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Table of Contents
Year : 2022  |  Volume : 8  |  Issue : 1  |  Page : 2-4

Remote critical care: We ought to make it work

Department of Critical Care Integration and Transformation, Apollo Hospitals Enterprise Limited, Chennai, Tamil Nadu, India

Date of Submission16-Jun-2022
Date of Decision01-Jul-2022
Date of Acceptance04-Jul-2022
Date of Web Publication21-Jul-2022

Correspondence Address:
Ravi P Mahajan
Director of Critical Care Integration and Transformation, Apollo Hospital, Greams Road, Chennai, Tamil Nadu 600006
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2773-1987.351577

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How to cite this article:
Mahajan RP. Remote critical care: We ought to make it work. Santosh Univ J Health Sci 2022;8:2-4

How to cite this URL:
Mahajan RP. Remote critical care: We ought to make it work. Santosh Univ J Health Sci [serial online] 2022 [cited 2022 Dec 8];8:2-4. Available from: http://www.sujhs.org/text.asp?2022/8/1/2/351577

According to published figures,[1],[2],[3],[4],[5],[6] India has only 0.55 government hospital beds available per 1000 population and approximately 70,000 intensive care unit (ICU) beds in total. In addition, these facilities are distributed unevenly in different geographical areas; Tier 1 and Tier 2 cities have most ICU beds concentrated, with very little available to large populations beyond these cities. The total number of doctors trained in critical care is also woefully short of what is required to run a safe and effective critical care service.

The implications of these gross shortages in resources mean that large parts of the country remain without access to critical care services. The situation is further made worse during disasters, such as the coronavirus disease-2019 pandemic.

In addition, the critical care services that are available tend to be variable in their scope, resources, and outcomes. This is due to the following reasons.

  • The different kinds of health-care facilities exist that range from private small clinics and nursing homes to remote district hospitals, teaching hospitals, or super-specialty state-of-the-art hospitals
  • These facilities have large variations in the way critical care may be provided to a patient, depending upon available expertise, staffing, equipment, space, supplies, and systems
  • The service model remains largely “centralized,” hence inaccessible to large population in remote areas
  • There is an overall shortage of health-care expertise in critical care.

  What is Remote Critical Care? Top

The principles of telemedicine have been applied in various different forms to create tele-ICUs in different countries. Different terms, such as “tele-ICU,” “virtual ICU,” and “remote ICU” have been used to describe similar critical care models; a remote critical care team is digitally networked with the bedside ICU team and patient. Using digitally-enabled audio-visual communication and computer systems, a seamless flow of information, knowledge, and advice is engineered for an integrated system.

The framework is based on a hub-and-spoke model. There can be a number of hubs with variable hub: spokes ratios in different locations [Figure 1] and [Figure 2].
Figure 1: Hub-and-spoke model, where on hub (center of excellence) can be digitally connected to a number of spokes (remote locations)

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Figure 2: Seamless two-way flow of patient data from the spoke to the hub and care plan instructions from the hub to the spoke

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Using hub-and-spoke model, a seamless flow, to and from the hub, of the following can be provided

  • Monitoring and information
  • Triggers for escalation or de-escalation
  • Referrals and advice
  • Transfer of care between the connected centers.

The precise model for the integrated system depends upon several factors; these include the number and location of patients requiring services, existing facilities requiring to be networked, bedside resources including staffing, technology, and expertise as well as contractual arrangements. The models can broadly be of the following three types, although they are not mutually exclusive.

Continuous care model

The patient is monitored continuously without interruption for a defined period (8-, 12-, or 24-h basis).

Scheduled care model

A periodic consultation would occur on a predetermined schedule (e.g., during patient rounds).

Reactive care model

Virtual visits would be prompted by a trigger and an alert; these visits are usually unscheduled.

  Remote Critical Care as Part of Solution to the Shortages and Lack of Access Top

In addition to making critical care accessible to many more people than currently possible, this model also has potential to have a very important population health impact in the following ways.

  • Early detection of worsening illness and prompt intervention[7],[8]
  • Compliance with best practices[9],[10],[11],[12]
  • Reduced preventable complications and mortality[13],[14]
  • Reduced length of stay in critical care and increased number of patients discharged directly to the home.[8],[10]

Although data are lacking, one can expect the following outcomes due to the above

  • Better chances of early return to normal life, employability, and overall patient satisfaction
  • Better capacity utilization of health-care facilities
  • Improvement in remote critical care expertise and facilities by peer support and advice
  • Overall improvement in quality of critical care services
  • Reducing the stress and burden on families, patients, and caregivers
  • Enabling the health system to become a provider of choice
  • Expanding a health system's reach and market share because they can offer ICU services in rural/less accessible areas.

Remote critical care also makes economic sense. Despite significant investment in the proposed system, based on the published evidence, a rapid return on investment can be expected due to increased capacity, better efficiency, throughput, improved documentation, and improved accuracy in billing. One of the reports has shown a 30% increase in both the average monthly profee billing charge and the annualized billing.[15]

Several analyses of the economic efficiency of bedside and remote teams working through a single electronic tele-ICU, as well as simulation analysis have projected significant cost savings and concluded that the technology is highly likely to be cost-effective compared to other health interventions.[16]

Yoo's 2018 study provides additional evidence that tele-ICU's economic efficiency for high-risk patients held true across most hospital types. It was highest for the hospitals that had high mortality rates and per-patient costs.[17]

In 2016, Lilly et al. showed that an initial $7.2M outlay for electronic infrastructure, bedside monitors, physical plant upgrades, and plus new audio-visual (AV) equipment, was recouped in <3 months due to a $31M increase in the annual direct contribution margin.[18]

  Conclusion Top

There is little doubt that remote critical care, using various forms of digital connectivity, offers real opportunity to save lives in a challenging landscape as in India. Outside India, the practice of remote critical care electronic intensive care unit (E-ICU) has grown in different parts of the world as part of a solution to many local issues such as staff shortages, lack of specialists in the area, and travel distance to reach ICU facilities. After the experience during the surges in pandemic and further growth in IT potential, it is now clear that remote critical care will grow even in those countries who until now thought that it was not for them.

It is heartening to see some green shoots both in public and private sectors embracing the concept of remote critical care in India. It is now for us, the professionals to lead the agenda. The critical care community needs to start a meaningful conversation in this area. It will be important to develop some generic standards of practice alongside training requirements, medicolegal aspects, safety considerations, quality indicators, and quality assurance.

Remote critical care requires significant paradigm shift in the way we, the society, look after our critically ill patients. It is now time for a combined big effort by all stakeholders including government agencies, regional leaders, professional organizations, government and private health-care providers, IT engineers, and innovators to turn this initiative into a routine reality. This will be a “win” “win” for all concerned, the government, health-care providers, and most importantly a vast majority of critically ill patients who, at present, are unable to access critical care.

  References Top

COVID-19 | Is India's Health Infrastructure Equipped to Handle an Epidemic? Available from: https://www.brookings.edu/blog/up-front/2020/03/24/is-indias-health-infrastructure-equipped-to-handle-an-epidemic/. [Last accessed on 2020 Apr 11].  Back to cited text no. 1
Jayaram R, Ramakrishnan N. Cost of intensive care in India. Indian J Crit Care Med 2008;12:55-61.  Back to cited text no. 2
[PUBMED]  [Full text]  
India's Doctor-Patient Ratio Still Behind WHO-Prescribed 1:1,000: Govt | Business Standard News. Available from: https://www.business-standard.com/article/pti-stories/doctor-patient-ratio-in-india- less-than-who-prescribed-norm-of-1-1000-govt-119111901421_1.html. [Last accessed on 2020 Apr 11].  Back to cited text no. 3
About ISCCM. Available from: https://isccm.org/. [Last accessed on 2020 Apr 11].  Back to cited text no. 4
Nurses and Midwives (Per 1,000 People) – India | Data. Available from: https://data.worldbank.org/indicator/SH.MED.NUMW.P3?locations=IN. [Last accessed on 2020 Apr 11].  Back to cited text no. 5
Kartik M, Gopal PB, Amte R. Quality indicators compliance survey in Indian Intensive Care Units. Indian J Crit Care Med 2017;21:187-91.  Back to cited text no. 6
[PUBMED]  [Full text]  
Venkataraman R, Ramakrishnan N. Outcomes related to telemedicine in the Intensive Care Unit: What we know and would like to know. Crit Care Clin 2015;31:225-37.  Back to cited text no. 7
Lilly CM, McLaughlin JM, Zhao H, Baker SP, Cody S, Irwin RS, et al. A multicenter study of ICU telemedicine reengineering of adult critical care. Chest 2014;145:500-7.  Back to cited text no. 8
Youn BA. ICU process improvement: Using telemedicine to enhance compliance and documentation for the ventilator bundle. Chest 2006;130:226S.  Back to cited text no. 9
Lilly CM, Cody S, Zhao H, Landry K, Baker SP, McIlwaine J, et al. Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes. JAMA 2011;305:2175-83.  Back to cited text no. 10
Patel B, Kao L, Young EC. Improving compliance with surviving sepsis campaign guidelines via remote electronic ICI monitoring. Crit Care Med 2007;32:A275.  Back to cited text no. 11
Kalb T, Raikhelkar J, Meyer S, Ntimba F, Thuli J, Gorman MJ, et al. A multicenter population-based effectiveness study of teleintensive care unit-directed ventilator rounds demonstrating improved adherence to a protective lung strategy, decreased ventilator duration, and decreased Intensive Care Unit mortality. J Crit Care 2014;29:691.e7-14.  Back to cited text no. 12
Fusaro MV, Becker C, Scurlock C. Evaluating Tele-ICU implementation based on observed and predicted ICU mortality: A systematic review and meta-analysis. Crit Care Med 2019;47:501-7.  Back to cited text no. 13
Wilcox ME, Adhikari NK. The effect of telemedicine in critically ill patients: Systematic review and meta-analysis. Crit Care 2012;16:R127.  Back to cited text no. 14
Hine JJ. The effect of instituting an ICU electronic medical record on professional fee billing. Crit Care Med 2006;34:A21.  Back to cited text no. 15
Yoo BK, Kim M, Sasaki T, Melnikow J, Marcin JP. Economic evaluation of telemedicine for patients in ICUs. Crit Care Med 2016;44:265-74.  Back to cited text no. 16
Yoo BK, Kim M, Sasaki T, Hoch JS, Marcin JP. Selected use of telemedicine in Intensive Care Units based on severity of illness improves cost-effectiveness. Telemed J E Health 2018;24:21-36.  Back to cited text no. 17
Lilly CM, Motzkus C, Rincon T, Cody SE, Landry K, Irwin RS. “ICU Telemedicine Program Financial Outcomes.” – Pubmed – NCBI; February, 2017. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27932050. [Last accessed on 2018 Feb 05].  Back to cited text no. 18


  [Figure 1], [Figure 2]


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