Tele-ICUs: The Indian experience - Dileep Raman, MD

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Dileep Raman, MD

March 2019

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<b>Disclosure</b>

Dr. Dileep Raman is a Co-founder and

Director at Cloudphysician Healthcare

Pvt limited, a tele-ICU company.

www.cloudphysician.net

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<b>Critically ill patients require specialized </b>

<b>care.</b>

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.”

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<b>Physician:Patient ratio mismatch</b>

<b>3,00,000</b>

<b>+</b>

ICU beds

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<b>Physician:Patient ratio mismatch</b>

<b>3,00,000</b>

<b>+</b>

ICU beds

intensivists

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● 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

<b>Physician:Patient ratio mismatch</b>

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

<b>3,00,000</b>

<b>+</b>

ICU beds

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<b>Skewed physician:patient ratio is here to stay!</b>

<b>Hospitals and ICUs are going </b>

<b>to be built at a faster pace </b>

<b>than an increase in </b>

<b>intensivists</b>

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<b>Skewed physician:patient ratio is here to stay!</b>

<b>Hence, the need to find other </b>

<b>solutions:</b>

1. Technology

1. Increasing the number of non

physician trained personnel

(nurse practitioners, physician

assistants).

2. This requires Government and

licensing body support

<b>Hospitals and ICUs are going to be built </b>

<b>at a faster pace than an increase in </b>

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<b>Problem </b>

<b>Lack of availability</b>

of highly skilled

Critical Care personnel

Inadequate and

<b>inefficient </b>

utilization

of ICU infrastructure and services

<b>Inability </b>

to deliver quality care

Medical

<b>errors</b>

, inaccurate

<b>diagnosis </b>

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<b>Problem </b>

<b>Lack of availability</b>

of highly skilled

Critical Care personnel

Inadequate and

<b>inefficient </b>

utilization

of ICU infrastructure and services

<b>Inability </b>

to deliver quality care

Medical

<b>errors</b>

, inaccurate

<b>diagnosis </b>

and missed treatment opportunities

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<b>Problem </b>

<b>Lack of availability</b>

of highly skilled

Critical Care personnel

Inadequate and

<b>inefficient </b>

utilization

of ICU infrastructure and services

<b>Inability </b>

to deliver quality care

Medical

<b>errors</b>

, inaccurate

<b>diagnosis </b>

and missed treatment opportunities

<b>Solution</b>

<b>Effective ICU Management System</b>

that

enables:

-

<b>Integrative </b>

tele-ICU system

-

<b>Centralized </b>

command center

staffed with

<b>24/7 </b>

highly skilled

intensivists

-

Automated early warnings

-

Advanced and actionable

<b>decision </b>

<b>support</b>

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<b>What is a tele-ICU</b>

● 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

<b>integral component </b>

of a

<b>Smart ICU</b>

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<b>Hub and Spoke</b>

<b>HUB</b>

<b>24/7</b>

centralized critical care

expertise at the

<b>Cloudphysician </b>

<b>Command Center</b>

<b>SPOKE</b>

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<b>Technology, the value add in the ICU</b>

● Access

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<b>Technology, the value add in the ICU</b>

● Access

● Quality

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<b>Technology, the value add in the ICU</b>

● Access

● Quality

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<b>Technology, the value add in the ICU</b>

● Access

● Quality

● Cost effective care

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<b>Technology, the value add in the ICU</b>

● Access

● Quality

● Cost effective care

<b>???</b>

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<b>Future of Tele-ICUs in India</b>

- Technology needs to do more than providing geographical connectivity/access
- Improve efficiency; clinical decision support

- <b>DOES NOT Replace physicians; rather, augments their capability</b>

- Augment the capability of physicians to provide higher quality care to a larger group of
patients, change ratio from 1 Intensivist for 15 patients to 1 Intensivist for 150 patients,
while maintaining the quality of care provided

- Data in structured format allows effective clinical research

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<b>Healthcare: slow to embrace technology</b>

Unlike other industries, for example, manufacturing or airlines, technology has not been actively
leveraged to reduce errors and increase efficiency

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<b>Can technology augment the Doctor’s intuition?</b>

24
<b>Device </b>
<b>integration: </b>
bedside monitors,
infusion pumps,
ventilators

Patient data repository (mini

<b>EMR</b>): Labs, radiology,
demographic data, patient
history, bedside physician and
bedside nurse documentation

<b>ANALYTICS </b>

<b>ENGINE</b>

<b>CLINICAL </b>
<b>DECISION </b>
<b>SUPPORT</b>
<b>Video </b>
<b>monitoring</b>,
Image capture,
<b>real- time</b>

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<b>CLINICAL DECISION SUPPORT</b>

(coming from technology or from
upskilled personnel or from both)

<b>EXPERT PHYSICIAN INPUT </b>

(Command Centre based Intensivist)

<b>EFFECTIVE COORDINATION</b>

(between bedside and command
centre: video conferencing, voice, text)

High

Quality

Clinical

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<b>Challenges</b>

Current players are extremely

<b>cost prohibitive</b>

for the

developing world - where the need is highest.

Hardware

<b>interoperability </b>

is worse in rural areas as

technology is older of doesn’t meet interoperability standards

(HL-7 or FHIR)

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<i>Private and confidential</i>

<b>How we do it</b>

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<b>Prerequisites</b>

● Critical care medicine (CCM) team and the hospital

administration must

<b>share aspirations and clinical goals.</b>

● An ICU is a

<b>semiautonomous </b>

mini-hospital.

● The ICU design

<b>process is iterative</b>

and cannot be overly

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<i>Private and confidential</i>

<b>SERVICE is critical</b>

<b>PRASHANT HOSPITAL</b>

<b>Bihar</b>

14 year old boy with severe

respiratory failure.

<b>Cloudphysician instituted </b>

<b>‘prone ventilation’ therapy </b>

<b>which the hospital had never </b>

<b>used before to save the boy’s </b>

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<i>Private and confidential</i>

<b>Not every hero wears a cape</b>

Dr Vimohan runs the ICU at this

hospital with massive resource

constraints.

The patient’s chances of survival

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Outpatient
Emergency
Ward

Command Center

24/7 HOTLINE
<b>24/7 Monitoring</b>

Early warning systems
active on demand and
proactive decision support

<b>Daily Rounds</b>

Steps 2 to 5 repeated until
patient is discharged

<b>New Admission Alert</b>

Patient admitted via two-way audio/visual interface
A visual assessment and data transfer takes place

<b>Admission Review</b>

Intensivist performs medical
review at the command center

<b>Recommendations and Orders</b>

Cloudphysician recommendation
action delivered via printer/
electronic record at hospital

<b>Command </b>

<b>Center</b>

<b>Best Practices </b>

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<b>Keys to success</b>

● <b>Appreciate the underlying informatics concepts.</b>

● Identify the solutions that work best in the new ICU design.

● Sophisticated

<b>planning</b>

, technology testing.

● <b>Phased introduction</b>

of informatics platforms.

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<b>Global tele-ICU landscape</b>

<b>STRONG EVIDENCE FOR TELE-ICU</b>

Proven model in the West

15 years of peer reviewed evidence

<b>Reduced mortality</b>

<b>Reduced hospital </b>

<b>length of stay</b>

<b>Lower rates of </b>

<b>complications</b>

<b>Reduced response </b>

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<b>JAMA 2011</b>

In a single academic medical center study,

implementation of a tele-ICU intervention was

associated with

<b>reduced adjusted odds of mortality</b>

and,

Reduced hospital length of stay, as well as with

changes in

<b>best practice adherence </b>

and

<b>lower rates </b>

<b>of preventable complications.</b>

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<b>Chest 2014</b>

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

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<b>Quality metrics</b>

<b>Retrospective review: </b>

Patients admitted to a seven bed tele-ICU from May 2017

to April 2018

Two

<b>quality indicators</b>

measured:

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Antibiotic

<b>prescription practices</b>

measurement:

-

Counting the number patients exposed to amikacin,

levofloxacin and linezolid each month

-

Chosen based on prevalent resistance patterns and

<b>potentially inappropriate</b>

use

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PRIVATE AND CONFIDENTIAL - DO NOT
SHARE

<b>Admissions with predicted mortality > </b>

<b>12%</b>

The ICU is able to accept and manage sicker patients

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<i>Private and confidential</i>

<b>Current Status</b>

<b>14 </b>

hospitals

<b>100+</b>

ICU beds

<b>6,001 </b>

patient bed

days

<b>7</b>

Intensivists

Largest

team in

Bangalore

outside of a

hospital

system

<b>413,896</b>

vital signs tracked

<b>40,536</b>

lab values

interpreted

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<b>Who benefits?</b>

Patient, Patient, Patient

<b>Reduced rates of medical complications</b>

and mortality

Shorter ICU and post-ICU floor

<b>lengths of stay</b>

Comforted by the

<b>high quality layer of care</b>

provides

Ability to stay closer to home/

<b>avoid transfer</b>

Impact of an Intensive Care Unit Telemedicine Program on a Rural Health Care System. Zawada, et al.

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<b>Clinical Staff (Physician/Nurse) benefits</b>

• Increased

<b>focus </b>

on patients

• <b>Rapid response </b>

to patient needs

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<b>Hospital benefits</b>

• <b>Cost effective </b>

solution

• <b>Increased average daily census</b>

• Reduced

<b>nursing turnover</b>

• Improved physician

<b>retention </b>

and recruitment (less burnout)

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