Authors: Halima Kangau & Habib Raj (Arcada UAS)
WHO (2018) defines eHealth as “the use of information and communication technologies (ICT) for health. eHealth technology has opened ways in which information should be shared, received and used by the whole healthcare system hospital team in general. It is said that eHealth is one of the fastest growing solutions in the future of healthcare. Goran (2010a) defines Tele-ICU “as the use of medical information exchanged from one site to the other through electronic communications with a target to improve patient’s health status”. Kumar et al (2013) wrote that tele-ICU is a command centre with critical care team connected to the critical care ward by technology.
Evidence shows there is a contradiction of the how much each user group supports the eHealth. Jong-Yi, W, et al (2015). In addition, Gesulga et al (2017) also mentioned other factors like lack of education, user resistance, training as well as other issues arising from data security that may bring challenges along the line. It has been reported that the hospital mortality rate remains the same in surgical ICU according to Breslow, et al., (2004). In another study by Morrison, et al., (2010) it shows more than 4,000 patients in two large hospitals, did not find any differences in mortality rate and length of stay in the hospital before and after the adoption of tele-ICU because of existing higher standard of care.
Therefore, the aim and purpose of this paper are to provide an overview of how this Tele-ICU works, asses how beneficial the Tele-ICU is and explore the advantages and disadvantages of this product to the ICU setting.
eHealth technology in advanced care and user needs can be perceived by both the professional service providers’ and/or patients’ perspectives. These needs are usually derived from fundamental human needs like protection, creation, identity, freedom, and many more (Kraft 2012). Consequently, it is seen for instance, that the demand of critical care unit has increased due to the ageing population, and improvement of life-sustaining treatment. ICU care providers or intensivists have been decreasing in numbers thus reducing the number of human resources. A study by (Duke, 2006) shows that the US will need 4,300 critical care physicians by 2020 and will shortfall by 1,500. There is also an increase in patients’ admissions. Evidence shows that more than 4 million patients get admission to ICUs each year in the USA. Treatment needed has been estimated to be around 30% of total acute care hospital costs (Wenham & Pittard, 2009). Patient safety is a major concern in ICU, serious medication errors account for 78% of all errors in the ICU (Rothschild, Landrigan, & Cronin, 2005) with mortality rates from 10%- 28% (Mayr, Dünser, & Greil, 2006). In support of the same issue is Ghazvini & Shukur (2013) who also reported that one of the most common challenges that lead to a breach of data is mainly caused by human error. Other studies done by Camiré, et al., (2009), Dimick, et al., (2001), Needleman, et al., (2002) also emphasize that lack of ICU staffs will lead to increased lengths of stay with higher complication rates, medication errors and increased risk of pneumonia and reintubation. This calls out for more improved technologies like Tele-ICU which is said to offer help in improving care as well as enhancing patients care. Goran, (2010a) implies that through the Tele-ICU is considered as the “second eyes” that are considered to assist the bedside ICU nurse. The addition clinical surveillances will assist in providing that extra care without destruction and offer immediate interventions.
An extensive data was done in the following search engines: – EBSCO, Google Scholar as well as PubMed. Search words used included “Tele-ICU”, “Critical care unit”, advantages and eHealth were done. All articles that included the Tele-ICU topic was chosen and read carefully. There was no consideration of the years since the search was done randomly. The articles had to have English language, full text and abstract though not in all cases. Any articles that did not fall on the criteria mentioned was excluded.
How Tele-ICU works
Tele-ICUs technology monitors ICU (intensive care unit) patients and permits ICU doctors and ICU nurses to manage the care of patients in multiple distant units (Goran & Mullen-fortino, 2012c). In the tele-ICU platform, there are several vendor-specific apparatuses of hardware and software which concerns both the technology team and the bedside nurses. Tele-ICU and the bedsides team have the same accessibility in matters related to patients’ vital signs. It includes results of the laboratory tests and radiology images among others. The accuracy of the patient’s care is monitored where the exact problem is immediately identified and followed up. High-quality cameras, microphones and speakers are attached to the rooms. The devices will give the tele-ICU team one or two-way video and audio assessment ability and the communication at the bedside. A vendor called “VISICU” gives the bedside team the ability to request tele-ICU support when needed. The demands of the hospital within the system where program staffing models are concerned. It has been noted that the tele-ICU works 24/7 and is equipped with highly specialised critical care nurse (Goran, 2010a), (Goran, 2012b)
Goran, (2010a) defines an intensivist as a highly certified physician who is positioned at a station and collaborates with the bedside nurse. Tele-ICU nurses (intensivist) or physicians review patient-specific data documentation and assessments thus providing a general survey and intervention. The higher the number of patients, the number of physicians is readjusted again to fit the group. The patients are accessed every 1 to 4 hours but also according to the demand of the patient. The intensivist will insert orders into the system software but if there is the time he/she will put it orders directly into the patient’s records. The patient safety relies on the tele-ICU director; therefore, teamwork is essential for the better success of this technology. (Goran & Mullen-fortino, 2012c), (Goran 2010a).
The command centre positioned in the consolidated area provides the ability to stabilize and regulate care which will maximize bed utilization by reducing transfers. This consolidated area is known as the “CORE, BANKER or the BOX”. This large room can house one workstation with 30-35 patients. There are a lot of computer screens which display the patients’ data, keyboards for typing as well as headsets for communication between the two teams. The responsibility of the telenurse is to do virtual rounding, alert recognition and response, providing support to the bedside team and lastly coaching and collaborating. (Goran 2010a).
In the intensive care unit, there are many lifesaving machines with endless beeping sounds. These sounds could be in most cases just false alarm and can be very frustrating to the workers thus causing alarm fatigue. In some cases, unnecessary sound alarms are muted thus putting the patients at a big risk (Cho et al 2016). Goran (2010a) makes it clear that the purpose tele-ICU is not to cover up for shortage but is another set of eyes that provides extra care. The exhaustion created for the ICU nurses by an ending alarm can cause destruction thus causing danger if the nurse is taking care of two patients. The ICU nurse and the tele-ICU nurse collaborate thus reducing destruction.
The telecare is also seen as one of the solutions that will help in increasing wellness, enhancing patient outcomes as well as the overall health. Panlaqui et al (2017) assert that telecare looks promising whereby special care can still be received remotely since transportation can be endangering to life. Despite the cost of telecare being expensive, Coustasse (2014) asserts that not only will telecare provide better care but also will help at a lowering cost, reduce the length of stay and mortality in the Intensive Care Unit (ICU).
The design of tele-ICU is said to provide improved safety and treatment in critical care, to enhance outcomes through standardization. Tele-ICU provides additional support and clinical surveillance as a “second set of eyes” (Susan, 2010). Tele-ICUs can improve the care of ICU patients, save lives, and increase both the productivity and the reach of specialists in critical care medicine. (Goran & Mullen-fortino, 2012c)
The Tele-ICU is also reported to have more positive outcome than negative in an interview done to explore the quality of care and safety through this technology. According to Khunlertkit & Carayon, (2013), findings that emerged in that research where it was found out that this technology added more resources to the ICU patients. It also served as a quality improvement trigger for the ICU. This means that the feedback data that the tele-ICU delivered to the ICU staffs where evidence-based procedure submissions rates. Standard protocols for ventilators associated pneumonia, sepsis as well as blood transfusion where it will double check by the tele-ICU nurse. In the end, tele-ICU can be able to help in increasing procedure acquiescence rates. Medical errors were also seen to be less recorded as the tele-ICU manages it though further research is required. Having the tele-ICU pharmacists reduced medical errors where medical emergency and safety is required. Williams et al. (2012) noted that the work of tele-ICU nurses is not to replace the bedside nurses and as a matter of fact, cannot be replaced. The unique position filled by tele-ICU nurses is to also serve as consultants, collaborators, colleagues to enhance as well as devotion.
The relation between families and tele-ICU was that little is known because the majority of them lucked knowledge about this technology. There were concerns from the family where the majority worried about technology failure. In addition, tele-ICU technology gets less or negative contributions from physicians in regards to the care process and outcomes (Khunlertkit & Carayon, 2013). A NEHI report by Leventhal, (2013) points out that after the implementation of tele-ICU patient mortality decreased significantly along with patients’ length of stay reduced. Tele-ICUs have a rapid payback of investment for hospitals with substantial financial benefit to payers.
In conclusion, tele-ICU allows the hospitals to care more ICU patients and to provide more continuous care by decreasing mortality rare and length of stay at the hospital. The advantages of tele-ICU are providing critical care in the rural area, decreasing air transportation costs and improving the care with a “second set of eyes”. The main disadvantages of tele-ICU are big initial investments and high maintenance costs. But tele-ICU is a practical and effective solution to provide critical care to underserved communities with higher quality.
Tele-ICU has more advantages than disadvantages. It is recommended though that there should be more research on when it comes to enforcing the command centre and where it should be located. What safety measures can be done if the equipment malfunctions and safety? Lastly, how much of human centred design principles are going to be considered so as the technology can be user accepted.
Breslow, M.J., Rosenfeld, B.A., Doerfler, M., Burke, G., Yates, G., Stone, D.J., Tomaszewicz, P., Hochman, R. & Plocher, D.W., 2004. Effect of a multiple-site intensive care unit telemedicine program on clinical and economic outcomes: an alternative paradigm for intensivist staffing. Crit Care Med, 31(8), p. 32.
Camiré, E., Moyen, E. & Stelfox, H., 2009. Medication errors in critical care: risk factors, prevention and disclosure. CMAJ, 180(9), p. 936–943.
Coustasse, A., Deslich, S., Bailey, D., Hairston, A., & Paul, D. (2014). A Business Case for Tele-Intensive Care Units. The Permanente Journal, 18(4), 76–84. http://doi.org/10.7812/TPP/14-004 Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4206175/ Assessed 22.06.2018
Cho, O. M., Kim, H., Lee, Y. W., & Cho, I. (2016). Clinical Alarms in Intensive Care Units: Perceived Obstacles of Alarm Management and Alarm Fatigue in Nurses. Healthcare Informatics Research, 22(1), 46–53. http://doi.org/10.4258/hir.2016.22.1.46 Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4756058/ assessed on 26.06.2018
Dimick, J., Swoboda, S., Pronovost, P. & Lipset, P., 2001. Effect of nurse-to-patient ratio in the intensive care unit on pulmonary complications and resource use after hepatectomy. Am J Crit Care, 10(6), p. 376–382.
Duke, E. (2006). The Critical Care Workforce: A Study of the Supply and Demand for Critical Care Physicians. HRSA. Retrieved June 18, 2018
Gesulgaa, J, M., Berjame, A, Moquialac, K, S, Galidod, A. 2017, Barriers to Electronic Health Record System Implementation and Information Systems Resources: A Structured Review, Procedia Computer Science 124 (2017) 544–551. Available at:https://www-sciencedirectcom-ezproxy.arcada.fi:2443/science/article/pii/S1877050917329563. Assessed on 17.06.2018
Ghazvini, A. & Shukur, K. 2013, Security Challenges and Success Factors of Electronic Healthcare System, Faculty of Information Science and Technology, Universiti Kebangsaan Malaysia,43600 Bangi,
Goran, SF 2010a, ‘A Second Set of Eyes: An Introduction to Tele-ICU’, Critical Care Nurse, 30, 4, pp. 46-56, Academic Search Elite, EBSCOhost, viewed 12 July 2018.
Goran, SF 2012b, ‘Making the Move: From Bedside to Camera-Side’, Critical Care Nurse, 32, 1, pp. e20-e29, Academic Search Elite, EBSCOhost, viewed 12 July 2018.
Goran, S. F., & Mullen-fortino, M. 2012c. Partnership for a Healthy Work Environment: Tele-ICU/ICU Collaborative. AACN Advanced Critical Care, 23(3), 289-301. doi:10.1097/NCI.0b013e31825c1cc2
Jong-Yi, W, Hsiao-Yun, H, Jen-De, C, Sinkuo, C, Chih-Jaan, T, & Yung-Fu, C 2015, ‘Attitudes toward inter-hospital electronic patient record exchange: discrepancies among physicians, medical record staff, and patients’, BMC Health Services Research, 15, 1, pp. 1-15, Academic Search Elite, EBSCOhost, viewed 17 June 2018.
Jiang, Q, Khan, M, Lu, X, Ma, J, & He, D 2016, ‘A privacy preserving three-factor authentication protocol for e-Health clouds’, Journal Of Supercomputing, 72, 10, pp. 3826-3849, Academic Search Elite, EBSCOhost, viewed 22 June 2018.
Kraft, C., 2012. User experience innovation: User centered design that works. Apress.
Khunlertkit, A. & Carayon, P 2013, Contributions of tele–intensive care unit (Tele-ICU) technology to quality of care and patient safety, Journal of Critical Care (2013) 28, 315.e1–315.e12 Available from:
https://www.jccjournal.org/article/S0883-9441(12)00332-2/pdf Assessed 12.07.18
Kumar, S., Merchant, S., & Reynolds, R., 2013. Tele-ICU: Efficacy and Cost-Effectiveness Approach of Remotely Managing the Critical Care. The Open Medical Informatics Journal, 7, 24–29. http://doi.org/10.2174/1874431101307010024
Leventhal, R., 2013. NEHI Report: Tele-ICU Poised for Major Growth, s.l.: Healthcare Informatics Institute
Mayr, V. D., Dünser, M. W., & Greil, V. (2006). Causes of death and determinants of outcome in critically ill patients. Crit Care, 10(6). Doi:10.1186/cc5086.
Morrison, J.L., Cai, Q., Davis, N., Yan, Y., Berbaum, M.L., Ries, M. &Solomon, G., 2010. Clinical and economic outcomes of the electronic intensive care unit: results from two community hospital. Crit Care Med, pp. 2-8.
Needleman, J., Buerhaus, P. & Mattke, S., 2002. Nurse-staffing levels and the quality of care in hospitals. N Engl J Med, 346(22), p. 1715–1722.
Panlaqui, O, Broadfield, E, Champion, R, Edington, J, & Kennedy, S 2017, ‘Outcomes of telemedicine intervention in a regional intensive care unit: a before and after study’, Anaesthesia & Intensive Care, 45, 5, pp. 605-610, Academic Search Elite, EBSCOhost, viewed 12 July 2018.
Rothschild, J. M., Landrigan, C. P., & Cronin, J. W. (2005). The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med, 33(8), 1694-1700. Doi:10.1097/01.CCM.0000171609.91035.BD
Wenham, T., & Pittard, A. (2009). Intensive care unit environment. Continuing Education in Anaesthesia, Critical Care & Pain, 9(6), 178-183. Doi:10.1093/bjaceaccp/mkp036
World Health Organization, 2018. Global Observatory for eHealth. Available from: http://www.who.int/goe/en/ Assessed on 17.06.2018
Williams, L, Hubbard, K, Daye, O, & Barden, C 2012, ‘Tele-ICU Enhancements. Telenursing in the Intensive Care Unit: Transforming Nursing Practice’, Critical Care Nurse, 32, 6, pp. 62-69, Academic Search Elite, EBSCOhost, viewed 13 July 2018.