Hospital Mortality, Length of Stay and Preventable Complications Among Critically Ill patients Before and After Tele-ICU Reengineering of Critical Care Processes.. Chest 2014[r]
(1)Dileep Raman, MD
March 2019
(2)Disclosure
Dr Dileep Raman is a Co-founder and Director at Cloudphysician Healthcare Pvt limited, a tele-ICU company.
www.cloudphysician.net
(3)(4)Critically ill patients require specialized care.
Having an intensivist has been considered
“the most effective intervention to improve
survival of the critically ill that has been
devised in the past 30 years.”
(5)Physician:Patient ratio mismatch
5
3,00,000+
ICU beds
(6)Physician:Patient ratio mismatch
6
3,00,000+
ICU beds
~3,500
intensivists
(7)● The 3,500 Intensivists concentrated in urban areas and within these areas in large tertiary care centers
● Large portion of these Indian ICU
beds (~2,50,000) not in Metros NO access to critical care expertises Physician:Patient ratio mismatch
India is projected to have 3,00,000 ICU beds in the coming three years and there are ~3,500 trained ICU specialists to manage them
7
3,00,000+
ICU beds
~3,500
(8)Skewed physician:patient ratio is here to stay!
Hospitals and ICUs are going to be built at a faster pace than an increase in
intensivists
(9)Skewed physician:patient ratio is here to stay!
9
Hence, the need to find other solutions:
1 Technology
1 Increasing the number of non physician trained personnel (nurse practitioners, physician assistants)
2 This requires Government and licensing body support
Hospitals and ICUs are going to be built at a faster pace than an increase in
(10)Problem
Lack of availability of highly skilled Critical Care personnel
Inadequate and inefficient utilization
of ICU infrastructure and services
Inability to deliver quality care
Medical errors, inaccurate diagnosis
(11)Problem
Lack of availability of highly skilled Critical Care personnel
Inadequate and inefficient utilization
of ICU infrastructure and services
Inability to deliver quality care
Medical errors, inaccurate diagnosis
and missed treatment opportunities
(12)Problem
Lack of availability of highly skilled Critical Care personnel
Inadequate and inefficient utilization
of ICU infrastructure and services
Inability to deliver quality care
Medical errors, inaccurate diagnosis
and missed treatment opportunities
Solution
Effective ICU Management System that enables:
- Integrative tele-ICU system - Centralized command center
staffed with 24/7 highly skilled intensivists
- Automated early warnings
- Advanced and actionable decision
support
(13)What is a tele-ICU
● Tele-ICU is the delivery of critical care services by a specialized team of intensivists located at an off-site command center
● Real-time audio-video, EMR and technology platforms are used to deliver expert care
● It is an integral component of a
Smart ICU
(14)Hub and Spoke
HUB
24/7centralized critical care expertise at the Cloudphysician Command Center
SPOKE
(15)(16)(17)Technology, the value add in the ICU
● Access
(18)Technology, the value add in the ICU
● Access ● Quality
(19)Technology, the value add in the ICU
● Access ● Quality
(20)Technology, the value add in the ICU
● Access ● Quality
● Cost effective care
(21)Technology, the value add in the ICU
● Access ● Quality
● Cost effective care ???
(22)Future of Tele-ICUs in India
- Technology needs to more than providing geographical connectivity/access - Improve efficiency; clinical decision support
- DOES NOT Replace physicians; rather, augments their capability
- Augment the capability of physicians to provide higher quality care to a larger group of patients, change ratio from Intensivist for 15 patients to Intensivist for 150 patients, while maintaining the quality of care provided
- Data in structured format allows effective clinical research
(23)Healthcare: slow to embrace technology
Unlike other industries, for example, manufacturing or airlines, technology has not been actively leveraged to reduce errors and increase efficiency
(24)Can technology augment the Doctor’s intuition? 24 Device integration: bedside monitors, infusion pumps, ventilators
Patient data repository (mini
EMR): Labs, radiology, demographic data, patient history, bedside physician and bedside nurse documentation
ANALYTICS ENGINE CLINICAL DECISION SUPPORT Video monitoring, Image capture, real- time
(25)25
CLINICAL DECISION SUPPORT
(coming from technology or from upskilled personnel or from both)
EXPERT PHYSICIAN INPUT
(Command Centre based Intensivist)
EFFECTIVE COORDINATION
(between bedside and command centre: video conferencing, voice, text)
High Quality Clinical
(26)Challenges
Current players are extremely cost prohibitive for the developing world - where the need is highest
Hardware interoperability is worse in rural areas as
technology is older of doesn’t meet interoperability standards
(HL-7 or FHIR)
(27)Private and confidential
How we it
(28)Prerequisites
● Critical care medicine (CCM) team and the hospital
administration must share aspirations and clinical goals. ● An ICU is a semiautonomous mini-hospital.
● The ICU design process is iterative and cannot be overly
(29)Private and confidential
SERVICE is critical
PRASHANT HOSPITAL Bihar
14 year old boy with severe respiratory failure
Cloudphysician instituted
‘prone ventilation’ therapy
which the hospital had never
used before to save the boy’s
(30)Private and confidential
Not every hero wears a cape
Dr Vimohan runs the ICU at this hospital with massive resource constraints.
The patient’s chances of survival
(31)Outpatient Emergency Ward Command Center 24/7 HOTLINE 24/7 Monitoring
Early warning systems active on demand and proactive decision support
Daily Rounds
Steps to repeated until patient is discharged
New Admission Alert
Patient admitted via two-way audio/visual interface A visual assessment and data transfer takes place
Admission Review
Intensivist performs medical review at the command center
Recommendations and Orders
Cloudphysician recommendation action delivered via printer/ electronic record at hospital
Command Center
Best Practices
(32)Keys to success
● Appreciate the underlying informatics concepts.
● Identify the solutions that work best in the new ICU design. ● Sophisticated planning, technology testing.
● Phased introduction of informatics platforms.
(33)Global tele-ICU landscape
33
STRONG EVIDENCE FOR TELE-ICU
Proven model in the West
15 years of peer reviewed evidence
Reduced mortality Reduced hospital
length of stay
Lower rates of complications Reduced response
(34)JAMA 2011
In a single academic medical center study,
implementation of a tele-ICU intervention was
associated with reduced adjusted odds of mortality
and,
Reduced hospital length of stay, as well as with
changes in best practice adherence and lower rates of preventable complications.
(35)(36)(37)Chest 2014
ICU telemedicine interventions, specifically interventions that increase early intensivist case involvement:
- Improve adherence to ICU best practices - Reduce response times to alarms
- Encourage the use of performance data - Lower mortality
(38)(39)(40)Quality metrics
Retrospective review:
Patients admitted to a seven bed tele-ICU from May 2017 to April 2018
Two quality indicators measured:
(41)Antibiotic prescription practices measurement:
- Counting the number patients exposed to amikacin, levofloxacin and linezolid each month
- Chosen based on prevalent resistance patterns and
potentially inappropriate use
(42)(43)(44)(45)(46)PRIVATE AND CONFIDENTIAL - DO NOT SHARE
Admissions with predicted mortality > 12%
The ICU is able to accept and manage sicker patients
(47)(48)(49)(50)(51)(52)Private and confidential Current Status 14 hospitals 100+ ICU beds 6,001 patient bed days 7 Intensivists Largest team in Bangalore outside of a hospital
system
413,896 vital signs tracked 40,536
lab values interpreted
(53)Who benefits?
Patient, Patient, Patient
Reduced rates of medical complications and mortality Shorter ICU and post-ICU floor lengths of stay
Comforted by the high quality layer of care provides Ability to stay closer to home/avoid transfer
Impact of an Intensive Care Unit Telemedicine Program on a Rural Health Care System Zawada, et al
(54)Clinical Staff (Physician/Nurse) benefits
• Increased focus on patients
• Rapid response to patient needs
(55)Hospital benefits
• Cost effective solution
• Increased average daily census
• Reduced nursing turnover
• Improved physician retention and recruitment (less burnout)
(56)(57)Conclusions
Global shortage of critical care delivery Required criteria for tech solutions
○ access to expertise
○ cost effective
○ quality centric
Smart ICUs - highly efficacious ways to close gaps in care Large body of evidence
www.cloudphysician.net