A young mother nearly died after giving birth in a midsized American city, a stark reminder that even routine medical procedures can turn deadly when critical care is fragmented. The tragedy stemmed from retained placental tissue following delivery, leading to a life-threatening infection and septic shock.
The Cascading Failure of Tele-ICU Care
Table of Contents
A reliance on remote monitoring, without the crucial element of hands-on expertise, contributed to a preventable death, raising serious questions about the direction of modern intensive care.
- The increasing use of tele-ICU care is not always improving patient outcomes, and can even be detrimental.
- A lack of consistent, in-person handoffs and detailed patient assessments can lead to critical errors.
- The depersonalization of care through remote monitoring diminishes physician ownership and potentially impacts patient survival.
- Specialized ICU expertise is being lost with the practice of tele-critical care.
As a traveling ICU physician, I first encountered this patient after she returned from the operating room. Surgeons had removed some retained products of conception – placental fragments that hadn’t been expelled after childbirth – in an attempt to control the source of a developing infection. I anticipated a full recovery with intravenous fluids, antibiotics, and medications to support her blood pressure.
By 4 p.m. that day, she was improving, even off the ventilator. But her condition rapidly deteriorated that evening. By 9 p.m., she required high doses of three different blood pressure medications and soon went into cardiac arrest.
Unbeknownst to me, the ICU nurses, instead of contacting me or an in-house advanced practice provider, summoned the on-call tele-ICU physician. This physician, simultaneously managing seven to eight ICUs and receiving no detailed sign-out on individual patients, joined the resuscitation effort via video link. After a brief period of CPR, the patient’s pulse returned, a brief note was entered, orders were placed, and the tele-ICU physician moved on.
There was no call to me, the operating surgeon, or any attempt to understand the cause of the arrest. The nurses were left to manage a critically unstable patient, hoping for the best. When I arrived the next morning, the patient was critically ill, exhibiting multisystem organ failure and requiring a fourth blood pressure medication. Within minutes, I realized additional placental fragments had been missed during the initial surgery, and her sepsis remained uncontrolled. A second operation successfully removed the remaining tissue, but it was too late; the damage was irreversible, and she died later that day.
The Importance of Continuity in Critical Care
Effective critical care hinges on meticulous attention to detail. ICU patients generate a constant stream of data – from vital signs and lab results to imaging studies and medication regimens. A skilled ICU team – physicians, nurses, pharmacists, and therapists – synthesizes this information to create a clear clinical picture and guide treatment. Knowledge builds day by day, but this continuity is disrupted when teams change, particularly on Mondays.
During my time at Brown University Medical ICU, morning and evening sign-out rounds were invaluable. Physicians who worked week-long shifts shared a running knowledge of each patient, discussing nuances often absent from electronic medical records. Tele-ICU care eliminates this crucial handoff process, leaving remote physicians “half-blind,” relying on fragmented data without the benefit of context.
The Limits of Remote Examination
Good critical care requires a physical examination – listening to the lungs, assessing circulation, and palpating the abdomen. Subtle findings, like the crackles of lung disease or signs of abdominal ischemia, can be missed when the exam is outsourced to someone not directly present with the patient. Tele-ICU forces physicians to make critical decisions based on potentially unreliable data.
The Erosion of Physician-Patient Connection
Tele-ICU also diminishes physician ownership and emotional investment in patients. Regular interaction with patients and their families fosters a vital bond. A physician deeply involved in a patient’s care feels the loss acutely when things go wrong. Tele-ICU transforms the physician into a virtual consultant, detached and less invested in individual outcomes.
During the COVID-19 pandemic, I provided tele-ICU support to rural hospitals. We offered recommendations, but our advice wasn’t always followed, and nurses sometimes deviated from the plan without direct physician oversight. Being physically present allows a physician to address concerns and ensure proper execution of care. Tele-ICU creates a leadership void.
Data Reveals a Troubling Trend
Recent research confirms these concerns. A 2024 randomized trial of over 17,000 patients found no difference in mortality or ICU length of stay between those receiving tele-ICU care and those treated by non-specialty physicians. In effect, the benefits of specialized ICU expertise were lost when delivered remotely.
The result is a system where patients and physicians alike question the quality of care. I overheard an anesthesiologist in one ICU remark, after receiving orders from a “TikTok Doc” providing tele-ICU coverage, “You’ll probably want to check over those.” The disdain was palpable.
Nurses consistently express concerns about the quality of care in hospitals relying heavily on tele-ICU. Many physicians wouldn’t want their own families treated in such settings. Yet, the expansion of tele-ICU continues, driven by cost-cutting measures.
In 2010, less than 8 percent of ICU patients received tele-ICU care; by the start of the pandemic, that number had risen to 15-20 percent. Anecdotally, its use has exploded since then, not just in rural areas but also in medium and large cities. Health systems are prioritizing profits over patient care.
A Call to Action
Unfortunately, many healthcare administrators prioritize billable encounters over quality of care. To reverse this trend, specialty-trained critical care physicians must refuse to participate in tele-ICU programs that substitute for in-person coverage. Professional organizations like the Society of Critical Care Medicine, the American Thoracic Society, and the American Medical Association should adopt policies restricting the use of tele-ICU. If we wouldn’t want our loved ones cared for in a tele-ICU, it’s time to take a stand.
Keith Corl is a critical care and emergency physician.
