By Greg Basky for SHRF
Through its Solutions Program, the Saskatchewan Health Research Foundation (SHRF) is funding a pair of projects that are exploring use of virtual tools to improve care and communication in intensive care units (ICUs). Dr. Sabira Valiani, a Saskatoon intensivist, is leading a team that’s looking at how technology can facilitate patient- and family-centred care, improve communication, and strengthen the relationship among patients, their loved ones, and their health care team. Dr. Eric Sy, an intensivist in Regina, is leading a project to assess the effectiveness of a virtual ICU follow-up clinic for patients who are discharged home after their ICU stay. Read on to learn more about these exciting projects.
Fresh off a week working in the ICU, Saskatoon intensivist Dr. Sabira Valiani knows only too well just how challenging it can be to keep family members apprised of their loved one’s status. “If a patient’s family isn’t at the bedside, and I get to call them twice a week, I’m doing pretty good,” says Valiani. “So unless a family member calls and says ‘I want to talk to the doctor’ I don’t really get a chance to talk to them. That’s not patient- and family-centred care. I can’t imagine what that’s like for family members.”
Communication in the ICU is difficult, for a host of reasons. The care delivered there is complex. Time is tight. There are frequent handovers between health providers. For families, there’s the emotional toll of having a loved one in intensive care. It’s difficult processing everything that’s happening, seeing the patient in a state they’re not used to, debilitated, possibly in a coma.
The pandemic has pushed virtual care to the forefront, with health systems everywhere trying to shut down the spread of COVID by linking patients, loved ones, and providers through cell phones and video conferencing over tablets. “Our thought was: there’s got to be a better way than just an iPad, because families really...they just crave information,” says Valiani. “And they feel like they’re not getting enough. And as providers, we feel like we can’t communicate effectively enough, and we can’t give them what they need.”
Eileen Reimche, a patient and family partner who’s involved in Valiani’s project (and that of Dr. Eric Sy), has first-hand experience with ICU care. After open heart surgery in spring 2019, her late husband Doug spent 11 days in a surgical ICU, eight of them intubated and in an induced coma. While Reimche played an active, assertive role in her partner’s care, and says she was treated as a care team member by his doctors and nurses, she’s still excited about the potential to improve ICU communication further. “Communication is very, very important,” says Reimche. “The more that people know and know what to expect...it just alleviates anxiety. Knowing what to expect helps to prepare you either way, whether things are going well, or not so well.”
Valiani says the team’s aim is to figure out how to leverage communication technologies to foster a more effective therapeutic relationship among patients, their loved ones, and the health care team. “If there’s a better way to integrate technology into the workflow that would be really, really helpful for health care providers -- but even more so for the loved ones. What we’re looking for is something that really integrates nicely into the ICU environment.”
Valiani and her team of researchers, multidisciplinary ICU clinicians, and patient partners are borrowing a page from business product development. Using an approach called design thinking, they’ll start by defining the current state. This “What IS” stage will involve reviewing the literature on communication, technology and relationship development in the ICU; scanning the environment to see how health systems elsewhere are using tech to facilitate patient- and family-centred care in the ICU; and interviewing patients and loved ones who’ve experienced ICU care, and health care providers who work in that setting, to identify those points during a patient’s ICU stay where relationships are either built or broken. These critical junctures, says Valiani, may be places where technology can improve communication.
The ideas generated in the What IS stage will then go back to patients, family members, and providers -- along with administrators, communication technology experts -- to find which possibilities most resonate with them. This engagement process for defining the potential future state -- the “What IF” -- will include patients and loved ones who represent diverse identities and intersections of identities, in order to ensure potential solutions are inclusive and culturally safe. By summer 2022 Valiani hopes to share a final set of recommendations with the Saskatchewan Health Authority and various health advocacy groups around the province.
Helping patients stay at home once they’re discharged from the ICU
Dr. Eric Sy and his colleagues in Regina recently analyzed local data on ICU patients who were discharged directly to home. They found that a significant proportion were either being readmitted or showing up in the emergency department within 90 days of leaving hospital. Now Sy and a team of researchers are preparing to test a new, virtual approach to supporting patients that they hope will help prevent those return visits.
Convenience and ease of access are at the heart of the concept of virtual follow-up clinics. “We have a lot of patients that come to our ICU from across the province,” says Sy. “Driving three hours from say, Yorkton, for a 30-minute appointment, and then having to drive three hours home -- for some people that might be prohibitive. A virtual clinic would be very similar to a regular office visit with an intensivist, but with the convenience of being able to do it from your home, from your phone or tablet.” Sy says COVID has paved the way for the project, by facilitating the use of virtual technology by patients, family members, and providers.
Through surveys and focus groups, they’ll gather feedback from patients, family members, and participating health care providers. Sy and the team will look at how often patients who use the virtual clinics are presenting to the emergency department, being readmitted to hospital, or making unplanned visits to their family doctor, and compare those numbers with data from an earlier cohort of ICU patients, prior to follow-up care. They also plan to evaluate cost effectiveness, to see whether the expenses associated with running a virtual clinic are offset by cost savings of avoided hospital readmissions. “We’re hoping that this clinic is effective, efficient, and safe for patients, and is also sustainable at the same time, from a financial standpoint,” says Sy.
In addition to reducing unnecessary hospitalizations and visits to the Emergency, Sy hopes participants -- patients and their family members -- report more satisfaction with their ICU care. He’s also hopeful the project results in better mental health outcomes among participating patients, shorter recovery time, and improved quality of life.
A virtual follow-up clinic is not intended to replace a patients’ existing relationship with their family doctor or internist. “What we’re trying to do is help complement existing structures, to ensure a bit of a safety net for patients to prevent those readmissions,” says Sy. A big focus in post-ICU follow-up is on patients’ mental health and well-being. The team will be drawing on the expertise of psychologists at the University of Regina to identify tools that lend themselves to virtual care.
Patients will connect with their ICU doctor with Pexip, a video conferencing platform already being used by Saskatchewan physicians and supported by the Saskatchewan Medical Association. The digital health team at the Saskatchewan Health Authority is lending their expertise to develop software for patients to schedule appointments and for physicians to dictate clinical notes from the visits. Sy says the team expects to have the virtual clinic up and running some time in winter 2021-22.
Why this work matters
Because ICU physicians devote so much energy to ensuring patients survive and make it out of the unit, they don’t typically focus on a patient’s quality of life -- including their mental wellbeing -- during recovery. “I think this project will really allow us to get at that human side of intensive care medicine,” says Sy. “Most of our patients, when we look after them in the ICU, they’re on ventilators, they’re heavily sedated. We don’t get to know them as people because they’re not able to interact. This project will give us the opportunity to connect and engage with the patients we looked after in hospital.”
And how will Dr. Valiani define success in her team’s project? “If we can bring a loved one to the bedside, without actually being at the bedside,” says Valiani. “The crux of it, really, is using the technology and innovation in a way that integrates with the workflow, that is easy for patients, loved ones, and health care providers. I hope it will change the way we practice medicine in the ICU.”