An introduction to nursing surveillance in the tele-ICU

The use of remote, high-tech surveillance by critical care nurses in tele-ICUs is not widely understood. The American Association of Critical-Care Nurses (AACN) describes tele-ICU nursing as critical care nursing using telecommunications technologies to practice over distance.1 Because the subspecialty of tele-ICU nursing is relatively new, a lack of knowledge exists about the role, scope of practice, and technologies used to conduct surveillance and assess large numbers of patients from a remote setting. This article describes how tele-ICU nurses use technology to enhance the surveillance of critically ill and injured patients. There are about 1,000 nurses working in tele-ICUs across the country and over 16,000 clinical nurses who interact with them.2 Describing this subspecialty of nursing can lead to greater insight into how this type of practice may reduce adverse events in this vulnerable population. The history of tele-ICU Tele-ICU care first appeared in the 1970s.3 In 1982, the first clinical trial involving telemedicine in the ICU environment was published.4 In 2000, the first around-the-clock tele-ICU model was described, and by 2007 there were approximately 30 tele-ICU centers across the United States.5 Today there are over 300 hospitals across 40 U.S. states working with more than 50 tele-ICU centers. A typical tele-ICU nurse can be assigned 30 to 40 patients, with tele-ICU physician-to-patient ratios as high as 1 per 250 patients.1,6,7 Tele-ICUs can care for high volumes of critically ill patients because (1) the use of high-tech audio-video and other telecommunication tools allow clinicians to move more efficiently between patients; (2) alerts and clinical decision support tools assist with triage and surveillance; and (3) the primary responsibilities of the tele-ICU team are to gather information, monitor for adverse events, and ensure compliance with best practices.6,8,9 The American Telemedicine Association has described tele-ICUs as those providing either centralized, continuous care or decentralized, episodic care.10 In the centralized model, a care team works together within a physical structure to provide remote telemedicine and telenursing services across a distance. Decentralized models do not require the physical structure, and individuals or teams work from any location with Internet access. Most telestroke programs are decentralized and episodic. Most tele-ICU nurses practice in centralized, continuous care models, which include gathering information and conducting surveillance, which in turn are acted upon by direct care providers using clinical reasoning from a distance. Simply put, tele-ICU nursing is critical care nursing practiced over a distance using telecommunication and various health information technologies.1 The AACN established the CCRN-E certification for tele-nursing in 2011 and published the TeleICU Nursing Guidelines in 2013.1 These guidelines focus primarily on important proficiencies such as skilled communication, true collaboration, and expertise in critical care, as well as a requisite aptitude for working with multiple computer applications and telehealth technologies. Environment and tools The tele-ICU environment consists of large computer workstations arranged to enhance communication among members of the tele-ICU team (see Example of a tele-ICU room layout). Ergonomic design features are often incorporated because clinicians working in these centers typically work long 8- to 12-hour shifts. Adaptable workstations (such as sit-to-stand desks), adjustable computer monitor arms, and chairs of differing sizes that conform to ergonomic standards should be used in these environments. Commonly, tele-ICU team structure consists of 1 or 2 clerical/technical support personnel for every 100 patients, 1 nurse for every 30 to 40 patients, and 1 intensivist for up to 250 patients. Just like ICUs, some tele-ICUs are staffed with advanced practice nurses (such as NPs and clinical nurse specialists). Intensivist staffing may only include evening or night shift coverage, but nurses and support personnel generally staff the unit 24 hours a day, 7 days a week.Figure: Example of a tele-ICU workstation setupIn order to support active and continuous surveillance on large populations of high-acuity patients, each workstation is equipped with at least six monitors displaying clinical data from different health information systems (see Example of a tele-ICU workstation setup). Alarm fatigue in the hospital setting continues to be a significant health hazard.11 Because tele-ICU nurses are conducting all their tasks using multiple computer applications and technologies, they are uniquely positioned and equipped to provide continuous monitoring and response to clinical alerts, a task that is difficult to accomplish at the bedside.Figure: Example of a tele-ICU room layoutTele-ICU nurses are also highly trained and skilled at finding relevant clinical information. From responding to clinical decision support systems (CDSS), listening to dictation of a history and physical, and reviewing clinical data in an electronic health record (EHR) to conducting a nursing assessment using high-tech audio-video equipment, these nurses have adapted to using these tools to conduct surveillance activities from a distance. More information related to various health information systems, other technologies, and infrastructure requirements to support these centers can be found in literature.6,8,10 Remote surveillance Surveillance is the purposeful ongoing collection, interpretation, synthesis, and analysis of individual patient or population data to support clinical decision-making.12,13 Dissemination of and/or acting on these data can reduce morbidity and mortality and improve overall health in three main ways: (1) through early warning of impending clinical or public health emergencies; (2) documenting the impact of interventions; and (3) tracking progress toward specific healthcare goals.12,13 Surveillance is an intervention that involves a number of key activities. Central to effective surveillance are patient assessment and monitoring.14 Patient assessment includes evaluating the patient's medical history and current status to determine risk factors for developing complications or adverse reactions related to interventions, procedures, or medications. Monitoring includes all the traditional variables such as vital signs, lab values, ECGs, and so on. Although monitoring is an essential component of surveillance, it is dissimilar in purpose and scope.14 Unlike monitoring, which may be routine and standardized for all ICU patients, surveillance is goal-directed and individualized for a specific patient or patient population. Tele-ICUs have access to many of the same technologies used in traditional ICUs, such as acute care physiologic monitoring devices and clinical data from EHRs. However, other technologies are required to support nurses in carrying out effective surveillance in the tele-ICU setting. These include video monitoring and technologies that allow for direct communication among the nurse, patient, family, and in-hospital healthcare providers, such as secure texting, smartphones and wearable devices, and instant messaging. Most important, the large numbers of patients and patient data require CDSS that assist the nurse in prioritizing patient needs and collaborating with other providers.2,8 There are many types of CDSS used by tele-ICUs across the nation. A commonly used tele-ICU software application uses acuity algorithms and alerts to help nurses identify patients whose condition may be worsening or provide disease surveillance for time-sensitive conditions such as sepsis.9 Tele-ICU nurses also use the alerts built into EHRs to conduct surveillance. Much like the systems that facilitate surveillance in the ICU, the tele-ICU uses structured handoffs, checklists, and a collaborative approach to care planning and delivery.2 Barriers to effective surveillance include both system and human factors. System factors include inadequate resources, lack of collaboration, and underuse of existing technology. Human factors include any lack of skills, rules, and/or knowledge-based behaviors on the part of the critical care nurse.15 Relevance to nursing practice Tele-ICUs are staffed with experienced critical care nurses who generally have 3 to 5 years of ICU experience and advanced certification such as the CCRN and CCRN-E.1,2,6,9,10,16 Tele-ICU nurses draw from their knowledge and experience as they conduct surveillance, and they are uniquely positioned to improve patient outcomes via the early recognition of medical errors and adverse events. Access to trends in an individual patient's data and aggregate data for specific patient populations allow for the detection of events less obvious in a traditional ICU setting. For example, in 2004, tele-ICU nurses began remote monitoring of clinical trends (lab, vital sign, and other criteria) related to sepsis in a large health system in Northern California.9,16,17 Over the course of several years, this team of nurses not only advocated for better care in the moment, they also collected data and published their findings at the local and system levels. Their efforts supported a decision to make sepsis a system-wide healthcare initiative at over 20 acute care hospitals by 2008. A recent study reported a number of benefits of tele-ICU nursing practice and surveillance, such as improved monitoring of vital sign trends, better detection of physiologic instability and dysrhythmias, increased advocating for medical management, and enhanced patient safety.2 Tele-ICU nurses have also used surveillance to (1) decrease adverse events such as cardiac and respiratory arrest, patient falls, and unplanned removal of tubes, lines, and airways; (2) enhance detection and treatment of time-sensitive diseases such as sepsis; and (3) reduce days on mechanical ventilation.9,18,19 Traditional bedside surveillance performed by nurses is dependent on accessing data from multiple sources; however, distractions and interruptions can interfere.14 Tele-ICU nurses receive extensive training on how to access data from multiple sources including the EHR, lab operating systems, dictation systems, CDSS, health information systems with trending capabilities, web-based biomedical monitoring devices, and high-tech audio-video equipment.1 The primary responsibility of tele-ICU nurses is to engage in surveillance, so they are not often distracted by other tasks or overwhelmed by time constraints in the same way that nurses at the bedside are.1,14 Just as air traffic controllers do not replace the need for pilots and other flight crew members, adding tele-ICU nurses does not negate the need for safe nurse-to-patient ratios in the ICU environment. Tele-ICU nurses can conduct surveillance, serve as knowledge (evidence-based care) translators and mentors to prevent adverse events, provide safer and more timely care, and support fellow nurses practicing at the bedside.1,2,16 The AACN has described several scenarios to demonstrate how tele-ICU nurses can impact care delivery. From supporting direct care nurses at a critical access hospital through the care of a patient in septic shock, to disaster management after a tornado, to coaching a novice nurse through how to prepare chest tubes before transport, tele-ICU nurses can use their knowledge and skills as they practice critical care nursing over a distance.1 However, the number of patients and amount of data present tele-ICU nurses with challenges related to prioritization and communication not typical in a traditional bedside nursing role. A recent study by Kleinpell and colleagues found that barriers to tele-ICU can include technical problems (audio-video), the perception that tele-ICU nurses are interfering with care or interruptive, and negative attitudes of ICU direct care staff (the top barrier).2 The AACN provides continuing-education opportunities and guidelines for practice as well as advanced certification to support nurses as they face these challenges. Implications An appreciation of the role of the tele-ICU nurse and the strategies used to conduct surveillance has implications for both tele-ICU and traditional ICU practice. The structures and processes implemented in either setting that result in positive patient and family outcomes can be optimized if data are shared across settings. Effective strategies for conducting surveillance in the tele-ICU can inform strategies in the traditional ICU setting and vice versa. There is a paucity of research examining the relationship between effective nurse surveillance and patient outcomes. Studies conducted in tele-ICUs suggest that surveillance plays an important role in the identification and prevention of adverse events and in early detection of serious illness.2,17 This is encouraging and should serve as an impetus for future surveillance research in both the tele- and traditional ICU setting.