Current Status and Future Direction of Telemedicine ICU Consultation (Tele-ICU) in Kenya Wangari Waweru-Siika MBChB, MMed(Anaes), FRCA(UK) Consultant Anaesthetist and Paediatric Intensivist April 2015

OBJECTIVES To define telemedicine and tele-ICU To outline the potential benefits of tele-ICU in a resource-limited country such as Kenya To describe the current limitations of tele-ICU efforts in Kenya and chart the way forward

Case Report A young woman was admitted to MTRH ICU with septic shock and Adult Respiratory Distress Syndrome (ARDS). After initiation of mechanical ventilation, her chest X-ray was e-mailed to an ICU consultant in the US. Using Skype® via a wireless internet connection (Safaricom®), the ICU consultant and the Kenyan medical officer: reviewed the patient optimised ventilation using ARDSnet guidelines initiated sepsis management using the sepsis bundle.

The scope of the problem Sub-Saharan Africa bears 24% of the global burden of disease. Only 3% of the world’s healthcare workers serve Sub- Saharan Africa Kenya has only 18 physicians/100,000 population USA 254 physicians/100,000 Brazil 170 physicians/100,000 India 60 physicians/100,000 WHO 2010 World health statistics WHO 2006 Working together for health; the World Health Report

Telemedicine “The use of electronic information and communication technology to provide health care when distance separates the participants”. Institute of Medicine. Telemedicine: A Guide to Assessing Telecommunications in Health Care. Field MJ, ed. Washington, DC: National Academy Press; 1996.

Telemedicine icu consultation (Tele-ICU) ‘The use of computers and audiovisual communication systems to link an ICU patient and the ICU team with a remotely-based critical care team’. Surveillance and support provided for a large number of ICU patients in a variety of geographical locations. Remote monitoring of physiological variables possible in active systems. Also referred to as “virtual ICU,” “remote ICU,” or “eICU” First described in 1982 by Grundy et al

Tele-ICU equipment

Tele-ICU equipment

The case for Tele-ICU Outcomes of critically ill patients are improved by the 24-hour presence of intensivists. The first large scale study in 2000 demonstrated a 60% reduction in severity-adjusted ICU mortality Tele-ICU fueled by the shortage of trained intensivists. Rosenfeld BA, Dorman T, Breslow MJ, et al: Intensive care unit telemedicine: Alternate paradigm for providing continuous intensivist care. Crit Care Med 2000; 28:3925–3931

Meta-Analysis of Mortality with Tele-ICU Crit Care. 2012 Jul 18;16(4):R127. doi: 10.1186/cc11429.

TELE-ICU AND ICU LENGTH OF STAY

Critical Care in Kenya There are a limited number of adult intensivists in Kenya There are even fewer paediatric intensivists ICUs in Kenya are manned by anesthesiologists Kenya has 148 anesthesiologists registered with the KMPDB MTRH has only 7 anesthesiologists who cover both theatre and ICU.

Tele-ICU in Kenya The Ministry of Health plans to have ICUs in two hospitals in each of the 47 counties by the end of May 2015, at a cost of equipment of KShs 3.3 billion. Tele-ICU consultation between these ICUs, the two national referral hospitals and external partners could be a key component of realising this goal. Tele-ICU in Kenya would provide consultant support in ICUs that would otherwise not be able to support this level of staffing.

Benefits of tele-ICU Provides support to anesthesiologists with heavy clinical obligations. Improves morale of ICU staff. Allows access to specialists and sub-specialists in short supply. Potential reduction in ICU transfers from other hospitals Improved pre-transfer resuscitation and stabilisation.

Limitations of tele-ICU in Kenya Limitations due to current internet connectivity: Quality, stability and cost Limitations of Skype® as a platform for tele-ICU Time-zone differences when clinicians overseas need to be consulted Legal issues of data protection and patient confidentiality.

Future directions for tele-ICU in Kenya Improved informatics infrastructure. Research to define optimal tele-ICU configuration for a resource limited setting Regulatory and confidentiality issues regarding transmission of protected health information. Development of tele-ICU consultation and triage

SUMMARY The critical care setting is an important arena to develop telemedicine in Kenya Tele-ICU in Kenya has the potential to provide remote support to ICU patients and staff, and to improve patient outcomes There are limitations that need to be overcome for tele-ICU to be successfully adopted in Kenya.

Thank you