Novel Virtual Critical Care Program Extends Specialist Patient Care across Northeastern

By Derek Manchuk, MD, Critical Care Lead, North East LHIN

On May 25th 2014, the North East Local Health Integration Network (NE LHIN) and Health Sciences North (HSN) launched an innovative program called Virtual Critical Care (VCC) that extends the reach of expert providers to critically ill patients in our region’s community . To date, with only three sites participating, this unique technology-based system has benefited 25 patients across Northeastern Ontario.

This model of care is unique in Canada. Worldwide, it has previously only been described in three projects in the United States, all of which were smaller in both scale and capability. Our Northeastern program has major partnerships with Ontario Telemedicine Network, CritiCall and Critical Care Services Ontario.

The VCC is helping to address health human resource and geographic challenges of Northeastern Ontario.

There are major differences in the availability of health care professionals in the region's Critical Care Units. At HSN for example, all patients are cared for by a Critical Care Medicine specialist (an intensivist) and also have access to respiratory therapists, critical care dieticians and critical care pharmacists. Apart from Sault Ste. Marie, all other hospitals in our region lack one or more of these key health care providers, depending on the size of the institution. Before this program, physicians could get telephone consultations from Intensivists in Sudbury, but there was no opportunity for follow up visits, and no access to the other health care providers. All members of an ICU team contribute significant benefits to patients, such as decreased mortality, costs, length of stay and other important outcomes. The VCC project allows patients to access this team through videoconferencing (telemedicine) without costly and inconvenient transfers. This should allow all patients in the NE LHIN access to the same care providers that are standard in a large academic .

Through training and expansion, eight VCC sites are now up and running: Elliot Lake, , Temiskaming, Kapuskasing, Timmins, North Bay, West Nipissing and Parry Sound. This covers all of the Critical Care Units in the NE LHIN region (outside of Sault Ste. Marie, which has all

of these care providers). Eventually, 15 hospitals with emergency departments will be added, for a total of 23 hospitals participating.

Remote sites can request a consultation from the VCC team 24/7. The VCC Intensivist and a specialty trained ICU nurse will perform the first video consult and support the local care being provided. At the end of the consultation, the local health care providers and the VCC team decide on the disposition of the patient. They will either have a consult only, be transferred to a larger

ICU for care or stay in their local and be “admitted” to the Virtual Critical Care Unit. Once "admitted" to the Virtual Critical Care Unit, patients are reviewed daily by the full VCC team, and can have urgent re-assessments at any time. Thus, patients at remote sites can have their local care supported instead of being transferred, or while awaiting transfer, to a larger centre.

In many consults so far, the use of the VCC prevented the need for a medical transfer by air ambulance helicopter from a smaller hospital to HSN. This has saved the health care system about. $280,000 as a round trip is $20,000. Most critically ill patients are not transported by ambulance, as they need access to specialized paramedics that are not available in Northern Ontario outside of the air ambulance service.

There are many benefits to this model of care, both to the patients and also to the greater health care system. In addition to improving access to health care providers that are not locally available, the VCC model allows videoconferencing assessments to provide better information for consulting physicians (rather than over the phone) and an opportunity for patients and their families to interact with the consulting team. Supporting the local care in this way translates into opportunities for education and collaboration between the local and remote care providers. The potential to avoid transfer to a distant ICU is better for families as well as a system cost saving. The VCC program also helps to standardize care, promote sharing of best practices, and build relationships between the centres in the NE LHIN.

This innovative solution to the Critical Care challenges in a vast region like Northeastern Ontario signals a transformational change in the way acute care medicine services are delivered.

Dr. Derek Manchuk was named Critical Care Lead for the North East LHIN in May 2011. He is currently Chief of the Service of Critical Care at Health Sciences North and is a staff Anesthesiologist and Intensivist. He is an Associate Professor in the Clinical Faculty of Medicine, Northern Ontario School of Medicine (NOSM). Dr. Manchuk is also the Virtual Critical Care Medical Director.