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  • Three years ago Clarian heath instituted the electronic monitoring of its ICU patients. IT stated the Adult and neuroscience critical cares at Methodist. A year later University hospital’s Medical, Surgical, Neurosurgical, and Progressive care Units were gradual added The ICU’s at the North and West locations were the first contracted hospitals. Within the year we will ass the New transplant and Oncology units at University hospital. This year we will also contract out to hospitals in northern Indiana. NASA scientists help developed this technology while monitoring astronauts. The future may bring telemedicine as part of routine home care for out patients. I Just want to toot some the contributions of the space program for medicine Programmable pacemakers, Implant defibrillators, Joint replacement technology. Voice activated wheel chairs Insulin pumps and Blood sugar analysis and cancer therapies.
  • The complexity of the ICU environment and the shortage of trained physicians initiated this the typed of “managed” care. To mount a response and enhance patient care the bedside nurse can now mobilize resources from unseen nurses and physicians. The staffing models were to improve hospital quality and safety for the critically ill. The nursing shortage of 1980’s spurred research on patient outcomes among different health providers. They were retrospective studies of hospitalized patients who experienced adverse events that led to complications. The focus of this search showed the need for comprehensive and precise collaborations to rescue the patient. Timely interventions in preventing deaths are dependent upon the bedside nurse’s diligent surveying of the patient’s alterations in normal responses to clinical management. Nurses are often the first to detect early signs of possible complications their vigilance makes timely responses more likely (Clarke &, Aiken 2003).
  • Tele Latin distance Medicine mederi healing We use the term telemedicine rather than tele health because tele health is more a descriptive of the technology. Telemedicine uses a variety of disciplines to administer heath. The age of manage care has limited access with early discharges, decreased community agencies
  • Benner states, “Where good communication exist between doctors and nurses and collaborative interactions prevail, flexibility increases and the patient benefit” (Benner, 2001, p. 144). Benner’s conclusion notes that the influencing factor to benefit our patients is the staff’s adaptability. The changing environment in the intensive care unit (ICU) is beginning to include a one-way camera and push button access to another human relationship via the remote audio and visual monitoring of a telemedicine unit (TMU). Technology is providing the bedside nurse with a safety net to aid in the perception and detection of changes. Communicating changing alterations in the patient’s health status provides a safe plan of care. What does the bedside nurse say about adapting to this telecommunications technology?
  • Containing the health has cause a health environment the a is utilizing technology to increase the contact with experts which delete constrains of distance. The equipment allows for increased contacts with the patient but creates controversy regarding liability responsibility. Is it the consulting or treatment physician. The current legal trend is putting responsibility on the physician with most physical contact . CHF readmission $600,000 Computer touch screen, monitor, speaker, medical device for measuring VS -Monitor heart and lung sounds and provide interactive audio visual conferencing Neonates monitoring infants with apnea with radio signal for respiration and heart beat
  • Explain informative lessons learned in unit dievelopment Give demonstration of equipment and explaining our processes to monitor patients. Charges for the service are based on the Costs include hardware networking, wiring, connection links and interfaces licenses
  • Complaints for Physicians MC could not take shift because of incomplete paper work Review critical patients and Task request
  • smart alerts for vital sign changes smart alerts for labs Acid/Base alert Creatinine Clearance Alert Hemoglobin alert Potassium alert
  • The changing environment in the intensive care unit (ICU) is beginning to include a one-way camera and push button access to another human relationship via the remote audio and visual monitoring of telemedicine unit Benner states, “Where good communication exist between doctors and nurses and collaborative interactions prevail, flexibility increases and the patient benefit” (Benner, 2001, p. 144). Benner’s conclusion notes that the influencing factor to benefit our patients is the staff’s adaptability.
  • Equipment 2 bedside VS monitors open Patient profile care plan Camera Patient chart Smart alerts Review process of low sat alarm’ After 2 minutes Check bedside VS monitor Review alarms Camera in to room Check Profile trends Patient record; Read Only Enter orders in to the Viscue EICU program the unit secretary enters orders into the electronic patient record Cerner Physician station has computer access to all radiological images and reports Verify placement of corpac tubing Small bore feeding tube with mercury weighted tip enertal for nasointestional feedings into the small bowel, to reduce aspiration risk.
  • Changing monitor for traveling to procedures interventional radiology angiogram PICC line Radiology CAT scan Bedside procedures Endoscopic Trach Peg Line placements
  • DVT Device SCD Meds: Heparin drip, Coumadin, subcutaneous heparin Monitoring neuro unit call
  • Paging Non compliant MD ICU Referrals Patient Safety Taking non-prescribed medications Agitated ICU psychosis Family dysfunction Antibiotic changes match Culture sensitivity
  • This study will be looking existing data only as it relates to the 443 responses to the two open-ended questions to evaluate trends and categorize responses regarding advantages and disadvantages for the nurse practicing at the bedside. Comments were tallied to establish a list of the advantages and disadvantages. Five main viewpoints from the bedside nurse perspective were developed.
  • Telemedicine Consultations .Lack of access to physicians was a priority to address for the nurse because it eliminate leaving the patient to page and then wait for a return call. They felt it tackle their need to be available to the patient when they were unable to access an attending physician. The fast response and medical availability relieved their frustrations when they could not get a physician response or determine whom to call. While they preferred to speak to the attending, the telemedicine unit provides quick non-critical miscellaneous orders. The ability to obtain orders was seen by some as a reason to extend the hours into the day shift. For the nightshift the push button access was consider an easy back up when patient problems need responders. Nurse felt it was difficult for them consulting an “e-physician” who had no knowledge of the patient’s background. Further, the e-physician may send orders regarding the patient that the bedside had not addressed. Such orders did not always accompany accurate notification hindering actions at the bedside. Nurse Consultants The tele-nurses monitoring patients around the clock and were considered professional and courteous. Staff was appreciative of their availability, readiness to assist, and their strong clinical backgrounds. Staff concerns were in confidence of a nurse monitoring an ICU specialty that did not match previous clinical experience. The bedside felt each tele-nurse should be educated to the specific patient population. Surveillance The enhanced level of monitoring was seen as an advantage since it allowed the patient to be watched when the nurse was away from the bedside. “It’s like having an extra pair of eyes especially when I am spread thin”. The greatest advantage was visual surveillance when unit demands were high. The operational aspects of the equipment were disruptive to the nurse at the bedside. Common complaints were the bell to announce the tele-nurses activation of the camera was too loud, did not always work or it disturbed the patient. Nurse also wanted two-way monitoring to see who was addressing them and identifying patient issues. Further bedside wanted the nurse behind the camera to always announce him or herself and state their purpose for entering the room. Emergent/Patient Safety Help when no one was around was due to a faster physician response. Patients received better care during emergencies was a common conclusion. Emergency response for a coding patient allowed immediate treatment orders; again, the nurses wanted to be sure to receive written notification sent. In addition, the tracking of done by the monitoring unit was seen as patient safety. The nurse expressed relief that someone was keeping “up on things”. Some expressed relief in having a convenient support to follow the physiological trends and maintain a comprehensive view of the patient. Patient Collaborations Providing communications that are more effective was the primary disadvantage expressed by the bedside nurse. Relaying of the information they already had or not getting information to them earlier troubled the bedside nurse. The phone calls for gathering patient data interrupted the management of clinical issues and interaction with patient’s families. A telemedicine advantage was a resource of information. Researching a disease, sending information or a medication, and trouble-shooting equipment were helps to the bedside nurse.
  • Telemedicine

    1. 1. Telemedicine Lilith J. Hutchinson BSN, RN
    2. 2. Objectives <ul><li>Define terminology regarding telemedicine /teleheath </li></ul><ul><li>Review the historical presentation of this technology </li></ul><ul><li>Present current expertise and enterprises incorporating telemedicine interfaces </li></ul><ul><li>Learn how technology monitors management of the Intensive Care Unit (ICU)patient </li></ul><ul><li>Discover the support and resources for the bedside nurse </li></ul><ul><li>Explore the nursing practice in teleheath </li></ul>
    3. 3.
    4. 4. Historical perspective <ul><li>Studies documenting patient benefit with access to intensivist. </li></ul><ul><li>Gap between intensivist and un-served populations </li></ul><ul><li>Linda Aiken nursing shortage studies </li></ul><ul><li>Leapfrog Group established staffing standards of 24/7 for physicians in the ICU. </li></ul>
    5. 5. Definition of terms <ul><li>Telemedicine ~ Medical information transmitted for patient safety by the inclusion of a camera and push button access to another human relationship. </li></ul><ul><li>Tele-physician ~ The physician has training and certification in the care of the patients who require monitoring in a critical care setting. </li></ul><ul><li>Tele-nurse ~ The nurse is one that has worked in a challenging critical care setting for at least five years. </li></ul>
    6. 6. Telemedicine Programs <ul><li>Collaboration ~Team members engaged to be flexible in gaining positive patient health outcomes. </li></ul><ul><li>Consultation ~ Contacting an expert individual to state a message and transfer ideas to reach an agreement. </li></ul><ul><li>Surveillance ~ Close observation and inspection paying attention to response or lack of progression to health. </li></ul>
    7. 7. Utilization of A Networking Technology <ul><li>ICU Consultations </li></ul><ul><li>Child Abuse </li></ul><ul><li>CHF monitoring </li></ul><ul><li>Updates Families of Neonates </li></ul><ul><li>Access for remote locations </li></ul><ul><li>Access for the medically underserved populations. </li></ul><ul><li>Treatment of wounded soldiers </li></ul><ul><li>Radiological consultations </li></ul><ul><li>Wound management </li></ul><ul><li>Emergency care </li></ul>
    8. 8. Telemedicine Monitoring <ul><li>Expand structures geographically to reach the community </li></ul><ul><li>Optimize the safety of critical care services </li></ul><ul><li>Offer services to increase referrals and spread out cost </li></ul><ul><li>Organized Networking Visits </li></ul><ul><ul><li>Ratios: Unit monitor / Hours covered </li></ul></ul><ul><ul><ul><li>Physicians </li></ul></ul></ul><ul><ul><ul><li>Nurse </li></ul></ul></ul><ul><ul><li>Fixed Costs </li></ul></ul><ul><ul><ul><li>Work stations </li></ul></ul></ul><ul><ul><ul><li>Computers </li></ul></ul></ul><ul><ul><ul><li>Building </li></ul></ul></ul>
    9. 9. Physicians <ul><li>Meet credentialing polices for each hospital system </li></ul><ul><li>Ventilator and Pharmacological trends </li></ul><ul><li>Order implementations </li></ul><ul><li>Manage Coding Patients </li></ul><ul><li>Radiological Conferences </li></ul>
    10. 10. E-Nurses <ul><li>Five years of clinical ICU experience </li></ul><ul><li>Assess baseline data for policy </li></ul><ul><ul><li>Vent Bundle/DVT prophylaxis </li></ul></ul><ul><ul><li>Sepsis/ microbiological </li></ul></ul><ul><ul><li>EKG rhythms/alarms </li></ul></ul><ul><li>Assess electrolyte correction </li></ul><ul><li>Glucose/Heparin verification </li></ul><ul><li>Educate partnership care </li></ul><ul><li>Facilitate contact with Indiana Organ Procurement Association (IOPA ) </li></ul>
    11. 11. Equipment <ul><li>Nurse are paired into monitoring pods for continuous coverage </li></ul><ul><li>Real-time vital signs from bedside monitor </li></ul><ul><li>E-Monitoring: Alarm Alerts, E-profile ,care plan </li></ul><ul><li>Virtual patient record </li></ul><ul><li>Radiology evaluation per physician / View written reports </li></ul><ul><li>Standards of care resource manual </li></ul>
    12. 12.
    13. 13. Assessment <ul><li>170 beds monitored in 4 hospitals 9 units </li></ul><ul><li>6 nurses per shift/ 24 hour accountability </li></ul><ul><li>1-2 physicians for 15 hours per day ( 4PM-7AM) </li></ul><ul><li>Patient Profile / correctly identified </li></ul><ul><ul><li>Last 6 hours of VS trends </li></ul></ul><ul><ul><li>New lab notification and alerts </li></ul></ul><ul><ul><li>Physician tasks: line removal, meds, protocols </li></ul></ul><ul><ul><li>Pertinent labs: ABG, Hg, WBC trends, lytes </li></ul></ul><ul><ul><li>History and progress notes </li></ul></ul>
    14. 14. Montoring Plans/Interventions <ul><li>Labs: Transfusion / Electrolyte replacement </li></ul><ul><ul><li>Creatinine clearance </li></ul></ul><ul><ul><ul><li><30 Notify pharmacy if no documented renal disease </li></ul></ul></ul><ul><li>Hypotension Bolus </li></ul><ul><li>Drip- Levophed / Dopamine </li></ul><ul><li>Vent bundle </li></ul><ul><ul><li>Deep vein thrombosis prophylaxis (DVT) </li></ul></ul><ul><ul><li>Head of bed 30 degrees </li></ul></ul><ul><ul><li>Oral care </li></ul></ul><ul><li>Peptic Ulcer Disease (PUD) prevention </li></ul><ul><ul><li>Eternal feedings/ Antacid </li></ul></ul>
    15. 15. Documentation <ul><li>Care plans updated qshift/admission notes / </li></ul><ul><li>Studies </li></ul><ul><ul><li>Evaluate aseptic technique for line placement </li></ul></ul><ul><ul><ul><li>Hand washing / Sterile set up / Puncture attempts </li></ul></ul></ul><ul><ul><li>Sepsis </li></ul></ul><ul><ul><ul><li>VS trends: HR >110, /WBC, bands, platelets/ </li></ul></ul></ul><ul><li>Interaction Statistics : </li></ul><ul><ul><li>Paging, lab follow-up, patient safety, alarms, medication /allergy incompatibilities </li></ul></ul><ul><ul><li>Unit oral and written notification of new orders </li></ul></ul>
    16. 16. Evaluation <ul><li>The survey looked at four areas </li></ul><ul><li>1) confidence and trust, </li></ul><ul><li>2) usefulness of information </li></ul><ul><li>3) professionalism </li></ul><ul><li>4) collaborative interactions. </li></ul><ul><li>The survey included two open-ended questions that asked the respondents to provide one positive aspect of the telemedicine unit and what aspect they would like to change. </li></ul>
    17. 17. Bedside Nurse Viewpoint Categories <ul><li>Telemedicine Consultations </li></ul><ul><li>Nurse Consultants </li></ul><ul><li>Surveillance </li></ul><ul><li>Emergent Patient Safety </li></ul><ul><li>Patient Collaborations </li></ul>
    18. 18. Bedside Clinician Perspective <ul><li>Advantages </li></ul><ul><li>Physician Assistance </li></ul><ul><li>Willingness to serve as an assistant to support patient </li></ul><ul><li>Identifying untoward trends </li></ul><ul><li>Mentoring to novice nurses </li></ul><ul><li>Collaborating outcomes </li></ul><ul><li>Disadvantages </li></ul><ul><li>Similar levels of expertise </li></ul><ul><li>Loss of bedside experience/assistance </li></ul><ul><li>Timing interruptions </li></ul>
    19. 19. References <ul><li>Benner, P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. New Jersey: Prentice Hall Health. </li></ul><ul><li>Clarke, S., & Aiken, L. (2003). Failure to rescue. American Journal of Nursing, 103 (1), 42-47. </li></ul><ul><li>Breslow, B., Rosenfeld, B., Doerfler, M., Burke, G., Yates, G., Stone, D., et al. (2004). Effect of multiple-site intensive care unit telemedicine program on clinical and economic outcomes: An alternative paradigm for intensive staffing. Critical Care Medicine, 31 (1), 31-38. </li></ul>
    20. 20. Questions?