Telecritical Care Clinical and Operational Strategies in Response to COVID-19

Abstract

Background:

The cororavirus disease 19 (COVID-19) pandemic has strained intensive care unit (ICU) material and human resources to global crisis levels. The risks of staffing challenges and clinician exposure are of significant concern. One resource, telecritical care (TCC), has the potential to optimize efficiency, maximize safety, and improve quality of care provided amid large-scale disruptions, but its role in pandemic situations is only loosely defined.

Planning and Preparation Phase:

We propose strategic initiatives by which TCC may act as a force multiplier for pandemic preparedness in response to COVID-19, utilizing a tiered approach for increasing surge capacity needs. The goals involved usage of TCC to augment ICU capacity, optimize safety, minimize personal protective equipment (PPE) use, improve efficiencies, and enhance knowledge of managing pandemic response.

Implementation Phase:

A phased approach utilizing TCC would involve implementing remote capabilities across the enterprise to accomplish the goals outlined. The hardware and software needed for initial expansion to cover 275 beds included $956,670 for mobile carts and $173,106 for home workstations. Team role deployment and bedside clinical care centering around TCC as critical care capacity expand beyond 275 beds. Surge capacity was not reached during early phases of the pandemic in the region, allowing refinement of TCC during subsequent pandemic phases.

Conclusions:

Leveraging TCC facilitated pandemic surge planning but required redefinition of typical ICU staffing models. The design was meant to workforce efficiencies, reduce PPE use, and minimize health care worker exposure risk, all while maintaining quality care standards through an intensivist-led model. As health care operations resumed and states reopened, TCC is being used to support shifts in volume and critical care personnel during the pandemic evolution. The lessons applied may help health care systems through variable phases of the pandemic.

Introduction

The 2019 novel coronavirus disease 19 (COVID-19) pandemic has disrupted critical care resources to crisis levels. With surges of critically ill patients due to COVID-19, there have been well-documented shortages of key material and human resources,¹ including personal protective equipment (PPE),² mechanical ventilators,³ and intensive care unit (ICU) nurses and providers⁴ similar to those seen in other pandemics.⁵ Many health care institutions were concerned about the anticipated challenges of communication, care coordination, and crisis management, especially with increasing critical care resource scarcity. The constantly evolving recommendations for COVID-19 disease management only amplified these concerns due to the difficulty of managing the stress of rapidly changing clinical information.⁶

One resource, telecritical care (TCC), which involves providing care to critically ill patients through synchronous, two-way audiovisual communication, has had wide global adoption.^7,8 The TCC industry has expanded since recent global pandemics, such as H1N1 influenza, severe acute respiratory syndrome, and Middle Eastern respiratory syndrome.⁸ The Society of Critical Care Medicine's Tele-ICU committee recently published a timely refresher that describes the various models of TCC and its contemporary applications.⁹ However, the management of COVID-19 creates its unique social and economic challenges,^1

–4 so existing TCC guidelines during pandemics¹⁰ may be insufficient to provide specific guidance. It is also unclear which TCC care delivery models are most apt for this evolving pandemic, as its role in pandemic and mass casualty planning is only loosely defined.^7

–12 Moreover, concerns of expensive startup and operating costs have limited the adoption of TCC in several centers.^9,13

In this article, we describe strategic deployment of TCC to facilitate response in pandemic surge situations. Based on our own health system's experience with COVID-19, we describe organizational and structural adjustments that can be implemented utilizing TCC to maintain critical care quality standards while addressing concerns of health care safety, and operational efficiencies in this process. As resources become increasingly strained during pandemic evolution, we provide guidance to buffer the impact of potential challenges health systems may encounter. We argue that the costs of leveraging TCC may be favorable in comparison with other structural and operational surge planning preparations. The project received an institutional review board exemption.

Planning and Implementation

Atrium Health's Pre-COVID-19 Operations

Atrium Health is an integrated not-for-profit health care system in the southeastern United States with >40 hospitals and 900 care locations throughout the Carolinas and Georgia. Atrium Health's TCC service, Virtual Critical Care (VCC), was established in 2013 and now serves >300 adult critical care beds, across 12 hospitals and 3 states. VCC uses a largely decentralized hybrid hub-node-spoke care delivery model¹⁴ and is staffed full time by board-certified intensivists and certified critical care nurses 24 h daily, 365 days yearly, as well as part time by critical care pharmacists¹⁵ and respiratory therapists. VCC utilizes the eCareManager platform (Philips, Amsterdam, Netherlands).^8,9 Depending on patient location, two integrated electronic medical records (Cerner, North Kansas City, MO and Epic, Verona, WI) provide access to documentation and clinical parameters, including laboratories and radiology. Before the COVID-19 pandemic, two hospitals already had mobile cart monitoring available in emergency departments.¹⁶ A real-time dashboard through a customized SharePoint tool (Microsoft, Redmond, WA) along with Microsoft Teams (Microsoft) and DocHalo (Halo Health, Cincinnati, OH) provides additional synchronous and asynchronous communication across the enterprise.

Atrium Health'S TCC Pandemic Response

To complement facility-based, system-wide, and regional pandemic preparation, Atrium Health Incident Command and critical care leadership identified its needs in alignment with strategic capacity development consistent with the Society of Critical Care Medicine's (SCCM's) Preparation Checklist.¹⁷ VCC leadership then assessed which strategies would best be managed with a virtual strategy rather than the intrafacility approach (Table 1). As such, a phased multipronged strategy for TCC was developed specifically to optimize technological capacity, digital resource availability, and clinician training. Through this planning, an additional 275 beds could be added readily through remote cart acquisition and support. Should capacity for an additional 275–900 critical care beds be needed, then off-site facilities with TCC support could be added as schemes are adjusted. Figure 1 summarizes these goals in a surge capacity context. Figure 2 summarizes the physician and team-based staffing that would need to be adjusted, emphasizing patient care leadership through VCC intensivists.

Fig. 1.

Increasing involvement of VCC initiatives is outlined as the trend moves toward increasing surge capacity and bed capabilities. As bedside staff are increasingly taxed, VCC involvement in clinical decision making increases. APPs, advance practice providers; ICU, intensive care unit; PACU, post-anesthesia care unit; VCC, Virtual Critical Care.

Fig. 2.

Redefining bedside intensivist staffing with surge, based on critical care bed expansion requirements. CRNAs, certified registered nurse anesthetists.

Table 1.

Telecritical Care Value in Relation to Intensive Care Unit Preparation Checklist by Society of Critical Care Medicine

	ICU PREPARATION CHECKLIST FOR INCIDENT COMMAND STRUCTURE	VCC ROLES
Preparedness	Review and test your ICU emergency response plan and infection control policies. Review external disaster management and evacuation plans. Provide just-in-time training to staff.	Provide real-time and rapid assessment of interfacility capabilities. Can coordinate interfacility transfers. Develop and coordinate asynchronous and synchronous institution-specific educational training to staff.
Logistics/surge capacity	Assess ICU capability and identify contingency units. Mitigate therapies that cause aerosolization. Consult facilities management to safely cohort COVID-19 patients. Understand how to sustain mechanical ventilation outside of an ICU.	Provide clinical supervision of contingency units identified. Virtual clinicians can assess appropriateness of aerosolized therapies. Virtual clinicians can facilitate and manage mechanical ventilation and oxygen therapies outside of ICU.
Communication	Understand your ICU's organization and chain of command. Discuss communication methods with all departments, patients, and families. Utilize online tools to maintain situational awareness and educate large groups.	Facilitate real-time communication with patients and families through virtual platforms. Facilitate team-based communication especially in rooms under isolation precautions. Coordinate multispecialty interactions.
Critical care triage	Ensure that all ICU staff members are familiar with your triage protocol. Work with the emergency department to identify, isolate, and test for COVID-19. Determine inclusion/exclusion criteria for ICU admission.	Clinician oversight of ICU triage including ICU admission appropriateness. Facilitate disposition from ICU especially if interfacility transfer needed.
Protection of ICU workforce	Review policies for when ICU staff should be tested and take precautions. Prepare contingency plans for staff or their families who are quarantined or infected. Confirm that ICU staff will receive pay and benefits during quarantine situations.	Home workstations allow ICU clinicians to function if deemed too high risk for bedside care, and if quarantined. Minimize exposure risk as staffing is flexed for intensivists who can provide expertise from home. External consultants can view patient from outside the ICU.
Staffing capacity	Prepare alternative staffing strategies in the event of a surge in patients or illness among ICU staff. Consider quarantine effects and work–rest cycles during increased patient load.	Leverage the expertise of board-certified intensivists and nurses across the health care system. Additional providers able to provide expertise across the region.
Essential equipment	Ensure ICU staff members know how PPE will be distributed. Practice donning and doffing procedures. Inventory equipment/supplies and anticipate shortages.	Verify proper PPE precautions at bedside. Facilitate ICU clinical standards being applied despite potential shortages of ICU-related equipment and medications.

ICU, intensive care unit; PPE, personal protective equipment; VCC, Virtual Critical Care.

Goal 1: augment capacity for VCC

Increase the system-wide total number of beds available for critically ill patients by equipping non-ICU rooms with VCC interface technology. Notably, an additional 130 mobile telehealth carts were purchased for critical care overflow and emergency department use (Table 2). Internal carts from other existing telehealth platforms (telestroke and behavioral health) were also repurposed to be compatible with existing critical care platforms with minimal investment to achieve the initial 275-bed surge goal.

Coordinate hardware and software acquisition and installation with the Atrium Health Information and Analytics Services (IAS) team to supply the necessary number of remote workstations across the enterprise.

○ Allows clinicians who cannot perform bedside duties (e.g., high-risk pre-existing conditions, self-quarantined, and retired) to work from home.

Train and credential advance practice providers (APPs) to perform VCC duties in alignment with scope of practice defined by state regulations, while exploring virtual supervision rules of site-based APPs through VCC intensivists.

Develop a team-based approach toward patient care (Fig. 2), whereby critical care procedures would preferentially be performed by surgeons, anesthesiologists, and/or certified registered nurse anesthetists, allowing bedside intensive care providers to facilitate medical care.

Develop and coordinate use of institution-specific educational and resource materials for non-intensivists to provide critical care, including just-in-time resources.

Table 2.

Costs for Configuration of Carts and Home Workstations

	ITEM	COSTS (U.S. DOLLARS)	DESCRIPTION
Mobile cart solution	Cart	$5,149	Caspa M38
	Camera	$910	Logitech Pro 2 PTZ
	Speaker/microphone	$150	Jabra 510
	CPU and motherboard	$900	HP ProOne 600
	Other/software	$250	Vidyo, cables, etc.
	Cost per station	$7,359
	Total (130 carts)	$956,670

	ITEM	COSTS (U.S. DOLLARS)	DESCRIPTION
Home workstation	Monitors	$280	Two HP Monitors ($140 each)
	Personal computer	$989	HP 650 Probook
	Docking station	$134	HP Slim
	Other items/software	$300	Headset, Cables, etc.
	Cost per station	$1,703
	Total (102 Workstations)	$173,706
	Grand total	$1,130,376

Goal 2: (a) minimize health care worker exposure while (b) controlling PPE use

Add virtual access in multiple clinical areas, including proximate nursing workstations and non-ICU areas, such that ICU staff can communicate with patients in isolation without direct exposure.

Verification of proper PPE worn by bedside teams by VCC nurses.

Assistance with monitoring, communication, and documentation during high-risk procedures (e.g., intubation and advanced cardiac life support) by VCC nurses and physicians, thereby minimizing the need for additional personnel entering and exiting rooms for these purposes.

Goal 3: improve efficiencies in bedside ICU team management

As bedside providers are increasingly taxed, expand roles and degree of involvement of VCC providers in all aspects of clinical decision making, order entry, care coordination, and documentation.

Minimize potential delayed recommendations from specialists by providing remote virtual capabilities in non-ICU clinical areas, such as echocardiography reading rooms, infectious disease, and endocrinology specialists' offices.

Facilitate coordination through surgery and anesthesiology teams for procedural support for on-site teams.

Promote virtual team-based rounding as traditional ICU interprofessional rounding teams might have members deemed “nonessential” and hence only available remotely.

Serve as a central point of coordination and communication for evolving critical care clinical algorithms, based on advancing knowledge of management of COVID-19.

Goal 4: optimize ICU bed utilization

Create a real-time ICU surveillance dashboard listing active ICU patients, including COVID-19 confirmed or suspected cases, which provides insight into each facility's ICU capacity and better equips Atrium Health's Incident Command structure.

Centralize ICU triage decision making by the creation of a dedicated intensivist “VCC quarterback” position with explicit responsibilities to facilitate admission, transport, and communication to ICUs across the system.

Lessons Learned During Implementation

We describe the components and strategies of a multifaceted TCC program's response to the COVID-19 pandemic as it supports the organization's Incident Command structure, which, in turn, aligns with the SCCM's pandemic preparation checklist.¹⁷ Several key lessons are being learned during this early phase of the pandemic (Table 3). The approach described did facilitate rapid capacity expansion with the aim to provide intensivist-led critical care coverage 24 h a day, 7 days a week to the system's hospitals and ICUs. Alternative strategies mainly involved repurposing noncritical care trained frontline ICU staff to function without intensivist oversight, perhaps leading to provider dissatisfaction or burnout,^18,19 or even potential adverse patient outcomes.^20,21 In addition, a nonvirtual-care-based strategy may also pose a higher risk of exposure by bringing more health care workers to the bedside, whereas virtual patient care solutions may increase staff safety.²² Notably, important aspects of larger integrated health care systems also applied that favored a virtual intensivist option: (1) the geographical distances and number of facilities limit the ability for rapid workforce deployment directly to a site as staff may not physically be able nor willing to travel physically across long distances; (2) staffing by the health care system's own virtual intensive care team (virtual care physician, nurse, pharmacist, and respiratory therapist) is perhaps more likely to adhere to existing clinical and operational standards as this team is already familiar with current practices, protocols, electronic health record, and site-specific capabilities; (3) the ability to regionalize advanced critical care support such as nonconventional mechanical ventilation modes, extracorporeal membrane oxygenation, and other complex needs may be partially eased by incorporating telemedicine.²³

Table 3.

Assessment of Telecritical Care-Specific Goals, Learned to Date During Pandemic

Goal 1: Augment capacity for VCC

VCC augmentation likely more cost-effective and rapid than structural facility changes

Initial home workstation technology acquisition investment required; further acquisition may be limited by supply-chain shortages of specific equipment (e.g., webcams)

Extensive support from technology department required for setup and maintenance

Team-based care and role changing can cause initial confusion, so practice and intense initial communication of newer team models with VCC are recommended

Just-in-time training is challenging for many providers to complete, variable in composition, and may not be relevant especially if TCC support is present

Goal 2: Minimize health care worker exposure while controlling PPE use

Providing virtual access nearby was helpful for consultants, but bedside teams often would simply opt to resort to bedside use in PPE if PPE available.

Assessment of donning/doffing compliance was technically challenging for VCC nurses as not always in camera view

Goal 3: Improve efficiencies in bedside management

Augmentation of critical care nursing, pharmacist, and respiratory therapy roles is well received across facilities

VCC help with clinical decision making, especially for respiratory failure management, is well received for sites particularly for those without 24-h-intensivist models

For patients in 24–7 intensivist-covered facilities, an extra onsite intensivist is favored over a VCC intensivist if manpower can be flexed

Moving ventilators and IV pumps outside the room limited the virtual intensivist's ability to assess patients

Bedside communication is hampered by PPE and visitor restrictions, and virtual intensivists were challenged in involving families particularly if language barrier exists.

Goal 4: Optimize ICU bed utilization

VCC can support Incident Command with real-time metrics of bed utilization

Teleintensivist quarterback triage position is most useful for interfacility transfer, triage assessment, and resource utilization; recommendations were best received by physicians with intimate knowledge of system resources and capabilities.

Support limited to only those hospitals in the system network, limiting geographical impact

TCC, telecritical care.

An important initial step involved rapid expansion of an available pool of teleintensivists. These providers come from within the system's existing clinician workforce that engenders trust²⁴ and assures familiarity with existing critical care resources, while also facilitating nimble redeployment of providers to areas of need within the system. Moreover, the expansion of home workstations limits the need to hire new VCC clinicians and ensures staff availability even when under quarantine or other stay-at-home restrictions. By having intensivists work remotely, this may also mitigate the risk of hospital-acquired COVID-19 transmission. If nonintensivists are pulled to manage critically ill patients during major surge periods, VCC teleintensivists can support in bedside critical care decision making. Layering teleintensivist support over nonintensivists may be better received than asking or even mandating nonintensivists to complete just-in-time critical care training. As such, the VCC intensivists can support clinical decision making across all ICUs, including advanced modes of mechanical ventilatory support when needed. The VCC “Quarterback” position also is proving useful for coordinating interfacility transfer requests and active triage to capable facilities during bed and staffing crises; notably initial feedback was that this was best received by those intensivists with more intimate knowledge of different ICU staffing and capabilities. In summary, by expanding the teleintensivist pool, several potential physician staffing issues may be minimized.

The participation of VCC nurses can offset clinical load from nurses working at the bedside under normal circumstances²⁵; their expanded role in pandemic situations can provide additional critical relief. The COVID-19 pandemic has exacerbated the pre-existing shortage of ICU nurses in the United States,^26,27 leading to higher patient-to-nurse ratios, or to less experienced nurses (such as non-ICU nurses flexed to ICUs), providing front-line care. Atrium Health's VCC nurses have, on average, 14 years of bedside ICU experience and are certified as critical care registered nurses. Their assistance during pandemic situations may enhance patient safety, the accuracy of documentation, and reduce the risk of bedside nurse burnout.^19,27 In addition, remote provision of PPE education may help preserve crucial PPE supplies, optimize PPE use, and increase overall safety for on-the-ground clinical staff. Lastly, the involvement of virtual care pharmacists and respiratory therapists was continued to augment support the virtual and on-site care teams.

This enormous augmentation of the health system's VCC resources requires substantial monetary investment; this is especially relevant considering that the program, like many others, is not directly revenue generating. The initial surge budget assumed one bed per patient and was estimated to be ∼140% of current ICU bed capacity, and 300% capacity for critical surge. At critical surge capacity, 130 mobile carts and 102 home workstations would be needed. The estimated costs of $173,106 for home workstations and $956,670 for the initial 130 mobile carts (Table 2) do not account for labor and other indirect expenses. Although these costs seem high, they are far less than building or restructuring hospital facilities; moreover, the process is clearly faster than building new hospitals or units. The system's clinical and administrative leadership has prioritized these investments as part of its pandemic preparation, but also for future planning for critical care and other services. Still, such scale and complexity may prove cost prohibitive for smaller health systems, and the response outlined may be feasible only for larger systems with more mature TCC programs. Importantly, global supply-chain shortages affected by the pandemic did affect our ability to also purchase additional equipment when needed, such as webcams, mobile carts, and other specialized equipment.

Despite the benefits of a robust TCC program in pandemic situations, there remain many uncertainties and potential limitations of this strategy. Many facilities used extension tubing to move ventilators and intravenous pumps to outside the patient's room; this helped to minimize bedside staffs' PPE usage but impaired the ability for VCC intensivists to assess the patient and intervene. Teleintensivists also cannot provide procedural assistance other than remote review of bedside ultrasonographic images.^28,29 Audiovisual experience with bedside staff using PPE is occasionally quite challenging, so communication with the bedside clinicians often would occur outside the patient rooms. Restrictions and limitations on patient and family visitation may further risk poor bedside communication. These factors limited the role of virtual intensivists to involve families, with several noting that when language barriers exist, the communication is limited even further. Given that COVID-19 may affect those with racial and ethnic disparities,²⁸ this may limit utility of VCC families with non-English speakers. Communication risks with other team members, role confusion, and potentially conflicting medical decision making between bedside and virtual providers can still occur. The leadership changes depicted in Figure 2, with the virtual intensivist depicted as team leader could be a significant adjustment for bedside teams, so practice or simulation is recommended if feasible. TCC is only as effective as its technology, so hardware and software issues resulting from internet service disruption or cybersecurity issues, for example, require rapid resolution. Furthermore, difficult end-of-life decision making, especially considering evolving discussions amid resource scarcity,³⁰ can be challenging for virtual intensivists and potentially reduce patient/family satisfaction. Administrative and financial barriers, including fiscal viability, information technology optimization, and credentialing of new providers, can create additional strain on health systems already taxed with high patient volumes, PPE shortages, and staff safety concerns.³¹ The full value of TCC in pandemic situations also may not be fully realized without regional coordination between geographically proximate health systems and institutions. Such intersystem connectivity is not feasible at present, although being investigated by the SCCM.

Despite these numerous challenges, the efforts undertaken position a large health care system's TCC program to fulfill a critical role not only in the acute phase of pandemic planning, but also in postpandemic clinical and research operations. As the COVID-19 pandemic enters a reopening phase with cautious resumption of previous health care operations, the level of virtual support can flex upward or downward as needed. Creative modeling is now being considered to improve efficiency and streamline the number of teammates needed at any given location to provide bedside care during periods of lower acuity and census. The infrastructure is also now in place for virtual clinical research capabilities across the health care system's critical care population, with several COVID-19 therapeutic trials relying on the virtual intensivist for screening and enrollment. The experiences from this COVID-19 response will surely spur new innovations as the “lessons learned” become clearer.

Still, many questions remain as to the impact of the VCC's role in the pandemic response. We aim to improve understanding of whether the outlined steps provide meaningful impact and identify those resources that are required to accomplish each goal outlined. We specifically aim to understand which of these virtual solutions may aid the various phases of the pandemic and which persist after the pandemic has resolved.

Conclusions

We describe strategic initiatives within an integrated health care system that permits TCC to become the nexus of critical care delivery and coordination during the COVID-19 pandemic, aiding the Incident Command in its execution of pandemic preparedness and ability to deliver care as the situation evolves. By emphasizing efficiency, safety, and quality, the health care system's TCC program evolved from a luxury to a necessity by complementing bedside clinical care while respecting the physical and psychological safety of front-line workers. The VCC model may serve as a resource to other systems looking to expand their telehealth programs. Further research is needed to address important questions related to this model's cost-effectiveness and impact on patient outcomes and operational goals. By addressing these questions, TCC programs can continue to advance the field through innovations in clinical care and clinical research. Such advancements are not restricted to pandemic situations, when traditional methods of care delivery are challenged, but may also affect the transition to the near future state. Our hope is the lessons learned may catalyze the quality, versatility, and value of our organization in the care of a complex critically ill population.

Footnotes

Acknowledgments

The authors thank Dr. Chris Russell and Ms. Sandy Arneson for editorial assistance, Jonathan Tedder and Marie Mercier for their clinical and operational leadership of VCC, and Alex Obert and the IAS team for their assistance with the operations. This study was performed at Atrium Health, Charlotte, NC, USA.

Disclosure Statement

J.S. receives consulting fees from Medtronic, Inc., and Somnoware Sleep Solutions. All other authors declare no conflicts of interest.

Funding Information

No funding was received for this article.

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