Hospital Pharmacy - July/August 2019 - 233

233

Kosmisky et al
and cost savings associated with these programs.7-14 The purpose of this article is to provide a description of the implementation and evolution of ICU telepharmacy across a health
system.

Tele-ICU Services
The tele-ICU for Atrium Health (previously Carolinas
HealthCare System), also known as Virtual Critical Care
(VCC), was established in May 2013 with 24-hour nurse
monitoring and 12 hours of intensivist coverage provided for
92 ICU beds. By the time of telepharmacy service implementation in September 2015, a total of 136 ICU beds at 8
facilities were covered. The service has continued to expand,
with current coverage of 337 beds across 12 facilities in
North Carolina and South Carolina. Nurse monitoring is
24/7, and 16 hours of intensivist coverage are provided daily.
Five intensivists work 4- to 12-hour shifts from 3 pm to 7 am
each day with review of new admissions during this time.
Virtual respiratory therapists work from 6 am to 6 pm.
Advanced Practice Providers are not currently incorporated
into this model. The VCC provides an added layer of care
and safety to bedside services, prompt patient evaluation,
and reduced ICU and hospital length of stay, particularly at
facilities without 24/7 on-site intensivist coverage.

Description of Technology
This tele-ICU is a hub (Clinical Operations Room [COR] in
Mint Hill, NC, USA) and spoke (the 12 acute facilities managed) model using continuous monitoring and fully collaborative care for all 337 ICU beds. Although the model can
be entirely centralized with the intensivists, nurses, respiratory therapists, and pharmacists all located in the COR, it is
more often decentralized as the intensivists and pharmacists
often work from remote locations. Telepharmacists commonly work from workstations called bunkers, which are
located in 3 of the larger North Carolina facilities as well as
1 facility in South Carolina. Intensivists may be located
across North Carolina and South Carolina, in several US
states, or even in countries across the world, necessitating
robust technology and collaboration to ensure coordination
of care.
TheraDoc® is used as clinical decision support system
(CDSS) for telepharmacy to facilitate review via the electronic
medical record (EMR), Cerner®. Philips eCare Manager® is
used by the telepharmacist to determine patient census, but is
relied on extensively by other VCC staff. eCare Manager® is
the clinical workflow application providing decision support,
predictive analytics, risk-adjusted scoring, and surveillance
for the tele-ICU population that also facilitates audiovisual
calls. Face-to-face communication if the pharmacist is working alongside other VCC staff, video conferencing, telephone
calls, EMR notes, and Skype® communication are also used to
relay messages with VCC and bedside staff.

The tele-ICU physicians and nurses engage in real-time
telemedicine with synchronous communication using video
conferencing software. Although the VCC has a continuous
care model with 24/7 monitoring by nurses, there are also
elements of the scheduled and reactive care models incorporated into care. Scheduled care occurs with VCC nursing
rounds at least once per shift and during new patient admissions. Responsive (reactive) care occurs when the VCC physician is alerted by the bedside or VCC staff due to a phone
call, alarm, alert, or bedside staff pushing the eLert® button
located within the patient's room.

Initiating Telepharmacy
In preparation for VCC go-live, during a system-wide daylong continuing education program in 2012, the eCare
Manager® platform was exhibited. Shortly after this program, one of the system's Critical Care Clinical Pharmacy
Specialists routinely discussed with the tele-ICU Medical
Director how pharmacy services could be incorporated into
the current workflow. After VCC implementation and as
additional facilities went live, additional physician coverage
was needed daily for patient evaluation and management.
The intensivists recognized that many medication-related
interventions performed, particularly those related to glycemic control, could be delegated to a pharmacist with physician oversight. As a result, in 2014, a proposal for a pilot
telepharmacy program was presented to and approved by
pharmacy administration. Prior to telepharmacist implementation, the intensivist staffing model was one intensivist from
3 pm to 11 pm, a second physician from 11 pm to 7 am, and a
swing shift physician from 6 pm to 12 am if ICU census
exceeded 70 patients. The swing shift was used an estimated
329 days per year, or 90% of the time, per VCC physician
leadership. It was proposed that the addition of a residencytrained critical care pharmacist to the VCC team could
replace the need for the swing shift physician, providing
anticipated cost savings of $140 000 to $167 000 in physician
salary annually after accounting for pharmacist salary. It was
also estimated that an additional $102 000 in savings of physician salary could be realized by the telepharmacist performing 30% of the activities with physician oversight that
were previously performed by the intensivist alone. This was
theorized to provide intensivists with more time to extend the
depth of medical decision-making for existing patients and
to expand care to an increased number of patients. Adding a
critical care pharmacist resource to facilities without this
coverage, decreasing the number of adverse drug events, and
reducing targeted medication costs were also anticipated
benefits of the telepharmacy service. The optimal time for
the initial telepharmacist shift was determined to be 3 pm to
11 pm Monday through Friday. This mirrors the first intensivist shift, is during peak admission time, and provides access
to a critical care-trained pharmacist on second shift for the
entire system.

Hospital Pharmacy - July/August 2019

Table of Contents for the Digital Edition of Hospital Pharmacy - July/August 2019