Turning night into day

By Laini Bennett
Thursday, 20 September, 2018

Turning night into day

Working nightshift is par for the course for healthcare clinicians. But what if there was a way to turn night into day? In the US, Emory Healthcare’s founding director of its Emory Critical Care Center, Dr Tim Buchman, went looking for a solution. He found it — Down Under.

Off the back of yet another exhausting overnight shift, Dr Tim Buchman knew he had to find a new way to support the US-based Emory Healthcare ICU team during their nightshifts. “I turned to my work partner, eICU Operations Director Cheryl Hiddleson, and said, ‘I can’t do this anymore. I need to find a way to turn night into day.’”

If they could base themselves in a country on the other side of the globe, he explained, where it was daytime during their nightshift, they could support the Atlanta-based bedside team remotely via technology.

Australia: on everyone’s bucket list

At the next staff meeting, Dr Buchman brought a globe of the world with him and put the idea to the team, asking, “Who wants to spend a couple of months in Beijing, China?” There was no response.

Looking further south on the globe, he asked: “Okay, who would like to spend eight weeks in Singapore?” A couple of hands went up, but the enthusiasm level was still low.

Figuring third time’s a charm, Dr Buchman said: “Okay, how about the Harbour Bridge, the Opera House and Crocodile Dundee?” All hands in the room shot up.

“Australia is on everyone’s ‘I really want to go there but it will never happen’ bucket list,” Dr Buchman laughed. “It became very clear that Australia was everyone’s desired destination.”

Logistics, logistics, logistics

Then it became a question of how to make it happen. Dr Buchman’s wife suggested he speak with one of her old bosses, Professor Bruce Dowton, now Vice Chancellor of Macquarie University. Before long, they’d agreed to a six-month research pilot.

“That’s how we ended up at Macquarie University Hospital, seeing if it was even possible to move our technology and providers to the other side of the globe and have them tell us ‘we can do this’,” Dr Buchman said.

As it turned out, the pilot was so popular that the participants not only said ‘we can do this’, but ‘when can we do this again?’ resulting in a decision to turn the pilot into a permanent program.

Finding new digs

Much as Sydney had been welcoming, the time difference during daylight saving in both countries meant that the Emory care staff in Sydney’s summer were working from 11 am to 11 pm to cover the Atlanta 7 pm to 7 am night shift. As a result, they resolved to establish their next support outpost in Perth, Western Australia, where the work schedules and time zones aligned serendipitously. A hosting relationship between Emory Healthcare and the Royal Perth Hospital has since been announced, leveraging Philips’ remote intensive care unit monitoring technology.

Working with Cheryl Hiddelson to establish the new facilities in Australia, Dr Buchman said the set-up “was at once more difficult and easier than you’d imagine”. Their biggest challenge was implementing an end-to-end secure circuit linking the Atlanta site and the Perth site that guaranteed privacy. “Our IP addresses and VoIP telephones must be completely isolated so we can guarantee a level of reliability and security that our patients, their families and our institution demands. That was the most complex part of it,” he said.

On the other hand, the legalities around having care staff working out at the Australia sites turned out to be straightforward. Rather than attempting to license US doctors and nurses locally, or license Australian healthcare workers for the US, it was simpler to send US care workers to Australia for limited rotations. The Australian medical and legal authorities had no issues with this approach, so long as the Emory team were not servicing Australian patients.

Cheryl Hiddelson working in the Perth eICU.

Noah’s Ark philosophy

Not wanting their caregivers to be isolated in Australia, the remote intensive care unit (ICU) is always manned by clinicians working in pairs. An Emory doctor and nurse team in Perth partner with two nurses in Atlanta to support the ICUs three to four nights a week, while the remaining nights are covered entirely by an Atlanta-based night-shift team. Together they support five hospitals and a dozen ICUs.

Typically, a nurse supports between 35 to 45 beds and a doctor supports 120 to 130 beds, delivered via an ultrahigh-resolution audio visual circuit into the patients’ rooms, allowing them to interact with the patient, their family and caregivers. Mobile communication carts can also be taken into the emergency department to support patients who are critically ill, but for whom no bed is yet available in the ICU, and closed-circuit conferencing is available for confidential discussions.

Long-distance care welcomed

Having conducted 90 goals-of-care conversations for critically ill patients, including from Sydney and Perth, Dr Buchman remains surprised at how amenable patients and their families are to receiving difficult news and emotional support via videoconferencing.

“People are so used to talking about their most intimate lives in their cell phones that having the undivided attention of a senior physician who knows about their loved one, essentially on demand, is something they embrace with a fervor that I still find difficult to fathom,” he said.

Increasing demand

While the remote ICU is popular with both patients and clinical staff, and Emory is considering establishing a second pair of caregivers in Perth, any expansion of the service will occur slowly to ensure quality is not sacrificed. “Trust among the care staff and patients is essential,” Dr Buchman said.

“The technology, interpersonal and communication skill sets are hard won and not everyone can do it.

“If we expand, the focus will always being on the needs of the patient and family, and not on the bottom line, the spreadsheet.”

Dr Tim Buchman.

Top image: Dr Tim Buchman liaises with a colleague in the US via the Perth eICU. All images credit: ©Emory Healthcare

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