Tele-ICU
King Faisal specialist hospital and research center

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
As King Faisal specialist hospital and research center is one of the leading health care institution in the region, it is usually a targeted facility for citizens in the Kingdom of Saudi Arabia who is seeking advanced medical treatment, and it’s the first choice for the regional hospitals to transfer their complicated cases. Their for, a very long waiting list of patients were continuously present, while some medical conditions can be waiting for a while, there are other medical conditions that could be effected if delayed. And in addition to other medical conditions were considered as urgent and should not be delayed in receiving the treatment in any way. This complicated issue has mainly affected the public. They are in definite need of being treated at KFSHRC and the capacity of KFSHRC is always full. This issue has directly affected them in two ways. If they are a patients already under treatment at KFSHRC, they might be discharged before completing their psychological and other support, because of beds need, or if it’s too long waiting time, might affect their response to treatment and too late to recover their conditions. While the group of patients who are in urgent needs for advance medical treatment (mainly patients in intensive care unit- ICU ) has very limited chances of being transferred and treated at KFSHRC because of many complicated factors, beds availability, safety of transfer and the physical distance between hospitals in the Kingdom of Saudi Arabia. Another aspect in this problem is the cost of traveling and living in Riyadh to receive their treatment at KFSHRC which is non-profit organization. Some of those patients cannot tolerate the sum of frequent traveling tickets and other required costs.

B. Strategic Approach

 2. What was the solution?
Tele-ICU’s are networks of videoconference devices, patient medical monitoring system and computer network connectivity that link critical care doctors and nurses to intensive care units (ICU’s) in other remote hospitals. A. Mission - The government of KSA is committed in providing basic health care to all KSA citizens, not as a privilege, but as a fundamental right. KFSHRC mission is to provide the highest level of specialized healthcare in an integrated educational and research setting. With the increasing number of patients needing intensive care, Tele-ICU aims to provide optimum patient care in the critical area in different MOH hospitals around the Kingdom. B. Vision - With the continuous close collaboration between KFSHRC, Riyadh and MOH Hospitals, HOSD would be able to expand the existing Tele-ICU in KFSHRC into a National Center for Tele-ICU and become the leader in the field of Tele-ICU monitoring system throughout the Kingdom. It is envisioned to promote and foster the growth and provision of intensive care services using telemedicine technologies for all ICU patients Kingdom wide. Goals and Objectives: • Improve access to health care at remote & distant areas • Accelerate diagnosis & treatment by reducing time for the critically-ill patients • Provide telemedicine service and improve the provision of critical care to patients within the Kingdom • Provide second opinion and assessments on ICU cases at the request of the on-site treating physicians • Reduced necessity/cost of travel for patient & relatives • Reduced professional isolation for rural doctors Facilities and Equipment The e-Health Services have started working with a research team from the King Abdul-Aziz City for Science and Technology, the Saudi Telecom Company and Professor Rao and his team from the University of California in the completion of the software for alert system. This software will assist in the monitoring of several patients at the same time. Likewise, the following state of the art equipment is vital for video conference and advanced communications: • Installation of a fiber optic network • Building of (PACS system) to be able to review radiology image by our intensive care consultants • Developing a website link to enable regions to request cases electron ally. • Procurement of high definition remote controlled camera to remotely oversee patients in ICUs in other hospitals, This also requires installation of multiple cameras in designated ICUs throughout the regions. • Procurement of high definition computers and monitors required for KFSHRC and the other HOS regional hospitals as well. Diagnostic Visits – diagnostic and educational visits to regional MOH hospitals are being conducted Operational Review Committee to oversee the protocols, infectious control, education and any other services related to improve ICU. Educational Training/Courses: a. Fundamental Critical Care Support (FCCS) Course – HOSD supports the vision of spreading essential critical courses, education and training such as the FCCS program. This internationally recognized program has direct impact on critical aspects of patient care. A. Educational Activities (Regional) Educational opportunities and CME’s are being offered for both Physicians and Nurses. Likewise, visitations to MOH hospitals to provide in-house educational opportunities are being conducted. I. Marketing Scheme To facilitate announcement of Tele-ICU Services through local media, assistance from Public Relations and Media Affairs were requested in the form of: 1. Television Advertisement 2. Newspaper half-page advertisement 3. Public Announcement 4. Social media marketing campaign II. Issues/Challenges and Recommendations 1. Language Barrier 2. Differences in the education and training background of ICU Physicians, technical expertise to deal with the system in the regional hospitals. 3. Lack of digitized medical equipment such as x-ray, echo, lab, etc.

 3. How did the initiative solve the problem and improve people’s lives?
Although the idea of Tele-ICU is not a unique globally, and it’s already existing in so many advance countries, it is still the first and only approach in the kingdom and the region. The idea has mainly focuses in solving the problem form the existing source, reaching the public medical needs in their remote urban areas, with fostering in receiving the high quality of care with ZERO limitations. From the live patient assessment, direct medical management, ability to read medical images, capability of performing lab analysis at KFSHRC and sending unavailable medications right to patients or caregiver, only the real hand touching is still missing. The huge effort from our team to build the system from the scratch, and to customize it accordingly to each different hospital needs has added a value of reaching the public where ever they are in the kingdom, at any time and with any available resources. Additional to the live contact with the patients, a simple soft application was created to continuously monitor the patients’ vital signs and their ECG right from our control Tele-ICU center.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The execution started by team assembly of administrative, medical and technical staff to set the rules and regulation and plan to start the Tele-ICU project. A site survey was conducted to the selected area (Hail 600 K distance from Riyadh) to determine and afford the requirements, the choice of the site was based on the geographic location, ability to start a new project, possibly of network connect at the time , the information collected was consist of medical staff , RT and physical therapy technicians, technical information such as network connection possibility starting with 2 MB of MPLS bandwidth , availability of IT and technical staff to manage and support the project , availably of administrative staff to manage and coordinate the project with no previous experience in the region , availability of other medical services such as medical informatics system, PACS , electronic medical record system. The team stared to design the solutions according the available resources were the main challenge was the lack of standardizing and system compatibility between our hospital and the remote area. Prove of concept was successfully performed between our hospital and King Khalid hospital in Hail an ICU case was presented by the remote medical staff , the patient was seen by video conferencing system, the vital signs were also monitored live thru network using live stream server , the radiology studies were seen thru the video system , an IP telephone was used as back up for easy communication , the patient’s family attended the medical discussion and agreed to the treatment plan , this was a good release for the family and hospital from the stress of transferring the patient over 650 KM using ambulance or mobile medical transporter , beside the social impact that the patient is been treated in his society and family eliminating the time and cost of the travel, this was published in official and social media , and very well documented as the first Tele- ICU case in the region of EMRO. Facing limited fund and resources we planned to expand to other hospitals and regions using the same strategy of custom solution in order to fit with the lack of standardization and multiple used system. Next step we selected different regions considering the equal geographic distributing in order to cover the country collecting and analyzing more data to help in our future plan.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The Tele-ICU project was up and functioning with a collaborative unlimited efforts from vast of persons and organizations. Public: Taking the time and effort from the patients and their families to answer the initial questioners and surveys and speaking out loud when being asked about their specific regional medical needs / limitations, has designed the outlines picture of the project and added the first main stone in progression of this initiative. Government: Starting by discussing this initiative in the parliament of the kingdom and considering it as a major project. The effort from the ministry of health in facilitating the access and the resources within the different hospitals. To the wise understanding from the ministry of finance, all together has fully supported this initiative. Privet sector: The Saudi Telecommunication Company (STC) The MEd unit internet company Media: Were several newspaper articles, the social media (FB & Twitter), TV advertisements and direct public awareness days have distributed the idea and increased the acceptance
 6. How was the strategy implemented and what resources were mobilized?
The Tele-ICU project was fully funded by the Saudi government as part of the government plan to move towards the electronic services implementation in the healthcare and other sectors, for easy fast and secure services, the fund release was based on the prove of concept , practical utilization , media documentation and official statistics on the actual presented and treated cases. The technical recourse used in the project mainly based on the customization strategy we followed since the beginning in fact that all Tele-ICU methods implemented globally will not apply in our area with lack of standardization and system compatibility , our IT and telemedicine technical came up with customized technical solution that consist of locally developed software to send the new cases , the software was designed and developed by a hospital medical IT staff who is very well aware of the Tele-ICU requirements and parameters to give adequate information about the case and to exchange the management plan, stand-alone portable video conferencing system was also customized by our staff used to evaluate the patient if required and to secure an encrypted communication between the 2 hospitals . The remote hospital also contributed also by assigning medical, technical and administrative staff locally to support the project , the candidates were fairly trained in our hospital to meet the required standards , the cost of the local staff was mainly funded by their local employer ( ministry of health ) with incentive level participation of our hospital , no other external contributors were involved .

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
In urgent situations were treating a critically ill patient, a very stressed family and loved persons is concerned, a limited resources, and when a single medical order can make a huge difference in saving the patient life, the core of this project is illustrated, the visible and existed project can be utilized for discussing the challenges, changing the plan of care as needed 24/7, monitoring vitals, taking action and even supporting the family. 2- Intensive care unit –ICU beds utilization The more and efficient utilization of the Tele-ICU initiative has dramatically reduces the needs of transferring patients from regional hospitals. Since they can be treated remotely with the same high quality and standards as KFSHRC patients, this has also minimize the length of stay in the regional hospitals. 3- Return of Investment (coast effectiveness) Reducing and saving amount of money needed for travelling, tickets, ICU beds and coast of other resources, etc. considering that the same quality of care provided, has made this initiative an essential project in the growing medical and health sector in the country. 4. Education In addition to delivery of high quality of care, the initiative has also added the access to deliver massive medical, nursing and respiratory education. This education has directly impact the standard and quality of care in the regional hospitals. 5- Psychological and cultural support As a culturally known in the Kingdom, the whole family usually should be supporting the critically ill patient, This initiative has embower this aspect that rarely considered in the traditional way of treating patient from outside Riyadh, it usually happened that one or two members of the patient family will accompanied the patient throughout the treatment time at KFSHRC, while in this initiative the patients will be treated while with family and their loved one. As known medically: half of the treatment comes from psychological wealth.

 8. What were the most successful outputs and why was the initiative effective?
1. Establishing a 24/7 call center: The call center has all the features of communication available in the market (video & audio), another feature of connecting the land line, pager system and cellular phones together, when calling any of them all of them will give the notification immediately. Nevertheless using all social media application as another way of communication (WhatsApp, Facebook, twitter and emails) which can be accessed from a cell phone. 2. Notifying and organizing the care team (MD, RT and ICU nurse): After receiving the call/notification of service need, the care team will be notified for care discussion and recommendations 3. Close monitoring of the patient condition: Through the established monitoring software that allows the team to review vital signs and the ECG, and to contact the requesting region when needed. 4. Recommendation will be dictated and reported to the requesting MD: Throughout a software that created by our team, a holistic initial report will be created immediately with the biographical data of the patient, the general condition, APACHE score, diagnosis, current medications and ventilator setting. A dictated professional report will be send to the requesting MD. 5. Another follow up discussion will be performed as much the patient in need: To firmly evaluate the patient outcomes and the process, a follow up discussion will be formed frequently till patient improved, family of the patient is usually e evaluation process. 6. Documentation The whole process of each case discussion, from the call time to the signing off is documented and recorded in a filing system.

 9. What were the main obstacles encountered and how were they overcome?
1. Shortage of expert manpower: As known worldwide, the shortage of ICU medical team (physician, nurses and respiratory therapist) was one of the obstacles we faced in implementing this project, while an extra assignment was made for our ICU manpower which took an extra time and effort from them covering and helping the regional hospitals in treating their patients. The issue was solved in utilizing the time of physician more efficiently and distributing the remote coverage through the team 2. Financial obstacles: Low amount of governmental financial support was provided initially, based on hesitancy of program successes. Till a new concept of Tele-ICU, treating patient remotely, was proven outcomes. The governmental fund was raised considering the future expansion and the extensive geographical needs. 3. Geographical challenges: With a very wide extended country, with varies differences in the resources availability. A huge effort was made from the implementing team to customize the project logistics based on feasible trusted resources, in the far regions were internet connectivity was not high speed, another resources were created like free call lines and downloadable software

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The key benefits resulting from the initiative is the live saving , the ICU is and emergency medical required services that cannot be delayed or re-scheduled , it has to be given immediately. In fact the are many situation that the medical condition of the patient will not allow and mode of transporting , the medical care has to be given in the same time and same location , Tele-ICU is the right tool to provide the proper expert care in an area that has no expert and has critical need . Tele- ICU can serve the public by providing the expert medical services immediately using technology, eliminating unnecessary travel and risky patient transfer. Keeping the patient treated in his society will also allow the family to continue practicing their routine activities while giving the patient their support such and workers , students , baby care , and other family contribution . Keeping the patient treated in his society will also reduce or cut the travel expenses such as flights, accommodation, hospitality, and other. Also by the case management and standardizations the healthcare in the remote site will benefit to improve the knowledge and increase the education level which will have good impact in treating other similar cases. The impact was measured thru the statistics and number of cases been treated and also by comparing the time that patients used to spend in ICU before and after the program , by number of case transferred before and after , number of certified and trained medical and technical staff , mortality and morbidity statistics. Amount of money saved from short stay in the hospital, cost of travel and patient transfer saved, time the family spend in their normal activities.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
As WHO collaborative center for ehealth in EMRO area , many commutations were established with GCC countries , Yemen , Sudan ,Libya , Jordan ,Palestine, Bahrain , Qatar . An active Tele-ICU education is in progress with Sudan, Jordan, and Palestine. The program did not go smoothly in some other countries due to the political unstable situation, also the lack of financial resources, technical experts, mature network was the major challenge to continue replicating our experience, once the custom Tele ICU is documented in a case study reach and prove of concept format it can be replicated even in more customized form based on the available resources in each country. However the education and online training may continue and be replicated with minimum technology and network usage.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
The Tele-ICU at KFSHRC is a unique project in the Middle East and North Africa, and has been accredited by the World Health Organization as a Tele-medicine project. The Tele-ICU initiative currently should be an ideal solution for countries suffering from variations in their health system, the shortage of some specialty should be an extra reason for applying this project. In a wide country like Saudi Arabia, with a conditional cultural factors such as family centered life style, where the presence of parents and/or children is essential in the plan of care which been reflected in the public health. The Tele-ICU initiative has added a significant value in treating patients with high standards, minimal coast, considering cultural needs, and supporting the patients’ psychological factors. Despite all the challenges and barriers faced in implementing this project, the program has achieved the targeted goals and objectives. Customizing equipment, finding software solutions and bridging the gap between distance and experts were strategies used to approve that technology has embowered the health care field, although technology was not a source of trust in medical field for public and physicians, and after researches and trail it became one of the medical requirement for both. Nevertheless, applying this project has enriches our experiences from different aspects, mainly that a scientific try, focused targets and learning from errors will always be your keys for success. We, at KFSHRC (The Tele-ICU team/ health outreach department) would highly recommend other medical facilities in the kingdom and the region to benefit from our experience (medically and/or applications), we would also recommend and support initiation of such project in places that have the similar situations, were at the end can be measured in helping the public and the community.

Contact Information

Institution Name:   King Faisal specialist hospital and research center
Institution Type:   Government Agency  
Contact Person:   Jehad Alwatban
Title:   MD  
Telephone/ Fax:   RIYADH
Institution's / Project's Website:  
E-mail:   jehad@kfshrc.edu.sa  
Address:   3354 MBC #80
Postal Code:   11211
City:   RIYADH
State/Province:   RIYADH
Country:  

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