Telemedicine helps rural hospitals meet intensivist shortage

Nearly three years ago, Valley Health—a regional health system based in rural Virginia—was struggling to recruit critical-care physicians for its flagship hospital and referral center.

That’s reflective of a nationwide problem, with just half of acute-care hospitals with intensive-care beds boasting intensivist coverage, according to a recent assessment by the Society of Critical Care Medicine’s education committees. That shortage of critical-care physicians will likely increase in the coming years, with demand for those services projected to grow as the U.S. population ages.

Recruiting specialists is particularly challenging in rural areas, Valley Health found.

“We were faced with a demand for intensivist services and a slow and challenging rate of recruitment of physicians,” said Dr. T. Glen Bouder, medical director of critical care at the system’s flagship Winchester (Va.) Medical Center. That put a strain on the hospital’s limited ICU staff, particularly during night shifts. Staff often had to allocate their attention toward admissions and “putting out fires” in the ICU, rather than actively managing the other beds and preparing patients for discharge as soon as possible, Bouder said.

So in 2017 the hospital decided to contract with a clinical services provider focused on remote critical care, to help monitor patients.

Winchester Medical Center now has just a single intensivist on-site at night, who’s charged with overseeing any admissions, emergencies or procedures. Otherwise, an off-site care team from the company Advanced ICU Care remotely manages patients via video and audio equipment. The team, which is led by an intensivist and includes nurses and respiratory therapists, also has access to the hospital’s electronic health record system and electronic feeds of patients’ physiological data.

“Now we have active management of the patients (at night) on top of the usual care that we’re providing during the day,” Bouder said.

In Winchester Medical Center’s first year using teleICU services, the hospital reduced its ICU mortality rate by 32% compared with outcomes predicted by the version of the Acute Physiology and Chronic Health Evaluation it uses, known as APACHE IVa. The hospital reduced its ICU length of stay by 34%.

It also saved costs, since without tele-ICU, the hospital would have had to continue to try to recruit three to four more intensivists for night shifts.

That’s one of the core benefits of telemedicine services, said Rick Kes, healthcare senior analyst at audit and consulting firm RSM.

“The benefit at the very highest level with any virtual health, including telemonitoring of ICUs, is the scale (the virtual platform) can provide the services at,” he said. “Hopefully, with scale, it drives down the cost.”

Advanced ICU Care charges customers on a per-bed or per-patient basis. That cost includes telemedicine equipment and access to the company’s physicians and nurses, who are stationed at off-site operations centers. Advanced ICU’s clinical staff is licensed in the roughly 30 states the company has customers, as well as credentialed at each facility where they monitor patients.

Some health systems use their own staff to offer teleICU services to other facilities in their network.

That’s more likely to be the case for larger health systems that span a wide region, while it’s often more convenient for small and midsized systems to contract with third-party vendors, Kes said.

Since 2013, Dignity Health, now part of CommonSpirit Health, has used telemedicine equipment from InTouch Health to connect critical-care specialists at its larger hospitals with patients at its smaller rural facilities.

Before implementing teleICU services, Dignity often had to transfer rural patients in need of critical-care services to one of its tertiary facilities. “What we recognized pretty early on was that some of those conditions could have easily been managed at their sites with just the assistance of a specialist,” said Denise Pimintel, nurse coordinator for Dignity Health Telemedicine Network’s intensive-care and outpatient clinic service lines.

Dignity now prioritizes keeping ICU patients at their local hospitals, with remote specialists working with on-site hospitalists, respiratory therapists, emergency room physicians, surgeons and other clinicians as needed to manage their care. If a patient does have to be transferred for a specialized procedure, they’ll be brought back to their local facility soon afterward.

Since the teleICU program’s mission is to bring specialists to areas where they weren’t before, it’s difficult to quantify cost savings. But it does help smaller hospitals get coverage for their ICUs without having to recruit full-time staff, according to Pimintel. “We come in to an area that doesn’t have specialists,” she said.