Tele-medicine, tele-rounds, and tele-intensive care unit in the COVID-19 pandemic

Pradeep Rangappa; Karthik Rao; Thrilok Chandra; Sunil Karanth; Jose Chacko

doi:10.4103/injms.injms_100_20

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Year : 2021 | Volume : 12 | Issue : 1 | Page : 4-10

Tele-medicine, tele-rounds, and tele-intensive care unit in the COVID-19 pandemic

Pradeep Rangappa¹, Karthik Rao¹, Thrilok Chandra², Sunil Karanth³, Jose Chacko⁴
¹ Department of Critical Care, Columbia Asia Referral Hospital, Bengaluru, Karnataka, India
² Department of Health and Family Welfare, Government of Karnataka, Karnataka, India
³ Department of Critical Care Medicine, Manipal Hospital, Bengaluru, Karnataka, India
⁴ Department of Critical Care, Majumdar Shaw Medical Center, Bengaluru, Karnataka, India

Date of Submission	22-Aug-2020
Date of Decision	21-Oct-2020
Date of Acceptance	23-Oct-2020
Date of Web Publication	04-Jan-2021

Correspondence Address:
Dr. Pradeep Rangappa
Department of Critical Care, Columbia Asia Referral Hospital, Bangaluru - 560 055, Karnataka
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injms.injms_100_20

Abstract

The COVID-19 pandemic has caused a worldwide health crisis, laying stress on existing health-care systems and causing an unprecedented financial crisis. In this situation, provision of homogenized, evidence-based care by all levels of health-care providers, including those in a low-resource setting, is of paramount importance. As a specialized offshoot of Tele-medicine, Tele-intensive care unit (Tele-ICU) offers an innovative solution in the care of critically ill COVID-19 patients, by off-site clinicians, using audio, video, electronic, and tele-communication links to leverage technical, informational, and clinical resources. Tele-ICU also helps overcome the shortage of expertise like intensivists in these settings and helps to take the clinical expert to the patient bedside by remote monitoring and supervision. Telemedicine applications can be classified into four basic types, according to the mode of communication, timing of the information transmitted, the purpose of the consultation, and the interaction between the individuals involved-be it doctor-to patient/caregiver or doctor to doctor. The benefits and concerns of tele-medicine have been described in detail.

Keywords: COVID-19, COVID health care, distance health care, telemedicine, video conferencing

How to cite this article:
Rangappa P, Rao K, Chandra T, Karanth S, Chacko J. Tele-medicine, tele-rounds, and tele-intensive care unit in the COVID-19 pandemic. Indian J Med Spec 2021;12:4-10

How to cite this URL:
Rangappa P, Rao K, Chandra T, Karanth S, Chacko J. Tele-medicine, tele-rounds, and tele-intensive care unit in the COVID-19 pandemic. Indian J Med Spec [serial online] 2021 [cited 2023 May 29];12:4-10. Available from: http://www.ijms.in/text.asp?2021/12/1/4/306114

Introduction

India is a land of diversity with a heterogeneous health-care facility across the country. Against the background of widespread COVID-19 infection, the goal is to homogenize care across designated COVID-19 hospitals to deliver the optimal care, improve outcomes, reduce morbidity, and save lives. We need to restructure care-processes across the district level hospitals to ensure uniform care based on updated, evidence-based information. We face additional challenges considering our incomplete understanding of the clinical manifestations, diagnostic dilemmas, therapeutic modalities, and preventive strategies of COVID-19 infection. Administrative challenges include capacity building, structural adjustments, creation of new standard operating procedures (SOP), and maintenance of the supply chain of personal protective equipment (PPE). Besides, we need to ensure adequate availability of diagnostic tools, drugs, and oxygen delivery devices.

Tele-intensive care unit (Tele-ICU) constitutes care provided to critically ill COVID-19 patients by off-site clinicians using audio, video, electronic, and tele-communication links to leverage technical, informational, and clinical resources,^[1] as shown in [Figure 1]. The World Health Organization defines telemedicine as “the delivery of health-care services, where distance is a critical factor, by all health-care professionals using information and communication technologies for the exchange of valid information for the diagnosis, treatment, and prevention of disease and injuries, research and evaluation, and the continuing education of health-care workers, with the aim of advancing the health of individuals and communities.” There is a shortfall of qualified intensivists to meet the growing demands of the COVID-19 pandemic both in the cities and in district hospitals that provide care to COVID-19 patients. Early recognition of warning signs portending a possible downward spiral with clearly defined care processes leads to improved outcomes in these patients.^[2] Research has also shown more favorable outcomes with high-intensity staffing models that include mandatory intensivist consult.

Figure 1: Integration of clinical variables, monitored variables and investigative variables between District Hospital Physician and Expert at Bangalore to guide decision making

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The role of telemedicine during the COVID-19 pandemic is two-fold: To connect intensivists with patients and to support frontline bedside clinicians, regardless of patient location.^[3],[4] This is achieved by imparting best practice guidelines complying with national protocols, optimization of oxygen delivery devices, and assistance with troubleshooting crisis situations. This strategy involves a flexible, multi-disciplinary approach, accompanied by rapid response and ability to improvise. The limited availability of intensivists and increased cost of care may make onsite presence untenable; hence, the utilization of tele-ICU as means to access critical care expertise appears promising.^[1]

Tools For Telemedicine

Telemedicine involves the use of multiple tools to assist doctors including telephone, video, devices connected over Local Area Network (LAN), Wide Area Network (WAN), internet, mobile or landline phones, chat platforms such as WhatsApp and Facebook Messenger or mobile applications or internet-based digital platforms for telemedicine. Data transmission systems such as Skype and E-mail are also useful tools. However, the core principles underlying the practice of telemedicine remain the same. Whichever mode of communication is used, it comes with its own strengths and limitations, as shown in [Table 1].

Table 1: Strengths and limitations of various modes of communication

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Telemedicine applications can be classified into four basic types, according to the mode of communication, timing of the information transmitted, the purpose of consultation, and the type of interaction; this may be between the doctor and the patient or caregiver, or between doctors,^[5] as shown in [Figure 2].

Figure 2: Components of tele-ICU tele-rounds

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Mode of communication

Video (telemedicine facility, applications, video on chat platforms, Skype/Facetime)
Audio (Phone, Voice over internet protocol (VoIP), applications)
Text based.

Telemedicine chat-based applications (specialized telemedicine smartphone applications, websites, and other internet-based systems)
General messaging/text/chat platforms (WhatsApp, Google Hangouts, Facebook Messenger)
Asynchronous (E-mail/Fax).

Timing of information transmitted

Real time Video/audio/text interaction

Asynchronous exchange of relevant information.

Transmission of a summary of patient complaints and supplementary data including images, laboratory reports, and radiological investigations. This type of data may be forwarded to the individuals involved at any point of time and accessed later as required.

Telehealth Modalities

Telemedicine communication between doctors and patients can be classified^[6] as:

Synchronous: This includes real-time telephone or live audio-video interaction, typically with a patient using a smartphone, tablet, or computer

A health care provider may be able to use specialized medical equipment including digital stethoscopes, otoscopes, ultrasonography, etc., with remote evaluation by a specialist.

Asynchronous: This includes “store and forward” technology where messages, images, or data are collected initially and interpreted later. Patient portals can facilitate this type of communication between the provider and the patient through secure messaging
Remote patient monitoring: This allows direct transmission of clinical measurements remotely to the health-care provider, in real-time or as saved data.

Benefits and Potential Uses of Telehealth

Telehealth services can complement public health strategies during the COVID-19 pandemic by enabling social distancing and reduce the risk of exposure to infections. The requirement for PPE can be cut down and lessen financial constraints. Hence, these services are the need of the hour. These services have both benefits and potential concerns, as shown in [Table 2].

Table 2: Benefits and concerns of tele-intensive care unit

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Telemedicine can facilitate continuity of care by avoiding delays in routine care. Telemedicine also enables care for patients who are unable to either travel or have difficulty in accessing regular care. Remote access can also help preserve the patient-provider relationship when a physical visit is not feasible. Telehealth services can be used to:

Screen patients who may have symptoms of COVID-19 and referral as appropriate
Provide care for non-COVID-19 conditions, identify patients who may need additional consultation or assessment, and refer as appropriate
Access primary care providers and specialists, including mental and behavioral health care, for chronic health conditions and medication management
Provide medical help and support for patients suffering from chronic health conditions
Participate in physical therapy, occupational therapy, and other modalities, thus providing optimal health
Monitor clinical signs and relevant data in chronic medical disease including blood pressure and blood glucose measurements
Follow up with patients after hospitalization
Deliver advance care planning and counseling to patients and caregivers to document preferences if a life-threatening event or medical crisis occurs
Provide education and training for the health-care provider through peer-to-peer professional medical consultations (inpatient or outpatient) that are not locally available, particularly in rural areas.

The Concept of Public-Private Partnership

The think-tank of the health department of the Government of Karnataka conceptualized a public-private partnership in creating a critical care resource team including three private hospitals from the city of Bangalore. The team would carry out tele-rounds as an outreach service to cover all the districts in the state providing care to COVID-19 patients. A taskforce was set up with consensus among specialists and COVID-designated hospitals were established in all districts. The public health fraternity stepped in to take up the responsibility and additional workload. The concerning situation that evolved over time required rapid deliberation and sustainable action. Protocols and SOPs had to be created to ensure homogeneity of care based on an updated level of evidence throughout Karnataka under specialist supervision. The Government was ready with frontline health-care workers. The private establishments were forthcoming to work with public hospitals to lend their multi-specialty expertise to homogenize the care and assist in complicated cases.

Tele-Intensive Care Unit/Tele-Medicine and Tele-Rounds

Tele-ICU is care provided to critically ill patients by off-site clinicians using audio, video, and electronic links to leverage technical, informational, and clinical resources. Tele-ICU care includes the ability to detect clinical instability or laboratory abnormalities in real-time. It involves collection of additional clinical information regarding the patient, orders diagnostic testing, enables diagnosis, implements treatment, and provides other facets of intensive care including the management of life-support devices and communication with patients and bedside care providers.^[3]

Tele-ICU deals with real-time continuous monitoring of patients by off-site physicians. Tele-rounds constitute an innovative middle-path introduced by the Government of Karnataka, as shown in [Figure 3]. Using this system, ward rounds are performed twice daily along with district hospital doctors by an off-site multi-specialty team using audio-visual aids (Zoom platform, WhatsApp,) akin to handover rounds that typically occurs in the ICU. Cases are prioritized, and details of critically unwell patients are deliberated in great detail, vulnerable trends captured, and appropriate diagnostic and therapeutic interventions are suggested. Follow-up interventions that emanate from the guidance offered are carried out through WhatsApp or telephonically to ensure mitigation and prevention of a downward spiral. During the tele-rounds interaction, all district hospitals are logged in and enable active learning across 14 districts through scientific discussion. Relevant knowledge is imparted, updated interventions offered, and scientific cues of a transformational nature are provided. Onsite doctors are encouraged to participate in decision-making to achieve the best possible outcomes for the patients. Following rounds, there is an ongoing exchange of academic insights involving the latest publications, videos, and other useful scientific material.

Figure 3: Tele-medicine-decision-tree-for-COVID-19-patient

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There could be practical prblems during tele-medicine, when one is wearing Personal Protective Equipment (PPE). These include-

Difficulty in having a clear line of communication

Recognizing the person participating
Muffled speech and nonclarity of speech due to the mask/eye-shield
Inability to perceive the feelings/mood of the participating health care workers.

Inability to participate for prolonged periods of time

Discomfort of wearing PPE
Frustration occurring out of the combination of discomfort of PPE and the difficulty in communicating the information.

Risk errors due to miscommunication.

Tele-Intensive Care Unit/Tele-Rounds Impact on Influencing Favorable Outcome in Patients

From the available literature,^{[7],[8],[9],[10],[11],[12],[13],[14],[15]} it has been clearly demonstrated that tele-ICU has influenced favorable outcomes including reduced mortality and length of stay in ICU and hospital, decreased the occurrence of critical events, and most importantly, ensured adherence to “Best Practice Guidelines” leading to improved clinical outcomes. Studies have also shown that by minimizing the critical events in vulnerable patients and improving clinical outcomes, cost minimization was achieved. In the COVID-19 scenario, recent U. S data showed a significant reduction in PPE utilization by minimizing the number of health-care personnel required to provide bedside care.^[3] Tele-medicine was valuable in facilitating effective communication with the patient by family members, counseling by psychologists, interaction with social workers, and spiritual support by chaplains.^[3] Tele-medicine enables casting an expert remote eye that may influence favorable outcomes.

What are the Key Requisites for the Success of Tele-Intensive Care Unit/Tele-Rounds?

The degree of benefit from tele-ICU/tele-rounds is directly proportional to the degree of acceptance by the involved clinicians and a mindset to adapt to a change in process, keeping the best interest of the patients as the envisaged mission.^[1] Transformative knowledge gain, shared decision making, establishing good rapport and good inter-personal communication are quintessential for success. Tele-rounds specialists have to be of good academic standing with reasonable seniority and adequate experience to address complicated cases. Tele-specialists typically should be active clinicians regularly caring for critically unwell patients by the bedside and involved in tele-medicine in addition, in contrast to carrying out tele-work alone.^[16] Good audio-visual interface without interruptions is also a key to facilitate adequate compliance.^[1]

The clinical success of tele-ICU, as seen in a meta-analysis shown in [Table 3],^{[17],[18],[19],[20]} lies in capturing accurate information and effective integration of clinical, monitored, and investigative variables in establishing the diagnosis and plan appropriate therapeutic modalities and interventions.

Table 3: Meta-analysis and systematic reviews of tele-intensive care unit

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Experience of Tele-Rounds So Far in Karnataka

The Columbia-Asia Referral Hospital Yeshwantpur, Bangalore, and Manipal Hospital, Airport Road, Bangalore, have been performing tele-rounds for 28 Districts for the past 10 weeks. As on June 28, 2020, tele-rounds were carried out for 9771 patients, of whom 115 died with a case fatality rate (CFR) of 1.17%. These results were compared with the urban and rural Bangalore hospitals that were not connected to tele-ICU. The Bangalore hospitals cared for 3419 patients during this period; 92 patients had died, accounting for CFR of 2.69%. From these observations, we could assume that tele-ICU, by casting a remote eye, may facilitate more effective vigilance and diligent care. Besides, imparting of transformational knowledge, and empowerment of the off-site team in shared decision making, facilitation of capacity building is enabled. Integration and more efficient mobilization of valuable resources are possible, with support by governmental agencies. Tele-rounds have enabled to integrate scientific data from multiple centers to initiate multi-centric observational study.

Tele-rounds have led us to develop robust state-wide protocols to manage different dimensions of COVID-19 patients, as shown in [Table 4]. This includes a protocol for general hospitalized COVID-19 patients, protocols for ventilator management, sepsis and septic shock with COVID-19, and management of patients with severe acute respiratory illness. We are currently in the process of creating protocols for acute kidney injury in COVID-19. These protocols are presented regularly to all the district hospitals, and any concerns or queries are clarified in a timely manner.

Table 4: Checklist for the tele-intensive care unit

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Recommendations

We recommend the use of Tele-ICU services in remote areas of need where trained Intensivists are in short supply, especially in pandemics like COVID-19 where care can be optimized with the use of technology and co-ordination between specialists on one end and doctors on the other end providing care
We recommend the use of multiple tools to assist doctors in providing Tele-ICU services, which include LAN, WAN, Internet, wifi-enabled webcams, social media platforms such as WhatsApp, Facebook, or mobile Apps without the need to invest heavily on the software platforms
We recommend the use of tele-medicine facility to triage and make decision planning easier, especially during pandemics like COVID-19 where there could be a lot of ambiguity in shifting high-risk patients into appropriate care facilities and adopting general treatment protocols
We recommend the use of Tele-ICU in making shared decisions, by involving every doctor and nurse, in order to optimize care. It could either be in drafting protocols, to sharing practical experiences, or help one another out during times of stress, or psychological and emotional support in times of crisis, etc.
We recommend the use of Tele-ICU facilities in academic pursuits, collating and publishing data, which would serve as a strong evidence for later years to come for clinicians to draw valuable inputs in other areas of need
We recommend active clinicians who are teachers of Intensive Care Courses involved in onsite patient care to be part of tele-ICU teams contrary to stand-alone tele-units to minimize the disconnect

Conclusions

Tele-Medicine/tele-ICU is bound to revolutionize the future health care in India by homogenizing the care between public and private hospitals. Root cause analysis with corrective and preventive action happens instantly in the off-site with this model and minimizes the lag. This model is easily implementable in acute pandemic situation and is scalable with minimal costs. Tele-medicine/tele-ICU provides a good space for senior eminent medical professionals who otherwise cannot impart their skills at the bedside in COVID-19 pandemic to contribute their service and wisdom to serve the humanity.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.

References

1.	Lilly CM, Thomas EJ. Tele-ICU: Experience to date. J Intensive Care Med 2010;25:16-22.
2.	Udeh C, Udeh B, Rahman N, Canfield C, Campbell J, Hata JS. Telemedicine/Virtual ICU: Where are we and where are we going? Methodist Debakey Cardiovasc J 2018;8:126-33.
3.	Srinivasan SR. Editorial: Tele-ICU in the age of COVID-19: Built for this challenge. J Nutr Health Aging 2020;24:536-7.
4.	Telemedicine Practice Guidelines. Government of India. Board of Governors in Supersession of the Medical Council of India. Telemedicine Practice Guidelines; 2020.
5.	Using Telehealth Services. Telehealth. CDC; 10 June, 2020.
6.	Kahn JM, Gunn SR, Lorenz HL, Alvarez J, Angus DC. Impact of nurse-led remote screening and prompting for evidence-based practices in the ICU*. Crit Care Med 2014;42:896-904.
7.	Hravnak M, Devita MA, Clontz A, Edwards L, Valenta C, Pinsky MR. Cardiorespiratory instability before and after implementing an itegrated monitoring system. Crit Care Med 2011;39:65-72
8.	Kim MM, Barnato AE, Angus DC, Fleisher LA, Kahn JM. The effect of multidisciplinary care teams on intensive care unit mortality. Arch Intern Med 2010;170:369-76.
9.	Kahn JM. Intensive care unit telemedicine: Promises and pitfalls. Arch Intern Med 2011;171:495-6.
10.	Dayton E, Henriksen K. Communication failure: Basic components, contributing factors, and the call for structure. Jt Comm J Qual Patient Saf 2007;33:34-47.
11.	Plumb JJ, Hains I, Parr MJ, Milliss D, Herkes R, Westbrook JI. Technology meets tradition: The perceived impact of the introduction of information and communication technology on ward rounds in the intensive care unit. Int J Med Inform 2017;105:49-58.
12.	Black AD, Car J, Pagliari C, Anandan C, Cresswell K, Bokun T, et al. The impact of eHealth on the quality and safety of health care: A systematic overview. PLoS Med 2011;8:e1000387.
13.	Rosenfeld BA, Dorman T, Breslow MJ, Pronovost P, Jenckes M, Zhang N, et al. Intensive care unit telemedicine: Alternate paradigm for providing continuous intensivist care. Crit Care Med 2000;28:3925-31.
14.	Kohl B, Sites F, Gutsche JT, Kin P. Economic impact of eICU implementation in an academic durgical ICU. Crit Care Med 2007;35:A26.
15.	Zawada E, Herr P, Erickson D, Hitt J. Financial benefit of a tele-intensivist program to a rural health system. Chest 2007;132:444.
16.	Rotter JB. Generalized Expectancies for Internal Versus External Control of Reinforcement. Washington, DC: American Psychological Association; 1966.
17.	Chen J, Sun D, Yang W, Liu M, Zhang S, Peng J, et al. Clinical and economic outcomes of telemedicine programs in the intensive care unit: A systematic review and meta-analysis. J Intensive Care Med 2018;33:383-93.
18.	Mackintosh N, Terblanche M, Maharaj R, Xyrichis A, Franklin K, Keddie J, et al. Telemedicine with clinical decision support for critical care: A systematic review. Syst Rev 2016;5:176.
19.	Wilcox ME, Chong CA, Niven DJ, Rubenfeld GD, Rowan KM, Wunsch H, et al. Do intensivist staffing patterns influence hospital mortality following ICU admission? A systematic review and meta-analyses. Crit Care Med 2013;41:2253-74.
20.	Young LB, Chan PS, Lu X, Nallamothu BK, Sasson C, Cram PM. Impact of telemedicine intensive care unit coverage on patient outcomes: A systematic review and meta-analysis. Arch Intern Med 2011;171:498-506.

Figures

[Figure 1], [Figure 2], [Figure 3]

Tables

[Table 1], [Table 2], [Table 3], [Table 4]

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