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The Initial Impact of Tele-Critical Care on the Surgical Services of a Community Military Hospital

The Initial Impact of Tele-Critical Care on the Surgical Services of a Community Military Hospital Downloaded from https://academic.oup.com/milmed/article/183/11-12/e494/4959960 by DeepDyve user on 19 July 2022 MILITARY MEDICINE, 183, 11/12:e494, 2018 The Initial Impact of Tele-Critical Care on the Surgical Services of a Community Military Hospital LT Jan-Michael Van Gent, MC USN*; CDR Konrad L. Davis, MC USN†; Nichole Henry, RN‡; LT Ashley L. Zander, MC USN*; LCDR Matthew A. Kuettel, MC USN§; CAPT Theodore Edson, MC USN§; CAPT Thomas J. Nelson, MC USN§; CDR Matthew D. Tadlock, MC, USN§ ABSTRACT Introduction: Mortality is reduced in hospitals staffed with intensivists, however, many smaller military hospi- tals lack intensivist support. Naval Hospital Camp Pendleton (NHCP) is a Military Treatment Facility (MTF) that operates a 6-bed Intensive Care Unit (ICU) north of its referral center, Naval Medical Center San Diego (NMCSD). To address a gap in NHCP on-site intensivist coverage, a comprehensive Tele-Critical Care (TCC) support system was established between NHCP and NMCSD. To examine the initial impact of telemedicine on surgical ICU patients, we compare NHCP surgical ICU admis- sions before and after TCC implementation. Materials and methods: Patient care by remote intensivist was achieved utiliz- ing video teleconferencing technology, and remote access to electronic medical records. Standardization was promoted by adopting protocols and mandatory intensivist involvement in all ICU admissions. Surgical ICU admissions prior to TCC implementation (pre-TCC) were compared to those following TCC implementation (post-TCC). Results: Of 828 ICU admissions, 21% were surgical. TCC provided coverage during 35% of the intervention period. Comparing pre- TCC and post-TCC periods, there was a significant increase in the percentage of surgical ICU admissions [15.3 % vs 24.6%, p = 0.01] and the average monthly APACHE II score [4.1vs 6.5, p = 0.03]. The total number of surgical admissions per month also increased [3.9 vs 6.3, p = 0.009]. No adverse outcomes were identified. Conclusion: Implementation of TCC was associated with an increase in the scope and complexity of surgical admissions with no adverse outcomes. Surgeons were able to safely expand the surgical services offered requiring perioperative ICU care to patients who previously may have been transferred. Caring for these types of patients not only maintains the opera- tional readiness of deployable caregivers but patient experience is also enhanced by minimizing transfers away from family. Further exploration of TCC on surgical case volume and complexity is warranted. INTRODUCTION managed by tele-ICU programs. For surgical patients, the Telemedicine can be defined as “the use of electronic infor- use of telemedicine has been described in the management mation and communications technologies to provide and of neurosurgical, trauma, and burn patients in areas where support health care when distance separates participants,” there is limited access to surgical subspecialty care. and has been successfully implemented in the management Mortality is significantly reduced in hospitals staffed with of acute stroke, myocardial infarction, and intensive care intensivists, however, many military hospitals lack intensivist 1 4 unit (ICU) patients. Currently, as many as 14% of non- support. To address this intensivist shortage, we recently federal intensive care unit beds in North America are described the successful implementation of a low cost compre- hensive Tele-Critical Care (TCC) support solution in a military *Department of Surgery, Naval Medical Center San Diego, 34800 Bob community hospital. This model allows remote staff with Wilson Drive, San Diego, CA 92134 access to video-teleconferencing technology (VTC), real-time †Department of Pulmonary and Critical Care Medicine, Naval Medical bedside monitors, and patient clinical data in order to collabo- Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134 rate with the local health care team in providing patient care. ‡Department of Nursing, Naval Hospital Camp Pendleton, 200 Mercy The literature demonstrates that the implementation of TCC Circle, Oceanside, CA 92055 §Department of Surgery, Naval Hospital Camp Pendleton, 200 Mercy has been associated with reduced hospital mortality, hospital Circle, Oceanside, CA 92055 length of stay (LOS), improved rates of best clinical practice The views expressed are solely those of the authors and do not reflect adherence, and lower rates of preventable complications. the official policy or position of the U.S. Army, U.S. Navy, U.S. Air Force, However, there is limited literature describing TCC in the sur- the Department of Defense, or the U.S. Government. gical ICU population. Our objective was to compare surgical I am a military service member. This work was prepared as part of my official duties. Title 17 U.S.C. 105 provides that “Copyright protection ICU admissions before and after TCC implementation at a mil- under this title is not available for any work of the United States itary community hospital. Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’sofficial duties.” MATERIALS AND METHODS doi: 10.1093/milmed/usy051 Naval Hospital Camp Pendleton (NHCP) operates a modified Published by Oxford University Press on behalf of the Association of open, level II, six bed-ICU. It supports a patient population of Military Surgeons of the United States 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US. 157,000 active duty personnel, family members and retirees. e494 MILITARY MEDICINE, Vol. 183, November/December 2018 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e494/4959960 by DeepDyve user on 19 July 2022 The Initial Impact of Tele-Critical Care on the Surgical Services Specialties currently available include: cardiology, gastroen- arterial lines, and tube thoracostomy were performed by the in- terology, general surgery, colorectal surgery, oral and maxillo- house anesthesia provider or duty general surgeon as appropriate. facial surgery (OMFS), pulmonology, neurology, orthopedics, The decision to admit surgical patients to the ICU was based on and otolaryngology. attending surgeon preference in conjunction with the approval of Naval Medical Center San Diego (NMCSD), located the duty intensivist (either in-house or tele-intensivist). approximately 41 miles south of NHCP, is the regional ter- To assess the impact of TCC on the surgical services at tiary referral center for four Military Health System (MHS) NHCP, quality assurance/process improvement data were retro- hospitals. NMCSD offers a full spectrum of subspecialty spectively reviewed. Surgical ICU admission data for the 12-mo care, and hosts medical students and trainees from more than period prior to TCC implementation (2/2013-2/2014; pre-TCC) 20 Accreditation Council for Graduate Medical Education was compared with the 19-mo period following TCC imple- (ACGME) training programs. mentation (3/2014-9/2015; post-TCC). Admissions were com- Per Navy instruction, an intensivist consultation is required pared per month to account for the longer time period in the for all patients admitted to the NHCP ICU. To address inten- Post-TCC group. The post-TCC Acute Physiology and Chronic sivist staffing shortages, NMCSD and NHCP established a Health Evaluation II (APACHE II) scores and LOS were also comprehensive TCC support solution utilizing a “hub and compared with the pre-TCC baseline data. Adverse outcomes 5,8 spoke” model. As previously described, NMCSD provided during the study period were reviewed utilizing the Navy on-demand bidirectional synchronous high-definition VTC- Medicine Patient Safety Reporting system. Student’s t-test was enabled consultation for all patients admitted to the NHCP performed for all comparisons, with two-sided p-values. ICU. In order to enable this consultation, the tele-intensivist Significance was attributed to a p-value <0.05. possessed real-time access to all electronic medical record doc- umentation, imaging studies, and laboratory results (Fig. 1). In order to facilitate standardization of best-practice measures, a RESULTS joint website was established by the TCC program manager During the 32-mo study period, a total of 828 patients were (author K.L.D.) to share medical and administrative protocols admitted to the NHCP ICU. Surgical ICU admissions com- between the two institutions. Table I shows the initial proto- prised 21% of this volume (or 171 admissions). TCC provided cols created during the implementation of TCC coverage at ICU coverage on an average of 35% of the days with the lon- NHCP. The Fundamentals of Critical Care Support curricu- gest period of continuous TCC coverage being 3 mo. During lum from the Society of Critical Care Medicine was also the post-TCC period, there was an increase in the absolute taught at NHCP bi-annually by the NMCSD tele-Intensivists number of surgical ICU (SICU) admissions per month (3.9 vs in order to enhance critical care skillset of the staff and facili- 6.3, p = 0.009), and the percentage of surgical admissions to tate positive working relationships. the ICU (15.3% vs 24.6%, p = 0.01) (Table II). When analyz- The NMCSD (“hub” site) tele-intensivist covered the NHCP ing types of surgical admissions per month, statistically signifi- ICU (“spoke” site) when no local intensivist was available. TCC cant increases were seen in monthly trauma admissions (0.2 vs call periods ranged from days to months. Emergency interven- 0.8, p = 0.009) and OMFS admissions (0.1 vs 0.5, p = 0.04) tions such as intubations, central venous catheter placement, in the post-TCC period (Table III). There was also a trend towards increased abdominal, bariatric, urologic, and obstetrics, thoracic and gynecology ICU admissions each month in the post-TCC period (Table III). All three thoracic admissions dur- ing the pre-TCC period were non-operative (i.e., tube thoracost- omy). However, during the post-TCC period, five of the seven admissions were operative, including four video-assisted thora- coscopic surgeries (VATS) and one VATS converted to thora- cotomy for a patient with an empyema. A statistically significant increase in surgical patient acuity, based on APACHE II scores, was seen after TCC implementa- tion (4.1 vs 6.5, p = 0.03). LOS was unchanged throughout TABLE I. Spoke Site Protocols Created During Study Period 1. ICU Electrolyte Management 2. Pain, Agitation and Delirium 3. Massive Transfusion Protocol 4. Post-Cardiac Arrest Resuscitation 5. Continuous Insulin Infusion 6. Anticoagulation Reversal FIGURE 1. Tele-Critical Care Program Director (author K.L.D.) rounding 7. Sepsis Protocol from hub site facility. MILITARY MEDICINE, Vol. 183, November/December 2018 e495 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e494/4959960 by DeepDyve user on 19 July 2022 The Initial Impact of Tele-Critical Care on the Surgical Services TABLE II. Total ICU and Surgical ICU Admissions Pre-TCC Post-TCC Total p Total ICU admissions 315 513 828 — ICU admissions/month [mean (SD)] 24.2 (8.4) 26.8 (6.5) 25.8 (7.3) 0.33 Total SICU Admissions 51 120 171 — SICU admissions/month [mean (SD)] 3.9 (2.9) 6.3 (2.0) 5.3 (2.6) 0.009 %Surgical/total ICU admissions [mean (SD)] 15.3 (9.2) 24.6 (9.5) 20.8 (10.3) 0.01 TABLE III. ICU Admissions By Surgical Case Type Surgical Case Type Pre-TCC Post-TCC Total p Abdominal 28 46 74 — Cases/month [mean (SD)] 2.2 (1.9) 2.4 (1.5) 2.3 (1.6) 0.66 Thoracic 3 7 10 — Cases/month [mean (SD)] 0.2 (0.6) 0.4 (0.5) 0.3 (0.5) 0.43 Bariatric 0 5 5 — Cases/month [mean (SD)] 0 (0) 0.2 (0.4) 0.1 (0.3) 0.08 Trauma 2 16 18 — Cases/month [mean (SD)] 0.2 (0.4) 0.8 (0.8) 0.6 (0.8) 0.009 Urology 0 1 1 — Cases/month [mean (SD)] 0 (0) 0.1 (0.2) 0.03 (0.2) 0.42 Skin/Soft Tissue 2 2 4 — Cases/month [mean (SD)] 0.2 (0.6) 0.1 (0.3) 0.1 (0.4) 0.75 OMFS 1 10 11 — Cases/month [mean (SD)] 0.1 (0.3) 0.5 (0.7) 0.3 (0.6) 0.04 ENT 6 9 15 — Cases/month [mean (SD)] 0.5 (0.5) 0.5 (0.6) 0.5 (0.6) 0.86 OB/GYN 8 16 24 — Cases/month [mean (SD)] 0.6 (1.0) 0.8 (0.8) 0.8 (0.8) 0.47 Orthopedics 4 6 10 — Cases/month [mean (SD)] 0.3 (0.5) 0.3 (0.6) 0.3 (0.5) 0.97 ENT, ear, nose, and throat; OB/GYN, obstetrics and gynecology. the study period (Table IV). During both the pre-TCC and TABLE IV. APACHE II Score & ICU LOS for Surgical ICU Patients post-TCC periods, no surgical patients were identified that required transfer from the NHCP ICU to other hospitals. Four Pre-TCC Post-TCC Total p deaths occurred following implementation of TCC. All of APACHE II/month 4.1 (2.8) 6.5 (3.1) 5.5 (3.2) 0.03 these deaths occurred in patients receiving palliative care, and [mean (SD)] none of them were surgical. Of these four patients, TCC was ICU LOS/month 1.5 (0.6) 1.5 (0.5) 1.5 (0.5) 0.99 involved in the care of three. No adverse outcomes related to [mean (SD)] TCC were reported upon review of the patient safety reporting system. requirements. Furthermore, NMCSD has expanded its regular DISCUSSION coverage to Naval Hospital Camp Lejeune’s ICU, over 2600 In the current study, after the implementation of TCC there was miles away, as well as Naval Hospital Jacksonville and Naval an increase in the scope and complexity of surgical ICU admis- Hospital Guantanamo Bay. sions at a MHS community hospital. Statistically significant The surgical critical care experience of “telemedicine” has 3,9 increases were seen in surgical ICU admissions, and patient largely focused on coverage for rural trauma, traumatic intra- APACHE II scores with no adverse outcomes identified. Our cranial injury, and in the evaluation and triage of burn experience suggests that high-definition, bidirectional, synchro- patients with good results. For rural trauma, the use of tele- nous telemedicine can successfully extend critical care physician medicine consultation has been shown to conserve trauma expertise into a small stateside community hospital, thereby resources, aide rural community hospitals by decreasing enabling the local staff to care for a higher volume and com- unnecessary transfers, and efficiently identify and facilitate the plexity of surgical patients. Due to the success of this program, expeditious movement of more severely injured patients to a NMCSD TCC continues to cover NHCP typically one week in higher level of care. In the initial evaluation of burn patients, every 4-6 wk, or more often if needed due to operational telemedicine has been associated with improved patient triage, e496 MILITARY MEDICINE, Vol. 183, November/December 2018 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e494/4959960 by DeepDyve user on 19 July 2022 The Initial Impact of Tele-Critical Care on the Surgical Services and the more appropriate use of air transport resources. speculate that the next major conflict will occur in the Indo- Finally, robotic presence and remote oversight of surgical Asia-Pacific region, and may involve air-sea engagements. patients have also been described in the ICU, andinthe With currentU.S.militarystrategypivotingtothe Indo-Asia- post-operative period, with no significant increases in mortal- Pacific region, the number of personnel, ships and aircraft sta- ity or adverse outcomes. tioned or deployed in the region are increasing, particularly Other studies have described the use of telemedicine in Navy and Marine Corps personnel. Furthermore it is esti- surgical ICU patients, but to our knowledge this is the first mated that nearly 60% of the U.S. Naval Fleet will be based to describe TCC program implementation on surgical vol- in the Pacific by the year 2020. Future conflict in the Indo- ume and complexity in a small community hospital in non- Asia-Pacific Theater will likely be characterized by disaggre- 13,14 burn and mostly non-trauma surgical ICU patients. gated hostility with distributed lethality. This type of war has Collins and colleagues recently described the use of telemed- not been experienced by our nation in more than 50 yr. In icine in post-operative ICU patients left in the post anesthe- this future conflict, the time required for evacuation of casual- sia care unit to provide a bed surge capacity when ICU beds ties from point of injury to evacuation to a higher level of were full; however, these patients were managed remotely care will be pushed from 60 min (which was typical in from elsewhere within the same hospital, not from a distant Operation Iraqi Freedom and Operation Enduring Freedom), hospital. The studies describing the use of telemedicine in to as long as 48 or 72 h. If we are to maintain the high sur- 3,9–11 civilian rural trauma and burn patients coupled with our vival that was hard-earned during the last 15 yr of ground positive experience utilizing TCC may, therefore, provide a combat in the Middle East, we must be prepared to support proof-of-concept for implementation of comprehensive TCC prolonged field care of casualties. coverage of overseas military hospitals, where intensivist Complicating this requirement, operational units within availability is often limited. In the Pacific Theater, the MHS the Navy and Marine Corps organization often function in provides care from hospitals located in Guam, Okinawa, significant isolation, which limits the medical capabilities of Japan, and South Korea. Similar to NHCP, the organic medi- these operating platforms. Furthermore, as a result of retire- cal personnel assigned to these hospitals is often limited. ment and attrition, the combat trauma corporate knowledge Anecdotally, overseas surgeons have described instances to that has been acquired these last 15 yr is rapidly being lost the authors where the local command does not allow them to from Navy Medicine. In isolated environments, the existence perform an elective surgery requiring overnight or extended of casualties that cannot be cared for by the limited organic mechanical ventilation because no formally trained intensi- medical assets may affect mission execution and success. vist is available to manage intubated patients. While manag- Imagine a young general surgeon or non-surgeon physician ing mechanically ventilated patients is a significant aspect of embarked at sea or in a remote forward deployed location general surgery residencies, many overseas general surgeons with limited resources and personnel managing multiple may be far removed from their initial training that they are complex critically ill combat trauma patients with the ability uncomfortable with performing basic ventilator management. to “phone a friend” via high-definition bidirectional VTC. We believe that comprehensive TCC (and telemedicine) sup- Real-time, various seasoned specialists (i.e., vascular or port with standardization of protocols and best practices trauma surgery, neurosurgery or critical care) could help could have a significant positive impact and help facilitate guide these deployed caregivers in the initial resuscitation, the safe expansion of the medical and surgical capability of critical care support, and surgical management while waiting these overseas military hospitals that lack local intensivists. for evacuation to a higher level of care. The importance of After the inception of the Joint Trauma System, technol- enhancing the medical personnel embedded within these ogy improvements, including regular video teleconference, units cannot therefore be overstated. Tools that enable high- have allowed military providers across the range of care to fidelity bidirectional medical consultation have the potential discuss patients while they are undergoing evacuation. to significantly expand the capability of organic medical per- While these teleconferences are valuable for decision making sonnel embedded within these isolated units. Just as syn- rationale and loop closure, patients are not evaluated real- chronous high-definition bidirectional TCC can enhance care time by another provider remotely. Therefore, we also in a small stateside hospital, we believe the same type of believe that our findings may have military relevance beyond support holds the promise of enabling the limited medical support of the surgical services in overseas and stateside mil- assets of forward deployed operational units to provide more itary hospitals. robust medical care on the battlefield. In order to prove this The extraordinary survival in the recent Middle East theory, the NMCSD hub is currently in the process of devel- ground conflicts has been achieved through a combination of oping a high-definition bidirectional TCC support and an heroic battlefield care, damage control surgery, and resusci- Operating Room Tele-consultation capability for the NATO tation near the point-of-injury, and expedient medical air Role 3 hospital in Kandahar, Afghanistan. evacuation to a higher level of care. However, trends in This study has several limitations. First, it only describes world politics and recent events have forced the U.S. mili- TCC support of a single hospital, over a limited period of tary to begin preparations for conflict in new areas. Many time (19 mo), utilizing limited quality assurance and process MILITARY MEDICINE, Vol. 183, November/December 2018 e497 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e494/4959960 by DeepDyve user on 19 July 2022 The Initial Impact of Tele-Critical Care on the Surgical Services improvement data. While this, and the observational nature were non-operative patients with chest tubes only, while 5 of of the study, may limit the generalizability of our results, no the 7 in the Post-TCC were operative patients requiring adverse outcomes were identified. Furthermore, other factors VATS, one of which was converted to a formal thoracotomy may also have influenced patient care trends at NHCP. due to an empyema. Regardless of whether the patients in Policies designed to increase the volume and scope of surgi- this study would have been ICU patients at larger higher cal services were implemented during the study intervention acuity hospitals or not, without reliable protocolized critical period and surgeons were encouraged to offer a wider scope care services many of the patients including the trauma, tho- of services when appropriate. While TCC did not directly racic and the more complex abdominal surgical cases would result in an increase in surgical admissions, the availability not have been patients at NHCP and either transferred out of of reliable and continuous protocol driven critical care ser- the direct care network or to NMCSD, further away from vices likely facilitated the safe expansion of surgical services their families and support structure. offered at NHCP to include those procedures requiring peri- For complex surgical cases, such as VATS, thoracoto- operative ICU care. mies, and complicated abdominal cases (such as distal pan- For the purposes of this study, we equate surgical com- creas resections), a cardiothoracic or hepatobiliary surgeon plexity with need for ICU admission which is a problematic from NMCSD assisted the local NHCP general surgeon definition without any physiologic criteria. While APACHE allowing them to safely manage more complex patients peri- II scores did increase significantly for surgical patients in the operatively, improving not only provider satisfaction but post-TCC period, the scores were still relatively low com- improving operational readiness for the surgeons as well. pared to higher acuity hospitals. Further study is needed to Additionally, the specialty surgeon from NMCSD had the see if the acuity of surgical ICU admissions based on ability to round on their patients via VTC ensuring appropri- APAHE II scores have continued to increase at NHCP. ate post-operative care and avoiding any potential sense of Unfortunately, we were unable to determine if the imple- patient abandonment. mentation of TCC at NHCP truly minimized the transfer of In conclusion, this study describes the initial impact on surgical ICU patients to other hospitals. Our previous evalu- the surgical services of comprehensive TCC coverage imple- ation of the TCC program implementation as a whole, did mentation in a stateside military community hospital. TCC show a significant decrease in total ICU transfers from was associated with an increased surgical ICU admissions NHCP to civilian hospitals during the study period (12 ± 0.9 and facilitated the expansion of surgical services provided, to 0.0 ± 0, p = 0.0008). In this study, during the entire with no adverse events identified. The average APACHE II 31-mo period reviewed, no surgical patients were identified scores of the surgical ICU patients also increased, with no as being transferred from the NHCP ICU to other hospitals. increase in patient mortality or LOS. For the military, this However, there was no way to capture which elective increased volume and case complexity also helps maintain patients requiring perioperative ICU care, if any, where the operational readiness of forward deployable caregivers referred from NHCP to either NMCSD or local civilian including surgeons, non-surgeon physicians, nurses and sup- hospitals. port staff, all while enhancing patient experience by allowing During the entire study period, the need for ICU admis- them to remain in close proximity to their families and units sion was based on surgeon preference and duty intensivist by minimizing patient transfers. Although additional study approval. It is entirely possible that patients admitted to the is warranted to validate our findings, we believe that the NHCP ICU would have not been ICU patients at larger hos- MHS should explore further expansion of TCC and synchro- pitals, inflating the number of post-TCC SICU admissions. nous telemedicine services not only in support of our over- One example is bariatric patients. While the care of bariatric seas military hospitals, but also to enhance the capabilities of patients is beyond the scope of this study, these patients forward deployed medical teams caring for critically ill and often require either a specialized ward, or a higher level pro- injured patients aboard ship and on the battlefield. tocolized post-operative care than a basic medical-surgical ward can provide. During the intervention period, NHCP was actively expanding its bariatric program and it was REFERENCES decided to place these patients in the ICU post-operatively. 1. 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The Initial Impact of Tele-Critical Care on the Surgical Services of a Community Military Hospital

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Oxford University Press
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Copyright © 2022 The Society of Federal Health Professionals
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0026-4075
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1930-613X
DOI
10.1093/milmed/usy051
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Abstract

Downloaded from https://academic.oup.com/milmed/article/183/11-12/e494/4959960 by DeepDyve user on 19 July 2022 MILITARY MEDICINE, 183, 11/12:e494, 2018 The Initial Impact of Tele-Critical Care on the Surgical Services of a Community Military Hospital LT Jan-Michael Van Gent, MC USN*; CDR Konrad L. Davis, MC USN†; Nichole Henry, RN‡; LT Ashley L. Zander, MC USN*; LCDR Matthew A. Kuettel, MC USN§; CAPT Theodore Edson, MC USN§; CAPT Thomas J. Nelson, MC USN§; CDR Matthew D. Tadlock, MC, USN§ ABSTRACT Introduction: Mortality is reduced in hospitals staffed with intensivists, however, many smaller military hospi- tals lack intensivist support. Naval Hospital Camp Pendleton (NHCP) is a Military Treatment Facility (MTF) that operates a 6-bed Intensive Care Unit (ICU) north of its referral center, Naval Medical Center San Diego (NMCSD). To address a gap in NHCP on-site intensivist coverage, a comprehensive Tele-Critical Care (TCC) support system was established between NHCP and NMCSD. To examine the initial impact of telemedicine on surgical ICU patients, we compare NHCP surgical ICU admis- sions before and after TCC implementation. Materials and methods: Patient care by remote intensivist was achieved utiliz- ing video teleconferencing technology, and remote access to electronic medical records. Standardization was promoted by adopting protocols and mandatory intensivist involvement in all ICU admissions. Surgical ICU admissions prior to TCC implementation (pre-TCC) were compared to those following TCC implementation (post-TCC). Results: Of 828 ICU admissions, 21% were surgical. TCC provided coverage during 35% of the intervention period. Comparing pre- TCC and post-TCC periods, there was a significant increase in the percentage of surgical ICU admissions [15.3 % vs 24.6%, p = 0.01] and the average monthly APACHE II score [4.1vs 6.5, p = 0.03]. The total number of surgical admissions per month also increased [3.9 vs 6.3, p = 0.009]. No adverse outcomes were identified. Conclusion: Implementation of TCC was associated with an increase in the scope and complexity of surgical admissions with no adverse outcomes. Surgeons were able to safely expand the surgical services offered requiring perioperative ICU care to patients who previously may have been transferred. Caring for these types of patients not only maintains the opera- tional readiness of deployable caregivers but patient experience is also enhanced by minimizing transfers away from family. Further exploration of TCC on surgical case volume and complexity is warranted. INTRODUCTION managed by tele-ICU programs. For surgical patients, the Telemedicine can be defined as “the use of electronic infor- use of telemedicine has been described in the management mation and communications technologies to provide and of neurosurgical, trauma, and burn patients in areas where support health care when distance separates participants,” there is limited access to surgical subspecialty care. and has been successfully implemented in the management Mortality is significantly reduced in hospitals staffed with of acute stroke, myocardial infarction, and intensive care intensivists, however, many military hospitals lack intensivist 1 4 unit (ICU) patients. Currently, as many as 14% of non- support. To address this intensivist shortage, we recently federal intensive care unit beds in North America are described the successful implementation of a low cost compre- hensive Tele-Critical Care (TCC) support solution in a military *Department of Surgery, Naval Medical Center San Diego, 34800 Bob community hospital. This model allows remote staff with Wilson Drive, San Diego, CA 92134 access to video-teleconferencing technology (VTC), real-time †Department of Pulmonary and Critical Care Medicine, Naval Medical bedside monitors, and patient clinical data in order to collabo- Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134 rate with the local health care team in providing patient care. ‡Department of Nursing, Naval Hospital Camp Pendleton, 200 Mercy The literature demonstrates that the implementation of TCC Circle, Oceanside, CA 92055 §Department of Surgery, Naval Hospital Camp Pendleton, 200 Mercy has been associated with reduced hospital mortality, hospital Circle, Oceanside, CA 92055 length of stay (LOS), improved rates of best clinical practice The views expressed are solely those of the authors and do not reflect adherence, and lower rates of preventable complications. the official policy or position of the U.S. Army, U.S. Navy, U.S. Air Force, However, there is limited literature describing TCC in the sur- the Department of Defense, or the U.S. Government. gical ICU population. Our objective was to compare surgical I am a military service member. This work was prepared as part of my official duties. Title 17 U.S.C. 105 provides that “Copyright protection ICU admissions before and after TCC implementation at a mil- under this title is not available for any work of the United States itary community hospital. Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’sofficial duties.” MATERIALS AND METHODS doi: 10.1093/milmed/usy051 Naval Hospital Camp Pendleton (NHCP) operates a modified Published by Oxford University Press on behalf of the Association of open, level II, six bed-ICU. It supports a patient population of Military Surgeons of the United States 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US. 157,000 active duty personnel, family members and retirees. e494 MILITARY MEDICINE, Vol. 183, November/December 2018 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e494/4959960 by DeepDyve user on 19 July 2022 The Initial Impact of Tele-Critical Care on the Surgical Services Specialties currently available include: cardiology, gastroen- arterial lines, and tube thoracostomy were performed by the in- terology, general surgery, colorectal surgery, oral and maxillo- house anesthesia provider or duty general surgeon as appropriate. facial surgery (OMFS), pulmonology, neurology, orthopedics, The decision to admit surgical patients to the ICU was based on and otolaryngology. attending surgeon preference in conjunction with the approval of Naval Medical Center San Diego (NMCSD), located the duty intensivist (either in-house or tele-intensivist). approximately 41 miles south of NHCP, is the regional ter- To assess the impact of TCC on the surgical services at tiary referral center for four Military Health System (MHS) NHCP, quality assurance/process improvement data were retro- hospitals. NMCSD offers a full spectrum of subspecialty spectively reviewed. Surgical ICU admission data for the 12-mo care, and hosts medical students and trainees from more than period prior to TCC implementation (2/2013-2/2014; pre-TCC) 20 Accreditation Council for Graduate Medical Education was compared with the 19-mo period following TCC imple- (ACGME) training programs. mentation (3/2014-9/2015; post-TCC). Admissions were com- Per Navy instruction, an intensivist consultation is required pared per month to account for the longer time period in the for all patients admitted to the NHCP ICU. To address inten- Post-TCC group. The post-TCC Acute Physiology and Chronic sivist staffing shortages, NMCSD and NHCP established a Health Evaluation II (APACHE II) scores and LOS were also comprehensive TCC support solution utilizing a “hub and compared with the pre-TCC baseline data. Adverse outcomes 5,8 spoke” model. As previously described, NMCSD provided during the study period were reviewed utilizing the Navy on-demand bidirectional synchronous high-definition VTC- Medicine Patient Safety Reporting system. Student’s t-test was enabled consultation for all patients admitted to the NHCP performed for all comparisons, with two-sided p-values. ICU. In order to enable this consultation, the tele-intensivist Significance was attributed to a p-value <0.05. possessed real-time access to all electronic medical record doc- umentation, imaging studies, and laboratory results (Fig. 1). In order to facilitate standardization of best-practice measures, a RESULTS joint website was established by the TCC program manager During the 32-mo study period, a total of 828 patients were (author K.L.D.) to share medical and administrative protocols admitted to the NHCP ICU. Surgical ICU admissions com- between the two institutions. Table I shows the initial proto- prised 21% of this volume (or 171 admissions). TCC provided cols created during the implementation of TCC coverage at ICU coverage on an average of 35% of the days with the lon- NHCP. The Fundamentals of Critical Care Support curricu- gest period of continuous TCC coverage being 3 mo. During lum from the Society of Critical Care Medicine was also the post-TCC period, there was an increase in the absolute taught at NHCP bi-annually by the NMCSD tele-Intensivists number of surgical ICU (SICU) admissions per month (3.9 vs in order to enhance critical care skillset of the staff and facili- 6.3, p = 0.009), and the percentage of surgical admissions to tate positive working relationships. the ICU (15.3% vs 24.6%, p = 0.01) (Table II). When analyz- The NMCSD (“hub” site) tele-intensivist covered the NHCP ing types of surgical admissions per month, statistically signifi- ICU (“spoke” site) when no local intensivist was available. TCC cant increases were seen in monthly trauma admissions (0.2 vs call periods ranged from days to months. Emergency interven- 0.8, p = 0.009) and OMFS admissions (0.1 vs 0.5, p = 0.04) tions such as intubations, central venous catheter placement, in the post-TCC period (Table III). There was also a trend towards increased abdominal, bariatric, urologic, and obstetrics, thoracic and gynecology ICU admissions each month in the post-TCC period (Table III). All three thoracic admissions dur- ing the pre-TCC period were non-operative (i.e., tube thoracost- omy). However, during the post-TCC period, five of the seven admissions were operative, including four video-assisted thora- coscopic surgeries (VATS) and one VATS converted to thora- cotomy for a patient with an empyema. A statistically significant increase in surgical patient acuity, based on APACHE II scores, was seen after TCC implementa- tion (4.1 vs 6.5, p = 0.03). LOS was unchanged throughout TABLE I. Spoke Site Protocols Created During Study Period 1. ICU Electrolyte Management 2. Pain, Agitation and Delirium 3. Massive Transfusion Protocol 4. Post-Cardiac Arrest Resuscitation 5. Continuous Insulin Infusion 6. Anticoagulation Reversal FIGURE 1. Tele-Critical Care Program Director (author K.L.D.) rounding 7. Sepsis Protocol from hub site facility. MILITARY MEDICINE, Vol. 183, November/December 2018 e495 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e494/4959960 by DeepDyve user on 19 July 2022 The Initial Impact of Tele-Critical Care on the Surgical Services TABLE II. Total ICU and Surgical ICU Admissions Pre-TCC Post-TCC Total p Total ICU admissions 315 513 828 — ICU admissions/month [mean (SD)] 24.2 (8.4) 26.8 (6.5) 25.8 (7.3) 0.33 Total SICU Admissions 51 120 171 — SICU admissions/month [mean (SD)] 3.9 (2.9) 6.3 (2.0) 5.3 (2.6) 0.009 %Surgical/total ICU admissions [mean (SD)] 15.3 (9.2) 24.6 (9.5) 20.8 (10.3) 0.01 TABLE III. ICU Admissions By Surgical Case Type Surgical Case Type Pre-TCC Post-TCC Total p Abdominal 28 46 74 — Cases/month [mean (SD)] 2.2 (1.9) 2.4 (1.5) 2.3 (1.6) 0.66 Thoracic 3 7 10 — Cases/month [mean (SD)] 0.2 (0.6) 0.4 (0.5) 0.3 (0.5) 0.43 Bariatric 0 5 5 — Cases/month [mean (SD)] 0 (0) 0.2 (0.4) 0.1 (0.3) 0.08 Trauma 2 16 18 — Cases/month [mean (SD)] 0.2 (0.4) 0.8 (0.8) 0.6 (0.8) 0.009 Urology 0 1 1 — Cases/month [mean (SD)] 0 (0) 0.1 (0.2) 0.03 (0.2) 0.42 Skin/Soft Tissue 2 2 4 — Cases/month [mean (SD)] 0.2 (0.6) 0.1 (0.3) 0.1 (0.4) 0.75 OMFS 1 10 11 — Cases/month [mean (SD)] 0.1 (0.3) 0.5 (0.7) 0.3 (0.6) 0.04 ENT 6 9 15 — Cases/month [mean (SD)] 0.5 (0.5) 0.5 (0.6) 0.5 (0.6) 0.86 OB/GYN 8 16 24 — Cases/month [mean (SD)] 0.6 (1.0) 0.8 (0.8) 0.8 (0.8) 0.47 Orthopedics 4 6 10 — Cases/month [mean (SD)] 0.3 (0.5) 0.3 (0.6) 0.3 (0.5) 0.97 ENT, ear, nose, and throat; OB/GYN, obstetrics and gynecology. the study period (Table IV). During both the pre-TCC and TABLE IV. APACHE II Score & ICU LOS for Surgical ICU Patients post-TCC periods, no surgical patients were identified that required transfer from the NHCP ICU to other hospitals. Four Pre-TCC Post-TCC Total p deaths occurred following implementation of TCC. All of APACHE II/month 4.1 (2.8) 6.5 (3.1) 5.5 (3.2) 0.03 these deaths occurred in patients receiving palliative care, and [mean (SD)] none of them were surgical. Of these four patients, TCC was ICU LOS/month 1.5 (0.6) 1.5 (0.5) 1.5 (0.5) 0.99 involved in the care of three. No adverse outcomes related to [mean (SD)] TCC were reported upon review of the patient safety reporting system. requirements. Furthermore, NMCSD has expanded its regular DISCUSSION coverage to Naval Hospital Camp Lejeune’s ICU, over 2600 In the current study, after the implementation of TCC there was miles away, as well as Naval Hospital Jacksonville and Naval an increase in the scope and complexity of surgical ICU admis- Hospital Guantanamo Bay. sions at a MHS community hospital. Statistically significant The surgical critical care experience of “telemedicine” has 3,9 increases were seen in surgical ICU admissions, and patient largely focused on coverage for rural trauma, traumatic intra- APACHE II scores with no adverse outcomes identified. Our cranial injury, and in the evaluation and triage of burn experience suggests that high-definition, bidirectional, synchro- patients with good results. For rural trauma, the use of tele- nous telemedicine can successfully extend critical care physician medicine consultation has been shown to conserve trauma expertise into a small stateside community hospital, thereby resources, aide rural community hospitals by decreasing enabling the local staff to care for a higher volume and com- unnecessary transfers, and efficiently identify and facilitate the plexity of surgical patients. Due to the success of this program, expeditious movement of more severely injured patients to a NMCSD TCC continues to cover NHCP typically one week in higher level of care. In the initial evaluation of burn patients, every 4-6 wk, or more often if needed due to operational telemedicine has been associated with improved patient triage, e496 MILITARY MEDICINE, Vol. 183, November/December 2018 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e494/4959960 by DeepDyve user on 19 July 2022 The Initial Impact of Tele-Critical Care on the Surgical Services and the more appropriate use of air transport resources. speculate that the next major conflict will occur in the Indo- Finally, robotic presence and remote oversight of surgical Asia-Pacific region, and may involve air-sea engagements. patients have also been described in the ICU, andinthe With currentU.S.militarystrategypivotingtothe Indo-Asia- post-operative period, with no significant increases in mortal- Pacific region, the number of personnel, ships and aircraft sta- ity or adverse outcomes. tioned or deployed in the region are increasing, particularly Other studies have described the use of telemedicine in Navy and Marine Corps personnel. Furthermore it is esti- surgical ICU patients, but to our knowledge this is the first mated that nearly 60% of the U.S. Naval Fleet will be based to describe TCC program implementation on surgical vol- in the Pacific by the year 2020. Future conflict in the Indo- ume and complexity in a small community hospital in non- Asia-Pacific Theater will likely be characterized by disaggre- 13,14 burn and mostly non-trauma surgical ICU patients. gated hostility with distributed lethality. This type of war has Collins and colleagues recently described the use of telemed- not been experienced by our nation in more than 50 yr. In icine in post-operative ICU patients left in the post anesthe- this future conflict, the time required for evacuation of casual- sia care unit to provide a bed surge capacity when ICU beds ties from point of injury to evacuation to a higher level of were full; however, these patients were managed remotely care will be pushed from 60 min (which was typical in from elsewhere within the same hospital, not from a distant Operation Iraqi Freedom and Operation Enduring Freedom), hospital. The studies describing the use of telemedicine in to as long as 48 or 72 h. If we are to maintain the high sur- 3,9–11 civilian rural trauma and burn patients coupled with our vival that was hard-earned during the last 15 yr of ground positive experience utilizing TCC may, therefore, provide a combat in the Middle East, we must be prepared to support proof-of-concept for implementation of comprehensive TCC prolonged field care of casualties. coverage of overseas military hospitals, where intensivist Complicating this requirement, operational units within availability is often limited. In the Pacific Theater, the MHS the Navy and Marine Corps organization often function in provides care from hospitals located in Guam, Okinawa, significant isolation, which limits the medical capabilities of Japan, and South Korea. Similar to NHCP, the organic medi- these operating platforms. Furthermore, as a result of retire- cal personnel assigned to these hospitals is often limited. ment and attrition, the combat trauma corporate knowledge Anecdotally, overseas surgeons have described instances to that has been acquired these last 15 yr is rapidly being lost the authors where the local command does not allow them to from Navy Medicine. In isolated environments, the existence perform an elective surgery requiring overnight or extended of casualties that cannot be cared for by the limited organic mechanical ventilation because no formally trained intensi- medical assets may affect mission execution and success. vist is available to manage intubated patients. While manag- Imagine a young general surgeon or non-surgeon physician ing mechanically ventilated patients is a significant aspect of embarked at sea or in a remote forward deployed location general surgery residencies, many overseas general surgeons with limited resources and personnel managing multiple may be far removed from their initial training that they are complex critically ill combat trauma patients with the ability uncomfortable with performing basic ventilator management. to “phone a friend” via high-definition bidirectional VTC. We believe that comprehensive TCC (and telemedicine) sup- Real-time, various seasoned specialists (i.e., vascular or port with standardization of protocols and best practices trauma surgery, neurosurgery or critical care) could help could have a significant positive impact and help facilitate guide these deployed caregivers in the initial resuscitation, the safe expansion of the medical and surgical capability of critical care support, and surgical management while waiting these overseas military hospitals that lack local intensivists. for evacuation to a higher level of care. The importance of After the inception of the Joint Trauma System, technol- enhancing the medical personnel embedded within these ogy improvements, including regular video teleconference, units cannot therefore be overstated. Tools that enable high- have allowed military providers across the range of care to fidelity bidirectional medical consultation have the potential discuss patients while they are undergoing evacuation. to significantly expand the capability of organic medical per- While these teleconferences are valuable for decision making sonnel embedded within these isolated units. Just as syn- rationale and loop closure, patients are not evaluated real- chronous high-definition bidirectional TCC can enhance care time by another provider remotely. Therefore, we also in a small stateside hospital, we believe the same type of believe that our findings may have military relevance beyond support holds the promise of enabling the limited medical support of the surgical services in overseas and stateside mil- assets of forward deployed operational units to provide more itary hospitals. robust medical care on the battlefield. In order to prove this The extraordinary survival in the recent Middle East theory, the NMCSD hub is currently in the process of devel- ground conflicts has been achieved through a combination of oping a high-definition bidirectional TCC support and an heroic battlefield care, damage control surgery, and resusci- Operating Room Tele-consultation capability for the NATO tation near the point-of-injury, and expedient medical air Role 3 hospital in Kandahar, Afghanistan. evacuation to a higher level of care. However, trends in This study has several limitations. First, it only describes world politics and recent events have forced the U.S. mili- TCC support of a single hospital, over a limited period of tary to begin preparations for conflict in new areas. Many time (19 mo), utilizing limited quality assurance and process MILITARY MEDICINE, Vol. 183, November/December 2018 e497 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e494/4959960 by DeepDyve user on 19 July 2022 The Initial Impact of Tele-Critical Care on the Surgical Services improvement data. While this, and the observational nature were non-operative patients with chest tubes only, while 5 of of the study, may limit the generalizability of our results, no the 7 in the Post-TCC were operative patients requiring adverse outcomes were identified. Furthermore, other factors VATS, one of which was converted to a formal thoracotomy may also have influenced patient care trends at NHCP. due to an empyema. Regardless of whether the patients in Policies designed to increase the volume and scope of surgi- this study would have been ICU patients at larger higher cal services were implemented during the study intervention acuity hospitals or not, without reliable protocolized critical period and surgeons were encouraged to offer a wider scope care services many of the patients including the trauma, tho- of services when appropriate. While TCC did not directly racic and the more complex abdominal surgical cases would result in an increase in surgical admissions, the availability not have been patients at NHCP and either transferred out of of reliable and continuous protocol driven critical care ser- the direct care network or to NMCSD, further away from vices likely facilitated the safe expansion of surgical services their families and support structure. offered at NHCP to include those procedures requiring peri- For complex surgical cases, such as VATS, thoracoto- operative ICU care. mies, and complicated abdominal cases (such as distal pan- For the purposes of this study, we equate surgical com- creas resections), a cardiothoracic or hepatobiliary surgeon plexity with need for ICU admission which is a problematic from NMCSD assisted the local NHCP general surgeon definition without any physiologic criteria. While APACHE allowing them to safely manage more complex patients peri- II scores did increase significantly for surgical patients in the operatively, improving not only provider satisfaction but post-TCC period, the scores were still relatively low com- improving operational readiness for the surgeons as well. pared to higher acuity hospitals. Further study is needed to Additionally, the specialty surgeon from NMCSD had the see if the acuity of surgical ICU admissions based on ability to round on their patients via VTC ensuring appropri- APAHE II scores have continued to increase at NHCP. ate post-operative care and avoiding any potential sense of Unfortunately, we were unable to determine if the imple- patient abandonment. mentation of TCC at NHCP truly minimized the transfer of In conclusion, this study describes the initial impact on surgical ICU patients to other hospitals. Our previous evalu- the surgical services of comprehensive TCC coverage imple- ation of the TCC program implementation as a whole, did mentation in a stateside military community hospital. TCC show a significant decrease in total ICU transfers from was associated with an increased surgical ICU admissions NHCP to civilian hospitals during the study period (12 ± 0.9 and facilitated the expansion of surgical services provided, to 0.0 ± 0, p = 0.0008). In this study, during the entire with no adverse events identified. The average APACHE II 31-mo period reviewed, no surgical patients were identified scores of the surgical ICU patients also increased, with no as being transferred from the NHCP ICU to other hospitals. increase in patient mortality or LOS. For the military, this However, there was no way to capture which elective increased volume and case complexity also helps maintain patients requiring perioperative ICU care, if any, where the operational readiness of forward deployable caregivers referred from NHCP to either NMCSD or local civilian including surgeons, non-surgeon physicians, nurses and sup- hospitals. port staff, all while enhancing patient experience by allowing During the entire study period, the need for ICU admis- them to remain in close proximity to their families and units sion was based on surgeon preference and duty intensivist by minimizing patient transfers. Although additional study approval. It is entirely possible that patients admitted to the is warranted to validate our findings, we believe that the NHCP ICU would have not been ICU patients at larger hos- MHS should explore further expansion of TCC and synchro- pitals, inflating the number of post-TCC SICU admissions. nous telemedicine services not only in support of our over- One example is bariatric patients. While the care of bariatric seas military hospitals, but also to enhance the capabilities of patients is beyond the scope of this study, these patients forward deployed medical teams caring for critically ill and often require either a specialized ward, or a higher level pro- injured patients aboard ship and on the battlefield. tocolized post-operative care than a basic medical-surgical ward can provide. During the intervention period, NHCP was actively expanding its bariatric program and it was REFERENCES decided to place these patients in the ICU post-operatively. 1. 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Journal

Military MedicineOxford University Press

Published: Nov 5, 2018

Keywords: military hospitals; intensive care unit; military personnel; surgical procedures, operative; telemedicine; intensivist

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