Telecritical Care Clinical and Operational Strategies in Response to COVID-19

Goal 1: augment capacity for VCC

• Increase the system-wide total number of beds available for critically ill patients by equipping non-ICU rooms with VCC interface technology. Notably, an additional 130 mobile telehealth carts were purchased for critical care overflow and emergency department use (Table 2). Internal carts from other existing telehealth platforms (telestroke and behavioral health) were also repurposed to be compatible with existing critical care platforms with minimal investment to achieve the initial 275-bed surge goal.

• Coordinate hardware and software acquisition and installation with the Atrium Health Information and Analytics Services (IAS) team to supply the necessary number of remote workstations across the enterprise.

• ○ Allows clinicians who cannot perform bedside duties (e.g., high-risk pre-existing conditions, self-quarantined, and retired) to work from home.

• Train and credential advance practice providers (APPs) to perform VCC duties in alignment with scope of practice defined by state regulations, while exploring virtual supervision rules of site-based APPs through VCC intensivists.

• Develop a team-based approach toward patient care (Fig. 2), whereby critical care procedures would preferentially be performed by surgeons, anesthesiologists, and/or certified registered nurse anesthetists, allowing bedside intensive care providers to facilitate medical care.

• Develop and coordinate use of institution-specific educational and resource materials for non-intensivists to provide critical care, including just-in-time resources.

Goal 2: (a) minimize health care worker exposure while (b) controlling PPE use

• Add virtual access in multiple clinical areas, including proximate nursing workstations and non-ICU areas, such that ICU staff can communicate with patients in isolation without direct exposure.

• Verification of proper PPE worn by bedside teams by VCC nurses.

• Assistance with monitoring, communication, and documentation during high-risk procedures (e.g., intubation and advanced cardiac life support) by VCC nurses and physicians, thereby minimizing the need for additional personnel entering and exiting rooms for these purposes.

Goal 3: improve efficiencies in bedside ICU team management

• As bedside providers are increasingly taxed, expand roles and degree of involvement of VCC providers in all aspects of clinical decision making, order entry, care coordination, and documentation.

• Minimize potential delayed recommendations from specialists by providing remote virtual capabilities in non-ICU clinical areas, such as echocardiography reading rooms, infectious disease, and endocrinology specialists’ offices.

• Facilitate coordination through surgery and anesthesiology teams for procedural support for on-site teams.

• Promote virtual team-based rounding as traditional ICU interprofessional rounding teams might have members deemed “nonessential” and hence only available remotely.

• Serve as a central point of coordination and communication for evolving critical care clinical algorithms, based on advancing knowledge of management of COVID-19.

Goal 4: optimize ICU bed utilization

• Create a real-time ICU surveillance dashboard listing active ICU patients, including COVID-19 confirmed or suspected cases, which provides insight into each facility’s ICU capacity and better equips Atrium Health’s Incident Command structure.

• Centralize ICU triage decision making by the creation of a dedicated intensivist “VCC quarterback” position with explicit responsibilities to facilitate admission, transport, and communication to ICUs across the system.

Lessons Learned During Implementation

We describe the components and strategies of a multifaceted TCC program’s response to the COVID-19 pandemic as it supports the organization’s Incident Command structure, which, in turn, aligns with the SCCM’s pandemic preparation checklist.¹⁷ Several key lessons are being learned during this early phase of the pandemic (Table 3). The approach described did facilitate rapid capacity expansion with the aim to provide intensivist-led critical care coverage 24 h a day, 7 days a week to the system’s hospitals and ICUs. Alternative strategies mainly involved repurposing noncritical care trained frontline ICU staff to function without intensivist oversight, perhaps leading to provider dissatisfaction or burnout,^18,19 or even potential adverse patient outcomes.^20,21 In addition, a nonvirtual-care-based strategy may also pose a higher risk of exposure by bringing more health care workers to the bedside, whereas virtual patient care solutions may increase staff safety.²² Notably, important aspects of larger integrated health care systems also applied that favored a virtual intensivist option: (1) the geographical distances and number of facilities limit the ability for rapid workforce deployment directly to a site as staff may not physically be able nor willing to travel physically across long distances; (2) staffing by the health care system’s own virtual intensive care team (virtual care physician, nurse, pharmacist, and respiratory therapist) is perhaps more likely to adhere to existing clinical and operational standards as this team is already familiar with current practices, protocols, electronic health record, and site-specific capabilities; (3) the ability to regionalize advanced critical care support such as nonconventional mechanical ventilation modes, extracorporeal membrane oxygenation, and other complex needs may be partially eased by incorporating telemedicine.²³

An important initial step involved rapid expansion of an available pool of teleintensivists. These providers come from within the system’s existing clinician workforce that engenders trust²⁴ and assures familiarity with existing critical care resources, while also facilitating nimble redeployment of providers to areas of need within the system. Moreover, the expansion of home workstations limits the need to hire new VCC clinicians and ensures staff availability even when under quarantine or other stay-at-home restrictions. By having intensivists work remotely, this may also mitigate the risk of hospital-acquired COVID-19 transmission. If nonintensivists are pulled to manage critically ill patients during major surge periods, VCC teleintensivists can support in bedside critical care decision making. Layering teleintensivist support over nonintensivists may be better received than asking or even mandating nonintensivists to complete just-in-time critical care training. As such, the VCC intensivists can support clinical decision making across all ICUs, including advanced modes of mechanical ventilatory support when needed. The VCC “Quarterback” position also is proving useful for coordinating interfacility transfer requests and active triage to capable facilities during bed and staffing crises; notably initial feedback was that this was best received by those intensivists with more intimate knowledge of different ICU staffing and capabilities. In summary, by expanding the teleintensivist pool, several potential physician staffing issues may be minimized.

The participation of VCC nurses can offset clinical load from nurses working at the bedside under normal circumstances²⁵; their expanded role in pandemic situations can provide additional critical relief. The COVID-19 pandemic has exacerbated the pre-existing shortage of ICU nurses in the United States,^26,27 leading to higher patient-to-nurse ratios, or to less experienced nurses (such as non-ICU nurses flexed to ICUs), providing front-line care. Atrium Health’s VCC nurses have, on average, 14 years of bedside ICU experience and are certified as critical care registered nurses. Their assistance during pandemic situations may enhance patient safety, the accuracy of documentation, and reduce the risk of bedside nurse burnout.^19,27 In addition, remote provision of PPE education may help preserve crucial PPE supplies, optimize PPE use, and increase overall safety for on-the-ground clinical staff. Lastly, the involvement of virtual care pharmacists and respiratory therapists was continued to augment support the virtual and on-site care teams.

This enormous augmentation of the health system’s VCC resources requires substantial monetary investment; this is especially relevant considering that the program, like many others, is not directly revenue generating. The initial surge budget assumed one bed per patient and was estimated to be ∼140% of current ICU bed capacity, and 300% capacity for critical surge. At critical surge capacity, 130 mobile carts and 102 home workstations would be needed. The estimated costs of $173,106 for home workstations and $956,670 for the initial 130 mobile carts (Table 2) do not account for labor and other indirect expenses. Although these costs seem high, they are far less than building or restructuring hospital facilities; moreover, the process is clearly faster than building new hospitals or units. The system’s clinical and administrative leadership has prioritized these investments as part of its pandemic preparation, but also for future planning for critical care and other services. Still, such scale and complexity may prove cost prohibitive for smaller health systems, and the response outlined may be feasible only for larger systems with more mature TCC programs. Importantly, global supply-chain shortages affected by the pandemic did affect our ability to also purchase additional equipment when needed, such as webcams, mobile carts, and other specialized equipment.

Despite the benefits of a robust TCC program in pandemic situations, there remain many uncertainties and potential limitations of this strategy. Many facilities used extension tubing to move ventilators and intravenous pumps to outside the patient’s room; this helped to minimize bedside staffs’ PPE usage but impaired the ability for VCC intensivists to assess the patient and intervene. Teleintensivists also cannot provide procedural assistance other than remote review of bedside ultrasonographic images.^28,29 Audiovisual experience with bedside staff using PPE is occasionally quite challenging, so communication with the bedside clinicians often would occur outside the patient rooms. Restrictions and limitations on patient and family visitation may further risk poor bedside communication. These factors limited the role of virtual intensivists to involve families, with several noting that when language barriers exist, the communication is limited even further. Given that COVID-19 may affect those with racial and ethnic disparities,²⁸ this may limit utility of VCC families with non-English speakers. Communication risks with other team members, role confusion, and potentially conflicting medical decision making between bedside and virtual providers can still occur. The leadership changes depicted in Figure 2, with the virtual intensivist depicted as team leader could be a significant adjustment for bedside teams, so practice or simulation is recommended if feasible. TCC is only as effective as its technology, so hardware and software issues resulting from internet service disruption or cybersecurity issues, for example, require rapid resolution. Furthermore, difficult end-of-life decision making, especially considering evolving discussions amid resource scarcity,³⁰ can be challenging for virtual intensivists and potentially reduce patient/family satisfaction. Administrative and financial barriers, including fiscal viability, information technology optimization, and credentialing of new providers, can create additional strain on health systems already taxed with high patient volumes, PPE shortages, and staff safety concerns.³¹ The full value of TCC in pandemic situations also may not be fully realized without regional coordination between geographically proximate health systems and institutions. Such intersystem connectivity is not feasible at present, although being investigated by the SCCM.

Despite these numerous challenges, the efforts undertaken position a large health care system’s TCC program to fulfill a critical role not only in the acute phase of pandemic planning, but also in postpandemic clinical and research operations. As the COVID-19 pandemic enters a reopening phase with cautious resumption of previous health care operations, the level of virtual support can flex upward or downward as needed. Creative modeling is now being considered to improve efficiency and streamline the number of teammates needed at any given location to provide bedside care during periods of lower acuity and census. The infrastructure is also now in place for virtual clinical research capabilities across the health care system’s critical care population, with several COVID-19 therapeutic trials relying on the virtual intensivist for screening and enrollment. The experiences from this COVID-19 response will surely spur new innovations as the “lessons learned” become clearer.

Still, many questions remain as to the impact of the VCC’s role in the pandemic response. We aim to improve understanding of whether the outlined steps provide meaningful impact and identify those resources that are required to accomplish each goal outlined. We specifically aim to understand which of these virtual solutions may aid the various phases of the pandemic and which persist after the pandemic has resolved.

Conclusions

We describe strategic initiatives within an integrated health care system that permits TCC to become the nexus of critical care delivery and coordination during the COVID-19 pandemic, aiding the Incident Command in its execution of pandemic preparedness and ability to deliver care as the situation evolves. By emphasizing efficiency, safety, and quality, the health care system’s TCC program evolved from a luxury to a necessity by complementing bedside clinical care while respecting the physical and psychological safety of front-line workers. The VCC model may serve as a resource to other systems looking to expand their telehealth programs. Further research is needed to address important questions related to this model’s cost-effectiveness and impact on patient outcomes and operational goals. By addressing these questions, TCC programs can continue to advance the field through innovations in clinical care and clinical research. Such advancements are not restricted to pandemic situations, when traditional methods of care delivery are challenged, but may also affect the transition to the near future state. Our hope is the lessons learned may catalyze the quality, versatility, and value of our organization in the care of a complex critically ill population.

Disclosure Statement

J.S. receives consulting fees from Medtronic, Inc., and Somnoware Sleep Solutions. All other authors declare no conflicts of interest.

Funding Information

No funding was received for this article.