BEDSIDE NURSES PERCEPTIONS OF INTENSIVE CARE UNIT TELEMEDICINE. Innovative Approaches. 1.0 Hour

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1 Innovative Approaches BEDSIDE NURSES PERCEPTIONS OF INTENSIVE CARE UNIT TELEMEDICINE By Margaret Mullen-Fortino, RN, MSN, Joseph DiMartino, RN, MSN, Lorraine Entrikin, RN, BSN, Sophia Mulliner, RN, BSN, C. William Hanson, MD, and Jeremy M. Kahn, MS, MD C E 1.0 Hour Notice to CE enrollees: A closed-book, multiple-choice examination following this article tests your under standing of the following objectives: 1. Describe the purpose of intensive care unit telemedicine. 2. Identify perceptions of bedside nurses using intensive care unit telemedicine. 3. Examine research findings for compatibility to one s own practice. To read this article and take the CE test online, visit and click CE Articles in This Issue. No CE test fee for AACN members American Association of Critical-Care Nurses doi: Background Intensive care unit telemedicine is an innovative approach to providing critical care services for a broad geographic area, but its success may depend on acceptance by bedside providers. Objectives To determine critical care nurses attitudes toward and perceptions about the use of telemedicine in critical care. Methods A total of 179 nurses in 3 critical care units in 2 university-affiliated academic hospitals that use telemedicine intensivists and nurses were surveyed via the Internet about their practice and perceptions of telemedicine. Results Among the 93 respondents (response rate, 52%), worked at least 1 night shift and therefore had experience with the tele medicine unit. Reported contact with the tele med i cine unit was relatively infrequent: 31% reported being called by the unit 3 or more times in the preceding 6 months. A total of 44% reported regularly incorporating interventions suggested by the telemedicine staff. A majority (%) thought that telemedicine increases patients survival, but fewer thought that telemedicine prevents medical errors (47%) or improves the satisfaction of patients families (42%). Some respondents thought that telemedicine interrupted work flow (9%), was intrusive (11%), or resulted in a feeling of being spied upon (13%). Most nurses thought that personally knowing the telemedicine physician was important (79%), and nurses were more likely to contact the telemedicine unit if they knew the physician on call (61%). Conclusions Practicing bedside nurses with experience in telemedicine generally support its use, but concerns about privacy issues and the desire to personally know the tele - medicine physician may hinder broader application of the technology. (American Journal of Critical Care. 2012;21:24-32) 24 AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2012, Volume 21, No. 1

2 Advances in technology and an aging population have contributed to an everincreasing demand for critical care services. 1,2 Workforce studies 2,4 suggest that the number of intensivist physicians and nurses is not enough to meet increasing demand. Consequently, relatively few intensive care units (ICUs) have optimal staffing. Staffing can be an issue even in ICUs with an intensivist-led model of care; 24-hour staffing by intensivists is uncommon, and preventable morbidity and mortality may occur at night when intensivists are not immediately available. 5 Small hospitals and rural hospitals may be particularly at risk; they are less likely to be staffed by intensivists and health care providers in training and may have worse risk-adjusted outcomes than do larger hospitals. 6 Telemedicine is one approach to expand access to high-quality critical care. 7 ICU telemedicine makes use of electronic medical records and video teleconferencing to provide critical care from a remote location. Using telemedicine, a small number of physicians and nurses can complement bedside care for a large number of patients at several locations simultaneously. The remote ICU team can consult on critical issues, monitor patients for changes in physiological status, and facilitate communication between care providers. As such, telemedicine has the potential to improve patients outcomes in the ICU. Strong empirical data on the relationship between ICU telemedicine and outcomes are lacking, although the results of some before-and-after studies 8-11 suggest improvements in mortality and length of stay over time coincident with the introduction of a telemedicine program. As telemedicine programs expand, acceptance by frontline ICU nurses will be essential. Successful implementation of telemedicine requires effective interaction between the telemedicine team and bedside nurses. Currently, no information exists about About the Authors Margaret Mullen-Fortino is operations director and Joseph DiMartino is the outcomes coordinator for the Penn e-lert eicu, Lorraine Entrikin is an eicu staff nurse, and Sophia Mulliner is an ICU staff nurse, University of Pennsylvania Health System, Philadelphia, Pennsylvania. C. William Hanson is a physician, University of Pennsylvania Health System, Department of Anesthesia and Critical Care, University of Pennsylvania School of Medicine, Philadelphia. Jeremy M. Kahn is a physician, University of Pennsylvania Health System, Division of Pulmonary, Allergy and Critical Care, Center for Clinical Epidemiology, and Department of Anesthesia and Critical Care, University of Pennsylvania School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia. Corresponding author: Margaret Mullen-Fortino, RN, MSN, Operations Director, Penn e-lert eicu, 1800 Lombard St, Philadelphia PA ( margaret.fortino@uphs.upenn.edu). nurses perceptions of ICU telemedicine or potential strategies to improve communication between nurses and the telemedicine team. We used an Internet-based survey to examine bedside nurses perceptions of ICU telemedicine. Methods The study protocol was approved by the University of Pennsylvania, Philadelphia, Pennsylvania, institutional review board. Study Design and Participants An Internet survey was used in a cross-sectional study of critical care nurses. The study was performed in the University of Pennsylvania Health System, which operates an ICU telemedicine program (eicu) in 3 independently managed hospitals in Philadelphia, Pennsylvania: the Hospital of the University of Pennsylvania (HUP), a 695-bed academic, tertiary referral hospital with 5 ICUs, 1 of which participates in the program; Pennsylvania Hospital, a 385-bed community hospital with 2 ICUs, both of which participate in the telemedicine program; and Presbyterian Hospital, a 275-bed community hospital with 3 ICUs, all of which participate in the program. The ICU nurses at Presbyterian Hospital participated in a separate but related study, so that hospital was excluded from this study. The survey was administered to actively practicing nurses in the 3 remaining units with telemedicine programs: the surgicaltrauma ICU at HUP, the combined medical-surgical ICU at Pennsylvania Hospital, and the combined cardiac-neurological ICU at Pennsylvania Hospital (Table 1). The surgical-trauma ICU at HUP is a closed unit that uses residents and critical care fellows for nighttime coverage. The medical service at Pennsylvania Hospital incorporates a closed intensivist There are not enough intensivist physicians and nurses to meet increasing demand. AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2012, Volume 21, No. 1 25

3 Table 1 Characteristics of intensive care units in the study Intensive care unit Variable HUP PAH, medical-surgical PAH, cardiac-neuro Patient population No. of beds No. of admissions in 2007 Nighttime in-house staffing Intensivist staffing model Trauma, general surgical Residents plus critical care fellow Closed Mixed medical-surgical Residents only Closed/optional consultation a Abbreviations: HUP, Hospital of the University of Pennsylvania; PAH, Pennsylvania Hospital. a Closed for patients on medical services, optional consultation for patients on surgical services. Mixed cardiac-neurological Residents only Optional consultation The telemedicine program offers nighttime intensivist consultation to bedside staff. staffing model with optional consulting for all other patients. Residents provide nighttime coverage at Pennsylvania Hospital. Each hospital maintains separate physician staff and separate residency programs. The telemedicine program offers nighttime intensivist consultation to bedside staff for all of the units. Participation in the survey was limited to nurses whose primary assignment was to a unit that used telemedicine. Nurses were identified through each hospital s nursing administration office. The Telemedicine Program The University of Pennsylvania Health System has provided eicu services in each of the 4 study ICUs continuously since Implementation of the eicu program was done collaboratively with all units involved. Representatives from each unit along with the eicu medical director and operations director attended a clinical process design workshop for the purpose of developing ICU-eICU integrated work flows. Program goals and processes were approved by senior leaders at each entity, who in turn were responsible for relaying information to front-line practitioners. The eicu program was activated independently for each hospital, with a duration of 1 month between each activation. Education consisted of a presentation on the rationale for a change in the current care delivery model, instruction on the integrated clinical work flows, and hands-on instruction on how to document vital signs, fluid status, assessment scores, and best-practice measures in the electronic medical record. Before implementation of the eicu program, paper processes were used for documentation. In preparation for the change from paper to electronic documentation, management and staff representatives performed a gap analysis that was used to develop a quick reference guide for resource uses and staff during the activation. Additional computers were installed in each unit to accommodate the transition to electronic documentation. The program uses the VISICU eicu remote monitoring system (Philips Electronics, Amsterdam, the Netherlands) to electronically link the ICUs to an offsite central monitoring facility. The eicu system includes 2-way audio conferencing, 1-way video conferencing (ie, the telemedicine team can view activity in a patient s room via a remotely controlled camera), an electronic medical record available to both the telemedicine and bedside clinicians, and continuous physiological monitoring that can detect trends in vital signs and laboratory values and alert the telemedicine staff. Telemedicine physicians have access to radiology examinations and continuous telemetry through separate electronic systems. All ICU admissions are entered into the system by either the telemedicine nurse or a trained data coordinator. One or two specially trained telemedicine nurses continuously monitor ICU patients 7 days a week. Staffing patterns vary among different eicus, although typically each telemedicine nurse monitors 30 to 40 patients. 12 During the day, the telemedicine nurse performs audits for benchmarking of outcomes, reviews patients profiles for updates in the plan of care, and responds to clinical alarms and queries. Interventions made by the telemedicine nurse are mostly related to ensuring patients safety, providing additional patient monitoring or education, and providing consultation for bedside nurses. A board-certified intensivist physician and a critical care nurse staff the eicu between 7 PM and 7 AM. Updates related to patient acuity and unit status are communicated by the day telemedicine nurse to the physician and nurse coming on duty. While on duty, each telemedicine clinician performs virtual rounds on ICU patients (the frequency depends on the severity of a patient s condition), monitors physiological alerts, and responds to specific queries by on-site physicians and nurses. Patients are assigned by the telemedicine nurse to 1 of 3 acuity categories: 26 AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2012, Volume 21, No. 1

4 high, medium, and low. Virtual assessments are completed every 1 to 4 hours according to the acuity category. Telemedicine physicians are credentialed at each hospital, but their nontelemedicine clinical duties are entirely at HUP. Survey Development and Administration The survey instrument was based on a preliminary qualitative study in which semistructured interviews were conducted with 28 practicing ICU nurses at each of the 3 hospitals. All interviews were recorded and transcribed. Content analysis of the transcriptions resulted in 4 specific domains: functionality, patients outcomes, privacy, and culture. The final survey instrument was based on these domains; it consisted of a mix of positively and negatively worded questions and language obtained directly from the qualitative interviews. The survey was pilot tested on a second sample of ICU nurses located solely at Presbyterian Hospital (the hospital excluded from the final survey) and was revised on the basis of the nurses feedback. In order to establish content validity, the pilot survey results were reviewed with physician and nurse telemedicine practitioners. The original survey included several questions about the electronic documentation record that was implemented at the same time as the telemedicine component. On the basis of feedback from the expert telemedicine practitioners, the electronic documentation questions were removed from the questionnaire, allowing the survey to focus on satis faction with telemedicine services. At the onset of the survey, telemedicine was defined as the continuous offsite monitoring of ICU patients and the interaction between the bedside nurse and the telemedicine staff via audio and visual equipment. In order to separate opinions about telemedicine from opinions about the eicu electronic medical record, which in theory need not accompany the telemedicine intervention, the following statement was added: We specifically do NOT mean the electronic documentation that accompanies the telemedicine program. The final survey contained 22 questions with Likert-type responses and an area for open-ended, general opinion. The survey was anonymously administered via by using an Internet-based survey tool (SurveyMonkey, Portland, Oregon). Nurses who reported no night shifts were directed to the end of the survey without the opportunity to complete the other questions because they had limited or no experience with the telemedicine component. The first was sent on October 24, 2008, and reminder notices were sent every 2 weeks. The last completed survey was received on December 30, As a monetary incentive, respondents were invited to leave their name and contact information to be entered into a random drawing for two $100 gift cards. The information for the drawing was collected via a separate Web site to preserve the respondents anonymity. Data Analysis The response rate was the number of completed surveys received divided by the number of nurses sent an . Survey responses were collected as either categorical or Likert-scaled responses ranging from 1 to 5 (ie, strongly disagree, disagree, neutral, agree, and strongly agree). Responses were grouped into 2 categories, (1) strongly disagree and disagree and (2) strongly agree and agree, and were reported as the percentage of responses in each category. Opinions about telemedicine were compared between the 2 hospitals by using an unpaired t test on the raw Likert responses and the Bonforroni correction to account for multiple comparisons. Respondents were also given space to report their opinions about telemedicine. These responses were reviewed, and key themes were identified. The responses are reported by theme, with illustrative quotes. The selected quotes were edited for spelling but not grammar or syntax. Stata 9.2 (StataCorp, College Station, Texas) software was used for quantitative analyses. Results The survey was sent to 179 nurses, 102 at HUP and 77 at Pennsylvania Hospital. A total of 55 nurses from HUP and 38 from Pennsylvania Hospital completed the surveys, for an overall response rate of 52%. Among the returned surveys, 2 from respondents who completed only the demographic questions and 19 from nurses who reported not working night shifts were excluded from data analysis, for a total of surveys in the final analysis. Respondents were generally female, had worked in their respective ICUs for a mean of 5 years, and had a bachelor s degree in nursing or higher (Table 2). Reported contact with the telemedicine staff was relatively rare (Table 3). A total of 50 nurses (69%) reported receiving contact from the telemedicine staff 2 times or less in the preceding 6 months, and 64 nurses (89%) reported contacting the telemedicine staff 2 times or less in the same time period. A telemedicine nurse continuously monitors about 30 to 40 intensive care unit patients at a time. A total of 44% of nurses reported regularly incorporating suggestions by the intensive care unit staff. AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2012, Volume 21, No. 1 27

5 Table 2 Self-reported characteristics of eligible survey respondents Variable Age, mean (SD), y Female Years in current position, mean (SD) Highest degree Associate s Bachelor s Master s Primary nursing unit HUP, trauma/surgical PAH, medical/surgical PAH, cardiac/neurological Respondents a (n = 74) Abbreviations: HUP, Hospital of the University of Pennsylvania; PAH, Pennsylvania Hospital. a Unless otherwise indicated, data in the table are expressed as number (percentage). Numbers may not add up to total number of respondents because of incomplete responses on some questions. Table 3 Patterns of use of intensive care unit (ICU) telemedicine Variable ICU telemedicine to nurse contacts in past 6 months None 1-2 times 3-4 times 5 or more times Nurse to ICU telemedicine contacts in past 6 months None 1-2 times 3-4 times 5 or more times 35 (8) 59 (80) 5 (4) 10 (14) 45 (65) 14 (20) 41 (58) 13 (18) 17 (24) Respondents a (n = ) 9 (13) 41 (57) 17 (24) 5 (7) 33 (46) 31 (43) 6 (8) 2 (3) a All values are expressed as number (percentage). Because of rounding, not all percentages total 100. Nursing opinions about telemedicine are shown in Table 4 (percentages for each item are based on the number of responses to that item). In questions about system functionality, 32 nurses (44%) reported regularly incorporating suggestions by the ICU staff. None reported that telemedicine makes them less likely to communicate with the on-site physician, and only 6 of (8%) reported that telemedicine interrupts daily work flow. Respondents generally endorsed the idea that telemedicine has a positive effect on patients outcomes. A total of 59 (82%) expressed confidence in the recommendations of the telemedicine staff, and 52 (%) thought that telemedicine increased a patient s chance of survival. Fewer respondents agreed with the statements that telemedicine prevented medical errors (47%) or improved family satisfaction (42%), and 28 of (40%) agreed with the statement that the overall quality of the ICU is equally good with or without telemedicine in place. A minority of nurses agreed with the statements that telemedicine is intrusive (11%), decreases patient privacy (27%), or creates a feeling of being spied upon (13%). Almost all nurses (87%) agreed that it is important that telemedicine staff alert the bedside nurse when virtually entering a patient s room, and most respondents (57%) agreed that telemedicine would be improved with 2-way video monitoring instead of the existing 1-way monitoring. Personal familiarity with the telemedicine staff was important to responding nurses, both in general (79% agreed) and in terms of how likely the nurses are to communicate with the telemedicine staff (61% agreed). Responses were similar between the 2 responding hospitals. The exception was the statement, I am more likely to communicate with the telemedicine department if I personally know the physician. The mean score for this question was 3.9 (SD, 1.0) at HUP, where the majority of telemedicine physicians also attend onsite in the ICU, and 3.1 (SD, 0.9) at Pennsylvania Hospital, where no physicians attend onsite (corrected P =.007). Open-ended comments were both positive and negative and often contained specific suggestions to improve interaction between eicu and beside staff (Table 5). Bedside nurses endorsed the immediate availability of expert staff and stressed the need for familiarity with the telemedicine physician and direct communication between eicu and bedside staff. Discussion In our anonymous Internet survey, nurses experienced with ICU telemedicine generally supported use of the technology. The majority thought that ICU telemedicine improves survival in the ICU, although fewer thought that telemedicine decreases medical errors or improves the satisfaction of patients families. Contact with the telemedicine staff was less than anticipated; only a minority of nurses indicated that they regularly incorporate suggestions from the telemedicine staff into patient care, and nearly all nurses reported a mean of fewer than 1 contact with the telemedicine unit per month. A small but significant number of nurses expressed concerns about privacy and intrusions into daily work flow, but a large number thought the intervention would be improved by 2-way video conferencing and would prefer personally knowing the telemedicine physician. 28 AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2012, Volume 21, No. 1

6 Table 4 Nurses perceptions of intensive care unit (ICU) telemedicine Question No. a Disagree Neutral Agree Functionality I regularly incorporate interventions suggested by the telemedicine staff into my patient's care. The presence of telemedicine makes me less likely to communicate with the on-site physician. Telemedicine interrupts my daily work flow. 10 (14) 67 (93) 58 (83) 30 (42) 5 (7) 6 (9) 32 (44) 0 (0) 6 (9) Patient and family outcomes When I consult the telemedicine physician, I am confident that the interventions are best for the patient. Having telemedicine prevents medical errors. Having telemedicine increases the patient's chance of survival. Having telemedicine improves family satisfaction. The quality of our ICU care is equally good with or without a telemedicine unit in place. 0 (0) 12 (17) 2 (3) 5 (7) 22 (31) 13 (18) 26 (36) 18 (25) 37 (51) 22 (31) 59 (82) 34 (47) 52 () 30 (42) 26 (38) Privacy I find telemedicine intrusive. Having telemedicine decreases patients privacy. It is important that the telemedicine staff alert me to their presence whenever they enter the room. I feel like I am being "spied upon" when working in my patient's room. I would feel more comfortable communicating with telemedicine staff if we had 2-way video monitoring (63) 42 (59) 5 (7) 48 (67) 14 (19) 19 (26) 10 (14) 4 (6) 15 (21) 17 (24) 8 (11) 19 (27) 62 (87) 9 (12) 41 (57) Organizational climate The telemedicine physician sometimes leaves me unaware of communication he or she has with the on-site physician. It is important that I am familiar with the telemedicine physician. I am more likely to communicate with the telemedicine department if I personally know the physician. Overall, I am satisfied with the service that telemedicine provides. 15 (21) 4 (6) 14 (20) 2 (3) 18 (26) 11 (16) 13 (19) 6 (9) 37 (53) 55 (79) 43 (61) 62 (89) a Number of respondents that completed the question. Because of rounding, not all percentages total 100. Our results have important implications for the organization and management of critical care with respect to telemedicine. Telemedicine may improve survival and prevent ICU complications by allowing direct continuous monitoring of critically ill patients by trained intensivists, especially at night. 7 Telemedicine also allows rapid contact with a critical care expert when an in-house physician is not immediately available. However, for telemedicine to fulfill its promise, effective communication between the telemedicine staff and bedside nurses is essential. Concerns have been raised that the use of telemedicine may alienate the bedside caregivers or interrupt daily work processes. 13 Additionally, some experts 14 worry about tensions that may exist if nurses perceive that the funds spent on telemedicine would be better invested in providing nursing assistance or in lowering nurse to patient ratios. Our study shows that nurses generally endorse telemedicine and think it improves outcomes. Although some nurses thought that the eicu program has minimal effects on quality, overall satisfaction with the program was high. Data from our study can help improve existing telemedicine programs. Nurses had strong feelings about having telemedicine staff introduce themselves when the staff members virtually enter a room and about the need for telemedicine physicians to contact the nurses directly about patient care matters instead of bypassing the nurses to talk to in-house physicians. Managing communication between physicians and nurses is an important challenge to all intensive care. 15,16 These issues are compounded in telemedicine programs in which off-site physicians, on-site physicians, and bedside nurses must efficiently coordinate complex care for critically ill patients. Our findings indicate that time invested in creating personal relationships between bedside nurses and telemedicine staff and communicating care plans with all in-house clinicians most likely will affect satisfaction with an ICU telemedicine program. Our results can also help in efforts to expand telemedicine programs to small rural hospitals. As the number of telemedicine programs increases, telemedicine physicians most likely will monitor patients in hospitals in which the physicians have no direct clinical experience. In the extreme scenario, the off-site telemedicine unit may not be located in the same state, or even the same country, as the monitored hospital. This model is used in many radiology telemedicine programs; radiologists interpreting AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2012, Volume 21, No. 1 29

7 Table 5 Themes and illustrative quotes from open-ended responses Theme Communication Quality Work flow Familiarity Quote I think it would be helpful if the staff introduced themselves when speaking with us in patient s rooms to foster better communication. I find it not appropriate when the telemedicine doctors bypass nursing when an issue is present with the patient. There are inconsistencies between telemedicine communication. Some are proactive, really on the ball. Some seem almost annoyed when you call. The doc communicated via cell phone with the on-site physician and I didn t know anything that was said, and I felt uneasy as a result because I didn t know what the plan was. If there is a problem or question with the plan of care please do not go above the nurse s head and call the doctor first... Please include the nurse in the discussion first show that he/she knows what is going on. The [telemedicine] physician sees the situation in real time and understands exactly what is happening and is able to give another perspective to a situation. This increases patient safety as well as satisfaction. I always call the intern/resident first, but if they are unable to be of assistance, or if I feel that we need recommendations from an attending then we call [the telemedicine staff]. I love telemedicine. I feel they do an excellent job and are always available to lend a second opinion. Telemedicine is a great help to all nursing staff, most especially if the patient is at risk. There have been times where they do not see you in your room, when you are. They will ring in and tell you that your [vital signs] are irregular at that time you may be very busy attempting to fix them. Some of the problems that I have is that I do find it to be a hassle to fax over information. We need more hands and less eyes. Too many cooks spoil the soup. My comfort level increases exponentially when I am familiar with the doc in the box. I like that in our unit we have posted the schedule so we know who is working that day. We also have a picture board so we can put a face to a name when we are working with the telemedicine staff. I feel that knowing the staff better would be helpful. We do know one of the doctors on staff at VISICU. It does create a better path of communication with some you have worked with in the unit assisting you. Nurses felt strongly that telemedicine staff should introduce themselves when virtually entering a room. radiological findings obtained at night are often in another country. 17 Our findings suggest that beside nurses are less likely to contact the telemedicine unit for help, and may be less receptive to interventions suggested by the telemedicine staff, when the nurses are not familiar with the clinicians. This finding indicates a major challenge to widespread application of ICU telemedicine, especially in areas geographically remote from the telemedicine unit. Bedside nurses will increasingly take direction from physicians with whom the nurses have had no personal contact, potentially limiting the effectiveness of the telemedicine program. Issues of privacy and intrusion with work flow were also important to some nurses. These issues may become more prominent when telemedicine physicians must interact with nurses in units where the physicians are not familiar with local norms and customs. As with all new technologies, success depends on the implementation. Leadership support during implementation of the eicu varied between the 2 hospitals. The success of individual units was indicated by improved patient outcomes in the units in which physicians and nurses engagement and acceptance of the eicu was strong. 18 Higher levels of satisfaction may be linked to nurses whose units have improved outcomes. Additionally, perceptions of the eicu program were linked with use of the electronic medical record. Management at 1 hospital made the decision to have 1 computer workstation for every 2 beds, with the workstation outside the patient rooms, whereas the other hospital chose to have 1 workstation per patient room installed in the room. Having the computers outside the patients rooms required the nurses to document vital signs and other pertinent information on paper for later transfer to the electronic medical record. This requirement was a major source of dissatisfaction for bedside nurses. Delays in updating the electronic medical record made it difficult for the eicu to obtain an accurate understanding of the patient s clinical condition, prompting the eicu to make several many telephone calls to the ICU and subsequent interruptions in care. Conversely, having the computer in 30 AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2012, Volume 21, No. 1

8 the room was well received by nursing staff and fostered use of the electronic medical record. Satisfaction with the implementation of the electronic documentation system was closely linked to activation of the eicu program, so success with the former influenced greatly the perceptions of the latter. Our study has several limitations. The response rate of 52%, although typical for most surveys of health care professionals, leaves open the possibility of response bias. 19,20 We have no data on the characteristics of the nonrespondents and so cannot formally evaluate this possibility. Because nurses both strongly in favor and strongly opposed to telemedicine would be highly motivated to respond, we doubt any selection bias would be major. Although the study hospitals differed in size, ICU organization, and patient populations, both were urban, universityaffiliated hospitals, and both had resident physicians in house 24 hours a day. Our results may not be generalizable to ICUs without resident-level trainees, rural hospitals, or smaller hospitals. Finally, we did not survey other important groups with a stake in telemedicine, including on-site physicians, respiratory therapists, clinical pharmacists, patients, and patients families. Future research should be directed at understanding the perceptions of these important groups. Technology is playing an increasingly important role in health care delivery, and ICU telemedicine most likely will expand in the future. Clinicians, hospital administrators, and policy makers can use our results to help design optimal ICU telemedicine programs, evaluate new programs as the programs are introduced, and anticipate potential barriers to the adoption of ICU telemedicine as new programs are introduced. ACKNOWLEDGMENTS This research was done at the University of Pennsylvania. FINANCIAL DISCLOSURES None reported. eletters Now that you ve read the article, create or contribute to an online discussion on this topic. Visit and click Submit a response in either the full-text or PDF view of the article. SEE ALSO For more about Telemedicine, visit the Critical Care Nurse Web site, and read the article by Goren, A New View: Tele-intensive Care Unit Competencies. (October 2011). REFERENCES 1. Halpern NA, Pastores SM, Greenstein RJ. Critical care medicine in the United States : an analysis of bed numbers, use, and costs. Crit Care Med. 2004;32: Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J Jr; Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA. 2000;284(21): Buerhaus PI, Staiger DO, Auerbach DI. Is the current shortage of hospital nurses ending? Health Aff (Millwood). 2003; 22: Angus DC, Shorr AF, White A, et al; Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations. Crit Care Med. 2006;34(4): Parshuram CS, Kirpalani H, Mehta S, Granton J, Cook D; for the Canadian Critical Care Trials Group. In-house, overnight physician staffing: a cross-sectional survey of Canadian adult and pediatric intensive care units. Crit Care Med. 2006;34: Kahn JM, Goss CH, Heagerty PJ, Kramer AA, O Brien CR, Rubenfeld GD. Hospital volume and the outcomes of mechanical ventilation. N Engl J Med. 2006;355(1): Breslow MJ. Remote ICU care programs: current status. J Crit Care. 2007;22: Rosenfeld BA, Dorman T, Breslow MJ, et al. Intensive care unit telemedicine: alternate paradigm for providing continuous intensivist care. Crit Care Med. 2000;28(12): Breslow MJ, Rosenfeld BA, Doerfler M, et al. Effect of a multiple-site intensive care unit telemedicine program on clinical and economic outcomes: an alternative paradigm for intensivist staffing. Crit Care Med. 2004;32: Zawada ET Jr, Kapaska D, Herr P, et al; Avera eicu Research Group. Prognostic outcomes after the initiation of an electronic telemedicine intensive care unit (eicu) in a rural health system. S D Med. 2006;59(9): Vespa PM, Miller C, Hu X, Nenov V, Buxey F, Martin NA. Intensive care unit robotic telepresence facilitates rapid physician response to unstable patients and decreased cost in neurointensive care. Surg Neurol. 2007;67(4): Goran S. A new view: tele intensive care unit competencies. Crit Care Nurse. 2011;31(5): Groves RH Jr, Holcomb BW Jr, Smith ML. Intensive care telemedicine: evaluating a model for proactive remote monitoring and intervention in the critical care setting. Stud Health Technol Inform. 2008;131: Weinstein RS, Lopez AM, Krupinski EA, et al. Integrating telemedicine and telehealth: putting it all together. Stud Health Technol Inform. 2008;131: Shortell SM, Rousseau DM, Gillies RR, Devers KJ, Simons TL. Organizational assessment in intensive care units (ICUs): construct development, reliability, and validity of the ICU nurse-physician questionnaire. Med Care. 1991;29(8): Cook DJ, Meade MO, Hand LE, McMullin JP. Toward understanding evidence uptake: semirecumbency for pneumonia prevention. Crit Care Med. 2002;30(7): Wachter RM. International teleradiology. N Engl J Med. 2006;354: Sites FD, Hanson CW III, Mullen-Fortino M. Implementation of a critical care telemedicine system with smart data analysis and electronic documentation. Comput Inform Nurs. 2007;25(5): Kellerman SE, Herold J. Physician response to surveys: a review of the literature. Am J Prev Med. 2001;20(1): Asch DA, Jedrziewski MK, Christakis NA. Response rates to mail surveys published in medical journals. J Clin Epidemiol. 1997;50: To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA Phone, (800) or (949) (ext 532); fax, (949) ; , reprints@aacn.org. AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2012, Volume 21, No. 1 31

9 CE Test Test ID A : Bedside Nurses Perceptions of Intensive Care Unit Telemedicine. Learning objectives: 1. Describe the purpose of intensive care unit telemedicine. 2. Identify perceptions of bedside nurses using intensive care unit telemedicine. 3. Examine research findings for compatibility to one s own practice. 1. Which of the following is not one of the functions of a remote telemedicine team? a. Consult on critical care issues b. Monitor patients for changes in physiological status c. Facilitate communication between care providers d. Provide bedside care of the intensive care unit (ICU) patient 2. Which of the following statements is true? a. Telemedicine has proven outcomes in various literature citings. b. Strong empirical data on telemedicine and outcomes are lacking. c. Cause and effect of telemedicine on mortality is proven. d. Cause and effect on telemedicine and reduced length of stay is proven. 3. What type of research tool was used in this study? a. Internet based survey b. Phone survey c. Direct observation of practice d. Questionnaire mailed to home 4. How long has the eicu program been provided to the study s intensive care units? a. 0-1 year c. 8-9 years b. 5-6 years d years 5. What other change occurred with the telemedicine implementation? a. One-on-one care for patients b. Intensivist program initiated in all units c. Electronic medical record for documentation d. Onsite monitoring equipment 6. In this study, how many patients did 1 telemedicine nurse typically monitor? a. 10 to 15 patients c. 30 to 40 patients b. 20 to 25 patients d. 40 to 50 patients 7. Which of the following items was not part of the telemedicine eicu equipment? a. Two-way audio conferencing b. Two-way video conferencing c. Continuous physiological monitoring d. Electronic medical record 8. Which of the following statements is true? a. Patients are assigned acuity categories of heavy, medium, or light. b. Each telemedicine clinician performs virtual rounds on ICU patients. c. Virtual assessments are completed once a shift. d. Telemedicine physicians are credentialed only at the hospital where they are employed. 9. How many times did most of the bedside nurses say they contacted the telemedicine staff over the preceding 6 months? a. Every shift b. Two times a week c. Two times a month d. Two times or less within the 6-month period 10. Which of the following statements is true? a. Reported contact with telemedicine staff was frequent, at least once a week. b. Twenty percent of bedside nurses reported telemedicine made them less likely to speak to on-site physicians. c. Eight percent of bedside nurses reported telemedicine interrupts workflow. d. Eighty percent of bedside nurses reported regularly incorporating suggestions from telemedicine staff. 11. Which of the following changes to the telemedicine program did bedside nurses who participated in the research study recommend? a. Two-way audio conferencing b. Two-way video conferencing c. Continuous physiological monitoring d. Electronic medical record 12. Which of the following statements is true? a. Bedside nurses prefer eicu intensivists to contact them personally about a patient care issue rather than bypassing them to speak to in-house physicians. b. It is not necessary to invest in creating personal relationships between bedside nurses and telemedicine staff and communicating care plans with all in-house clinicians. c. Bedside nurses contacted telemedicine staff more often than in-house staff. d. There is no need to make bedside staff aware that virtual rounds are occurring. Test ID: A Contact hours: 1.0 Form expires: January 1, Test Answers: Mark only one box for your answer to each question. You may photocopy this form. 1. a 2. a 3. a 4. a 5. a 6. a 7. a 8. a 9. a 10. a 11. a 12. a b b b b b b b b b b b b c c c c c c c c c c c c d d d d d d d d d d d d Fee: AACN members, $0; nonmembers, $10 Passing score: 9 Correct (75%) Category: Synergy CERP C Test writer: Jane Baron, RN, CS, ACNP For faster processing, take this CE test online at ( CE Articles in This Issue ) or mail this entire page to: AACN, 101 Columbia, Aliso Viejo, CA Program evaluation Yes No Objective 1 was met Objective 2 was met Objective 3 was met Content was relevant to my nursing practice My expectations were met This method of CE is effective for this content The level of difficulty of this test was: easy medium difficult To complete this program, it took me hours/minutes. Name Member # Address City State ZIP Country Phone address RN License #1 RN License #2 Payment by: Visa M/C AMEX Check Card # Signature State State Expiration Date The American Association of Critical-Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. AACN has been approved as a provider of continuing education in nursing by the State Boards of Nursing of Alabama (#ABNP0062), California (#01036), and Louisiana (#ABN12). AACN programming meets the standards for most other states requiring mandatory continuing education credit for relicensure.

10 Bedside Nurses' Perceptions of Intensive Care Unit Telemedicine Margaret Mullen-Fortino, Joseph DiMartino, Lorraine Entrikin, Sophia Mulliner, C. William Hanson and Jeremy M. Kahn Am J Crit Care 2012; /ajcc American Association of Critical-Care Nurses Published online Personal use only. For copyright permission information: Subscription Information Information for authors Submit a manuscript alerts The American Journal of Critical Care is an official peer-reviewed journal of the American Association of Critical-Care Nurses (AACN) published bimonthly by AACN, 101 Columbia, Aliso Viejo, CA Telephone: (800) , (949) , ext Fax: (949) Copyright 2016 by AACN. All rights reserved.