TeleCritical Care: Another Member of the Multidisciplinary Critical Care Team

To the Editor:

The recent Official American Thoracic Society Workshop Report (ATSWR), Symptom Assessment for Mechanically Ventilated Patients: Principles and Priorities, highlights the need for a more complete multidisciplinary assessment of the physical and psychological status of mechanically ventilated patients to minimize distress, enhance patient experience, and improve short- and long-term patient outcomes (1). This report identifies and defines essential symptoms that should be assessed in mechanically ventilated patients, instruments for their evaluation, and potential strategies to enhance patient comfort, safety, and long-term recovery. While advocating a multidisciplinary approach, the report omits a key member of many critical care management teams, telecritical care (TeleCC).

Recent reviews suggest that nearly 20% of all U.S. hospitals with ICUs use TeleCC (2, 3). With the rapid expansion of inpatient telemedicine during the coronavirus disease (COVID-19) pandemic, the proportion of hospitals with TeleCC or inpatient telemedicine services may be even higher. Within the VA (Veterans Affairs) healthcare system, TeleCC is currently implemented in 74 facilities covering 1,109 ICU beds. It is scheduled to expand to over 80% of VA hospitals with ICUs. As practitioners in the VA National TeleCC Program, we often manage patients who have unique characteristics and needs outlined in the ATSWR (risk for posttraumatic stress disorder development or exacerbation, ICU exacerbations of alcohol and/or polysubstance use disorders, and/or psychiatric states including suicidal ideation).

TeleCC is synchronous telemedicine that uses bidirectional audiovisual technology to connect bedside ICU providers with remotely located critical care intensivists and nurses supported by real-time, comprehensive clinical data flow from the bedside (including vital signs, laboratory studies, and waveforms). Data flows seamlessly into an integrative software platform that continually analyzes and evaluates clinical acuity and actively alerts TeleCC providers to physiologic and biochemical derangements. This technology-augmented patient evaluation facilitates and enhances TeleCC participation in the management of ICU patients in collaboration with bedside providers. Although study findings are variable, TeleCC has been associated with improvements in clinical outcomes (4, 5). TeleCC-directed daily evaluation of ventilated patients is associated with durably enhanced adherence to lung protective ventilation and reduced ventilator duration and mortality ratios (6).

On the basis of their spatial separation from the bedside, TeleCC staff are highly attuned to the visual and nonverbal assessment of the mechanically ventilated patient. TeleCC can assist with mechanical ventilator adjustment to improve patient:ventilator synchrony, assess patient comfort, adjust sedative and analgesic medications, and coordinate spontaneous awakening and breathing trials with the bedside team. TeleCC clinicians evaluate the work of breathing, respiratory rate, depth of respirations, breathing patterns, and subtle changes such as vibrations in the ventilatory circuit that might suggest secretions. Camera activations facilitate near-instantaneous patient visualization allowing TeleCC nurses to assess endotracheal tube stability and prevent unplanned extubations by notifying bedside staff. Collaborating with the bedside team, TeleCC staff can provide standardized assessments on a scheduled basis. As new patient evaluation tools are developed, TeleCC proficiencies and capabilities may expand the breadth of new instruments for holistic patient assessment.

In addition, TeleCC can disseminate best practices and provide education and training in the assessment of mechanically ventilated patients either during active patient management or through combined bedside–TeleCC simulations throughout the multihospital network associated with a TeleCC program.

The authors thank the ATSWR members for this seminal report and believe that the TeleCC community and its resources can be instrumental in developing, expeditiously disseminating, and implementing holistic symptom assessment of patients receiving mechanical ventilatory support. We look forward to the ongoing dialogue stimulated by this report and hope that TeleCC resources can be included in the discussions and successful realization of the cultural shift toward patient-focused critical care management.