In the 1999 publication by the Institute of Medicine, To Err Is Human, the authors painted a grim picture of medical errors in hospitalized patients [1]. The report stated tens of thousands of patients each year suffer a preventable medical error. Errors can lead to death, physical impairment, increased length of stay, and cost increases amounting to billions of dollars. The Institute of Medicine (IOM) estimated that almost 100,000 American patients die yearly from medical errors making it the eighth leading cause of death in the United States.

Historically, Intensive Care Units (ICUs) are major sites for medical errors and complications. Patient safety experts cite outmoded systems of work as the reason for many of healthcare’s errors and quality problems [2]. It is believed that redesigned systems will yield safer, better care. According to the Leapfrog Group, a healthcare advisory board for Fortune 500 companies [3], more than four million patients are admitted to the ICUs and approximately 500,000 die annually. They estimated that providing a dedicated, intensivist-based care model could save between 50,000 and 100,000 lives annually [4] and that mortality could be reduced by 15% to 20%.

Modern ICUs are complex and prone to errors [5]. In 1999, Doering described what she termed as threats to effective collaboration in the critical care setting [6]. These threats included the complexity of the environment and the increasing workloads of staff at the bedside. She suggested that the process of effective collaboration required a commitment of administrators and staff alike when both are facing competition for scarce resources. Effective communication and collaboration required time and nurturing from all involved. It should be built on a concept of trust and could not be rushed and is often the first thing to be omitted when outside forces pull caregivers in different directions.

Long lengths of stay, higher rates of infection, and failure to rescue are patient care outcomes that have been linked with nurse staffing levels [7]. Concerns related to the implications of a projected nursing shortage has influenced interest in how staffing mix as well as sheer loss of numbers of critical care nurses could lead to an increase in errors in patient care. This led to the passing of the Nurse Reinvestment Act (NRA), Public Law 107–205 in 2002 by Congress. This legislation was aimed at stimulating the growth of the nursing profession [8].

The composition of the registered nurses (RNs) workforce was predicted to shift to the largest group of RNs being in the 50- to 60-year-old age group by 2010 and according to a recent study by Auerbach et al., RNs in their 50s will outnumber all other age groups in this profession by 2012 [9]. The demand for RNs is predicted to accelerate at the same time as the nation’s eighty million baby boomers begin to reach the age of 65. By 2020, the gap between supply and demand of RNs is estimated at over 400,000 [10].

Although some progress has been made in recruitment and retention of nurses, the future projections still fall short of the goal of maintaining a supply and demand balance for this vital workforce. Discovering more innovative solutions to leverage nursing expertise and practice is needed. The Sixth report by the National Advisory Council on Nurse Education and Practice (NACNEP) recommended the use of simulation-based education as well as utilization of interactive Internet-based learning programs to enhance effectiveness of nursing education and critical thinking skills. Strategic use of technology to not replace the nursing workforce but to enhance skill mix and staffing as well as to prepare and support the novice nurse was also recommended [11]. Leveraging nursing practice and expertise through the use of technology is the essence of telenursing.

A task force was commissioned by the Robert Wood Johnson Foundation to publish a white paper in 2006 to identify
strategies and opportunities for retaining the experienced nursing workforce. This paper examined the effects of loss of knowledge that occurs when older experienced nurses leave the profession [12]. Leading experts are convinced that organizations suffer detrimental effects on productivity and performance with loss of older employees. Shifting the ratio of experienced nurses to less experienced nurses will have serious implications on quality and safety of patient care according to national experts [12]. If the emerging role development of the telemedicine team is fostered by internal driving forces of clinical competence, independent decision making, and strong interpersonal skills, then can telemedicine enable a new care delivery model that embraces empowerment through leveraging of critical resources?

What happens to nursing knowledge, if as projected, large numbers of experienced nurses leave the field all at once? Bleich et al. warns that the implications of loss of knowledge will be devastating to not only performance and productivity but the shift from “experienced to less experienced nurses will have serious implications for quality and safety of patient care” [13]. The authors go on to explain that more than just “rudimentary skills and routine know-how about common processes” are required, these nurses also have “deep-smarts,” a “tacit knowledge” that is difficult but not impossible to articulate into formal language. It is a knowledge that is gained through the maturation process of being a nurse; a synthesis of learned knowledge, deep insight, and intuition that allows the experienced nurse to incorporate multiple assessment variables rapidly into an assessment and a plan of care. It is the “state of knowing” that could be lost as nurses leave the profession if we do not find innovative and creative solutions to maintain and leverage it.

According to leading experts, telemedicine may be leveraged to support a multidisciplinary intensivist-led team and incorporates re-engineering of workflow processes, outcome measurement, collaboration and professional role development to facilitate efforts to change behavior for improved patient quality [14]. Telemedicine is defined as the transmission of electronic data from one location to another to allow for remote evaluation of the data by a medical professional [15,16,17]. Data may include pictures, EKGs, radiology studies, or audio–video feeds. The remote medical professional then communicates back to the sending facility with an opinion using one of several means, including fax, audio, video, or other electronic means.

The concept of telemedicine has been around for several decades. Telemedicine in its current form can be found in the literature as far back as the 1950s [15]. The National Aeronautics and Space Administration monitored astronauts’ heart rate and respirations while in space from a remote location or during test runs on the earth. NASA continued to monitor astronauts and to develop computer software over the ensuing years [15]. Several projects were funded by government agencies in the 1960s, 1970s, and 1980s to bring medical care to remote or hard to reach locations both nationally and internationally, often using microwave audio and video communication. Most of these early projects could not be sustained due primarily to the prohibitive cost of the microwave communication technology [16].

During the 1990s, the availability and transmission of digital radiological studies allowed the efficient reading of images remotely, allowing a single radiologist from a different location to interpret studies when an on-site radiologist was not available. Another use that gained favor around the same time was the use of psychiatric staff doing remote evaluations. Telemedicine has also allowed neurologists to remotely review studies and allow for real-time decision making in the treatment of acute stroke care [17]. This along with changes to the laws required for consults to allow for neurologists to bill for their remote services has greatly enhanced the care of these patients.

Today telemedicine is a significant component of the Department of Veterans Affairs strategic plan to care for veterans [18]. According to the American Psychiatric Association, “Telepsychiatry is currently one of the most effective ways to increase access to psychiatric care for individuals living in underserved areas” [19]. The Department of Health and Human Services, Health Resources and Services Administration (HRSA), supports the use of telehealth to meet the needs of underserved people [20].

Over the past 10 years the advancement of computer systems of relatively low cost and of faster transmission has greatly enhanced what data can be viewed from a remote location. The advent of clinical documentation systems at the bedside have further made the data readily available using electronic means. Over the past 35 years, research scientists have worked to develop computer systems to assist clinicians in making decisions related to patient care [21]. This coupled with high-resolution audio–video technologies have led to the emergence of telemedicine in the intensive care unit or tele-ICU care.

A modern tele-ICU center is typically staffed by both clinical and nonclinical members. The fundamental component to the remote clinical team includes experienced critical care nurses and physicians specializing in Critical Care Medicine. Other board certified specialty physicians such as cardiothoracic, pulmonary medicine, cardiology, and trauma/surgery may serve as the tele-ICU physician. Affiliate practitioners such as Nurse Practitioners and Pharmacists are adjunctive team members in some tele-ICUs to leverage resources in patient monitoring, management, and performance improvement. Operational processes are supported by nonclinical staff in the tele-ICU center through timely, current data entry and by facilitation of communication between remote and onsite teams.

The number of clinical and nonclinical staff required for each program is dependent upon the volume of monitored beds and the off-site team’s level of involvement with the bedside. At least one physician along with several nurses and nonclinical support consist of the core team members each shift. An additional physician or mid-level practitioner such as an advanced practice nurse may be needed to meet the demands of monitoring larger patient volumes. The tele-ICU care team composition is dependent on the type of service provided. There are specialty physicians providing consultative care models using telemedicine technology to support the care of critically ill patients. Some of these care modalities use telenursing support in their programs.

Tele-ICU staffing is impacted by several factors including the ratio of patients monitored per tele-ICU nurse. Typically, one tele-ICU nurse monitors approximately 35 to 50 patients. The ratio affects the number of nurses required each shift to staff the tele-ICU.

One consideration of staffing is the degree of integration and effort needed by the tele-ICU nurse to maintain timely data for monitoring and interventional purposes. Another consideration in managing this many patients is the degree of electronic documentation performed at the bedside versus the remote site. Fragmentation of documentation (paper, electronic, combination) impacts monitoring abilities of the tele-ICU nurse and demands greater oversight to maintain accuracy of data.

The ICU nurse is a key leader to clinical transformation and the re-engineering of care processes. Therefore, it would follow that the tele-ICU nurse would and should be an integral part of the tele-ICU team. What makes the tele-ICU nurse think differently than the bedside ICU nurse? How does the tele-ICU nurse use or draw upon innate cognitive abilities when processing information? Drawing from previous experience, training and knowledge the expert critical care nurse uses tacit knowledge to synthesize complex physiological information and care modalities into nursing diagnoses and recommendations for optimizing patient care. Information technologies (ITs) allow nurses to not only view information remotely but to observe pertinent data in an organized, real-time manner enhance the efficiency in which clinicians can amalgamate information.

The tele-ICU nurse requires a transitioning process to fulfill role development. The transitioning period or role development may last several months past orientation. A fundamental aspect of this period is learning new responsibilities as a tele-ICU nurse versus an ICU nurse. Role development encompasses expanded functions as mentor, preceptor, educator, leader, and program advocacy. Unlike bedside care, the tele-ICU nurse must learn to transition from hands-on care to technology-driven care.