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Telemedicine to Expand Access to Critical Care Around the World. Crit Care Clin 2022; 38:809-826. [PMID: 36162912 DOI: 10.1016/j.ccc.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This multiauthored communication gives a state-of-the-art global perspective on the increasing adoption of tele-critical care. Exponentially increasing sophistication in the deployment of Computers, Information, and Communication Technology has ensured extending the reach of limited intensivists virtually and reaching the unreached. Natural disasters, COVID-19 pandemic, and wars have made tele-intensive care a reality. Concerns and regulatory issues are being sorted out, cross-border cost-effective tele-critical care is steadily increasing Components to set up a tele-intensive care unit, and overcoming barriers is discussed. Importance of developing best practice guidelines and retraining is emphasized.
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Laudanski K, Huffenberger AM, Scott MJ, Wain J, Ghani D, Hanson CW. Pilot of rapid implementation of the advanced practice provider in the workflow of an existing tele-critical care program. BMC Health Serv Res 2022; 22:855. [PMID: 35780144 PMCID: PMC9250728 DOI: 10.1186/s12913-022-08251-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 06/15/2022] [Indexed: 11/25/2022] Open
Abstract
Incorporating the advanced practice provider (APP) in the delivery of tele critical care medicine (teleCCM) addresses the critical care provider shortage. However, the current literature lacks details of potential workflows, deployment difficulties and implementation outcomes while suggesting that expanding teleCCM service may be difficult. Here, we demonstrate the implementation of a telemedicine APP (eAPP) pilot service within an existing teleCCM program with the objective of determining the feasibility and ease of deployment. The goal is to augment an existing tele-ICU system with a balanced APP service to assess the feasibility and potential impact on the ICU performance in several hospitals affiliated within a large academic center. A REDCap survey was used to assess eAPP workflows, expediency of interventions, duration of tasks, and types of assignments within different service locations. Between 02/01/2021 and 08/31/2021, 204 interventions (across 133 12-h shift) were recorded by eAPP (nroutine = 109 (53.4%); nurgent = 82 (40.2%); nemergent = 13 (6.4%). The average task duration was 10.9 ± 6.22 min, but there was a significant difference based on the expediency of the task (F [2; 202] = 3.89; p < 0.022) and type of tasks (F [7; 220] = 6.69; p < 0.001). Furthermore, the eAPP task type and expediency varied depending upon the unit engaged and timeframe since implementation. The eAPP interventions were effectively communicated with bedside staff with only 0.5% of suggestions rejected. Only in 2% cases did the eAPP report distress. In summary, the eAPP can be rapidly deployed in existing teleCCM settings, providing adaptable and valuable care that addresses the specific needs of different ICUs while simultaneously enhancing the delivery of ICU care. Further studies are needed to quantify the input more robustly.
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Affiliation(s)
- Krzysztof Laudanski
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, 19104, USA. .,Leonard Davis Institute for Health Economics, Philadelphia, PA, 19104, USA. .,Department of Anesthesiology and Critical Care, Leonard Davis Institute for Health Economic, JMB 127; 3620 Hamilton Walk, Philadelphia, PA, 19146, USA.
| | | | - Michael J Scott
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Justin Wain
- School of Osteopathic Medicine, Campbell University, Buies Creek, NC, 27506, USA.,Penn Medicine Center for Connected Care, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Danyal Ghani
- College of Art & Sciences, Drexel University, Philadelphia, PA, 19104, USA
| | - C William Hanson
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, 19104, USA
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Roberts KJ, Zumstein KK, Lamphere TR, Williams M, Powell SA, Moran A, Kellar B, Solly WR, Pierce M. Improving Students' Knowledge and Skills Through a Tele-ICU Clinical Rotation. Respir Care 2022; 67:789-794. [PMID: 35640997 PMCID: PMC9994093 DOI: 10.4187/respcare.09896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In the course of their education, respiratory therapy students participate in clinical rotations, which are essential to their education. Recently, the number of clinical sites has decreased as some have been eliminated. During the COVID-19 pandemic, schools were challenged to find hospitals to accommodate students due to the risk of infection. Tele-ICU has emerged as a means for staff therapists to assess and monitor patients via remote monitoring systems. We hypothesized that a clinical rotation at a tele-ICU would strengthen students' knowledge of mechanical ventilation, telemedicine, and COVID-19. METHODS In this study, students completed clinical rotations in a tele-ICU. Students spent two 4-h clinical rotations rounding on 320 ICU beds at 5 hospitals. Under the supervision of experienced therapists, students performed remote patient-ventilator assessments, including review and interpretation of ventilator waveforms, patient-ventilator interaction, arterial blood gases, and chest x-rays. Students completed pre- and post-rotation surveys assessing their confidence managing mechanical ventilation, experience with telemedicine, ARDS, and patients with COVID-19. RESULTS Mean self-confidence in mechanical ventilation (P = .001), assessing waveforms (P = .001), and knowledge of ARDS increased after the clinical rotation (P = .001). Similarly, reported knowledge related to spontaneous breathing trial protocols (P = .009), lung-protective ventilation (P = .002), patient care planning (P = .001), and use of Excel spreadsheets (P = .002) increased from the beginning to the end of the clinical rotation. Student confidence in interprofessional communication increased from 85 [69-98] to 95 [78-100]; P = .03). Overall, the largest change was students' ability to assess patients with COVID-19 (pre-rotation 50.0 [11.5-65.7], post-rotation 80.0 [58.5-100]; P = .001). Qualitative results revealed overwhelmingly positive results for both students and preceptors. CONCLUSIONS Students' confidence in assessing patients via remote monitoring increased in a tele-ICU clinical rotation. Self-assessed knowledge related to COVID-19 also increased to statistical significance.
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Affiliation(s)
- Karsten J Roberts
- Department of Respiratory Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Karen K Zumstein
- Department of Respiratory Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas R Lamphere
- Department of Respiratory Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maria Williams
- Center for Connected Care, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Susan A Powell
- Department of Respiratory Care, West Chester University-Bryn Mawr Hospital, Bryn Mawr, Pennsylvania
| | - Alexa Moran
- Department of Respiratory Care, West Chester University-Bryn Mawr Hospital, Bryn Mawr, Pennsylvania
| | - Brian Kellar
- Department of Respiratory Care, West Chester University-Bryn Mawr Hospital, Bryn Mawr, Pennsylvania
| | - William R Solly
- Department of Respiratory Care, Gwynedd Mercy University, Gwynedd Valley, Pennsylvania
| | - Margarete Pierce
- Department of Respiratory Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Laudanski K, Scott M, Huffenberger AM, Wain J, Hanson CW. Deployment of Tele-ICU Respiratory Therapy and the Creation of an eRT Service Line. NEJM CATALYST 2022. [PMCID: PMC9580011 DOI: 10.1056/cat.21.0239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Penn Medicine launched a 24-7 telemedicine respiratory therapist (eRT) service as part of its tele–critical care medicine (tele-CCM) service serving seven hospitals and more than 320 critical care beds. Service line interventions were focused on protocolized evidence-based practices, safety, documentation compliance, and urgent emergent ad hoc clinical needs. Concomitantly, the eRTs were available to respond to urgent and emergent interventions on the basis of the clinical bedside situation. Their activity was triggered by Penn E-lert staff (serving the tele-ICUs), bedside staff, algorithmic trigger software, or the eRT’s own review of a patient’s clinical condition. A standardized data collection was deployed to gather information about the interventions. The value of the eRT service was defined in terms of estimated lives saved by implementing the standards of care earlier than the bedside staff would or acute respiratory distress syndrome (ARDS) algorithmic trigger and by intervening during emergent and urgent clinical request, improving care delivery, and complying with best clinical practices, and by the time freed for onsite staff to perform other duties. Between May 2020 and August 2021, eRTs registered 31,609 activities; 97.8% of interventions were related to the routine established workflows, while 1.9% were urgent and 0.3% emergent. In 51.2% of all eRT accomplished activities, no communication with other staff was needed. When communication did take place, eRTs connected with the bedside respiratory therapist in 36.7% of interactions, followed by house staff (7.2%), advanced practice providers (5.2%), and registered nurses (1.6%). The eRTs communicated via phone (81.4%), asynchronous text platform (16%), or tele-CCM software (1.4%). While prompted by staffing, safety, and logistics challenges during a Covid-19 surge, the resulting eRT service line has been well received and has become a part of the standard of care. Overall efficiency of respiratory care service delivery was increased as Penn retained staff and increased the flexibility of bedside therapists. Furthermore, the eRT service detected unfavorable practice patterns in ARDS treatment and intervened before the ARDS algorithmic trigger was activated or acted upon. Some of the tasks can be accomplished by the eRT in a shorter amount of time than it would take bedside staff. In addition, the remote staffing reduced personal protective equipment utilization. All of these gains translated into postpandemic time savings. Penn’s experience shows that the eRT care model can be transformed into a system-valued proposition and retained with sustained benefit beyond the pandemic surge.
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Affiliation(s)
- Krzysztof Laudanski
- Assistant Professor, Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Senior Fellow, Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Assistant Professor, Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael Scott
- Division Chief, Critical Care Medicine, Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Medical Director, Penn E-lert Tele-Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Professor, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ann Marie Huffenberger
- Director, Center for Connected Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Justin Wain
- Medical Student, Campbell University School of Osteopathic Medicine, Buies Creek, North Carolina, USA
| | - C. William Hanson
- Chief Medical Information Officer and Vice President, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
- Professor of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Pierce M, Gudowski SW, Roberts KJ, Jackominic A, Zumstein KK, Shuttleworth A, Ho J, Susser P, Parikh A, Chandler JM, Huffenberger AM, Scott MJ, Hanson CW, Laudanski K. The Rapid Implementation of Ad Hoc Tele-Critical Care Respiratory Therapy (eRT) Service in the Wake of the COVID-19 Surge. J Clin Med 2022; 11:jcm11030718. [PMID: 35160170 PMCID: PMC8837076 DOI: 10.3390/jcm11030718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/10/2022] [Accepted: 01/21/2022] [Indexed: 02/04/2023] Open
Abstract
A 24/7 telemedicine respiratory therapist (eRT) service was set up as part of the established University of Pennsylvania teleICU (PENN E-LERT®) service during the COVID-19 pandemic, serving five hospitals and 320 critical care beds to deliver effective remote care in lieu of a unit-based RT. The eRT interventions were components of an evidence-based care bundle and included ventilator liberation protocols, low tidal volume protocols, tube patency, and an extubation checklist. In addition, the proactive rounding of patients, including ventilator checks, was included. A standardized data collection sheet was used to facilitate the review of medical records, direct audio–visual inspection, or direct interactions with staff. In May 2020, a total of 1548 interventions took place, 93.86% of which were coded as “routine” based on established workflows, 4.71% as “urgent”, 0.26% “emergent”, and 1.17% were missing descriptors. Based on the number of coded interventions, we tracked the number of COVID-19 patients in the system. The average intervention took 6.1 ± 3.79 min. In 16% of all the interactions, no communication with the bedside team took place. The eRT connected with the in-house respiratory therapist (RT) in 66.6% of all the interventions, followed by house staff (9.8%), advanced practice providers (APP; 2.8%), and RN (2.6%). Most of the interaction took place over the telephone (88%), secure text message (16%), or audio-video telemedicine ICU platform (1.7%). A total of 5115 minutes were spent on tasks that a bedside clinician would have otherwise executed, reducing their exposure to COVID-19. The eRT service was instrumental in several emergent and urgent critical interventions. This study shows that an eRT service can support the bedside RT providers, effectively monitor best practice bundles, and carry out patient–ventilator assessments. It was effective in certain emergent situations and reduced the exposure of RTs to COVID-19. We plan to continue the service as part of an integrated RT service and hope to provide a framework for developing similar services in other facilities.
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Affiliation(s)
- Margarete Pierce
- Respiratory Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA; (M.P.); (S.W.G.); (K.J.R.); (A.J.); (K.K.Z.); (A.S.)
| | - Steven W. Gudowski
- Respiratory Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA; (M.P.); (S.W.G.); (K.J.R.); (A.J.); (K.K.Z.); (A.S.)
| | - Karsten J. Roberts
- Respiratory Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA; (M.P.); (S.W.G.); (K.J.R.); (A.J.); (K.K.Z.); (A.S.)
| | - Anthony Jackominic
- Respiratory Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA; (M.P.); (S.W.G.); (K.J.R.); (A.J.); (K.K.Z.); (A.S.)
| | - Karen K. Zumstein
- Respiratory Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA; (M.P.); (S.W.G.); (K.J.R.); (A.J.); (K.K.Z.); (A.S.)
| | - Amanda Shuttleworth
- Respiratory Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA; (M.P.); (S.W.G.); (K.J.R.); (A.J.); (K.K.Z.); (A.S.)
| | - Joshua Ho
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (J.H.); (P.S.); (A.P.)
| | - Phillip Susser
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (J.H.); (P.S.); (A.P.)
| | - Alomi Parikh
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (J.H.); (P.S.); (A.P.)
| | - John M. Chandler
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Ann Marie Huffenberger
- Penn Medicine Center for Connected Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA; (A.M.H.); (M.J.S.); (C.W.H.III)
| | - Michael J. Scott
- Penn Medicine Center for Connected Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA; (A.M.H.); (M.J.S.); (C.W.H.III)
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - C. William Hanson
- Penn Medicine Center for Connected Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA; (A.M.H.); (M.J.S.); (C.W.H.III)
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Krzysztof Laudanski
- Penn Medicine Center for Connected Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA; (A.M.H.); (M.J.S.); (C.W.H.III)
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
- Leonard Davis Institute for Healthcare Economics, University of Pennsylvania, Colonial Penn Center, 3641 Locust Walk #210, Philadelphia, PA 19104, USA
- Correspondence:
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The Impact of Delayed Symptomatic Treatment Implementation in the Intensive Care Unit. Healthcare (Basel) 2021; 10:healthcare10010035. [PMID: 35052199 PMCID: PMC8774917 DOI: 10.3390/healthcare10010035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 12/21/2021] [Accepted: 12/23/2021] [Indexed: 11/21/2022] Open
Abstract
We estimated the harm related to medication delivery delays across 12,474 medication administration instances in an intensive care unit using retrospective data in a large urban academic medical center between 2012 and 2015. We leveraged an instrumental variables (IV) approach that addresses unobserved confounds in this setting. We focused on nurse shift changes as disruptors of timely medication (vasodilators, antipyretics, and bronchodilators) delivery to estimate the impact of delay. The average delay around a nurse shift change was 60.8 min (p < 0.001) for antipyretics, 39.5 min (p < 0.001) for bronchodilators, and 57.1 min (p < 0.001) for vasodilators. This delay can increase the odds of developing a fever by 32.94%, tachypnea by 79.5%, and hypertension by 134%, respectively. Compared to estimates generated by a naïve regression approach, our IV estimates tend to be higher, suggesting the existence of a bias from providers prioritizing more critical patients.
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Roberts KJ, Johnson B, Morgan HM, Vrontisis JM, Young KM, Czerpak E, Fuchs BD, Pierce M. Evaluation of Respiratory Therapist Extender Comfort With Mechanical Ventilation During COVID-19 Pandemic. Respir Care 2021; 66:199-204. [PMID: 33323412 PMCID: PMC9994228 DOI: 10.4187/respcare.08459] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Staffing strategies used to meet the needs of respiratory care departments during the COVID-19 pandemic included the deployment of respiratory therapist extenders. The purpose of this study was to evaluate respiratory therapist extenders' comfort level with critical care ventilators while caring for patients with COVID-19. To our knowledge, this is the first study to evaluate the deployment of certified registered nurse anesthetists (CRNAs) in a critical care setting. METHODS A qualitative survey method was used to assess CRNA experience with critical care ventilators. Prior to deployment in the ICU, CRNAs were trained by clinical lead respiratory therapists. Education included respiratory clinical practices and ventilator management. Sixty-minute sessions were held with demonstration stations set up in ICUs for hands-on experience. RESULTS Fifty-six CRNAs responded to our survey (63%). A mean ± SD of 9.48 ± 12.27 h was spent training prior to deployment in the ICU. CRNAs were at the bedside a mean ± SD of 73.0 ± 40.6 h during the pandemic. While CRNA comfort level with critical care ventilators increased significantly (P < .001) from the beginning to the end of their work experience, no statistically significant differences were found between CRNA comfort based on years of experience. Differences in comfort level were not found after training (chi-squared test 23.82, P = .09) or after ICU experience was completed (chi-squared test = 15.99, P = .45). Similarly, mean comfort level did not increase based on the number of hours spent working in the ICU (chi-squared test = 13.67, P = .55). CONCLUSIONS Comfort level with mechanical ventilation increased for CRNAs working alongside respiratory therapists during the COVID-19 pandemic.
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Affiliation(s)
- Karsten J Roberts
- Department of Respiratory Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Bridgette Johnson
- Department of Respiratory Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Heather M Morgan
- Department of Respiratory Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jody M Vrontisis
- Department of Respiratory Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Katie M Young
- Department of Respiratory Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edward Czerpak
- Department of Anesthesia - CRNAs, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Barry D Fuchs
- Department of Respiratory Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Margie Pierce
- Department of Respiratory Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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