Presentation
Developing Socio-Technical Components of a Tele-Critical Care Consultation Service for Hospitalized Patients at Risk for Intensive Care Unit Admission
DescriptionIntroduction. Unplanned patient admissions to intensive care units (ICU) from acute care floor units (medical, surgical, or telemetry) are common and mostly in response to clinical derangements in patient status. While a fraction of these unplanned ICU admissions, especially those of higher-acuity patients needing immediate critical care interventions, are unavoidable and clinically warranted, a majority of unplanned admissions of lower-acuity patients can be avoided. Lower-acuity patients can receive timely interventions in-place on the floor units, if early signs of clinical deterioration often signaled by abnormal vital signs can be identified, thereby avoiding an unplanned ICU transfer. This can potentially reduce ICU-related complications, shorten hospital stays, decrease costs of care, and reduce inappropriate use of ICU beds/resources. Several hospitals have implemented Clinical Decision Support (CDS) alerts and early warning systems (EWS) that can monitor and immediately alert floor clinicians of any abnormal vital signs, indicating early signs of clinical deterioration. However, the effectiveness of such systems is often compromised by multiple human-factor challenges such as false alarms, alert fatigue (i.e., declining responsiveness or desensitization to multiple alerts), cognitive burden and work-related fatigue, and clinical data integration gaps across systems (EWS and EHR) leading to delays in prompt and effective care delivery. To address this, in our prior study, we explored the need and role of tele-ICU as a potential care delivery model for preventing avoidable lower-acuity patient admissions to the ICU. Supported by contextual inquiry methods, we highlighted that a Tele-Critical Care Consultation (TC3) service staffed by tele-ICU clinicians (intensivists and specialized critical care practitioners) can remotely monitor patients for early signs of deterioration and also remotely assist with management of these patients to avert avoidable ICU admissions. In this abstract, we present findings from an implementation planning study where we examined the different needs for implementing the TC3 service at our study setting. Methods. The study was conducted at a large academic hospital in St. Louis, Missouri, with 1,263 staffed beds and 53,039 inpatient admissions annually. We followed an implementation mapping (IM) approach to further develop the TC3 service, aiming to bridge the gap between theory (potential for a TC3 service) and practice (i.e., development and implementation of TC3 service). This approach entailed six steps: needs assessment, objective development, intervention design, intervention development, implementation planning and evaluation planning. The IM steps were guided by input from a 10-member interprofessional stakeholder advisory board (SAB), including practicing clinicians, unit champions and leaders from the floor, ICU, and hospital rapid response team (RRT). Informed by the IM steps, we developed a semi-structured meeting guide to brainstorm and review the following with the SAB: the functions and role for a TC3 service, the performance and change objectives for developing the TC3-embedded ICU admission workflow, TC3 workflow steps including TC3 activation, communication protocols, TC3 monitoring equipment, TC3 documentation in EHR, implementation strategies including educational materials and metrics to evaluate the initial efficacy of TC3 and clinician experiences with TC3. Our research team (experts in implementation science, telemedicine, critical care) conducted four virtual meetings with the SAB lasting 120 minutes. Two researchers openly coded the meeting transcripts using an inductive data-driven approach leading to themes (repeated patterns within and across SAB meetings) related to the IM steps. These steps were systematically followed to develop strategies essential for the adoption, implementation, and sustainability of the TC3 service. Findings. We identified four themes underlying the successful design and implementation of a tele-critical consult service: First, TC3 can help address unplanned ICU admissions in one of two ways: (1) by preventing avoidable, lower-acuity ICU admissions by offering a second set of eyes via remote monitoring and providing guidance to bedside and rapid response teams in the care delivery of these patients on the floor, and (2) by promoting timely triages of unavoidable, higher acuity ICU admissions from the floor. Second, three functions for TC3 included (1) remote monitoring support, where the primary responsibility of TC3 team is to monitor the borderline patients and treatment responses and communicate with hospitalist; (2) co-management support, where the TC3 and the hospitalist collaboratively develop and implement a care plan (including placing orders); and (3) clinical advisory support, where the TC3 team is used for clinical advice by the hospitalist. Third, TC3 can best be characterized as a socio-technical care system (as opposed to a digital telemedicine intervention). Towards this end, we borrow the Systems Engineering Initiative for Patient Safety (SEIPS) framework to describe the TC3 as a socio-technical system and its impact on care continuity, safety and care quality of avoidable and unavoidable ICU admissions. Such a human-factors, systems-oriented approach allowed us to ascertain the TC3 socio-technical workflow using three components — the work system (wherein the TC3 would operate), the process (the workflows that the TC3 would affect or be a part of), and the outcomes (the intended improvements in outcomes with TC3 implementation). The TC3 worksystem components to be considered while developing and implementing the TC3 service included clinicians (delineating roles for tele-ICU nurse or intensivist, hospitalist, RRT, charge and floor nurse); clinician tasks (clinician tasks such as consult initiation, tasks based on the type of consult service requested, decision making and communication, TC3 sign-off); tools and technologies (EHR TC3 activation alerts, patient remote monitoring equipment, tele-ICU mobile cart, telemetry, EHR TC3 communication and documentation notes); physical environment (the floor, tele-ICU and ICU contexts); and hospital organization (developing hospital and unit-based protocols for a TC3-floor-RRT collaborative approach for supporting both avoidable lower-acuity and unavoidable higher-acuity unplanned admissions to the ICU). Our findings suggested that the interactions among these five components are critical to effective TC3-embedded treatment of deteriorating floor patients (e.g., consult completion rates, TC3 video session duration), thereby leading to better patient outcomes including ICU and hospital length of stay, ICU readmissions. Lastly, our SAB highlighted that the two key characteristics -- essential for extending the delivery of critical care services beyond the ICU -- underlying a telemedicine critical care consultation model would include its virtual footprint and on-demand and optional service features. Conclusion. The human factors framework highlights that the success of TC3 service will depend on timely interventions, accurate diagnoses, and collaborative decision-making, active partnership among TC3, RRT, floor, and ICU teams. In sum, tele-critical care is a novel solution for delivering safe and high-quality critical care services to hospital floor patients at risk for ICU admission.
Event Type
Oral Presentations
TimeWednesday, March 2710:30am - 11:00am CDT
LocationSalon A-3
Patient Safety Research and Initiatives