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 Abstract Introduction Mortality is reduced in hospitals staffed with intensivists, however, many smaller military hospitals 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 admissions before and after TCC implementation. Materials and methods Patient care by remote intensivist was achieved utilizing 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 operational 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 Telemedicine can be defined as “the use of electronic information and communications technologies to provide and support health care when distance separates participants,” and has been successfully implemented in the management of acute stroke, myocardial infarction, and intensive care unit (ICU) patients.1 Currently, as many as 14% of non-federal intensive care unit beds in North America are managed by tele-ICU programs.2 For surgical patients, the use of telemedicine has been described in the management of neurosurgical, trauma, and burn patients in areas where there is limited access to surgical subspecialty care.3 Mortality is significantly reduced in hospitals staffed with intensivists, however, many military hospitals lack intensivist support.4 To address this intensivist shortage, we recently described the successful implementation of a low cost comprehensive Tele-Critical Care (TCC) support solution in a military community hospital.5 This model allows remote staff with access to video-teleconferencing technology (VTC), real-time bedside monitors, and patient clinical data in order to collaborate with the local health care team in providing patient care. The literature demonstrates that the implementation of TCC has been associated with reduced hospital mortality, hospital length of stay (LOS), improved rates of best clinical practice adherence, and lower rates of preventable complications.6 However, there is limited literature describing TCC in the surgical ICU population. Our objective was to compare surgical ICU admissions before and after TCC implementation at a military community hospital. MATERIALS AND METHODS Naval Hospital Camp Pendleton (NHCP) operates a modified open, level II, six bed-ICU. It supports a patient population of 157,000 active duty personnel, family members and retirees. Specialties currently available include: cardiology, gastroenterology, general surgery, colorectal surgery, oral and maxillofacial surgery (OMFS), pulmonology, neurology, orthopedics, and otolaryngology. Naval Medical Center San Diego (NMCSD), located approximately 41 miles south of NHCP, is the regional tertiary referral center for four Military Health System (MHS) hospitals. NMCSD offers a full spectrum of subspecialty care, and hosts medical students and trainees from more than 20 Accreditation Council for Graduate Medical Education (ACGME) training programs. Per Navy instruction, an intensivist consultation is required for all patients admitted to the NHCP ICU.7 To address intensivist staffing shortages, NMCSD and NHCP established a comprehensive TCC support solution utilizing a “hub and spoke” model.5,8 As previously described, NMCSD provided on-demand bidirectional synchronous high-definition VTC-enabled consultation for all patients admitted to the NHCP ICU.5 In order to enable this consultation, the tele-intensivist possessed real-time access to all electronic medical record documentation, imaging studies, and laboratory results (Fig. 1). In order to facilitate standardization of best-practice measures, a joint website was established by the TCC program manager (author K.L.D.) to share medical and administrative protocols between the two institutions. Table I shows the initial protocols created during the implementation of TCC coverage at NHCP.5 The Fundamentals of Critical Care Support curriculum from the Society of Critical Care Medicine was also taught at NHCP bi-annually by the NMCSD tele-Intensivists in order to enhance critical care skillset of the staff and facilitate positive working relationships. FIGURE 1. View largeDownload slide Tele-Critical Care Program Director (author K.L.D.) rounding from hub site facility. FIGURE 1. View largeDownload slide Tele-Critical Care Program Director (author K.L.D.) rounding from hub site facility. Table I. Spoke Site Protocols Created During Study Period4 ICU Electrolyte Management Pain, Agitation and Delirium Massive Transfusion Protocol Post-Cardiac Arrest Resuscitation Continuous Insulin Infusion Anticoagulation Reversal Sepsis Protocol  ICU Electrolyte Management Pain, Agitation and Delirium Massive Transfusion Protocol Post-Cardiac Arrest Resuscitation Continuous Insulin Infusion Anticoagulation Reversal Sepsis Protocol  View Large Table I. Spoke Site Protocols Created During Study Period4 ICU Electrolyte Management Pain, Agitation and Delirium Massive Transfusion Protocol Post-Cardiac Arrest Resuscitation Continuous Insulin Infusion Anticoagulation Reversal Sepsis Protocol  ICU Electrolyte Management Pain, Agitation and Delirium Massive Transfusion Protocol Post-Cardiac Arrest Resuscitation Continuous Insulin Infusion Anticoagulation Reversal Sepsis Protocol  View Large The NMCSD (“hub” site) tele-intensivist covered the NHCP ICU (“spoke” site) when no local intensivist was available. TCC call periods ranged from days to months. Emergency interventions such as intubations, central venous catheter placement, arterial lines, and tube thoracostomy were performed by the in-house anesthesia provider or duty general surgeon as appropriate. The decision to admit surgical patients to the ICU was based on attending surgeon preference in conjunction with the approval of the duty intensivist (either in-house or tele-intensivist). To assess the impact of TCC on the surgical services at NHCP, quality assurance/process improvement data were retrospectively reviewed. Surgical ICU admission data for the 12-mo period prior to TCC implementation (2/2013-2/2014; pre-TCC) was compared with the 19-mo period following TCC implementation (3/2014-9/2015; post-TCC). Admissions were compared per month to account for the longer time period in the Post-TCC group. The post-TCC Acute Physiology and Chronic Health Evaluation II (APACHE II) scores and LOS were also compared with the pre-TCC baseline data. Adverse outcomes during the study period were reviewed utilizing the Navy Medicine Patient Safety Reporting system. Student’s t-test was performed for all comparisons, with two-sided p-values. Significance was attributed to a p-value <0.05. RESULTS During the 32-mo study period, a total of 828 patients were admitted to the NHCP ICU. Surgical ICU admissions comprised 21% of this volume (or 171 admissions). TCC provided ICU coverage on an average of 35% of the days with the longest period of continuous TCC coverage being 3 mo. During the post-TCC period, there was an increase in the absolute number of surgical ICU (SICU) admissions per month (3.9 vs 6.3, p = 0.009), and the percentage of surgical admissions to the ICU (15.3% vs 24.6%, p = 0.01) (Table II). When analyzing types of surgical admissions per month, statistically significant increases were seen in monthly trauma admissions (0.2 vs 0.8, p = 0.009) and OMFS admissions (0.1 vs 0.5, p = 0.04) 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 during the pre-TCC period were non-operative (i.e., tube thoracostomy). However, during the post-TCC period, five of the seven admissions were operative, including four video-assisted thoracoscopic surgeries (VATS) and one VATS converted to thoracotomy for a patient with an empyema. 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    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 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    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  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. 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  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. A statistically significant increase in surgical patient acuity, based on APACHE II scores, was seen after TCC implementation (4.1 vs 6.5, p = 0.03). LOS was unchanged throughout the study period (Table IV). During both the pre-TCC and post-TCC periods, no surgical patients were identified that required transfer from the NHCP ICU to other hospitals. Four deaths occurred following implementation of TCC. All of these deaths occurred in patients receiving palliative care, and none of them were surgical. Of these four patients, TCC was involved in the care of three. No adverse outcomes related to TCC were reported upon review of the patient safety reporting system. Table IV. APACHE II Score & ICU LOS for Surgical ICU Patients   Pre-TCC  Post-TCC  Total  p  APACHE II/month [mean (SD)]  4.1 (2.8)  6.5 (3.1)  5.5 (3.2)  0.03  ICU LOS/month [mean (SD)]  1.5 (0.6)  1.5 (0.5)  1.5 (0.5)  0.99    Pre-TCC  Post-TCC  Total  p  APACHE II/month [mean (SD)]  4.1 (2.8)  6.5 (3.1)  5.5 (3.2)  0.03  ICU LOS/month [mean (SD)]  1.5 (0.6)  1.5 (0.5)  1.5 (0.5)  0.99  Table IV. APACHE II Score & ICU LOS for Surgical ICU Patients   Pre-TCC  Post-TCC  Total  p  APACHE II/month [mean (SD)]  4.1 (2.8)  6.5 (3.1)  5.5 (3.2)  0.03  ICU LOS/month [mean (SD)]  1.5 (0.6)  1.5 (0.5)  1.5 (0.5)  0.99    Pre-TCC  Post-TCC  Total  p  APACHE II/month [mean (SD)]  4.1 (2.8)  6.5 (3.1)  5.5 (3.2)  0.03  ICU LOS/month [mean (SD)]  1.5 (0.6)  1.5 (0.5)  1.5 (0.5)  0.99  DISCUSSION In the current study, after the implementation of TCC there was an increase in the scope and complexity of surgical ICU admissions at a MHS community hospital. Statistically significant increases were seen in surgical ICU admissions, and patient APACHE II scores with no adverse outcomes identified. Our experience suggests that high-definition, bidirectional, synchronous telemedicine can successfully extend critical care physician expertise into a small stateside community hospital, thereby enabling the local staff to care for a higher volume and complexity of surgical patients. Due to the success of this program, NMCSD TCC continues to cover NHCP typically one week in every 4-6 wk, or more often if needed due to operational requirements. Furthermore, NMCSD has expanded its regular coverage to Naval Hospital Camp Lejeune’s ICU, over 2600 miles away, as well as Naval Hospital Jacksonville and Naval Hospital Guantanamo Bay. The surgical critical care experience of “telemedicine” has largely focused on coverage for rural trauma,3,9 traumatic intracranial injury,10 and in the evaluation and triage of burn patients with good results.11 For rural trauma, the use of telemedicine consultation has been shown to conserve trauma resources, aide rural community hospitals by decreasing unnecessary transfers, and efficiently identify and facilitate the expeditious movement of more severely injured patients to a higher level of care.3 In the initial evaluation of burn patients, telemedicine has been associated with improved patient triage, and the more appropriate use of air transport resources.11 Finally, robotic presence and remote oversight of surgical patients have also been described in the ICU,12 and in the post-operative period,1 with no significant increases in mortality or adverse outcomes. Other studies have described the use of telemedicine in surgical ICU patients, but to our knowledge this is the first to describe TCC program implementation on surgical volume and complexity in a small community hospital in non-burn and mostly non-trauma surgical ICU patients.13,14 Collins and colleagues recently described the use of telemedicine in post-operative ICU patients left in the post anesthesia care unit to provide a bed surge capacity when ICU beds were full; however, these patients were managed remotely from elsewhere within the same hospital, not from a distant hospital.15 The studies describing the use of telemedicine in civilian rural trauma and burn patients3,9–11 coupled with our positive experience utilizing TCC may, therefore, provide a proof-of-concept for implementation of comprehensive TCC coverage of overseas military hospitals, where intensivist availability is often limited. In the Pacific Theater, the MHS provides care from hospitals located in Guam, Okinawa, Japan, and South Korea. Similar to NHCP, the organic medical personnel assigned to these hospitals is often limited. Anecdotally, overseas surgeons have described instances to the authors where the local command does not allow them to perform an elective surgery requiring overnight or extended mechanical ventilation because no formally trained intensivist is available to manage intubated patients. While managing mechanically ventilated patients is a significant aspect of general surgery residencies, many overseas general surgeons may be far removed from their initial training that they are uncomfortable with performing basic ventilator management. We believe that comprehensive TCC (and telemedicine) support with standardization of protocols and best practices could have a significant positive impact and help facilitate the safe expansion of the medical and surgical capability of these overseas military hospitals that lack local intensivists. After the inception of the Joint Trauma System, technology improvements, including regular video teleconference, have allowed military providers across the range of care to discuss patients while they are undergoing evacuation.16 While these teleconferences are valuable for decision making rationale and loop closure, patients are not evaluated real-time by another provider remotely. Therefore, we also believe that our findings may have military relevance beyond support of the surgical services in overseas and stateside military hospitals. The extraordinary survival in the recent Middle East ground conflicts has been achieved through a combination of heroic battlefield care, damage control surgery, and resuscitation near the point-of-injury, and expedient medical air evacuation to a higher level of care. However, trends in world politics and recent events have forced the U.S. military to begin preparations for conflict in new areas. Many speculate that the next major conflict will occur in the Indo-Asia-Pacific region, and may involve air-sea engagements. With current U.S. military strategy pivoting to the Indo-Asia-Pacific region, the number of personnel, ships and aircraft stationed or deployed in the region are increasing, particularly Navy and Marine Corps personnel. Furthermore it is estimated that nearly 60% of the U.S. Naval Fleet will be based in the Pacific by the year 2020.17 Future conflict in the Indo-Asia-Pacific Theater will likely be characterized by disaggregated hostility with distributed lethality. This type of war has not been experienced by our nation in more than 50 yr. In this future conflict, the time required for evacuation of casualties from point of injury to evacuation to a higher level of care will be pushed from 60 min (which was typical in Operation Iraqi Freedom and Operation Enduring Freedom), to as long as 48 or 72 h. If we are to maintain the high survival that was hard-earned during the last 15 yr of ground combat in the Middle East, we must be prepared to support prolonged field care of casualties.18 Complicating this requirement, operational units within the Navy and Marine Corps organization often function in significant isolation, which limits the medical capabilities of these operating platforms. Furthermore, as a result of retirement and attrition, the combat trauma corporate knowledge that has been acquired these last 15 yr is rapidly being lost from Navy Medicine. In isolated environments, the existence of casualties that cannot be cared for by the limited organic medical assets may affect mission execution and success. Imagine a young general surgeon or non-surgeon physician embarked at sea or in a remote forward deployed location with limited resources and personnel managing multiple complex critically ill combat trauma patients with the ability to “phone a friend” via high-definition bidirectional VTC. Real-time, various seasoned specialists (i.e., vascular or trauma surgery, neurosurgery or critical care) could help guide these deployed caregivers in the initial resuscitation, critical care support, and surgical management while waiting for evacuation to a higher level of care. The importance of enhancing the medical personnel embedded within these units cannot therefore be overstated. Tools that enable high-fidelity bidirectional medical consultation have the potential to significantly expand the capability of organic medical personnel embedded within these isolated units. Just as synchronous high-definition bidirectional TCC can enhance care in a small stateside hospital, we believe the same type of support holds the promise of enabling the limited medical assets of forward deployed operational units to provide more robust medical care on the battlefield. In order to prove this theory, the NMCSD hub is currently in the process of developing a high-definition bidirectional TCC support and an Operating Room Tele-consultation capability for the NATO Role 3 hospital in Kandahar, Afghanistan. This study has several limitations. First, it only describes TCC support of a single hospital, over a limited period of time (19 mo), utilizing limited quality assurance and process improvement data. While this, and the observational nature of the study, may limit the generalizability of our results, no adverse outcomes were identified. Furthermore, other factors may also have influenced patient care trends at NHCP. Policies designed to increase the volume and scope of surgical services were implemented during the study intervention period and surgeons were encouraged to offer a wider scope of services when appropriate. While TCC did not directly result in an increase in surgical admissions, the availability of reliable and continuous protocol driven critical care services likely facilitated the safe expansion of surgical services offered at NHCP to include those procedures requiring perioperative ICU care. For the purposes of this study, we equate surgical complexity with need for ICU admission which is a problematic definition without any physiologic criteria. While APACHE II scores did increase significantly for surgical patients in the post-TCC period, the scores were still relatively low compared to higher acuity hospitals. Further study is needed to see if the acuity of surgical ICU admissions based on APAHE II scores have continued to increase at NHCP. Unfortunately, we were unable to determine if the implementation of TCC at NHCP truly minimized the transfer of surgical ICU patients to other hospitals. Our previous evaluation of the TCC program implementation as a whole, did show a significant decrease in total ICU transfers from NHCP to civilian hospitals during the study period (12 ± 0.9 to 0.0 ± 0, p = 0.0008).5 In this study, during the entire 31-mo period reviewed, no surgical patients were identified as being transferred from the NHCP ICU to other hospitals. However, there was no way to capture which elective patients requiring perioperative ICU care, if any, where referred from NHCP to either NMCSD or local civilian hospitals. During the entire study period, the need for ICU admission was based on surgeon preference and duty intensivist approval. It is entirely possible that patients admitted to the NHCP ICU would have not been ICU patients at larger hospitals, inflating the number of post-TCC SICU admissions. One example is bariatric patients. While the care of bariatric patients is beyond the scope of this study, these patients often require either a specialized ward, or a higher level protocolized 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 decided to place these patients in the ICU post-operatively. However, bariatric patients only accounted for 5 of the 120 surgical ICU admissions in the post-TCC period (Tables II and III). Upon review of Table III, the number of thoracic ICU patients doubled and the trauma ICU admissions significantly increased from 0.2 per mo to 0.4 per mo. Certainly, these are small numbers, but the clinical and operational readiness impact of caring for these patients on nurses, corpsman, and ancillary services cannot be overstated. For example, all of the thoracic patients in the Pre-TCC period were non-operative patients with chest tubes only, while 5 of the 7 in the Post-TCC were operative patients requiring VATS, one of which was converted to a formal thoracotomy due to an empyema. Regardless of whether the patients in this study would have been ICU patients at larger higher acuity hospitals or not, without reliable protocolized critical care services many of the patients including the trauma, thoracic and the more complex abdominal surgical cases would not have been patients at NHCP and either transferred out of the direct care network or to NMCSD, further away from their families and support structure. For complex surgical cases, such as VATS, thoracotomies, and complicated abdominal cases (such as distal pancreas resections), a cardiothoracic or hepatobiliary surgeon from NMCSD assisted the local NHCP general surgeon allowing them to safely manage more complex patients perioperatively, improving not only provider satisfaction but improving operational readiness for the surgeons as well. Additionally, the specialty surgeon from NMCSD had the ability to round on their patients via VTC ensuring appropriate post-operative care and avoiding any potential sense of patient abandonment. In conclusion, this study describes the initial impact on the surgical services of comprehensive TCC coverage implementation in a stateside military community hospital. TCC was associated with an increased surgical ICU admissions and facilitated the expansion of surgical services provided, with no adverse events identified. The average APACHE II scores of the surgical ICU patients also increased, with no increase in patient mortality or LOS. For the military, this increased volume and case complexity also helps maintain the operational readiness of forward deployable caregivers including surgeons, non-surgeon physicians, nurses and support staff, all while enhancing patient experience by allowing them to remain in close proximity to their families and units by minimizing patient transfers.5 Although additional study is warranted to validate our findings, we believe that the MHS should explore further expansion of TCC and synchronous telemedicine services not only in support of our overseas military hospitals, but also to enhance the capabilities of forward deployed medical teams caring for critically ill and injured patients aboard ship and on the battlefield. REFERENCES 1 Gunter RL, Chouinard S, Fernandes-Taylor S, Wiseman JT, Clarkson S: Current use of telemedicine for post-discharge surgical care: a systematic review. J Am Coll Surg  2016; 222( 5): 915– 27. Google Scholar CrossRef Search ADS PubMed  2 Pastores SM, Halpern NA, Oropello JM, Kostelecky N, Kvetan V: Critical care organizations in academic medical centers in North America: a descriptive report. Crit Care Med  2015; 43( 10): 2239– 44. Google Scholar CrossRef Search ADS PubMed  3 Duchesne JC, Kyle A, Simmons J, Islam S, Schmieg REJ, Olivier J: Impact of telemedicine upon rural trauma care. J Trauma  2008; 64( 1): 92– 8. Google Scholar CrossRef Search ADS PubMed  4 Provonost P, Angus DC, Dorman T, Bobinson K, Dremsizov T, Young T: Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA  2002; 288( 17): 2151– 62. Google Scholar CrossRef Search ADS PubMed  5 Davis K, Perry A, Tadlock M: Successful implementation of low cost tele-critical care solution by the US Navy: initial experience and recommendations. Mil Med  2017; 182( 5): e1702– 7. Google Scholar CrossRef Search ADS PubMed  6 Lilly CM, Cody S, Zhao H, Landry K, Baker SP, McIlwaine J: 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. Google Scholar CrossRef Search ADS PubMed  7 BUMED Instruction 6320.97A. Navy Medical Treatment Facility Intensive Care Unit Model and Redesignation. 2016. Available at http://www.med.navy.mil/directives/ExternalDirectives/6320.97 A.pdf 8 Reynolds HN, Rogove H, Bander J, McCambridge M, Cowboy E, Niemeier M: A working lexicon for the tele-intensive care unit: we need to define tele-intensive care unit to grow and understand it. Telemed J E-Health  2011; 17( 10): 773– 83. Google Scholar CrossRef Search ADS PubMed  9 Rogers FB, Ricci M, Caputo M, Shackford S, Sartorelli K, Callas P: The use of telemedicine for real-time video consultation between trauma center and community hospital in a rural setting improves early trauma care: preliminary results. J Trauma  2001; 51( 6): 1037– 41. Google Scholar PubMed  10 Klein Y, Donchik V, Jaffe D, Simon D, Kessel B, Levy L: Management of patients with traumatic intracranial injury in hospitals without neurosurgical service. J Trauma  2010; 69( 3): 544– 8. Google Scholar CrossRef Search ADS PubMed  11 Saffle JR, Edelman L, Theurer L, Morris SE, Cochran A: Telemedicine evaluation of acute burns is accurate and cost-effective. J Trauma  2009; 67( 2): 358– 65. Google Scholar CrossRef Search ADS PubMed  12 McNelis J, Schwall GJ, Collins JF: Robotic remote presence technology in the surgical intensive care unit. J Trauma Acute Care Surg  2012; 72( 2): 527– 30. Google Scholar CrossRef Search ADS PubMed  13 Lilly CM, Fisher KA, Ries M, Pastores SM, Vender J, Pitts JA, et al.  : A national ICU telemedicine survey: validation and results. Chest  2012; 142( 1): 40– 7. Google Scholar CrossRef Search ADS PubMed  14 Fortis S, Weinert C, Bushinski R, Koehler AG, Beilman G: A health system-based critical care program with a novel tele-ICU: Implementation, cost, and structure details. J Am Coll Surg  2014; 219( 4): 676– 83. Google Scholar CrossRef Search ADS PubMed  15 Collins TA, Robertson MP, Sicoutris CP, Pisa MA, Holena DN, Reilly PM KB: Telemedicine coverage for post-operative ICU patients. J Telemed Telecare  2016; 360– 4. 16 Blackbourne LH, Baer DG, Eastridge BJ, Kheirabadi B, Kragh JF, Cap AP: Military medical revolution: prehospital combat casualty care. J Trauma Acute Care Surg  2012; 73( 6): S372– 7. Google Scholar CrossRef Search ADS PubMed  17 A Cooperative Strategy for 21st Century Seapower. 2015. Available at http://www.navy.mil/local/maritime/150227-CS21R-Final.pdf 18 Navy Medicine Commander’s Guidance. 2016. p. 1–5. Available at https://mccareer.files.wordpress.com/2016/05/navy-medicine-commanders-guidance.pdf Author notes The views expressed are solely those of the authors and do not reflect the official policy or position of the U.S. Army, U.S. Navy, U.S. Air Force, the Department of Defense, or the U.S. Government. 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 under this title is not available for any work of the United States 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’s official duties.” Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018. 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Association of Military Surgeons of the United States
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Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018.
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Abstract

Abstract Introduction Mortality is reduced in hospitals staffed with intensivists, however, many smaller military hospitals 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 admissions before and after TCC implementation. Materials and methods Patient care by remote intensivist was achieved utilizing 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 operational 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 Telemedicine can be defined as “the use of electronic information and communications technologies to provide and support health care when distance separates participants,” and has been successfully implemented in the management of acute stroke, myocardial infarction, and intensive care unit (ICU) patients.1 Currently, as many as 14% of non-federal intensive care unit beds in North America are managed by tele-ICU programs.2 For surgical patients, the use of telemedicine has been described in the management of neurosurgical, trauma, and burn patients in areas where there is limited access to surgical subspecialty care.3 Mortality is significantly reduced in hospitals staffed with intensivists, however, many military hospitals lack intensivist support.4 To address this intensivist shortage, we recently described the successful implementation of a low cost comprehensive Tele-Critical Care (TCC) support solution in a military community hospital.5 This model allows remote staff with access to video-teleconferencing technology (VTC), real-time bedside monitors, and patient clinical data in order to collaborate with the local health care team in providing patient care. The literature demonstrates that the implementation of TCC has been associated with reduced hospital mortality, hospital length of stay (LOS), improved rates of best clinical practice adherence, and lower rates of preventable complications.6 However, there is limited literature describing TCC in the surgical ICU population. Our objective was to compare surgical ICU admissions before and after TCC implementation at a military community hospital. MATERIALS AND METHODS Naval Hospital Camp Pendleton (NHCP) operates a modified open, level II, six bed-ICU. It supports a patient population of 157,000 active duty personnel, family members and retirees. Specialties currently available include: cardiology, gastroenterology, general surgery, colorectal surgery, oral and maxillofacial surgery (OMFS), pulmonology, neurology, orthopedics, and otolaryngology. Naval Medical Center San Diego (NMCSD), located approximately 41 miles south of NHCP, is the regional tertiary referral center for four Military Health System (MHS) hospitals. NMCSD offers a full spectrum of subspecialty care, and hosts medical students and trainees from more than 20 Accreditation Council for Graduate Medical Education (ACGME) training programs. Per Navy instruction, an intensivist consultation is required for all patients admitted to the NHCP ICU.7 To address intensivist staffing shortages, NMCSD and NHCP established a comprehensive TCC support solution utilizing a “hub and spoke” model.5,8 As previously described, NMCSD provided on-demand bidirectional synchronous high-definition VTC-enabled consultation for all patients admitted to the NHCP ICU.5 In order to enable this consultation, the tele-intensivist possessed real-time access to all electronic medical record documentation, imaging studies, and laboratory results (Fig. 1). In order to facilitate standardization of best-practice measures, a joint website was established by the TCC program manager (author K.L.D.) to share medical and administrative protocols between the two institutions. Table I shows the initial protocols created during the implementation of TCC coverage at NHCP.5 The Fundamentals of Critical Care Support curriculum from the Society of Critical Care Medicine was also taught at NHCP bi-annually by the NMCSD tele-Intensivists in order to enhance critical care skillset of the staff and facilitate positive working relationships. FIGURE 1. View largeDownload slide Tele-Critical Care Program Director (author K.L.D.) rounding from hub site facility. FIGURE 1. View largeDownload slide Tele-Critical Care Program Director (author K.L.D.) rounding from hub site facility. Table I. Spoke Site Protocols Created During Study Period4 ICU Electrolyte Management Pain, Agitation and Delirium Massive Transfusion Protocol Post-Cardiac Arrest Resuscitation Continuous Insulin Infusion Anticoagulation Reversal Sepsis Protocol  ICU Electrolyte Management Pain, Agitation and Delirium Massive Transfusion Protocol Post-Cardiac Arrest Resuscitation Continuous Insulin Infusion Anticoagulation Reversal Sepsis Protocol  View Large Table I. Spoke Site Protocols Created During Study Period4 ICU Electrolyte Management Pain, Agitation and Delirium Massive Transfusion Protocol Post-Cardiac Arrest Resuscitation Continuous Insulin Infusion Anticoagulation Reversal Sepsis Protocol  ICU Electrolyte Management Pain, Agitation and Delirium Massive Transfusion Protocol Post-Cardiac Arrest Resuscitation Continuous Insulin Infusion Anticoagulation Reversal Sepsis Protocol  View Large The NMCSD (“hub” site) tele-intensivist covered the NHCP ICU (“spoke” site) when no local intensivist was available. TCC call periods ranged from days to months. Emergency interventions such as intubations, central venous catheter placement, arterial lines, and tube thoracostomy were performed by the in-house anesthesia provider or duty general surgeon as appropriate. The decision to admit surgical patients to the ICU was based on attending surgeon preference in conjunction with the approval of the duty intensivist (either in-house or tele-intensivist). To assess the impact of TCC on the surgical services at NHCP, quality assurance/process improvement data were retrospectively reviewed. Surgical ICU admission data for the 12-mo period prior to TCC implementation (2/2013-2/2014; pre-TCC) was compared with the 19-mo period following TCC implementation (3/2014-9/2015; post-TCC). Admissions were compared per month to account for the longer time period in the Post-TCC group. The post-TCC Acute Physiology and Chronic Health Evaluation II (APACHE II) scores and LOS were also compared with the pre-TCC baseline data. Adverse outcomes during the study period were reviewed utilizing the Navy Medicine Patient Safety Reporting system. Student’s t-test was performed for all comparisons, with two-sided p-values. Significance was attributed to a p-value <0.05. RESULTS During the 32-mo study period, a total of 828 patients were admitted to the NHCP ICU. Surgical ICU admissions comprised 21% of this volume (or 171 admissions). TCC provided ICU coverage on an average of 35% of the days with the longest period of continuous TCC coverage being 3 mo. During the post-TCC period, there was an increase in the absolute number of surgical ICU (SICU) admissions per month (3.9 vs 6.3, p = 0.009), and the percentage of surgical admissions to the ICU (15.3% vs 24.6%, p = 0.01) (Table II). When analyzing types of surgical admissions per month, statistically significant increases were seen in monthly trauma admissions (0.2 vs 0.8, p = 0.009) and OMFS admissions (0.1 vs 0.5, p = 0.04) 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 during the pre-TCC period were non-operative (i.e., tube thoracostomy). However, during the post-TCC period, five of the seven admissions were operative, including four video-assisted thoracoscopic surgeries (VATS) and one VATS converted to thoracotomy for a patient with an empyema. 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    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 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    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  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. 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  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. A statistically significant increase in surgical patient acuity, based on APACHE II scores, was seen after TCC implementation (4.1 vs 6.5, p = 0.03). LOS was unchanged throughout the study period (Table IV). During both the pre-TCC and post-TCC periods, no surgical patients were identified that required transfer from the NHCP ICU to other hospitals. Four deaths occurred following implementation of TCC. All of these deaths occurred in patients receiving palliative care, and none of them were surgical. Of these four patients, TCC was involved in the care of three. No adverse outcomes related to TCC were reported upon review of the patient safety reporting system. Table IV. APACHE II Score & ICU LOS for Surgical ICU Patients   Pre-TCC  Post-TCC  Total  p  APACHE II/month [mean (SD)]  4.1 (2.8)  6.5 (3.1)  5.5 (3.2)  0.03  ICU LOS/month [mean (SD)]  1.5 (0.6)  1.5 (0.5)  1.5 (0.5)  0.99    Pre-TCC  Post-TCC  Total  p  APACHE II/month [mean (SD)]  4.1 (2.8)  6.5 (3.1)  5.5 (3.2)  0.03  ICU LOS/month [mean (SD)]  1.5 (0.6)  1.5 (0.5)  1.5 (0.5)  0.99  Table IV. APACHE II Score & ICU LOS for Surgical ICU Patients   Pre-TCC  Post-TCC  Total  p  APACHE II/month [mean (SD)]  4.1 (2.8)  6.5 (3.1)  5.5 (3.2)  0.03  ICU LOS/month [mean (SD)]  1.5 (0.6)  1.5 (0.5)  1.5 (0.5)  0.99    Pre-TCC  Post-TCC  Total  p  APACHE II/month [mean (SD)]  4.1 (2.8)  6.5 (3.1)  5.5 (3.2)  0.03  ICU LOS/month [mean (SD)]  1.5 (0.6)  1.5 (0.5)  1.5 (0.5)  0.99  DISCUSSION In the current study, after the implementation of TCC there was an increase in the scope and complexity of surgical ICU admissions at a MHS community hospital. Statistically significant increases were seen in surgical ICU admissions, and patient APACHE II scores with no adverse outcomes identified. Our experience suggests that high-definition, bidirectional, synchronous telemedicine can successfully extend critical care physician expertise into a small stateside community hospital, thereby enabling the local staff to care for a higher volume and complexity of surgical patients. Due to the success of this program, NMCSD TCC continues to cover NHCP typically one week in every 4-6 wk, or more often if needed due to operational requirements. Furthermore, NMCSD has expanded its regular coverage to Naval Hospital Camp Lejeune’s ICU, over 2600 miles away, as well as Naval Hospital Jacksonville and Naval Hospital Guantanamo Bay. The surgical critical care experience of “telemedicine” has largely focused on coverage for rural trauma,3,9 traumatic intracranial injury,10 and in the evaluation and triage of burn patients with good results.11 For rural trauma, the use of telemedicine consultation has been shown to conserve trauma resources, aide rural community hospitals by decreasing unnecessary transfers, and efficiently identify and facilitate the expeditious movement of more severely injured patients to a higher level of care.3 In the initial evaluation of burn patients, telemedicine has been associated with improved patient triage, and the more appropriate use of air transport resources.11 Finally, robotic presence and remote oversight of surgical patients have also been described in the ICU,12 and in the post-operative period,1 with no significant increases in mortality or adverse outcomes. Other studies have described the use of telemedicine in surgical ICU patients, but to our knowledge this is the first to describe TCC program implementation on surgical volume and complexity in a small community hospital in non-burn and mostly non-trauma surgical ICU patients.13,14 Collins and colleagues recently described the use of telemedicine in post-operative ICU patients left in the post anesthesia care unit to provide a bed surge capacity when ICU beds were full; however, these patients were managed remotely from elsewhere within the same hospital, not from a distant hospital.15 The studies describing the use of telemedicine in civilian rural trauma and burn patients3,9–11 coupled with our positive experience utilizing TCC may, therefore, provide a proof-of-concept for implementation of comprehensive TCC coverage of overseas military hospitals, where intensivist availability is often limited. In the Pacific Theater, the MHS provides care from hospitals located in Guam, Okinawa, Japan, and South Korea. Similar to NHCP, the organic medical personnel assigned to these hospitals is often limited. Anecdotally, overseas surgeons have described instances to the authors where the local command does not allow them to perform an elective surgery requiring overnight or extended mechanical ventilation because no formally trained intensivist is available to manage intubated patients. While managing mechanically ventilated patients is a significant aspect of general surgery residencies, many overseas general surgeons may be far removed from their initial training that they are uncomfortable with performing basic ventilator management. We believe that comprehensive TCC (and telemedicine) support with standardization of protocols and best practices could have a significant positive impact and help facilitate the safe expansion of the medical and surgical capability of these overseas military hospitals that lack local intensivists. After the inception of the Joint Trauma System, technology improvements, including regular video teleconference, have allowed military providers across the range of care to discuss patients while they are undergoing evacuation.16 While these teleconferences are valuable for decision making rationale and loop closure, patients are not evaluated real-time by another provider remotely. Therefore, we also believe that our findings may have military relevance beyond support of the surgical services in overseas and stateside military hospitals. The extraordinary survival in the recent Middle East ground conflicts has been achieved through a combination of heroic battlefield care, damage control surgery, and resuscitation near the point-of-injury, and expedient medical air evacuation to a higher level of care. However, trends in world politics and recent events have forced the U.S. military to begin preparations for conflict in new areas. Many speculate that the next major conflict will occur in the Indo-Asia-Pacific region, and may involve air-sea engagements. With current U.S. military strategy pivoting to the Indo-Asia-Pacific region, the number of personnel, ships and aircraft stationed or deployed in the region are increasing, particularly Navy and Marine Corps personnel. Furthermore it is estimated that nearly 60% of the U.S. Naval Fleet will be based in the Pacific by the year 2020.17 Future conflict in the Indo-Asia-Pacific Theater will likely be characterized by disaggregated hostility with distributed lethality. This type of war has not been experienced by our nation in more than 50 yr. In this future conflict, the time required for evacuation of casualties from point of injury to evacuation to a higher level of care will be pushed from 60 min (which was typical in Operation Iraqi Freedom and Operation Enduring Freedom), to as long as 48 or 72 h. If we are to maintain the high survival that was hard-earned during the last 15 yr of ground combat in the Middle East, we must be prepared to support prolonged field care of casualties.18 Complicating this requirement, operational units within the Navy and Marine Corps organization often function in significant isolation, which limits the medical capabilities of these operating platforms. Furthermore, as a result of retirement and attrition, the combat trauma corporate knowledge that has been acquired these last 15 yr is rapidly being lost from Navy Medicine. In isolated environments, the existence of casualties that cannot be cared for by the limited organic medical assets may affect mission execution and success. Imagine a young general surgeon or non-surgeon physician embarked at sea or in a remote forward deployed location with limited resources and personnel managing multiple complex critically ill combat trauma patients with the ability to “phone a friend” via high-definition bidirectional VTC. Real-time, various seasoned specialists (i.e., vascular or trauma surgery, neurosurgery or critical care) could help guide these deployed caregivers in the initial resuscitation, critical care support, and surgical management while waiting for evacuation to a higher level of care. The importance of enhancing the medical personnel embedded within these units cannot therefore be overstated. Tools that enable high-fidelity bidirectional medical consultation have the potential to significantly expand the capability of organic medical personnel embedded within these isolated units. Just as synchronous high-definition bidirectional TCC can enhance care in a small stateside hospital, we believe the same type of support holds the promise of enabling the limited medical assets of forward deployed operational units to provide more robust medical care on the battlefield. In order to prove this theory, the NMCSD hub is currently in the process of developing a high-definition bidirectional TCC support and an Operating Room Tele-consultation capability for the NATO Role 3 hospital in Kandahar, Afghanistan. This study has several limitations. First, it only describes TCC support of a single hospital, over a limited period of time (19 mo), utilizing limited quality assurance and process improvement data. While this, and the observational nature of the study, may limit the generalizability of our results, no adverse outcomes were identified. Furthermore, other factors may also have influenced patient care trends at NHCP. Policies designed to increase the volume and scope of surgical services were implemented during the study intervention period and surgeons were encouraged to offer a wider scope of services when appropriate. While TCC did not directly result in an increase in surgical admissions, the availability of reliable and continuous protocol driven critical care services likely facilitated the safe expansion of surgical services offered at NHCP to include those procedures requiring perioperative ICU care. For the purposes of this study, we equate surgical complexity with need for ICU admission which is a problematic definition without any physiologic criteria. While APACHE II scores did increase significantly for surgical patients in the post-TCC period, the scores were still relatively low compared to higher acuity hospitals. Further study is needed to see if the acuity of surgical ICU admissions based on APAHE II scores have continued to increase at NHCP. Unfortunately, we were unable to determine if the implementation of TCC at NHCP truly minimized the transfer of surgical ICU patients to other hospitals. Our previous evaluation of the TCC program implementation as a whole, did show a significant decrease in total ICU transfers from NHCP to civilian hospitals during the study period (12 ± 0.9 to 0.0 ± 0, p = 0.0008).5 In this study, during the entire 31-mo period reviewed, no surgical patients were identified as being transferred from the NHCP ICU to other hospitals. However, there was no way to capture which elective patients requiring perioperative ICU care, if any, where referred from NHCP to either NMCSD or local civilian hospitals. During the entire study period, the need for ICU admission was based on surgeon preference and duty intensivist approval. It is entirely possible that patients admitted to the NHCP ICU would have not been ICU patients at larger hospitals, inflating the number of post-TCC SICU admissions. One example is bariatric patients. While the care of bariatric patients is beyond the scope of this study, these patients often require either a specialized ward, or a higher level protocolized 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 decided to place these patients in the ICU post-operatively. However, bariatric patients only accounted for 5 of the 120 surgical ICU admissions in the post-TCC period (Tables II and III). Upon review of Table III, the number of thoracic ICU patients doubled and the trauma ICU admissions significantly increased from 0.2 per mo to 0.4 per mo. Certainly, these are small numbers, but the clinical and operational readiness impact of caring for these patients on nurses, corpsman, and ancillary services cannot be overstated. For example, all of the thoracic patients in the Pre-TCC period were non-operative patients with chest tubes only, while 5 of the 7 in the Post-TCC were operative patients requiring VATS, one of which was converted to a formal thoracotomy due to an empyema. Regardless of whether the patients in this study would have been ICU patients at larger higher acuity hospitals or not, without reliable protocolized critical care services many of the patients including the trauma, thoracic and the more complex abdominal surgical cases would not have been patients at NHCP and either transferred out of the direct care network or to NMCSD, further away from their families and support structure. For complex surgical cases, such as VATS, thoracotomies, and complicated abdominal cases (such as distal pancreas resections), a cardiothoracic or hepatobiliary surgeon from NMCSD assisted the local NHCP general surgeon allowing them to safely manage more complex patients perioperatively, improving not only provider satisfaction but improving operational readiness for the surgeons as well. Additionally, the specialty surgeon from NMCSD had the ability to round on their patients via VTC ensuring appropriate post-operative care and avoiding any potential sense of patient abandonment. In conclusion, this study describes the initial impact on the surgical services of comprehensive TCC coverage implementation in a stateside military community hospital. TCC was associated with an increased surgical ICU admissions and facilitated the expansion of surgical services provided, with no adverse events identified. The average APACHE II scores of the surgical ICU patients also increased, with no increase in patient mortality or LOS. For the military, this increased volume and case complexity also helps maintain the operational readiness of forward deployable caregivers including surgeons, non-surgeon physicians, nurses and support staff, all while enhancing patient experience by allowing them to remain in close proximity to their families and units by minimizing patient transfers.5 Although additional study is warranted to validate our findings, we believe that the MHS should explore further expansion of TCC and synchronous telemedicine services not only in support of our overseas military hospitals, but also to enhance the capabilities of forward deployed medical teams caring for critically ill and injured patients aboard ship and on the battlefield. 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Google Scholar CrossRef Search ADS PubMed  13 Lilly CM, Fisher KA, Ries M, Pastores SM, Vender J, Pitts JA, et al.  : A national ICU telemedicine survey: validation and results. Chest  2012; 142( 1): 40– 7. Google Scholar CrossRef Search ADS PubMed  14 Fortis S, Weinert C, Bushinski R, Koehler AG, Beilman G: A health system-based critical care program with a novel tele-ICU: Implementation, cost, and structure details. J Am Coll Surg  2014; 219( 4): 676– 83. Google Scholar CrossRef Search ADS PubMed  15 Collins TA, Robertson MP, Sicoutris CP, Pisa MA, Holena DN, Reilly PM KB: Telemedicine coverage for post-operative ICU patients. J Telemed Telecare  2016; 360– 4. 16 Blackbourne LH, Baer DG, Eastridge BJ, Kheirabadi B, Kragh JF, Cap AP: Military medical revolution: prehospital combat casualty care. J Trauma Acute Care Surg  2012; 73( 6): S372– 7. Google Scholar CrossRef Search ADS PubMed  17 A Cooperative Strategy for 21st Century Seapower. 2015. Available at http://www.navy.mil/local/maritime/150227-CS21R-Final.pdf 18 Navy Medicine Commander’s Guidance. 2016. p. 1–5. Available at https://mccareer.files.wordpress.com/2016/05/navy-medicine-commanders-guidance.pdf Author notes The views expressed are solely those of the authors and do not reflect the official policy or position of the U.S. Army, U.S. Navy, U.S. Air Force, the Department of Defense, or the U.S. Government. 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 under this title is not available for any work of the United States 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’s official duties.” Published by Oxford University Press on behalf of the Association 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.

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Military MedicineOxford University Press

Published: Apr 4, 2018

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