Strained hospitals get ICU help through telehealth, but it’s no substitute for staffing, capacity in COVID surge

Valley News Staff Writer
Published: 1/13/2022 1:43:09 PM
Modified: 1/13/2022 1:42:16 PM

LEBANON — The first patient to be hospitalized with COVID-19 in Vermont, back in early 2020, was at Southwestern Vermont Medical Center in Bennington.

Because the disease was so new and personal protective equipment in such short supply, the patient couldn’t be safely moved from the 99-bed community hospital to an academic medical center with more specialists. Instead, clinicians at SVMC, which has 10 intensive care beds, leaned on a virtual connection to critical care and infectious disease specialists at Dartmouth-Hitchcock Medical Center through a teleICU service, according to Dr. Trey Dobson, SVMC’s chief medical officer.

The virtual connection allowed the clinicians at the 396-bed DHMC in Lebanon to view the patient and talk with the care providers on the ground in Bennington about a treatment plan. It also enabled a quick shipment from Lebanon of the medication remdesivir, which was then in short supply, Dobson said.

That link helped “take care of the patient,” Dobson said.

During the ongoing surge in COVID-19 hospitalizations, which comes amid a workforce shortage, critical care beds are in short supply in the Twin States and beyond. One way some hospitals have tried to increase their capacity to care for more and sicker patients is through telehealth connections, which allow doctors and nurses at smaller hospitals to connect with specialists.

While telehealth doesn’t provide more hands to care for patients on the ground, it can help monitor patients’ vital signs from afar, and allow the remote clinicians to take notes, order treatments, answer questions from patients and families, or, when necessary, make dozens of calls necessary to find a critical care bed at a larger institution.

“Without telehealth (we) 100% wouldn’t be able to keep those sick ICU patients here,” Jessica Lussier, director of critical care and emergency services, at Cheshire Medical Center in Keene, N.H.

Like SVMC, Cheshire relies on a virtual teleICU link with Dartmouth-Hitchcock’s Connected Care service to help care for very sick patients by monitoring vital signs and placing orders for changes in medication or other treatment, Lussier said. The link has been in place for more than five years.

Cheshire also benefits from a teleED D-H Connected Care service, which allows providers in the emergency department to connect with remote specialists at the push of a button, she said. She referred to the service as “eyes in the sky,” which can help emergency room staff document a case or offer a second opinion.

While this background assistance helps staff on the ground, it doesn’t give them more hands to get the job done. Through telehealth doctors offsite can make a recommendation, but it still requires that someone on the ground make it happen.

It’s “not quite the same,” Lussier said. But, she added, “without it, we’d have nothing.”

Gifford Medical Center in Randolph has contracted with D-H for the teleICU program, but it has not yet started, said Dr. Joshua White, Gifford’s medical director. He hopes it will start soon.

“We are increasingly required to manage critical care patients at Gifford for longer and longer periods of time, despite not having an ICU or intensive care unit physicians,” White said.

“There is an obvious risk to the patients in this situation, and we hope to alleviate some of that risk by video-conferencing an intensivist into the room, albeit an imperfect solution. Simultaneously, we hope to alleviate the psychological burden on our providers and nurses, who are now required to manage patients that we are not equipped to manage, in providing them every available resource we can conceive of to do so.”

Dr. Kevin Curtis, D-H Connected Care’s medical director and an emergency medicine physician who works in the teleED program, said the service is asked several times a week to help find an ICU bed in New England for a patient in a rural emergency department. It keeps him up at night.

“I’m nobody special,” he said. But “it hurts me for the patient. It hurts me for the family. It hurts me for the bedside team.”

If he’s able to fall asleep again, he said, it’s because he feels the telehealth work is serving as “some bridging, partial solution in that situation.”

In some cases, such as at Valley Regional Hospital in Claremont, DHMC specialists are available to clinicians by phone.

The phone consultations can help guide management of patients, as well as help arrange transfers to a higher level of care or to a specialist, and to coordinate follow-up care in an outpatient setting, said Dr. Joshua Rudner, medical director for Valley Regional’s emergency department.

“While there are some limitations to this service (it is not a formal consult, the specialist at DHMC cannot examine the patient), it certainly does assist us in providing better care to a wide range of patients,” Rudner said.

Dr. Steve Surgenor, medical director of the teleICU program, said that through the service, DHMC clinicians have identified patients at rural hospitals who would benefit from being on an extracorporeal membrane oxygenation, or ECMO, machine, which serves as an artificial lung by taking blood from the body, oxygenating it and removing carbon dioxide, before returning it to the patient.

That service is available only at academic medical centers like DHMC. Through telehealth, Surgenor said the remote clinicians have been able to aid in bringing at least a couple of patients who are young and healthy enough to benefit from the treatment to the medical center to receive it in time to save their lives.

Those patients “survived their COVID as a result of that,” he said.

But expanding telehealth services isn’t easy. Like hospitals providing the direct care, telehealth services also are facing a workforce crunch.

“Telehealth doesn’t necessarily build humans,” Curtis said.

Still, the remote clinicians are doing what they can to help increase capacity at a time when resources are strained.

Lily Powell, director of acute care services for D-H Connected Care, said the program is offering clinicians the flexibility to log on from home for short periods. For example, she said, some of the teleICU nurses have had to be home with their children and aren’t available to work a full shift, but can help out in two-hour increments. That degree of flexibility is uncommon in nursing and it’s been a “big staff satisfier,” she said.

The remote nature of the work also allows clinicians from outside the region to assist, Surgenor said.

In addition to helping other hospitals such as SVMC and Cheshire to care for critical care patients, the teleICU team also has installed hardware necessary to oversee the 60 adult ICU beds at DHMC. Over the holidays, the team installed that equipment on 10 more beds at DHMC in an effort to expand ICU capacity as an increase in demand for the beds is expected due to holiday gatherings and the more transmissible omicron variant of the virus that causes COVID-19.

Without the approximately 30 beds in outside hospitals that D-H Connected Care supports by teleICU, Surgenor said the region’s current bed crunch could be even worse.

“We have built a significant enhanced capacity, which has really paid off in this pandemic,” he said. “We weren’t thinking we’d have a pandemic when we started the program.”

Nora Doyle-Burr can be reached at ndoyleburr@ or 603-727-3213.

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