May 24, 2010

Mission Critical: Telemedicine in the ICU
By Elizabeth S. Roop
For The Record
Vol. 22 No. 10 P. 20

How effective is remote care in this most crucial of units? A recent study produced interesting results while a Massachusetts children’s hospital reports early success with its pediatric program.

Concerned about the labored breathing of a young surgical patient whose breathing tube had recently been removed, the Fellow manning the overnight shift in Boston’s MassGeneral Hospital for Children’s pediatric ICU (PICU) placed a call to Phoebe Yager, MD, the attending physician on call.

But it wasn’t just any call. It was a video-enabled “home-to-hospital” call that allowed Yager to assess the patient in conjunction with the unit team, establish that his breathing was actually improved compared with earlier in the day, and even reassure the boy’s mother that he was indeed improving—all without losing valuable time commuting to assess the situation in person.

“No one on the overnight team had seen him earlier in the day, so they couldn’t tell if it was a significant difference,” recalls Yager. “We looked at the patient together, talked over what was going on, and I was able to provide assurances that [his breathing] actually represented an improvement from earlier in the day, so the team was dissuaded from replacing the breathing tube. That’s a big deal. … I was able to collect input from all members of the team, allay the fears of the mother, and provide her with reassurances that there was continuity in care over 24 hours.”

Deployed in 2009, MassGen’s Connected Pediatric Critical Care program marked a significant enhancement of the system’s telemedicine program that had been in place for more than a decade. The original inititiative started as a telephone link that allowed specialists at MassGen to consult with attending physicians at two affiliated community hospitals to stabilize patients in the critical care unit prior to transferring them to the main hospital.

In 1998, video capabilities were added to the program, allowing physicians to act as “another set of eyes to monitor the patient,” says Natan Noviski, MD, the MassGen’s chief of pediatric critical care medicine. Soon thereafter, the health system became the first to cross state lines when it established a video-based telemedicine program with a hospital in Puerto Rico.

The Connected Pediatric Critical Care program goes a step further, providing a video link between the clinical staff in the PICU and the attending physician at home. In the unit, the video system is attached to a robot that can be rolled from bedside to bedside. The attending physician can be at the bedside, albeit virtually, examining the patient and communicating directly with the multidisciplinary team.

The attending physician is able to control the robot from home, including zooming in or out and even viewing monitors. Special cameras and scopes can also be attached to the robot to allow for even closer examinations.

“It helps me guide the management of the patient or, depending upon what I see, I can decide to come in,” says Yager, adding that in the past, “if I received a call about an emergency situation, I would say ‘I’m coming in.’ While driving to the hospital, I’d be trying to imagine what was happening without being able to provide immediate assistance. Now a physician from home can stabilize a critical situation and then drive in a more peaceful way. It benefits the staff and patients.”

Yager cites the case of a young girl who was admitted during the night with breathing difficulties. Via video linkup, Yager was able to determine that the patient was in pending respiratory failure and then guided the on-site team through insertion of a breathing tube before heading to the hospital.

“There was no question she needed a breathing tube and she couldn’t wait,” says Yager. “I was able to have a much greater impact by staying at home and stabilizing the patient via telemedicine than hopping in the car and driving in. When I got to the bedside, I wasn’t coming in new and saying ‘Tell me what happened.’”

Mixed Results
Though it’s too early for measurable outcomes from MassGen’s PICU telemedicine program, anecdotal results indicate communications are significantly improved.
“It goes without saying because otherwise it would be one attending talking with someone at home. Now everyone is participating in the communications,” says Noviski. “So far the response we have heard is that it is a very good system to enhance communications and improve quality of care, but we need to prove it with more objective measures.”

To that end, Noviski and his team are designing a long-term, large-scale study to evaluate any gains or improvements resulting from the telemedicine program. Once complete, the findings will be a welcome addition to a fairly limited pool of scientific research surrounding the efficacy of telemedicine in an ICU setting.

Most recently, research from the University of Texas Health Science Center at Houston (UT Health) published findings from a study that measured the impact of remote patient monitoring in ICUs on patient outcomes. Researchers analyzed the records of more than 2,000 patients before the implementation of an ICU telemedicine program by a major U.S. health system and the records of more than 2,100 patients after implementation.

The study, “Association of Telemedicine for Remote Monitoring of Intensive Care Patients with Mortality, Complications and Length of Stay,” involved six ICUs in five hospitals. It appeared in the December 2009 issue of The Journal of the American Medical Association and was supported by the Agency for Healthcare Research and Quality, the National Center for Research Resources, and the Center for Clinical and Translational Sciences at UT Health.

Researchers found no significant overall changes in death rates, the frequency of eight complications, or patients’ ability to leave the ICU earlier. They did find that survival rates for the extremely ill improved in all the ICUs studied. These findings ran counter to the results of a 2004 study in which death rates and average lengths of stay declined in two adult ICUs in a large tertiary care facility after the implementation of a telemedicine program.

“I was a little bit surprised,” admits Eric Thomas, MD, MPH, the study’s lead author and a professor of medicine at UT Health Medical School at Houston. “I doubted that we would find as big of an impact as was found in the first study. I thought there would be something, though.”

The studied system consisted of a remote office located in the health system’s administrative offices, separate from all the hospitals. It was equipped with audiovisual monitoring equipment and was staffed by two intensivists, each working with two nurses and one technician to monitor ICU beds. Computer workstations provided real-time vital signs with graphic trends, audiovisual connections to patients’ rooms, early-warning signals regarding abnormalities in a patient’s status, and access to imaging studies and medication administration records.

Thomas and his colleagues point to three factors they believe impact the effectiveness of an ICU telemedicine program:

• how the program is used by remote intensivists to alter care in the monitored units;

• its acceptance by physicians in the monitored units; and

• integration of the telemedicine program and monitored units’ information systems.

For example, in the study, most of the physicians who cared for patients in the monitored units retained control of decisions affecting their patients but did give the remote monitors authority to intervene in life-threatening situations. Progress notes were faxed from monitored units to the telemedicine program, while telemedicine orders were entered into the computer workstations and printed in the monitored units.

“In general, the telemedicine technology wasn’t as well integrated with EMRs as it could have been or might be in some places,” Thomas notes. “That is another issue for an individual ICU to look at: Will [telemedicine] be integrated with current record systems or will it require additional work, even something as simple as printing or faxing? It’s a serious issue. Nurses and physicians don’t have extra time, especially if there is skepticism about the value.”

Thomas says the broad definition of telemedicine—which could mean anything from telephone consultations and video conferences to real-time vital signs monitoring and bedside audiovisual connections—coupled with its relative youth may also be reasons for the varied research findings. So hospitals considering telemedicine programs for their ICUs should evaluate each study on its individual merits. “Just as they shouldn’t have looked at the first study and said it’s good, they shouldn’t look at this one and say it’s bad,” he says. “It’s a complicated issue. … It’s still very spotty depending upon the facility and technology.”

Thomas points out that telemedicine may not be the best approach to resolving specific issues within a given ICU, particularly when the technology’s cost is taken into consideration. For example, he says studies have shown that utilizing checklists has been shown to prevent catheter-related infections and ventilator-related pneumonia—a far less costly solution than implementing telemedicine.

There are no proven processes for determining when and if telemedicine is the best bet for a particular hospital or ICU. Rather, Thomas recommends facilities consider the unit patients’ severity of illness as well as the quality of care provided in the unit.

“You have to think broadly about efforts to increase quality in the ICU and not automatically run for the most expensive technology,” he says. “There are other ways to improve quality. Some are a lot cheaper and there is good evidence behind them. I encourage people to look at their other options and all the things they can do to improve quality of care in the ICU. This is just one of many.”

The Future of Telemedicine
Despite the Texas study’s finding that telemedicine did not have a significant impact on outcomes, expectations are that the concept will continue to grow in popularity. In fact, some believe the study’s findings demonstrate the true worth of telemedicine.

“The real value of telehealth is that the outcomes were the same but the hospitals were able to use their resources more efficiently and possibly keep their ICU open with full physician coverage. I wonder how many of these facilities would have to consider closing their ICU if it were not for their teleICU program,” says Christina Thielst, FACHE, executive director of the Northwest Regional Telehealth Resource Center, a consortium of 33 experienced telehealth networks in Alaska, Hawaii, Idaho, Montana, Oregon, Utah, Washington, Wyoming, and U.S.-affiliated Pacific islands that serves as an information agent and shares resources to develop new programs.

“Another important factor to look at is the impact of a telehealth program on the nursing staff. Are nurses in ICUs less frustrated and stressed, more effective, more productive in hospitals where they have access to a physician using telehealth? For some administrators, this could be a real return on their investment,” she adds.

In fact, for many facilities, more efficient use of resources is a primary consideration for deploying telemedicine programs. According to the Society of Critical Care Medicine, 10% to 20% of all hospital beds are dedicated to critical care and account for 30% of overall acute care hospital costs. An aging population and increasingly complex illnesses, coupled with a worsening shortage of critical care physicians and nurses, is expected to drive those costs even higher while simultaneously making it more difficult to keep ICUs staffed at appropriate levels.

These trends are combining to drive adoption by small and rural hospitals in particular “but also any hospital that may not have access to needed specialists locally,” says Thielst. “On the other side are the larger, more regional hospitals that assist the smaller and rural hospitals by facilitating access to their specialists. Urban and suburban hospitals that need access to a particular specialist also use telehealth. It’s a tool that cuts down on patient and/or physician travel times, is a really efficient use of physician time and, in some cases, it gets a patient in front of the needed specialist faster.”

Thielst points to several examples of how Northwest Regional Telehealth Resource Center members are utilizing technology to combat specialist shortages, including using telehealth for retinopathy-of-prematurity examinations of neonatal ICU babies and emergent pediatric consults with pediatric intensivists.

Nevertheless, barriers remain that prevent telemedicine from achieving its full potential. These include reimbursement, cross-state licensing, and privileging.

“My feeling is that given the recent health reform legislation and the FCC’s [Federal Communications Commission] new broadband plan, we may see some improvements in this area. I think we will also see telehealth expand to suburban and urban areas once reimbursement is addressed,” says Thielst. “I think we will see some growth after the reimbursement, privileging, and credentialing issues are addressed by CMS [the Centers for Medicare & Medicaid Services]. The anticipated shortage of physicians, an aging population, bundled payments focused on keeping patients healthy, and reduced payments will all motivate hospitals and doctors to find more efficient ways of providing care. Telehealth isn’t a solution for every patient encounter, but it is equally effective for some.”

— Elizabeth S. Roop is a Tampa, Fla.-based freelance writer specializing in healthcare and HIT.