Help during the pandemic for overwhelmed, overworked intensive care unit (ICU) nurses at some health systems came in the form of experienced tele-ICU nurses working remotely to support on-site colleagues as they cared for COVID-19 patients.
Nurses and a physician at Atrium Health described how they revved up an existing tele-ICU system to meet increased ICU demands during the pandemic in a paper published in August in Critical Care Nurse.
Atrium Health has had a tele-ICU system, which it calls the virtual critical care (VCC) unit, in its hospitals and network of ICUs throughout the Carolinas since 2013. The VCC uses real-time, two-way audio and high-definition video communication to critical care beds. Mobile carts deliver the virtual care in two of the system’s emergency departments. And the pre-pandemic VCC team included more than 80 board-certified tele-intensivists and 40 board-certified critical care nurses.
Virtual nurses and physicians provide coverage for adult critical care patients 24/7, helping nursing staff on the ground with a layer of critical care expertise, monitoring, and communication, according to the paper’s authors.
But with the quickly increasing demands on ICUs by COVID-19 patients, Atrium Health had to expand and prioritize its VCC.
The health system granted more than 300 physicians, nurses, pharmacists, and respiratory therapists technology access so they could help care for patients remotely. It also added nearly 200 mobile carts and allowed more than 20 tele-intensive care unit nurses to work from home.
Among the nurses selected for VCC coverage were ICU nurses who were considered at risk for serious COVID-19 complications, others who had adequate internet access, and still others who were willing to add VCC shifts to their workloads. The system also offered VCC work to experienced ICU nurses who might have been furloughed during the crisis.
Experienced VCC nurses helped to train others on how to use the technology. They focused on expanding VCC coverage at three facilities to make room for more COVID-19 patients.
“At these three facilities alone, the VCC enabled conversion of existing hospital beds into critical care beds increasing the capacity to provide ICU level care by 43% to 175%,” the authors wrote.
The technology allowed experienced ICU clinicians to virtually assess and communicate with patients in isolation, reducing onsite nurses’ exposure and saving personal protective equipment (PPE) use.
Virtual nurses provide an integral role in patients’ well-being, according to Marie Mercier, MSN, APRN, AGCNS-BC, VCC Nurse Manager at Atrium Health.
“One area of critical importance is in helping relieve the stress of hospitalization for patients,” Mercier said. “One VCC nurse described her recent experience while rounding via camera on a COVID-19 positive patient. The patient was visually upset and crying in her room. The virtual nurse stayed with the patient and in talking with her, learned the patient was nervous about being hospitalized and was missing her family. The VCC nurse was able to provide needed comfort to her patient while also calming her concerns by providing education on her medications and talking her through what she can expect during her hospital stay.”
The goals of virtual ICU care during the pandemic were not only to provide proactive patient care, but also to support and protect nurses caring for COVID-19 patients, the authors wrote.
To reduce unnecessary time spent in isolation rooms, VCC nurses would connect at the start of each shift with bedside nurses. VCC nurses were responsible for visual patient rounding at least every other hour and assessing intravenous sites, infusions, and equipment. They also virtually attended bedside procedures or significant events to monitor patients and help with documentation.
Atrium’s VCC leadership also made team self-care a priority, with debriefings, music therapy, meditation, and more.
Inova Health System Supports Tele-ICU Model
Inova Health System implemented a tele-ICU in 2004, according to Theresa M. Davis, PhD, RN, NE-BC, CHTP, FAAN, Clinical Operations Director of enVision eICU at Inova Health System, Falls Church, Virginia. She is also director of the American Association of Critical-Care Nurses (AACN) national board of directors. Davis said the tele-ICU’s voice and video tech, plus the expert staff of nurses and intensivists, created a system that supports critical care patients and clinicians across the health system.
In response to COVID-19, Inova doubled the size of its tele-ICU RN team and added 24/7 intensivists and an advanced practice practitioner.
“This enabled the tele-ICU team to meet the needs of the ICU clinicians and their patients across the system,” Davis said. “Critical care surge areas opened within days of the arrival of COVID-19 in all five of our hospitals to manage the capacity of critically ill patients. A system transfer center as well as a resource management center were centralized in the tele-ICU to manage transfers across the system and ensure staffing resource needs were met each shift.”
While there were many expert clinicians at the bedside, the sheer volume and acuity of patients required larger clinical teams to manage high tech pulmonary needs, Davis said. These might include ventilator support, proning, extracorporeal membrane oxygenation (ECMO), and continuous renal replacement therapy (CRRT).
“Voice and video capabilities were added to the surge areas using repurposed virtual sitter technology, video carts, and iPads to enhance two-way communication between tele-ICU and ICU, clinicians, and their patients as well as patients and their families,” she said.
An interdisciplinary Critical Care Strike Team at Inova shared data and lessons learned daily to inform care across the system. Leadership met every day to make sure clinical teams had the equipment and staffing they needed, the workflow was ideal, and team well-being was addressed, Davis said.
“A peer-to-peer support program encourages clinicians to recognize when a colleague is struggling to cope and provides teaching and tools to ensure the employee feels supported and gets the help they need,” said Davis. “Other ongoing efforts include compassion carts, flexible staffing, weekly well-being webinars, and a wellness website with many offerings to enhance resilience during this unprecedented time.”
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