Technology and Disasters: The Evolution of the National Emergency Tele-Critical Care Network

Abstract

BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic and the resulting public health emergency have placed incredible strains on U.S. healthcare infrastructure. Faced with the threat of large-scale shortages of resources, our nation reacted by making things—ventilators, face masks, and personal protective equipment—and seeking new disease-specific diagnostic and therapeutic solutions to combat the virus. Less attention, however, was given to another critical resource: clinical experts in critical care medicine, who understand how, and more importantly when, to apply both old and new tools to achieve the best outcomes for the sickest patients. The purpose of this article is to describe the origins, development, and proof-of-concept testing of the National Emergency Tele-Critical Care Network (NETCCN), a system intended to deliver expertise anywhere needed, at a moment’s notice. The U.S. healthcare “industry” is poorly designed to address pandemics or other disasters (1,2), especially those producing large volumes of critically ill or injured patients. Resources are clustered in population centers: indeed, fewer than half the counties in the United States have ICUs (3), and those that do have highly variable capacity (4). When and where critical care capacity is insufficient, hospitals expect to rapidly transfer patients to referral centers. Unfortunately, during patient surges, referral centers and transfer systems become overwhelmed, and smaller hospitals are forced to manage patients beyond their expertise and resources. Even when limited capacity exists, the most precious resource—trained and experienced clinicians—is vulnerable to exhaustion, burnout, and disease itself, which increases their risk for mental illness (5–8). Traditional solutions, which involve sending additional clinicians and equipment into the distressed environment (9), are reasonable for disasters of limited size and short duration but are reactive in nature, slow to mobilize, costly, and place deployed clinicians at risk for the same sequelae of overwhelming patient volume—exhaustion, burnout, and disease. When overwhelmed, healthcare systems are forced to triage “patients to conserve resources” (10). But, triage decisions are terrible to make for any clinician and are inherently devastating for patients. Both patients and providers deserve better whenever possible. As the U.S. military and the National Disaster Medical System (NDMS) shift focus to great power competition and heightened risk of large-scale disaster, they must prepare to address massive casualty numbers and concomitant resource limitations (11,12). For this reason, the U.S. Army Medical Research and Development Command (USAMRDC) has partnered with federal and civilian disaster response systems to devise solutions that minimize triage. Telemedicine is a powerful force multiplier in resource limited healthcare (13–16). The right expertise can be delivered to the point of need faster and at less cost using technology rather than physical resource deployment to local capabilities and thus capacity by increasing local caregiver scope of practice (16–18). Technology can insulate overwhelmed caregivers by helping with nonphysical tasks—taking histories, managing low risk medical patients, completing documentation—which allows local teams to focus on tasks that require physical presence. Task relief and care prioritization ultimately help the system manage more patients better than systems based solely on physical care. Similarly, telemedicine, using data collected with the technology, allows the system to optimize resources by reducing unnecessary patient transfers and “reverse transferring” patients who do not require referral center capabilities (19). In addition to telemedicine, technology exists that allows for remotely guided and autonomous operation of monitors, IV pumps, and ventilators (20,21). Although these technologies are not ready for mainstream healthcare, they may offer “better” care in the absence of local expertise and thus avoid the triage alternative. TECHNOLOGY IN DISASTER ENVIRONMENTS In 2018, at the Society of Critical Care Medicine (SCCM) annual congress, military and civilian experts, including authors of this article, discussed the potential role of technology, specifically tele-critical care (TCC), in disaster medicine. In mature tele-ICUs, doctors manage as many as 150 patients and nurses care for 30–50 patients at a time. TCC hubs, we believed, could therefore leverage excess capacity using extra workstations and on-call staff to rapidly respond to emergent healthcare needs during a disaster. Likewise, a network of hubs could provide load balancing and support to each other in response to regional system stress. Discussion quickly turned to the myriad reasons why such an approach would not work: In an actual disaster, would these ratios be realistic? Establishing relationships between tele-ICU hubs and local caregivers takes time, how would all the hubs work together? What would happen if network infrastructure was lost during the disaster? Perhaps most challenging, how would this kind of response fit into our current liability, credentialing, and reimbursement paradigms? Although these challenges seemed nearly insurmountable, a handful of successful pilot programs in military and civilian TCC inspired submission of two strategic proposals to the SCCM. The first sought to establish a task force to research and develop a white paper addressing telemedicine during disasters. The second proposed a multiinstitution collaborative network to expand communication and coordination between major stakeholders in TCC, including members of the Critical Care Societies Collaborative. Proposals were submitted following the 2019 annual congress and approved the following year. Consequently, work had begun in January of 2020 through these task forces that ultimately led to development of the NETCCN. THE NETCCN Early in the U.S. COVID-19 pandemic (March 2020), the Telemedicine and Advanced Technology Research Center (TATRC), part of the USAMRDC, was tasked to develop research proposals that could produce rapidly deployable capabilities to aid the national COVID-19 medical response. Building upon TATRC’s core research areas in digital health, data science, medical simulation, medical robotics, and autonomous systems, and the work initiated by the SCCM task forces, TATRC developed a Technology in Disaster Environments research proposal. Following discussions with the leaders at the Health and Human Services office of the Assistant Secretary for Preparedness and Response (HHS-ASPR), the telemedicine effort shifted to focus on a rapidly deployable, hardware-light, TCC solution that could augment clinical expertise when local critical care experts were unavailable (Fig. 1 and Table 1). The NETCCN project, a concept endorsed by SCCM and led by many of its TCC committee members, was born from this revision. This article is written at the end of the final development sprint (Fig. 2), which was designed to test platforms in real patient care settings on a small scale to demonstrate proof-of-concept. TABLE 1. - National Emergency Tele-Critical Care Network Minimum Essential Characteristics for the Tele-Critical Care Technical Platform at the End of Phase 1 (Sprints 1–3) and Phase 2 Development Phase 1 MECs (4 teams completed) 1) Secure, mobile communications capabilities, including synchronous audio/video and asynchronous messaging. 2) Capability for basic documentation in real time as well as data collection and reporting. 3) A patient registration and cohorting system. 4) A team organization and management tool including handoff features for change of shifts and transfers of care. 5) Cloud-based information storage including ability for later offloading to electronic health records, health information exchanges, and other systems. 6) HIPAA compliant. 7) Survey and consent tools. 8) A well-described clinical and staffing model that incorporates the technology in a simple, reliable manner for scaling during a disaster. Phase 2 MECs (in progress) Able to deliver clinical service using mobile enabled TCC platform developed in phase 1 to large numbers of hospitals/patients AND, incorporation of the following into the TCC platform: 1) Wearable continuous monitor data and access to ventilator waveforms and pressures into the TCC platform. 2) Remote control for medical equipment including monitors, ventilators, and IV pumps. 3) Autonomous systems into the workflow, as possible. 4) Artificial intelligence and machine learning to predict clinical deterioration, resource allocation, and outbreak forecasting. 5) Interfaces with drop-in mobile network capabilities in the event of loss of critical communications infrastructure. 6) Interoperability with medical devices. 7) Interoperability and communication with three major existing electronic medical record systems. MEC = minimum essential characteristic, TCC = tele-critical care. Figure 1.: The National Emergency Tele-Critical Care Network uses network enabled mobile device applications and elastic cloud computing to create a digital health ecosystem where multiple tele-critical care (TCC) service providers can partner to deliver easy access expertise to any connected mobile device. This allows rapid, flexible implementation of TCC services without prior relationships or hardware installation. Using this model, remote experts can help to staff virtual wards established across patient homes, field hospitals in gymnasiums or parks, and within more traditional hospital spaces. In a tiered staffing model with remote expert support, local caregivers working beyond their normal scope of practice can coordinate care with remote experts when local experts are unavailable. This model offers economies of scale because remote experts—unburdened by physical patient care tasks like walking between beds, performing procedures, donning/doffing PPE—have more time for patient interaction, care coordination, and documentation. Virtualized care teams are seamless, and patient/local caregivers are unaware of the physical location of remote experts. Furthermore, the distributed system is more resilient to cyber-attacks, network degradation, power outage, etc. APP = advanced practice provider, CC = critical care, RT = respiratory therapist.In parallel, USAMRDC-TATRC’s collaboration with HHS-ASPR matured to establish a memorandum of agreement between the organizations with three goals: 1) create a collaborative partnership to study and improve technology applications that support disaster healthcare, 2) create a sustainment framework that integrates NETCCN into the ASPR’s operational response capabilities, and 3) to transition the operational execution of the NETCCN from TATRC to ASPR. Ultimately, we intend to deliver two-to-three platforms to the HHS-ASPR that are able to rapidly deploy TCC support at scale using cost effective, data-centric solutions to aid local care teams managing COVID surge—or other future disasters—across the country. Additional enhancements will be made to the system in phase 2 work (Table 1). CURRENT STATUS AND LESSONS LEARNED To date, NETCCN has deployed support to six small, rural hospitals and enrolled 260 local caregivers, 248 remote experts. Over 220 patients have received care supported by NETCCN clinicians, including 30 patients at home (Table 2) (Supplementary Material Table 1, https://links.lww.com/CCM/G473). Of note, data collection during pilot deployments was not standardized across teams but will be in phase 2 work. Average time from local hospital engagement to initiating services has been 28 days (range 2–46 d). Our teams have experienced numerous successes including: 1) treating tension pneumothorax, while local experts were managing a cardiac arrest in a different location; 2) stabilizing respiratory failure, while the local tele-ICU system suffered communications failure; 3) avoiding hospitalizations through remote home monitoring and delivery of home oxygen therapy; and 4) supporting end-of-life care at a small hospital and in a home with a family, both unaccustomed to this experience. NETCCN has provided hundreds of hours of consultation with nurses, interns, hospitalists, patients, and other intensivists to optimize care and prevent unneeded transfers to hospitals otherwise overwhelmed by patients; hundreds of hours of shift coverage, so that local experts could rest; and dozens of multidisciplinary rounds to ensure that patients received the highest quality of care possible. Thus, NETCCN has conducted nearly 5,000 asynchronous (text/chat based) and synchronous (real-time) voice or video encounters (Table 2). TABLE 2. - Preliminary Data for Sprint 3 Pilot and Limited Clinical Deployment (as of 30 December 2020) NETCCN Team Metrics Total Range Number of NETCCN teams 4 Models: proactive/reactive/hybrid 0/1/3 Number of remote experts registered 238 10–179 Teams with physicians 4 Teams with nurses 4 Teams with respiratory therapists 3 Teams with pharmacists 3 Teams with palliative care specialists 3 Number of local caregivers registered 240 19–160 Number of patients registered 221 2–199 Number of virtual wards monitored 10 1–5 Number of home patients 30 0–30 Asynchronous encounters 3,010 15–1,460 File exchanges 459 0–399 Synchronous encounters (voice only) 777 2–567 Video encounters 1,070 0–840 Patient “saves”a 2 (1%) 0–1 Potential transfers home-to-hospital 10 NA Avoided transfers home-to-hospital 5 NA Supported Hospital Demographics Average ± sd Range Number of locations 6 Hospital capacity (number of beds) 126 ± 63 25–217 ICU capacity (number of beds) 9 ± 4 2–14 Number of fill (% capacity) at time of start 45 ± 30 0–90 Number of local intensivists 0 ± 0 0–1 Number of local critical care nurses 8 ± 6 0–17 Days to “go live” 28 ± 17 2–38 Current days of support, mean (interquartile range) 24 (18–28) 2–105 NETCCN = National Emergency Tele-Critical Care Network.aA patient “save” is an emergency situation that would have been otherwise managed without critical care support because there was no local intensivist available, but for which a NETCCN intensivist was able to provide guidance that helped stabilize the emergency and avert cardiac arrest. At the time of article submission, the NETCCN is working to expand remote capacity and establish collaborative processes and governance for the four remaining NETCCN performers and to integrate this new disaster support paradigm into national disaster response systems. Rapid scaling of the pilot clinical models and technical platforms necessitate standardizing a variety of processes inherent to delivering services at scale using a “network” of clinical service providers. For example, we are working to standardize how each team integrates new clinical volunteers, how they help hospitals rapidly credential and privilege new remote experts, how we govern the network’s clinical practice standards including who gets help and for how long, and how we assure quality of service. Another, significant, ongoing effort is to bring together the disparate technical platforms into a seamless, integrated, and interoperable platform able to balance load and share data across the network. This effort should result in opportunities for other clinical groups using non-NETCCN–developed technical platforms to interface with the NETCCN common (i.e., standards based) back-end infrastructure and facilitate further expansion of capacity and increased flexibility of the network to respond to future disasters. Among our many lessons learned, the most important has been that compassionate care rendered by professional, respectful, and trained clinicians through telemedicine platforms is value added during a pandemic. Trust remains the crucial ingredient for successful adoption of technology, including TCC during a disaster. Supplementary Material Table 2 (https://links.lww.com/CCM/G473) summarizes some of the challenges and our solutions to rapidly deploying this type of care model. In telemedicine, the technology itself is less important than how it is used. TCC can be delivered from anywhere to anywhere using a variety of clinical service models. The concept that local caregivers “can” work beyond their scope of practice supervised by remote experts to expand local capability, and thus, capacity without the experts’ physical presence remains foreign and uncomfortable for many healthcare and disaster response communities. We are still working to understand the differences between models of rapid deployment of remote support using technology instead of, or in addition to, physical support: what makes one more successful or more suitable for different contexts? Similarly, we are evaluating the different technical platforms developed thus far. Although there are many similarities between the platforms, key differences need more study to understand what impact they have on workflow, usability, acceptability, and patient outcomes. Fortunately, others have taken this journey as well, and we look forward to continued collaboration with them to better understand how TCC, and indeed technology in general, can best be used to expand clinical capability and system capacity during this and future disasters. CONCLUSIONS Ultimately, the NETCCN addresses the lack of expertise available nationally due to the scarcity of critical care trained clinicians during overwhelming demand from COVID-19 surge. The NETCCN is an evolving paradigm of clinical care teams that provide expertise to anyone who needs it using readily accessible mobile device applications. Remote support enables local caregivers, from family members to physicians, to care for more patients with higher acuity at the point of need. Although the current effort has produced a fledgling NETCCN, establishing this as a national capability that could aid future disaster healthcare requires centralized, likely federal, resources as well as new state and national regulatory frameworks to streamline essential processes (like licensure, privileging, reimbursement, and liability), so the NETCCN can be ready to help at a moment’s notice. Dr. Richard Catherina, Chief Medical Officer, NDMS, HHS, best captured the value and essence of NETCCN when opining: “The simple truth is, what we’re trying to develop is the means to deliver care anywhere, under any circumstances. If we build this correctly, we will have created the axial skeleton of a brand new organism: a health-centric telecommunications system that will allow anyone, anywhere, to get any kind of care they need at any given time. 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