Implementation of Tele-Intensive Care Unit Services During the COVID-19 Pandemic: A Systematic Literature Review and Updated Experience from Shandong Province
Introduction
Telemedicine refers to the use of audio and/or visual communication among some combination of staff–staff,1,2 staff–patient,3,4 staff–family,5,6 and patient–family7,8 settings. This may involve real-time monitoring of patient conditions and metrics,9,10 consultation between physicians and patients11 or among physicians of various specialties,1,2 and remote support of staff performing bedside patient care,12,13 among other functions.
Among the applications of telemedicine in both outpatient and inpatient contexts, its use in intensive care units (ICUs) has emerged as being of particular importance in the care of patients infected with COVID-19 who are experiencing severe symptoms.14 During the pandemic, many ICUs have been partially or completely converted to COVID-19 units,15 and tele-ICU has allowed critical care staff to continue providing the best patient care possible while also minimizing their own infection risks.
There are many currently available tele-ICU platforms that provide services such as visual patient monitoring,16 incorporation of real-time telemetry data,9 audio-visual communication for consultations,12,17,18 and collaborative virtual rounding.19 While startup costs may be steep due to the equipment requirements,20 some locations with financial limitations have successfully repurposed commonly available devices to substantially mitigate expenditures.21
In addition, hospitals may have telemedicine in place for other specialties, such as telestroke, which can be adapted to suit the needs of an ICU.20,21 A 2018 American Hospital Association Annual Survey found that a median of 15% of all hospitals in each state offered tele-ICU services,22 indicating that a number of institutions had adopted this technology before the pandemic and could more quickly alter existing frameworks to accommodate creation of a COVID-19 unit, personnel shifts, and other rapid pandemic responses.15,21
The majority of tele-ICU systems involve a team of intensivists, critical care nurses, and other personnel who provide advice and support to patients and/or bedside health care workers from a remote location.15,20,23 As these specialties were already experiencing shortages before the COVID-19 pandemic,24,25 it has been imperative that hospitals maximize the proportion of intensivists and critical care nurses actively working by reducing infection risk as much as possible. In the event that these health care workers are exposed to COVID-19 or fall into a high-risk category, some hospitals have provided home workstations to allow them to continue working through tele-ICU during self-quarantine periods.20,26
In addition, many institutions have devoted resources to separate COVID-19 ICUs, and charged intensivists and critical care nurses with the management of these patients. This has left physicians and nurses from other specialties to care for non-COVID-19 ICU patients.15 Many hospitals have also expanded their ICU capacity to accommodate patient surges, increasing the total number of beds devoted to critically ill patients.13,15,16,23 Tele-ICU has enabled intensivists and critical care nurses to virtually care for a larger number of COVID-19 and non-COVID-19 patients through the ability to supervise multiple staff members performing bedside procedures as well as directly perform patient care themselves.15
Another major motivation for tele-ICU usage is the conservation of personal protective equipment (PPE).15,20,21,26,27 This was particularly important during the early stages of the pandemic, when manufacturing shortages limited the supply of these items.28,29 However, even when full PPE is readily available, limiting exposure by reducing the number of staff members who directly interact with patients known or suspected to be infected with COVID-19 remains essential.30
While many hospitals share common motivations for tele-ICU usage during COVID-19, the details of its implementation vary between institutions. Here, we share the details of tele-ICU use at our own institution and six others in an attempt to consolidate a portion of the knowledge gained thus far. Our hope is that this will provide guidance and encouragement to hospitals contemplating the initiation of tele-ICU services as well as those in the early stages of implementation.
Methods
SEARCH STRATEGY
We performed a systematic review using the AutoLit platform (Nested Knowledge, St. Paul, MN).31 Using the Application Program Interface (API) in AutoLit, we searched the PubMed database for the terms in Table 1. Following this initial PubMed literature search, one additional reference was manually added based upon expert recommendation.32
| SEARCH TERM | RESULTS RETURNED | DATE SEARCHED |
|---|---|---|
| (telehealth OR telemedicine OR tele-ICU OR “telecritical care” OR “teleintensive care”) AND icu AND covid | 162 | May 18, 2022 |
SCREENING PROCESS
Titles and abstracts of each study were screened by a single reviewer, followed by further evaluation of full-text versions of initially included articles. Articles were included if they discussed the use of telemedicine technology in an ICU setting during the COVID-19 pandemic. Studies were excluded if they did not relate to telemedicine or its use in the ICU, or if they did not give sufficient description of the implementation of and experience with telemedicine technologies.
Articles that mentioned that telemedicine was initiated as part of the response to COVID-19 but did not give further description of the platform, users, equipment, or outcomes were excluded. Articles which described an ICU setting but involved a specialty other than critical care (e.g., rehabilitation, cardiac care, palliative care) were excluded. Studies published between 2020 and 2022 were included. Systematic reviews and meta-analyses were excluded, as were those published before January 1, 2020, and those not published in English.
DATA EXTRACTION
Data from each study were extracted by a single reviewer. Qualitative data relating to hospital location, time period, tele-ICU platform, users, equipment, associated costs, implementation and training details, assessments of tele-ICU use, advantages/disadvantages, and other outcomes were collected. Quantitative data relating to the number of ICU beds and the number of implemented tele-ICU devices were also collected.
Results
UPDATED EXPERIENCE FROM SHANDONG PROVINCE
Since the outbreak of COVID-19, Shandong Province has been providing guidance, training, communication, and remote consultation for community residents by telemedicine. In 2020, we published our summarized experience in critical care,17 providing a template for the application of tele-ICU in public health emergencies. We have applied telemedicine in the ICUs of three hospitals in Shandong Province.
Shandong Provincial Hospital affiliated to Shandong First Medical University, where authors X.S and C.W are employed, is the largest comprehensive tertiary hospital in Shandong Province and was the first in the province to implement tele-ICU technology. Over the past 2 years, we have observed that the shift of more and more consultations, trainings, and meetings to online platforms can effectively reduce novel Coronavirus transmission while providing convenience to patients and medical staff. Here, we update and summarize the application of telemedicine during the COVID-19 pandemic in Shandong Province from the perspective of medical professionals working in three institutions in an academic hospital system.
Since the onset of the pandemic, Cloud ICU, a telemedicine platform, has set up a COVID-19 section that contains the latest scientific knowledge related to COVID-19, and is frequently updated for the timely release of information. Specialists can provide suggestions to community members, and Shandong Provincial experts provide remote consultation for the management of COVID-19. As of April 30, 2022, there have been 121 remote consultations for COVID-19 patients and 855 for non-COVID-19 cases conducted using the Cloud ICU platform.
C.W. (corresponding author), as the leader of the COVID-19 medical treatment expert team in Shandong Province, has performed remote consultations with patients every day during this year’s outbreak. The number of people willing to participate in remote diagnosis and treatment is increasing, and more and more patients are receiving access to high-quality medical resources and services from their own homes rather than traveling long distances.
As a result of pandemic prevention measures, on-site academic conferences remain limited, with many meetings switching instead to online platforms. Shandong Province hosted its first webinar on the prevention and management of COVID-19 in pregnant women on January 24, 2020, with 36,478 attendees from across China. Subsequently, China held regular webinars on COVID-19 topics and shared the country’s experience of COVID-19 patient management with others throughout the world (e.g., Belgium, Italy, the United States, South Korea, Australia, India, Thailand) to help contain the global spread. Since 2020, Cloud ICU has organized 187 workshops on COVID-19, with a total of 1.33 million participants.
Since attendance is not limited by time and cost restrictions, many additional medical staff have benefitted from the convenience of telemedicine. Standardized teacher training for critical care residents and specialist physicians and the Shandong Province Critical Care Skills Competition were held online, allowing more critical care professionals to participate. Figure 1 shows the annual number of remote consultations and conferences held through Cloud ICU since 2017.
Fig. 1. Telemedicine uses in Shandong Province from 2018 through 2021.
During the COVID-19 period, medical staff in Shandong Province have served as the main force for pandemic control. They have achieved phased successes while also exposing problems such as differences in diagnosis and treatment patterns between areas and hospitals, complicating that task of extracting and analyzing clinical data from multiple sites. Based on this observation, Shandong Province has utilized Cloud ICU to establish a quality control platform for critical care.
Clinical tasks such as ward rounds, consultation, and case discussion can be guided and supervised using telemedicine among different hospitals, helping to standardize ICU patient care. The Shandong Province Critical Medicine Emergency Internet of Things Center has also been created to coordinate personnel, equipment, and other critical care resources, aid in government decision-making, and improve emergency management capabilities. Importantly, Cloud ICU is simultaneously being used for multicenter clinical research, as well as the distribution, collection, and analysis of surveys to promote the scientific research capacity of critical care medicine in Shandong Province.
LITERATURE SEARCH RESULTS
A total of 162 articles were identified through our search of the PubMed database, and an additional article was identified through expert recommendation. Of the 163 articles screened, 4 studies were excluded as they were published in languages other than English, and 16 studies were not related to telemedicine. Twenty-one studies were excluded as they did not describe tele-ICU use in an ICU setting. One study described telemedicine use in the ICU but involved a specialty other than critical care. A total of 121 articles were selected for full-text review. Nine full-text versions were not available, so 112 full-text articles were screened for inclusion.
During the full-text review, an additional two articles were excluded as they were not published in English, and one was excluded as it was published during the pandemic but data collection preceded the onset of the pandemic. Twenty-four studies were not related to telemedicine, and 44 did not refer to telemedicine use in an ICU setting; these were excluded. Nine studies were excluded as they described telemedicine in ICUs but involved specialties besides critical care. A total of 20 studies mentioned tele-ICU technology in passing (e.g., listed it among a series of pandemic responses) but did not include a sufficient level of detail for our purposes. The remaining 11 studies were included in the qualitative summary (Fig. 2). All of the included studies were retrospective descriptions of a particular institution’s experience implementing and utilizing tele-ICU technology.12,13,15–18,20,21,23,26,27
Fig. 2. Preferred reporting items for systematic reviews and meta-analyses diagram.
DESCRIPTION OF SITES UTILIZING TELE-ICU TECHNOLOGIES
Besides our own institution described above, we included six other sites using tele-ICU services (Table 2). Tele-ICU technologies are being implemented in multiple countries, including the United States,12,15,18,20,21,26,27 Mexico,12,18 Israel,13,16 El Salvador,23 and China.17 While many sites utilized telemedicine more broadly throughout hospitals, we chose to focus solely on its use in an ICU setting. Four sites used tele-ICU services to facilitate collaboration between multiple hospitals,12,17,18,21,26 while the remaining three used it primarily within a single medical center.13,15,16,23,27
| STUDY | SITE(S) | LOCATION(S) | NUMBER OF COVID-19 ICU BEDS |
|---|---|---|---|
| Ramnath (2021)12,18 | UC San Diego Health System, ECRMC, HGT, HGM | Section of the U.S.–Mexico border containing two pairs of sister cities, San Diego-Tijuana and El Centro-Mexicali | — |
| Al-Saadi (2020),27 Dhala (2020)15 | Houston Methodist Hospital | Houston, TX | 150 |
| Arneson (2020),26 Singh (2021)20 | Atrium Health | North Carolina, South Carolina, and Georgia | >300 Total |
| Pilosof (2021)13,16 | Sheba Medical Center | Tel HaShomer, Ramat Gan, Israel | 97 |
| Bello (2021)23 | Hospital El Salvador | San Salvador, El Salvador | 105 |
| Ong (2020)21 | Yale New Haven Health System | Connecticut and Rhode Island | — |
| Song (2020)17 | Liaocheng Cardiac Hospital, DongE Hospital, Shandong Provincial Hospital (all affiliated with Shandong First Medical University) | Liaocheng and Jinan, Shandong, China | — |
ORGANIZATION OF TELE-ICU SYSTEMS
Of the seven total sites implementing tele-ICU services, three created a centralized hub where intensivists, critical care nurses, and other specialists performed monitoring and communication with bedside personnel,13,15,16,23,27 while three others allowed providers to use home workstations and/or mobile devices to access tele-ICU platforms from other remote locations.12,17,18,21 The remaining site described the organization of their tele-ICU system as a “largely decentralized hybrid hub-node-spoke care delivery model” that involved a subset of intensivists supplied with home workstations, but did not describe the structure more specifically.20,26
TELE-ICU PLATFORMS
Four of the seven sites specified which platform(s) were used in the provision of tele-ICU services,15,17,20,21,26,27 with an additional site stating that it used “open-source digital platforms.”23 Houston Methodist Hospital utilized Consultant Bridge and Sickbay (Medical Informatics Corp.)15,27; Atrium Health utilized eCareManager (Philips), a customized SharePoint tool (Microsoft), Microsoft Teams (Microsoft), and DocHalo (Halo Health)20,26; the Yale New Haven Health System utilized Mobile Heartbeat (Waltham), Facetime (Apple), and Zoom (Zoom Video Communications, Inc.)21; and Shandong Province utilized Cloud ICU.17
TELE-ICU USERS
At three of the sites, communication using tele-ICU platforms typically consisted of intensivists and critical care nurses providing advice and support to bedside teams comprised of physicians and nurses from other specialties.15,20,23,26,27 At the U.S.–Mexico border site, intensivists from the UC San Diego Health System provided direct care at El Centro Regional Medical Center; however, due to limitations of medical licensure, their role at Mexicali General Hospital and Tijuana General Hospital was limited to consulting with Mexican physicians and nurses, and providing education through the presentation of journal articles relating to COVID-19 patient care.12,18 Sheba Medical Center planned its patient care model around efforts to reduce staff burnout, splitting physicians, nurses, and support personnel into two teams, which would rotate between the communications hub and bedside service every 3 h during a 12-h shift.13,16
Aside from intensivist and nursing consultation, the Yale New Haven Health System cited several other use cases for tele-ICU technology, including allowing patients (particularly children) to view a staff member’s face before it was obscured by PPE to decrease anxiety and enhance patient rapport.21 In Shandong Province, the uses of tele-ICU extended beyond consultations to include the dissemination of PPE instructional videos and other remote training for health care providers, which was critical as practices evolved rapidly at the start of the pandemic.
The platform also included a diary and hotline to help combat staff burnout, and descriptions from specialists of their experiences caring for critically ill COVID-19 patients shared in an effort to reduce global spread of the disease. Panel discussions held nationwide in China using tele-ICU technology were attended by over half a million participants.17
All of the included sites mentioned that staff located remotely could use tele-ICU systems to directly view and/or communicate with patients.12,13,15–18,20,21,23,26,27 Four sites described the installation of cameras in patient rooms.13,15,16,20,23,26,27 Two sites reported that existing telemetry systems were incorporated into the tele-ICU platform to enable staff to view vital signs, intravenous (IV) infusion rates, and other real-time patient information.15,20,26,27 One site utilized Amazon Echo devices to communicate with patients and baby monitors to visualize equipment from outside the room,21 while another deployed InTouch Telepresence robots for direct assessment (Table 3).13,16
| SITE | TELE-ICU PLATFORM | EQUIPMENT | USERS |
|---|---|---|---|
| UC San Diego Health System12,18 | — | Two-way audio-visual telemedicine technology | At ECRMC, UCSDHS intensivists provided direct services (e.g., order-writing, note-writing, care plan review, etc.) At HGM and HGT, UCSDHS intensivists were limited to a consultative/educational role (e.g., individual case discussion with bedside team, journal article presentation, etc.)a |
| Houston Methodist Hospital15,27 | Consultant Bridge application—consultations, family virtual visits Sickbay (Medical Informatics Corp.)—visualization of bedside monitors and EHR data |
Adjustable camera in patient rooms with 360° pan, tilt, and zoom Two-way audio system Direct digital connection to monitoring system (used to view vital signs monitors, IV infusion rates, and other devices) |
MDs and RNs provide direct care Residents communicate with nursing staff, patients, and families |
| Atrium Health20,26 | eCareManager (Philips) Customized SharePoint tool (Microsoft)—real-time dashboard Microsoft Teams (Microsoft) DocHalo (Halo Health)—synchronous and asynchronous communication |
Carts in patient rooms containing high-resolution camera, monitor, microphone, and speaker Incorporation of existing telemetry monitors to be compatible with tele-ICU platforms Existing workstations enabled with tele-ICU technology 24 Telemedicine mobile carts initially deployed with another 50+ ordered and designated for ICU use >100 Tablets distributed for patient–family communication 20 Nurses were given laptops with an additional monitor for use in case of quarantine or exposure |
Operation center staffed full-time by intensivists and critical care nurses, as well as part-time by critical care pharmacists and RTs Surgeons, anesthesiologists, and nurse anesthetists preferentially performed critical care procedures that would normally be performed by intensivists >300 Physicians, nurses, pharmacists, and RTs were given access to tele-ICU software to facilitate team-based care and virtual assessment Tele-ICU nurses served as superusers for all tele-ICU technologies and performed any troubleshooting Tele-ICU nurses could work from home if they were at high risk or offered to work extra shifts should the need arise |
| Sheba Medical Center13,16 | — | Video camera in each patient room Spatial video cameras Walkie-talkies InTouch Telepresence robot Closed club car |
Teams rotated between tele-ICU operation center and bedside area every 3 h during a 12-h shift Directors used club car for visits |
| Hospital El Salvador23 | Open-source digital platforms | High-resolution pan–tilt–zoom cameras in patient rooms Phones |
18 Critical care specialists and 25 internal medicine physicians served in operation center 157 General practitioners and 251 nurses performed bedside duties |
| Yale New Haven Health System21 | Mobile Heartbeat application (Waltham) Facetime (Apple) Zoom (Zoom Video Communications, Inc.) |
>1,800 Total devices deployed for inpatient tele-ICU use iPhones >300 iPads 112 Echo Dots Echo Show Amazon Fire tablets Initial purchase of 20 InTouch Health audio-visual devices in patient rooms Repurposing of 150 existing clinical workstations for tele-ICU use Baby monitors |
Clinicians used iPhones for secure text messaging Patients used tablets (iPad and Kindle Fire) for virtual visitation Echo Show devices were used for video communication Staff used baby monitors to view equipment from outside patient rooms |
| Handong Province17 | Cloud ICU | — | Medical staff could communicate with colleagues, listen to lectures, seek consultations, etc. The SAEEG shared PPE videos and conducted remote training for health care providers 50 Training and panel discussions were held nationwide using tele-ICU technology and included >500,000 participants The SAEEG invited Chinese topic authorities to share their experiences caring for critically ill COVID-19 patients |
NOTABLE USES OF TELE-ICU TECHNOLOGIES OUTSIDE DIRECT PATIENT CARE
Two sites reported that tele-ICU technologies were also used for virtual patient visits with family and friends.20,21,26 Atrium Health distributed >100 tablets to patients,20,26 and the Yale New Haven Health System acquired >300 Apple iPads and a number of Amazon Fire tablets specifically for this purpose.21
Houston Methodist Hospital expanded its tele-ICU permissions to allow residents to participate in the care of COVID-19 patients without being directly exposed. While direct care was limited to trained specialists, the residents communicated with nurses, patients, and families. The goal was to provide an adequate level of education and experience without compromising safety, though admittedly at the cost of hands-on practice.27
ADVANTAGES AND DISADVANTAGES OF TELE-ICU USE
Five of the included sites reported opinions of tele-ICU usage collected over the course of its implementation.12,13,15,16,18,20,21,26,27 The most cited advantage of tele-ICU use was the reduction in PPE usage, reported by four sites.15,20,21,26,27 Three sites described advantages related to staff members’ increased confidence in their clinical decision-making due to tele-ICU oversight.12,13,16,18,20,26
Interestingly, bedside personnel at the UC San Diego Health System sites reported increased confidence in the care of both COVID-19 and non-COVID-19 ICU patients, even though tele-ICU support was only provided for the COVID-19 ICU. Staff at Atrium Health conveyed appreciation for the expert help with clinical decision-making, also noting that they valued the ability of tele-ICU remote supervisors to alert them of any unintentional PPE errors. Those working at Sheba Medical Center also reported appreciation for assistance in verifying proper PPE practices while they were on bedside shifts. In addition, staff perceived that fewer medical errors were made due to tele-ICU real-time oversight.
Reported disadvantages were variable, although four sites described frustrations with logistical issues of tele-ICU deployment such as practical inconsistencies and difficulties across multiple hospitals,12,18,21 and maintaining conditions amenable to virtual monitoring.13,16,20,26 More specifically, the UC San Diego Health System reported issues with maintaining consistency between teleintensivists and bedside physicians, and the distribution of hospitals within the Yale New Haven Health System across three states in the United States made tele-ICU deployment logistically challenging.
Staff members in the Atrium Health network reported that ventilators, IV pumps, and other in-room equipment were occasionally moved outside patient rooms so that bedside providers could access them without donning PPE and entering the room; however, this removed them from view of the cameras, so tele-ICU personnel could no longer monitor them. Sheba Medical Center encountered issues of patient privacy after discovering that the portable curtains that had been arranged between beds in a shared space were obscuring camera views and needed to be removed. Aside from the elimination of personal privacy, this increased patient anxiety as those at the earlier stages of COVID-19 who were not mechanically ventilated could see patients undergoing more severe symptoms sometimes seen at the later stages of the disease. Other site-reported opinions of tele-ICU experiences are shown in Table 4.
| SITE | ASSESSMENT(S) | ADVANTAGES | DISADVANTAGES | OTHER OPINIONS |
|---|---|---|---|---|
| UC San Diego Health System12,18 | At ECRMC: Survey Monkey electronic surveys completed by 27 staff members 2 months after launch At HGM and HGT: 9 structured qualitative interviews conducted by UCSDHS staff |
Increased confidence in caring for both COVID-19 and non-COVID-19 ICU patients Enhanced confidence performing procedures related to mechanical ventilation Increased ability to ask questions to intensivists Fewer patients from border region required transfer to other U.S. hospitals Virtual rounding was time-saving, particularly for academic providers with competing responsibilities |
Lack of consistency at times between teleintensivists and bedside physicians Too few coverage hours (tele-ICU services were not provided 24/7) |
UCSDHS intensivists expressed that they felt less stressed during their home campus ICU shifts knowing how hard their community health colleagues were working It is very important that tele-ICU systems foster team building between teleintensivists and bedside providers |
| Houston Methodist Hospital15,27 | — | Reduced PPE usage High degree of scalability Many families expressed gratitude for the ability to virtually visit patients Residents were still able to receive education, learn effective communication with patients and families, and maintain safety and well-being |
High startup costs Lack of hands-on experience for residents |
Overall, opinions expressed by patients, families, and staff favor the continued use of tele-ICU One solution to high startup costs is repurposing of alternative tools (e.g., phones, PCs, other communication devices) |
| Atrium Health20,26 | — | Clinicians who were at high risk or self-quarantined could work from home Verification of proper PPE practices of bedside team Assistance with monitoring, communication, and documentation during high-risk procedures, minimizing personnel needed in patient rooms Help with clinical decision-making Infrastructure is already in place for virtual clinical research Reduced PPE usage Tele-ICU allows redeployment for experienced ICU nurses who may otherwise have been furloughed |
Occasionally ventilators and IV pumps were moved outside patient rooms, and were no longer in view of the cameras Supporting bedside teammates virtually may create situations of fear, frustration, and helplessness for tele-ICU nurses |
Real-time dashboard listing of active COVID-19 ICU patients aids in monitoring each facility’s capacity Hardware and software issues must be resolved rapidly Teleintensivist support of bedside nonintensivists may be better received than having nonintensivists perform just-in-time critical care training |
| Sheba Medical Center13,16 | 40 Formal interviews with staff members, telemedicine experts, and members of the architectural design team 4 Days of observation Guided tours given by unit directors |
Verification of proper PPE practices of bedside team Monitoring patient movement allowed staff to alert bedside team of fall risks Enhanced staff’s sense of control Oversight helped prevent medical errors PPE and audio-visual communication eliminated normal hierarchy of medical staff |
Compromised patient privacy Fragmented visibility of multiple monitoring systems can emotionally stress an already stretched staff Due to the elimination of portable curtains between beds, which interfered with virtual visibility, patients who were not mechanically ventilated could see patients in the later stages of COVID-19 nearby |
Staff reported a significant decrease in general practical abilities while wearing PPE Staff were forced to develop new way to convey empathy and connect with patients The telepresence robot allowed patients to see a human face, although virtually, that was not covered by a mask and other PPE |
| Hospital El Salvador23 | — | — | — | — |
| Yale New Haven Health System21 | — | Estimated PPE savings: at least 631,426 items | Tele-ICU deployment was challenging in such a widely distributed network of hospitals | Centralized model of IT services already in place was valuable for the support of tele-ICU technologies |
| Shandong Province17 | — | — | — | — |
Discussion
Tele-ICU technology has been a valuable part of the COVID-19 responses of many hospitals throughout the world. At a time of uncertainty and rapid reorganization, it has provided health care workers with a means of continuing to efficiently care for critically ill patients while conserving valuable PPE,15,21 reducing infection risk,13,20 and fostering collegial support.17,26
While the specific details of tele-ICU systems varied between sites, there are some common ideas that merit further consideration. First, the minimal overlap in the tele-ICU devices deployed by each site highlights the adaptability of the technology. Given the variety of platforms available, hospitals are able to tailor a system that suits the needs of each individual ICU, taking into account elements such as personnel, financial situation, and patient capacity.15,16,21 In addition, telemedicine services initiated before the onset of COVID-19 (e.g., telestroke, telerehabilitation) may be adaptable for use in an ICU setting.20,21 The designs of tele-ICU systems were equally adaptable, with some sites allowing intensivists and nurses to work from home,18,20 some creating a centralized command center,15,23 and one rotating teams between the command center and bedside care.13,16
A second common idea is that, while patient-centered care is the primary goal of health care facilities, the support of medical staff members has proven to be of paramount importance, and tele-ICU may alleviate some of the stresses under which they have tirelessly performed decisive roles in pandemic response.26 Remote communication can afford medical staff with a break from the added challenge of performing procedures while wearing full PPE.13
Those medical professionals who are quarantined or would have been furloughed due to high-risk conditions are able to continue working and actively contribute to the care of COVID-19 patients.20,26 Staff members working in unfamiliar specialties can be advised in real time by critical care experts while performing bedside procedures.13,20,26 Rapidly changing protocols can be rapidly disseminated to allay the stress of constantly attempting to keep up with current best practices.17
As with any recent technology, there have been some shared downsides to tele-ICU use that could be considered as well. Countless logistical elements must be accounted for, such as camera placement relative to the patient and in-room equipment,20 barrier construction between patients in shared spaces,16 maintenance of reliable internet connectivity,20 and troubleshooting of equipment issues.26 While some sites had information technology (IT) services personnel on whom they could rely for tele-ICU assistance,21 others trained nurses as superusers who could independently perform training and troubleshooting.26
Limitations
This review has two notable limitations. First, while it is important to share the experiences of one hospital system using tele-ICU technology, the insights described may not be generalizable to the wider population. There are many variables that must be adapted to suit the specific needs and resources of each individual health care center, and these must be taken into consideration when implementing a tele-ICU system if its usage is to be successful. Second, nearly all of the outcomes described are subjective, primarily consisting of surveys of patients and health care workers, as appropriate objective metrics were rarely available.
Conclusions
Although applications and user feedback showed a high degree of variability, the general opinion of the institutions included in this review was that tele-ICU is a valuable asset that has positively affected staff experiences without compromising patient outcomes. The implementation of this technology in the diverse settings described here demonstrates that it is highly adaptable and capable of serving a wide range of functions. Our own experience using tele-ICU has been very favorable, and our hope is that the number of hospitals establishing similar systems continues to increase.
Authors’ Contributions
C.W. and X.S. had conception and designed this review; X.L. performed the literature review; R.D. and K.A.K. were responsible for screening articles; X.S., X.L., R.D., and K.A.K. drafted the article; X.S. had critical revision of the article for important intellectual content; C.W. conducted the final approval of the article. All authors agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy of any part of the work are appropriately investigated and resolved.
Disclosure Statement
The authors declared no potential conflicts of interest concerning the research, authorship, and/or publication of this article.
Funding Information
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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