The Role of the Tele-ICU in a Pre- and Post-COVID-19 World
The COVID-19 pandemic spotlighted the use of telemedicine, notably in critical care, but the tele-intensive care unit (ICU) existed two decades beforehand. John Kazianis, MD, medical director at InSight Tele ICU at Yale University School of Medicine, discussed the past, present, and future of tele-ICU during a live session at the CHEST Annual Meeting 2020 titled “Tele-healthcare in Pulmonary and Critical Care Medicine – Current and Future Practice.”
Dr. Kazianis acknowledged that the use of tele-ICU played a significant role during the COVID-19 pandemic, but the concept is by no means new. “We have to think back that there were many reasons why tele-ICUs were conceived in the first place 20 years ago,” he noted. “First, we know that intensivists improve outcomes. But unfortunately, in many parts of the country, especially in rural areas, there simply aren’t enough of us. And even when there are enough, there are few hospitals [that] can justify having 24/7 in-hospital coverage.”
Daytime care differs significantly from that provided at night and on weekends, he admitted. But, “Tele-ICUs can help bridge that gap.”
Tele-critical care has many definitions. Dr. Kazianis defined it as “an intervention to address gaps in clinical coverage, as well as a tool for the diffusion of evidence-based medicine, quality improvement, and standardization of care.” The three domains through which this is done are: (1) real-time monitoring and data collection, (2) best practice adherence/protocol compliance, and (3) bringing expert opinion and interventions in real time to the bedside when necessary. The success of an institution’s tele-ICU “depends mostly on this third domain,” he added.
Data supports the use of tele-ICUs, associating them with reduced hospital mortality and length of stay, improved compliance with best practices, and fewer preventable complications. However, these outcomes varied largely by hospital in one study, Dr. Kazianis noted. High admission volume urban centers saw the most significant reductions in mortality.
His own institution, the Yale-New Haven InSight Tele ICU, oversees 135 beds across the states in nine ICUs across six delivery networks. They have one out-of-network partner. From the start of the pandemic through September, his hospital system saw 3,736 COVID-19 discharges.
In terms of the future of tele-critical care, Dr. Kazianis cited the example of acute respiratory distress syndrome (ARDS). “We know that ARDS is underdiagnosed and undertreated. Imagine a system in which you leverage your tele-ICU technology to identify ARDS early, perhaps through some type of screening based on P/F ratio,” he suggested.
Looking ahead at tele-critical care in a post-COVID-19 world, Dr. Kazianis predicted that “it will focus more on the core competencies of the intensivist, specifically identification and management of ARDS, [ventilator] management, and ventilator liberation. I think in the future, we’ll rely more on the hospital electronic health record for the routine best practice prompting of the bedside team.” He believes it will allow for 24/7/365 care.
“Tele-critical care has evolved from a solution to regional staffing shortages to a clinical service applicable to a wide range of bedside staffing models. More data are needed to determine how to effectively utilize it. I also think there’s a need to develop structured educational programs for telehealth for the next generation of physicians,” Dr. Kazianis concluded.