Photo Credit: Gorodenkoff
A lack of intensivists in US hospitals has led to growing electronic ICU popularity, but significant questions about costs, resources, and benefits remain.
The presence of on-site, board-certified intensivists is associated with significant improvements in ICU outcomes such as length of stay and mortality, but most US hospitals do not have intensivists on staff. Electronic ICU (eICU or tele-ICU) is a form of telemedicine that uses state-of-the-art technologies to provide additional care and safety to these vulnerable patients. The use of eICUs has greatly increased since 2000, so there are currently approximately 250 eICUs servicing 450 hospitals in the US. Despite the popularity and increasing use of eICU, significant questions remain regarding its resources, costs, organization, and benefits.
eICU care is based on a multi-faceted technological framework, which traditionally includes high-definition audio-visual two-way conferencing, EHR access, data analytics, and real-time patient monitoring. Most US eICUs operate on a ‘hub-and-spoke’ model using a single command center where intensivists, nurses, and other personnel can monitor and manage patients who are critically ill across several hospitals, ranging in different ways from small critical access hospitals to large tertiary-care facilities, often within the same eICU organization.
Some observational studies have suggested that eICU care is associated with lower mortality, shorter length of ICU stay, improved patient safety, better end-of-life planning, enhanced protocol and best-practice compliance, and less need for inter-hospital transfer. These benefits, however, are inconsistent sometimes and must be judged within the context of the methods with which each eICU organization uses the provided technologies and data to provide clinical decision-making and care for each hospital within the eICU network.
Efforts are currently being made to evolve some eICU resources away from the standard ‘hub-and-spoke’ organization to a more decentralized and flexible adaptation of the technologies to explore use in non-ICU settings such as ED assessment and hospital floor patients, particularly in hospitals that cannot offer rapid response, and, in the future, disaster areas and military conflict zones. Mobile telemedicine carts are often used, even now, for this purpose.
Challenges include certain legal and administrative concerns, including professional staffing, improvements in network and audio-visual connections, evolving best practices involving staffing, workflow, clinical responsibilities, and disparate organizational models. Certainly, eICU care has significant original and continuing costs, so financial concerns, return on investments, the greatest savings, and improved outcomes for a reasonable overall cost are of vital concern for many healthcare organizations.
There is great growing potential for eICU enhancement of protocolized care for critical illnesses such as sepsis and other ICU conditions and end-of-life evaluation and care. Although expert consultation is an important part of eICU care, studies also suggest better outcomes when degrees of decision-making authority occur. The amount of decision-making authority will vary according to the resources of each hospital within each eICU organization. eICU care is not meant to replace bedside care or be a primary attending service.
eICU care will likely continue to expand, and its future may depend on its flexibility and adaptability for innovative uses consistent with perceived cost efficiency.
Those of us working in eICU commonly see our efforts significantly benefit the served patients, even occasionally to life-saving degrees, and the future of eICU care, as well as telemedicine, in general, will be intriguing to follow.
