Staff is divided between in-house and off-site personnel, and medical and ancillary services (Table 80–2). The hospital staff available varies from facility to facility and the duties of the tele-intensivist depend on the staff available for that particular ICU.
Table 80–2In-house and off-site staff. ||Download (.pdf) Table 80–2In-house and off-site staff.
|In-house ||Off-Site Tele-Icu Command Center |
|Bedside RN ||Unit Clerk/Medical Secretary |
|Hospitalist ||Tele-RN |
|Respiratory therapist ||NP |
|Emergency Department physician ||Teleintensivist |
|Information technologies (IT) ||IT |
|Subspecialists, surgeons, and anesthesiologists may be called into hospital as needed || |
The ICU nurse is present at bedside and provides most of the hands-on care to the patient. The bedside RN is the key provider with whom the tele-ICU staff interacts; they discuss any medical events that arise, such as a change in status, or hemodynamic or respiratory issues, and the care plan is delivered per recommendations and orders given by the tele-ICU physician.
In the majority of hospitals with tele-ICU programs, there is an in-house hospitalist available 24 hours a day. The hospitalist is often responsible for the care of patients admitted to the medical floor, the ICU, as well as any new patients admitted through the ER. In some institutions, there are private internists who are responsible for new admissions and the care of admitted patients; these physicians may not be present on-site all the time. Some hospitals do not employ an on-site hospitalist or internist during the night hours.
The respiratory therapist helps manage invasive and noninvasive respiratory support. At some facilities, the respiratory therapist is also certified in performing intubations for invasive ventilation. In recent years, some hospitals have expanded the role of the respiratory staff to include critical care procedures such as the placement of central IV access, arterial access, peripherally inserted central catheters (PICC), and conducting focused bedside echocardiography.
In many of the hospitals, there is an emergency medicine physician whose primary responsibility is the emergency room, but the physician can be called to help out on the floors and the ICU for codes, intubations, or other procedures.
Surgeons and Anesthesiologists
Hospitals generally have an anesthesiologist and surgeon on-call. Aside from working in the OR, the anesthesiologist or surgeon can be called to help manage an airway problem or perform other invasive ICU procedures.
Specialists in other fields may be available for consultation; they generally round in the ICUs during the day and are on-call from home during the night. The types of specialists available vary from hospital to hospital; in some of the more rural facilities, there may not be access to specialists in certain fields of medicine.
Command Center/Tele-ICU Monitoring Site Staff
The off-site center may be located on the premises of one of the hospitals in the system or may be located off-site. The medical staff in these command centers has at their fingertips sophisticated EMR technologies, bedside ICU monitoring, PACS system for imaging, and audio-video access to the patient’s room (Figure 80–2). The tele-ICU has medical secretaries, critical care nurses, and critical care physicians. Some tele-ICUs also have acute care NPs. Each member of the medical and nonmedical staff should be oriented, before starting to work in the service, to their own respective roles and duties as well as the roles of the other staff to ensure a cohesive and efficiently run service.
Command center tele-ICU monitoring.
Unit Clerk/Medical Secretary
The unit clerk or secretary triages phone calls from different hospitals and helps the medical staff communicate with on-site personnel such as the beside nurses, hospitalists, ER physicians, and other on-call specialists. They also ensure that patient data are properly entered into the EMR. When necessary, they also help identify potential or current technical problems in software or hardware that arise with the network and communicate with the IT team.
The tele-ICU RN has several roles; the most important is to support the bedside RN with any medical concerns that arise. The tele-ICU RN is assigned patients to follow and monitors vital signs, hemodynamics and other tracings, laboratory values and other tests, and can also visually assess the patient using video cameras located in the patient’s room. The tele-ICU RN is in close communication with the bedside RN and proactively involves the tele-intensivist with any problems or concerns that arise.
Another tele-ICU RN role is to monitor standards of care and the application of best practices. For instance, the off-site RN can confirm glycemic monitoring and control, GI and DVT prophylaxis, sepsis and delirium alerts, and the VAP bundle. The team is alerted to ensure appropriate protocol-driven care, which can help the hospital meet standards of care developed by national and international medical societies such as the Society of Critical Care Medicine, the American College of Chest Physicians, the American Association of Critical Care Nurses, The Joint Commission (TJC, formerly known as JCAHO), and the World Federation of Societies of Intensive and Critical Care Medicine.
The tele-ICU nursing team also includes a clinical manager, or team leader. The clinical manager, together with the medical director, models the workflow and assigns the specific tasks for the tele-ICU nursing team.
The tele-intensivist is a board-certified or board-eligible CCM physician who is licensed in the state(s) where the hospital(s) is located. The responsibilities of the tele-intensivist are similar to that of the bedside ICU attending physician. The tele-intensivist is available to triage all matters of medical concern such as electrolyte replacement, pain management, sedation, ventilator management, titration of vasoactive agents, coordination and follow-up with consultants, as well as treat hemodynamic instability and respiratory distress. The tele-intensivist is in close communication with the bedside RN, respiratory therapist, and when applicable, the hospitalist or ER physician. Entering notes into the medical chart is a prudent form of communication and legal recording. Even minor details are recorded in a short note so the bedside staff will know the care provided by the tele-ICU staff.
Some of the larger or busier tele-ICUs also have acute care NPs, state licensed with specialty certification from the American Association of Critical Care Nurses. The NP, assigned to patients in a fashion similar to the off-site doctor, is responsible for patient care and is in constant communication with the CCM physician. The NP will generally take calls for laboratory orders, medication orders, and radiology requests. The NP may be asked to assist a physician who is attending to other patient care matters. A clear job definition for the NP should be outlined by the medical chief of staff together with the chief of service of each hospital system.
IT support is an important component of telemedicine, ensuring that all telecommunications lines, hardware, and software are working reliably and smoothly. IT staff should be available 24/7, in-house and off-site.