COVID-19 and the Transformation of Intensive Care Unit Telemedicine

Abstract

The concept of telecritical care has evolved over several decades. ICU Telemedicine providers using both the hub-and-spoke ICU telemedicine center and consultative service delivery models offered their services during the COVID-19 pandemic. Telemedicine center responses were more efficient, timely, and widely used than those of the consultative model. Bedside nurses, physicians, nurse practitioners, physician assistants, and respiratory therapists incorporated the use of ICU telemedicine tools into their practices and more frequently requested critical care specialist telemedicine support.

Keywords: COVID-19; Critical care; Digital health; Digital medicine; Tele-ICU; Telehealth; Telemedicine.

Fig. 1

The expansion of existing tele-ICU infrastructure by adding spokes to established ICU telemedicine centers to expand the medical center and community hospital ICU capacity and provide safe care at field hospital sites that did not exist before the pandemic. During the COVID-19 pandemic, the hub-and-spoke model deployed telemedicine carts with monitoring capability to direct off-site critical care clinicians to at-risk patients, often before physiologic instability and organ failure had occurred. This allowed an approximate 15% increase in bed ICU capacity by conversion of telemetry beds and intensivist support of care by bedside staff who did not work in an ICU before the pandemic. This was conducted without additional telemedicine center staffing.

Fig. 2

Lateral expansion of existing infrastructure was 50-fold more effective than the deployment of the consultative model. This is due, in part, to the more efficient 2-step activation characteristics of the hub-and-spoke infrastructure (top) compared with the 6-step activation process for arranging telemedicine intensivist consultations (bottom). Expansion of the consultative model also requires the resolution of crediting, privileging, privacy, connectivity, and security barriers before being deployed.

Fig. 3

When off-the-shelf devices were no longer available, telemedicine team information systems professionals continued to expand ICU capacity by cobbling together the camera, microphone, speaker, help button, power supply, sound and network cards, cables, connections, power supply, battery, and antenna (for wireless carts) into a functional telemedicine cart from spare or parts that were commercially available or could be scavenged from out of service devices or carts originally designed for EHR documentation or other nontelemedicine uses. One skilled professional was able to build a cart every 4 hours.

Fig. 4

Wired ICU in room camera usage episodes increased at the time of COVID-19 ICU caseload increased during the pandemic (A). The increase in camera usage by off-site usage (B; red bars) was in proportion to the ICU telemedicine-supported ICU bed expansion. A more than 10-fold increase in camera usage by bedside providers occurred at the time that access was granted (B; blue bars). Camera usage by bedside ICU providers exceeded, in aggregate, telemedicine provider usage (C).