Last year, in the month of November, when the pandemic reached its intensity heights, Kerala Health Minister, K Shailaja, inaugurated her state’s first tele-ICU command center. Sponsored by the National Health Mission (NHM), this tele-ICU command center was established at the Government Beach Hospital. The launch of this center is notably a breakthrough and a significant revolution in health-tech innovation and an outstanding example of a public-private partnership.
Supervised by a team of intensivists from the command center of Meitra Hospital, the electronically-equipped medical facility aims to cover up for the shortage of Intensivists in the public healthcare sector.
Tele-ICU is the use of an off-site command center in which a critical care team (intensivists and critical care nurses) is connected with patients in distant ICUs to exchange health information through real-time audio, visual, and electronic means.
In its simplest form, a tele-ICU enables off-site clinicians to interact with bedside staff to consult on patient care. One centralized care team ideally manages a large number of geographically dispersed ICU locations to exchange health information electronically, in real-time. A tele-ICU system, therefore, is a supplement (not a replacement) to the bedside team, offering support to increasingly scarce clinical resources, especially during pandemic situations.
Phillips, in its white paper on tele-ICU, has expressed that tele-ICU programs concentrate clinical resources in remote care centers (a central monitoring facility) and extend those resources to the bedside via technology, independent of the care center or hospital’s location. Using A/V conferencing and a real-time data stream of patient information from multiple interfaces, a physician working from a care center in location A can rapidly care for a patient in location B, day or night.
Exposing India’s intensivists shortage
Dr. P Mohanakrishnan, CEO, Meitra Hospital, while inaugurating the center at Kerala, had said that there are more than 3 lakh ICU beds against a mere 5000 intensivists in the country. “The gap is huge & cannot be left unaddressed, especially when it comes to life-saving critical care treatments. Technology advancements have ensured that we can now democratize quality healthcare and bring it closer to people through wider access. Our Tele-ICU setup is a proud Made-in-India solution that is at par with global standards. Our team of intensivists will monitor the Tele-ICUs from our Command Center based at Meitra Hospital, which will offer round-the-clock monitoring of critical care patients. We have also trained the staff at Beach Hospital so that they stay abreast of the new technology,” said the doctor.
Also, while addressing the center’s virtual inauguration ceremony, K Shailaja informed that Kerala’s health department had taken up the initiative to set up an ICU with 22 beds at the Government Beach Hospital. In light of the Covid-19 pandemic, the project would be funded by NHM funds. To ensure 24X7 security within the facility, Meitra hospital has installed high-definition cameras and advanced software at the general hospital ICU. The cameras are further connected to the command center for 24-hour monitoring of the patients.
Vouching for the several advantages of tele-ICU, Dr. N. Ramakrishnan, Founder & Managing Director, Chennai Critical Care Consultants & TACT Academy for Clinical Training, says distance is not a real barrier for Critical Care anymore. It is currently not feasible to staff every ICU with qualiﬁed Intensivists as they are far and few and mostly concentrated in tertiary care centers in larger cities.
India has only 0.55 government hospital beds per 1000 population and approximately 70,000 ICU beds (inclusive of public and private healthcare facilities). Most ICU beds are concentrated in tier 1 and tier 2 cities with limited to no critical care capacity in rural districts and smaller towns.
In terms of human resources, India currently has 1 doctor for every 1445 Indians (still below the WHO target of 1:1000). While the total number of doctors with intensive/critical care training in India is unknown, the Indian Society of Critical Care Medicine (the largest critical care body for the country) has just about 12,046 members (including consultants and in-training members) across branches.
Clearly, these numbers are inadequate for a country as large and as populous as India. There are similar human resource constraints with nursing capacity in general and major gaps in the availability of trained critical care nurses. These gross shortages in resources imply that large parts of the country do not have access to skilled personnel or ICU beds. These shortages will be further amplified in the middle of disasters and pandemics like COVID-19.
This is where, says Dr Ramakrishnan, tele-ICU or tele-Critical Care serves as a customized solution for hospitals using technology to bridge experienced Critical Care Specialists (Intensivists) and nurses to monitor and support care for patients in the ICU. The Intensivists and nurses operate from a centralized monitoring center using digital communication technologies.
Dr. N. Ramakrishnan is American Board Certified in Internal Medicine, Critical Care Medicine & Sleep Medicine and also has a Master’s degree in Medical Management from the University of Southern California. He is a fellow of the American College of Physicians (FACP), American College of Chest Physicians (FCCP), American College of Critical Care Medicine (FCCM), Indian College of Critical Care Medicine (FICCM) & Indian Sleep Disorders Association (FISDA). He has been practicing Critical Care Medicine for about 15 years and Sleep Medicine for over 10 years and is currently Senior Consultant in Critical Care & Sleep Medicine & Director, Critical Care Services for Apollo Hospitals.
Relevance of tele-ICU in pandemic times
Dr Ramakrishnan, through this blog, shares insights on where tele-ICU scores as a viable digital model to deliver patient care from anywhere, thwarting all barriers in critical care delivery during demanding times like the ongoing pandemic.
According to the doctor, the benefits of tele-ICU become readily apparent in the face of pandemics, such as COVID-19. First, tele-ICUs can provide expert advice in the screening of patients and regulate triage into COVID units. Often during pandemics, panic among healthcare providers can lead to suboptimal triage and the healthcare system can be overwhelmed by unnecessary admissions. Guidance from a remote specialist can help mitigate this.
Second, expert tele-ICU staff can provide clear instructions regarding the need for testing of admitted patients and serve as a resource hub for bedside caregivers with regard to infection-control practices.
Third, the biggest advantage of tele-ICU is the ability to closely monitor patients suspected or diagnosed with COVID-19 from remote sites and minimize the exposure time of the bedside staff. Consistent evidence has demonstrated that the exposure time of caregivers correlates with the risk of incurring the illness and the viral load once infected. Tele-ICU serves as an effective alternative for the provision of high-quality care while attenuating caregiver exposure.
Fourth, at times of a pandemic when bedside staff are burdened by high volume and high acuity of patients, there is little time to interact and counsel family members. Tele-ICU teams enable families to interact with a care provider without disrupting the flow of bedside care.
Finally, several isolation wards and high-dependency units could be managed simultaneously centrally by a team of intensive care physicians with assistance from ground teams, thereby maximizing the efficiency of the available personnel. Simple and innovative solutions using existing applications (apps) on smartphones may also be used to provide tele-health solutions.
Tele-ICU technology deployed as a force multiplier
Dhruv Joshi, Director – Cloudphysician Healthcare Pvt Ltd, in one of the earlier HCITExpert blog post, had shared that with a tele-ICU system it is possible for 1 intensivist to cater to the needs of 60-80 sick patients as opposed to the current ratio of 1:15, where an intensivist is seeing a patient at the bedside.
According to Joshi, trained healthcare workers needed to treat a large influx of COVID-19 patients are limited. Even more scarce are ICU specialists (intensivists) who will need to be involved in the care of these patients. Transitions from High Dependency Care (HDU) to ICU will need to be triaged and supervised by them. Patients who need advanced therapies will require their services at a moment’s notice. Such coordination and decentralization of care is only possible if superspecialists are connected to as many beds as possible so that their skill and experience is maximally utilized.
Hence, a command center can either be a part of a “hub and spoke” model where it covers multiple smaller ICUs or be a part of a “hive” model where a large 1,000-bed open air ICU is covered by tele-ICU providers remotely. Another advantage is that healthcare staff at the bedside can also use monitoring technology to reduce their exposure and risk of infection.
In this way, the specialists in the command centers can determine which patient cannot be managed using merely nasal oxygen under pressure and would require ventilators thereby ensuring appropriate triaging of patients for a limited number of ventilators. If required these patients can then be moved to a separate/same unit where they are placed on ventilators for further care. These units too will be under tele-observation ensuring patients are appropriately managed on ventilators.
Can tele-ICUs offer financial advantages to hospitals?
Physicians admit that tele-ICU not only serves a critical role in the effective regional management of ICUs, but positively impacts the healthcare system as a whole. Digital technological advancements make anything possible in this era. Tele-ICU, being a confluence of the best minds that work in health and IT drives and enhances the medical outcomes of the patients regardless of where they are.
The underlying fact in healthcare is however achieved, i.e., tele-ICU fulfills an integrated and collaborative workflow where patient care is the major focus. And most importantly mortality rates can significantly be lowered when tele-ICU facilities are made available.
Having a centralized remote patient monitoring center provides the ability to consolidate and standardize care, reduce transfers while maximizing bed utilization, and support onsite staff. This reduces costs while enhancing revenues, patient flow, and capacity management across the system.
This would also mean a career advancement option for the intensivists and the critical care nurses. Only the highly experienced ones can be given the major responsibility of handling tele-ICU.
A 2017 study in the journal CHEST published the efficacy of the tele-ICU model, examining more than 51,000 patients in the US across seven adult ICUs. While tele-ICUs have previously been associated with improving mortality rates and length of stay, this study claimed to be the first to address the financial outcomes in depth.
The results showed:
• An ICU managed by a tele-ICU improved case volume by 21% over traditional models.
• A centralized tele-ICU model improved contribution margins by 376% ($37.7 million compared to $7.9 million) due to increased case volume, shorter lengths of stay and higher case revenue relative to direct costs.
• A tele-ICU, when co-located with a logistical center (to improve bed utilization), improved case volume 38% over traditional models.
• A tele-ICU with added logistical center and quality care standardization improved contribution margins by 665% ($60.6 million compared to $7.9 million).
• This care delivery model allowed recovery of the initial capital costs of the ICU telemedicine program in less than 3 months.
In conclusion, when more hospitals have this model engaged in their medical setup, they are paving the way for better financial as well as clinical benefits and that too across a wider healthcare system. Success therefore would depend greatly on how one would use the system and get the maximum benefits out of it.