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DTSTAMP:20240325T185837Z
LOCATION:Salon A-3
DTSTART;TZID=America/Chicago:20240327T103000
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UID:HFESHCS_2024 International Symposium on Human Factors and Ergonomics i
 n Health Care_sess150_INDLEC166@linklings.com
SUMMARY:Developing Socio-Technical Components of a Tele-Critical Care Cons
 ultation Service for Hospitalized Patients at Risk for Intensive Care Unit
  Admission
DESCRIPTION:Oral Presentations\n\nJoanna Abraham, Bradley Fritz, Lavanya P
 edamallu, and Chris Palmer (Washington University School of Medicine in St
 . Louis)\n\nIntroduction. Unplanned patient admissions to intensive care u
 nits (ICU) from acute care floor units (medical, surgical, or telemetry) a
 re common and mostly in response to clinical derangements in patient statu
 s. 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 clini
 cal 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 hav
 e implemented Clinical Decision Support (CDS) alerts and early warning sys
 tems (EWS) that can monitor and immediately alert floor clinicians of any 
 abnormal vital signs, indicating early signs of clinical deterioration. Ho
 wever, the effectiveness of such systems is often compromised by multiple 
 human-factor challenges such as false alarms, alert fatigue (i.e., declini
 ng responsiveness or desensitization to multiple alerts), cognitive burden
  and work-related fatigue, and clinical data integration gaps across syste
 ms (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-acu
 ity patient admissions to the ICU. Supported by contextual inquiry methods
 , we highlighted that a Tele-Critical Care Consultation (TC3) service staf
 fed by tele-ICU clinicians (intensivists and specialized critical care pra
 ctitioners) can remotely monitor patients for early signs of deterioration
  and also remotely assist with management of these patients to avert avoid
 able ICU admissions. In this abstract, we present findings from an impleme
 ntation planning study where we examined the different needs for implement
 ing 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 b
 eds and 53,039 inpatient admissions annually. We followed an implementatio
 n mapping (IM) approach to further develop the TC3 service, aiming to brid
 ge the gap between theory (potential for a TC3 service) and practice (i.e.
 , development and implementation of TC3 service). This approach entailed s
 ix steps: needs assessment, objective development, intervention design, in
 tervention development, implementation planning and evaluation planning. T
 he IM steps were guided by input from a 10-member interprofessional stakeh
 older advisory board (SAB), including practicing clinicians, unit champion
 s 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 th
 e TC3-embedded ICU admission workflow, TC3 workflow steps including TC3 ac
 tivation, communication protocols, TC3 monitoring equipment, TC3 documenta
 tion 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, telemedic
 ine, critical care) conducted four virtual meetings with the SAB lasting 1
 20 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 system
 atically followed to develop strategies essential for the adoption, implem
 entation, and sustainability of the TC3 service. Findings. We identified f
 our themes underlying the successful design and implementation of a tele-c
 ritical consult service: First, TC3 can help address unplanned ICU admissi
 ons in one of two ways: (1) by preventing avoidable, lower-acuity ICU admi
 ssions by offering a second set of eyes via remote monitoring and providin
 g guidance to bedside and rapid response teams in the care delivery of the
 se patients on the floor, and (2) by promoting timely triages of unavoidab
 le, higher acuity ICU admissions from the floor. Second, three functions f
 or TC3 included (1) remote monitoring support, where the primary responsib
 ility of TC3 team is to monitor the borderline patients and treatment resp
 onses and communicate with hospitalist; (2) co-management support, where t
 he TC3 and the hospitalist collaboratively develop and implement a care pl
 an (including placing orders); and (3) clinical advisory support, where th
 e 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 di
 gital telemedicine intervention). Towards this end, we borrow the Systems 
 Engineering Initiative for Patient Safety (SEIPS) framework to describe th
 e TC3 as a socio-technical system and its impact on care continuity, safet
 y and care quality of avoidable and unavoidable ICU admissions. Such a hum
 an-factors, systems-oriented approach allowed us to ascertain the TC3 soci
 o-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 w
 hile developing and implementing the TC3 service included clinicians (deli
 neating roles for tele-ICU nurse or intensivist, hospitalist, RRT, charge 
 and floor nurse); clinician tasks (clinician tasks such as consult initiat
 ion, tasks based on the type of consult service requested, decision making
  and communication, TC3 sign-off); tools and technologies (EHR TC3 activat
 ion alerts, patient remote monitoring equipment, tele-ICU mobile cart, tel
 emetry, EHR TC3 communication and documentation notes); physical environme
 nt (the floor, tele-ICU and ICU contexts); and hospital organization (deve
 loping hospital and unit-based protocols for a TC3-floor-RRT collaborative
  approach for supporting both avoidable lower-acuity and unavoidable highe
 r-acuity unplanned admissions to the ICU). Our findings suggested that the
  interactions among these five components are critical to effective TC3-em
 bedded treatment of deteriorating floor patients (e.g., consult completion
  rates, TC3 video session duration), thereby leading to better patient out
 comes including ICU and hospital length of stay, ICU readmissions. Lastly,
  our SAB highlighted that the two key characteristics -- essential for ext
 ending 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 hu
 man factors framework highlights that the success of TC3 service will depe
 nd 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-qualit
 y critical care services to hospital floor patients at risk for ICU admiss
 ion.\n\nTrack: Patient Safety Research and Initiatives\n\nSession Chair: M
 arian Obuseh (Purdue University)
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