Tele-ICU Enhancements

Telenursing in the Intensive

Care Unit: Transforming
Nursing Practice
Lisa-Mae Williams, RN, MSN
Kenneth E. Hubbard, RN, AAS, CVRN-BC
Olive Daye, RN, BSN, CVRN-BC
Connie Barden, RN/CNS, MSN, CCRN-E, CCNS

In teleintensive care units, informatics, telecommunication technology,

telenursing, and telemedicine are merged to provide expert, evidence-based, and
cutting-edge services to critically ill patients. Telenursing is an emerging subspecialty
in critical care that is neither well documented in the extant literature nor well
understood within the profession. Documentation and quantification of telenursing interventions help to clarify the impact of the telenurses role on nursing practice, enhancement of patient care, patient safety, and outcomes. Teleintensive care
unit nursing will continue to transform how critical care nursing is practiced by
enhancing/leveraging available resources through the use of technology. (Critical
Care Nurse. 2012;32[6]:62-69)

ursing practice is
constantly evolving
along with the technology being used to
enhance and deliver
care. Teleintensive care unit (teleICU) nursing, as an outgrowth of
the rapidly exploding telemedicine
approach to care, has the potential
to influence the ongoing transformation of nursing practice and significantly contribute to care. It is a
developing subspecialty of critical
care nursing and requires highlevel critical thinking and analytical skills.
2012 American Association of Critical-Care Nurses
doi: http://dx.doi.org/10.4037/ccn2012525

Telenursing is the use of telecommunications technology to provide

nursing care while using information and data remotely.1 Telemedicine is defined as the use of medical
information exchanged from one
site to another via electronic communications to improve patients
health status.2 The tele-ICU is the
arena where informatics and telecommunication technology coupled with
telemedicine and telenursing are
brought together to affect the care
of critically ill patients. Tele-ICU
provides expert-driven, evidencebased, cutting-edge services to the
monitoring and treatment of critically ill patients. In addition, tele-ICU

62 CriticalCareNurse Vol 32, No. 6, DECEMBER 2012

delivers support to the bedside health

care team through collaborations
between the tele-ICU nurse and the
bedside team.3
Having had an active tele-ICU in
our health system for several years,
we felt it important to begin to
delineate the role and contributions
to care of this developing nursing
subspecialty in our health system.
During the period of observation,
themes emerged that helped to categorize tele-ICU nursing practice at
Baptist Health South Florida in
Miami. The purpose of this article
is to describe these tele-ICU nursing
interventions that contributed to
patient care within our health system during the course of 1 year.

The Tele-ICU Environment

Tele-ICU nurses have been an
integral part of the tele-ICU since
its inception. Examination of the
usefulness of the tele-ICU in improving outcomes for critically ill patients
has demonstrated reductions in ICU
mortality,4-8 shorter stays in the
ICU5-10 and the hospital,5-7,9,10

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Table 1

Color-coded acuity system used to categorize patients on the basis of physiological criteria, therapeutic measures
currently in use, and safety concernsa
Acuity status

Sample physiological criteria

Sample therapeutic measures

Sample safety concerns

Red

New admission <6 hours earlier

Critically unstable condition

Titrating infusions of vasoactive agents

Starting mechanical ventilator support
Emergency interventions

High acuity level indicates high

potential risk from deteriorated
disease states

Yellow

Admission in past 6 hours, vital

signs have stabilized

Minimal requirement for intravenous

infusions of vasoactive agents and
little titration needed, weaning off of
infusions
Improvement in condition allows
weaning off of therapies

Moderate acuity level indicates a

reduction in potential risk for
harm, disease state stabilizing

Green

Physiologically stable
Preparing for potential transfer
to a reduced level of care

Stable condition with oxygen delivered

via nasal cannula, maintenance intravenous fluids, or saline lock

Prepared for transfer out of unit

a Adapted

from Philips VISICU workgroup, 2010.

increased compliance with evidencebased best practices such as screening

for sepsis,11,12 improved outcomes in
cardiopulmonary arrest patients,13
and decreased costs for patient care.8-10
In the tele-ICU, experienced ICU
nurses and intensivist physicians
help to monitor and treat critically
ill patients and provide an additional
layer of safety. Communication
occurs via audio and video technology on demand from either the teleICU or the bedside so that nurses
and physicians can interact immediately. Often remotely located from
the actual hospital facilities, the
tele-ICU has the ability to assess
and monitor hundreds of patients
through any electronic technique in
use at the patients bedside. Standard
monitoring such as electrocardiography and hemodynamic values are

maintained continually, and access

to medical records, diagnostic images,
and laboratory results is available
at the click of a mouse.
A few reports3,14,15 describe activities and challenges for nurses working in the tele-ICU. One major role
of the tele-ICU nurse is making
rounds via the camera and assessing
all patients. Assessments require the
same observation skills and nursing
expertise as used at the bedside16
and include but are not limited to
video assessment of patients physical appearance; equipment safety
check; verification of continuous
infusions; and verbal interactions
with patients, their families, and
staff. The frequency of the rounds is
dictated by the acuity of the patient,
and tele-ICU nurses use a color-coded
system to categorize their patients

Authors
Lisa-Mae Williams is a nurse manager, Kenneth E. Hubbard and Olive Daye are staff
nurses, and Connie Barden is a clinical nurse specialist at Baptist Health South Florida in
Miami.
Corresponding author: Lisa-Mae Williams, RN, MSN, Baptist Health South Florida, 2100 NW 84th Avenue,
Miami, FL 33122 (e-mail: lisamaesw@baptisthealth.net).
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.
Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.

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and prioritize their work (Table 1).

Aided by alarms that alert the teleICU nurse to physiological trends,
subtle changes in patients condition can be noted earlier by nurses
overseeing the big-picture view of
multiple patients. Such surveillance
can avoid reintubation of tenuous
patients and prevent unplanned extubations, critical decreases in blood
pressure, dislocation of catheters,
and a host of other untoward outcomes that are difficult for bedside
nurses to monitor at every moment.
The tele-ICU nurse also acts as a
resource for the bedside nurse, who
finds an experienced colleague with
a second set of eyes and ears to
observe the patient and with whom
to collaborate as they have instant
access to the same information as
the bedside nurse via print and electronic resources. They can quickly
retrieve vital pieces of data for the
ICU nurse in order to save them
valuable time, provide accurate current information, and potentially
improve patient care and safety.17
Tele-ICU nurses can also draft a
detailed admission note when a

CriticalCareNurse Vol 32, No. 6, DECEMBER 2012 63

patient arrives in the unit so that

complete information about a patient
is available promptly to all care
providers in the electronic medical
record. Other aspects of the tele-ICU
nurses role may include ensuring
that best practices are adhered to, for
example, prophylaxis of venothromoembolism/stress ulcer, follow-up
on new laboratory values, and
responding to questions and requests
from bedside staff. Unique activities
such as watching over a bedside
nurses second patient while that
nurse transports a patient off the
unit to diagnostic tests supports the
safety of patients and decreases the
workload of everyone at the bedside.
In this environment, the intensivists role is described as providing
continuous vigilance, early intervention, and ongoing care as delegated by the attending physician
supporting the patient care plan and
decreasing ICU-related morbidity
and mortality.18 In addition to performing tasks related to patient
management such as prescribing
tests and medications for critically
ill patients, teleintensivists intervene
in emergency situations when a
patients condition deteriorates,
requiring immediate clinical attention. At times teleintensivists may
educate bedside novice physicians
and nurses by walking them through
unfamiliar procedures such as emergent cardioversion of an unstable,
symptomatic patient or a host of
other urgent interventions.19 Teleintensivists also provide consultative
comanagement of critically ill
patients as well as recognition of
changes in patients trends, diagnoses, and intervention for patients
needs often resulting in improved
outcomes for patients.20

Leveraging ICU Resources

The application of the sophisticated monitoring and intervention
capabilities of a fully functional teleICU holds promise as 1 method for
broadening the reach and enhancing
the ability of the bedside care team
to meet the needs of sicker patients.
According to the Leapfrog Group
a national program focused on creating giant leaps in health care
quality and safetythe quality of
care in hospital ICUs is strongly
influenced by whether intensivists
are providing care. . . . The Leapfrog
standard for ICU physician staffing4
calls for the presence of intensivists
who provide clinical care exclusively
in the ICU during daytime hours.
The standard acknowledges that
teleintensivist coverage together
with some on-site intensivist presence can help to meet this recommendation. In our system, in 2007,
only 1 hospital had round-theclock intensivist coverage. The teleICU was therefore able to provide
access to critical care physicians and
nurses, 24/7, to the other hospitals
that did not have critical care physician coverage.

Assessing the
Tele-ICU Nurses
Contributions to Care
Baptist Health South Florida is a
5-hospital, 1500-bed health care system based in Miami, Florida. Baptist
Health began using tele-ICU technology in 2005, and since mid-2007
it has been part of the standard of
care for critically ill patients in all 5
hospitals. The tele-ICU nurses at
Baptist Health have an average of 15
years of critical care nursing experience and are chosen to work in the
tele-ICU because of the depth and

64 CriticalCareNurse Vol 32, No. 6, DECEMBER 2012

breadth of their knowledge, their

extensive expertise in the care of
critically ill patients, and their
proven skills in communication
and collaboration.
From September 1, 2008,
through August 31, 2009, nursing
interventions made by tele-ICU
nurses at Baptist Health were selfreported or documented by nurses
who observed colleagues making
them. Actions reported were those
that, in the opinion of the tele-ICU
nurse, resulted in changes in care
for patients and/or assisted bedside
nurses in their work with patients.
Tele-ICU nurses were asked to send
accounts of their interventions via
e-mail or handwritten notes as they
occurred with enough text to describe
the event. Reports of these interventions were then communicated to
and collected by the clinical nurse
specialist of the tele-ICU. A small
group of tele-ICU nurses then
reviewed and categorized the types
of interventions described by the
staff. Interventions were then
sorted into 1 of the following 4 categories: rescue, assist, prevention, or
consultation (Figure 1). Working
definitions of these categories are
described in Table 2.

Tele-ICU Nursing
Interventions: The Results
Five hundred ninety-four nursing interventions were documented
and categorized during the year of
the project. Of the interventions
collected and categorized, 477
(80%) were independent nursing
interventions where assistance,
brainstorming, and overall collaboration took place solely between
the bedside nurse and the tele-ICU
nurse. The remaining activities

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Rescue
Prevention

Assist
Consultation

Figure 1 Documented teleintensive care unit (tele-ICU) nurse

interventions from September 2008 to August 2009 (N = 594).
Rescue indicates patient in trouble, immediate action required;
assistance indicates that interventions were made that were initiated by the tele-ICU nurse; prevention indicates interventions
that most likely prevented occurrences such as falls, unplanned
extubation, and allergic reactions; consultation indicates interventions such as troubleshooting equipment, thinking together,
educating or coaching bedside staff, and answering questions
and requests initiated by the bedside team.

Table 2

were interdependent, usually

involving the
intensivist
physician or
telepharmacist
in collaboration
with the teleICU nurse.
Thirty-six
(6%) interventions were
coded as rescue
interventions.
Another 116
interventions
(20%) were
coded in the
prevention category, and all of
these interventionsrescue
and prevention

(n=152 or 26%) when combined

were described as affecting patient
safety. Included in this number were
42 falls, 16 accidental catheter displacements, and 11 intubations that
were avoided by the direct intervention of the tele-ICU nurses (Figure 2).
Assists and consultations, when
combined, were those interventions
described as enhancing nursing
practice (Figure 3). A total of 302
assists (51%) and 140 consultations
(24%) were reported during the year
of this project.

Discussion
In 2008, Stafford and colleagues3
published an ethnographic study
describing the tele-ICU environment
and the experiences of those working
in that environment. In that report,
the experience of the tele-ICU nurse
manager in describing the value of

Definition and examples of teleintensive care unit (tele-ICU) nursing interventions that affect safety and nursing

practice
Type
Safety
Rescue

Definition

Examples

Patient in trouble who needs immediate action

Interventions that helped to avoid imminent
deterioration of patients condition

Avoid codes
Avoid intubation
Identify critically low blood pressure
Identify rapidly declining oxygen saturation

Interventions that most likely prevented occurrences

Avoid falls
Avoid unplanned extubation
Avoid unplanned removal of catheters
Avoid abnormal blood pressures and oxygenation
Correct inaccurate information in patients electronic
medical record
Collaborate about results of laboratory tests or radiographic
findings that were pertinent to patients condition

Nursing practice
Assist

Interventions initiated by the tele-ICU nurse

Bring allergy discrepancies to attention of bedside nurses

Obtain laboratory and disgnostic test results for bedside nurses
Confirm findings from physical examination with bedside nurse
Bring arrhythmias to attention of bedside nurses
Suggest evidence-based treatment for stress ulcer prevention,
deep venous thrombosis, electrolyte replacement, and glucose
control

Consultation

Interventions initiated by the bedside nurse

Troubleshoot equipment
Brainstorm with bedside staff
Coach/educate bedside staff
Answer questions and other requests initiated by bedside team

Prevention

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CriticalCareNurse Vol 32, No. 6, DECEMBER 2012 65

50

No. of interventions

40
30
20
10
0

Falls

Blood pressure,
oxygen saturation

Medication,
allergy

Catheter
displacement

Avoid
code

Avoid
deterioration

Avoid
intubation

Patient
identification

Type of intervention
Prevention

Rescue

Figure 2 Teleintensive care unit nursing interventions that affect safety.

140

No. of interventions

120
100
80
60
40
20
0
Facilitation
of care

Coach/think
together

Expedite
treatment

Best
practices

Documentation

Type of intervention
Assist

Consultation

Figure 3 Teleintensive care unit nursing interventions that enhance nursing practice.

the service to the organization

included, I quickly evaluated that
the true value in this service was all
of the interventions that are happening by these fabulous nurses in the
[tele]-ICU unit.3 The manager went
on to explain the power of this information in demonstrating the value

of the tele-ICU and in garnering

administrative support for its valued place as part of the model of care.
Similarly, in 2008, Myers and
Reed15 described tele-ICU nurse
interventions that prevented errors
and complications, thus improving
quality and safety. Although the

66 CriticalCareNurse Vol 32, No. 6, DECEMBER 2012

authors pointed out that the teleICU nurse is not meant to replace
the bedside nurse, they described
that the actions of the tele-ICU
nurse in monitoring and vigilance
improved processes and outcomes
produced in their health system.
The authors noted not only the teleICU nurses role in safety and quality, but also their unique position to
serve as consultant, collaborator,
and colleague to ensure adherence
to best practice as major components of the role that contribute to
care improvement.
In our system, we similarly
found that actions performed by
tele-ICU nurses fell into 1 of 2
broad categories: affecting patient
safety or enhancing nursing practice. The smallest group of interventions we recorded were actions
categorized as rescue, where there
was imminent danger to patients.
Only 6% of our interventions were
in this category. It is not known
from the literature what an expected
benchmark for this type of intervention by tele-ICU nurses should

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Sidebar: Preventing a Fall

From 30 Miles Away

A tele-ICU nurse checks the

camera view in a patients room
after noticing a change on the
monitor and sees a patient out
of bed, appearing unsteady. The
tele-ICU nurse calmly speaks to
the patient and quickly realizes
that he is confused and disoriented. The tele-ICU nurse calls
the bedside staff to alert them of
the patients situation. The bedside team quickly arrives at the
patients side, reorients him, and
returns him to bed.
be, but it could certainly serve as
an indicator used collaboratively
between the tele-ICU and ICU teams
as a barometer for safety challenges
at the bedside. For example, if a
given unit had a baseline of 10% of
rescue interventions by the tele-ICU
and this number suddenly jumped
to 30% or 40%, these data might serve
as the starting point for fruitful discussions about changes in the care
environment that might be contributing to the increase in potentially
dangerous situations for patients.
Stafford et al3 discussed the challenges of quantifying cost-avoidance
using the tele-ICU. Indeed documenting the exact value of preventing
harm and avoiding complications is
fraught with uncertainty. The interventions in this category were those
that even though danger may not
have been imminent, without intervention the situations were very
likely to have led to negative outcomes for the patients (see Sidebar).
Examples of preventions include a
confused patient with his hand
pulling the dressing away from the

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entry site of the central venous

catheter, a patient with an allergy to
aspirin ordered to receive an aspirincontaining analgesic, and patients
found climbing out of bed when
bedside staff were occupied outside
of the room. In our opinion, interrupting these potentially dangerous
scenes that could otherwise have
gone unnoticed in the midst of a
busy critical care unit elevates the
level of care and safety that is delivered to patients.
We found that most of the teleICU nurse interventions occurred
in the broad category that enhanced
nursing practice. Depending on the
location from which the intervention was initiated, we coded these
actions as either assists or consultations. The largest group
assistswere initiated by the
tele-ICU nurse and then acted on
by the bedside team, the tele-ICU
team, or both. Goran17 describes
the concept of tele-ICU practice as
including a second set of eyes not
to control or intrude, but to support or enhance current care.
Experienced nurses working in the
tele-ICU, free from the often unpredictable situations and expectations
of patients, families, colleagues,
and other departments, have the
opportunity to assess patients
findings in an environment that
lends itself to careful analysis. Supporting colleagues at the bedside
who may not have this opportunity
creates a team with a built-in double check on patients safety and
well-being. To use James Reasons
well-known analogy for preventing
harm in complex systems,21 fewer
mishaps are likely to slip through
the holes in the Swiss cheese and
cause harm in such a system.

The category of interventions

labeled as consultation hold particular promise for supporting care and
colleagues at the bedside. Consultations, which were initiated by bedside nurses seeking information or
support, represent an opportunity
for nurses to gain help from a
knowledgeable colleague whose job
it is to support their practice. In the
tightly staffed and very busy environment of most critical care units,
this opportunity is often not available between bedside nurses. Unique
activities such as the tele-ICU watching over a bedside nurses patients
while that nurse responds to an
emergency also support the safety
of patients and decrease the workload of everyone at the bedside.
Some tele-ICUs have produced
outstanding results by creating formal telementoring programs for
nurses new to critical care. In these
environments, inexperienced nurses
who have completed orientation are
then paired with an experienced
tele-ICU nurse who connects with,
coaches, and mentors the newcomer
until the nurse feels confident to function totally independently (Wendy
Deibert, RN, personal communication, May 2011). Although just in
the beginning stages of development,
such creative and proactive programs
hold promise as a true opportunity
to support our young and create a
humane environment for all.
Despite the described advantages
of the partnership between the teleICU and bedside staff, these relationships do not develop effortlessly,
automatically, or perfectly. Using a
telecommunication tool is new and
challenging, and a level of trust must
be developed and sustained between
the tele-ICU and the bedside staff in

CriticalCareNurse Vol 32, No. 6, DECEMBER 2012 67

the absence of face-to-face communication. With many never having

met, bedside and tele-ICU nurses
must build relationships in this new
practice model. In addition, the
challenges of technologyovercoming inevitable equipment malfunction, network downtimes, or software
upgradeshave given staff the
opportunity to fine tune their collaboration and communication skills
further. This fine tuning requires a
consistent effort to build and
strengthen relationships and to be
relentless in pursuing and fostering
true collaboration.22
The study of tele-ICU nursing
and its impact is in its infancy. More
information is needed not only to
further delineate the contributions
that tele-ICU nurses make, but to
also outline methods to enhance the
acceptance and full utility of this
new approach to care. This project
was designed to look, from the teleICU side of practice, at the interventions reported by tele-ICU nurses.
It was not our intention to investigate tele-ICU contributions to care
from the bedside nurses perspective. The views of bedside nurses,
however, are critical and should be
the subject of future studies related
to the impact of this model. Using
technology for this purpose has
inherent challenges, and future
studies should be undertaken to
delineate these issues and define
best practices in implementation.
Although both the literature and
common sense mandate that an
appropriate number of skilled and

qualified nurses must be present on

a unit at any given time, groundbreaking alternatives to how these
nurses work gets accomplished are
just in their infancy of exploration,23-26
and the tele-ICU is one of those
alternatives.

Conclusion
Safety, cost avoidance, and
patients outcomes are being
improved in our health system by
these interventions. As technology
becomes more integrated into patient
care, the significance of tele-ICUs
and tele-ICU nursing will most
likely become more apparent. TeleICU nursing has the potential to add
to the tools available to the critical
care team by altering how the care of
the most critical and vulnerable
patients in the system is delivered.
Although the role of the bedside caregiver can never be replaced or diminished, it can certainly be augmented,
enhanced, and facilitated. The key to
the long-term success is the continued consistent collaboration between
the bedside team and the tele-ICU
nurses, which can transform how
critical care nursing is practiced. CCN
Now that youve read the article, create or contribute
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Acknowledgments
We thank our colleagues Rosemary Lee, DNP, RN-CNS,
ACNP-BC, CCRN, CCNS, and Donna Lee Wilson, RN, MSN,
CCRN, for their expert review and assistance in the
preparation of this article. We also acknowledge
the outstanding work of the nurses in the Baptist
Health South Florida e-ICU, whose dedication
and hard work created the outcomes described.

Financial Disclosures
None reported.

To learn more about tele-ICU, read A Second Set of Eyes: An Introduction to Tele-ICU
by Goran in Critical Care Nurse, August 2010;
30:46-55. Available at www.ccnonline.org.

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CriticalCareNurse Vol 32, No. 6, DECEMBER 2012 69

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