Page 100 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

68 PART 1: An Overview of the Approach to and Organization of Critical Care

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the ICU? What are specific goals of telemedicine in this setting? What EDUCATING NEW CLINICIANS
are our current workforce needs and what will our needs be under the Traditional medical education emphasized bedside care, with lessons on
telemedicine model? How receptive is the ICU staff to organizational the pathophysiology of disease tightly linked to the patient assessment at
change? What existing clinical information systems must be integrated the bedside. Over the last few decades, the profession added additional
with the new technology? What are the budgetary constraints? How education in communication, ethics, and professionalism in response to
scalable will the system need to be in the event of expansion or shift- new challenges faced by doctors. However, the current medical educa-
ing need? The answers to these questions will inform the type of tele- tion system still does not prepare trainees to practice in the fully inte-
medicine program and the ways in which effectiveness of the program grated health system of the future, one in which care is provided across
is evaluated. regions using a combination of technological and physical approaches.
There are several additional operational considerations. Physical
space for the telemedicine unit is important, and should be considered To ensure a prepared workforce, we must rethink the way we educate the
next generation of clinicians.
on par with the physical environment of the ICU itself. As in other
industries such as air-traffic control, workstation design and ergonom- ■ BALANCING STAKEHOLDER NEEDS
ics have potential to influence worker effectiveness. Although the
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location of the telemedicine unit is not limited to any one place, hos- Reorganizing critical care will mean carefully balancing the needs of
pitals may want to locate it in close proximity to one or another ICU competing stakeholders. Relevant stakeholders in critical care include
if telemedicine physicians might ever be asked to provide in-person community physicians, academic physicians, other clinicians, hospitals,
care. Important technological issues include whether to include two- governmental agencies, and health care purchasers. Frequently the needs
way video (such that bedside clinicians can see the telemedicine unit), and incentives for these stakeholders may not align. For example, region-
whether to integrate the telemedicine application with an existing clini- alization and telemedicine may require community physicians to sacrifice
cal information system, how to ensure data privacy and security, and autonomy in order to achieve greater health care quality. Conversely, in
how to manage and store the vast amounts data involved. There are sev- settings where regionalization and telemedicine do not make sense, aca-
eral commercial vendors that provide a range telemedicine services—if demic physicians with personal or financial stakes in their success may
a commercial solution is sought then the vendor can often help assess have to sacrifice. Clearly these approaches are not panaceas for the prob-
and review local needs. lems facing critical care, but are just two of many possible tools. Figuring
out ways to use these tools in ways that prioritize the needs of all major
■ ROLE OF INTENSIVISTS stakeholders is a pressing challenge for the profession.

Intensivist physicians must recognize their special role within a telemed- ■ MAINTAINING PATIENT CENTEREDNESS
icine program, and how that role differs from traditional in-person care. In all the discussions about regional care delivery and technological
This role can also be customized from program to program. In some innovation, it is easy to lose sight of the patient. It is essential that as we
programs teleintensivists will manage all aspects of patient care just as in work to reorganize the health care system we maintain a patient focus.
a closed ICU. In some programs, teleintensivists will comanage patients We must not forget to consider patient and family wishes when we sug-
with nonintensivists, a relationship common to many existing ICUs, the gest transferring critically ill patients far from their homes, or replacing
only difference being distance. In still other programs, teleintensivists the soothing presence of a physician at the bedside with a disembodied
will comanage patients with other intensivists, a novel cooperative care voice coming over a loudspeaker. Moreover, some important aspects
model that will require new strategies for communication between phy- of critical care may be totally incompatible with transfer to a distant
sicians. Teleintensivists under this model will simultaneously be team regional care centers or use of telemedicine, such as pastoral care or
leaders and members of a larger team, a role that may not come naturally end-of-life care. Certainly health care value is a major priority: the
to most intensivists. health care system should achieve the greatest benefit for the greatest
All participating intensivists will have to learn a new method of number of people in the most efficient manner possible. Regionalization
patient care, one for which they may not have received any specific and telemedicine are likely to be part of the value equation in the years
training. The skills required to provide critical care across a distance are to come. Yet we must not lose sight of the fact that an equal priority is
not necessarily intuitive. These skills include the ability to make diag- reinforcing the importance of the patient in our efforts to implement
noses in the absence of a traditional physical examination, the ability regional critical care.
to effectively communicate with other providers through cameras and
speakerphones, and the ability to integrate multiple simultaneous data
sources in patients for whom they may have little or no familiarity. Most KEY REFERENCES
challenging among these may be the ability to gain the trust and confi-
dence of patients and bedside nurses from the other side of a camera. • Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J Jr. Current
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Effective interpersonal communication is the cornerstone of effective and projected workforce requirements for care of the critically
multidisciplinary ICU care, and the ability to provide it is almost cer- ill and patients with pulmonary disease: can we meet the require-
tainly a learned skill. ments of an aging population? JAMA. 2000;284(21):2762-2770.
• Barnato AE, Kahn JM, Rubenfeld GD, et al. Prioritizing the organiza-
tion and management of intensive care services in the United States:
SPECIAL CHALLENGES the PrOMIS Conference. Crit Care Med. 2007;35(4):1003-1011.
Both telemedicine and regionalization involve a fundamental reorga- • Kahn JM, Goss CH, Heagerty PJ, Kramer AA, O’Brien CR,
nization of the way we provide critical care. Although each evolved Rubenfeld GD. Hospital volume and the outcomes of mechanical
separately, they both developed out of the need to bring a regional ventilation. N Engl J Med. 2006;355(1):41-50.
perspective to critical care medicine. The problems that created this • Kahn JM, Linde-Zwirble WT, Wunsch H, et al. Potential value of
need—the gap between evidence and practice, variation in quality regionalized intensive care for mechanically ventilated medical
between hospitals, growing workforce crisis—are unlikely to go away patients. Am J Respir Crit Care Med. 2008;177(3):285-291.
soon. Consequently, the use of these strategies and others that might • Kahn JM, Asch RJ, Iwashyna TJ, et al. Physician attitudes toward
improve access to high-quality critical care are likely to expand. With regionalization of adult critical care: a national survey. Crit Care
that in mind, there are several special challenges that the field must face Med. 2009;37(7):2149-2154.
as critical care reorganizes across the world.

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