Tuesday July 23rd 2019

Back to the future?

Telehealth services, tele-nursing are on the rise

Leigh Ann Chandler Poole (left) and her students use telehealth to reach rural residents.

Routinely assessing subtleties in a patient’s condition and offering spot-on interventions from afar may once have seemed more like science fiction than reality.

But telehealth — or technology-enabled care — has now been around for a few decades. In some instances, telehealth involves answering patients’ emails or making post-discharge, follow-up calls to those who may be living in another state. In other instances, it encompasses providing critical care to patients in rural hospitals or monitoring others with chronic conditions from their homes using an array of advanced technology.

Whatever the case, telehealth will only continue to grow, especially as technology becomes more sophisticated, accessible, affordable — and accepted — by patients, providers and policymakers.

Industry experts with the American Telemedicine Association estimate that within the next five years, 50 percent of health care services will be provided by telehealth, said Leigh Ann Chandler Poole, PhD, RN, FNP-BC, CRNP, an assistant professor at The University of Alabama Capstone College of Nursing and telehealth expert.

“And the new technology that is out there is going to change the face and practice of health care,” said Poole, an Alabama State Nurses Association member. Tricorders (as in “Star Trek”), DNA virtualization, medication-delivering nanotechnology, wearable technology, sensors, gaming and avatar use will all be part of the health care mix.

That said, as it is practiced now, telehealth already is improving patients’ access to care and health outcomes.

Inside the tele-ICU

A tele-ICU is just one type of telehealth, and it is defined by the American Association of Critical-Care Nurses (AACN), an organizational affiliate of the American Nurses Association, as “Networks of audiovisual communication and computer systems that link critical care physicians (intensivists) and nurses to ICUs in other, remote hospitals.”

Around since the 1990s, tele-ICU services began as models that connected onsite health care providers with off-site consultants to discuss patient care, according to the AACN Tele-ICU Nursing Practice Guidelines.

Now tele-ICUs use cutting-edge technology and are far more comprehensive. Further, tele-ICU nursing has become its own subspecialty, prompting AACN to develop guidelines around its practice. AACN’s Certification Corporation also offers nurses working in tele-ICUs a certification exam, resulting in the CCRN-E credential.

Theresa Davis

Theresa Davis, PhD, RN, NE-BC, clinical operations director of enVision eICU, Inova Health System in Virginia and co-chair of the task force that created the AACN guidelines, offered an inside look at how certain tele-ICUs — or virtual ICUs — operate.

Tele-ICU nurses and physicians generally work 12-hour shifts, and each nurse typically oversees 35 to 45 patients, although that number may vary among tele-ICUs. From an offsite location, clinicians conduct proactive rounds using highly sensitive cameras capable of assessing physical elements such as pupillary response and labored respirations. Using evidence-based practice principles, eRNs assess patients for the presence of early preventive measures such as DVT and stress ulcer prophylaxis to reduce ICU complications. They also screen patients for signs of sepsis so that early interventions can be implemented, said Davis, who is also a Virginia Nurses Association member. This rounding serves as an important backup for bedside nurses and physicians who may be busy attending to other patients. The tele-ICU provides an extra level of support to novice nurses in particular.

“For example, if a bedside nurse is taking care of Mr. Jones, and a tele-ICU nurse observes that Mr. Smith in the room next door has become agitated, is pulling on lines and has one leg half out of the bed, he or she can quickly call the ICU and let them know Mr. Smith needs attention right away,” said Connie Barden, MSN, RN, CCRN-E, CCNS, co-chair of the tele-ICU nursing guidelines task force, former director of telehealth initiatives at Baptist Health South Florida and currently AACN’s chief clinical officer. Barden also is an AACN past president.

Through these complex technology systems, tele-ICU nurses also can access patients’ electronic health records and medication lists, assess ventilator settings, and of course, alert staff when urgent actions are needed, according to Davis. Tele-ICU staff, whose services are available around the clock, are available for immediate and ongoing consults.

Connie Barden

“Since tele-ICUs began, we have been working to constantly raise the bar for safety and quality,” Barden said. “What I love about this technology is that it provides a team of highly experienced health care professionals who’ve got the backs of their colleagues at the bedside. Tele-ICU nurses and intensivists are not running around from one patient to the next, but have the time to observe what’s going on with several patients from that 30,000-foot view.”

Barden said that data exist showing the benefits of tele-ICUs. She pointed to statistics from Baptist Health’s tele-ICU services, which in one year alone prevented 160 falls from occurring throughout the health care system. Tele-ICU staff also alerted bedside staff 110 times around other safety issues, including patients trying to pull out their endotracheal tubes.

These interventions lead to reduced patient mortality and shorter length of stay, and translate to increased cost savings for the hospital, according to Barden.

And while the technology is amazing, Davis stressed that it really is about the people. Tele-ICU nurses are accomplished in critical care and technology, and they have highly developed critical thinking skills. Because of their past and ongoing experience with ICU patient populations, they can identify emerging complications sooner and share the best, evidence-based ways to troubleshoot those complications with bedside staff.

“Tele-ICU nurses also have to be highly qualified and diplomatic,” Davis said. “Not only does their knowledge have to at least match that of bedside nurses’, but they have to be able to build professional relationships through which team members at the bedside develop trust and confidence that the tele-ICU team is there to support them and their patients.”

Although some health care professionals and leaders are still reluctant to embrace the technology, Davis and Barden believe that tele-ICU services will indeed expand, which means that more tele-ICU nurses will be needed.

Keeping people healthier, out of the hospital

The AACN Tele-ICU Nursing Practice Guidelines includes factors that are integral to making tele-nursing and telehealth work successfully.

The University of Alabama’s Poole is the director of a project aimed at advancing nursing education and interprofessional collaboration to address multiple chronic conditions in rural communities that is partially funded by the Division of Nursing, U.S. Health Resources and Services Administration (see reference at end of story).

Under that program, NP students lead interprofessional teams, which include students from medicine, social work and nutrition, and these students learn to work together to address health concerns of rural residents with multiple chronic conditions through the use of telehealth.

Before working with the rural residents, students learn how to use the telehealth equipment, including details ranging from maintaining cybersecurity to ensuring adequate room lighting. NP students then check in with patients once a week and then each other, and then with their faculty via iPads at least once every two weeks for at least one year, Poole said. The ultimate goal is that NP and other students learn to work together to effectively manage their patients’ chronic conditions through implementing individualized action plans and conducting virtual visits, which in turn, will improve outcomes and quality of life.

Poole is a firm believer in telehealth as a way to augment face-to-face primary care, particularly in rural areas.

“Telehealth services have been proven to offer safe, quality and cost-effective care,” she said. “Telehealth improves patient outcomes, decreases admissions and reduces disparities caused by geographic location. A lot of this technology also puts health care into the hands of consumers — giving them the ability to monitor their health and make choices.”

Telehealth additionally may be able to help older adults age in place.

Marye Dorsey Kellermann

Marye Dorsey Kellermann, PhD, RN, CRNP, FAANP, and Lee Ann Kingham, MBA, LCSW, the CEO of Abilities Network, designed a model that uses easy-to-operate telecommunications equipment to monitor the health and well being of older, healthy adults. With the support of a physician, Kellermann served as the main health care provider, routinely checking in with the test subject to pick up any early signs of health problems and assess other potential needs.

“Elderly people don’t want to be hospitalized, but they often don’t know when they should seek health care,” said Kellermann, a Maryland Nurses Association member. For example, Kellermann noticed a lesion on the leg of the woman she was visiting virtually. The woman considered it just a bad bump, but Kellermann realized that the woman needed antibiotics to heal the injury.

“An advantage of telehealth is that it gives older adults who may not have family or friends the opportunity to touch base with someone from the health care community who can address their individual needs,” Kingham said. And it keeps them in their homes, which is generally more comfortable, less disruptive and less costly than living in long term care or assisted housing.

While Kellermann noted that older adults may worry about losing their privacy by having cameras in their homes, she said telehealth is a less invasive option than having a caregiver come to their homes.

Final thoughts

Poole and Kellermann have both spoken about the need to adequately reimburse telehealth services across the nation. Poole also raised ongoing issues around credentialing and licensing, specifically when nurses are licensed in one state but need to provide health care to patients in another state in which they are not licensed. (Read the July/August issue of The American Nurse for an update on ANA’s work to address licensure jurisdiction for cross-border nursing practice.)

Finally, Poole often speaks at international conferences about telehealth and emerging technology.

“I find that many people think that some of the technology I talk about is coming 30 or 40 years down the road,” she said. “But I know it already exists. And we have to be prepared, because health care is going to change.”

— Susan Trossman is the senior reporter for The American Nurse.


AACN Tele-ICU Nursing Practice Guidelines

CCRN-E – Adult Tele-ICU Acute/Critical Care Nursing Certification
Information related to HRSA grant: This project is/was supported in part by funds from the Division of Nursing (DN), Bureaus of Health Professions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (HHS) under grant number 6D09HP25938 and title “Advancing Nursing Education: Interprofessional Collaboration addressing Multiple Chronic Conditions in Rural Communities” for $997,173. The information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by the Division of Nursing, BHPr, HRSA, HHS or the U.S. Government.

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