information we’re able to glean at one time,” says Berman, adding that patients appreciated the human connection during a time of intense isolation.

“We could camera in and say, ‘Hello, we’re watching. You’re OK,’” she says.

Sutter Health Makes Critical Connections with Patients

Like Northwell, Sutter Health in California fast-tracked some of its tele-ICU plans in response to COVID-19.

Sutter has relied on a tele-ICU setup for several years, with two hubs supporting more than 300 ICU rooms in 20 of its 22 hospitals. Earlier this year, plans were underway to double the number of critical care beds at Sutter Roseville Medical Center, with a grand opening set for late May.

When it became clear those beds would be needed sooner, Sutter moved to open the facility early.

For remote clinicians, in-room technology performs double duty, says Dr. Vanessa Walker, medical director of the Sutter Valley Area e-ICU in Sacramento: It virtually brings them into the room while preserving a distance that can be useful in high-stress situations.

“It is phenomenal how much you can learn about somebody through the cameras and utilizing the technologies available to us,” she says. “I feel like I am in the room talking to the patient.”

At the same time, she says, when a physician runs codes from the command center, he or she is a step removed.

“Because of that remote sensation, you’re able to treat it more the way that it should be: a protocolized approach,” says Walker.

Dr. Vanessa Walker
It is phenomenal how much you can learn about somebody through the cameras and utilizing the technologies available to us. I feel like I am in the room talking to the patient.”

Dr. Vanessa Walker Sutter Health

When Sutter designed its tele-ICU program, says Dr. Tom Shaughnessy, medical director of the Bay Area eICU in San Francisco, part of the intent was to give all patients the same level of care, whether they were in a large hospital or a small, rural one.

That played out this spring, when iPad devices helped Sutter extend critical care to outlying areas with less internal expertise. Because nurses could take tablets into isolation rooms and hold them up to facilitate virtual consultations, extremely sick COVID-19 patients were able to stay at local hospitals. That kept them close to their families, minimized pressure on hospital transport and, most of all, improved outcomes.

“The tele-ICU has really broadened the scope of our ability to handle a surge of critically ill patients,” says Shaughnessy.

At Memorial Hospital Los Banos, one of Sutter’s smallest hospitals, bedside nurses needed to prone COVID-19 patients, but weren’t experienced in the delicate procedure. Remote nurses walked them through each step.

“If they had not had that iPad, they simply would not have been able to do that lifesaving maneuver for those patients,” Walker says. “That was a pretty awesome experience, to be able to see our plans, which we had worked so hard on, coming to fruition.”

Tele-ICU Programs Look to Achieve Common Objectives

Tele-ICU clinicians emphasize that their role is to enhance, not replace, bedside caregivers. One of biggest ways they do that is through the data that streams into operations centers. Data-driven analysis, paired with a high-level view, is a strong advantage, says Scott

“You can see larger-scale practice patterns and illness patterns, you can identify trends that are happening across a system, and you can use the data that you generate in these programs to help drive improvements in care,” he says.

In Houston, Pletcher describes day-to-day coordination among colleagues — the workflows, handoffs and communication — as the heart of the tele-ICU program. It takes effort to get everyone on the same page, she says, but the results are worth it.

“If you build the relationships and that culture where everybody feels like they’re all part of the same team, whether they’re remote or at the bedside, that’s when you get the symphony,” she says.

sturti/Getty Images

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