Chapter 8: Adult Emergency and Critical Care Telehealth

Emergency medical services (EMS) is called to a roadside motor vehicle collision. EMS personnel are wearing helmet and body cameras, with head-mounted microphones and earphones. EMS notifies the regional telemedicine center EMS/MD that a single passenger in the driver position, belted with front air-bag deployment but no side-window airbags, was “T-boned” from the driver side with about 18 inches intrusion on the driver door. EMS connects the patient to a cellular-enabled vital signs monitor with connectivity to the telemedicine center. The driver is hypotensive, unconscious, and with obvious deformity to the left femur. The EMS doesn’t hear breath sounds on the left chest, and neither does the telemedicine center EMS/MD. The telemedicine center EMS/MD recognizes the risk of tension pneumothorax, splenic rupture, lateral compression fracture of the pelvis, and possible traumatic brain injury. The EMS does a quick on-scene focused assessment with sonography for trauma (FAST) exam as the telemedicine center EMS/MD observes remotely but cannot see sliding pleural lines on the left. Additionally there is fluid in the left upper quadrant (LUQ). The remote physician confirms no sliding pleura and authorizes needle decompression of the left hemithorax and advises 1 liter crystalloids immediately if blood pressure (BP) is no better after needle decompression. The telemedicine center EMS/MD recognizes this patient will need a tertiary trauma center and advises a bypass of local facilities. While the EMS decompresses the left chest and establishes an IV, the telemedicine center contacts aeromedical services to dispatch a medevac helicopter to global positioning system (GPS) coordinates transmitted from the EMS vehicle on scene. Airway patency is a concern in this unconscious critical patient. The paramedic begins a rapid sequence intubation with video laryngoscope and has difficulty. The telemedicine center EMS/MD views remotely and advises on an epiglottis lift with the blade of the scope. Immediately, both the paramedic and telemedicine EMS/MD can see the cords and endotracheal tube inserted. On scene the EMS places the patient in a pelvic binder on a back board after a cervical collar is placed. The medevac helicopter arrives 15 minutes later. The helicopter remains “hot” with rotors turning while the EMS and flight paramedic load the patient. Audio/video connection switches over to the flight paramedic during loading in addition to a portable screen in the aircraft. The patient becomes hypotensive again, and another liter of saline is authorized by the EMS/MD, who also recommends insertion of a left chest tube. The flight paramedic inserts a 32 F chest tube—there is a large gush of air. The helicopter lands on the roof of the trauma center 21 minutes after the crash. The telemedicine center physician follows the patient to the trauma bay with a portable audio–video screen and meets the trauma MD, hands off the patient, and advises of decompressed tension pneumothorax, risk of splenic rupture (which may account for the hypotension), and LUQ fluid on FAST exam. At the telemedicine center, the EMS/MD hands off to the intensivist/MD. Plain films confirm a pelvic fracture, and the rapid FAST is repeated by trauma staff and found to be positive for hemoperitoneum. The patient is taken as a “priority 1” to the operating room (OR) for splenectomy. A portable computed tomography (CT) of the head while in the OR reveals an expanding epidural hematoma. Images are transmitted immediately to radiology and neurosurgery. The neurosurgeon performs craniectomy while the general trauma team does the splenectomy and stabilizes the pelvic fractures. The telemedicine center intensivist/MD is intermittently observing the surgery from OR overhead cameras. After completion, trauma workup, and time-sensitive surgical interventions, the patient goes to the intensive care unit (ICU) with tele-ICU technology. The telemedicine center intensivist/MD appears on the video screen above the bed in the ICU and performs a hand-off to the bedside physician staff (intensivists, surgeon, anesthesiologists, etc.) to include OR blood products, estimated blood loss, difficulties seen with surgery, etc.

From the scene to the final destination in the ICU, the events are documented accurately and annotated with images by the EMS/MD in an electronic format. The electronic document is forwarded to the receiving physician in the ICU, leaving only the documentation of the physical exam for the ICU MD.

• Technologies utilized

  1. 700 megahertz public safety bandwidth

  2. 700 megahertz deployable cellular systems

  3. GPS transmitted to the telemedicine center from the EMS vehicle

  4. Audio–video headsets and head/body cameras

  5. Broadband cellular

  6. Portable handheld ultrasonography visible to the telemedicine center

  7. Electronic stethoscope audible to the telemedicine center

  8. Portable vital signs monitor with broadband connectivity

  9. Portable 12-inch screen for audio–video in the aircraft

  10. Video laryngoscopy visible to the telemedicine center MD

  11. Overhead audio–video technology in the operative suite

  12. Teleradiology to radiologists

  13. Radiology cellular technology link to the neurosurgeon

  14. Tele-ICU technology

Although this scenario involved trauma, similar technology and process could apply to any nontraumatic unconscious patient, cardiac arrhythmias, etc.

This scenario provides the foundation for a proposed “Complete Emergency–Critical Care Telemedicine System.” Generally, the concept is to have qualified, real-time, audio–video physician oversight from the first moment medical care begins to intervene on a critically ill patient at the scene, in route to a medical facility, through the emergency resuscitation, the operative suite, and on to the landing zone in the ICU. This proposed scenario (Figure 8-1) would take advantage of the changing demographics of the physician workforce to include more physicians with combined training in emergency medicine and critical care medicine (CCM). The rest of this chapter provides a summary of which pieces of this future model exist and where the challenges lie that require more effort to make it happen.

Figure 8-1.

Connecting critical care services from the scene, through prehospital transport, through the emergency department, to the OR if necessary and on to the ICU. All connected with currently available technology.

Graphic Jump Location

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There is an extremely close relationship between the prehospital realm, the emergency department (ED), and critical care services. In most cases, the largest percentage of hospital admissions come from the ED. Typically, 20% of acute hospital admissions are to an ICU, but up to 58% of ED admissions result in an ICU admission. ¹ Often, critically ill patients are initially discovered “down”—unconscious—following cardiac arrest, blunt trauma, interpersonal violence, falls, entrapments, new intracerebral pathology, sepsis, respiratory failure, diabetic ketoacidosis, intoxication, or overdose. When a patient is discovered, he or she may not be breathing or protecting their airway, bleeding or hypotensive, and require immediate lifesaving interventions. Critical care begins at the scene with initial stabilization; airway maintenance; oxygenation/ventilation; attempts to establish return of spontaneous circulation (ROSC); early resuscitation with fluids or vasoactive agents; decompression of tension pneumothorax; stabilization of cervical, thoracic, and lumbar spine, etc. The onsite EMTs and paramedics are expected to process huge amounts of information quickly, “stabilize the scene,” make immediate lifesaving decisions and interventions, and participate in extraction efforts. Additionally, the on-scene care providers are gathering information as to mechanism of injury or illness and patient status in preparation for communication to the local medical facility.

The “information overload” ² can be paralyzing, or at least overwhelming, partly due to normal human “limited attention capacity” ³ and difficulty assuring the information is the “right type.” ⁴ Once moved from the scene, the patient spends time in transport. The mode of transport is essentially always compromised due to space constraints, noise, need to communicate with receiving facilities, limited personnel, and limited capabilities, with associated risk to the patient and personnel. ⁵ Patient care must continue in route and response to therapy noted and shared with awaiting staff at the ED. With quick sharing of information, care shifts to the ED staff for ongoing stabilization, often with a visit to the OR, and subsequent transfer to the ICU for completion of resuscitation and management of life support equipment.

The concept of a second set of eyes has been well described in the tele-ICU ⁶ and in the corporate sphere. ⁷ A remote provider, away from the noise and chaos of the scene, protected from information overload could substantially add to decision making, data gathering, and information sharing as a patient moves from scene to ED to OR and on to the ICU. The purpose of this chapter is to expand upon this continuum of critical care and review applications of telehealth in all these arenas.

There is increasing interest in the virtual presence of a high-level care provider “at the scene.” In the trauma dogma, the six places patients lose blood are the pleural space, the retroperitoneal, the peritoneum, the pelvis, large extremities, and “the street”. The trauma physician essentially never sees “the street” blood loss. Transmitting the images of a severe scalp wound with blood loss in situ could direct the trauma physician and avoid excessive searches for blood loss at the other sites. Injury prediction can be refined with direct visualization at the scene and patients directed to proper facilities initially. With recognition of injury risk, surgical interventions may be more rapid, leading to improved outcomes and a tightening of the “golden hour.”

In 2012, the U.S. Congress enacted the Middle Class Tax Relief and Job Recovery Act of 2012, forming the First Responder Network Authority ⁸ within the U.S. Department of Commerce. FirstNet is charged with responsibility for deploying and operating the nationwide public safety broadband network and holds the license for the public safety broadband spectrum (763 to 769 MHz/793 to 799 MHz), commonly known as the 700 MHz public safety spectrum (Figure 8-2).

The 700 MHz band is a 108 MHz-wide segment of the electromagnetic spectrum, from 698 to 806 MHz, available for both commercial wireless and public safety communications.

This segment of the spectrum became available with the transition away from analog television. Located just above the remaining TV broadcast channels, this 700 MHz signal will penetrate building walls and cover large geographic areas with relatively modest infrastructure required, providing ideal capability for EMS services. The National Institute on Standards and Technology ⁹ has promoted development of technology to accelerate the deployment of 700 megahertz FirstNet technology (Figure 8-3).

The National Public Safety Telecommunications Council ¹⁰ published the EMS Telemedicine Report. The report is a result of a nationwide questionnaire to EMS providers and directors, hospital ED and trauma center directors, and online EMS medical control physicians and summarized the following applications of telecommunications that seemed most relevant in the EMS environment:

• Real-time transmission of video and still images of the patients, scene environment (eg, crashed vehicle, home setting), specific injuries, and/or other physical assessments

• Bidirectional conferencing between field providers and patients with medical control or consulting staff

• Transmission of diagnostic still and video images (eg, ultrasound, eye/ear/nose/throat images, electronic stethoscope sounds, and multi–vital sign monitoring devices)

When selectively querying EMS medical control physicians, physicians judged that the most important elements included:

• Physician-assisted critical care at the scene (64%)

• Risk management/mitigation and patient refusal scenarios (60.5%)

• Improved decision support (57.3%)

In the following scenario-specific situations:

• 81.4% suggested use in severe injury/motor vehicle trauma

• 81% for physician-assisted assessment for stroke patients

• 79.5% for assistance with pediatric asthma patients

• 76.5% thought two-way audio–video would be helpful in managing mass casualty situations

• 65.1% thought it would help with diabetic patients who refuse care

On-Scene Documentation

To operationalize the video communications, the scene staff have the choice of body cameras, helmet cameras, combination devices, and vehicular cameras. ¹¹ This camera evidence is acquired in real time and can be transmitted and archived for clear documentation of what actually happened. ^12–14 Real-time video allows remote staff to observe and advise on the application of complex/unique technology such as the abdominal aortic junctional tourniquet for severe inguinal and pelvic hemorrhage, ¹⁵ aid in the interpretation of complex dysrhythmias, advanced cardiac life support (ACLS) direction, etc. The technology can include audio with the video and be supplemented by GPS positioning. ¹⁶

Vendors are solving the connectivity problems by developing technology that roams between carriers and communication technologies and developing “ruggedized” equipment for the scene incorporating real-time audio and video, which can be linked with SpO2 monitoring, electrocardiogram (ECG), noninvasive BP monitoring, electronic stethoscope, specialized cameras, and screening ultrasonography.

LifeBot technology can be carried to the scene, moved with the patient to the transport vehicle, and travel with the patient into the ED, allowing a virtual physician presence from the scene to the hospital (Figure 8-4).

There are concerns and challenges with real-time recordings that may slow or limit adoption in some jurisdictions. The pros and cons of video recordings include ¹⁷ :

Pros:

• Every patient interaction chronicled

• Speech patterns, statements, complaints, skin color, and environmental factors confirmed and considered by remote providers

• Treatments, techniques, and processes chronicled and used for reference and training

• False accusations refuted while mistreatment or misconduct is quickly addressed

• Care providers and patient accountability

Cons:

• Every patient interaction chronicled

• Existence of information begets the disclosure

• Patient privacy compromised

• Fear of disclosure could prevent patients from sharing sensitive medically essential facts

• Delayed unsupported judgment by reviewers and legal community

• Significant expense and logistic challenges

Of note, there have recently been decisions regarding Health Insurance Portability and Accountability Act (HIPAA) confidentiality of patient images, rendering it a punishable offense if identifiable images are posted on any form of public media. ¹⁸ The acquisition, transmission, viewing, and storage must meet the HIPAA requirements to protect both patient health information (PHI) and personal identification information.

In summary, there is EMS interest in enhanced, on-scene, high-level medical assistance; there is meaningful and functional bandwidth set aside for the EMS; there is government promotion of technology; the technology is available; and there is private-sector investment in developing it further. Other than technical issues with archiving, the negative concerns and objections are relatively small and manageable.

In an extensive review of telemedicine in the prehospital environment, Amadi-Obi et al. ¹⁹ screened 1,279 pertinent articles published between 1970 and 2014, excluding 1,240 from review and focusing on 39 articles. Twenty-five were related to stroke, nine to trauma, and five to myocardial infarction. Summarizing the 25 stroke articles, the application of the National Institute of Health Stroke Score (NIHSS) was as reliable when performed remotely via telemedicine as when done face to face, the number of consults with experts was greater, and the clinical outcomes were equivalent to rapid face-to-face encounters. Summarizing the trauma literature, where local expertise was lacking, teleradiology as part of the trauma diagnosis improved the diagnosis and decreased the rate of expensive transfers. Burn assessment was equally accurate remotely as when performed face to face. In particular, EMS staff paramedics were able to perform a FAST exam under the guidance of remote emergency medicine physicians and were able to identify key physical signs and better direct medical decision making. Finally regarding myocardial infarction, transfer time to a STEMI center (ST elevation myocardial infarction) for percutaneous coronary intervention (PCI) was shorter with an associated decrease in mortality when the emergency vehicle is equipped with 12-lead ECG telemedicine technology for the transmission of prehospital ECG data. Despite computer and/or paramedic interpretation of ECGs for STEMI being 92.6% sensitive and 85.4% specific, ²⁰ interventional cardiologists may still prefer to have the ECG transmitted directly for decisions to activate the interventional cardiac catheterization lab.

Delivery of critical care services and life-sustaining interventions are essential at the scene and must continue in route to the hospital. In general, the United States has adhered to a “swoop and scoop” philosophy, ²¹ also referred to as the “Anglo-American” model, where ambulances are staffed with EMTs and paramedics. By contrast, in the German-Franco model, the ambulance is staffed by physicians ^22,23 who provide advanced physician skills for stabilizing interventions on the scene. The World Health Association ²⁴ has maintained that prehospital care be:

• Simple, sustainable, practical, efficient, and flexible

• Integrated into a country's existing health care, public health, and transportation infrastructures where available

The meaning and magnitude of integration are undefined, but should include real-time audio–video integration with remote higher-level care providers. On the other hand, The Association of Critical Care Transport, ²⁵ while defining what a critical care transport is (eg, describing the characteristics of a patient needing critical care transport and staffing requirements), has been silent on the place, need, or requirements for a virtual physician presence.

Combining high-level technology with telemedicine, the University of Texas (UT) ²⁶ in consortium with the Cleveland Clinic has launched a mobile stroke unit (MSU): an ambulance equipped with small, relatively portable CT scanners. The telestroke literature indicates that the visual exam enhances accuracy for neurologic diagnosis and increases application of the NIHSS. When a stroke is suspected, a remote exam is performed, and physicians review the field-generated CT scan of the brain to determine if there is sufficient evidence to administer tissue plasminogen activator (tPA). Preliminary data from the MSUs suggest that patients get tPA about 40 minutes sooner than those receiving usual EMS transport and care once arriving at the ED. Brain tissue is particularly vulnerable to ischemia. Complete interruption of blood flow to the brain for only 5 minutes triggers the death of vulnerable neurons in several brain regions, whereas 20 to 40 minutes of ischemia is required for cardiac myocytes or kidney cell death. ²⁷

The concept and value of expediting efforts to reperfuse brain tissue related to a thrombotic stroke has been demonstrated multiple times. ^28–30 This MSU technology minimizes the brain loss associated with the time of transport. However, the technology is expensive. The Economic Cycle Research Institute (ECRI) estimates that the total fixed and continuing costs over 5 years for the University of Texas's unit will be $1.65 million. That includes a $375,000 mobile CT scanner, a $60,000 retrofit of the vehicle, $30,000 in telemedicine equipment, and other ongoing expenses related to training and certification of personnel and telemedicine network coverage. ³¹

Ongoing real-time management is possible with cellular-based communications during the transport with continuous physician management (Figure 8-5). The medical staff performing the transport management could be an ED physician, a specialist consultant, etc., but would be available to provide continuous care in route and a “hand-off” to the next physician receiving the patient with specific details of assessment, interventions, responses, and impressions.

EDs are under siege. There is a “perfect storm” of shrinking capacity, ever-increasing demand for services, and more Americans relying on EDs for their routine and acute care needs, including aging “Boomers” and people newly enrolled in Medicaid. The American College of Emergency Physicians (ACEP) published the national Emergency Medicine Report card, ³² giving a D+ overall, which is down from a C− 5 years earlier. In specific areas of patient access to care and access to subspecialists, the grade was essentially failing at D−. The general “lay-of-the-land” per the report is shown in Figure 8-6.

The ACEP report provides 11 general recommendations, including the recommendation to “continue to increase the use of systems, standards, and information technologies to track and enhance the quality and patient safety environment.” ³² This recommendation could be interpreted as support for the growth and expansion of telemedicine to, among other things, enhance access to subspecialists. The Emergency Telemedicine section of the ACEP was established almost 2 decades ago, in 1998, to bring together emergency medicine practitioners with an interest in telehealth. At that time, the ACEP produced The Telemedicine in Emergency Medicine Information Paper ³³ outlining status and capabilities to include collaborative patient management, “remote sensing” (ECG and digital radiographs), and decision-making tools accessible online. The section lost membership over time in the mid-2000s and was re-established in 2012. This revived section updated the information paper in the 2014 “primer” of Telemedicine for the Emergency Department ³⁴ and reviewed technology, clinical applications, billing codes, reimbursement, mobile apps, cost, security, and integration with existing electronic medical records.

In general, applications of telemedicine within the ED can be categorized into three models:

1. Use of telemedicine to enhance ED processes

2. Extend capabilities outside the local ED

3. Bring specialists or capabilities into the ED from the outside

The following is not meant to be an exhaustive review of all applications, but rather a review of several important concepts designed to provoke the interested reader to examine new applications.

Patient ED Flow

The University of California San Diego launched a pilot project to virtually bring in an ED physician for triage in the event of a major patient surge. The EDTITRATE study ³⁵ was designed to solve the problem of wasted overstaffing versus the delay of arrival of an on-call back-up physician. During times of patient surges, the back-up MD is called in virtually. The on-call back-up physician meets the patient via telemedicine technology, with the support of an on-site ED-RN, and examines the ear, nose, and throat; listens to lung and heart sounds; remotely reviews laboratory and radiographic data; and either triages to higher expedited care or prescribes care and discharges the patient. Currently, the study is not completed but suggests a creative solution for the surge problem.

Avoiding Unnecessary Transfers

Brennan et al. ³⁶ performed a comparative analysis of traditional face-to-face care with remote care to demonstrate that remote ED care can be performed from an urban to a rural ED without degradation of quality. In a unique cross-over fashion, they demonstrated equivalent quality of care, with similar 72-hour return rate, patient satisfaction, and a 10-minute shorter average ED length of stay with telemedicine. The implication is that urban ED overcrowding could be mitigated by telemedicine by reducing transfers from rural to urban settings.

A Houston-based effort called the Emergency Tele-health and Navigation project (ETHAN) ³⁷ connects emergency physicians with EMS providers who are on scene with the intent of avoiding needless transports to the ED. The process includes real-time communications among EMS, physicians, and the patient. When summoned to see a patient, if the EMS judges the issue not urgent, a video link is established with an ED physician, and an evaluation is performed by an ED physician using a tablet, with the EMS provider performing vital signs and physical assessment under the direction of the remote physician. Early results suggest that up to 40% of EMS transports in Houston did not require acute care, but rather needed referral to primary care for their chronic conditions. ³⁸ The ETHAN project was able to avoid unnecessary transport, ultimately reducing ED overcrowding and reducing wait times for those needing urgent care.

Extend Capabilities Outside the Local Emergency Department

The concept is to take advantage of the unique characteristics of EDs staffed 24/7/ 365 with physicians and advanced practitioners who possess a broad skill set (eg, general medicine, pediatrics, CCM, trauma, toxicology) and apply the specialty skills remotely outside of the specialty center or ED setting.

Emergency Department Consultations

Sophisticated or specialty centers can reach out to other less resource-rich institutions, extending the capabilities to the more remote ED. As far back as 1996, a Chinese university–based program established ED outreach to an offshore hospital in Taiwan. ³⁹ During a 12-month period, they performed 275 consultations, including 24 specialist/subspecialists spanning more than 100 different members of the medical staff with a very high satisfaction rating. This type of program has been operational at the University of Maryland Medical System since February 2017.

Trauma

Eastern Maine Medical Center ⁴⁰ Tele-Emergency Department and Trauma Services connects more than 12 hospital centers to the main trauma center. Receiving over 800 patients per year with 50% from rural community hospitals, the program is able to consult immediately, avoid unnecessary transfers, and begin therapy within minutes rather than waiting hours to arrive at distant specialty centers for interventions.

In 2006, the University of Arizona Medical Center joined with the Tucson Fire Department and Tucson Department of Transportation (DOT) to develop a citywide EMS telemedicine system built around the DOT's mesh broadband wireless network. ^41,42 At the hospital end there were workstations located in the ED and the “trauma room.” On the EMS vehicle, cameras were positioned both inside the ambulance and outside with a 360-degree pan capability with a 19-inch monitor for the patient or EMS personnel to see the remote trauma physician in real time. Although there were limitations to coverage and a full report was not published, the authors did describe remote assistance with endotracheal intubation when onsite providers used the video laryngoscope device Glidescope technology. ⁴³

Correctional System Health Care

This area suffers from complexity of movement, security risks with prisoner transport, and major public safety issues if a detainee were to become violent or attempt to escape. The ACEP has nicely outlined the issues of correctional care in the ED. ⁴⁴ As far back as 1997, telemedicine within the correctional system has been shown to be cost and medically effective while minimizing security risk of transport. ⁴⁵ ED telemedicine programs can serve as an immediate resource for prison-related trauma or general emergency medical services.

Remote Care

A variety of industries and individual adventure travelers require emergency medical support in remote and often austere environments. There are both commercial and university-based providers of on-demand emergency care via telemedicine to oil, gas, aviation, maritime, and remote research stations. Medical support services may be provided directly to patients and in other cases a remote EMT, paramedic, nurse, or physician providing care in consultation with the remote physician. With 24/7 staffing, the ED may be the optimal provider.

Mobile Integrated Health Care with Direct Audio-Visual Patient Contact

Evolution Healthcare in Dallas has implemented an audiovisual connection with EMS providers who go into the homes of at-risk patients and provide a patient–physician real-time, live audio–video interaction. ⁴⁶ The goal is to avoid EMS responses, ED visits, and medical inpatient admissions. The project has demonstrated a 19% decrease in ED visits per member per month (PMPM) costs, a 21% decrease in ED utilization, a 37% decrease in inpatient PMPM costs, and a 40% decrease in patient utilization (all reaching statistical significance) through this telemedicine-coordinated care program.

Bring Specialists or Capabilities into the Emergency Department from the Outside

“Tele-radiology is one of the oldest, most established, successful, and widely used clinical telemedicine specialties” ^47–49 “with on-call emergency reporting being used in over 70% of radiology practices in the US.” ⁵⁰ Teleradiology is of primary value to smaller hospitals with the inability to staff onsite radiologists. From the perspective of the ED physician, timeliness of reports is paramount. Distant radiologists must be available and work in real time to avoid delayed overreads that can be problematic once the patient has left the ED. ^51,52 Currently there are no data regarding the penetration of teleradiology into the ED, but it is presumed high in otherwise uncovered facilities.

Telecardiology

When considering the raw numbers of ECGs transmitted, next to teleradiology, telecardiology may be the second-most used remote technology to support ED physicians and patients. Telecardiology includes remote reading of ECGs, echocardiograms, pacemaker interrogation and monitoring, and review of angiograms. When looking at a prehospital review of electronically transmitted ECGs, there has been a shortened “door to balloon” time. ⁵³ There is little information regarding the development of telecardiology networks as is seen in telestroke networks. Nor has there been much emphasis on the visual examination of the cardiac patient. Certain European programs have evolved to cloud-based 12-lead ECG computing, making the information available to a cardiologist via a handheld device. ⁵⁴ The University of Maryland telemedicine program is currently providing remote support and management of congestive heart failure (CHF) patients with chronically implanted left ventricular assist devices (personal communication with program director).

Telestroke

It is recognized that tPA improves outcomes for nonhemorrhagic thrombotic stroke. The American Heart Association estimates that only 3% to 5% of patients eligible to receive tPA actually receive it. ⁵⁵ With the desire to share risk in the administration of tPA, the ED physician may seek a qualified and emergent neurologic opinion. Silva et al. ⁵⁶ in a Health Resources and Services Administration (HRSA)–supported national study was only able to identify 56 active telestroke programs in the United States as of 2012. Of the programs being interviewed, 100% provide ED consultations. All highlighted limitations or barriers to implementing or maintaining these programs, such as lack of reimbursement, need for state licensure, and lack of sustained funding. Therapeutically, telestroke programs can lead to use of tPA in greater than 50% of the eligible candidates, dramatically better than those without telestroke. ⁵⁷ Due to remote geographic sites, the shortage of neurologists, and the relative paucity of telestroke systems, stroke patients in rural areas are 10 times less likely to receive timely administration of tPA. ⁵⁸ Of note, the visual examination of the stroke patient was felt to be important and improved the accuracy of diagnosis.

Telepsychiatry

According to the World Health Organization and the American Hospital Association (AHA), ^59,60 neuropsychiatric illnesses are now the number-one cause of disability. As many as 40% of ED patients may have a mental illness, with mental illness being the fastest-growing component of emergency medical practice. ⁶¹ To confound the situation, the AHA has reported a growing shortage of psychiatrists and mental health care workers in general. The American Psychiatry Association believes that video-based telepsychiatry helps meet patients’ needs for convenient, affordable, and readily accessible mental health services, leading to improved outcomes. ⁶² In 2009, ED telepsychiatry was rare, with only three recognized programs. ⁶³ More recently in 2011, the ACEP ⁶⁴ reported results of a statewide telepsychiatry program managing ED psychiatric patients. Six thousand patients seen by telepsychiatry in the ED were compared to equal numbers of patients in nontelepsychiatry EDs. Admission rate was reduced 30% (from 12% to 8%), 30-day outpatient follow-up was increased 36%, and both Medicaid and private payors received smaller bills. By 2015, the South Carolina Department of Mental Health ⁶⁵ reported that daily telepsychiatry visits had increased from 8.7 to 14.7 during the period 2010 to 2015, and ED length of stay (LOS) had dropped from approximately 48 to 72 hours to 8.5 hours. In telepsychiatry programs, the visual evaluation of the mentally distressed or ill was generally felt to be significant.

Tele-ICU in the Emergency Department

Little is written about tele-ICU in the ED, perhaps because the ED is staffed with physicians trained in acute care and critical illness. There is an increasing interest among ED physicians to continue critical care until the patient actually leaves the ED. ⁶⁶ The growing concept is that the ED intensivists (EDIs) would staff an ED-ICU. This concept could simply provide an expansion of coverage of a larger resuscitation bay or more bays. A lexicon has developed surrounding the ED-ICU adopted from Weingar et al. ⁶⁶ :

• Emergency medicine critical care—subspecialty of emergency medicine focused on care of the critically ill in the ED

• EP intensivist—a physician who has completed a residency in emergency medicine and a fellowship in critical care.

• ED critical care—emergency medicine critical care practiced specifically in the ED

• ED-ICU—unit within an ED with the same or similar staffing, monitoring, and capability for therapies as an ICU

• RED-ICU—hybrid Resuscitation unit in the Emergency Department providing ICU care

If the concept of a second set of eyes is valid, then the application to the ED tele-ICU is logical and would be a mechanism to smooth transition from the ED to the ICU or to provide comprehensive intensive care in the ED in the event of a patient surge.

Telesupervision of Advance Practice Providers

Appropriate distribution for trained human resources in emergency care is a challenge across the United States, but especially in rural areas. Advanced practice providers (nurse practitioners [NPs] and physician assistants) help meet provider needs, but often require consultation with a supervisory physician. Since 2003, the University of Mississippi has been providing trained NPs working in rural EDs remote supervision and collaborative consultation via telemedicine. ⁶⁷ A decade later Summers et al. ⁶⁸ reported that the program had expanded to 19 rural hospital EDs, with each NP seeing approximately 200 patients per month. The parent program had conducted over 400,000 teleconsultations (about 40% of patient encounters). Of the patients seen by acute care practitioners, 57% were discharged from the ED and 21% were transferred to a higher level of care. General satisfaction was high, with 93% of patients comfortable or very comfortable with the telemedicine system, 98% could see and hear the remote physician well, 85% rated the combined NP with remote physician care as good or excellent, and 91% said they would return because of the telemedicine system.

The Society of American Gastroenterological and Endoscopic Surgeons ⁶⁹ has noted a multitude of applications for telemedicine, including surgical teleconferencing, teleproctoring (observing and teaching), telemonitoring, telemanagement, and telesurgery (Figure 8-7).

In fact, the first actual remote surgery was performed more than 14 years ago in 2002. ⁷⁰ In a similar era, despite a 14,000-km virtual round trip and a transmission delay of 155 ms Marescaux et al. ⁷¹ were able to successfully perform a remote cholecystectomy from New York with a patient in Strasbourg using robotic-assisted technology. With minimally invasive surgery, tele-OR management has extended into urological and other arenas. ⁷² In 2014, a newsletter was developed that is dedicated to telesurgery. ⁷³

Doarn and Latifi ⁷⁴ have conceptually connected telemedicine in trauma and the OR with telemedicine in the ED. With readily available technology, some utilizing open-architecture technology, it is easy to imagine a remote physician observing or just taking “hand-off” from a critically ill patient as they move through the operative suite heading to the ICU. However, at this time, utilization of the technology has not been described. A thorough review of the technology has been provided by Whitten and Mair. ⁷⁵

Intensivist Manpower Issues

According to the AHA's 2014 annual survey, ⁷⁶ the United States has 5,686 hospitals. Essentially all acute care hospitals have at least one ICU with nearly 55,000 critically ill patients cared for each day. From 2006 to 2010, the number of critical care beds in the United States increased 15%, from 67,579 to 77,809. ^77,78

In the late 1990s, the initial primary driving force for the development of the tele-ICU was the shortage of intensivists ^79–83 confounded by a maldistribution of the workforce. ⁸⁴ Recently, the American Association of Medical Colleges (AAMC) posted the 2016 update ⁸⁵ regarding predicted physician supply and demand. Although not focused on CCM, the estimated shortfall of physicians by 2025 is predicted to range from 61,700 to 98,700 and could be as high as 125,200 under worst-case scenarios. From 2016 to 2025, 41% of the population will be older than 65 years of age, the population known to be the greatest consumers of health care services. Reports in the early 2000s suggested a manpower undersupply of critical care physicians of +/−30,000. However, a new trend has evolved with more graduating medical students choosing EM residencies, and many doing an additional critical care fellowship. Data from the National Residency Matching Program (NRMP) ⁸⁶ indicate that from 2000 to 2015 there has been a near doubling of the EM residencies offered, from 971 to 1,821. With a near 100% match rate, this predicts a near doubling of EM physicians entering the marketplace.

In 2009, the American Board of Internal Medicine (ABIM) and the American Board of Emergency Medicine (ABEM) established a pathway for EM physicians to gain board certification in CCM and emergency medicine. ⁸⁷ The pathway has subsequently been approved by the American Board of Medical Specialties (ABMS) in 2011. Currently, at least 20 US programs train combined EM and CCM. ^88,89 However, it is not clear if this adds to the total number of trained intensivists, as EM-trained residents may just fill positions previously taken by internal medicine–trained residents. Additionally, as reported by the NRMP, the number of pulmonologists seeking combined pulmonary-CCM training has risen 17% a year from 118 to 135. Additional critical care board certification pathways for EM-trained physicians include surgical critical care (boards from the American Board of Surgery [ABS]), neurology critical care (certified by the United Council of Neurologic Subspecialties), and an anesthesia pathway (American Board of Anesthesia [ABA]).

In summary, pathways to achieve CCM certification now include ⁹⁰ :

The Critical Care Societies Collaborative, a joint effort between the American Association of Colleges of Nursing (AACN), American College of Chest Physicians (CHEST), American Thoracic Society (ATS), and the Society of Critical Care Medicine (SCCM), was established in 1995 to work on common issues in the critical care workforce. A history of the efforts through 2007 to optimize and enhance the critical care workforce is nicely reviewed at http://ccsconline.org/workforce. ⁸⁴

In addition to the early manpower shortage, a variety of quality issues further pushed the advancement of telemedicine in the ICU to include growing evidence of value of intensivists, ^91–94 a recognition of the value of structured care to mitigate unwarranted variability, ^95–102 an early burst of enthusiastic reports on the tele-ICU, ^103–113 and finally, hospital corporate pressure to comply with the so-called Leapfrog Guidelines. ¹¹⁴ However, despite numerous efforts to demonstrate a positive return on investment (ROI), growth of telemedicine in the ICU has plateaued at approximately 12% of all ICU beds in the United States (when considering Philips-Visicu and all other technologies).

As of fall 2012, there were 54 civilian and government tele‐ICU monitoring centers in the United States. These monitoring centers were owned and operated by academic medical centers, regional hospitals, certain health plans, the Veterans’ Health Administration (VHA), and commercial firms. Most (nearly 90%) of the technologies used by these monitoring centers are virtually identical and designed by a single leading vendor, and to a large extent tele‐ICU practice patterns have also been single-vendor driven across users.

The homogeneity of the technology stems from litigation launched by Visicu apparently intended to control the growth of competition in the early 2000s. ¹¹⁵ As a result, there was essentially no growth in competition, allowing Visicu to take a dominant hold of the market. Ultimately, the patent infringement case was dismissed in 2010, ¹¹⁶ but leaving Philips/Visicu with the lead market share. Because of this, most studies of the structured tele-ICU care delivery model employ Philips-Visicu technology. The Sentara Health system was the first to install the Philips-Visicu technology and is the longest-running Philips-Visicu program, currently covering 108 beds. ¹¹⁷ At the project's 10-year point (2010), approximately 1,000,000 patients had been under their tele-ICU management process. ¹¹⁸

For a detailed comparative discussion of tele-ICU characteristics, see Refs 119–121. The following definitions have been extracted from those references. Note, the definitions imply absolute purity of definition; certain programs may use a hybrid design and not fit into such strict definitions.

Centralized Tele-ICU vs. Decentralized

Centralized Tele-ICU

The “hub-and-spoke” model is one with the medical staff stationed at the hub and providing tele-critical care to a variety of “spoke” hospitals. The hub (or center) is an established “brick-and-mortar” site staffed with combinations of intensivists, nurses, and clerical and technical staff. The hub is connected to one or more medical facilities or one or more ICUs. Staff are physically located in this single facility for a defined number of hours per day. Centralized programs include a discrete site and generally a structured process. The Philips-Visicu model is a centralized program that employs a “continuous,” proactive care delivery model that is facilitated by integrated software and is intended to interface with local electronic health records (EHRs), including visualization of the patient remotely and essential laboratory and radiographic information.

Decentralized Tele-ICU

There is no defined or established central monitoring facility. The decentralized model typically involves computers, tablets, smart phones equipped with camera, speakers, and microphones located at sites of convenience for the physician, such as medical offices, homes, or clipped to a belt. The decentralized tele-ICU is not a specific site, but rather a process focused on convenience and flexibility for the care provider whether he or she is the intensivist or a consulting physician.

Communications Technology

Open Architecture

This involves a communications system without dedicated individual transmission lines that supports connectivity from one or many remote sites to one or many originating sites. Open architecture generally implies connectivity via the Internet, permitting a care provider to virtually visit patients from essentially anywhere. When the software includes conferencing capabilities, multiple remote care providers can virtually visit the same patient remotely for simultaneous consultations. There is inherent redundancy in the Internet negating the need for alternative lines but increasing the challenge of assuring system security.

Closed Architecture

This generally has dedicated, point-to-point, hardwired communication lines from the care provider to the patient area—typically a high-speed T1 or T3 line from a hub to a spoke. A single hard wire can be vulnerable to failure, mandating a second alternative pathway for data transmission. Medical care providers outside the system typically are not able to perform virtual evaluations. The dedicated lines exist outside the Internet, although data may be transmitted using Internet Protocol (IP). Presumably, the closed architecture has greater data security.

Care Service Model

Continuous Monitoring and Management

This implies 24/7 real-time monitoring and reactive and pre-emptive management, but some programs may only apply continuous monitoring 12 hours per day. During the “live” hours, the nurse virtually roams from patient to patient, reviewing their status, while the physician focuses on active or unstable patients.

Scheduled Intermittent

Physician staff schedules a particular time to perform routine rounds, such as 6 hours after the daytime intensivist has left. Alternatively, for programs without onsite intensivists, the remote intensivist can perform routine rounds for part of or the entire ICU.

Reactive

In this case the physician responds to a communication requesting support with a certain patient, performing an admission evaluation or a consultation.

An extensive review of the tele-ICU experience from 2004 through 2013 has been completed by Coustasse et al. ¹²² and included more than 35 studies. Summarizing the reviews:

• Sixteen studies demonstrated shortened LOS

• Eleven studies showed greater adherence to “best practices” protocols

• Seven studies indicated improved financial performance

• Four studies found greater teamwork

• Five studies described improved patient care without further specification

None of the studies suggested negative impact or worsened outcomes. Because most of these studies were published during the 10 years of tele-ICU litigation, they generally use the Philips/Visicu technology and similar care delivery models. ¹⁰⁶ Twenty-two of these studies were pre-post studies, nine literature reviews or meta-analysis, and four surveys. In no case was there a parallel comparative study of different models of the tele-ICU nor a head-to-head study of in-house 24/7 intensivists compared to the tele-ICU (Table 8-1).

Most studies used a before-and-after study design and are subject to numerous biases, including unmeasured changes in case mix, temporal trends, coincident interventions, and random variation. ¹²³ Additionally, ICU telemedicine often introduces multiple interventions at the same time, including audiovisual surveillance, staffing changes, decision-support tools, and new electronic medical records. Ultimately, the conclusions of these studies have been questioned. Khan et al. ¹²⁴ have suggested, in their 2011 “Research Agenda for ICU Telemedicine” that research should have a:

• Standardized approach to assessing the preimplementation ICU environment, including patients, hospital, ICU, community characteristics, and organizational context

• Standardized lexicon for defining the telemedicine intervention and develop a common language defining characteristics, processes, and intentions

This research agenda has proposed a specific framework for assessing telemedicine to include clinical outcomes, technical acceptability, health system interface, costs and benefits, patient/provider acceptability, and access. The research agenda includes a lists of unknowns or knowledge gaps. Khan et al. suggest that the first knowledge gap is: “What is the optimal telemedicine model for different clinical settings?”

To the point of needing better studies and improved quality of care, the New England HealthCare Institute (NEHI) ¹²⁵ developed the following recommendations for best practices (annotations by the authors in parentheses):

1. Collect 6 months of preimplementation data prior to going live with any tele-ICU program. Consider appointing a clinical manager 6 to 8 months prior to implementation (better pre/post implementation studies).

2. Extend tele-ICU coverage to institutions outside the parent or “home” organization, offsetting staffing and operational costs and establishing referral patterns (improve the ROI).

3. Rotate clinicians from the bedside to the tele-ICU environment: “human glue” to hold together the bedside clinicians with the remote tele-ICU monitoring site, both nursing and MD, and preferably rotate at clinical sites that have the remote monitoring technology (maintain connection to both the clinical side and remote side).

4. Extend coverage to the small and rural hospitals to include critical access hospitals. Essentially, all rural and critical access hospitals suffer from intensivists shortages. As per NEHI. less than 50% of the 54 tele-ICU programs connect to rural sites (greater chance to demonstrate greater impact).

5. Extend tele-ICU coverage outside of the ICU via carts and wireless devices. Most frequent uses include ED-telemonitored bed providing early remote management and monitoring of critically ill patients while awaiting transfer to the ICU and for assistance with Rapid Response Team (RRT) (greater value to the parent institution).

6. Make a business of renting services to other facilities. The advanced ICU model includes the following services (improve ROI):

   • Reviewing each ICU admission for appropriateness for ICU care, treatment protocol, and planned discharge

   • MD intensivist rounding on each patient every 12 hours

   • Nurse intensivist rounding on each patient every 12 hours

   • Preparation and review of ICU discharge documents

From the perspective of a tele-ICU user and operator, and from the perspective of a clinician at the bedside, there are some low-level, moment-to-moment elements that add to the frustration, as outlined by Lyden ¹²⁶ :

• Slow/multiple-click log-ins

• Short, security-driven, “on-time” requiring repetitive log-ins

• Frequent rebooting

• Different passwords and usernames for each facility Picture Archiving and Communications System (PACS) systems, computerized physician order entry (CPOE), or legacy systems

• Lack of familiarity with different icons in multiple PACS

• PACS with greater or lesser capability

• Incompatibility or incomplete data exchange and importation between the hospital legacy systems and the proprietary emergency medical record (EMR) of the tele-ICU system

• Laborious transition between the hospital CPOE systems and the tele-ICU technology

• Rigid hunt-and-click systems for creating diagnosis and medical plans embedded in the tele-ICU EMR

• Unintuitive hunt-and-click diagnostic systems embedded in the tele-ICU EMR

The biggest ongoing cost after the initial setup is physician, midlevel, and nursing clinician salaries and benefits. Initial setup costs for a typical complete Philips-Visicu tele-ICU have ranged from $1 million to more than $7 million. ^110,122 However, after the one-time setup, ongoing operational costs vary depending on the hours of coverage/support, but may range up to $2.2 million per year. Under the Philips/Visicu model, the yearly cost per bed charged to the facility ranges from $37,500 to $40,000. Under these models, the financial burden is carried by the medical facility receiving the tele-ICU services. The degree of charging fee for service is unknown but believed to be low.

In the past, there has been no Medicare fee-for-service billing for critical care services rendered via telemedicine. ¹²⁷ However, under pressure from the American Telemedicine Association (ATA), the Centers for Medicare and Medicaid Services (CMS) has proposed several changes in the codes to include a temporary code for critical care telemedicine services ^128–130

CMS did not propose adding critical care evaluation and management (E&M) codes. However, it recognized the potential benefit of critical care telemedicine and has now proposed creating temporary codes GTTT1 and GTTT2. The services would be limited to once per day, per patient, and would be valued relative to existing E&M services. The physician providing tele-ICU care will also have to define the point of service (POS)—the site where the patient is located, not where the provider is located.

Regarding billing commercial payors and Medicaid, the reader is referred to the State Telemedicine Gaps Analysis: Coverage and Reimbursement by Thomas and Capistrant. ¹³¹ In this document, the ATA has graded reimbursement by commercial and state Medicaid on a scale of A to F based upon state legislation. It should be noted that wording of legislation and functional outcomes after legislation is passed may vary widely. Maryland was given an “A” initially based on apparently good Medicaid legislation. However, the rating was downgraded to a “C” when it became apparent that Maryland state regulators were eager to limit the growth of telemedicine reimbursement. Additional information can be found in the SCCM publication Coding and Billing for Critical Care: A Practice Tool, sixth edition. ¹²⁷

• The sources of manpower and supply are changing significantly and could have a long-term impact upon the basic shortage premise driving tele-ICU. The Critical Care Societies Collaborative workforce must continue real efforts and include ACEP, as well as those representing surgery, anesthesia, and neurocritical care, as sources of critical care manpower. It is time to get beyond the limited four-society group.

• New innovative models need to be created and tested with a focus on the economics, particularly with different staffing models.

• Real scientific studies are needed, perhaps including the guidance from Kahn et al. and the NEHI.

• The tele-ICU providers need to look for expanded opportunities to provide greater ROI.

• Perhaps the tele-ICU model needs to expand widely in the spectrum of critical care as discussed earlier in the beginning of the chapter.

• The tele-ICU model should evolve away from proprietary EMRs that are limited to the ICU stay.