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.

 

MissingLinkText

Keywords

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

Background and Significance

Over 4.5 million intensive care unit (ICU) admissions occur annually in the United States.[1] Unplanned ICU admissions are common[2]; and nearly 25% of unplanned admissions lead to preventable patient adverse events,[3] which often result in longer hospital stays, misuse of ICU beds/resources, and increased costs of care.[4] [5] While unplanned ICU admissions are ill-defined,[6] a focus on patients' acute changes in status during their hospital stay (for example, in the emergency department [ED] or hospital floor units) presents an opportunity for timely identification of early signs of clinical deterioration, and immediate therapeutic interventions for those at risk of an ICU admission. In particular, hospitals have implemented early warning systems to identify clinically deteriorating patients and possibly avoid unplanned ICU admissions.[7] These system-generated alerts trigger hospitals' rapid response teams (RRTs) who primarily assist with immediate patient assessment and stabilization, either in place or help with admitting patient to an ICU—analogous to emergency medical service personnel “load and go” or “stay and play” following an out-of-hospital cardiac arrest or trauma.[8] [9]

While studies have shown that RRTs have reduced inpatient mortality,[10] [11] [12] others have demonstrated an increase in avoidable ICU admissions.[12] [13] [14] On one hand, this can be partly attributed to the limited ability of these warning systems in differentiating between avoidable lower acuity and unavoidable/higher acuity ICU admissions based on patients' risks to complications and adverse events. Due to challenges in assessing the true need for ICU-level care, between 2001 to 2009, ICU admissions from EDs have increased by nearly 50%.[15] Similarly, a United Kingdom study reported that almost 45% of ICU admissions from floor units ranged from possibly avoidable to definitely avoidable.[16]

On the other hand, clinicians in the ED and floor units have limited ability to effectively care for these “borderline” avoidable lower acuity admissions (ALA) in place due to a lack of ICU resources (e.g., monitor and equipment) available on the floor and ED, increased clinician workload to care for a critically ill borderline patient on floor and ED, and limited access to clinicians specialized in critical care delivery (e.g., Prints et al[17]). However, preventing such avoidable borderline patient admissions to the ICU can avert undesirable patient outcomes associated with an ICU stay, including sleep fragmentation and disturbance,[18] [19] cognitive dysfunction, delirium,[20] and hospital-acquired pneumonia or bloodstream infections.[21] In-person critical care consult services can bring intensivist-level decision-making to the floor patient in hopes of initiating early diagnosis and treatment[22]; however, the limited availability of intensivists makes the long-term sustainability of an in-person consult model questionable.

Taken together, these issues highlight the need for alternative novel and scalable solutions to support and manage ALA ICU admissions in the ED/floor units.[23] With the increasing growth of the geriatric population, complexity of clinical care needs, and a simultaneous shortage of intensivists and ICU nurses, we need to explore alternate ICU care models supported by technological advances such as use of machine-learning predictions of clinical deterioration signs,[24] [25] telemedicine, and virtual consults.[26] [27] [28] We examine the potential for utilizing and leveraging a telemedicine for critical care model that can bring intensivist-level expertise to deteriorating patients outside the ICU and prevent these ALA admissions. Although prior studies have demonstrated the impact of telemedicine ICU (or eICU) services in reducing mortality and length of stay of ICU patients, through enhanced standardization and compliance with best practice guidelines,[29] [30] [31] [32] [33] [34] there is no research investigating the potential role for such a telemedicine ICU service to remotely monitor ALA borderline ED/floor patients and provide critical care guidance to bedside ED/floor teams.

In this article, we report on a multi-stakeholder, multi-method needs assessment study that elucidates the potential role of a tele-critical care consult (TC3) service to remotely manage potential “borderline” ALA ICU admissions on the ED/floor units. The overarching goal of this study was to elicit the need for designing a TC3 service and develop an evidence-based plan for TC3 service implementation. Toward this goal, we had three study objectives: first, identify the current clinical workflows related to ALA borderline ICU admissions from the floor and ED; second, ascertain the factors associated with ALA admissions; and third, gather contextual determinants (i.e., enablers and barriers) influencing the implementation of TC3 service to assist with management of lower acuity borderline ICU patients outside the ICU.

 

MissingLinkText

Methods

Study Setting and Participants

We conducted an exploratory qualitative study at a large academic medical center in St. Louis, Missouri, across multiple clinical units (see [Table 1]), including ED, medical/surgical floor units, surgical ICU, medical ICU (MICU), and the tele-ICU. The remotely located tele-ICU affiliated with our medical center provides secondary monitoring and clinical decision support for ICU-admitted patients. During the day (6a-6p), the tele-ICU is staffed with one intensivist, one advanced practice provider (APP), and seven nurses. During the evening (6p-6a), two tele-intensivists have split coverage roles and no APPs. During this study period, the tele-ICU was not providing care to floor or ED patients.

Table 1 Details on clinical units at study setting

Unit	Description	Beds	Patient:RN (Registered Nurse) ratio	Patient:MD (Doctor of Medicine)/APP (Advanced Practice Provider) ratio
General Medicine floor	Provides acute hospital care for medical patients	48	4:1	12:1
Surgical floor	Provides acute hospital care for surgical patients	62	4:1	10:1
ED	Level 1 trauma center, quaternary care academic medical center	80	4:1	15:1
SICU	Cares for critically ill general surgical, burn, and trauma patients	36	2:1	6:1
MICU	Cares for critically ill medical patients	44	2:1	6:1
Tele-ICU	Uses AV technology to communicate with S/MICU clinicians and patients; conducts visual assessments, chart reviews, and identifies vital sign trends for patients; discusses findings and recommendations with S/MICU clinicians	164	30:1	164:1

Abbreviations: ED, emergency department; ICU, intensive care unit; MICU, medical intensive care unit; SICU, surgical intensive care unit.

Participants included inpatient clinicians (APPs, Doctors of Medicine, Registered Nurses [RNs], Assistant Nurse Managers [ANMs]) working in these units and our RRT RNs (referred to as acute care team [ACT] in our setting). All participants were recruited on-site and/or through direct email communication. The Washington University Human Research Protections Office (IRB# 202205091) approved this study, and verbal consent was obtained from all participants.

 

MissingLinkText

Data Collection

We followed a contextual inquiry approach supported by qualitative methods, including general observations, clinician shadowing, and semi-structured clinician interviews at these various units. These methods allowed us to gather rich and deeper insights into clinician workflows related to ICU admissions from the floor and the ED, including workflows underlying ALA borderline ICU admissions and unavoidable higher acuity ICU admissions, and also gather clinician perceptions related to the contextual determinants influencing the proposed TC3 service in preventing ALA admissions to the ICU and its implementation considerations. Participants chose to participate in one or multiple methods of data collection. Two researchers (J.A., M.K.) were involved in collecting the data using these methods (with M.K. as the primary researcher collecting the data). J.A. is a Ph.D. research scientist with over 15 years of experience using qualitative methods to study clinical workflows. M.K. is a research assistant (medical student) trained in qualitative research with over 1 year of experience using these methods.

General clinician observations: we conducted general observations in participating units and took handwritten notes on general workflow related to clinician roles (e.g., RN, APP, MD) and their interactions, tasks, timing, paper and electronic tools, and activities underlying patient care and their respective responsibilities relevant to patient transfers. During these observations, we also asked informal questions about the ICU transfers from the floor and ED. These observations helped us gain familiarity with the unit workflows and also with the clinicians. Observation sessions occurred Sunday through Friday between 9 a.m. and 12 a.m. and lasted four hours on average. Observations continued until they had a final grasp of the units' workflows.

Clinician shadowing: following the observations, we closely followed clinicians and took meticulous notes on their patient care workflows (sequence of steps, activities, and tasks). For example, we shadowed floor and ED clinicians to understand their steps in identifying clinical signs of deterioration and managing patients at risk of decompensation and eventual ICU admission. This helped us understand the factors contributing to ICU admissions (avoidable and unavoidable). We also shadowed the ICU clinicians to understand their role and clinical workflows in admitting ED and floor patients. We shadowed the tele-ICU clinicians to understand their workflow supporting remote monitoring and management of ICU patients. Lastly, we followed the RRT clinicians to understand their tasks and processes regarding their response to EWS alerts/calls from the various inpatient units. During our shadowing sessions, similar to the observations, we conducted informal interviews to inquire more about their clinical practices and reasons underlying ALA ICU admissions. All these sessions allowed us to map the various clinical workflows and unit interdependencies, determine any barriers, and identify possible approaches to incorporate the proposed TC3 service into existing workflows. Our shadowing sessions lasted 4 hours on average and were performed until we arrived at data saturation (where no new data were obtained).[35]

Clinician interviews: we conducted in-person and virtual semi-structured interviews with clinicians, including MDs, APPs, and nurses, to capture their perceptions on the current ICU admission processes from floor and ED, and also the need for proposed TC3 service and its implementation considerations. Interview questions focused on clinicians' experiences with floor and ED patient transfers and admissions to the ICU, factors contributing to avoidable, lower acuity admissions, first-hand impressions of the proposed telemedicine role in ICU admissions from floor and ED, and perceived barriers and enablers to TC3 implementation (see [Supplementary Material S1] for interview guide, available in the online version only). All interviews were audio-recorded and lasted 30 minutes on average. Interviews continued until we achieved thematic saturation.[36]

 

MissingLinkText

Data Analysis

All data were transcribed verbatim and organized into a Microsoft Excel workbook for analysis. Observation and shadowing data were analyzed using an inductive method, where data were openly coded line by line. Examples of open codes included clinical deterioration signs, reasons for admitting/declining patients to ICU, triggers for RRT calls, etc. Interview data were analyzed using a hybrid inductive − deductive coding approach: we used open coding to analyze emerging findings and then applied a structured coding framework informed by the Consolidated Framework for Implementation Research (CFIR).[37] CFIR is an implementation science framework that guides the identification and assessment of contextual determinants influencing evidence-based intervention implementation. In our study, it helped us to assess the context in terms of existing or potential barriers and facilitators to successful TC3 implementation. It consists of 39 constructs across five domains: intervention characteristics, inner setting, outer setting, characteristics of individuals, and process of implementation (see [Supplementary Table S1] for descriptions, available in the online version only). Intervention characteristics refer to aspects of an intervention that may impact implementation success; inner setting relates to characteristics of the implementing organization; outer setting refers to external influences on intervention implementation; characteristics of individuals refer to individuals' beliefs, knowledge, self-efficacy, and personal attributes that may affect implementation; and lastly, the process of implementation focuses on the stages of implementation such as planning, execution, and evaluation.[38] In this analysis, we applied four domains and their related constructs: intervention characteristics: TC3 service characteristics, inner setting: hospital units, individual characteristics: clinician end-user characteristics, and process of implementation: TC3 service implementation process. We excluded the outer setting because this domain relates to the external influences related to economic, political, and social contexts where the organization resides (which was not the focus of this study). Next, we identified themes (i.e., repeated patterns) relevant to current workflows and admission processes (e.g., higher acuity and lower acuity avoidable admissions), as well as the potential role and implementation of TC3 (e.g., TC3 functions, implementation design requirements, relative advantage, characteristics of clinician users) (see [Table 2]).

Table 2 Example of hybrid coding approach

Interview transcript	CFIR domain	CFIR code	Open code	Sub-theme
Interviewer: How can we build trust in this service?	n/a
Floor MD6: Personally, I would like it. I'm always about asking for help if I don't feel comfortable with something. It's ultimately what's good for the patient, and I personally have no problem asking for help, it's better to have multiple perspectives if possible. But I'm sure not everyone is on the same page about that.	Characteristics of individuals	Self-efficacy (+)	TC3 implementation	Participant comfortable with asking for help, appreciates multiple perspectives
I wouldn't want it to be a thing where it feels like Tele-ICU is watching over like, “Oh, are you checking this?” Because of course I don't want to miss something, and I want them to help, but if it's a feeling of “Oh, there's somebody you know watching over my work,” I could see how that would feel like, “Oh, there's another attending over me.”	Inner setting	Culture	TC3 implementation	Negative perception of TC3 as “watching over” hospitalists' work
But when you think about what's best for the patient, I can't be upset about that.	Innovation characteristics	Relative advantage (+)	TC3 implementation	Patient safety prioritized

Two researchers (J.A., M.K.) independently coded and analyzed the transcripts; all discrepancies (<5%) in codes and themes were discussed until we reached a 100% consensus. To ensure the validity and reliability of the data coding and analysis/interpretations, we followed best practices for these methods, including peer review, team debriefing, and data triangulation across various data sources.[39] We report on repeated themes and sub-themes representing the rich meaning, nuances, and diversity in our data.

 

MissingLinkText

 

MissingLinkText

Results

We conducted approximately 165 hours of observations and shadowing involving 49 clinician participants. During these shadowing sessions, we observed 20 avoidable and unavoidable ICU patient admissions from the floor/ED. We performed 26 clinician interviews (floor (n = 10), ICU (10), ED (5), RRT (1)) (see [Table 3]) and several informal interviews during the observations and shadowing sessions.

Table 3 Number of participants in each role and unit across the methods

Practicing clinicians	Medical/surgical floor units	Medical, surgical, tele-intensive care units	Emergency department	Acute care team
Registered Nurses (RNs)	7	3		5
Advanced Practice Providers (APPs)	2	10
Assistant Nurse Managers (ANMs)	1	1
Physicians (MD)	7	5	8

Findings from observations and shadowing highlight the following: nature and types of ICU admissions from the floor and ED; current clinical workflows related to unavoidable higher acuity and ALA ICU admissions from the floor and ED; and factors contributing to ALA ICU admissions. Informed by the CFIR analysis of the interviews, we elucidate clinician needs and contextual determinants influencing tele-critical care consult service implementation, including desired functions, role, and integration within the current ICU admission workflows, potential barriers and facilitators to TC3 implementation, and related implementation strategies.

Nature and Types of ICU Admissions from Floor and ED Units

Our participants characterized ICU admissions from the floor and ED as unavoidable, higher acuity, and ALA admissions. Patients who met the unavoidable higher acuity admission standards often required acute care treatment and frequent nursing interventions and were not clinically recommended for an extended stay on the floor/ED. Examples of unavoidable higher acuity admissions included cardiopulmonary arrest, organ failure/shock, severe sepsis, high oxygen requirements, significant bleeding, severe laboratory abnormalities, and trauma cases. Alternatively, patients who met the ALA admission standards could potentially stay in place on the floor or move from the ED to the floor and receive appropriate and timely interventions to stabilize their condition, avoiding unnecessary ICU admissions. Examples of ALA admissions included cirrhosis, brittle diabetes, hypoglycemia, altered mental status, mild hypotension without shock, etc. These insights highlighted an untapped opportunity for the tele-ICU team to support remote monitoring and management of ICU admissions via the prevention of ALA admissions from the floor/ED and timely triage of unavoidable higher acuity admissions.

 

MissingLinkText

Current Floor and ED Workflows for Managing Patients at Risk for an ICU Admission

The current floor/ED admission workflows for managing and evaluating patients at risk for ICU admission are illustrated in [Fig. 1]. When a patient on the floor acutely decompensates, the floor nurses and MD/APP evaluate clinical options and potentially notify the RRT to mobilize resources, assist with stabilization, and help with an ICU admission and transfer. Once the RRT and the floor team confirm the need for an ICU bed, they contact triage clinicians in various ICUs to identify and admit the patient to the appropriate ICU.

Fig. 1 Floor/ED admission workflows for managing patients at risk for an ICU admission. ED, emergency department; ICU, intensive care unit.

Alternatively, when an ED patient acutely decompensates, ED MDs/APPs contact ICU triage clinicians to identify an available ICU bed. The patient remains an ED boarder (waitlisted), while the ICU is at capacity and transferred upon bed availability.

Regardless of the ICU admission type, the tele-ICU team participates in ICU admission handoffs, monitors ICU patients, and assists bedside teams from remote locations as needed.

 

MissingLinkText

Factors Contributing to Avoidable, Lower Acuity ICU Admissions

We analyzed several related factors contributing to ALA admissions, including delayed recognition of early signs of clinical deterioration of patients on the floor/ED, differences between clinician reports on patient acuity, limited critical care training and experience for floor/ED clinicians, differences in ICU and floor/ED nursing workflows, premature ICU to floor transfers, and absence of step-down care for “in-between” borderline patients.

Delays in recognizing early signs of clinical deterioration of ED and floor patients: several clinicians voiced concerns about missing signs of deterioration of decompensating patients in the ED and floor units. These signs were often missed due to limited time interacting with patients due to the heavy clinician workload (patient-to-nurse ratios), limited specialized training and prior experience with critically ill patients in floor/ED units, and lack of guidance on patient risk mitigation strategies. For example, floor/ED clinicians felt that recognizing early signs of deterioration could ensure more “aggressive, upfront resuscitative care in the emergency department… your heart failure exacerbation patients with aggressive BIPAP, diuresis, you can make them floor stable after a little while (ED MD14),” prior to transfer. According to Floor ANM2, ICU admissions could be avoided by “recognizing that the patient is starting to go septic, [they] could start antibiotics sooner.” Tele-ICU MD3 similarly noted ICU admissions were affected by a lack of “education [and alerts] for bedside nurses to be aware of [worrisome] signs and symptoms…” Some patients arrive at the ICU with “zero intervention [on the floor] and [with a] simple tweak they're fine (ICU APP4),” indicating the preventable nature of these transfers.

Differences between clinician reports on nature and level of patient acuity: ICU clinicians expressed varied levels of satisfaction with the triage communication report provided by floor and ED clinicians. In some situations, verbal telephone reports of the patient's condition by floor/RRT clinicians were not aligned with ICU MD/APP in-person assessment, as ICU clinicians reported they had “no idea what's going to get here when [patients] show up (ICU APP4).” Thus, with confusing reports from floor/ED clinicians with limited training and experience with acutely ill and critical care patients, ICU clinicians often worried that they would receive either a lower acuity patient who did not warrant ICU level of care or a higher acuity patient who was much more ill than described in the verbal triage report. Missed symptoms of decline could occur if “the first line of information is to the intern and their experience just hasn't taught them what the usual course of that illness is (Floor MD8).”

Limited critical care training and experience for floor/ED clinicians: the limited critical care experience and training also contributed to poor awareness of early critical care interventions on the floor/ED. An ICU clinician also reported, “sometimes people get nervous, and don't actually go through all the treatment options they can do [first] (ICU APP4),” indicating some ALA admissions may be due to lack of clinician comfort with such patients. With an overflow of patients and limited resources in the ICU, these situations often led to stress and poor management in the ICU. ICU MD2 reported that “there's a lot of direct transfers to that ICU because of discomfort from the intern that's overnight.” RRT RNs received many questions from new graduates and travel RNs, indicating that experience level may factor into clinicians' comfort levels with critically ill floor patients. As Floor RN2 described, “when I was a younger nurse, I would freak out and call the doctors and say, 'this doesn't look right,' before I did any of my interventions.” Similarly, ICU MD2 reported how when novice floor physicians feel uncomfortable with sicker patients, “it defaults to the ICU fellow to try to figure out 'does this patient really need to come to the ICU or can we do something more.'”

Differences in ICU and floor/ED nursing workflows: several clinicians, including hospitalists, mentioned that they often rely on their clinical judgment and experience (rather than objective vital sign data) to recognize patients requiring closer monitoring and on the trajectory for a potential decline—however, caring for these patients in the floor unit and ED required a more extensive set of tasks especially from bedside nurses. The nurse:patient ratio on the floor typically ranged from 1:3–5 patients, while the lower ICU nurse:patient ratios (1:1, 2:1) allowed for closer monitoring of these patients on the ICU. As an RRT clinician described, “When the doctor wants vitals every 15 minutes… [Floor RNs] can't sit there and do those things because they have all these other patients, and it's not safe (RRT RN11).” Similarly, some ED patients had “subjective criteria” for ICU admission due to patient monitoring needs, such as “patients with ethanol withdrawal, sepsis, and certain overdose patients (ED MD12).”

Premature ICU to floor patient transfers: several clinicians noted that premature transfers to floor from the ICU due to the extra pressure of patient waitlists for an ICU bed sometimes resulted in floor patients being redirected back to the ICU. Clinicians faced challenges caring for these higher to moderate acuity patients on the floor with fewer resources. They struggled to readmit them to the ICU until the patient decompensated or experienced an adverse event.

Absence of step-down intermediate care units: a lack of step-down intermediate care units for managing moderately ill or “in-between” borderline patients exacerbated this issue of transferring patients directly between the ICU and ED/floor. Several floor/ED clinicians wished for “an observation unit, or this idea of an ED-ICU that was managed remotely by the Tele-ICU (ED MD7)” to care for those borderline patients between floor status and ICU to avoid ALA ICU admissions.

 

MissingLinkText

Proposed TC3 Functions

Our clinicians provided suggestions on conceptualizing and utilizing a tele-critical care consult service (supported by the tele-ICU) to address the factors associated with ALA ICU admissions. Many voiced that a tele-critical care consultation service staffed by intensivists, APPs, and critical care nurses could promote the following functions: (1) offer a second set of eyes via remote patient monitoring, and (2) provide guidance to bedside and RRT teams on diagnostic and therapeutic decisions to ensure faster interventions to patients on the verge of clinical deterioration. In addition to their role in supporting care management of avoidable ICU admissions from floor and ED, clinicians strongly agreed that the TC3 service could be leveraged to coordinate an ICU triage, leading to timely transfers of higher acuity ICU admissions.

Offer a Second Set of Eyes via Remote Patient Monitoring

Clinicians across units recommended TC3's potential for monitoring vital signs, telemetry, and “closer lab follow-up” of floor patients (ICU PA3) and “feedback on vital signs and lab results (Floor MD9).” ED MD7 reported the need for longitudinal monitoring of critically ill patients prior to ICU transfers, as ED physicians “focus on new stabilizations.” This longitudinal care can include placing temporally sensitive laboratory orders and imaging, following up and interpreting these results, maintaining medication titration or dosing, and updating charts and documentation.

 

MissingLinkText

Provide Guidance to Bedside and RRT Teams on Potential Critical Care Interventions to Prevent Sudden Patient Deterioration

Many clinicians felt that given their critical care training and expertise, TC3 staff could provide recommendations to improve patients' conditions before they develop unavoidable ICU admission indicators. ICU clinicians believed that the floor nurses and physicians could use TC3 to discuss emergent situations and brainstorm timely interventions to manage the patient's condition: “if something can be managed outside of the unit, that's helpful because then we can focus on people who are truly sick and in need of an ICU bed (ICU APP1).” Floor RN12 noted that use of TC3 in conjunction with RRT “would decrease a lot of the burden on the ACT [RRT] nurses too, to have already troubleshot all that stuff beforehand,” by remotely placing orders for “any imaging, lab work they want done right away.” This would in turn facilitate RRT delivery of hands-on and timely care.

 

MissingLinkText

Coordinate Triage and Transfer of Unavoidable Higher Acuity Patients to the ICU

Most floor and ED clinicians agreed that TC3 could support the floor and ED clinicians in their presentation and report of the patient's case to ICU triage clinicians and assist with ICU bed coordination—relieving them from these additional transfer tasks while they care for their other patients. Floor MD4 recalled one delay in a recent admission: “I feel like I was spending more time trying to [explain] as to why this [ICU admission] was necessary, so I do think the Tele-ICU would have helped from that perspective and also knowing that there were beds open.” According to ED MD15, the service could “provide safer care for all our patients, especially if we are in a situation where we have multiple critically ill patients coming in - help expedite care, improve patient experiences going forward.” Treatments in ED are focused on rapid patient stabilization; TC3 could recommend methods of treating patients that prepare them for timely interventions upon ICU admission. While troubleshooting care discussions, TC3 could also educate new floor nurses and physicians unfamiliar with critical care.

 

MissingLinkText

 

MissingLinkText

CFIR-Informed Contextual Determinants Guiding the Implementation of TC3 Service

Informed by our interview analysis using the CFIR, we identified several contextual determinants influencing the TC3 service implementation planning, with specific emphasis on potential enablers to TC3 implementation, barriers to TC3 implementation (see [Supplementary Table S2] for clinician quotes), and lastly, implementation strategies to TC3 adoption and use, as depicted in [Fig. 2].

Fig. 2 CFIR-informed contextual determinants guiding TC3 implementation. *Indicates not studied. CFIR, Consolidated Framework for Implementation Research.

Potential Enablers to TC3 Service Implementation

Clinician-reported enablers to TC3 service implementation were related to characteristics of the proposed TC3 intervention, individual characteristics, the TC3 implementation process, and the hospital's inner setting.

 

MissingLinkText

 

MissingLinkText

Intervention Characteristics

When describing what TC3 should encompass, clinicians believed that TC3 should be “readily available for use in floor units (Tele-ICU APP1)” through a mobile tablet with audio-visual communication. They reported a particular need for TC3 overnight as a resource for newer nurses (Floor ANM2) and cross-covering physicians (Floor MD4). Clinicians desired TC3 intervention characteristics to include “ease of use (ED MD15)” and supporting a “rapid response (ED MD14)” after a TC3 activation. An ED clinician reported that “the best-case scenario is that you have an expert opinion at your fingertips in consultation services readily available to assist with complex patients to offset the cognitive burden (ED MD13).” Others anticipated that the service's underlying goal toward optimal care and patient safety would bolster acceptance: “when you take a step back and think about patient safety, I think a lot of people will be open to it (Floor MD6).”

 

MissingLinkText

Characteristics of Individuals

Within the current workflow, clinicians in different roles described how TC3 would impact their responsibilities. Tele-ICU clinicians saw themselves as “an invaluable resource (Tele-ICU RN14)” often “underutilized (Tele-ICU RN15).” In their enthusiasm to provide impact, they, along with floor/ED clinicians, felt that TC3 implementation could provide support during challenges like hierarchy-based decision-making and brainstorming early interventions. In one example, floor and RRT clinicians disagreed about the patient's condition and the necessity of ICU transfer, and a floor clinician mentioned that an arbitrator would have been helpful: “In critical situations, it makes sense if there is good collegiality and knowledge sharing rather than this superiority/inferiority complex (Floor MD2).” Alternatively, ED clinicians described themselves as managing “basically anything that walks through the door,” but would appreciate TC3 input for “advanced ventilator titration, people with critical cardiopulmonary conditions like pulmonary hypertension, right heart failure, major valvopathies, patients on multiple pressors, septic shock” (ED MD14), indicating the potential for TC3 to assist with brainstorming early interventions for ED patients requiring critical care.

 

MissingLinkText

Implementation Process

Most participants expressed support and suggestions for implementing TC3, even while sharing their concerns. One clinician described the culture of acceptance among floor RNs: “If one person uses it once and it's done right, the word will go around (Floor ANM2).” Others suggested, “If there are data that show that these types of alerts or integration of additional services improve patient outcomes and experiences, it would be much more accepted (Floor MD8).” Furthermore, established guidelines and policies for using TC3 in consideration of other resources like RRT were necessary, as “the person calling the Tele-ICU would have to know the difference between when to call an ACT [RRT] and when to call the Tele-ICU (Floor MD2).” ED MD14 described successful, sustained implementation measures that TC3 could use: “we're getting constant reminders, feedback on metrics, updates, we're getting pushed to remember, 'This is how to use this. This is how we're doing.'”

Several clinicians also felt that consistent TC3 staffing and interactions at bedside could foster connections, trust, and buy-in. Many recommended focusing on TC3's efficiency advantages: “If it's something that could be intervened on beforehand, you're actually making less work for yourself, because then you don't have to go through 20 steps to stabilize this patient, whereas maybe you could have just given some Lasix 6 hours ago” (Tele-ICU APP7). ED physicians felt that clinician buy-in for TC3 implementation might be straightforward for ED given that: “A lot of the intensive care docs here are ED trained, they're our colleagues that we work alongside constantly and know socially… it always helps when there's a personal social connection. You can trust that people that are coming in with good intentions to help you, and that you can get along with them (ED MD14).” ED MD7 further recommended that “letting [ED physicians] sit behind the screen and see” the scope of TC3 and their capabilities will foster trust in TC3 and also understand its impact in streamlining ICU admissions. One floor clinician even described the value of training a “super user” for TC3 who could disseminate information and advice to other nurses on the floor: “A staff member… who's already familiar with the product and can use it and explain it (Floor ANM2).”

 

MissingLinkText

Inner Setting

Floor physicians reported time-consuming and frustrating aspects of ICU transfers, such as “calling around for a bed (Floor MD5)” and contacting units “in vain” (Floor MD8), with “a lot of presentations to different providers (Floor MD6).” Meanwhile, ICU triage clinicians revealed that they were often under time pressure and heavy workloads with their ICU patients, which made it challenging to visit floor patients for triage. To address such barriers across current workflows in different units, several clinicians, especially hospitalists, noted that TC3 could reduce delays in ICU admissions during triage and bed placement. Floor RNs were also enthusiastic about TC3; Floor RN2 stated, “a lot of us would feel very supportive and optimistic about wanting to use this service.” Considering the possibility of TC3 working in conjunction with RRT, ICU APP4 described how “sometimes even with ACTs [RRT], a little more time could calm down the situation to avoid an ICU transfer. Especially with the way the hospital is right now, anything we can do to avoid ICU level of care is probably a good idea.” One tele-ICU clinician echoed the goal of preventing ICU-avoidable admissions with earlier recognition and timely interventions: “It's a domino system. If you can see things that are occurring before they get too far down the road, you can prevent them from coming to the ICU, such as when sepsis is occurring. When you see… [certain] criteria occurring, if the providers could offer fluids or antibiotics or cultures sooner, they might not go into full septic shock (Tele-ICU APP7).” If simple interventions such as administration of antibiotics or diuresis were conducted on the floor/ED, patients might not need to be admitted to the ICU (ICU APP4, Floor ANM2). ICU clinicians strongly argued for reserving ICU beds for the most critically ill patients: “Our ICU beds are so tight, we have to be cognizant of taking only the very sick patients. And sometimes when we get the patients that aren't very sick, it's frustrating… It's awesome and admirable we're trying to make sure those beds are allocated correctly, and if we're using the Tele-ICU monitoring system to help with that and maybe help keep patients where they are, [avoiding] unnecessary admissions, that would be great (Tele-ICU RN14).”

 

MissingLinkText

Potential Barriers to TC3 Service Implementation

Similar to the enablers, clinician-reported barriers to implementation of TC3 were related to characteristics of the proposed intervention, individual characteristics, TC3 implementation process, and the hospital's inner setting.

 

MissingLinkText

Intervention Characteristics

Two major concerns arose regarding TC3's roles and responsibilities. First, clinicians were concerned about potential situations where “a patient does actually need the ICU, but we're trying to manage them on the floor with the Tele-ICU consult (Floor MD4).” While a few clinicians agreed that remote care was not sufficient for some critically ill patients, they agreed this could be mitigated by collaboration between remote and bedside clinicians: “the Tele-ICU person can sit there and look at the patient, and if something happens, they could alert the nurse's station. But if they're stable to that degree, why do they need to move to the ICU in the first place? (Floor MD2).”

Second, a few clinicians noted that use of audio-visual tools can be a potential barrier and enabler to TC3 service with some clinicians advocating for use of remote monitoring: “Audio/video [communication] seems to make the most sense. We are, after all, in the 21st century, and we recognize the value of visual capabilities…there could be some creep or perceived creep about the use of those tools (ED MD13).” However, others perceived TC3 as a remote surveillance mechanism that can result in clinician resistance and hesitancy in its adoption.

 

MissingLinkText

Characteristics of Individuals

Several concerns arose regarding the roles and responsibilities of different clinicians with the introduction of TC3. For example, floor physicians emphasized the importance of retaining autonomy in care decisions and a sense of ownership; “I should be willing to say, 'I'm okay with you taking over,' or 'let's not use your services at this time,' so that should be my call (Floor MD2).” Other floor clinicians shared similar sentiments and felt that they had “enough experience to really prevent those sort of unnecessary ICU transfers (Floor MD5).” Thus, some thought that the floor units “would not be a good fit” for the TC3 model and, that all their patients to ICU were “appropriately transferred (Floor APP9), ” and that their patients “needed a hands-on physical assessment (Floor APP8).”

Other floor physicians were also hesitant and reported that “people could worry about the idea of stepping on each other's toes (Floor MD4).” Furthermore, RRT clinicians were concerned about the overlap between their role and that of TC3: “That's essentially what we do, then that's taking our job away from us… We're already here to do that, and we can actually go physically see the patient (RRT RN11).” Floor RNs reported the discomfort they currently feel with managing a higher acuity patient that might become exacerbated if TC3 care keeps such “borderline” patients on the floor with increased floor nursing requirements: “I don't have the time to split between a 3–5 patient assignment for a patient that needs a 1:1 or 2:1 ratio for staffing” (Floor RN12).

 

MissingLinkText

Implementation Process

For successful TC3 implementation, clinicians remarked on the need for “specific guidelines (Tele-ICU APP1)” regarding the duration of TC3 involvement to ensure definitive endpoints of service use. Since the ED functions at “such a different pace than the ICU (ED MD7),” unique unit guidelines were required to accommodate different workflows and contexts.

However, guidelines aside, clinicians also raised several questions about implementation workflow, including, “Do you call whoever is taking care of the patient on the floor, or do you call that Tele-ICU person first? How would that flow work? (ICU MD2)?” Several clinicians also worried about TC3 workflow uncertainties where responsibilities might overlap between floor/ED and TC3 clinicians. For example, “I wouldn't want there to be a gray area of, 'OK, is this person ICU level or floor level? And are we okay with having this patient starting on this drip on the floor while waiting?'” (Floor MD6); “If an ACT [RRT] nurse is with a patient, getting stabilized for 2 hours with the Tele-ICU MD, who else is responding to codes and ACTs in the hospital? (Tele-ICU RN14)”; “One of the metrics that we're graded on … is critical care billing. If I call the Tele-ICU, do they now override me? Does that person now override me for critical care billing for taking care of the patient? (ED MD14).”

 

MissingLinkText

Inner Setting

Several barriers to TC3 implementation across units were identified. Clinicians across units felt the service would be limited by staff shortages and a lack of nursing personnel available to carry out TC3 orders and recommendations. Shadowing sessions with RRT RNs revealed unpredictable schedules with multi-tasking responsibilities (e.g., helping floor RNs with IV placements while remaining available to address potential RRTs/codes).

Shadowing of floor nurses revealed that certain medications (vasopressors, intravenous lidocaine, amiodarone) could only be administered in ICUs or to floor patients in low doses with a plan for immediate transfer to ICUs (Floor RN2). In the ED, these medication requirements, intubation, ventilator use, and frequent neurological checks warranted ICU admissions (ED MD14). As populations become sicker and more complex with limited ICU beds, aspects of critical care will likely be performed outside the ICU. One ED clinician noted a broader system shift: a “transition away from admitting relatively stable patients to the hospital; the hospital [floors] will start to shift towards more ICU type patients (ED MD13),” increasing the need for ICU-level care on non-ICU floors.

 

MissingLinkText

Implementation Strategies for TC3 Adoption

Clinicians suggested defining acceptable deployment requirements for TC3 for a successful implementation, for example, clear protocols for TC3 initiation notification, communication channels between floor/ED and TC3 clinicians, and scope and length of TC3 service. [Table 4] presents the top-cited strategies for implementing TC3 service and its uptake (see [Supplementary Table S3] for all clinician-reported implementation strategies to support TC3 service along with quotations, available in the online version only).

Table 4 Clinician-reported implementation strategies for TC3 adoption

Needs for acceptable and feasible deployment of TC3	Specific implementation strategies
Reliable and robust technical elements	High-quality AV equipment
Seamless communication and with critical stakeholders	Clearly defined notification protocols
Defined scope of service on the floor/ED	Defined protocols for time for start–end service and decision-making roles
Transparent model of care	Determine benefits of a co-management or shared decision-making model versus TC3 as a passive consult-only service
Ensuring clinician buy-in and engagement during the development phase	Increasing awareness and education about the TC3 service, and sharing empirical evidence about its feasibility and impact on clinical and financial outcomes

 

MissingLinkText

 

MissingLinkText

Discussion

ALA ICU (re)admissions financially strain hospital resources, with ICU expenses representing approximately 30% of total hospital costs.[40] In this study, we ascertained that the factors associated with ALA admissions to the ICU from the floor and ED settings include delayed recognition and management of early signs of clinical deterioration, differing clinician opinions about patient acuity levels, limited critical care training and ICU patient care experiences among floor/ED staff, varying nursing workflows in different locations, premature ICU-to-floor transfers, and absence of step-down and intermediate care unit for borderline patients. Our participants highlighted that a tele-critical care consult (TC3) service staffed by intensivists could potentially address these factors with its underlying core functions, including remote monitoring and management of borderline patients outside of the ICU, providing 24/7 guidance and support to clinicians for collaboratively making diagnostic and therapeutic decisions, and lastly, streamlining ICU admission triage process for unavoidable, higher acuity patients. Informed by CFIR, our participants identified that enablers impacting the successful implementation of the TC3 service would include the optional and on-demand features of the TC3 service, around-the-clock availability, and continuous access to trained critical care clinicians for 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 include a desire to uphold physician autonomy by floor/ED clinicians, potential role conflicts with the RRT, additional workload for floor/ED nurses, concerns about obstructing unavoidable, higher acuity admissions, and discomfort with audio-visual tools.

To support these potential enablers and mitigate potential barriers to TC3 implementation, informed by this study, we propose that the two key characteristics—essential for extending the delivery of critical care services beyond the ICU—underlying a telemedicine critical care consultation model include its virtual footprint and on-demand and optional service features.

Expanding critical care service with TC3 virtual footprint: unlike an in-person inpatient consult, a TC3 clinician can see many patients in disparate geographic locations simultaneously if needed. Mobile, location-independent capabilities of TC3 service, supported by audio-visual equipment, real-time patient monitoring equipment, operating protocols, the electronic health record system, etc., afford the delivery of critical care for borderline patients readily available, regardless of patient location. This could also decrease bedside provider workload and enhance efficiency, increasing floor/ED patient discharges and facilitating patient movement out of the ICU. TC3 can facilitate prolonged continuous patient monitoring and enable critical care teams to evaluate multiple patients remotely and simultaneously in different hospital locations, acting as a force multiplier, offloading bedside tasks, streamlining disposition challenges, enacting life-saving critical care needs, and increasing clinician bandwidth.

Expanding critical care service with TC3 on-demand, optional service: the TC3 service can be an optional critical care consultation service available to all floor and ED clinicians who wish to use the service voluntarily when the patient is not yet in extremis, thereby fulfilling a niche role and promoting the delivery of the “right care” model. Such a voluntary option can encourage the autonomy of floor and ED clinicians and create a collaborative partnership for shared clinical decisions. Furthermore, to address the potential role conflicts with the RRT, a TC3 service can focus primarily on lower acuity patients at risk of developing critical care needs but are not yet in extremis warranting an ICU admission. Alongside bedside and RRTs, a TC3 service can proactively detect triage and co-manage deteriorating floor patients at risk for ICU admissions. TC3-RRT collaborative partnership could address some barriers limiting a virtual consult service in providing bedside assistance to floor/ED clinicians—for example, in such circumstances, the RRT can provide physical hands-on assistance, while TC3 provides triage expertise and intensivist guidance. A synergy between TC3 and RRT will be the first step toward creating a successful implementation plan for expanding critical care services outside the ICU to deliver safe and high-quality care to the right patient at the right time, regardless of location.

A TC3 service can also offer a scalable approach by bringing intensivist-level expertise to deteriorating patients and preventing low-acuity ICU admissions.[41] [42] Utilizing telemedicine services to divert ALA ICU admissions can be generalized across hospitals seeking to address ICU resource shortages. For example, one study assessed the impact of a similar service using tele-ICU monitoring of ED boarders admitted to the MICU.[41] They found that 36% of tele-ICU-monitored patient conditions changed and thus were transferred to a less intensive level of care. Tele-ICU monitoring was also associated with decreased mortality but with longer ED boarding time. In another study, tele-ICU physicians in Washington conducted virtual rounds on patients in New York to meet the need for increased intensivist staffing[43]; this resulted in virtual rounding on an additional 40 to 60 patients within 3 weeks of the intervention's introduction. Both sites employed existing telemedicine infrastructure to merge resources, indicating the potential to scale TC3 by collaborating with other hospital sites with established telemedicine resources. Similarly, another study ascertained the impact of a telemedicine consultation team working with ED nurses to assess patients for sepsis using EHR-linked automated monitoring and early detection.[44] They found that tele-sepsis intervention significantly increased sepsis care delivery rates, compared with a “surveillance-only” group, demonstrating the value of telemedicine in the ED in expediting sepsis care through remote monitoring and assessment. Similar eConsult models have been proposed previously as a viable strategy to increase access to specialty care, especially for underserved populations with infectious diseases in outpatient care contexts.[45] [46]

Proposed TC3 workflow: we have developed a preliminary workflow for integrating TC3 service into the current ICU admission workflow from floor and ED units.

As illustrated in [Fig. 3], TC3 may become involved in a patient's care in one of two ways. First, the floor or ED team may identify patients who potentially need critical care services and call TC3 to assist with patient evaluation and treatment. Second, TC3 may independently identify patients who potentially need critical care services based on data available within the electronic health record. If an ICU transfer is warranted, TC3 can call ICU triage clinicians until an appropriate ICU bed has been obtained.

Fig. 3 Preliminary conceptualization of the TC3-integrated ICU admission workflow. ICU, intensive care unit.

Study Limitations

We acknowledge the limitations of this exploratory study. First, the study was performed at a single academic site and informed by observational methods; some workflow-related findings may not be generalizable to other settings. Nevertheless, we highlight the potential value of a tele-critical care service to streamline appropriate and safe admissions to ICUs and to remotely monitor ALA admissions outside of ICUs; this multi-method study ascertained various stakeholder inputs to confirm our scientific premise that such a service will be welcomed and significantly useful for critical care services outside the ICU. Second, our methods did not include a balanced number of clinicians from the various study units, however, we ensured that we included a representative sample of clinicians participate in more than one data collection method. Third, given that this is a needs assessment study, we do not have any evidence on the clinical impact of the TC3 service. Future efforts will determine the effectiveness and implementation potential of TC3 at our setting. If successful, we will extend the reach of the service to other community and rural hospitals.

 

MissingLinkText

 

MissingLinkText

Conclusion

Given current trends in ICU bed scarcity and intensivist/nursing shortages, novel solutions are needed to deliver high-quality, safe care to lower acuity patients outside the ICU. We explored the role of a telemedicine service such as a TC3 as a viable and promising approach to provide the “right care at the right time to the right patient” at scale, by bringing intensivists expertise to the patient, regardless of the place/location. If successful, this service could revolutionize the provision of timely and desperately needed critical care services outside the ICU, but would require diligent planning, stakeholder buy-in, and further investigation of practical implementation and sustainability strategies to address the contextual determinants underlying TC3 implementation.

 

MissingLinkText

Clinical Relevance Statement

Clinicians in both academic and nonacademic settings can use the TC3 strategy described in this manuscript to provide critical care resources to patients outside the ICU. The user needs identified in this study can likely be generalized to many settings, although the details about how a TC3 service will address these needs may differ from setting to setting. Once implemented, a TC3 service may help clinicians address the near-universal problem of ICU bed scarcity.

 

MissingLinkText

Multiple-Choice Questions

1. Which of the following is a factor that contributes to potentially avoidable, lower acuity ICU admissions?

   • Abundant access to high-dependency units (step-down or observation units)

   • Early recognition of patient deterioration

   • Limited critical care training among floor clinicians

   • Similar nursing workflows between the ED, floor, and ICU

   Correct Answer: The correct answer is option c. Limited critical care training among floor clinicians can result in ICU transfer if the clinician is not sure whether the patient needs critical care services or not, or because the clinician does not feel comfortable managing the patient's condition.

   Choice a is incorrect because access to high-dependency units (step-down or observation units) is usually limited. In this case, a patient may be transferred to an ICU because they require high-dependency unit care, but no high-dependency unit is available. Choice b is incorrect because late recognition of patient deterioration, not early recognition, contributes to ICU admissions. Choice d is incorrect because the differences in nursing workflows between the ED, floor, and ICU sometimes contribute to the need for ICU transfer. Some of these differences include differences in nurse-to-patient ratios (affecting the time available to care for each patient without neglecting other patients) as well as training in administration of certain medications.

2. In addition to providing treatment recommendations for individual patients, which of the following is a potential function of a TC3 service?

   • To limit access to ICU beds

   • To provide mentorship to inexperienced nurses and physicians

   • To replace the rapid response team/acute care team

   • To take over all decision-making capacity from the bedside physician

   Correct Answer: The correct answer is option b. Because tele-critical care physicians and nurses have extensive training and experience in the care of life-threatening conditions, they can provide mentorship to other physicians and nurses who may have less experience with these conditions.

   Choice a is incorrect because an important role of a TC3 service is to make it easier to find an ICU bed when a patient requires ICU admission. Choice c is incorrect because rapid response teams/acute care teams can provide hands-on assistance to the bedside team, particularly when a patient deteriorates or becomes unstable. Thus, rapid response teams complement a TC3 service. Choice d is incorrect because bedside physicians highly value their autonomy. Therefore, care decisions need to be discussed between the TC3 service and the bedside physician.

 

MissingLinkText

 

MissingLinkText

Conflict of Interest

None declared.

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.

• References

• 1 Barrett ML, Smith MW, Elixhauser A, Honigman LS, Pines JM. Utilization of Intensive Care Services,. 2011. : Statistical Brief #185. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville, MD:: Agency for Healthcare Research and Quality (US); ; 2006
• 2 Groeger JS, Guntupalli KK, Strosberg M. et al. Descriptive analysis of critical care units in the United States: patient characteristics and intensive care unit utilization. Crit Care Med 1993; 21 (02) 279-291
• 3 Marquet K, Claes N, De Troy E. et al. One fourth of unplanned transfers to a higher level of care are associated with a highly preventable adverse event: a patient record review in six Belgian hospitals. Crit Care Med 2015; 43 (05) 1053-1061
• 4 Mulvey HE, Haslam RD, Laytin AD, Diamond CA, Sims CA. Unplanned ICU admission is associated with worse clinical outcomes in geriatric trauma patients. J Surg Res 2020; 245: 13-21
• 5 Rubano JA, Vosswinkel JA, McCormack JE, Huang EC, Shapiro MJ, Jawa RS. Unplanned intensive care unit admission following trauma. J Crit Care 2016; 33: 174-179
• 6 Weissman GE, Kerlin MP, Yuan Y. et al. Potentially preventable intensive care unit admissions in the United States, 2006-2015. Ann Am Thorac Soc 2020; 17 (01) 81-88
• 7 Kollef MH, Chen Y, Heard K. et al. A randomized trial of real-time automated clinical deterioration alerts sent to a rapid response team. J Hosp Med 2014; 9 (07) 424-429
• 8 Smith RM, Conn AK. Prehospital care - scoop and run or stay and play?. Injury 2009; 40 (Suppl. 04) S23-S26
• 9 Nirula R, Maier R, Moore E, Sperry J, Gentilello L. Scoop and run to the trauma center or stay and play at the local hospital: hospital transfer's effect on mortality. J Trauma 2010; 69 (03) 595-599 , discussion 599–601
• 10 Dacey MJ, Mirza ER, Wilcox V. et al. The effect of a rapid response team on major clinical outcome measures in a community hospital. Crit Care Med 2007; 35 (09) 2076-2082
• 11 Sharek PJ, Parast LM, Leong K. et al. Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a Children's Hospital. JAMA 2007; 298 (19) 2267-2274
• 12 Jung B, Daurat A, De Jong A. et al. Rapid response team and hospital mortality in hospitalized patients. Intensive Care Med 2016; 42 (04) 494-504
• 13 Karpman C, Keegan MT, Jensen JB, Bauer PR, Brown DR, Afessa B. The impact of rapid response team on outcome of patients transferred from the ward to the ICU: a single-center study. Crit Care Med 2013; 41 (10) 2284-2291
• 14 Orosz J, Bailey M, Udy A, Pilcher D, Bellomo R, Jones D. Unplanned ICU admission from hospital wards after rapid response team review in Australia and New Zealand. Crit Care Med 2020; 48 (07) e550-e556
• 15 Mullins PM, Goyal M, Pines JM. National growth in intensive care unit admissions from emergency departments in the United States from 2002 to 2009. Acad Emerg Med 2013; 20 (05) 479-486
• 16 McGloin H, Adam SK, Singer M. Unexpected deaths and referrals to intensive care of patients on general wards. Are some cases potentially avoidable?. J R Coll Physicians Lond 1999; 33 (03) 255-259
• 17 Prints M, Fishbein D, Arnold R. et al. Understanding the perception of workload in the emergency department and its impact on medical decision making. Am J Emerg Med 2020; 38 (02) 397-399
• 18 Pisani MA, D'Ambrosio C. Sleep and delirium in adults who are critically ill: a contemporary review. Chest 2020; 157 (04) 977-984
• 19 Altman MT, Knauert MP, Pisani MA. Sleep disturbance after hospitalization and critical illness: a systematic review. Ann Am Thorac Soc 2017; 14 (09) 1457-1468
• 20 Krewulak KD, Stelfox HT, Leigh JP, Ely EW, Fiest KM. Incidence and prevalence of delirium subtypes in an adult ICU: a systematic review and meta-analysis. Crit Care Med 2018; 46 (12) 2029-2035
• 21 Soriano MC, Vaquero C, Ortiz-Fernández A, Caballero A, Blandino-Ortiz A, de Pablo R. Low incidence of co-infection, but high incidence of ICU-acquired infections in critically ill patients with COVID-19. J Infect 2021; 82 (02) e20-e21
• 22 Al-Rajhi A, Mardini L, Jayaraman D. The impact of implementation of an ICU consult service on hospital-wide outcomes and ICU-specific outcomes. J Intensive Care Med 2016; 31 (07) 478-484
• 23 Nguyen HB, Rivers EP, Havstad S. et al. Critical care in the emergency department: a physiologic assessment and outcome evaluation. Acad Emerg Med 2000; 7 (12) 1354-1361
• 24 Churpek MM, Yuen TC, Winslow C, Meltzer DO, Kattan MW, Edelson DP. Multicenter comparison of machine learning methods and conventional regression for predicting clinical deterioration on the wards. Crit Care Med 2016; 44 (02) 368-374
• 25 Brankovic A, Hassanzadeh H, Good N. et al. Explainable machine learning for real-time deterioration alert prediction to guide pre-emptive treatment. Sci Rep 2022; 12 (01) 11734
• 26 Kahn JM, Cicero BD, Wallace DJ, Iwashyna TJ. Adoption of ICU telemedicine in the United States. Crit Care Med 2014; 42 (02) 362-368
• 27 Kleinpell RM, Ely EW, Grabenkort R. Nurse practitioners and physician assistants in the intensive care unit: an evidence-based review. Crit Care Med 2008; 36 (10) 2888-2897
• 28 Heisler M. Hospitalists and intensivists: partners in caring for the critically ill–the time has come. J Hosp Med 2010; 5 (01) 1-3
• 29 Lilly CM, Cody S, Zhao H. et al; University of Massachusetts Memorial Critical Care Operations Group. Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes. JAMA 2011; 305 (21) 2175-2183
• 30 Lilly CM, McLaughlin JM, Zhao H, Baker SP, Cody S, Irwin RS. UMass Memorial Critical Care Operations Group. A multicenter study of ICU telemedicine reengineering of adult critical care. Chest 2014; 145 (03) 500-507
• 31 Fusaro MV, Becker C, Scurlock C. Evaluating tele-ICU implementation based on observed and predicted ICU mortality: a systematic review and meta-analysis. Crit Care Med 2019; 47 (04) 501-507
• 32 Becker CD, Fusaro MV, Al Aseri Z, Millerman K, Scurlock C. Effects of telemedicine ICU intervention on care standardization and patient outcomes: an observational study. Crit Care Explor 2020; 2 (07) e0165
• 33 Young LB, Chan PS, Lu X, Nallamothu BK, Sasson C, Cram PM. Impact of telemedicine intensive care unit coverage on patient outcomes: a systematic review and meta-analysis. Arch Intern Med 2011; 171 (06) 498-506
• 34 Kahn JM, Le TQ, Barnato AE. et al. ICU telemedicine and critical care mortality: a national effectiveness study. Med Care 2016; 54 (03) 319-325
• 35 Fusch PI, Ness LR. Are we there yet? Data saturation in qualitative research. Qual Rep 2015; 20 (09) 1408-1416
• 36 Hennink M, Kaiser BN. Sample sizes for saturation in qualitative research: a systematic review of empirical tests. Soc Sci Med 2022; 292: 114523
• 37 Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009; 4: 50
• 38 Safaeinili N, Brown-Johnson C, Shaw JG, Mahoney M, Winget M. CFIR simplified: pragmatic application of and adaptations to the Consolidated Framework for Implementation Research (CFIR) for evaluation of a patient-centered care transformation within a learning health system. Learn Health Syst 2019; 4 (01) e10201
• 39 Cypress BS. Rigor or reliability and validity in qualitative research: perspectives, strategies, reconceptualization, and recommendations. Dimens Crit Care Nurs 2017; 36 (04) 253-263
• 40 Oye RK, Bellamy PE. Patterns of resource consumption in medical intensive care. Chest 1991; 99 (03) 685-689
• 41 Kadar RB, Amici DR, Hesse K, Bonder A, Ries M. Impact of telemonitoring of critically ill emergency department patients awaiting ICU transfer. Crit Care Med 2019; 47 (09) 1201-1207
• 42 Collins TA, Robertson MP, Sicoutris CP. et al. Telemedicine coverage for post-operative ICU patients. J Telemed Telecare 2017; 23 (02) 360-364
• 43 Chandra S, Hertz C, Khurana H, Doerfler ME. Collaboration between tele-ICU programs has the potential to rapidly increase the availability of critical care physicians-our experience was during coronavirus disease 2019 nomenclature. Crit Care Explor 2021; 3 (03) e0363
• 44 Gaieski DF, Carr B, Toolan M. et al. Can an end-to-end telesepsis solution improve the severe sepsis and septic shock management bundle-1 metrics for sepsis patients admitted from the emergency department to the hospital?. Crit Care Explor 2022; 4 (10) e0767
• 45 Lee MS, Nambudiri VE. Electronic consultations (eConsults) for safe and equitable coordination of virtual outpatient specialty care. Appl Clin Inform 2020; 11 (05) 821-824
• 46 Medford RJ, Granger M, Pickering M, Lehmann CU, Mayorga C, King H. Implementation of outpatient infectious diseases e-consults at a safety net healthcare system. Open Forum Infect Dis 2022; 9 (07) ofac341

Publikationsverlauf

Eingereicht: 21. Juli 2023

Angenommen: 15. Januar 2024

Artikel online veröffentlicht:
06. März 2024