In this post we interview Dr.Rachel Sackrowitz about Tele-ICU. Dr.Sackrowitz is a practicing intensivist with experience in hospital administration. She joined Advanced ICU Care in early 2016 and is responsible for clinical staff and for the ongoing improvement of clinical effectiveness and efficiency of the company’s services. Dr. Sackrowitz is board-certified in internal, pulmonary and critical care medicine.

Where do you see the ICU care in the US in the coming 5-years?

The many factors that make top-of-the-line care in the ICU more challenging also serve as drivers of innovation, and it is likely that advances will come to fruition in the next 5 years. Approximately 15% of hospital intensive care units are already using technology to link intensivist physicians and ICU patients hundreds, or even thousands, of miles away. This means hospitals and their patients have constant access to a level of care they have not had previously. We are also using algorithms to evaluate patient data and automate workflows to ensure earlier identification of patients at risk for complications such as sepsis, or to more quickly highlight those that are ready to be taken off a ventilator. In the next 5 years, these tools are only going to become more sophisticated and predictive in nature. The proactive care made possible by the use of these algorithms significantly addresses the pressures we are seeing and influences reductions in mortality and length of stay – enabling more people to celebrate more anniversaries and more birthdays.

I anticipate that more hospitals will look to technology to help bridge the gap between their resources and the level of care they should, and need to, provide. The use of tele-ICU has expanded dramatically and we can expect a continued rapid pace of adoption. Health systems can choose to develop their own tele-ICU to extend internal resources from their flagship to satellite hospitals, or they can partner with a clinical service provider such as Advanced ICU Care, who has technological and clinical infrastructure as well as extensive experience. Developments in technology will advance the uninterrupted integration between disparate systems. Our team crafts the interfaces between our platform and the various independent systems of our client hospitals so that we can seamlessly share data in real-time. We also developed our own proprietary systems that aggregate information such that it is easily accessible and ready to use. Technological advancements will allow us to share and analyze even larger volumes of data and transform critical information for remote practitioners in an increasingly streamlined and actionable manner, greatly enhancing and easing care coordination.

To further promote proactive care, hospitals will increasingly look outside the ICU to identify at-risk patients and intervene before further deterioration occurs. This concept of an ‘ICU without walls’ brings critical care to patients wherever they may be in the hospital, rather than waiting to react until they finally reach the ICU. Hospitals will look to extend and leverage the technology and access to intensivists inherent in their tele-ICU to provide critical care that is indifferent to patient location.

Healthcare reform is already shifting our focus towards the quality of patient care. Quality and cost often go hand in hand, with less than optimal care leading to costly complications. However, there are typically little data available to help the ICU team accurately measure and improve their performance. In the next 5 years, there will be a heightened focus on deriving performance analytics and then using that information to create or adjust workflows that are structured according to evidence-based best-practices. Tele-ICUs are ahead of the curve on this endeavor as they are inherently data-driven, collecting and analyzing terabytes of data. With this analysis in hand, we are able to help our partners identify crucial areas of focus. For example, at one hospital we may need to zero in on insulin protocols to better control blood sugar, while at another facility, we may need to work on the volume with which we ventilate patients.

What are the challenges facing the ICU units?

The very core of the challenge ICU teams face is that they must learn how to do more with fewer resources. The population that is 65+ is expected to double as baby boomers grow older and life expectancy increases. This population is also being successfully treated for increasingly serious and complex conditions. This results in a larger older population which requires advanced therapies and critical care support. However, the number of doctors becoming intensivists, or specifically trained in critical care, has leveled off. Additionally, this stagnant supply of intensivists, alongside their critical care nurse colleagues, suffer from high rates of professional burnout.

Simultaneously, healthcare reform is compelling hospitals to improve quality in what is essentially a cost-cutting reality. In ICUs, where the acuity of illness and the cost of care are highest, ICUs are under pressure to quickly and efficiently recalibrate how care is provided and become more outcomes-centric.

What is tele-ICU?

Most simply, tele-ICU is critical care provided remotely through the use of technology. Intensivist-led care teams of critical care advanced practitioners and registered nurses providing service from remote operations centers are connected in real-time to the bedside by a constant flow of patient data and two-way video conferencing technology. The tele-teams have access to the same information that they would use at the bedside – including EMR records, pharmacy and lab data, and physiologic monitoring. Tele-ICUs have ‘eyes’ and ‘ears,’ but still need the ‘hands’ of the bedside team.

Together, the tele-ICU and bedside teams collaborate to deliver excellent patient care and improve patient outcomes.

Can tele-ICU improve ICU care? How would that be? 

Tele-ICUs work collaboratively with the bedside team to improve ICU care. Our data reflect this. In 2015 alone, Advanced ICU Care contributed to saving over 1,400 lives and reducing mortality by 34% compared to what was predicted. Analytics attached to the data flow, when paired with intensivist oversight, allow for comprehensive care that is proactive in nature. One example of this is the use of multi-parameter sepsis alerts that simultaneously take into account multiple pieces of data rather than flagging when a singular measure reaches a predetermined limit. These types of alerts preemptively notify the tele-ICU team when a patient may be developing severe sepsis. The sooner an issue is identified, the sooner the care team can intervene and prevent a downward turn in the patient’s condition. The care prompted by these ‘smart alerts’ both saves lives and lessens the time patients stay in the ICU. These alerts also serve to prevent alarm fatigue, a common challenge among nurses and doctors who work in the ICU environment.

Concurrently, data-centric patient care provides valuable insight into ICU performance. We can see comparisons of what has happened against what was otherwise predicted. Subsequently, we are able to drill down to granular levels including, for example, evaluating who received blood transfusions when they were not necessarily required. The results for each hospital can then be benchmarked against system or national results. This enables the creation and ongoing adjustment of collaborative workflows to ensure that the care provided aligns with clinical best-practices.

Working in the pressure-filled environment of the ICU can be isolating when the appropriate support is not immediately available. Tele-ICUs serve as an exceptional resource. When a bedside physician is with another patient and a nurse needs to discuss an urgent situation, he or she can readily consult a tele-ICU partner. Due to the national diversity of the patient population they treat, tele-ICU practitioners often have greater exposure to a wide variety of challenging cases and can offer unique, experience-based perspectives. A bedside intensivist can go home and rest assured that their patients are well cared for even when the intensivist is unable to be physically present.

What types of healthcare organizations benefit most from tele-ICU products and services?

The rather rapid evolution of tele-ICU has proven that most ICUs can benefit from a tele-ICU presence. Originally, hospitals in more rural locations were the early adopters of tele-ICU because they were not able to provide intensivist coverage due to recruitment and retention challenges. These rural hospitals could not find a way to physically bring intensivists to the bedside so they did it virtually.

As the landscape has evolved, hospitals that have varying levels of intensivist staffing also find a tele-ICU relationship beneficial. Tele-ICUs can help hospitals to meet the Leapfrog standard of 24/7 intensivist coverage. Furthermore, tele-ICUs provide additional, experienced manpower that not only ease staffing constraints and allow bedside intensivists a better work/life balance, but they are also true partners in the joint effort to provide evidence-based care.

An additional tele-ICU model has also emerged. Some larger systems have sufficient intensivist staffing, but want to deploy their practitioner resources over multiple locations but find themselves ill-prepared to set up their own tele-ICU hub. What these systems do best is provide care, not supply and manage the infrastructure necessary for optimal tele-ICU operations. In these cases, they have found partnering with a tele-ICU service provider who wires and manages the systems’ underlying technology enables the best of both worlds.

What do you recommend to hospitals and health systems interested in a tele-ICU partnership to consider?

While perhaps an oversimplification, due diligence is a must when investigating a tele-ICU partnership. Much like the identification and selection of other strategic partners, a hospital or system must perform a comprehensive review of the service provider’s experience, capabilities and alignment with internal hospital priorities. Criteria to investigate include the number of facilities with which they work, the quality and timeliness of implementations, the partner resources available to support the ongoing relationship between the bedside and tele–ICU teams, a strong and growing tele-ICU clinical team, and the availability of strong references.

Since tele-ICU is the marriage of technology and clinical services, a potential partner should offer extensive and sustainable capabilities in these areas. A distinguished and experienced team of critical care-trained and certified clinicians is at the forefront of the service. Robust infrastructure and technical support serve as the imperative backbone.

Possibly most importantly, they must ensure that the tele-ICU partner is experienced in delivering service to a similar client. While a hospital may run its own tele-ICU proficiently, that does not mean it can successfully offer service to a partner, as the challenge involves adapting to different practices, workflows, reporting requirements, and staffing approaches, among other things.

Additionally, an often overlooked aspect of a strategic partnership is that the service provider is the ‘right fit’ for the hospital/system. Tele-ICU is truly collaborative and, in an environment where the stakes are high, a dysfunctional relationship can severely limit a productive partnership. The joint teams must collaboratively establish goals, measurements of success, and how to achieve those benchmarks – together. When identifying and selecting a tele-ICU partner, ensure they can customize the service to marry the hospital/system’s internal processes and strengths with the tele-ICU provider’s expertise. Otherwise, the ‘partnership’ will resemble trying to fit a square peg in a round hole.

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Dr. Sackrowitz is a practicing intensivist with experience in hospital administration. She joined Advanced ICU Care in early 2016 and is responsible for clinical staff and for the ongoing improvement of clinical effectiveness and efficiency of the company’s services. Dr. Sackrowitz is board-certified in internal, pulmonary and critical care medicine.

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