Tele-Critical Care Could be a Powerful Force-Multiplier in Extending Military Health System Resources to Acutely ill Patients | Deloitte US has been saved
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By Shaun Rangappa, M.D., managing director, and Laura Baker, senior manager, Deloitte Consulting LLP
The COVID-19 pandemic is dramatically increasing the complexity of the Critical or Intensive Care Unit (CCU/ICU) environment. It is highlighting the limited number of ICU beds in more than half of US counties,1 and is taxing the ability of health systems to care for acutely ill patients. However, the pandemic is also showcasing how a variety of US Military Health System (MHS) and civilian settings are using digital technology to create “virtual critical care wards” that can help bridge shortfalls in ICU specialty care.
Prior to the pandemic, our research already showed the influence virtual health would likely have on the health care landscape over the next few decades. According to a survey we conducted prior to the COVID-19 pandemic—in conjunction with the American Telemedicine Association (ATA)—96% of health executives expected industrywide investments in virtual health would increase over the next five years, and 74% of executives predicted the investments would be significant (25% or more).
COVID-19 has highlighted the need for investments in virtual health. According to the American Hospital Association, the US might need up to 1.9 million ICU beds in coming months—20 times the current supply2—to treat COVID-19 and other critically ill patients. Tele-Critical Care (TCC), as well as other forms of telemedicine, rely on digital channels—phone, text, video, physician electronic medical records, and connected devices—to shift care into the virtual space and provide hospitalized patients with continuous, remote coverage by critical care-trained clinicians.
For example, one of Deloitte’s COVID-19 rapid-response tools3 uses smartphone technologies to conduct secure, real-time, face-to-face interactions between clinicians and individuals or groups. This helps to move patients through the continuum of care without exposing them to infection risks that are inherent during physical visits.
TCC extends critical-care capabilities into smaller and/or remote health facilities that might lack the expertise and resources needed to treat COVID-19 and other ICU patients. Using a basic hub-and-spoke model, TCC doctors and nurses located at hub sites—often, a municipal or academic medical hospital—interact with staff and patients at spoke sites. This is typically done through high-definition videoconferencing, which allows them to review real-time bedside monitors, clinical data, and online clinical decision-support tools.4 The TCC clinicians provide recommendations and collaboratively develop care plans with the bedside caregivers.5 Moreover, these virtual critical care wards can be created regardless of location. This model’s emphasis is on mentoring and supporting the team on the ground, not replacing them. The role of the TCC clinician is diverse. For example, they might conduct virtual rounding where a simple status conversation becomes an opportunity for teaching, or they might be called to help support a newly admitted patient who is deteriorating.
Is it time to expand beyond the hub-and-spoke model?
Looking to the future, there likely will be situations in which the hub-and-spoke model is neither practical nor possible. During a sudden emergency or natural disaster, for example, relying on a co-located core group of TCC experts could be problematic if that site is rendered inoperable. Such challenges could be eliminated by moving from a hub-and-spoke model to a networked design where care can be provided anywhere. Working with MHS and commercial experts, Deloitte has developed an architectural framework that uses cellular networks, mobile technologies, and cloud computing to enable critical care specialists to deploy and scale medical care capacity when and where it is most needed—whether a health care facility, field hospital, gymnasium, or home.
COVID-19 has amplified the need for—and highlighted the limited availability of—critical care specialists, especially in rural or underserved areas. As COVID-19 cases have surged across the country recently, many hospitals and health systems are concerned about their capacity and are feeling the strain on their ICU staffs.
Fortunately, TCC is proving to be a powerful force-multiplier in supporting and augmenting these resources across the globe. Published ratios suggest that one virtual intensivist can monitor and respond to emergencies for 75-125 patients, and one remote ICU nurse can provide virtual monitoring for 30-60 patients.6 Civilian TCC has been shown to decrease patient mortality by enhancing care quality, safety, and process adherence.7 It also can reduce costs.8 In the military, TCC enhances the capability to address patient complexity and hospital volume challenges, while also reducing network costs.9
COVID-19 outbreaks are continuing to strain ICU/CCU resources, underscoring the urgency for military and civilian health systems to employ innovative ways to care for acutely ill patients. Digital technologies including TCC provide a powerful pathway to extend high-quality ICU/CCU capabilities to every patient’s bedside.
1. Millions of older Americans live in counties with no ICU beds as pandemic intensifies, Kaiser Health News, March 30, 2020
3.ConvergeHealth Connect for Telemedicine powered by Zyter (CCpZ)
4. Joint Telecritical Care Network
6. Request for Project Proposals MTEC-20-10-COVID-19_NETCCN_TATRCNumber W81XWH-15-9-0001
7. A multicenter Study of ICU Telemedicine Reengineering of Adult Critical Care, UMass Memorial Critical Care Operations Group, Chest Journal, March 1, 2014; Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes, JAMA, June 2011
8. ICU telemedicine program financial outcomes, Chest Journal, December 5, 2016; Economic Evaluation of Telemedicine for patients in ICUs, Society of Critical Care Medicine, February 2016
9. Successful implementation of low-cost tele-critical care solution by the US Navy: Initial Experience and Recommendations. Military Medicine, 2017
Dr. Rangappa is an Internal Medicine/Cardiology physician with over 20 years of health care experience. He trained at Cornell University and the University of Virginia and holds a Master’s degree in health care administration. He was a faculty member in the division of cardiology and led performance improvement efforts and overall strategy development across the cardiovascular service line at the Medical College of Virginia/VCU Health System. Dr. Rangappa has provided strategic guidance and operational assistance for many clients at Deloitte across commercial and federal sectors as a physician consultant, and has broad experience working in conjunction with teams of clinicians and administrators. Clients have included medical practice groups as well as academic and community hospitals across the United States, Canada, and the Middle East. He has been heavily involved with development of clinical content, clinical decision support & the implementation of electronic medical record systems across large organizations. He has focused on physician adoption, engagement and retention strategies needed for success.