As American cities face a surge of coronavirus patients who will require lifesaving care, they are also facing a rapidly dwindling supply of available intensive-care-unit beds. Physicians and nurses at many of the country’s largest hospital systems are leveraging a decades-old technology in new ways—at times coupling it with cheap, readily available gadgets—to expand their ability to care for and monitor patients.
Generally known as “tele-ICU,” this two-way bedside video is sort of like FaceTime or Zoom. The difference is that it typically adds a host of other technologies to videoconferencing, in order to connect critically ill patients in hospital ICU beds with teams of doctors and nurses who specialize in delivering care to the sickest, even when those teams are miles or even whole states away.
The technologies include high-definition cameras with pan, tilt and zoom abilities, so they can home in on anything in the hospital room, from the patient’s face to the instruments at bedside. They also include direct connections to equipment like heart-rate and blood-pressure monitors. These traditionally expensive systems can connect remote specialists to the doctors and nurses at patients’ bedsides, often at smaller hospitals and in rural locations.
But to treat waves of patients struggling with Covid-19, doctors and technicians are also appropriating less expensive remote-monitoring tech to their arsenal of existing tele-ICU systems. It’s the difference between spending tens of thousands of dollars a bed on top-of-the-line tech that could take weeks to be delivered and installed, and switching to systems that include commercial tablets and can be installed at patients’ bedsides immediately.
If things get really bad, medical providers could enlist the help of store-bought tablets and laptops, as they have in hurricanes and other past disasters.
In the sheer number of patients needing intensive care, coronavirus presents a trial far beyond any that such technology has been put through before. The result is an example of rapid innovation—even disruption—in action, as professionals are forced to improvise using only the gear at hand. By their own accounts, beyond finding it merely serviceable, they are developing and sharing new methods in real time. It’s a medical hackathon in which lives are at stake and the papers analyzing what worked best may have to wait until after the catastrophe has passed.
As in other disasters or even wartime, the results show what’s possible when people are asked to do the impossible and are freed to use any means necessary to accomplish it. It may be a taste of the medical innovation to come, as the entire world is forced to find ways to grapple with an accelerating pandemic.
The health professionals at Northwell Health, which includes 23 hospitals and 72,000 employees across New York state, are rapidly increasing the number of tele-ICU beds from 170 to 420, and say they could accommodate far more. (New York state has desperately tried to add to its 3,000 ICU beds; Gov. Andrew Cuomo has warned it might need 40,000.)
Swedish hospital system in Seattle, another coronavirus hot spot, is leveraging a variety of telehealth technologies, partly to keep health-care workers from being exposed to coronavirus and to keep patients at home when possible.
But of all of the programs to address shortages of health-care providers at Swedish, “I think the tele-ICU capacity is the most important one at this time,” says Elizabeth Meade, the medical director of pediatric quality and safety at Swedish.
The point of tele-ICU isn’t to replace staff on premise, but to supplement them while also keeping the scarce supply of trained intensivists physically removed from patients to minimize their risks of infection. Doctors on the other side of the screens at patients’ bedsides can help with monitoring and can even use local staff as their “hands” when they need to manipulate something in the room.
Four hospitals in Atlanta’s Emory Healthcare system are using tele-ICU technology to support staff. One example is easing the burden of monitoring stable patients when on-premise staff must intubate a Covid-19 patient, a procedure that requires extra people and effort due to the risk of infection, says Timothy Buchman, medical director of Emory’s electronic ICU service.
“In situations where requirements and demands are changing rapidly, the ability to move from one room to the next, or one hospital to the next, literally at the speed of light, allows us to make the most efficient allocation of what are increasingly scarce human resources,” Dr. Buchman says.
Northwell has a telehealth command center in Syosset, N.Y., from which teams of critical-care physicians and nurses are already monitoring more than 130 beds, of which 116 are occupied by Covid-19 patients, says Kara Benneche, director of clinical operations of telehealth services at Northwell.
Physicians and nurses at Northwell’s Syosset center sit at banks of six to eight monitors, connected to two-way video-conferencing systems that allow them to see and interact with patients and any health professionals in the patients’ rooms. The most elaborate of the bedside systems, produced by Philips under the trade name eCareManager, also gives doctors a live feed of a patient’s vital signs.
“That’s the beauty of tele-ICU: One person sitting in a tele-ICU center can take care of 50 to 100 beds,” says Saurabh Chandra, medical director of telehealth services at Northwell. Advanced tele-ICU systems make the monitoring of such numbers possible because they include software that alerts physicians when patients’ vital signs cross into dangerous territory, he adds.
But these devices, part of elaborate, expensive service packages for whole hospitals, can take time to install even under normal conditions. Facing a flood of new patients and obstacles to setting up new equipment, Northwell doctors are getting creative with tech they already have on hand. In December, Northwell ordered a batch of 35 movable carts with two-way video conferencing capability from American Well, which are scheduled to arrive in early April.
These carts were intended to be used in any department in any of Northwell’s hospitals and other facilities. But many are being pressed into service in a variety of roles necessitated by the pandemic, including connecting to ICU beds. Physicians can access the carts’ cameras remotely from a computer. Carts are being sent wherever they’re needed, across Northwell’s hospital system, and can be wheeled from room to room.
This system can also save doctors and nurses who are on site from having to enter patients’ rooms, says Ms. Benneche. Remote practitioners using these systems can’t do anything in patients’ rooms that requires their hands—such as adjusting an IV or a ventilator. But they can check patients’ overall condition, and use the system’s cameras to zoom in on bedside monitoring equipment, allowing them to check vital signs just as they would if they were in the room. Every time they do this, it saves them 10 to 15 minutes of suiting up in protective gear, she adds.
One challenge for the coronavirus patients is the isolation, with loved ones not allowed in. But while tele-ICU can also mean less human contact, nurses are on the other hand more readily available in at least one way: Patients who are able can touch a button at any time to talk to them, something they do frequently just to cope with loneliness, says Ms. Benneche.
SOC Telemed, which provides telemedicine technology to more than 600 hospitals across the U.S., will add 100 hospitals to its platforms in the next 45 days on account of the pandemic, says Jason Hallock, the company’s chief medical officer. About one in seven ICU beds in the U.S. already have tele-ICU capability, he adds.
In 2018, SOC Telemed equipped Onslow Memorial Hospital in Jacksonville, N.C., with telemedicine capabilities, including tele-ICU, in just 18 hours when flooding from Hurricane Michael cut off the hospital from outside help. Using a telemedicine cart Onslow staff already had on hand, “we took care of anyone from a newborn baby to someone in their late 90s,” says Dr. Hallock.
Tele-ICU is only one part of what must be a much broader response to the coronavirus pandemic, emphasizes Eric Toner, a senior scholar with the Johns Hopkins Center for Health Security and author of a report on the ultimate impact of coronavirus on the U.S. “I think [tele-ICU and related] strategies can improve our capacity to have trained people provide care, but I think they’re limited,” he adds.
One thing tele-ICU cannot do is remove existing barriers to which doctors can pitch in at any given hospital, notes Dr. Hallock. It can take 120 days for a physician to become authorized to work at a hospital. While “emergency privileges” can speed this process, for now the technology of allowing remote care is running far ahead of the system’s ability to absorb physicians who could consult through it. Another issue is that states traditionally do not allow doctors to practice medicine without a license specific to that state, limiting the ability of out-of-state doctors to help. These aren’t insuperable barriers—Emory Healthcare previously set up a tele-ICU facility in Australia so health professionals there could cover the night shift at Emory’s ICU units in the U.S.—but they take time to overcome.
Martin Doerfler, a Northwell senior vice president in charge of telemedicine, says he is preparing his hospitals both for the initial peak of the virus, as well as what could be an even bigger peak come November, should coronavirus become seasonal like the common flu.
If it comes to that, teams of doctors at Northwell might have to connect to any tablet or mobile device through a web app, from their central tele-ICU center and remote centers it has set up at each of its hospitals. This option would be limited, lacking the pan and zoom capabilities of dedicated cameras, while offering only basic two-way communication between a remote physician and a patient or bedside nurse.
“I’m practicing now for hundreds—or thousands—of cases and hopefully not tens of thousands,” says Dr. Doerfler.
Write to Christopher Mims at [email protected]
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