Tele-ICU: A New Paradigm
in Critical Care
Michael Ries, MD, MBA, FCCM,
FCCP, FACM
Advocate Healthcare, Kensington Support Center
Oak Brook and Pulmonary/Critical Care Division
Chicago, Illinois
’
Introduction
Critical care medicine in this country is undergoing a transforma-
tion. Clinical data, regulatory oversight, and public criticism identify
deficiencies in the quality of care provided, as evidenced by avoidable
adverse events and deaths in our intensive care units (ICUs). Intensivist-
directed care has been shown to reduce mortality and costs, in part by
reducing variation of care. Complications and medical errors can be
reduced and even prevented if detected early. Evidence-based protocols
of time-sensitive clinical conditions such as sepsis, myocardial infarc-
tions, trauma and strokes, as well as other common disease entities, have
been shown to reduce complications and mortality. To help make the
necessary improvements in these critical care dilemmas, healthcare has
turned to technology to help improve the delivery of care to ICU
patients, in the form of Tele-ICU. Not only can this technology assist
care by helping to ensure consistent application of protocols, thus
reducing variability of care, it can help solve the dilemma of scarce
human resources. Staffing problems caused by a nationwide shortage of
board-certified intensive care physicians and nurses can be ameliorated
through technology. The collaborative effort between the Tele-ICU and
INTERNATIONAL ANESTHESIOLOGY CLINICS
Volume 47, Number 1, 153–170
r
2009, Lippincott Williams & Wilkins
153
REPRINTS:MICHAEL RIES, MD, MBA, FCCM, FCCP, FACM, RUSH MEDICAL COLLEGE,DEPARTMENT OF MEDICINE,
PULMONARY/CRITICAL CARE DIVISION, 1753 WEST CONGRESS PARKWAY,CHICAGO,ILLINOIS 60612, E-MAIL:
MHRIESMD@AOL.COM

bedside healthcare providers enables redundancies in the care of
critically ill patients, thus reducing variation and adverse events.
Admittedly, due to its nascence, the full extent of Tele-ICU’s advantages
and potential deficiencies are not yet known, but what is clear is that
the traditional egocentric approach to the practice of intensive care
medicine is not sustainable. This paradigm must be relinquished and
replaced by a newer model: one that champions a cooperative culture
that harmonizes the bedside and remote care providers for the benefit
of the patient. Tele-ICU, in the form of technical and leveraged human
assistance, when integrated with beside healthcare, works to improve
care for the critical care patient. The following description of Tele-ICU is
presented first as a clinical vignette and then as a review of current
literature.
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Case
It is 1:30 AM and the remote care center eIntensivist is making his
rounds. He watches 120 patients in 12 ICU’s scattered across the region.
As is his routine during his 10-hour shift, the eIntensivist begins by
checking on the most critically ill patients, labeled ‘‘red.’’ He then
evaluates the ‘‘yellow’’-coded, less acutely ill patients, and finally the
‘‘green,’’ who are the most stable patients. A red SmartAlert that appears
on J.L., a 56-year-old patient at Qualitas Hospital, indicates that in the
last few minutes her heart rate (HR) has trended above the preset
110/min and that the mean arterial pressure (MAP) has fallen, slightly
below the preset 70 mm Hg. A glance at J.L.’s real-time vital signs
confirms a HR of 115/min, with frequent premature atrial contraction
and a MAP of 65 mm Hg. A brief discussion with the RN working in the
remote care center (eRN), who mans an adjacent console at the remote
site, substantiates that J.L.’s vital-sign changes are new. A click onto the
‘‘notes’’ section of J.L.’s electronic medical record (EMR) shows that she
was admitted through the emergency department 12 hours earlier with
such severe community-acquired pneumonia that she required mechan-
ical ventilation and that the sepsis protocol had been initiated. The
history and physical by the Qualitas Hospital medicine resident also
reveals that JL is diabetic and has possible coronary artery disease. A
quick check on the real-time bedside high-resolution audiovisual
equipment allows the ePhysician to see the patient, her bedside nurse,
and the ventilator waveforms. J.L. is on volume ventilation with a peak
airway pressure of 28 cm H
2
O with no evidence of auto-PEEP. Her
endotracheal tube, positioned at the 22 cm mark at the teeth, contains
light yellow secretions. EMR laboratory data show that modestly low
potassium (3.2) and magnesium levels (1.5), highlighted in red, were
identified and treated 2 hours earlier according to the potassium and
154 ’ Ries