Expanding Critical Care Delivery beyond the Intensive Care Unit: Determining the Design and Implementation Needs for a Tele-Critical Care Consultation Service

Abstract

Background Unplanned intensive care unit (ICU) admissions from medical/surgical floors and increased boarding times of ICU patients in the emergency department (ED) are common; approximately half of these are associated with adverse events. We explore the potential role of a tele-critical care consult service (TC3) in managing critically ill patients outside of the ICU and potentially preventing low-acuity unplanned admissions and also investigate its design and implementation needs.

Methods We conducted a qualitative study involving general observations of the units, shadowing of clinicians during patient transfers, and interviews with clinicians from the ED, medical/surgical floor units and their ICU counterparts, tele-ICU, and the rapid response team at a large academic medical center in St. Louis, Missouri, United States. We used a hybrid thematic analysis approach supported by open and structured coding using the Consolidated Framework for Implementation Research (CFIR).

Results Over 165 hours of observations/shadowing and 26 clinician interviews were conducted. Our findings suggest that a tele-critical care consult (TC3) service can prevent 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/ED. CFIR-informed enablers impacting the successful implementation of the TC3 service included the optional and on-demand features of the TC3 service, around-the-clock availability, and continuous access to trained critical care clinicians for avoidable lower acuity (ALA) patients outside of the ICU, familiarity with tele-ICU staff, and a willingness to try alternative patient risk mitigation strategies for ALA patients (suggested by TC3), before transferring all unplanned admissions to ICUs. Conversely, the CFIR-informed barriers to implementation included a desire to uphold physician autonomy by floor/ED clinicians, potential role conflicts with rapid response teams, additional workload for floor/ED nurses, concerns about obstructing unavoidable, higher acuity admissions, and discomfort with audio-visual tools. To amplify these potential enablers and mitigate potential barriers to TC3 implementation, informed by this study, we propose two key characteristics—essential for extending the delivery of critical care services beyond the ICU—underlying a telemedicine critical care consultation model including its virtual footprint and on-demand and optional service features.

Conclusion Tele-critical care represents an innovative strategy for delivering safe and high-quality critical care services to lower acuity borderline patients outside the ICU setting.

Keywords

ICU - admissions - transfers - rapid response teams - acute care - eICU - tele-ICU - telemedicine - early warning system - on-demand

Protection of Human and Animal Subjects

The Washington University Human Research Protections Office (IRB# 202205091) approved this study, and verbal consent was obtained from all participants.

Authors' Contributions

J.A., B.F., and C.P. led the conception and design of the study. M.K. and J.A. were involved in the data collection; J.A. and M.K. conducted independent data coding and analysis and drafted the manuscript. J.A., M.K., B.F., and C.P. participated in peer-debriefing sessions to discuss the results and their interpretations. All authors were involved in critically reviewing its content and editing the manuscript. All authors have provided their final approval of the version to be submitted.

Ethics Approval and Consent to Participate

The study was approved by the Washington University in St. Louis, Institutional Review Board (IRB # 202109011), and consents were obtained from all participants. Participants who completed interviews received compensation of $15 on a reloadable debit card.

Consent for Publication

All authors have approved the publication of this manuscript.

Availability of Data and Materials

The data that support the findings of this study are available on request from the corresponding author.

Publication History

Received: 21 July 2023

Accepted: 15 January 2024

Article published online:
06 March 2024

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