tele-critical care support for guam
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As of: 18 Jun 2019LTC(P) Hipp, Sean/ sean.j.hipp.mil@mail.mil / 1-844-VMEDCEN Slide 1 of 42
“Medically Ready Force…Ready Medical Force”
Tele-Critical Care Support for Guam
J. Jonas Carmichael, MD, FCCMCDR MC USN
Associate Director, Joint Tele-Critical Care NetworkNaval Medical Center San Diego
As of: 18 Jun 2019LTC(P) Hipp, Sean/ sean.j.hipp.mil@mail.mil / 1-844-VMEDCEN Slide 2 of 42
“Medically Ready Force…Ready Medical Force”
Background
• Island of Guam
• US island territory in the Western Pacific: 1600 miles to Manila, Philippines; 3800 miles to Honolulu, HI
• Guam Memorial Hospital
• Only public hospital on the island
• 130 inpatient beds, a single 12-bed ICU, and limited Intensivist support
• Guam experienced a surge in COVID-19 associated sepsis and respiratory failure in early September 2020
• State declared a public health emergency, FEMA was asked to provide support, DISCA mission was generated for DOD
As of: 18 Jun 2019LTC(P) Hipp, Sean/ sean.j.hipp.mil@mail.mil / 1-844-VMEDCEN Slide 3 of 42
“Medically Ready Force…Ready Medical Force”
Leveraging information & audiovisual technology to extend expertise.
Joint Tele-Critical Care Network = JTCCN Currently provides support to 11 military
treatment facilities from 3 hub sites
Working to expand to operational space
Platform components Synchronous AV communication
EHR access (including labs, imaging, and notes)
Real-time data
Predictive analytics
What is TCC?
As of: 18 Jun 2019LTC(P) Hipp, Sean/ sean.j.hipp.mil@mail.mil / 1-844-VMEDCEN Slide 4 of 42
“Medically Ready Force…Ready Medical Force”
Supporting Literature in MHS
• NMCSD supporting NHCP• 2013 (before) vs 2014 (after)
• Increased volume & acuity of patient admissions
• Decreased disengagements to network
• Care was safe (actual vs predicted mortality)
• BCA identified ROI of 16%
• Increase number of surgical cases
• GLWACH• 2013 (before) vs 2014 (after)
• Increased volume & acuity of patient admissions
• Decreased disengagements to network
• $233K cost savings with ROI of 19%
• Care was safe (actual mortality vs predicted)
• Positive staff satisfaction scores
• Increased number of surgical cases
• NMCSD supporting NMCCL• 2015 (before) vs 2016 (after)
• Civilian Literature• Decrease LOS
• Decrease cost
• Decreased mortality
• Increased “best practice” adherence
Can TCC be used for Defense in Support of Civil Authorities (DISCA) missions?
As of: 18 Jun 2019LTC(P) Hipp, Sean/ sean.j.hipp.mil@mail.mil / 1-844-VMEDCEN Slide 5 of 42
“Medically Ready Force…Ready Medical Force”
TCC DISCA Model
Bedside hospitalists act as Intensivist extenders
Ward nurses can support critically ill patients with TCC nurse mentorship and support
Critical Care physician and nurse available 24/7
Remote electronic health record access (including imaging)
Definition of “Critically Ill” Invasive or non-invasive mechanical ventilation for acute respiratory failure
High flow oxygen (≥ 20 liters and ≥ 50%)
Shock (of any cause) with acute organ failures
Administration of vasopressors or antihypertensive infusions
Emergency privileging by hospital
TCC team check in at beginning of shift, and periodically throughout the day
TCC Team available for questions 24/7
6
Concept of Support with TCC
NETCCN
• Links remote expertise using secure asynchronous and
synchronous mobile communications to frontline nurses and
providers
• Provide flexible (up to 24/7) support to healthcare teams using
mobile devices (personal or locally furnished) through a cloud
based, HIPAA compliant, industry standard application
National Emergency Tele-Critical Care Network (NETCCN)
NETCCN TCC TeamsDeloitte Consulting with the DHA Tele-Critical Care Network
Avera Health
Expressions Network
The Geneva Foundation
Telemedicine and Advanced Technology Research CenterMedical Research and Development Command, US Army
In collaboration with the Society of Critical Care Medicine (SCCM) and the Assistant Secretary for Preparedness and Response
(ASPR), the Telemedicine and Advanced Technology Research Center (TATRC) is funded to support tele-critical care delivery at 4
locations utilizing NETCCN through OCT 2020.
As an RDTE project, TATRC will collect de-identified data from the applications about how they are used as well as survey
data from the end-users to determine best solutions from a technical standpoint and a workflow/staffing model.
COL Jeremy C. Pamplin, Director, jeremy.c.pamplin.mil@mail.mil, (3-7967) UNCLASSIFIED
NETCCN MTEC Proposal = Competition
9 Teams 6 Teams 4 Teams
Completed 10
Jul
~1 Sep –
31 Oct
22 Jul –
20 Aug
DoD Funded
ASPR FundedMore information at: https://www.tatrc.org/www/resources/covid-19.html
~1 Oct - Complete
COL Jeremy C. Pamplin, Director, jeremy.c.pamplin.mil@mail.mil, (3-7967) UNCLASSIFIED 7
As of: 18 Jun 2019LTC(P) Hipp, Sean/ sean.j.hipp.mil@mail.mil / 1-844-VMEDCEN Slide 8 of 42
“Medically Ready Force…Ready Medical Force”
Most common physician calls for management of respiratory failure, mechanical ventilation, ABG interpretation, and/or vasopressors.
Most common nurse calls were for: questions regarding medication compatibility and administration, evaluation of patient agitation and ventilator dys-synchrony, and discussion of patient care plan.
Limitations of support exist.
Results
No adverse events associated with TCC support.
Several notable examples of positive impact by TCC team.
GMH requested telemedicine support after on-site personnel departed.
473
255
14
470
64
31 days
ICU Patient Days (total)
Length of Support (Reflected in this Table)
Calls for Physician Support
Calls for Nursing Support
Code Blue Events
Patient Days of Mechanical Ventilation
As of: 18 Jun 2019LTC(P) Hipp, Sean/ sean.j.hipp.mil@mail.mil / 1-844-VMEDCEN Slide 9 of 42
“Medically Ready Force…Ready Medical Force”
Buy-in of bedside personnel is critical! Need to establish roles and expectations for the whole healthcare team
Bedside staff will have to do procedures
Educational content ready to deploy
Plan for connectivity in advance Deployable options exist
Determinant of the models of care, efficiency, and efficacy of support
Framework and support for emergency privileging is necessary
Policy needs to be updated to reflect telemedicine capabilities and interoperability
TCC can reliably and effectively extend critical care expertise
Lessons Learned
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