Rapid implementation and innovative applications of a virtual ICU during the COVID-19 pandemic: A case study

Why does this study matter?
Surge was definitely a thing we were all worried about just a few months ago, and in some areas, all over again. The novelty of the coronavirus, combined with the complexity of treating COVID-19 patients, forced many organizations to redirect their critical care staff to the COVID-19 units for 24-hour bedside coverage. Other caregivers had to backfill for critical care in non-COVID units.

At the time of this case study at Houston Medical Hospital, part of the Texas Medical Center, the hospital already had 150 COVID ICU patients, and there was a potential for 2- to 4-fold increase. And as an aside, for the past few years, The Center has been doing quite a bit of investigation about the role of the built environment in telemedicine, and I wanted to see what they did. This offered a slightly different set of issues to consider.

How was the study done?
As a result of their surge, this hospital accelerated and expanded a tele-critical care program that connected ICU patient rooms to remote caregivers. They called it their virtual ICU or vICU. This technology ended up augmenting their critical care capacity during the COVID-19 surge, as admissions increased and staff tested positive for the virus. There were 3 main components: the Operations center where physicians and nurses were working, the patient room, and the audiovisual (AV) communication infrastructure linking the patient room, onsite staff, and the ops center.

The program was planned pre-COVID and was originally envisioned for the neuro-ICU, MICU, CVICU, and CICU, but the program was expedited with COVID and the MICU was turned into the first dedicated COVID-19 unit. Over the weeks, the other ICUs implemented the vICU and became COVID-19 units, too.  Eventually, non-COVID ICU units were equipped with the vICU, and step-down units and vacated units were equipped with mobile carts to extend coverage without compromising care.

So what do we learn from the study?
The vICU was planned pre-COVID and was set up to add consultants or specialist in a 3-way video call. Invitations could be sent by a text link. It was NOT intended for virtual visits, but when in-person visitation was suspended, the virtual setup became a welcomed communication tool for critically ill patients who weren’t able to use FaceTime or Skype without the help of fully donned staff. The Ops Center collaborated with bedside staff to coordinate 20-40 virtual family visits per day, for all patient types, through a link sent to a smart phone. Hearing voices and seeing faces improved emotional well-being for patients and families.

The technology also allowed more engaged family participation when they couldn’t be part of face-to-face decisions for palliative care, and the staff benefitted, too. Anxiety about PPE shortages were alleviated (knowing there was conservation of limited resources), and medical staff and specialists assigned to COVID-19 units felt more protected with a reduced number of times they had to go into the room.

Can we say the results are definitive?
This is not an empirical study but a narrative of some important lessons learned. We don’t have a quantifiable change in satisfaction or experience levels, in staff burnout, infection rates, or even the conservation rate of PPE. This was an adaptive use of an initiative already underway – an opportunistic happenstance, so to speak. In this case, cost evaluation wasn’t a driving concern, but it certainly could be under more normal circumstances.

Would this continue to work in a world where hospital visits are allowed? People still want to be able to touch and hug a loved one, especially at the end of life, but for those who can’t be there, for any number of reasons, this may still offer a viable solution for family engagement, improved morale, and in some cases, like an infectious disease, safety for everyone.

What’s the takeaway?
eICUs have been around for awhile. But the current COVID-19 pandemic reinforced Plato’s words - necessity is the mother of invention. In this case, we had improvisation. “Yes, and” is a pillar of improv. How do actors keep it going in improv? When someone says something, you agree and accept it as truth – “Yes.” “And” comes in to expand the reality you have been handed. You add to the narrative.

They had a problem with patient capacity due to COVID.

Yes, and they had a vICU in the works. Even though it had been planned for clinicians and specialists, they had the 3-way capabilities. The had the link by text function. Yes, and it could work for e-visits with family. Yes, and the staff won’t have to don PPE to go into the room to help.

Yes, and. It’s a lesson, let’s continue to think how we can leverage technology in the built environment to improve outcomes.

Dhala, A., Sasangohar, F., Kash, B., Ahmadi, N., & Masud, F. (2020). Rapid implementation and innovative applications of a virtual ICU during the COVID-19 pandemic: A case study. Journal of Medical Internet Research, 22(9), in press. https://doi.org/10.2196/20143

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