We are excited to share with you the second newsletter of the ICU4Covid project. It presents the inputs and outputs of the project as well as where the project vision is headed.
Accounting for the Heterogeneity of Hospitals: The Co-Creation of Models of Using CPS4TIC beyond the Tele-medical Ward Round Model
Prof. Dr. Ulrike Felt
(Timo Bühler, Carsten Horn, Michaela Scheriau, Neringa Simkute)
University of Vienna
Any technology comes with a vision of how it will be used. Developers envision future users, their skills, needs and the circumstances under which the technology will be used. They also anticipate the role of this technology in the place it is used. Often, innovators draw on their own experiences or at least experiences from their immediate environments when they imagine the future use of the technology they design. This technology, hence, often fits best with the circumstances developers experienced but may not be as easily transferable to other places as envisioned. In the ICU4Covid project, UNIVIE encountered similar transfer challenges. CPS4TIC or, more precisely, the tele-medical system MONA that is at its core responds best to the experiences and challenges from previous tele-medical projects in the region around Aachen in which the co-founders of the developing company have been involved. However, the hospitals in the ICU4Covid consortium are very heterogeneous. The varying starting points and health care systems hospitals are part of entail different needs, expectations, and concerns.
One example for this has been the models for doing telemedicine with CPS4TIC. Initially, and following the way telemedicine has been done in the Aachen region, the project had aimed for a “hub model” in which a central hospital is connected to one or several smaller hospitals as the telemedicine receivers. The consortium quickly had to realize that this was not applicable to all sites and that hospitals wanted and needed to develop site-specific models of using these tele-medical possibilities.
The co-creation approach that ICU4Covid has adopted seeks to explore and document the differences between the hospitals and facilitate conversations between developers and future users to collaboratively develop models of using CPS4TIC and corresponding user roles in ways that respond to these local needs and possibilities. Indeed, when engaging with the different hospital partners and during site visits, we encountered a considerable diversity of “socio-technical use models” across the hospitals in the consortium. In the following, we briefly describe each of these models that are either in practice or have been discussed as future scenarios for the use of CPS4TIC.
While it might seem as a “deviation” from the initial model proposed by the project, the opposite is true: Committing to co-creation means that there is space for acknowledging the heterogeneities of needs of future users and for adapting solutions accordingly.
Tele-medical Ward Round Model
This model is the initial vision of the project and follows the way telemedicine has been practiced in the Aachen region for more than ten years. In this case, the telemedicine unit at the University Clinic of Aachen conducts daily tele-medical ward rounds with other hospitals in the region. More recently, hospitals in Romania and in Greece have also taken up this offer and started presenting patients during regular rounds. As not all patients can be presented during the tele-medical online ward round, hospitals using this tele-medical model developed often tacit classification of patients in the ICU as “interesting”, “borderline cases” or “on the verge of deterioration” which needed external expertise. It would be interesting in the long run to reflect this classification in order to understand where telemedicine is seen as the most rewarding and necessary add on to classical care practices.
In Madeira and, to a lesser extent, in Germany, CPS4TIC has also been used to initiate telemedical consultations in case of emergencies. On Porto Santo, a smaller island in the archipelago of Madeira where care is provided by a small Regional Health Center, physicians can use the system to stabilize patients with the help of the remote consultants and prepared them for the airlift to Funchal hospital. The use of CPS4TIC in emergency cases requires a 24/7 availability of the telemedicine donors that not all hospitals may be able to provide, however, which also points to some limitations.
In-house Consultations or Remote Monitoring
Some hospitals, e.g. in Vienna, are built as a campus, sometimes entailing longer walking distances across campus between the wards of different specialties. In these cases, CPS4TIC will be used to connect different buildings on the same campus to speed up the flow of information and reduce the need for physically traversing the campus, especially in the case of emergencies. In one Viennese hospital, the emergency room will be equipped with a MONA device to make special expertise from other wards in the hospital quickly available. Similarly, in one hospital the healthcare professionals have used CPS4TIC for monitoring patients in the isolation ward for COVID-19 patients and for communicating with nursing staff within the ward. This has allowed them to reduce the time necessary for (time consuming) changing into the protective gear and the unnecessary exposure to infectious patients, making their work easier and safer.
In some hospitals, night and weekend shifts are staffed by resident doctors and non-intensivists with trained intensivists with more experiences on-duty at home. During interviews and conversations, CPS4TIC came up as one way to improve this situation: The on-duty intensivist could get a better image of the patient (especially if the data-solution the MONA system is capable of is activated) and give advice or participate in making clinical decisions. Yet, in some hospitals this model would entail fundamental changes of existing shift rhythms and of the culture of doing intensive care that can vary among different countries quite substantially. Thus, the home shift has been controversially discussed, also due to different legal frameworks.
Especially due to the pandemic, access to ICUs has been limited drastically. This has also meant that medical students could not enter the ICU as part of their training as usual. In the university hospitals participating in the project, physicians have thus discussed using CPS4TIC for a kind of tele-education: Using the technology, live images from patients could be transmitted to the lecture halls of the medical universities given patients’ consent. As an added value, this would also train doctors-in-training in the use of telemedicine as a routine component of their everyday work – a field that is currently still missing in most curricula.
CPS4TIC has mainly been developed to facilitate communication between physicians. But could it also be used to establish connections among nursing staff in different hospitals? Given the on-going scientification and specialization of nursing, the nurses we spoke to agreed that this could be a possibility, for instance, to exchange expertise about wound treatment. However, as nurses already saw themselves as under heavy time pressure due to understaffing, they expressed concerns that using more technology-mediated interaction with patients could compromise the patient-centric and physical proximity-based approach they feel is necessary when providing care for critically ill patients.
European Telehealth Network for Acute Care
ICU4Covid has a commitment to be sustainable beyond the duration of the two-year project. The vision for the time after is that of a European Telehealth Network for Acute Care. Using CPS4TIC as an infrastructure, hospitals with different core areas are envisaged to be connected to facilitate the exchange of clinical expertise across Europe. This is seen as essential to develop common standards of tele-medical consultation and documentation to further improve care.