At a rural ICU, Covid-19’s summer surge put telehealth to the test

On the surface, there’s little about Whitfield Regional Hospital that would make it a safety net for Alabama’s sickest Covid-19 patients. It has a small ICU with eight beds, and no critical care doctors on staff. The rural hospital has spent decades focused on caring for the community surrounding Demopolis, population 7,000, in the heart of the state’s Black Belt.

But over the summer, Whitfield became an unlikely landing pad for critically ill Covid-19 patients from across the entire state — with the help of a team of telemedicine specialists calling in from more than 100 miles away.

As Covid-19 swept through unvaccinated communities, every ICU bed in the state was full for weeks on end — including those at the state’s largest hospital, at the University of Alabama at Birmingham. Before the pandemic, the sickest patients would have been transferred to a major medical center like UAB, which is far more prepared to care for them than a rural hospital like Whitfield. But during the surge, “we pretty quickly realized that we ran out of space,” said William Stigler, a critical care pulmonologist at the 1,200-bed hospital, and head of its tele-ICU.

Every ICU patient that Whitfield could care for was one less patient on UAB’s waiting list. And UAB, while it couldn’t spare beds, could share its expertise. From an operations center in Birmingham, UAB’s critical care pulmonologists videoed into rooms in Demopolis, conducting remote exams of patients on ventilators in coordination with the hospitalists at the bedside. On four large monitors, they’d watch the video feed while scanning vital signs, patient records, and alert systems on their other screens.

By providing tele-critical care, Whitfield hasn’t just enabled more patients to receive advanced care closer to home. It has also become something of a backstop. “We’re now accepting transfers from smaller hospitals in the community, and even from places two and three hours away,” said Kamilah Spencer, one of Whitfield’s two hospitalists and medical director of its hospitalist program. “They have really sick patients who are on the vent and they’re unable to find an ICU bed.”

For an eight-bed ICU to take on such an outsized role in Alabama’s critical care is a contortion borne of the pandemic, not a long-term solution. But the forced experiment suggests that post-pandemic, tele-critical care could be an essential element to help build back the health of both rural hospitals and the patients they serve.

“Right now people in rural areas just aren’t getting the same level of care as in urban markets,” said Whitfield’s CEO, Doug Brewer, who came on in 2018, shortly after the telehealth partnership with UAB was established in 2017. “And the chasm has only grown over time.”

The surge of Covid-19 patients flooding the system blasts the rift still wider. “The pandemic has exploited beautifully a lot of the weaknesses that rural health care has in its systems,” said Brock Slabach, chief operations officer for the National Rural Health Association. From 2010 to 2020, Alabama lost six of its rural hospitals, and 12 of the 45 remaining were in dire straits.

In the decade before its telehealth partnership began, Whitfield was one of those struggling hospitals, with $20 million in losses leaving it “this close to closing,” said Brewer. But in three years, as Whitfield has imported the academic medical center’s expertise through a growing roster of programs, the hospital has close to tripled the volume of patients it’s able to care for, he said. This year, it stands to have some excess cash on hand for the first time in years.

“It’s really changed our financial trajectory,” said Brewer. And to double down, the hospital plans to continue to build on the telehealth programs that have contributed to that success.

When a patient is admitted to Whitfield’s ICU, its hospitalists can call for a consult with one of UAB’s tele-specialists, who usually pipes into the room via a rolling cart. As the Whitfield team conducts a physical exam, the remote doctor pivots the cart’s camera to see the patient and bedside monitors.

After establishing the initial care plan, UAB’s doctors will call in every day to make rounds on certain patients, circling back to make recommendations — say, a patient is going into renal failure, and the next step is to place a dialysis catheter — and adjust settings on equipment like ventilators. And whenever one of Whitfield’s hospitalists has a question or a patient takes a turn for the worse, the remote physician will be there to answer. It’s a model the providers sometimes call “round and respond.”

There are limits to what a specialist can do from afar, of course. Many of Whitfield’s Covid-19 patients need mechanical ventilation to breathe, and during the pandemic, doctors learned they usually do better when they lie on their stomachs. But safely flipping a ventilated patient over requires careful choreography to avoid disturbing IVs and tubes, and no small amount of brawn. Many rural hospitals, including Whitfield, typically transfer those patients to tertiary care centers like UAB — which wasn’t always possible during the summer surge.

“We had to do something,” said Spencer.

So Whitfield’s ICU nurses drew on the expertise of their operating room nurses to learn how to turn the patients on their own. Then it fell to the hospitalists, supported by the tele-specialists at UAB, to manage their care. The remote physicians can recommend proning protocols as they check the patients’ vital signs. It’s a prime example of how in-person staff and their far-off counterparts can join forces to bolster a hospital’s bandwidth.

“We would not be able to effectively care for them without the help of the critical care team,” said Spencer, who came to work at the hospital in 2019. In addition to tele-critical care, the hospital has UAB virtual care programs for neurology, infectious disease, and nephrology, the last of which has been especially critical to care for Covid-19 patients with failing kidneys. “Because we had the teleservices prior to the pandemic, that helped us to survive,” she said. “Not only to survive, but to handle it well.”

So in April, Whitfield and UAB announced that the regional hospital would double down on tele-critical care: By early 2022, it will become Alabama’s first full external tele-ICU.

Whitfield’s ICU will be outfitted with sensor-laden rooms that enable a team of remote nurses to monitor patients’ vital signs around the clock, managing their care and calling in reinforcements — whether bedside hospitalists or the remote critical care docs — when needed. “Really, it’s reactive versus proactive,” said Brewer. “It was just the natural progression.”

It’s an approach familiar to a growing number of academic hospitals, including UAB, which uses the same setup to improve care and efficiency in some of its own ICUs. “We are able to catch things,” said Paul Malito, nurse manager for UAB’s tele-ICU. With the system, he explained, remote nurses can identify signs of sepsis or other complications in real time, rather than a day or two after the physical downturn begins. And the rooms have an added benefit during the pandemic: The more Covid-19 patients can be monitored remotely, the less bedside staff have to expose themselves to infection.

When Whitfield deploys its tele-ICU next year, it expects to expand its patient population even further. “With the 24-hour tele-ICU monitoring we’re going to continue to take care of more acutely ill and critically ill patients in our surrounding communities,” said Spencer, “and that’s basically what we’re here for.”

Whitfield is far from the only rural hospital using telemedicine to shore up its care for critical Covid-19 patients. Some have expanded existing systems in the midst of the pandemic: In early 2020, the hospital system at Augusta University in Georgia, AU Health, was providing tele-critical care consults to five surrounding hospitals; now it’s at 13.

Others are trying it out for the first time. For most of the pandemic, Hoke Hospital in Raeford, N.C., would transfer severely ill patients to its flagship hospital, just about 10 miles away, or to the metropolitan Triangle. But as ICU beds began filling up this summer, said President Roxie Wells, “it just became critical that we be able to keep patients here.” Just a month ago, Wells brought on a critical care doctor to provide tele-intensive care.

But full tele-ICUs, also called eICUs, have been slower to reach resource-strapped rural hospitals. “If you look at what’s happening around the country, it’s still much more reliant on the old school model of making phone calls using video and sharing electronic records as best we can,” said Greg Martin, president of the Society of Critical Care Medicine.

“If you’re a CEO, it’s more costly and it’s more complicated,” to implement a full tele-ICU, said Dee Ford, who worked to establish the tele-ICU at the Medical University of South Carolina. Consulting with a tele-intensivist requires its own upfront investment in video-enabled carts, which can cost anywhere from $10,000 to $50,000, depending on how many tools like ultrasound and video laryngoscopes are connected. But that price tag pales in comparison to the cost of a fully tricked-out remote monitoring system. For that investment, increasingly, hospital systems are turning to specialized companies to build out the technical infrastructure — and remote staffing — necessary to keep a full tele-ICU running.

When Whitfield’s full tele-ICU goes live, even more of its care team will be at UAB, in a hub housing dozens of sleek cubicles outfitted with four monitors each. A critical care nurse can be looking at a patient’s vital signs and medical records while keeping track of their email, communications software, and more. Alerts appear for urgent patient needs, both on the screens and via an alarm that sounds when the patient’s bedside emergency button gets pushed.

The operations center is part of a partnership UAB announced last year with telehealth company Hicuity Health, which has 10 other operations centers that provide tele-critical care to more than 100 hospitals.

UAB has used this remote team to bolster its own critical care in some ICUs. To equip its beds for telehealth, UAB installed a console on the ceiling of each room outfitted with a monitor, camera, infrared light, microphone, and speaker. When the staff is doing their virtual rounds, they’ll ring a doorbell that sounds over the speaker to make sure it’s OK to camera into the room.

The system has given bedside staff more support during crunch times, and could potentially help catch more warning signs before they spiral into a bigger problem. In his first week, one of UAB’s new tele-intensivists noticed something off about a Covid-19 patient’s appearance and oxygenation levels, and diagnosed a collapsed lung, Malito recalled. “There’s no telling how long it would have taken somebody to get in and see that; this is a Covid patient, so it’s not like somebody’s in that room,” he said. “That’s exactly what we’re here for.”

Persistent monitoring systems also provide a chance to collect a wealth of data on ICU outcomes. “We try to learn from that and put together education,” said S. Ram Srinivasan, Hicuity’s chief medical officer. During Covid-19, said Srinivasan, much of that work was focused on ventilators. At UAB, one of the nurses on staff is devoted to mining data from a scoring algorithm called Apache, which predicts length of stay and mortality based on 17 data points. By comparing patients’ predicted and actual outcomes, they can determine how to best use the devices and minimize risks.

And as tele-ICUs help build expertise, they also may serve to consolidate existing knowledge, as hospitals across the country experience an extreme shortage in qualified care providers, especially nurses. “In many of those cases, the issue has been exacerbated by the fact that people are leaving the bedside in droves,” said Hicuity CEO Lou Silverman.

That’s the choice ICU nurse Jamie Norman, who has worked in nursing for eight years, found she needed to make this spring. “It’s not an easy job on the best day in the best circumstances,” she said, but after more than a year of fighting to keep Covid-19 patients alive, the anxiety had become too much. She wrestled for months over leaving her job: “I felt like I can’t walk away from the bedside right now,” she said. “There are only so many people like me, only so many nurses that are trained to do this.”

So instead of leaving the field entirely, she decided to try work in the tele-ICU. For the last four months, she’s worked in one of Hicuity’s operations centers, where she values helping other nurses do their job. The predictability has eased her anxiety somewhat. “It’s still sad, it’s still hard,” she said. “But even though we lose tele-ICU patients, you kind of know what to expect.”

On top of the emotional toll, the physical intensity of ICU work can sometimes limit the time an individual can specialize in critical care. But while the average bedside nurse has been working the job for two years, said UAB’s Malito, the tele-operations center averages 16 years of experience.

“I had nurses come up to me after we hired them here,” said Malito. “They said, ‘You know, I was going to retire in six months. Now, I see myself working another four or five years here, and I can use my knowledge without destroying my body.’”

Tele-ICU proponents hope that this combination of monitoring, education, and experience will drive a meaningful difference in their patients’ outcomes — especially for those rural residents who could go entirely without critical care in their local hospitals.

During the pandemic, it stands to reason that simply expanding access to more advanced care — like with Whitfield’s new proning program — would improve outcomes. “That probably is helping some people get through enough of that severe phase to come out on the other side,” said Ford. “They maybe wouldn’t have had that tele-ICU program not been in place.”

But long-term studies are needed to show whether a mere increase in availability changes individual outcomes, and whether those outcomes differ between the “round and respond” model with daily check-ins and round-the-clock tele-ICU monitoring. “If you believe in all the underlying work that’s been done independent of telehealth, the way you’ll get better outcomes with intensive care coverage through telehealth is something that works to replicate intensivist coverage completely, and not just consultation-based models,” said Ford.

Research from academic centers like Cleveland Clinic, which established a full internal tele-ICU in 2014, show improvements for patients, but it’s unclear whether those benefits will extend to rural hospitals without specialists on site.

“These are good hospitals, providing really good care,” said UAB’s Stigler. “But if you need certain types of procedures … those are things that are not routinely done in many of these hospitals. That’s a real limitation.”

At the least, it seems that tele-ICUs could help to keep some rural hospitals open to care for their local communities. “The services become very financially positive in as much as they keep patients at the external facility,” said Eric Wallace, medical director of telehealth at UAB. “More services means more patients, more patients means better bottom line. Unfortunately, the reverse is usually what happens at these rural hospitals. Less patients means less money, which means less services, which means less money, and then they eventually close.”

At Whitfield, the investment is already paying off. “The agreement ultimately was that UAB would get a percentage of excess income,” explained Brewer. Since the partnership began in 2017, there hasn’t been any extra to hand over — until now. “This year we may actually give them a little bit of money,” he said.

Whitfield is perhaps better poised than other rural hospitals to break even with the help of telemedicine. Demopolis, for all its remoteness, is a bit of a geographic anomaly, sitting smack in the middle of an advanced care desert. Major cities and their hospitals surround it in all directions, but the closest is still more than 50 miles away, perfectly positioning Whitfield to receive underserved rural patients in need of critical care.

“The question is, would it have been successful if we were only 25 minutes away?” asked Brewer. “My gut is that at this point in time, it probably wouldn’t have been.”

To Brewer, that just means that rural hospitals can be smarter about where they deploy fully monitored tele-ICUs. “It’s too early to say this, but we think recreating this might be the way to really start to care for rural America,” he said. “If you could geographically place these tertiary centers within 60 miles, there’s no reason to think that it might not be successful.”

“When we think about diversity, equity, and inclusion, for me it’s not only necessarily race and ethnicity, but it’s geography as well,” said Wells. “I truly believe that people who live in rural communities should expect outstanding high quality care in their communities, and now that telehealth is such a huge part of what we do, I think that it is highly plausible.”

For now, though, providers serving critical care patients in rural America continue to struggle against the reality of Covid-19. Alabama’s bed shortages are beginning to ease, but the state still has one of the country’s highest Covid-19 deaths per capita. Even the most advanced care can’t change the fact that so many Covid-19 patients who enter the ICU won’t make it out.

Often, it falls to Spencer to have the difficult, painfully honest conversation with a patient’s family about the odds of survival, and where to draw the line for care if their loved one’s condition worsens. “It requires a certain amount of skill and experience,” she said. But her work with UAB’s critical care doctors doesn’t end at ventilator settings and care plans: They are always willing to step up and support those conversations, too.

“I have found that particularly helpful,” said Spencer. “Having seen [patients] suffer and sometimes not making it, that part can be hard.”