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Research Highlight

Update on VHA TeleICU

Multiple studies have demonstrated mortality reduction in intensive care units (ICUs) that implemented evidence-based practices, improved ICU organization and teamwork, and used a high intensity critical care physician model. The Veterans Health Administration (VHA), responding to this evidence base, developed a system to track ICU performance and implemented national initiatives to reduce hospital-acquired infections. Although intensivists provided primary ICU care in more than 44 percent of VA ICUs compared to 24 percent in the private sector, 71 percent (135/188) of VA ICUs in 2007 experienced difficulty in recruiting intensive care physicians like the private sector. Demand for intensivists continues to be greater than supply in the United States, driving compensation for critical care services upward. A variety of strategies can manage the shortage of intensivists, including use of mid-level providers, regionalization, and contracting for tele-intensive care services (TeleICU).

VISN Implementation of TeleICU Models

Interest in improving ICU outcomes as well as increasing access to intensivist care in VHA led leaders in VISNs 10, 19, and 23 to pilot models of TeleICU that ranged from systematic utilization of existing VHA information technology (IT) (V19), to adoption of advanced commercial TeleICU systems (V10, V23). These systems include real time visualization, communication, and integrative software with advanced algorithms to alert clinicians about changes in patient status. In the VISN 19 system, expert nurses review patient status and new admissions in each VISN ICU, consult where needed, and facilitate access to services, procedures, and expertise. In VISNs 10 and 23, expert nurses monitor 25 to 35 patients 24/7, while physicians may follow as many as 100 patients in the TeleICU monitoring center. Physicians, nurse clinicians, and informatics experts lead VISN implementation of these programs. VA Tele- Health Services facilitated learning and planning across the pilots through a variety of means, creating a national TeleICU workgroup, developing an implementation checklist, and funding leadership and coordinator positions. Implementation of the pilots across hospitals within each VISN took place sequentially to allow for the development of workflow analysis, training, and communication systems.

Most of the TeleICU programs described in the literature involve either a single large hospital or hospitals in the same community. The VISNs' innovative regional approaches to TeleICU implementation add some complexity compared to programs in single hospitals. The qualitative evaluation of VISN 23's TeleICU implementation highlights the socio-cultural elements that contribute to staff acceptance, including training, local coordination, needs assessment, interpersonal relationships (particularly development of trust), and system design. ¹

TeleICU Best Practices

The importance of a strong relationship between the physical ICU staff and the TeleICU staff can be inferred from a study of more than 118,000 patients in 56 ICUs across 32 hospitals and 19 health care systems that identified four best practices associated with improved outcomes in TeleICU: (1) intensivist case review within one hour of admission; (2) timely use of performance data; (3) adherence to ICU best practices; and (4) faster alert response times. ² Creating the tools and relationships important in user acceptance requires development, testing, and revision to manage needs of multiple ICU cultures and staffing scenarios and, most of all, time. In a study that reviewed the logs of TeleICU nurses, Anders described an increase in interaction initiated by the unit nurse caring for the patient and in coordinating activities by the TeleICU nurse over two years.³ Studies of other technologies also describe such a shift—where changes in attitudes and beliefs over time can translate to increased use of the technology. Valid and reliable analyses regarding the impact of TeleICU on VHA ICU outcomes will need to span multiple years.

Funded by the Networks, ICUs in VISNs 7 and 15 will be added to the TeleICU system in VISNs 10 and 23 respectively; and VISN 21 is adopting the VISN 19 approach, resulting in TeleICU support of 24 percent of VHA ICU beds. Work by the national TeleICU Workgroup and the TeleHealth Service facilitates a system-wide approach where appropriate. Once established, the Networks will need to analyze their utilization of the best TeleICU practices described above to achieve the full promise of TeleICU.

References

1. Moeckli, J. et al. "Staff Acceptance of a Telemedicine Intensive Care Unit Program: a Qualitative Study," Journal of Critical Care 2013; 28(6):890-901.
2. Lilly, C.M. et al. "A Multicenter Study of ICU Telemedicine Reengineering of Adult Critical Care," Chest 2014; 145(3):500-7.
3. Anders, S.H. et al. "The Effects of Health Information Technology Change Over Time: a Study of Tele-ICU Functions," Applied Clinical Informatics 2012; 3(2):239-47.