crit care nurse 2012 williams 62oip 9

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Published online http://www.cconline.org 2012 American Association of Critical-Care Nurses

doi: 10.4037/ccn2012525 2012;32:62-69Crit Care Nurse

Lisa-Mae Williams, Kenneth E. Hubbard, Olive Daye and Connie BardenTelenursing in the Intensive Care Unit: Transforming Nursing Practice

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by AACN. All rights reserved. 2012 ext. 532. Fax: (949) 362-2049. Copyright101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050,Association of Critical-Care Nurses, published bi-monthly by The InnoVision Group Critical Care Nurse is the official peer-reviewed clinical journal of the American

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delivers support to the bedside healthcare team through collaborationsbetween the tele-ICU nurse and thebedside team.3

Having had an active tele-ICU inour health system for several years,we felt it important to begin todelineate the role and contributionsto care of this developing nursingsubspecialty in our health system.During the period of observation,themes emerged that helped to cat-egorize tele-ICU nursing practice atBaptist Health South Florida inMiami. The purpose of this articleis to describe these tele-ICU nursinginterventions that contributed topatient care within our health sys-tem during the course of 1 year.

The Tele-ICU EnvironmentTele-ICU nurses have been an

integral part of the tele-ICU sinceits inception. Examination of theusefulness of the tele-ICU in improv-ing outcomes for critically ill patientshas demonstrated reductions in ICUmortality,4-8 shorter stays in theICU5-10 and the hospital,5-7,9,10

Lisa-Mae Williams, RN, MSNKenneth E. Hubbard, RN, AAS, CVRN-BCOlive Daye, RN, BSN, CVRN-BCConnie Barden, RN/CNS, MSN, CCRN-E, CCNS

Telenursing in the IntensiveCare Unit: Transforming Nursing Practice

Tele-ICU Enhancements

Telenursing is the use of telecom-munications technology to providenursing care while using informa-tion and data remotely.1 Telemedi-cine is defined as the use of medicalinformation exchanged from onesite to another via electronic com-munications to improve patientshealth status.2 The tele-ICU is thearena where informatics and telecom-munication technology coupled withtelemedicine and telenursing arebrought together to affect the careof critically ill patients. Tele-ICUprovides expert-driven, evidence-based, cutting-edge services to themonitoring and treatment of criti-cally ill patients. In addition, tele-ICU

Nursing practice isconstantly evolvingalong with the tech-nology being used toenhance and delivercare. Teleintensive care unit (tele-ICU) nursing, as an outgrowth ofthe rapidly exploding telemedicineapproach to care, has the potentialto influence the ongoing transfor-mation of nursing practice and sig-nificantly contribute to care. It is adeveloping subspecialty of criticalcare nursing and requires high-level critical thinking and analyti-cal skills.

In teleintensive care units, informatics, telecommunication technology,telenursing, and telemedicine are merged to provide expert, evidence-based, andcutting-edge services to critically ill patients. Telenursing is an emerging subspecialtyin critical care that is neither well documented in the extant literature nor wellunderstood within the profession. Documentation and quantification of telenurs-ing interventions help to clarify the impact of the telenurses role on nursing prac-tice, enhancement of patient care, patient safety, and outcomes. Teleintensive careunit nursing will continue to transform how critical care nursing is practiced byenhancing/leveraging available resources through the use of technology. (CriticalCare Nurse. 2012;32[6]:62-69)

2012 American Association of Critical-Care Nursesdoi: http://dx.doi.org/10.4037/ccn2012525

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increased compliance with evidence-based best practices such as screeningfor sepsis,11,12 improved outcomes incardiopulmonary arrest patients,13

and decreased costs for patient care.8-10

In the tele-ICU, experienced ICUnurses and intensivist physicianshelp to monitor and treat criticallyill patients and provide an additionallayer of safety. Communicationoccurs via audio and video technol-ogy on demand from either the tele-ICU or the bedside so that nursesand physicians can interact immedi-ately. Often remotely located fromthe actual hospital facilities, thetele-ICU has the ability to assessand monitor hundreds of patientsthrough any electronic technique inuse at the patients bedside. Standardmonitoring such as electrocardiog-raphy and hemodynamic values are

maintained continually, and accessto medical records, diagnostic images,and laboratory results is availableat the click of a mouse.

A few reports3,14,15 describe activi-ties and challenges for nurses work-ing in the tele-ICU. One major roleof the tele-ICU nurse is makingrounds via the camera and assessingall patients. Assessments require thesame observation skills and nursingexpertise as used at the bedside16

and include but are not limited tovideo assessment of patients physi-cal appearance; equipment safetycheck; verification of continuousinfusions; and verbal interactionswith patients, their families, andstaff. The frequency of the rounds isdictated by the acuity of the patient,and tele-ICU nurses use a color-codedsystem to categorize their patients

and prioritize their work (Table 1).Aided by alarms that alert the tele-ICU nurse to physiological trends,subtle changes in patients condi-tion can be noted earlier by nursesoverseeing the big-picture view ofmultiple patients. Such surveillancecan avoid reintubation of tenuouspatients and prevent unplanned extu-bations, critical decreases in bloodpressure, dislocation of catheters,and a host of other untoward out-comes that are difficult for bedsidenurses to monitor at every moment.

The tele-ICU nurse also acts as aresource for the bedside nurse, whofinds an experienced colleague witha second set of eyes and ears toobserve the patient and with whomto collaborate as they have instantaccess to the same information asthe bedside nurse via print and elec-tronic resources. They can quicklyretrieve vital pieces of data for theICU nurse in order to save themvaluable time, provide accurate cur-rent information, and potentiallyimprove patient care and safety.17

Tele-ICU nurses can also draft adetailed admission note when a

Lisa-Mae Williams is a nurse manager, Kenneth E. Hubbard and Olive Daye are staffnurses, and Connie Barden is a clinical nurse specialist at Baptist Health South Florida inMiami.

Authors

Corresponding author: Lisa-Mae Williams, RN, MSN, Baptist Health South Florida, 2100 NW 84th Avenue,Miami, FL 33122 (e-mail: [email protected]).

To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected].

Table 1 Color-coded acuity system used to categorize patients on the basis of physiological criteria, therapeutic measurescurrently in use, and safety concernsa

Acuity status

Red

Yellow

Green

Sample physiological criteria

New admission

patient arrives in the unit so thatcomplete information about a patientis available promptly to all careproviders in the electronic medicalrecord. Other aspects of the tele-ICUnurses role may include ensuringthat best practices are adhered to, forexample, prophylaxis of venothro-moembolism/stress ulcer, follow-upon new laboratory values, andresponding to questions and requestsfrom bedside staff. Unique activitiessuch as watching over a bedsidenurses second patient while thatnurse transports a patient off theunit to diagnostic tests supports thesafety of patients and decreases theworkload of everyone at the bedside.

In this environment, the inten-sivists role is described as providingcontinuous vigilance, early inter-vention, and ongoing care as dele-gated by the attending physiciansupporting the patient care plan anddecreasing ICU-related morbidityand mortality.18 In addition to per-forming tasks related to patientmanagement such as prescribingtests and medications for criticallyill patients, teleintensivists intervenein emergency situations when apatients condition deteriorates,requiring immediate clinical atten-tion. At times teleintensivists mayeducate bedside novice physiciansand nurses by walking them throughunfamiliar procedures such as emer-gent cardioversion of an unstable,symptomatic patient or a host ofother urgent interventions.19 Telein-tensivists also provide consultativecomanagement of critically illpatients as well as recognition ofchanges in patients trends, diag-noses, and intervention for patientsneeds often resulting in improvedoutcomes for patients.20

Leveraging ICU ResourcesThe application of the sophisti-

cated monitoring and interventioncapabilities of a fully functional tele-ICU holds promise as 1 method forbroadening the reach and enhancingthe ability of the bedside care teamto meet the needs of sicker patients.According to the Leapfrog Groupa national program focused on cre-ating giant leaps in health carequality and safetythe quality ofcare in hospital ICUs is stronglyinfluenced by whether intensivistsare providing care. . . . The Leapfrogstandard for ICU physician staffing4

calls for the presence of intensivistswho provide clinical care exclusivelyin the ICU during daytime hours.The standard acknowledges thatteleintensivist coverage togetherwith some on-site intensivist pres-ence can help to meet this recom-mendation. In our system, in 2007,only 1 hospital had round-the-clock intensivist coverage. The tele-ICU was therefore able to provideaccess to critical care physicians andnurses, 24/7, to the other hospitalsthat did not have critical care physi-cian coverage.

Assessing the Tele-ICU Nurses Contributions to Care

Baptist Health South Florida is a5-hospital, 1500-bed health care sys-tem based in Miami, Florida. BaptistHealth began using tele-ICU tech-nology in 2005, and since mid-2007it has been part of the standard ofcare for critically ill patients in all 5hospitals. The tele-ICU nurses atBaptist Health have an average of 15years of critical care nursing experi-ence and are chosen to work in thetele-ICU because of the depth and

breadth of their knowledge, theirextensive expertise in the care ofcritically ill patients, and theirproven skills in communicationand collaboration.

From September 1, 2008,through August 31, 2009, nursinginterventions made by tele-ICUnurses at Baptist Health were self-reported or documented by nurseswho observed colleagues makingthem. Actions reported were thosethat, in the opinion of the tele-ICUnurse, resulted in changes in carefor patients and/or assisted bedsidenurses in their work with patients.Tele-ICU nurses were asked to sendaccounts of their interventions viae-mail or handwritten notes as theyoccurred with enough text to describethe event. Reports of these interven-tions were then communicated toand collected by the clinical nursespecialist of the tele-ICU. A smallgroup of tele-ICU nurses thenreviewed and categorized the typesof interventions described by thestaff. Interventions were thensorted into 1 of the following 4 cate-gories: rescue, assist, prevention, orconsultation (Figure 1). Workingdefinitions of these categories aredescribed in Table 2.

Tele-ICU Nursing Interventions: The Results

Five hundred ninety-four nurs-ing interventions were documentedand categorized during the year ofthe project. Of the interventionscollected and categorized, 477(80%) were independent nursinginterventions where assistance,brainstorming, and overall collabo-ration took place solely betweenthe bedside nurse and the tele-ICUnurse. The remaining activities


were interde-pendent, usuallyinvolving theintensivistphysician ortelepharmacistin collaborationwith the tele-ICU nurse.

Thirty-six(6%) interven-tions werecoded as rescueinterventions.Another 116interventions(20%) werecoded in theprevention cate-gory, and all ofthese interven-tionsrescueand prevention

(n=152 or 26%) when combinedwere described as affecting patientsafety. Included in this number were42 falls, 16 accidental catheter dis-placements, and 11 intubations thatwere avoided by the direct interven-tion of the tele-ICU nurses (Figure 2).

Assists and consultations, whencombined, were those interventionsdescribed as enhancing nursingpractice (Figure 3). A total of 302assists (51%) and 140 consultations(24%) were reported during the yearof this project.

DiscussionIn 2008, Stafford and colleagues3

published an ethnographic studydescribing the tele-ICU environmentand the experiences of those workingin that environment. In that report,the experience of the tele-ICU nursemanager in describing the value of

Figure 1 Documented teleintensive care unit (tele-ICU) nurseinterventions from September 2008 to August 2009 (N=594).Rescue indicates patient in trouble, immediate action required;assistance indicates that interventions were made that were ini-tiated by the tele-ICU nurse; prevention indicates interventionsthat most likely prevented occurrences such as falls, unplannedextubation, and allergic reactions; consultation indicates inter-ventions such as troubleshooting equipment, thinking together,educating or coaching bedside staff, and answering questionsand requests initiated by the bedside team.

Rescue AssistPrevention Consultation

Table 2 Definition and examples of teleintensive care unit (tele-ICU) nursing interventions that affect safety and nursingpractice

Type

SafetyRescue

Prevention

Nursing practiceAssist

Consultation

Definition

Patient in trouble who needs immediate actionInterventions that helped to avoid imminent

deterioration of patients condition

Interventions that most likely prevented occurrences

Interventions initiated by the tele-ICU nurse

Interventions initiated by the bedside nurse

Examples

Avoid codesAvoid intubationIdentify critically low blood pressureIdentify rapidly declining oxygen saturation

Avoid fallsAvoid unplanned extubationAvoid unplanned removal of cathetersAvoid abnormal blood pressures and oxygenationCorrect inaccurate information in patients electronic

medical recordCollaborate about results of laboratory tests or radiographic

findings that were pertinent to patients condition

Bring allergy discrepancies to attention of bedside nursesObtain laboratory and disgnostic test results for bedside nursesConfirm findings from physical examination with bedside nurseBring arrhythmias to attention of bedside nursesSuggest evidence-based treatment for stress ulcer prevention,

deep venous thrombosis, electrolyte replacement, and glucosecontrol

Troubleshoot equipmentBrainstorm with bedside staffCoach/educate bedside staffAnswer questions and other requests initiated by bedside team

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the service to the organizationincluded, I quickly evaluated thatthe true value in this service was allof the interventions that are happen-ing by these fabulous nurses in the[tele]-ICU unit.3 The manager wenton to explain the power of this infor-mation in demonstrating the value

of the tele-ICU and in garneringadministrative support for its val-ued place as part of the model of care.

Similarly, in 2008, Myers andReed15 described tele-ICU nurseinterventions that prevented errorsand complications, thus improvingquality and safety. Although the

authors pointed out that the tele-ICU nurse is not meant to replacethe bedside nurse, they describedthat the actions of the tele-ICUnurse in monitoring and vigilanceimproved processes and outcomesproduced in their health system.The authors noted not only the tele-ICU nurses role in safety and qual-ity, but also their unique position toserve as consultant, collaborator,and colleague to ensure adherenceto best practice as major compo-nents of the role that contribute tocare improvement.

In our system, we similarlyfound that actions performed bytele-ICU nurses fell into 1 of 2broad categories: affecting patientsafety or enhancing nursing prac-tice. The smallest group of interven-tions we recorded were actionscategorized as rescue, where therewas imminent danger to patients.Only 6% of our interventions werein this category. It is not knownfrom the literature what an expectedbenchmark for this type of inter-vention by tele-ICU nurses should

Figure 2 Teleintensive care unit nursing interventions that affect safety.

50

40

30

20

10

0

No. o

f int

erve

ntio

ns

Type of intervention

Falls Blood pressure, oxygen saturation

Prevention Rescue

Medication, allergy

Catheter displacement

Avoid code

Avoid deterioration

Avoid intubation

Patient identification

Figure 3 Teleintensive care unit nursing interventions that enhance nursing practice.

140

120

100

80

60

40

20

0

No. o

f int

erve

ntio

ns

Type of intervention

Facilitation of care

Coach/think together

Expedite treatment

Best practices

Documentation

Assist Consultation


be, but it could certainly serve asan indicator used collaborativelybetween the tele-ICU and ICU teamsas a barometer for safety challengesat the bedside. For example, if agiven unit had a baseline of 10% ofrescue interventions by the tele-ICUand this number suddenly jumpedto 30% or 40%, these data might serveas the starting point for fruitful dis-cussions about changes in the careenvironment that might be contribut-ing to the increase in potentiallydangerous situations for patients.

Stafford et al3 discussed the chal-lenges of quantifying cost-avoidanceusing the tele-ICU. Indeed document-ing the exact value of preventingharm and avoiding complications isfraught with uncertainty. The inter-ventions in this category were thosethat even though danger may nothave been imminent, without inter-vention the situations were verylikely to have led to negative out-comes for the patients (see Sidebar).Examples of preventions include aconfused patient with his handpulling the dressing away from the

entry site of the central venouscatheter, a patient with an allergy toaspirin ordered to receive an aspirin-containing analgesic, and patientsfound climbing out of bed whenbedside staff were occupied outsideof the room. In our opinion, inter-rupting these potentially dangerousscenes that could otherwise havegone unnoticed in the midst of abusy critical care unit elevates thelevel of care and safety that is deliv-ered to patients.

We found that most of the tele-ICU nurse interventions occurredin the broad category that enhancednursing practice. Depending on thelocation from which the interven-tion was initiated, we coded theseactions as either assists or consul-tations. The largest groupassistswere initiated by thetele-ICU nurse and then acted onby the bedside team, the tele-ICUteam, or both. Goran17 describesthe concept of tele-ICU practice asincluding a second set of eyes notto control or intrude, but to sup-port or enhance current care.Experienced nurses working in thetele-ICU, free from the often unpre-dictable situations and expectationsof patients, families, colleagues,and other departments, have theopportunity to assess patientsfindings in an environment thatlends itself to careful analysis. Sup-porting colleagues at the bedsidewho may not have this opportunitycreates a team with a built-in dou-ble check on patients safety andwell-being. To use James Reasonswell-known analogy for preventingharm in complex systems,21 fewermishaps are likely to slip throughthe holes in the Swiss cheese andcause harm in such a system.

The category of interventionslabeled as consultation hold particu-lar promise for supporting care andcolleagues at the bedside. Consulta-tions, which were initiated by bed-side nurses seeking information orsupport, represent an opportunityfor nurses to gain help from aknowledgeable colleague whose jobit is to support their practice. In thetightly staffed and very busy envi-ronment of most critical care units,this opportunity is often not avail-able between bedside nurses. Uniqueactivities such as the tele-ICU watch-ing over a bedside nurses patientswhile that nurse responds to anemergency also support the safetyof patients and decrease the work-load of everyone at the bedside.

Some tele-ICUs have producedoutstanding results by creating for-mal telementoring programs fornurses new to critical care. In theseenvironments, inexperienced nurseswho have completed orientation arethen paired with an experiencedtele-ICU nurse who connects with,coaches, and mentors the newcomeruntil the nurse feels confident to func-tion totally independently (WendyDeibert, RN, personal communica-tion, May 2011). Although just inthe beginning stages of development,such creative and proactive programshold promise as a true opportunityto support our young and create ahumane environment for all.

Despite the described advantagesof the partnership between the tele-ICU and bedside staff, these rela-tionships do not develop effortlessly,automatically, or perfectly. Using atelecommunication tool is new andchallenging, and a level of trust mustbe developed and sustained betweenthe tele-ICU and the bedside staff in

Sidebar: Preventing a FallFrom 30 Miles Away

A tele-ICU nurse checks thecamera view in a patients roomafter noticing a change on themonitor and sees a patient outof bed, appearing unsteady. Thetele-ICU nurse calmly speaks tothe patient and quickly realizesthat he is confused and disori-ented. The tele-ICU nurse callsthe bedside staff to alert them ofthe patients situation. The bed-side team quickly arrives at thepatients side, reorients him, andreturns him to bed.


the absence of face-to-face commu-nication. With many never havingmet, bedside and tele-ICU nursesmust build relationships in this newpractice model. In addition, thechallenges of technologyovercom-ing inevitable equipment malfunc-tion, network downtimes, or softwareupgradeshave given staff theopportunity to fine tune their col-laboration and communication skillsfurther. This fine tuning requires aconsistent effort to build andstrengthen relationships and to berelentless in pursuing and fosteringtrue collaboration.22

The study of tele-ICU nursingand its impact is in its infancy. Moreinformation is needed not only tofurther delineate the contributionsthat tele-ICU nurses make, but toalso outline methods to enhance theacceptance and full utility of thisnew approach to care. This projectwas designed to look, from the tele-ICU side of practice, at the interven-tions reported by tele-ICU nurses.It was not our intention to investi-gate tele-ICU contributions to carefrom the bedside nurses perspec-tive. The views of bedside nurses,however, are critical and should bethe subject of future studies relatedto the impact of this model. Usingtechnology for this purpose hasinherent challenges, and futurestudies should be undertaken todelineate these issues and definebest practices in implementation.

Although both the literature andcommon sense mandate that anappropriate number of skilled and

qualified nurses must be present ona unit at any given time, ground-breaking alternatives to how thesenurses work gets accomplished arejust in their infancy of exploration,23-26

and the tele-ICU is one of thosealternatives.

ConclusionSafety, cost avoidance, and

patients outcomes are beingimproved in our health system bythese interventions. As technologybecomes more integrated into patientcare, the significance of tele-ICUsand tele-ICU nursing will mostlikely become more apparent. Tele-ICU nursing has the potential to addto the tools available to the criticalcare team by altering how the care ofthe most critical and vulnerablepatients in the system is delivered.Although the role of the bedside care-giver can never be replaced or dimin-ished, it can certainly be augmented,enhanced, and facilitated. The key tothe long-term success is the contin-ued consistent collaboration betweenthe bedside team and the tele-ICUnurses, which can transform howcritical care nursing is practiced. CCN

Acknowledgments We thank our colleagues Rosemary Lee, DNP, RN-CNS,ACNP-BC, CCRN, CCNS, and Donna Lee Wilson, RN, MSN,CCRN, for their expert review and assistance in thepreparation of this article. We also acknowledgethe outstanding work of the nurses in the BaptistHealth South Florida e-ICU, whose dedicationand hard work created the outcomes described.

Financial DisclosuresNone reported.

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Correction

In the December 2012 article by Williams et al, Telenursingin the Intensive Care Unit: Transforming Nursing Practice (Crit Care Nurse. 2012;32[6]:62-69), there was an error in thecolor key in Figure 1. The figure, with correct colors representedin the key, is shown here.

Figure 1 Documented teleintensive care unit (tele-ICU) nurseinterventions from September 2008 to August 2009 (N=594).Rescue indicates patient in trouble, immediate action required;assistance indicates that interventions were made that were ini-tiated by the tele-ICU nurse; prevention indicates interventionsthat most likely prevented occurrences such as falls, unplannedextubation, and allergic reactions; consultation indicates inter-ventions such as troubleshooting equipment, thinking together,educating or coaching bedside staff, and answering questionsand requests initiated by the bedside team.

Rescue AssistPrevention Consultation

36(6%)

302(51%)116

(19%)

140(24%)

crit care nurse 2012 williams 62oip 9

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