Sample Paper on Future Healthcare Challenges and Recommendations for the Intensive Care Unit

Introduction/Background

The healthcare environment has been changing significantly over the years and is expected to continue changing into the future. Many healthcare institutions adapt to the challenges in different ways, realizing healthcare growth objectives such as the delivery of quality care and focus on patient safety. The ability to understand these changes and to make the right decisions regarding future progress will be an essential determinant of the paths taken by different healthcare departments in the future. The intensive care unit (ICU), of which I have been part for the last one year, is one of the recipients of the projected changes in healthcare, including medicinal and technological advancements and ethical challenges.

Future Healthcare Challenges – An Analysis

Telemedicine and Technological Advancements

One of the changes that have been occurring in the healthcare sector in recent times regards advancements in technology and medicine. Particularly, the adoption of various medical technologies and telemedicine has become a significant part of advancements in healthcare. According to Dinesen et al., this shift towards telemedicine is occasioned by increasing physician shortages in healthcare facilities and the choice of low-cost alternatives to healthcare, such as accessing healthcare without visits to the office.[1] In the next 5 to 10 years, it is expected that the shift from traditional office-dependent healthcare models will be even more significant, characterized by virtual and cyber-based physician interactions.[2] Telemedicine has proven effective in addressing various easily manageable conditions such as common cold, sprains, and flu, among others, as well as for easy management of patients suffering from chronic conditions that require daily management and interventions such as diabetes and high blood pressure.[3] However, its application to intensive care units remains limited.

Various factors have contributed to this shift towards telemedicine and technology-based healthcare delivery models. First, there is increasing pressure on patient safety and quality care delivery.[4] Further, an increasing influx of patient data aimed at achieving the objectives of patient safety and quality care is evident, which presents an increasing need for strictness in security observation, incremental costs of clinical care, and increasing pressure on healthcare providers.[5] For the ICU, these challenges have become even more pronounced, particularly with the increasing shortage in ICU staffing. Vranas, Slatore, and Kerlin report that telemedicine is increasingly becoming adopted in the ICU with purposes of improving access to and the quality of critical care offered to patients.[6] Various factors have influenced the adoption of telemedicine in the ICU. However, the effectiveness of telemedicine in the ICU is yet to be extensively studied, although there are indications of increasing future adoption.

The ICU is traditionally known to provide dedicated healthcare services to patients who need invasive and life-sustaining interventions, as well as for those who are considered to be at risk of dying. Because of the characteristics of patients in the ICU, the conventional perception about the departments is that patients therein need sustained one-on-one interactions with healthcare providers, particularly physicians and nurses.[6] Critical care provided in the ICU is also quite expensive and intensive, incurring nearly 15% of the total hospitalization costs in the U.S. [6] For this reason, there have been significant efforts towards improving the efficiency, value, and quality of care delivered in the ICU. The efforts have shown the probability of realization through the shift towards telemedicine and better technology utilization.[7] For ICU departments that would sustain operations in the long-term, planning effective adoption of such technologies is thus an imperative subject of consideration.

Tele-ICU, which is the implementation of telemedicine in the ICU, promises various benefits to adopters. The basis of tele-ICU is described as the capability to visualize patients and biomedical devices remotely, as well as the ability to access the electronic medical records (EMR) for those patients also remotely.[7] This capability would give the teleintensivist an advantage compared to the on-call intensivist based on the efficiency of verbal information relay by the bedside caregivers. Thus, physicians and nurses offering care in the ICU would have the opportunity to do so remotely, using tele-ICU platforms to provide decision support based on a combination of physiological parameters and clinical risk factors. Through the algorithms in the tele-ICU platforms, it becomes possible for teleintensivists to predict deterioration outcomes and to provide decision support guidelines to avoid negative outcomes in healthcare.[8] In this way, the teleintesivist is capable of augmenting conventional ICU coverage in facilities with multiple ICUs, as well as in providing support in nocturnal care or where there are staffing shortages.[6] With these perceived advantages, the shift towards telemedicine application in the ICU is imperative for all healthcare facilities, hence worth considering.

Ethical Challenges

With the adoption of telemedicine and technological advancements in healthcare, the ethical challenges faced in healthcare service delivery are also evolving. Since healthcare deals with humans consistently, ethical challenges in service delivery are a key concern that has to be addressed not only at the individual level but also at an institutional level. From medical research to clinical service delivery, adhering to ethical requirements is mandatory for effectiveness and morally acceptable healthcare service models.  The advent of tele-ICU poses the challenge of information delivery, which is a key ethical concern for the ICU. Reports by Kremer show that the provision of wrong or misleading information has, in the past, caused the death of patients.[9] For ICU patients, most of whom are at risk of death, this becomes even more important not only during tele-ICU practice but also during the conventional practice of intensive care delivery. New healthcare delivery models require trust between patients and healthcare providers, and misleading information and other conduct that borders on medical malpractice are considered detrimental to the patient-provider relationship even in tele-ICU settings.[5] Healthcare leaders must thus ensure that the behaviors exhibited by employees in any healthcare organization are in line with ethical codes of conduct. As such, the evolving practices in medicine imply that healthcare facilities have to clearly develop strategies for managing information flow among physicians, other healthcare service providers, and patients.

Other ethical issues also exist in healthcare delivery, including the emerging trend towards physician-assisted suicide (PAS), particularly for patients in the ICU. This is an important ethical concern in future medical practice due to the increasing advocacy for euthanasia. In the future, it is expected to be more probable for ICU patients to access PAS even remotely, particularly due to advances in communication.[10] Nurses working in the critical care environment aim at bringing ethical principles to the patient and patient families through non-maleficence, beneficence, and maintaining patient autonomy. With the emergence of new technologies and increased access to information on PAS, it is expected that healthcare providers in the ICU will increasingly face the dilemma of decision-making regarding whether to engage in PAS or not.[11] The lack of national regulations on the legality of PAS and the conflict between general humanitarian ethics and the ethical principles of patient care can be a source of significant decision-making challenges for healthcare providers.[12] While working towards better care quality and greater patient safety in the ICU, it is crucial for healthcare providers to understand the nature of PAS and to work towards implementing strategies that would help avoid legal costs and claims of medical malpractice in such decisions as PSA.

Planned Actions for Adaptation to projected Changes

Key Stakeholders to the Proposed Change

The projected shifts and challenges to healthcare imply that various decisions and actions have to be taken for ICU operations to remain consistently active. Healthcare leaders across different institutions will need to make various changes in their organizations in order to leverage the benefits caused by the various shifts and are therefore the key stakeholders in the change implementation plan. Healthfield, Pitty, and Hanka report that leaders have to understand and develop systems that provide knowledge to other healthcare workers towards further development.[13] Such knowledge is required both for adapting to advancements in telemedicine and for fine-tuning staff towards better ethical code adherence. Other stakeholders in the proposed project include other healthcare workers including physicians, nurses, and key workers in the ICU, who will be involved in implementing changes towards tele-ICU.  IT personnel will also play a key role in the implementation of the planned actions since the technology for tele-ICU will require installation of equipment.

Strategic Goals for the Planned Change Process

Various courses of action will be undertaken to foster adaptation to these shifts, particularly within the ICU. These actions will be taken with the following strategic goals in mind:

  • To ensure at least 80% awareness of the need for tele-ICU adoption among all caregivers within six months.
  • To develop and submit a complete implementation plan that will ensure successful adoption of new technologies in the ICU within the next year and a half.
  • To establish a work plan that will embody the intended shift to tele-ICU within the coming one year, and will include all stakeholders.

Action Plan towards Change

The first action for the ICU will be creation of awareness and training strategies for both patients and staff. The implementation of tele-ICU implies that ICU departments will be characterized by advanced technologies to help in patient monitoring, reporting on patient conditions, and predicting deterioration.[14] Such technology runs on algorithms that are different from those of other ICU equipment and using interfaces and interaction modules that are more intensive.[15] One of the barriers to utilizing such technology has been mentioned to be the lack of training for their application.[14] Healthcare administrators will therefore focus on finding techniques and materials for not only raising awareness about the impending shifts towards telemedicine but also training the users on the implementation of such technologies once availed. This is expected to take approximately one month.

Healthcare leaders will create fundamental relationships among employees that can support the healthcare changes. Raina et al. assert that healthcare relationships can be improved through ethical decision-making among employees.[16] With telemedicine, physicians and other healthcare providers will be called to higher standards of ethical conduct. For instance, teleintensivists make decisions in the absence of support from other healthcare providers and are expected to consistently make decisions that do not harm patients, and that results in positive outcomes for patients in the long-term.[17] Similarly, the use of information technology and access to patient data will impose higher pressure to adhere to the ethics of information-sharing within and across healthcare facilities.[16] Each of these practices requires stringent ethical measures, which can only be developed in the presence of effective relationships among healthcare service providers that encourage learning, knowledge sharing, and multidisciplinary implementation practices. This will thus be an on-going process that will continue even after implementation of the changes.

Afterwards, healthcare leaders will initiate structural reforms in order to support adaptation to the projected healthcare changes. Some of the implementation challenges, such as lack of implementation models, efficiency, and workflow concerns following the implementation of new technology, can only be addressed through extensive structural reforms initiated by leaders.[18] The roles of the leaders in such structural reforms include; the identification of the areas in need of change, benchmarking with other healthcare leaders to determine the implementation models that are already in use, and collaborating with multidisciplinary teams to identify organizational features for the customization of healthcare information systems technologies.[19] They will also send proposals for financing of the shift, and eventually spearhead the trainings and implementation monitoring during operations. This is expected to take place in a span of one year. The implementation models can be developed by the multidisciplinary teams, while changes such as adaptation to tele-ICU can be realized effectively, thus resulting in more efficient workflow management.

Measures for Success in the Planned Change

Organizational factors such as financial issues, staffing, and health records management are the most probable inhibitors to the success of planned change in the early implementation periods. Close monitoring of progress will be based on periodic reports from the project teams, to determine the status of awareness creation, implementation and training. Any challenges in the early implementation stages can only be a result of organizational factors and ethical issues.

The mentioned organizational factors should therefore be addressed as part of the initiative towards adaptation to the shifts in healthcare. Vranas reported that institutional factors play an important role in determining application efficiency, even where there is already technology-based equipment for use during the shifts in service delivery.[5] In line with this concern for intra-organizational issues, financial constraints are mentioned as a major area of internal focus due to the absence of effective costing and reimbursement models for implementation upon investment in technologies that facilitate effective institutional advancement in technology.[19] To address such internal issues, a cost-benefit analysis should be conducted to determine cost areas, which are mainly on the capital investment in machinery relative to benefits in staff reduction, operational cost reduction, and long-term efficiency and workflow. When these are considered, future adoption of tele-ICU is feasible as it will not only help to reduce pressure on staff but will also result in more cost-saving over the long-term compared to investment costs.[20] Since the objective of any change in healthcare would be to improve cost-effectiveness and service efficiency, addressing the internal organizational issues to attain this outcome is feasible.

The second recommendation presented herein is for the organization to invest in building trust. For the relationships between medical personnel and patients through telemedicine services to be sustainable and effective, trust is a primary requirement.[21] Similarly, adherence to ethical standards of operation requires trust. Ethical conduct in the ICU, particularly during the implementation of tele-ICU, will imply that individuals assigned to take care of patients remotely can be trusted to adhere to their timelines in order to deliver high quality and safe care to patients.[22] Therefore, trust earns the organization money. Investing in trust will, therefore, help healthcare organizations to not only achieve effectiveness among healthcare workers through collaboration with patients but also to practice ethically in information handling and patient protection according to the key nursing principles.

Conclusion

The emerging trends in healthcare service delivery have led to projected advancements in the application of telemedicine and other healthcare technology across various healthcare departments. Among these, the ICU has shown signs of telemedicine adoption through a concept referred to as tele-ICU. The recommended change in this project is for the healthcare facility to adopt tele-ICU as a measure for improving healthcare delivery. This will begin with the creation of awareness and will be followed by the implementation of structural changes towards effective adoption of tele-ICU. Tele-ICU is projected to result in various positive outcomes to adopters, including a reduction in staff pressure and costs of critical care. However, it has to be implemented alongside the building of effective work relationships for better adherence to ethical values in healthcare practice.

Bibliography

[1] Dinesen B, Nonnecke B, Lindeman D, Toft E, Kidholm K, Jethwani K, Young HM, Spindler H, Oestergaard CU, Southard JA, Gutierrez M, Anderson N, Albert NM, Han JJ, Nesbitt T. Personalized telehealth in the future: A global research agenda. J. Med. Internet Res. 2016 Mar [cited 2020 May 12];18(3):e53. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4795318/

[2] Teel P. Five top challenges affecting healthcare leaders in the future. Becker’s Hospital Rev. 2018 Feb [cited 2020 May 12]. Available from: https://www.beckershospitalreview.com/hospital-management-administration/five-top-challenges-affecting-healthcare-leaders-in-the-future.html

[3] MacPhee M, Chang L, Lee D, Spiri W. Global health care leadership development: Trends to consider. J. Healthc. Leadersh. 2013 [cited 2020 May 12];5: 21–29. Available from: https://www.dovepress.com/global-health-care-leadership-development-trends-to-consider-a13304

[4] Farzi S, Moladoost A, Bahrami M, Farzi S, Etminani R. Patient safety culture in intensive care units from the perspective of nurses: A cross-sectional study. Iran. J. Nurse. Midwifery Res. 2017 Sep-Oct [cited 2020 May 12];22(5):372-376. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5637146/

[5] Mahar JH, Rosencrance JG, Rasmussen PA. The future of telemedicine (and what’s in the way). Consult QD. 2019 Mar [cited 2020 May 12]. Available from: https://consultqd.clevelandclinic.org/the-future-of-telemedicine-and-whats-in-the-way/

[6] Vranas KC, Slatore CG, Kerlin MP. Telemedicine coverage of intensive care units: A narrative review. Ann. Am. Thorac. Soc. 2018 Nov [cited 2020 May 12];15(11):1256-1264. Available from: https://www.atsjournals.org/doi/pdf/10.1513/AnnalsATS.201804-225CME

[7] Khan JM, Le TQ, Barnato AE, Hravnak M, Kuza CC, Pike F, Angus DC. ICU telemedicine and critical care mortality: A national effectiveness study. Med Care. 2016 Mar [cited 2020 May 12];54(3)319-325. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4752864/

[8] Udeh C, Udeh B, Rahman N, Canfield C, Campbell J, Hata JS. Telemedicine/virtual ICU: Where are we and where we are going. Methodist Debakey Cardiovasc. J. 2018 Apr-Jun [cited 2020 May 12];14(2):126-133. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6027727/

[9] Kremer W. Paolo Macchiarini: A surgeon’s downfall. BBC World Service 2016 Sep [cited 2020 May 12]. Available from: https://www.bbc.com/news/magazine-37311038

[10] Goligher EC, Ely EW, Sulmasy DP, Bakker J, Raphael J, Volandes AE, Patel BM, Payne K, Hosie A, Churchill L, White DB, Downar J. Physician assisted suicide and euthanasia in the intensive care unit: A dialogue on core ethical issues. Crit. Care Med. 2017 Feb [cited 2020 May 12];45(2):149-155. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5245170/

[11] Aitken L, Marshall A, Chaboyer W. Critical care nursing. Elsevier Health Sciences; 2019 [cited 2020 May 12]. Available from: https://books.google.co.ke/books?id=J6aeDwAAQBAJ&pg=PA87&lpg=PA87&dq=euthanasia+as+a+concern+for+icu-+future+challenges&source=bl&ots=daywSz-Dqm&sig=ACfU3U3nG-jMplHm5lfNP-Z6x1vC2W8SZg&hl=en&sa=X&ved=2ahUKEwjlvveEpq_pAhX4VRUIHaaUC1YQ6AEwEHoECAoQAQ#v=onepage&q=euthanasia%20as%20a%20concern%20for%20icu-%20future%20challenges&f=false

[12] Bruning P, Baghurst T. Improving ethical decision making in health care leadership. J. Bus. Econ. 2013 [cited 2020 may 12];4(2). Available from: https://pdfs.semanticscholar.org/0719/aa57d242011f7f9ba532cd3090d5bc808936.pdf?_ga=2.83339218.578899853.1589366048-1386239139.1588281996

[13] Heathfield H, Pitty D, Hanka R. Evaluating information technology in healthcare: Barriers and challenges. BMJ. 1998 [cited 2020 May 12];316(7149):1959-1961. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1113407/

[14] Kruse CS, Karem P, Shifflett K, Vegi L, Ravi K, Brooks M. Evaluating barriers to adopting telemedicine worldwide: A systematic review. J. Telemed. Telecare. 2018 [cited 2020 may 12];24(1):4-12. Available from: https://journals.sagepub.com/doi/full/10.1177/1357633X16674087

[15] Herasevich V, Subramanian S. Tele-ICU technologies. Crit. Care Clin. 2019 Jul [cited 2020 May 12];35(3):427-438. Available from: https://www.criticalcare.theclinics.com/article/S0749-0704(19)30022-3/fulltext

[16] Raina RS, Singh P, Chaturvedi A, Thakur H, Parihar D. Emerging ethical perspective in physician-patient relationship. J. Clin. Diag. Res. 2014 Nov [cited 2020 May 12];8(11):X101-X104. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4290230/

[17] Langarizadeh M, Moghbeli F, Aliabadi A. Application of ethics for providing services and information technology. Med. Arch. 2017 Oct [cited 2020 May 12];71(5):351-355. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5723167/

[18] Scurlock C, Becker C. Telemedicine for trauma and emergency: The eICU. In, Latifi R (Ed). Telemedicine and innovative remote technologies for trauma. Springer, 2016 Jul [cited 2020 May 12]. Available from: https://link.springer.com/article/10.1007/s40719-016-0054-y

[19] Davis K, Perry-Moseanko A, Tadlock MD, Henry N, Pamplin J. Successful implementation of low-cost tele-critical care solution by the U.S Navy: Initial experience and recommendations. Mil. Med. 2017 May-Jun [cited 2020 May 12];182:e1702-e1707. Available from: https://watermark.silverchair.com/milmed-d-16-00277.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAowwggKIBgkqhkiG9w0BBwagggJ5MIICdQIBADCCAm4GCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMt5s7nc0a_XhFrCkkAgEQgIICPx8GX03kESShnRySsXcky9HapC9DiUJlhzijft_clZHxt96HXtTkhDd5-g6xaVr6SqFZY8PP1h6GO4YqqaN-endKlSQ2dLsRnyYnK9gltLrewy7U2h5PcHbBuaDYiKeoLem9Vesl7uBa8LwL2CIIJkkjrWtdW2nBj_P7rc3-jJBo2Vx8LknfVx4dvVaevucR8I8A0RSd2R40finSz1pS-5EJRbWVR3Pw0FGkoIJO3BU-PSwhl9Ul4NFslmCz-wVvUs07lC_MY7CoNoHdZiENmG91K9bdkZbgXP-fztaxmNactf7k-fRgj-hQQVjQgSSmDROM2d8vSBZeP7q4HCazUNhbHkT0zwoxOqCzKdyUKko3SCRD1wueD0S90Ehox31ezoncz8MCv_1Kkrbfm802FREId9cf5NHS9lmKluRhF6Y97oh1MWgM0RaSlal803lYLcieUwqSmXYtZYUKs5e8Sbhyhq2LilWdTlARlABaWHwJeUTCmUtBiHjwZlTuKE9-pScqKe7-ZvTwI5blXMbWrg6zCKWvLKT0gW5CQjikja52cdpgA2X336DuXLRjBb-Izgygt77qXsadEcZiCq-q2G6hG-nXJVosW1hmp5JlMBi0zsuDffzGTEhaLDZAyQuvQNCbEtt4Rj2uKCe7Qq2hGzW3ZxCBSE7PZUp55Ivy8FWQZBSaWrYYgv1ZJoz3fPJ9FPnslcif740OkmvHOZoht-RgB_-odIDefJhX72iM5OpnL7zwiwGNNvymHGMQ1R24

[20] Van der Sluijs AF, van Slobe-Bijlsma ER, Chick SE, Vroom MB, Dongelmans DA, Vlaar AP. The impact of changes in intensive care organization on patient outcome and cost-effectiveness – a narrative review. J. Intensive Care. 2017 [cited 2020 May 12];5(13). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5264296/

[21] Harriott A, DeVita MA. The tele-ICU: Case and commentary. AMA J. Ethics. 2014 Dec [cited 2020 May 12]. Available from https://journalofethics.ama-assn.org/article/tele-icu/2014-12

[22] Van Velsen L, Wildevuur S, Flierman I, van Schooten B, Tabak M, Hermens H. Trust in telemedicine portals for rehabilitation care: an exploratory focus group study with patients and healthcare professionals. BMC Med. Inform. Decis. Mak. 2016 [cited 2020 May 12];16(11). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4728819/