Successful Implementation of Low-Cost Tele-Critical Care Solution by the U.S. Navy: Initial Experience and Recommendations

MILITARY MEDICINE, 182, 5/6:e1702, 2017 Successful Implementation of Low-Cost Tele-Critical Care Solution by the U.S. Navy: Initial Experience and Recommendations CDR Konrad Davis, MC USN* ; LT Alexandra Perry-Moseanko, MC USN*; CDR Matthew D. Tadlock, MC USN ; Nichole Henry, RN ; LTC Jeremy Pamplin, MC USA ABSTRACT Intensivist physician involvement has been shown to improve outcomes for critically ill patients. Unfortunately, the number of Intensivists nationally is unable to meet the current demand. Similar to the civilian community, the Navy critical care workforce is limited by available resources. Tele-critical care (TCC) has recently been shown to improve outcomes for critically ill patients, and has been suggested as a suitable means of extending Intensivist expertise. Naval Hospital Camp Pendleton (NHCP) is a small community hospital located 41 miles north of Naval Medical Center San Diego (NMCSD). NHCP operates a relatively low-volume six-bed medical-surgical intensive care unit. The Intensivist staffing of NHCP has been variable, ranging from 3 Intensivists to periods of time with no on-site Intensivists. This intermittent staffing has led to (1) network disengagements, (2) unnecessary transfers to NMCSD, and (3) adverse outcomes for critically ill patients cared for at NHCP without Intensivist involvement. In early 2014, NMCSD established a TCC system to address this staffing challenge. Through the TCC program, the tele- Intensivist at NMCSD provides 24/7 coverage for patients located at NHCP using low-cost, off-the-shelf, synchronous high-definition video-teleconferencing equipment, and remote access to electronic medical record, imaging studies, and laboratory data. The tele-intensivist also participates in multidisciplinary teaching rounds with the NHCP house staff. Several medical protocols have also been developed and implemented as part of the TCC program. When comparing the 12 months before implementation with the 19 months following implementation, we found (1) a trend toward increase volume of admissions per month (22.9 ± 7.5 vs. 27 ± 6.6, p = 0.11), (2) a decrease in total number of avoidable disengagements (12 ± 0.9 vs. 0, p = 0.0008), (3) increased maximum Acute Physiology and Chronic Health Evaluation II score per month (17.22 ± 2.2 vs. 21.8 ± 5.5, p = 0.018), and no adverse outcomes related to the TCC system. This reduction in disengagements correlated with a savings in out-of-network expenditures of $1.3 million over the 19 months of program operation. There was no change in either the patients length of stay or the number of patients transferred to NMCSD. TCC improves readiness by increasing the volume and acuity of critical care patient encounters at the spoke hospital. TCC can also enhance Graduate Medical Education by providing Intensivist teaching, and supports the concept of Regionalized Care by improving the integration of care between hospitals. The quality of care is improved through the more rapid transfer of patients who require a higher level of care, standardization of care through protocols, and the Intensivist expertise that is applied to patients kept at the smaller facility. The value of care increased through both enhanced quality, and the cost savings associated with decreasing network disengagements. Leveraging new technology to provide remote care for our sickest beneficiaries has been proven a successful solution to the dilemma of limited Intensivist staffing. Leadership should consider TCC as a tool to extend Intensivist expertise to all of our small hospitals, and should explore the application of synchronous telehealth within the operational environment where similar staffing challenges exist. INTRODUCTION Critical care in the United States accounts for $81.7 billion annually, which is more than 10% of total hospital costs. 1 Much of this care is spent on patients over 65 years of age. 2 As the population continues to age, the percentage of *Department of Pulmonary and Critical Care Medicine, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134. Department of Surgery, Naval Hospital Camp Pendleton, 200 Mercy Circle, Camp Pendleton, CA 92055. Department of Nursing, Naval Hospital Camp Pendleton, 200 Mercy Circle, Camp Pendleton, CA 92055. U.S. Army Institute of Surgical Research, 3698 Chambers Pass, Suite B, JBSA Fort Sam, Houston, TX 78234. The Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20889. The views expressed herein are the authors own and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Government. doi: 10.7205/MILMED-D-16-00277 individuals over 65 years of age is expected to increase 50% by 2020 and double by 2030. 3 With an increasing shift of care to the outpatient setting, a greater percentage of inpatient care is also likely to focus on higher acuity patients. For all of these reasons, the need for critical care is likely to increase in the coming decades. Unfortunately, the number of intensivists nationally is unable to meet the current needs. 4 Similar to the civilian community, the Navy critical care workforce is limited by available critical care resources. For many reasons, the applicants to Navy Pulmonary and Critical Care Medicine (PCCM) graduate medical education programs have decreased in recent years. Currently the 3-year Navy PCCM training programs are only 42% filled. Related to Intensivist burnout and retirement, losses to the PCCM community are likely to exceed gains over the next several years, further exacerbating the staffing shortfall. As a result, not all Navy hospitals provide continuous coverage by critical care-trained physicians. 5 However, Intensivist staffing e1702

has been demonstrated to improve outcomes in the intensive care unit (ICU) and has been associated with a 30% hospital mortality reduction, a 40% ICU mortality reduction, 6 and a decrease in ICU length of stay. 7 Furthermore, Pronovost demonstrated a significantly reduced mortality in those ICUs utilizing a high intensity Intensivist staffing model. 6 Accordingly, over the last 15 years, Intensivist staffing has become the standard of care, and is recommended by the Leapfrog Group, 8 the American Academy of Critical Care Medicine, 9 the Society of Critical Care Medicine, 10 and is required by the current Navy Bureau of Medicine and Surgery (BUMED) instruction. 11 With predicted insufficient numbers of Intensivists to adequately staff all of the hospitals in the Navy, alternative solutions must be considered. Tele-critical care (TCC) allows for remote monitoring and extension of Intensivist expertise to areas that would otherwise have limited critical care resources. 4 In this model, remote monitoring staff interact (typically through high-definition video-teleconference [VTC] technology) with on-site patients and staff, and review real-time bedside monitors, clinical data, and online clinical decision support tools. 12 Although the earliest forms of TCC can be traced back to the 1970s, it was not until 2001, when the first real ICU telemedicine was performed. 13 TCC monitoring has spread rapidly over the last 15 years and has improved dramatically as technology has advanced. In 2003, only 16 hospitals out of 4,760 surveyed had adopted ICU telemedicine and provided coverage of 598 ICU beds. From 2003 until 2006, there was a rapid increase in tele-icu utilization with an annual growth rate of 132.3% per year. The growth has slowed but has continued steadily at 8.4% per year over 2007 2010. As of 2010, 213 hospitals were utilizing tele-icu capabilities with coverage for 5,799 beds. 13 A recent review of hospital practice identified 14% of ICU beds in the United States being supported through telemedicine. 14 Telemedicine is rapidly becoming standard of care. Related to limited staffing, Naval Hospital Camp Pendleton (NHCP) has experienced periods with no available on-site critical care physicians. In early 2014, Naval Medical Center San Diego (NMCSD) created a low-cost TCC capability to support NHCP. We describe our initial experience implementing and providing this capability. The results of this project are reviewed in this article, along with considerations for future Navy Critical Care staffing. MATERIALS AND METHODS NHCP is a military community hospital that operates a low acuity, modified-open, level II, six-bed ICU. 8 This facility supports a patient population of 157,000 active duty personnel, family members, and retirees. The hospital has access to subspecialists to include cardiology, pulmonology, gastroenterology, neurology, otolaryngology, orthopedics, and general surgery; however, procedural interventions are limited by support capabilities. NMCSD is located approximately 41 miles south of NHCP, and acts as the regional referral center for 4 other military Department of Defense hospitals. NMCSD is a 271-bed hospital with 1,400 ICU admissions per year that supports a patient population of 368,000 with a full spectrum of subspecialty care. The ICU at NMCSD is staffed by Pulmonary, Anesthesia, Surgical, and Infectious Disease Critical Care physicians, and hosts trainees from more than a dozen Accreditation Council for Graduate Medical Education training programs. As per BUMED policy, 11 all patients admitted to the NHCP ICU require an Intensivist consultation. Since August of 2014, Intensivist notification is required within 2 hours of admission and formal consultation within 12 hours. To address Intensivist shortages, NMCSD, in conjunction with NHCP leadership, established a TCC support solution. A TCC monitoring center was created at NMCSD, which included high-definition VTC equipment. Remote access to the NCHP electronic health record (EHR) was already available. Special permissions from higher headquarters were obtained for access to imaging studies performed at NHCP, but no additional equipment was necessary to obtain this access. Hub site VTC was conducted using a Cisco EX90 terminal at NMCSD, whereas NHCP utilized a Cisco Telepresence mobile VTC cart (model no. CTS-35F) (Cisco, San Jose, California). This low-cost solution allowed TCC providers to visualize the patient rooms during rounds and interact with the on-site staff. The program utilized a centralized paradigm sometimes referred to as a hub and spoke model. 10 The Tele-Intensivist at NMCSD (the hub site) would take shifts of call when intensivists were not available at NHCP (the spoke site). These periods lasted anywhere from a few days up to several months. A specific TCC consult note was created, and the program was staffed by 6 intensivists (5 PCCM physicians and 1 infectious disease CCM physician) who would take call 24 hours per day. By agreement, the hub site monitored the spoke for at least 1 week in every 6-week period; however, more shifts were often taken because of Intensivist shortages at the spoke site. The longest continuous coverage period was 3 months. In an effort to standardize best practice measures, a joint website was established to share protocols, policies, and care pathways on the government site Max.gov (https:// max.gov). Access to this document share is through permissions granted by the TCC program manager (the corresponding author, KD). Where protocols did not exist, NHCP was encouraged to either adopt the NMCSD protocols or develop their own in consultation with the NMCSD TCC service. Table I lists the new protocols that were created in association with initiation of the TCC system. Successful implementation also required the development of an inter-facility workflow to facilitate joint billing and coding by both NHCP and NMCSD. This workflow required the billing/coding departments for each hospital to run an EHR report once per week to identify patients who received TCC services. e1703

TABLE I. 1) ICU Electrolyte Management 2) Pain, Agitation, and Delirium 3) Massive Transfusion 4) Postcardiac Arrest Resuscitation 5) Continuous Insulin Infusion 6) Anticoagulation Reversal 7) Sepsis Protocol Protocols Developed for TCC Operation During periods of TCC coverage, the tele-icu attending was immediately available for phone consultation 24 hours a day. Multidisciplinary teaching rounds were conducted every morning at the spoke site utilizing the installed VTC technology. Additional virtual rounds were conducted when requested by the Tele-Intensivist or spoke site clinicians, or if requested by the ICU Nurse, resident physician, or attending physician using VTC technology. All of the NMCSD Intensivists working in the TCC unit were credentialed at NHCP, and had real-time access to patient information, imaging and laboratory data, and vital signs via remote access to NHCP s EHR. Documentation was performed by the TCC physicians in NHCP s EHR using a specific telemedicine consult note created to document tele-consultations and to better account for TCC resource utilization. During periods of TCC coverage, all procedures were performed by on-call, spoke site physicians as identified by local spoke site policy. Communication between the Tele-Intensivist and these local clinicians was facilitated by using the duty phone registry for the spoke hospital. A downtime plan was established to direct care and actions in the event of system technological failure. In the event of technological failure, the TCC Intensivist first determined whether the specific deficiency (i.e., VTC, remote electronic medical record access, remote radiology viewing) posed an immediate risk to patient safety or care. Second, the availability of on-site Intensivists was assessed. If the technological deficiency posed an immediate risk and no on-site Intensivists were available, then the patient was transferred to NMCSD. To examine the impact of the TCC implementation at NHCP, patient demographics and quality assurance data for ICU admissions were collected following program implementation (March 14 to September 15) and was compared to data collected retrospectively for a 12-month period before program implementation (January 13 to December 13). A 2-month period following TCC program implementation (January 14 and February 14) was excluded from data analysis to allow the program to mature its practices as reported by other authors (Lilly et al 2014). We also compared the number of patients transferred from NHCP to civilian hospitals before and after program implementation. Transfers were judged to be unavoidable if medical care required the patient to be sent to either the closest appropriate hospital (e.g., patients with ST-elevation myocardial infarction), or to a specific hospital for specialty care not available at NMCSD (such as burn critical care or for a trauma evaluation). Transfers for long-term placement and patients who were not eligible for care were excluded from analysis. All other transfers for critical care were termed avoidable. Adverse outcomes or events were collected by NHCP using a military specific Patient Safety Reporting ( PSR ) system. Review of the data for the TCC program was classified as quality assurance/process improvement by the NMCSD institutional review board. RESULTS The establishment and maintenance of this single-center TCC support capability was accomplished for less than $50,000, all of which was used for the initial procurement of equipment. For the 19-month period following implementation, a total of 171 patient consults were performed by the NMCSD TCC unit. This included patients requiring mechanical ventilation, active resuscitation with crystalloid and/or blood products, and patients requiring infusion of vasopressors. TCC coverage varied by month. During the summer of 2014, the TCC program provided 100% of coverage for NHCP over a 3-month period. Similarly, over the summer of 2015, the TCC program provided approximately 50% of the ICU coverage during a 4.5-month period. This variability in coverage was dependent on the availability of on-site Intensivist staffing. Since March 2014, the TCC system has been on-call for 34% of the NHCP ICU days. Over the 19-month period since program inception, there were no periods of down-time which lasted for greater than 12 hours, and no patient transfers were required because of technological failures. During the 12 months before the TCC program, a total of 12 avoidable transfers to civilian hospitals occurred for critical care services. Since TCC program implementation, there have been no avoidable transfers to the civilian network for ICU services. Over the same time period, there was no change in the average length of stay (1.25 vs. 1.26 days, p = 0.62); however, an increase was observed in the maximum Acute Physiology and Chronic Health Evaluation (APACHE II) score (17.2 ± 2.2 vs. 21.8 ± 5.5, p = 0.018) per month. Average patient ventilator days (0.9 ± 1.1 vs. 1.3 ± 0.8, p = 0.82) and central line days (1.3 ± 2.2 vs. 2 ± 2.5, p = 0.60) showed a nonstatistically significant increasing trend, as did the average monthly surgical ICU admissions (2.5 ± 1.8 vs. 3.6 ± 2.7, p = 0.23). Although there was an increase in ICU deaths at NHCP following TCC implementation (0 vs. 4), all of these deaths occurred in end-of-life situations where palliative care was delivered. TCC was involved in the care of 3 of these 4 patients. Table II compares the number of admissions, demographics, and outcomes for the ICU at NHCP during the 12 months before, and the 19 months after TCC implementation. There have also been no adverse outcomes related to TCC involvement on the basis of the Navy Patient Reporting System. e1704

TABLE II. Comparison of Data Before and After Implementation of a TCC Program Before TCC After TCC p Value Average NHCP ICU Admissions Per Month 22.9 ± 7.5 27.0 ± 6.6 0.11 Average NHCP Transfers to NMCSD ICU Per Month 1.7 ± 1.5 1.6 ± 1.3 0.92 Average Total ICU Transfers to Civilian Network (Hospital) a 12 ± 0.9 0.0 ± 0 0.0008 Average Patient Age 44.8 ± 5.9 48.2 ± 4.2 0.21 Average Patient APACHE II Score 7.1 ± 1.8 7.5 ± 1.4 0.60 Average Maximum APACHE II Score for Each Month 17.2 ± 2.2 21.8 ± 5.5 0.018 Average Number of Patients with APACHE II Score 15 for Each Month 2.3 ± 1.6 2.7 ± 1.7 0.88 Average Length of Stay (Hours) 30.0 ± 6.3 31.1 ± 6.3 0.62 Average Patient Ventilator Days Per Month 0.9 ± 1.1 1.3 ± 0.8 0.82 Average Patient Central Line Days Per Month 1.3 ± 2.2 2.0 ± 2.5 0.60 Total Deaths 0 4 0.60 Average Number Internal Medicine Admissions Per Month 11.4 ± 4.5 15.1 ± 8.3 0.27 Average Number Family Practice Admission Per Month 7.5 ± 3.8 4.8 ± 3.1 0.05 Average Number General Surgery Admissions Per Month 2.5 ± 1.8 3.6 ± 2.7 0.23 Does not include unavoidable transfers. Unavoidable transfers include (1) patients not eligible for care in our health care system, (2) patients requiring a specialized service not available in our system, such as burn ICU or trauma ICU, (3) patients requiring transport to the closest hospital for specialized care (such as management of ST-elevation myocardial infarction), or (4) patients requiring transfer to a facility for long-term care or placement. a Does not include Neonatal and Pediatric ICU patient transfers, only adult patients. The bold values in this table are the ones that reached statistical significance (based on their p value). Comparison of patient transfer to NMCSD from NHCP demonstrated similar rates of transfer per month (1.7 ± 1.5 vs. 1.6 ± 1.3, p = 0.92) when comparing pre- and postintervention periods. The TCC program also allowed for support of the Family Practice residency program at NHCP through teaching during TCC rounds. During the 19 months since TCC program inception, the TCC Intensivist has participated in teaching with 76 Graduate Medical Education residents or trainees. DISCUSSION In this comparison of patients admitted to a Navy community hospital before and after the introduction of a low-cost TCC service, we found that the number of patients admitted monthly to the spoke site ICU increased, the illness severity of these patients increased, the number of surgical ICU admissions increased, the number of transfers to partnering civilian centers for critical care support decreased dramatically, and no adverse outcomes related to TCC were identified. Ultimately, we believe that this comprehensive TCC support solution provided greater confidence for NHCP staff to retain care of their patients (instead of transferring that care to the community hospital network). These finding strongly support the need to continue, and indeed expand TCC services within the Navy and the Military Health System (MHS). Although our results are preliminary and only available from Quality Assurance data, they are similar to findings by others. In 2011, Lilly et al performed a study to evaluate hospital mortality, hospital length of stay, and preventable complications both before and after adoption of a TCC model in an attempt to quantify the benefits of tele-icu care. 15 It was performed at a single academic medical center from 2005 to 2007 in medical, surgical, and mixed cardiovascular ICUs. It also evaluated care processes around the implementation of a tele-icu. After implementation of a tele-icu model, the hospital mortality decreased to from 13.6% to 11.8%. Both ICU mortality and ICU length of stay decreased as well (10.7 8.6% and 6.4 4.5 days, respectively). Importantly, the study also demonstrated a greater adherence to best practices of stress ulcer prevention, deep vein thrombosis prevention, cardiovascular protection, ventilator-associated pneumonia prevention, and lower rates for preventable complications. These findings were consistent across all types of ICUs. Ultimately, this study demonstrated that patients in tele-icus were getting higher quality of care at lower cost. The same group published a follow-up study in 2014 that analyzed ICU length of stay, hospital length of stay, and mortality across 32 hospitals throughout the United States. 16 The study included 118,990 patients across 19 different U.S. health care systems. The ICUs involved in the study spanned from 88 to 834 licensed beds and served rural, suburban, and urban hospitals. The urban centers represented 57% of the hospitals involved in this study. The mortality rate for the telemedicine group was significantly lower than controls despite a higher APACHE II score in the telemedicine group. In addition, both hospital and ICU length of stay were reduced in the telemedicine group. In this study, telemedicine care was associated with higher frequency of Intensivist case review within 1 hour of ICU admission, more frequent review of performance data with hospital leadership, higher levels of adherence to ICU best practices, more rapid responses to alerts and alarms, more frequent interdisciplinary rounds, and a more effective ICU committee as judged by ICU clinical leaders. Finally, Sadaka et al conducted a retrospective review of data before and after implementation of a telemedicine ICU program for all patients admitted to their community e1705

hospital. 17 This study involved more than 2,700 patient admissions, and demonstrated a significant reduction in both ICU mortality (7.9 3.8%, p < 0.0001), and ICU length of stay (2.7 2.2 days, p = 0.01). The Department of Defense first started TCC in 2001 when Tripler Army Medical Center (TAMC) started a pilot program to remotely monitor and support U.S. Naval Hospital Guam. At the time of inception, this program was truly innovative. However, without dedicated manpower and no TCC nurses, the TAMC program has not been capable of providing continuous real-time monitoring, operating rather on an as needed basis. Outside of TAMC s program, the military has been slow to adopt TCC. The NMCSD TCC program has successfully provided TCC support to NHCP over an extended period with no adverse events. To our knowledge, this is the first description of a comprehensive TCC support solution implemented by the U.S. Military. This model has allowed for more efficient utilization of existing manpower, and it completely eliminates avoidable network disengagements. Although the query of patient-specific billing data was not within the scope of this PI project, estimations of the financial impact can be achieved through standardized data. The cost of critical care varies by institution; however, ICU occupancy rates typically exceed $3,000 to $4,000 per day. 18,19 Accounting for all expenses, the Agency for Healthcare Research and Quality estimates mean charges for patients requiring ICU-level care are $61,800 per hospitalization. 20 During the preintervention period, patient disengagements averaged one per month. Elimination of disengagements during the 19 months since TCC program inception would therefore correlate with a cost savings of $1.17 million. Other aspects of program impact may be harder to objectively quantify, but are perhaps even more important to consider. By supporting on-site staff to care for higher acuity patients (including patients requiring mechanical ventilation and active resuscitation), TCC also indirectly supports the operational readiness of forward-deployable staff including physicians, nurses, and corpsman to the demand for wartime skill competency. Retention of higher acuity patients also supports the graduate medical education program in Family Medicine located at the spoke site facility. Although currently limited by communication bandwidth, we believe that the application of our TCC model has even greater potential to extend medical subspecialist expertise to our forward deployed units and ships. Finally, patient experience is also enhanced by allowing NHCP beneficiaries to remain in close proximity to their families and units and by minimizing unnecessary transfers. When examining the four deaths at NHCP during the TCC period, an example of enhanced patient experience can also be found. All four of these patients were treated with palliative intent. In the past, these patients would have been transferred out of the direct care network, and would have died in an environment unfamiliar to them and their families. Through the support afforded by the TCC system, several of these patients and their families were able to stay closer to their homes and friends (while receiving care at NHCP) for their final days. This study has limitations worth mentioning. Our experience pertains to a single hub and spoke system over a relatively short intervention period (19 months). This raises concern for the generalizability of our results. However, we believe that NHCP is similar (in staffing and business processes) to many of the small hospitals in the Navy and that our results would therefore be similar at other locations. The observational nature of the study may also fail to account for factors that could have influenced trends in patient care at NHCP. However, this same observational nature helps to create a more realistic scenario in which to evaluate the impact of a TCC support solution. In conclusion, this study demonstrates the viability of a low-cost, pilot TCC solution for the MHS. TCC has the potential to increase patient admissions, patient illness severity, and surgical volume, and to decrease transfers of patients that need only critical care consultation and monitoring to nearby civilian centers. These successes could have significant impact on military readiness and value. On the basis of these finding, the potential to increase clinician experience caring for critically ill patients in our military community hospitals also has a direct impact on the operational readiness of these clinicians. In particular, the increase in surgical case volume may improve readiness of critical care nurses to manage postoperative trauma patients during combat operations. The potential for cost savings by maintaining critically ill patients within the MHS is also significant and requires further investigation. Related to enhanced readiness, potential cost savings, and improved quality of care, we believe that the MHS should consider enterprise wide expansion of TCC services. REFERENCES 1. Centers for Medicare and Medicaid Services. NHE Fact Sheet. Available at https://www.cms.gov/research-statistics-data-and-systems/ Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact- Sheet.html; accessed May 6, 2016. 2. Lilly CM, Zuckerman IH, Badawi O, Riker RR: Benchmark data from more than 240,000 adults that reflects the current practice of critical care in the United States. Chest 2011; 140: 1232 42. 3. Vincent GK, Velkoff VA: The next four decades: the older population in the United States: 2010 to 2050. US Census Bureau 2010. Available at http://www.census.gov/prod/2010pubs/p25-1138.pdf; accessed May 6, 2016. 4. Afessa B: Tele-intensive care unit: the horse out of the barn. Crit Care Med 2010; 38(1): 292 3. 5. Duke EM: US Department of Health and Human Services, Health Resources and Services Administration Report to Congress. The Critical Care Workforce: A Study of the Supply and Demand for Critical Care Physicians. Bureau of Health Professions 2006. Available at http://bhpr.hrsa.gov/healthworkforce/reports/studycriticalcarephys.pdf; accessed May 6, 2016. 6. Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL: Physician staffing patterns and clinical outcomes in critically ill patients. JAMA 2002; 288(17): 2151 62. e1706

7. Wilcox M, Chong CA, Niven DJ, et al: Do intensivist staffing patterns influence hospital mortality following ICU admission? A systematic review and meta-analyses. Crit Care Med 2013; 41(10): 2253 73. 8. Haupt MT, Bekes CE, Brilli RJ, et al: Guidelines on critical care services and personnel: recommendations based on a system of categorization of three levels of care. Crit Care Med 2003; 31(11): 2677 83. 9. Weled BJ, Adzhigirey LA, Hodgman TM, et al: Critical care delivery: the importance of process of care and ICU structure to improved outcomes: an update from the American College of Critical Care Medicine Task Force on models of critical care. Crit Care Med 2015; 43: 1520 5. 10. Reynolds NH, Rogove H, Bander J, McCambridge M, Cowboy E, Niemeier M: A working lexicon for the tele-intensive care unit: we need to define tele-intensive care unit to grow and understand it. Telemed e-health 2011; 17(10): 773. 11. BUMED Instruction 6320.97A: Navy Medical Treatment Facility Intensive Care Unit Model and Re-Designation. Available at http://www.med.navy.mil/directives/externaldirectives/6320.97a.pdf; accessed May 6, 2016. 12. Khunlertkit A, Carayon P: Contributions of tele-intensive care unit (Tele-ICU) technology to quality of care and patient safety. J Crit Care 2013; 28: 315e1 12. 13. Kahn J, Cicero BD, Wallace DJ, Iqashyna TJ: Adoption of intensive care unit telemedicine in the United States. Crit Care Med 2014; 42(2): 362 8. 14. Pastores S, Halpern N, Oropello J: Critical Care Organization in Academic Medical Centers in North America: a descriptive report. Crit Care Med 2015; 43(10): 2239 44. 15. Lilly CM, Cody S, Zhao H, et al: Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-icu reengineering of critical care processes. JAMA 2011; 305(21): 2175 83. 16. Lilly CM, McLaughlin JM, Zhao H, et al: A multicenter study of ICU telemedicine reengineering of adult critical care. Chest 2014; 145(3): 500 7. 17. Sadaka F, Palagiri A, Trottier S, et al: Telemedicine intervention improves ICU outcomes. Crit Care Resp Pract 2013; 2013: 1 5. 18. Cleveland Clinic. Patient Price Information List. Available at https:// my.clevelandclinic.org/ccf/media/files/patients/hb197_main_2010.pdf; accessed May 6, 2016. 19. Halpern NA, Pastores SM: Critical care medicine in the United States 2000 2005: an analysis of bed numbers, occupancy rates, payer mix, and cost. Crit Care Med 2010; 38: 65 71. 20. Barrett ML, Smith MW, Elixhauser A, Honigman LS, Pines JM: Utilization of Intensive Care Services 2011. HCUP 2014. Available at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb185-hospital-intensive- Care-Units-2011.pdf; accessed May 6, 2016. e1707