Integrating a Virtual ICU with Cardiac and Cardiovascular ICUs: Managing the Needs of a Complex and High-Acuity Specialty ICU Cohort

Abstract

A long-standing shortage of critical care intensivists and nurses, exacerbated by the coronavirus disease (COVID-19) pandemic, has led to an accelerated adoption of tele-critical care in the United States (US). Due to their complex and high-acuity nature, cardiac, cardiovascular, and cardiothoracic intensive care units (ICUs) have generally been limited in their ability to leverage tele-critical care resources. In early 2020, Houston Methodist Hospital (HMH) launched its tele-critical care program called Virtual ICU, or vICU, to improve its ICU staffing efficiency while providing high-quality, continuous access to in-person and virtual intensivists and critical care nurses. This article provides a roadmap with prescriptive specifications for planning, launching, and integrating vICU services within cardiac and cardiovascular ICUs-one of the first such integrations among the leading academic US hospitals. The success of integrating vICU depends upon the (1) recruitment of intensivists and RNs with expertise in managing cardiac and cardiovascular patients on the vICU staff as well as concerted efforts to promote mutual trust and confidence between in-person and virtual providers, (2) consultations with the bedside clinicians to secure their buy-in on the merits of vICU resources, and (3) collaborative approaches to improve workflow protocols and communications. Integration of vICU has resulted in the reduction of monthly night-call requirements for the in-person intensivists and an increase in work satisfaction. Data also show that support of the vICU is associated with a significant reduction in the rate of Code Blue events (denoting a situation where a patient requires immediate resuscitation, typically due to a cardiac or respiratory arrest). As the providers become more comfortable with the advances in artificial intelligence and big data-driven technology, the Cardiac ICU Cohort continues to improve methods to predict and track patient trends in the ICUs.

Keywords: burnout; cardiac ICU; cardiothoracic ICU; cardiovascular ICU; critical care; patient outcomes; predictive medicine; staffing; tele-critical care.

Figure 1

A primer on the virtual ICU (vICU) continuous model. The vICU platforms connect the hub (operations center) to the patient’s room using the audiovisual (AV) communication infrastructure, and patients are monitored by virtual intensivists and virtual critical care nurses vRNs) from the operations center using the AV infrastructure.^,,,,,, HL-7: Health Care Level 7; EMR: electronic medical record; ICD: International Classification of Diseases

Figure 2

The introduction of virtual intensive care unit (vICU) services to the cardiovascular ICU required stepwise integration, taking almost 1 year. Two months after the initial launch, the CVICU patient population was divided into integrated and nonintegrated groups. STEMI: ST elevation myocardial infarction; NSTEMI: non-ST elevation myocardial infarction; LVAD: left ventricular assist device; RVAD: right ventricular assist device; ECMO: extracorporeal membrane oxygenation

Figure 3

Workflow describing overnight integrated patient admissions to the CICU and nonoperating room (non-OR) patients to the CVICU, with the roles and responsibilities of the virtual MD (vMD). CICU: cardiac intensive care unit; CVICU: cardiovascular ICU; sMD: support intensivist; APPs: advanced practice providers; RNs: registered nurses; vRNs: virtual RNs; ECG: electrocardiogram

Figure 4

Workflow describing overnight admissions of patients from the operating room (OR) to the CVICU, with the roles and responsibilities of the virtual MD (vMD) covering the integrated patients, support intensivist (sMD) covering the nonintegrated patients, advanced practice providers (APPs), registered nurses (RNs) and virtual RNs (vRNs). CVICU: cardiovascular intensive care unit; ECG: electrocardiography

Figure 5

In-person intensivist staffing alignment pre-vICU and post-vICU across the entire Houston Methodist system, including HM hospital’s CICU and CVICU. CICU: cardiac intensive care unit; CVICU: cardiovascular ICU; vMD: virtual MD; sMD: support intensivist; vRN: virtual RNs; MICU: medical ICU; NICU: neonatal ICU: SLICU: surgical ICU

Figure 6

Number of cardiac, blood pressure, or respiratory alerts generated during the monitoring hours (2021–2022); Virtual alert triggered by bedside providers; nocturnal Code Blue trending for 1,000 patient days (2019–2022); and the Standardized Mortality Ratio for the Cardiac ICU Cohort (2021 & 2022). vICU: virtual intensive care unit; CICU: cardiac ICU: CVICU: cardiovascular ICU