Medicolegal Issues

Telemedicine Can Help Solve Intensivist Shortage


 

Having spent my medical career in the ICU and the hospital, I have followed the recent articles on the struggle to care for ICU patients with interest. Gretchen Henkel’s article on hospitalists filling ICU manpower gaps (“The New Intensivists,” October 2008, p. 1) poses a very real question for community hospitals, which face the greatest challenges in this area. Two issues are common: 1) difficulty in providing 24/7 ICU coverage and 2) the competing priorities that ICU medical leaders face. For these challenges, telemedicine offers a possible solution.

This unique, high-intensity, multidisciplinary approach to the patient population—an integral part of intensivist training—is a proven process shown to have meaningful results in the ICU. However, the team approach to managing ICU patients can be hard to come by. As suggested in Henkel’s article, there are several ways to approach this, but simply having a hospitalist consult on an ICU patient is not, I believe, a solution. Not only can this add to the strain on a hospitalist team, but a proactive approach to the ICU patient also can be hampered by the need for hospitalists to be present in the medical-surgical areas. Ideally, an intensivist should lead a multiprofessional team; however, there is a tremendous intensivist shortage, with less than 20% of ICUs staffed with them. Telemedicine offers a way to bridge the gap of expertise and manpower in many settings, bringing intensivists to the forefront of the ICU multidisciplinary team.

Community hospitals with teleintensivist programs are seeing a drop in ventilator-associated pneumonia, better blood glucose management, and compliance with sepsis and other bundles.

For the multidisciplinary approach to be effective, a physician must be committed to creating the team and identifying the measures that it will impact. In many community hospitals, this is the ICU medical director. However, competing priorities can make this directive difficult to achieve. Teleintensivists, intensivists that practice medicine via telemedicine, proactively establish best practices and a multidisciplinary approach, thus dramatically affecting the quality and financial metrics of the ICU.

Lack of 24/7 ICU coverage is another big challenge for community hospitals. Trying to meet this challenge by simply adding intensivists is likely to be met with defeat, given the shortage of hospitalists. And adding more hospitalists in the ICU continues to drive the hospitalist shortage. There is a variety of solutions for bedside procedures; however, the constant need to respond to phone calls and unpredictable patient interventions remains. While utilizing midlevel providers can help, this approach is not likely to support the demand of the aging population.

Hospitals increasingly are considering telemedicine to meet the 24/7 need. Teleintensivists have risen to add manpower and immediate response to ICU patients. Without the distraction of constant interruptions and with a process to manage the deluge of data, community hospitals with teleintensivist programs are seeing a drop in ventilator-associated pneumonia, better blood glucose management, and compliance with sepsis and other bundles.

This proactive approach to ICU patient care has led to significant decreases in mortality and lengths of stay.

A recent article in The New York Times focused on “disruptive innovation” in healthcare.1 Given the pressing issues facing the industry, disruptive innovation―at the bedside as well as with telemedicine technology―will be a key factor in meeting our ICU needs successfully.

Mary Jo Gorman, MD, MBA

Editor’s note: Dr. Gorman, a former SHM president, is the CEO of St. Louis-based Advanced ICU Care, which provides intensivists to community hospitals using telemedicine. TH

Reference

1. Rae-Dupree J. Disruptive innovation, applied to health care. The New York Times Web site. Available at: www.nytimes.com/2009/02/01/business/01unbox.html?scp=1&sq=disruptive%20innovation&st=cse. Accessed March 3, 2009.

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