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By Raney Linck and Colleen Hammill | 01/01/2015

VA uses tele-ICU to bring big-city resources to rural hospitals.


In 16 years, the United States’ intensive care unit (ICU) system must triple capacity to serve the needs of an aging population. How will such a monumental objective be achieved? Part of the answer is tele-intensive care units, or tele-ICUs.
Today, more than 6 million of the sickest and oldest patients are treated annually in ICUs in the United States. The U.S. population over age 65 is projected to double by 2030, which will result in a need for three times as many ICU beds. Rural communities, which have a larger percentage of older adults but fewer health care resources, are most at risk. Rural hospitals are especially challenged to recruit and retain experienced critical care staff. A severe imbalance between supply and demand is creating a perfect storm. As need increases, there will be a shortage of critical care nurses and “intensivists”—physicians certified in critical care medicine.
Clutter_Kay_embed_SFWTele-ICUs use telecommunicationnetworks to provide expert support and counsel around the clock to ICUs in remotehospitals. Key benefits include improved access to intensivists and experienced critical care nurses, providing an extra layer of support to ICU staff who work weekend and evening shifts, as well as during emergencies.
Now, two nurse leaders in the Veterans Health Administration, part of the U.S. Department of Veterans Affairs (VA), are innovating creative new solutions to address this urgent need. Tele-ICU networks are making critical care specialists available in unprecedented numbers to patients and bedside staff at rural hospitals. On 1 April, Kay Clutter, PhD, RN, operations director in the Central VA ICU Telemedicine System, and Sharon Stanke, DNP, RN, the system’s regional critical care educator, launched the Critical Care Advancement Program, or CCAP, to bring advanced, interdisciplinary, critical care education and continuing education units (CEUs) to any health care provider, anywhere.
Stanke_Sharon_embed_SFW2CCAP addresses the major problem of diminishing educational resources, especially in rural hospitals. The program will provide in-depth education and CEUs on best critical care practices, while simultaneously teaching best collaboration practices through tele-ICU.
“Tele-ICU has been around for about 10 years and is still seen as a bit of a novelty,” notes Stanke. “But I believe tele-ICU, because of how it proactively supports safe patient management, will eventually become standardized into the practice of care. I’m not sure exactly when that will occur, but it may be sooner than we think.”
Every moment crucial
Approximately 50 tele-ICU command centers reach more than 200 hospitals and 10 percent of all critically ill patients in the United States. This following real-life example illustrates how it works.

In Missouri, a veteran goes into cardiac arrest minutes after arriving at a VA Medical Center. He is resuscitated and rushed to the ICU, where an abnormal heart rhythm begins to develop. Another arrest could occur soon.

Every moment is crucial. Little is known about the patient at this point, and key lab results are pending. Many things need to happen simultaneously: entering orders for care, reviewing lab results as they become available, and researching the electronic health record (EHR) for essential history and details about the veteran.
The Missouri staff activates the tele-ICU by pressing a large button on the wall, and the Minnesota-based center immediately comes online. Cameras and screens inside the room create a real-time visual connection with the out-of-state expert team. An intensivist and experienced critical care nurse are now added virtually to the team at the patient’s bedside.

With the tele-ICU support from Minnesota, the Missouri physician and nurses never leave the bedside during the crisis. The Minnesota team enters orders and provides essential information in real time. They find past EKGs in the EHR, compare them with the current rhythm, and review lab results the moment they become available. Minnesota personnel immediately inform Missouri staff members of a result that indicates a critically low potassium level. The tele-ICU center enters orders as the local team corrects the deficiency, which normalizes the heart rhythm before a second cardiac arrest occurs.

Transforming care
The power of tele-ICU extends beyond emergency management: The patient’s vital sign trends, cardiac telemetry, and lab values are monitored continuously and remotely to provide an added layer of care. In addition, the tele-ICU enables the interdisciplinary team to virtually attend daily rounds at remote sites, so they are fully included on each patient’s plan of care. The quiet, less chaotic setting of a command center enables tele-ICU nurses to identify immediate changes and evolving trends without the repeated interruptions that a bedside nurse experiences on a busy critical care unit. This is one of many ways that tele-ICU specialists provide counsel and support (see Table 1).
Table1_teleICU_SFWIn many cases, tele-ICUs have been shown to decrease ICU and hospital mortality and length of stay, as well as improve compliance with evidence-based clinical practice guidelines, such as protocols to reduce ventilator-associated pneumonia. Partnership between the tele-ICU and remote sites in revising and standardizing clinical guidelines, pathways, and protocols is an essential co-intervention to transform care and outcomes. Tele-ICU has the potential to be a complex, multidimensional intervention that can transform every aspect of how an ICU functions.
Stark contrast
For many rural hospitals, 4 p.m. brings a daily and drastic change in available resources as the onsite physician and pharmacist—even the respiratory therapist—often depart the premises. In these hospitals, annual budgets for education are small and subject to cuts. An education “department” may consist of only one person to serve all specialties and staff members.
“At a large tertiary medical center, you get used to a lot of resources,” says Clutter. “It’s a very different experience for our rural hospitals.”
Table2_CentralVA_Telemedicine_SFWThe VA’s tele-ICU system was launched in 2011 to serve the Veterans Integrated Service Network 23 (VISN 23), which provides care to more than 430,000 enrolled veterans in the Midwest. It’s the third largest and third most rural region in the VA system. Now, four years later, Clutter has guided the expansion of the program to serve hospitals across nine states, from Washington to Illinois (see Table 2) and is currently working on an expansion that will allow that regional tele-ICU to serve active-duty soldiers at Department of Defense facilities. She began by connecting and developing relationships with the remote hospital sites, usually in rural areas. As she continued to listen, a pattern quickly emerged.
Education, she learned, was a critical need at small rural hospitals that typically have just one educator for all nursing staff, which makes ICU nurse managers responsible for critical care specialty education. In addition, limited resources often dictate that the manager cover one or two other units.
“Our bedside nurses in Fargo organized their own annual ICU skills fair to focus on critical care skills and training,” Clutter notes. The rural hospitals clearly have the desire and initiative to advance knowledge, but they lack the budget to support nurse travel to conferences or large medical centers that offer training support for advanced certification, even simulations.
Innovative model
Clutter came up with an innovative solution: What if the existing tele-ICU network could bring “big city” educational resources to rural sites? She wrote a grant proposal to the Office of Rural Health and secured funding for a regional critical care educator for the Central VA ICU Telemedicine System.
Sharon Stanke, who was recruited for the new position, has developed a comprehensive curriculum, just launched, with units on mechanical ventilation, ABG interpretation, and evidence-based practice. Future units will include renal, GI, endocrine, and many other topics.
CCAP utilizes three technology platforms to deliver content:
  • VoiceThread, an interactive presentation tool that allows learners to ask questions and make comments on each slide of a presentation, communicating directly with the instructor;
  • Blackboard Learn, a course management system; and
  • Blackboard Collaborate, a videoconferencing tool.
In developing the CCAP curriculum, Stanke first took into consideration the ICU patient and family and then the needs of critical care providers at the bedside (nurses, respiratory therapists, physicians, and medical residents) and in the tele-ICU.
“Installing the technology was only the very first step,” says Stanke. “We have to teach people how to use this new model of collaboration. We can’t advance patient care if tele-ICU is only utilized during big emergencies.” To improve care, advanced technology has to be paired with developing relationships for collaboration and education.
The next phase of CCAP will be to incorporate interdisciplinary simulations at remote sites. To improve training, the VA has invested in a Laerdal high-fidelity human-patient simulator at every site. Soon, coordinators at each site will conduct onsite simulations at specific time points as they progress through the program. The goal is to bring together nurses, respiratory therapists, physicians, and residents to apply their learning. This will enable providers to demonstrate performance outcomes after specific didactic content is completed.
Stanke earned her Doctor of Nursing Practice degree with a project that uniquely qualified her for developing this next phase. She created an innovative high-fidelity simulation program to train ICU nurses at the Minneapolis VA Medical Center, then tested the program’s impact on patient outcomes. She found that hemodynamic stability for open-heart surgery patients improved 172 percent after nurses completed simulation training.
“Combining simulation, tele-ICU, and collaborative didactic education is the cutting edge,” Stanke says. “In my doctoral project, I saw that when ICU nurses turned what they had learned into action during simulation, it changed their practice. The validation of their critical thinking gave them the confidence to apply it with their patients.”
Priority: To improve the human connection
Bringing higher levels of technology to the bedside should never be a goal in itself. What matters is how technology changes the human experience in the real world. Confident providers, empowered by interdisciplinary education and simulations in their home communities, provide better care.

The American Association of Critical-Care Nurses notes that the nursing shortage is more pronounced in the critical care specialty. Also, ICU nurses are particularly vulnerable to developing burnout from chronic occupational stressors. Tele-ICU can be a powerful intervention when the collaborative support it provides helps reduce stress and improve care at rural sites struggling with retention and advancement of critical care staff. By incorporating interactive models of critical care education that can be delivered to any VA site, the developers of CCAP hope to level the landscape of critical care, improving care in rural and urban facilities throughout the United States.
At the VA, intensivist support for tele-ICU has already enabled smaller ICUs to keep more patients on site, providing significant cost savings as well as support for families. Eliminating transportation costs for a single transfer can save thousands of dollars, but the greater benefit is enabling patients to heal in their own communities.
Clutter always thinks about how tele-ICU impacts both patient and family. “It’s hard on our veterans’ spouses to drive so far away, especially in winter. Some of them just can’t do it,” she explains. The plan is for the VA tele-ICU to continue the trend of reducing expensive transfers and keeping veterans close to family and friends. The real-world impact—emotionally and economically—of being able to care for ICU patients in their own communities cannot be minimized.
In the final analysis, the goal is never to advance technology for its own sake. The purpose of these VA initiatives is to use high-tech tools to bring best practices of critical care to any patient, anywhere.
Linck_Hammill_ID_duet_SFWRaney Linck, MSN, RN, clinical instructor at the University of Minnesota School of Nursing, is working toward a DNP in health innovation and leadership at the University of Minnesota. Colleen Hammill, MSN, RN, CCRN, is an adjunct clinical instructor at the University of Minnesota School of Nursing. Both are helping to prepare BSN nursing students through the Veteran Administration Nursing Academic Partnership (VANAP), an innovative education and practice collaboration between VA facilities and the University of Minnesota.
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