Voices of Family Members and Significant Others in the Tele–Intensive Care Unit
Introduction
The aging of the U.S. population is expected to result in increased numbers of patients with chronic, serious health conditions who will require treatment in intensive care units (ICUs). Current estimates by the U.S. Census Bureau project a 50% increase in demand for intensive care services among adults aged 65 and older from 2000 to 2020. One response to this increased demand has been the development of the tele-ICU, which uses technology that allows off-site physicians with special training in critical care medicine (intensivists), critical care nurses, and other specialists to coordinate patient care in collaboration with bedside staff at geographically dispersed ICUs.
Although the need for ICU services is expected to increase, the U.S. healthcare system faces a shortage of healthcare providers, including critical care nurses, largely due to an aging workforce and a decrease in the number of new, trained clinicians entering the field. The Committee on Manpower for Pulmonary and Critical Care Societies projects that this longstanding shortage of critical care nurses, combined with projected shortfalls of 22% and 35% in intensivist hours by 2020 and 2030 respectively, will make it difficult to meet increased patient demand. A similar shortfall of 29% by 2020 has been projected by the Health Resources and Services Administration. Furthermore, the 2010 Leapfrog survey revealed that only 34.5% of responding medical systems met their standard for ICU physician staffing, which requires intensivists to be present during daytime hours, dedicated to ICU care, and available via telemedicine or to return calls within 5 minutes when off-site.
One response to these needs and shortages has been the development of the tele-ICU model. The tele-ICU relies on a centralized or remotely located team of intensivists, critical care nurses, and other clinicians who collaborate with bedside staff through audiovisual communication and computer systems. This model is analogous to air traffic control, using technology and expertise to keep patients safe. The control room is staffed with critical care professionals who identify problems and intervene to improve care. Technology provides off-site staff with real-time access to patients’ clinical data, care plans, and visual access, enabling them to offer decision support to on-site staff.
Study Objective
This pilot study focused on the informational needs of patients’ significant others, assessing whether they were informed about the tele-ICU, their preferences for how and from whom they received this information, and their perceptions of the tele-ICU’s impact on care.
Methods
Study Design
A survey was conducted with a nonprobability, convenience sample of significant others of patients receiving care in tele-ICUs across three health system networks in Portland, Maine; Worcester, Massachusetts; and Columbus, Ohio. The study received institutional review board approval from each participating health system. The survey was developed by two coinvestigators with expertise in survey design.
Participants
Significant others were identified either by the patients (when possible) or ICU staff. Eligible participants were at least 18 years old, English literate, and associated with a patient who had been in the tele-ICU for at least 24 hours. Only one significant other per patient was surveyed.
Data Collection
Hospital volunteers were trained to distribute and collect surveys. They first provided informed consent forms, emphasizing anonymity and confidentiality. Participants completed a demographic form and an eight-question multiple-choice survey with two open-ended questions. Surveys were returned in sealed envelopes, mailed to the study team.
Data Analysis
Data were entered into a database and analyzed using SPSS. Descriptive statistics were used for multiple-choice responses. Open-ended responses were reviewed for common themes and categorized as positive, neutral, or negative. Positive comments were further classified as (1) source of comfort, (2) technology, or (3) improved safety and care.
Results
Respondent Characteristics
Six medical facilities participated in the study. A total of 306 significant others were approached, and 196 completed surveys were returned—a response rate of 64.1%. Of those respondents, 93.4% were immediate family members.
Awareness and Information Sources
Of the 192 respondents who answered the question, 66.1% reported they had not been informed that their loved one was receiving care in a tele-ICU. Among those who were informed, most received information from staff. Those uninformed preferred to receive such information directly from staff members.
Informational Preferences
The top three types of information respondents wanted about the tele-ICU were: (1) how patient privacy is protected, (2) how remote monitoring affects patient care, and (3) how the technology works. When asked about the perceived purpose of the tele-ICU, most respondents indicated it was to help ICU staff care for their loved ones, monitor patients when no one was in the room, and improve the quality and safety of care.
Perceptions of the Tele-ICU
Eighty-eight respondents answered the open-ended question about their feelings toward the remote care team. Most (79.6%) expressed favorable views, with many noting reassurance from knowing someone was monitoring the patient. Others appreciated the technology or perceived enhanced safety and care quality. A small number expressed neutral or negative views.
Contact With Remote Staff
Two-thirds of respondents reported contact with tele-ICU staff. Of those, some spoke with both the nurse and physician, and most interactions were initiated by the remote team during a visit. Fewer reported initiating contact via call buttons.
Discussion
The fact that two-thirds of significant others were unaware of the tele-ICU’s role suggests a need for better communication. Training and educational materials are needed to inform family members in a timely, appropriate manner. Significant others expressed a desire for information from clinical staff rather than indirect sources like posters or brochures.
Even though many had interacted with tele-ICU staff, it’s possible that they were unaware these clinicians were off-site, highlighting a possible misunderstanding. A two-way camera could help by humanizing off-site staff and clarifying their location. Accurate understanding may improve perceptions of care and help meet emotional and informational needs.
Future Research
Future studies should explore differences in satisfaction between family members of patients in traditional versus tele-ICUs. More detailed investigation into what specific information is most useful, particularly regarding privacy concerns, is needed. It would also be beneficial to study how demographic factors influence information preferences and satisfaction.
Limitations
There were limitations, including uneven response rates among sites. One site submitted a large number of blank surveys due to volunteer error. The questionnaire lacked formal reliability and validity testing as this was a pilot. Emotional states of respondents may have influenced recall and perception. Demographic data were not collected, and non-English speakers were excluded. These factors limit generalizability and may introduce bias.
Conclusion
This pilot study revealed significant communication gaps regarding the tele-ICU and showed that significant others preferred to be informed by staff directly. Most expressed favorable views of the tele-ICU. Addressing these gaps may improve satisfaction and strengthen the therapeutic alliance ECC5004 between caregivers and patients’ families.