What’s On People’s Mind

Naturally, predicting the future is valuable in any medical setting, and the ICU is of course no exception. Artificial intelligence is a means of The lack of availability (shortage of) intensivists is a central theme to many discussions relating to intensive care. The case for the eICU would not be as compelling without a dearth of board-certified critical care doctors. (It’s also important to note that a “board certified critical care doctor” is a physician who is board certified specifically in critical care by one of the boards capable of officially recognized certification in critical care, for example: the board of internal medicine, the board of surgery, etc. I.e., it would not be fair to say that a board certified internal medicine doctor who practices critical care in the ICU – which is very common – is generally what is meant by a “board certified critical care doctor” even though the IM doctor is indeed board certified and is also a physician who is a critical care doctor).
This shortage of boarded intensivists is exists in the context of — and is perpetuated by – an aging US population, coupled with an increase in the number of hospital ICU beds (and the proportion of ICU beds vs. total hospital beds). Further, increases in the prevalence of technology and the generally greater acceptance that there is value in a greater amount of data being captured/used, have created an environment where there is more data available to an ICU physician to enhance decision-making and judgement.

Companies and groups have endeavored to harness historical data for computer analysis in the creation of algorithms designed to predict the future. In other words, software was developed to examine whether complex statistical correlations exist between and among historical variables which then correspond to a certain clinical outcome or diagnosis some amount of time in the future. Sepsis would be one such outcome. Therefore when the same set of variables are captured in real time for a current patient and fed into a computer model, the algorithm would predict a diagnosis would occur in the future with some probability of accuracy, and before even the best doctor would be able to predict the same diagnosis.

It’s interesting how some terms and expression become dominant in typical parlance despite the intentions of academia or capital interests, and artificial intelligence (AI) as applicable the ICU is no exception. You may hear AI, machine learning (ML), decision support, decision tools, algorithmic assistance, RPM – remote proactive physiologic predictive monitoring, predictive tools, predictive monitoring, big data driven support, software-assisted clinical judgement, early warning systems, sepsis deterioration software, deterioration scoring system, robotic medicine, Sepsis Sniffer, and so on, being invoked. Regardless of the parlance, they are all essentially referring to artificial intelligence. A prime environment for such application is with eICU although it can also be equally useful in the bedside ICU.

Various groups and entities are pursuing standalone products or add-ons which aim to contribute in this realm, with various motivations, from performance to profit: Clew, Epic, Philips, Ceiba, and so on.

If you answered, “Accelerating adoption” you are correct. There are other correct answers of course, albeit obvious:  “Telemedicine.”  But one assumes the reader has that baseline knowledge already.

 

The ever-increasing burden on healthcare providers is due in part to a lack of adequate resources in non-urban areas and a simultaneous deficit of specialist physicians where they are needed. Non-urban areas for the purpose of this discussion also include remote areas and poorly developed, low economic strata areas. Simply put, there are not enough doctors.

 

Focusing on the United States for a moment, clearly the country is fully interconnected by telephone, so in theory a specialist physician is always only a phone call away. But that is theoretical only because the rural hospital in need has to have the capital resources to pay for a physician’s time and the physician’s telephone number must be known and the physician must be available and the physician has to be licensed in the state where the patient is located the have hospital privileges and credentials, all of which are non-trivial assumptions.

 

There is also a lack of immediacy in the chaos of a critical situation when clinical providers are frantically trying to find even a telephone number of someone to reach out to, meanwhile the clock is ticking. It’s said that in stroke situations, time is money, meaning every second counts toward saving the patient’s life. It’s no time to be searching for phone numbers. A potential stroke patient needs absolutely immediate assessment via videoconferenced tests done on the patient by a trained neurologist with stroke expertise. Additionally the neurologist must review neurological images in order to make rapid diagnoses, and to decide whether to administer alteplase by IV line, consideration of thrombolysis,  and whether the patient needs to be “shipped out” (i.e.,) transferred for invasive procedures like thrombectomy, etc.

 

A telestroke neurologist can additionally interpret brain computed tomography and make decisions of whether to transfer for management of hemorrhagic stroke, to neurosurgical treatment facilities. Tele-stroke physicians use the National Institutes of Health Stroke Scale (NIHSS). This is merely scratching the surface of the activities and capabilities what tele-stroke physicians and how they work hand-in-glove with eICU intensivists and other remote specialist doctors and nurses.

While remote stroke care requires at least some technology to make it function, and its results are supported by studies analyzing its quality / metrics, other highly specialized tele-activities are much the same.

 

Telecardiologists have remote access to ECGs and ECHOs (eletrocardiograms and echocardiograms) and ideally should also have two-way video communication with the bedside staff and patient in the hospital bed. Clearly although there has been cardiac care advancement in recent decades, cardiovascular disease is still the #1 leading cause of death across the United States. It behooves hospital systems to have a tele-cardiology program in place.

Deadly diagnoses like sepsis are often well-suited for telemedicine, in part, especially with the adaptation of eICU. One of the major causes of mortality in hospitals is sepsis. Indeed billions of dollars are spent treating sepsis; it is one of the most cost-contributing conditions in a hospital and accounts for between and by some estimations accounts for between a third and a half of ICU dollars spent. To the extent that sepsis can be diagnosed sooner in a given case, statistically outcomes improve. For over 20 years a professional collaborative called the Surviving Sepsis Campaign put forth guidelines for sepsis treatment, but there is far less than full adoption of the protocols among hospitals across the United States and the developed world. Part of wider acceptance of the protocols would be greater availability of expert clinicians in intensive care medicine. Due to the shortage of intensivists and because of the poor economics of placing a costly intensivist in person at the bedside in a hospital where he or she would be working at less than full capacity utilization, it is compelling to use Tele-ICU to alleviate the poor sepsis protocol adaptation problem.

 

Of note, it’s not just intensive care units where there is lackluster adherence to sepsis protocols, but also emergency departments. Tele-intensive care physicians can also help out with septic patients in the ED, or in determination that they are in fact not septic, i.e., diagnosis via eICU’s remote monitoring and care provision capabilities when staffed by US board certified critical care doctors.

 

Also of note, algorithmic tools developed using artificial intelligence trained on physiologic data such as from MIMIC (or MIMIC-III an MIMIC-IV and so on), show promise in early sepsis detection. Various startups have tried to make inroads with software for this purpose, as well as larger electronic medical record companies.

If you accept a basic concept and reality of modern medicine which is that instead of like in the early 1900s there were predominantly general practitioner physicians who did basically everything for any given patient regardless of the patient’s ailment, as opposed to today where there are increasingly specialized and sub-specialized physicians such as surgeons and cardiologists and nephrologists and endocrinologists and neurologists and, yes, intensive care specialist physicians (intensivists), and that these specialized physicians pursue their specialties and obtain officially accepted board certification in those specialties and then they naturally produce better clinical outcomes for patients in their area of expertise then, no, you cannot simply have your ICU patients treated by nurses alone and expect clinical outcomes to be as favorable vs. if they were treated by specialist doctors. You cannot expect lengths of stay to be as short without doctors. You cannot expect mortality to be as low. You can expect more malpractice lawsuits, higher costs, and a poorer reputation for your hospital.

 

The intensive care unit is a less understood field at a basic level by laymen versus, say, surgery. Laymen understand that surgery must be performed by a surgeon who is of course a physician. Laymen would not accept major surgery being performed by a nurse. Many patients are brought to the ICU in an unconscious state and even if not they don’t choose their intensivist physician like they choose their dermatologist or surgeon, i.e., based on a recommendation or referral. In fact they typically don’t choose the physician at all and may not notice their physician is not a physician at all. During Covid and especially during the peaks and lockdowns, family isn’t allowed in the hospital, let alone in the ICU so there wouldn’t have even been an opportunity for either the patient — if the patient were conscious — or the family to take note that the ICU in question were not being managed by intensive care physicians but actually was being managed by internal medicine doctors who are hospitalists who are doing ICU work or nurses, but in either case neither hospitalists or nurses are board certified in critical care, which means that that scenario does not meet today’s standard of care, and clinical outcomes are expected to be worse or stated more directly more people are expected to die and lengths of stay are expected to be longer. Few people would find that situation acceptable. But just because laymen and their families do not notice you aren’t meeting the standard of care doesn’t mean your hospital will not pay the price of not having eICU coverage with malpractice claims, massively inflated operational costs of having patients stay longer in the ICU than would otherwise be, reputation costs, etc.

 

The Leapfrog group ranks hospitals by various criteria and when it comes to the hospital’s ICU, patients have to be managed by a US board certified critical care doctor. The ICU patient can be managed remotely by a TeleICU doctor or in person by a bedside ICU doctor, but either way, to be in conformity with the Leapfrog standard that physician has to be board certified in critical care, and of course that means that provider has to be a physician. Any other provider is not sufficient to meet the de facto standard from Leapfrog.

The eICU solves this problem. RemoteICU can provide coverage to your hospital exclusively with us board certified critical care doctors managing patients via eICU.

Various terms are frequently invoked in TeleICUs and virtual ICU discussions, particularly in the planning stage. Reactive vs. proactive, COR, hub, etc. The reactive vs. proactive decision is based on the basic philosophy of the eICU and is also tied to finance and budgets (and therefore rather than being strictly philosophical the decision can be determined just by the reality of finance and cost limitations), so naturally it gets a lot of attention. A proactive virtual ICU protocol means that the physicians or other clinicians (RNs, for example) working in the TeleICU act in advance to deal with expected difficulties or changes, in a sense trying to anticipate problems with patients by routinely checking certain things in their medical charts, telemetry, etc. It is a mindset and policy whereby the clinicians try to better the situation by trying to identify emerging or existing problems in advance of when they would otherwise become known, in effect by causing the clinicians’ own behavior to change, rather than waiting for an alert or call from someone else or indication from a computer or alarm or machine after the problem or change happens. Reactive TeleICU on the other hand is simply “putting out fires,” though of course not literally; you can imagine that firefighters would typically get a call to alert them that there is a fire on 131 Main Street and they “react” to the call by going to put out the fire. To continue the analogy, they are not ordinarily driving around proactively looking for fires that there is no indication or information exist. Some eICUs are so busy that the physicians are constantly only reacting to calls from the bedside whereby the remote intensivists in the hub (the offsite control center where the intensivists works at a computer to handle such calls in which the doctor has the EMR, PACS (radiology), ICU waveforms, etc., for the patient) responds with counsel and actions (orders) to be put on the patient. If the eICU physicians are so busy with reactive teleICU that they have no time remaining for proactive work, one way to increase the bed count coverage footprint of that virtual intensive care unit would be to add another simultaneous remote intensivist seat to work alongside the existing doctor which of course has cost implications.

The CDC indicated that 78% of the new infections in the last week were due to BA.5. This extraordinarily transmissible subvariant of the Greek letter-named variant “Omicron” that we heard so much of is now the latest surge / wave of SARS-CoV-2. Hospitals are again busy, but not all ICUs are, perhaps because BA.5 causes serious illness less frequently. So does that mean hospital management doesn’t need to entertain obtaining an eICU? Virtual ICUs are still extremely relevant: It’s not how much the hospitals can handle in their intensive care units or how full they are, but rather when a patient is in the ICU, do we want the patient to have the greatest probability of survival, the best clinical outcomes? If there is just one patient in the ICU, does that patient not deserve a US board certified critical care doctor to be the treating doctor, making critical decisions, as opposed to another doctor? The fact remains and is unchallenged that the intensivists improve patient outcomes in the critical care unit. And that’s basic, widely accepted modern medicine:

 

Surgeons do better surgery than non-surgeons, anesthesiologists administer better anesthesia than non-anesthesiologists, hematologists do better hematology than non hem-oncs, and critical care doctors do better intensive care unit treatment than non-intensivists, and so on throughout all physician specialties and sub-specialties. So BA.5 or not, TeleICU is needed.

The SCOTUS ruled effectively to cede control back to the individual states regarding the issue of abortion, by overturning an approximately 50 year old case, Roe v. Wade, which had made abortion a “right” at the federal level. States may outlaw abortion at the state level, or may not. Putting aside completely this contentious issue itself, it is worthwhile for administrators to consider what they personally believe to be a right when it comes to their hospitals’ critically ill patients. Do they have a right to be less likely to die? If that is a right, and they are less likely to die by conforming with the Leapfrog standard, having board certified critical care doctors involved in the patient care equation, to the extent that hospitals do not have boarded intensivists on staff, are they obligated to integrate TeleICU?

As adoption of virtual ICU as a means of providing patients often life-saving critical care became more widespread over the last 20 years, appropriate and relevant standards gained traction. ICU medicine as a medical specialty in the United States requires care provision by physicians who are board certified in the critical care specialty, in order meet the standard of care. Such physicians, variously called intensivists, critical care doctors, intensive care physicians, boarded intensivists, and so on, can provide care via telehealth according to The Leapfrog group. Leapfrog is the de facto standard with which hospital should comply. How do hospital system administrators view the relative importance of conformity with clinical standards in the context of high inflation and interest rate hikes from the fed? Nearly everything is more expensive these days, and the cost of capital is higher, and there is expected to be an economic slowdown. Should capital expenditure decisions made by hospitals for innovative technologies which enhance patient care be tied to national economics when people’s lives depend on it? Today’s blog entry asks more questions than it answers — these are simply difficult questions that must be grappled with.

With leaders like Jamie Dimon, CEO from JPMorgan Chase, saying there’s a economic hurricane looming and we just don’t know if it’s a smaller hurricane or more like a Hurricane Sandy, and Elon Musk indicating he will cut 10% of the Tesla workforce ahead of an expectation of an economic downturn, what does that mean for TeleICU decisions? Hospitals broadly are saying they are under financial pressure so while an argument can be made it’s not an optimal time for them to make capital expenditures, TeleICU need not cost signficant capital expenditure, can save expense, and can actually increase revenue. Time will tell if hospital administrators will use pure financial logic while doing the best for the patient to make their eICU go / no go decisions.

Up >50% in the last 2 weeks. Hospital admissions also up significantly though not as much as new cases. But for admitted patients, will eICU play a signficant role? All signs point to yes, particularly for those hospitals adapting the technology, but even for those that do not, they will undoubtedly transfer out critically ill patients to those that do have access to remote intensivist physicians.

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