eNeuroIntensive Care in India: The Need of the Hour
Keywords: eNeuroIntensive care, tele neurointensive care, telehealth and COVID 19, telemedicine and neurosciencesKey Message: With telehealth being accepted by the medical community, providing remote neurocritical care from Tele ICU's is essential.
COVID-19 pandemic has put considerable stress on healthcare systems globally leading to increase in deployment of telehealth. COVID 19 has resulted in reorganization of care teams and expansion of hospital and ICU capacities. With notification of Telemedicine Practice Guidelines, specialists, familiar with neurocritical care, must extend their reach and provide virtual consultations. Telemedicine in Neurosciences has been advocated in India since 2002., Shortage of neurologists and neurosurgeons and travel restrictions makes it difficult to provide acute neurological care. Though, there is a strain on, ICU's there has not been a corresponding increase in growth of eICUs.
Teleintensive care is remote delivery of critical care services deploying augmented audiovisual conferencing technology. In the USA, 11% of nonfederal adult ICU beds are supported with teleICU coverage. Studies indicate that ICU telemedicine interventions reduce mortality and length of stay, with clinical alarms ensuring quick responses. Performance data helps ensure ICU best practices. ICUs are an important component of health care in U.S. hospitals. In 2012, six million of the sickest and oldest were treated. ICUs had the highest mortality and costs, accounting for 4.1% of $2.6 trillion in annual health care spending. TeleICU addresses the problem of increasing number of critical care patients and decreasing critical care physicians. Remote visualization of patient monitors enables clinicians to monitor, consult and care for ICU patients in multiple and distant satellite centers, thus increasing number of ICU patients managed and enabling TeleICUs to extend their productivity and reach. Clinicians at a command center can monitor vital signs and alerts in up to 6–8 monitors located remotely.
COMPACCS (Committee on Manpower for Pulmonary and Critical Care Services) estimates a 35% shortage of ICU specialists by 2030. One physician and four nurses in one command center can assist in overseeing up to 150 patients in distant ICUs. On-site ICU staff are better supported by a remote team in providing immediate management. 24/7 coverage gives a sense of security and confidence in handling complex patient problems. Greater staff satisfaction leads to reduced turnover and burnout rates. Telemedicine in ICU's have been studied for several decades. However, answers regarding costs and benefits are still controversial. Meta analyses of outcomes, mortality, and length of stay show increased survival and quality. This however is context dependent. Critical care is resource intensive and demands meticulous process control. Complexity of ICU support has increased, due to surgical advances and older patients. Remote video visualization of patients, devices, and access to electronic medical records (EMR) helps the tele intensivist. Tele ICU platforms leverage algorithms to scrutinize patient data, combining physiological parameters with clinical risk factors to predict deterioration and provide decision support. Insights afforded by embedded risk-prediction algorithms and push-notification dashboards promotes efficient interventions.
Tele ICU set up
The primary impediment in setting up a new service such as Tele ICU is adequate buy in and acceptance from the remote site. The value must be perceived and seen from a business as well as clinical benefit to the hospital and patients. Any top-down approach will generally not be welcome. A collaborative approach with physical meetings and open lines of communication are ideal. Nonavailability of medical and surgical neurologists, absence of CT and MRI scanners and higher expectations can be challenging. A trained and credentialed healthcare provider is needed at the remote site to implement instructions from the teleICU team in a safe and prompt manner. These obstacles can be overcome through training and modification of standard care pathways to incorporate local culture and workflows.
ICU telemedicine involves nurses and physicians located at a remote command center providing care to patients in multiple, scattered ICUs using computer and telecommunication technology. The command center is equipped with a workstation that has multiple monitors displaying in real-time, patient vital signs, a complete EMR, a clinical decision support tool, a high-resolution radiographic image viewer, and individual teleconferencing facilities for every patient and ICU room. The video system views parameters on ventilator screens, infusion pumps, other bedside equipment, visually assesses patients, and communicates. The tele intensivist can conduct virtual rounds even after inadvertent exposure to COVID-19 has led to provider quarantine. He/she can communicate with on-site caregivers, and be alerted to patient conditions automatically via software-monitored parameters. Videoconferencing is becoming part of “rounding” and consulting services. The specialist does not enter rooms or touch the patient—unheard of in earlier neurological practice, a form of “clinical distancing”.
In most countries, intensivists are based in urban tertiary care hospitals. Hospitals without on-site intensivists may benefit from tele-ICU services. Electronic systems can connect ICU patient data with intensivists at remote locations, as part of a collaborative network. Tele stroke and teleneurologic ICU's facilitate diagnosis and treatment of neurologic emergencies. Tele management of neurologic emergencies can be standardized to improve outcomes. Collaboration with a tertiary care facility with endovascular, neurosurgical, and neurocritical care advanced therapies helps facilitate transfer after stabilization. Protocols overseen through a tele intensivist help provide consistent, standardized care in a dynamic clinical environment. Neurocritical care requires understanding of pathophysiology of complex nervous system. Neurological emergencies such as acute ischemic strokes are time-sensitive requiring specialist diagnosis. Tele stroke management is also cost-effective from a societal and hospital perspective.
Tele Neuro ICU's – benefits
Supplemental, telemedicine-based, remote intensivist program improved clinical outcomes cost-effectively.,, Tele ICU effectiveness should emphasize delivery system and work-process innovations. If a hospital's outcomes are poor with inadequate resources, connecting to an eICU is advised. Availability of additional resources reduces mortality and length of stay. Tele-ICU software alerts, and monitoring by camera, reduces risk of patient falls and extubations rapidly, with 1 million ICU patients tele monitored in the past 10 years in the USA alone. Despite numerous clinical studies, safest ventilatory setting has yet to be established in reducing risk of ventilator-induced lung injury (VILI), impaired cerebral venous drainage, intracranial hypertension, and increased ICP.
Specific uses of Tele Neuro ICU
Access to a remote intensivist with hands-on experience in managing neuro critical cases, enables second opinions, imaging advice, managing stroke, diabetic ketoacidosis, hypertensive emergencies, and tele counselling for anxiety. End of life discussions and allowing natural death conversations are feasible. The treating team and the patients' family can discuss at any time, critical aspects of care. Tele-ICU guidance establishes and maintains best practices through alerts and impactful teachable scenarios. Frontline providers are guided by specialists and intensivists on current COVID-19 care or sepsis. Trainee physicians and nurses get experience, confidence, and practice safely while managing complex illness. Subspecialists can be upskilled outside their domain expertise.
Tele EEG monitoring
Continuous electroencephalogram (CEEG) monitoring is increasingly being used for brain monitoring in neurocritical care setting particularly for diagnosing non-convulsive status epilepticus (NCSE) as a cause of unexplained consciousness. Video EEG monitoring is often done. Analyzing change in EEG patterns over time is important. Remote reading of EEG would be particularly useful. In a COVID-19 patient EEG is to be taken only if the additional information will advance diagnosis or change management. Safety for the technologists is paramount.
Concept of Tele-ICU is evolving and maturing. In India, it is still in a nascent stage facing challenges of location, technology acceptance, language and finances. There are over 10,000 intensive care trained doctors in India who are members of the Indian Society of Critical Care Medicine. Currently, most ICUs in India have one trained intensivist for every 15-20 beds. In an Internet-based survey of 162 Critical Care Consultants in a discussion group, 36.42% stated they have exclusive Neurointensive care units. Prior to 2014, there were only 100 to 125 Neuro ICUs catering to Neurocritical Care patients in India.
In India, there are about 35 dedicated Stroke units, predominantly in the private sector hospitals in cities. Stroke Unit has a multidisciplinary team comprising medical, nursing, physiotherapy, occupational therapy, speech therapy and social work staff. As virtual systems evolve, acute stroke care using standardized clinical evaluation tools like NIH stroke scale, GCS as well as coordination with regional referral centres using neuro interventional techniques is an aspirational goal. Tele ICU enables one to assist distant locations. This results in major savings in travel, time and money for patients, with minimal disruption. This level of access makes tele-neurocritical care ideal for stroke triage when determining the need for thrombolytics or neuro-interventional procedures. As COVID19 continues to impact global health, the use of remote care to prevent, manage and triage stroke is essential. It would be ideal to initiate training programs for doctors, nurses, ASHA workers and the general public. Strokes cause major morbidity and mortality leading to excessive use of personal and healthcare resources. Early intervention by remote detection will be transformational.
The few dedicated Neuro Intensive Care Units in India, are in premier Government institutions and private quaternary care hospitals. Trained neuro intensivists, critical care specialists, Neuroanesthesiologists and interested medical and surgical neurologists staff these units. A dedicated neurocritical care fellowship has been recently started. Neuro Critical Care and Neuroanaesthesiology postdoctoral fellowship programs are now offered by the National Board of Examinations. Private hospitals like Apollo Hospitals are recognized for these programs. Standalone neurosurgical and neuromedical ICUs are uncommon. eNeuro ICU networks are a viable option in India, to manage critical care needs for primary neurological conditions and those secondary to COVID- 19. Sophisticated reliable tele triage can be implemented. A National tele-critical care network could be a game changer. This will allow availability of expert advice and standardization of critical care protocols to percolate throughout the country.
The teleICU system deployed has a dedicated command center with doctors, nurses, technicians and state of the art video communication technology using various off the shelf providers. Remote hospital ICUs in different parts of India are connected through the internet. A limited bandwidth of 2–4 mbps is used with a dedicated leased line. As the facility is physically within a hospital, the information technology resources are easily available to piggyback on existing leased line networks but with dedicated servers. Redundancy with backup connectivity is ensured. Communication occurs through a dedicated EMR system, through phone and WhatsApp based data exchange.
An example of an EMR used for recording critical care information is ICCA (IntelliSpace Critical Care and Anesthesia). It is designed by Philips and is able to record clinical data, lab data, vital signs and images. The presence of alerts assists in triaging priority of responses. The remote telemetry monitor data is fed into the ICCA software. Many remote ICU's connected to the Command Center have ICCA but some do not, due to cost. All radiology images, ECG tracings, lab reports, progress notes can also be shared by email or through WhatsApp. Central cardiac monitoring is duplicated and accessible in the command center for trends. It also presents alerts.
Patient consent, privacy of data and confidentiality are adhered to. Data is backed up in local servers. UPS power systems ensure no loss of connectivity. Standard Protocols for managing various clinical conditions are shared with remote ICU's. Continuing Medical Education Programmes are periodically carried out with remote site doctors and nurses, more in the lockdown period. Alternate video software (Vendors like Vidyo and Cisco) was also used. In an emergency, phone-based video was used. Communicating with bedside teams can be done directly via video but may need phone access if audio clarity or bandwidth is poor. Interactive hands-free voice-activated communication devices have been useful in the ICU.
The Apollo Hospitals backed 'eACCESS' tele-ICU service has remotely managed 3092 patients in 23 ICUs located in different states in India [Figure 1] from Feb 2016 to May 2020. From Nov 2018, the Apollo eACCESS Tele ICU at Hyderabad began providing subspecialty teleconsultations. This included 61 inpatient acute neurology and neurosurgery teleconsultations accounting for 10.8% of 565-subspecialty tele ICU consults.
These patients saved cost, avoided travel, and time away from work and home. Tele-consultations are now being widely adopted due to current travel restrictions. Tele neurology is an important component of tele ICU services at Apollo Hospitals. Emergency critical care advice is provided by critical care specialists, supported by critical care nurses. Ongoing documentation is as per the recommendations of the Telemedicine Practice Guidelines of India. 34 were male and 22 female (average age 50 y, Min 16 y, Max 96 y). 57 requests for teleconsultations were for neurologists and 4 were for neurosurgeons (Five additional consults were provided for the 56 unique patients). [Table 1] gives specific details. The pictogram given after the Table elaborates the Standard Operating Procedure for eNeuro ICU Consults. Some neurological problems were secondary to dementia, peripheral nerve disorders, movement disorders and even sepsis. Patients were generally advised medical management. Patients who had remote neurological consultation were triaged for local care or transferred out. Patients with organophosphate poisoning who developed neurological symptoms were closely watched till symptoms resolved. Post tracheostomy patients were monitored closely. 24 patients could not be followed up as they had been shifted from the designated monitoring beds – a decision by the remote bedside treating team and this was a retrospective analysis. [Figure 2], [Figure 3], [Figure 4] depict Viewing remote Ultrasound and Interacting with Remote ICU from Command Center.
Standard Operating Procedure for eNeuro ICU Consult
COVID-19 and Neurocritical care
Neurocritical care has changed with the arrival of COVID-19. Even dedicated neuro intensivists have to manage non-neurological patients. More than 100 neuro ICUs in China had launched emergency response plans. Many ICU patients infected with COVID-19 also have Parkinsons', Alzheimer's, motor neuron and cerebrovascular diseases. Delirium occurred in early and recovery stage of ICU management. SARS-CoV-2 RNA has been detected in CSF and in brains of patients and experimental animals. Prolonged ICU care, multi-organ involvement and use of muscle relaxants leads to higher risk for development of encephalopathy. ICU survivors often have cognitive impairment, psychiatric and/or physical disability. Neurological complications include seizures, encephalitis, ischemic stroke and intracerebral hemorrhage. Patients with primary neurological diseases requiring ICU admission, have to be managed as usual, independent of COVID-19 infection status. Shift of resources and potential risk of delayed diagnosis and treatment exists in the pandemic situation. Proving causality or coexistence of COVID 19 is often difficult. The tele-ICU solution can triage and manage patients in isolation - conserving Personal Protective Equipment (PPE), avoiding infection and optimizing human resources with constant remote monitoring. Close range telemedicine called 'ePPE' has evolved. Mobile devices are used to communicate with patients who can be physically attended to immediately if needed. Workforce sustainability, burnout reduction and limitation of specialist quarantining are secondary spin-offs of Tele ICU's. Video conferencing helps decrease infection risk during the pandemic. Karnataka was the first state in India to establish a dedicated command unit for critical care support, by linking ICUs of COVID hospitals onto a single platform. The unit is monitored by a centralized team. Cumulative data is monitored and analyzed by experts in real time.
Tele ICU technology will become more affordable and scalable. Today's capital intensive technology with modest dissemination will reach suburban hospitals in Tier II and Tier III cities. With widespread adoption, there is a need to develop a code of best practices. Neuro Tele ICU coverage can be a contract service to hospitals not having a domain expert. Virtual coverage of more beds and more hospitals will lower the per bed operating costs. Scalable and accessible, larger and more diverse coverage patterns can emanate from each monitoring center. Technology has grown exponentially. Remote monitoring today includes adjusting a noninvasive ventilator through the internet.
The precise professional accountability of tele intensivists is still a grey area. However, with the legalization of teleconsultations the standard of care expected would be the same as that in a face to face management. Electronic documentation of every discussion, decision taken and counselling would be the key element. Sharing of vicarious responsibility and the precise liability of the tele consultant when failure of technology leads to a misadventure will be decided only in a test case. Even after The Digital Information Security in Healthcare Act is enacted it would be an interpretation of the law. Perceived possible liability will not be an obstacle as awareness has resulted in sufficient precautions being taken.
Remote neuro intensive care can transform lives. As the nano-sized SARS nCOV-2 virus responsible for the COVID-19 pandemic has shown, humankind adapts quickly. The first author has participated in remote tele critical care consultations for patients 12,000 kilometers away, in rural America, with new stroke symptoms. These patients were physically evaluated in a small emergency room setting, by a physician assistant, assisted by a remote tele radiologist reading the brain CT scan within minutes and triaging to a tele neurologist who decided if administering tPA would help. A tele-emergency room doctor assisted the physician assistant in determining appropriate emergency transfer needs to a higher level of care center while a remote tele-hospitalist reviewed the complex medical history and took care of relevant admission documentation. The post thrombolytic monitoring was performed in the ICU under the supervision of the first author, physically located in another continent. This circle of trust within geographically distributed caregivers ensured the required standard of care. Necessity had made distance meaningless. For a patient remotely located, who is rapidly developing symptoms, which could be arrested or reversed with immediate intervention it makes all the difference. This is particularly so as a completed stroke could be devastating. Technology can be a great equalizer creating a world, we can collectively be proud of living in - caring for underserved populations everywhere, every time when a need arises. Today with the explosion of Information and Communication Technology eNeuro ICU should no longer be the prerogative of the elite. Tele ICU technology ensures democratization. After all Geography has become History!
We thank Lakshmi for secretarial assistance and Pankaj Gautham, Ramesh Rekala and Jagadish Sidagam for assistance in data abstraction and workflow discussion.
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Conflicts of interest
There are no conflicts of interest.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]