The Military Health System's success in adapting and expanding tele-critical care programs for critically ill patients in 2020 during the COVID-19 pandemic will play an essential role in bringing the virus under control in 2021.

The Defense Health Agency's tele-critical care programs have cared for thousands of patients, leveraging information and communications technologies to dynamically allocate and extend critical care capacity to the point of need, anytime and anywhere, especially to community hospitals and smaller intensive care units in remote locations.

"The number of COVID-19 cases continues to underscore the need for proactive virtual health planning and implementation," said U.S. Navy Capt. (Dr.) Konrad Davis, MHS director of tele-critical care. “The recent, rapid maturation of virtual health capabilities have made it possible to not only respond to the COVID-19 pandemic but to also prepare for future disasters as well — both natural and human-made."

Tele-critical care and other virtual health programs help sustain care while keeping beneficiaries and health care teams at a safe distance, said Jamie L. Adler, lead of the Virtual Health Clinical Integration Office at the Defense Health Agency Connected Health Branch.

The effectiveness of the virtual health programs has made tele-critical care an ever more important enterprise capability, and its popularity with providers and patients alike has made it integral to health care going forward, he said.

Joint Tele-Critical Care Network

A notable DHA success in 2020 was the expansion of the Joint Tele-Critical Care Network, an important force multiplier that leverages virtual health resources to extend critical care expertise and treatment at a distance. Critical care physicians, also known as intensivists, and critical care nurses located at three hub sites treat patients located at a growing number of spoke sites worldwide.

Once fully deployed, the JTCCN will allow intensivists to monitor hundreds of intensive care unit beds simultaneously through a setup conceptually similar to how air traffic control systems ensure planes — and their passengers — safely reach their destinations, Davis said.

The system tracks and analyzes vital signs, lab results, progress notes, and other real-time data, which helps providers quickly identify patients at risk for deterioration and more effectively intervene to improve outcomes.

In response to the COVID-19 pandemic, the JTCCN added seven new spoke site hospitals during calendar year 2020, nearly doubling the number of participating locations. In all of 2020, the JTCCN provided over 2,200 days of ICU coverage to 432 unique patients in 109 ICU beds spread across 15 spoke site hospitals. The JTCCN plans to add one additional spoke site hospital in calendar year 2021.

National Emergency Tele-Critical Care Network

In addition to leveraging existing resources such as the JTCCN, the DHA is working with the Telehealth and Advanced Technology Research Center, leaders at the Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response, academia, and industry to develop a rapidly deployable, hardware-light TCC capability. Launched in March 2020, the National Emergency Tele-Critical Care Network seeks to expand capabilities and capacity by augmenting bedside personnel who may lack the knowledge and skills to care for critically ill patients.

One NETCCN prototype has already demonstrated its effectiveness at a civilian hospital in Guam, Davis said.

In late August 2020, COVID-19 case numbers there spiked to more than 200 percent their normal volume, outstripping local resources. Guam Memorial Hospital reached out to the Federal Emergency Management Agency, which coordinated with the Defense Security Cooperation Agency. Roughly 72 hours after receiving its official DSCA mission assignment, the DHA shared a NETCCN mobile technology solution enabling the JTCCN to provide cyber-secure and HIPAA-compliant on-demand consultative support and monitoring for critically ill civilian patients.

Intensivists and nurses at DHA tele-critical care hub sites in California, Texas, and Washington state provided real-time guidance to bedside staff providing hands-on care. The system - still in use - vastly improved the ability of Guam's civilian providers to treat patients and save lives. Over a one-month period at the peak of the surge, the JTCCN fielded 64 physician calls and supported the care of 473 patient-ICU days, including 14 events of cardiac arrest.

Partnerships Key to Success

The on-the-ground successes of the JTCCN, NETCCN, and tele-critical care would not have been possible without partnerships the Department of Defense is cultivating among its own components, between itself and other U.S. government agencies, and between DOD and commercial and non-governmental organizations, said Dr. Simon Pincus, chief of the DHA Connected Health Branch. These collaborations help ensure tele-critical care capabilities can seamlessly reach across organizations through compatible technology, training, and protocols.

To increase surge capacity and technologic resiliency, the DOD is also pursuing a partnership with the Department of Veterans Affairs to create a single federal tele-critical care network for all U.S. forces globally, Davis said.

This network would enable any DOD or VA hub site to provide tele-critical care to any of the 1,700 VA or 400 DOD ICU beds through real-time distribution of workload to locations with capacity. The resulting partnership will enhance technological resiliency while also improving surge capability in response to pandemics and other crises. The goal is to have completely interoperable systems between the two largest users of tele-critical care in the U.S. government.