Healthcare, like other services, requires getting appropriate expertise to the place where it is needed at the right time. Requirements like these become critical when a patient faces a sudden and unpredictable life-threatening condition. The latter is a near-routine occurrence in a hospital’s intensive care unit (ICU). Still, a host of factors make it impossible for clinicians to be present at every point in the ICU, all the time.

Early acceptance of robotic telepresence
Such shortcomings are sought to be addressed by ICU robots, one of the latest applications in the emerging field of ‘robotic telepresence’. The use of ICU robots, also referred to as teleoperated medical devices, is growing rapidly as a supplement for patient care in the ICU. In its early stages, healthcare providers were overwhelmingly convinced of their potential. In September 2012, for example, a survey of over 10,000 ICU robotic interventions in the journal ‘Telemedicine journal and e-health’ found 100 percent of practitioners considered the robot to improve both patient care and patient satisfaction.

Autonomous, optimised for ICU, hospital environment
ICU robots essentially provide access for physicians and other specialists to implement a variety of medical procedures round-the-clock, while reducing delays for difficult admissions or procedures.
The robots can be pre-programmed to drive on their own around an ICU, or this mode can be overridden and controlled by an individual, located on the premises, at a facility near by or thousands of kilometres away, via a keyboard or joystick.
The robotic sensors are optimized to perform in a hospital environment, enabling the robot to identify and avoid things like IV lines, cables and glass doors.

Plug-and-play for medical devices
The robot itself contains combinations of display types, microphones, speakers and cameras; these have pan-tilt and zoom capabilities, and are powerful and manoeuvrable enough to permit physicians to view fine details and listen to the smallest sounds.
Typical accessories in an ICU robot include an integrated electronic stethoscope to allow physicians to listen remotely to heart and lung sounds using earbuds. However, most Class II medical devices can be plugged into the robot, which streams data back in real time. On the other side, robots can also access digitized medical records of patients.
Recent innovations include a smartphone application, enabling physicians to access the robot’s camera. Another is ‘point and click’ navigation, by virtue of which a user can simply click somewhere on a map of the hospital and the robot gets itself there.

UCLA pioneers ICU robot
The history of ICU robotics dates to 2005, when the University of California at Los Angeles (UCLA) Medical Center became the world’s first hospital to introduce a robot in its neurosurgery intensive care unit under a US military-funded pilot project. The UCLA pilot saw intensivists (clinicians specialized in the care of critically ill patients) monitoring patients from their homes and offices.

The robot was RP-6, developed by California-based InTouch, a company known for its ‘auto-drive’ robotics technology used in defence and public safety. Controlled by a webcam and joystick over a broadband connection, the 65 inch (166 cm) wheeled robot boasted 8-hour runtime from a single charge. Onwards from 2006, InTouch offered hospitals an option to rent the RP-6 for USD 4,000 a month, or buy it outright for USD 120,000. Its earliest customers included Detroit Medical Center and Baltimore’s Sinai Hospital.

The iRobot-InTouch Health Alliance
Meanwhile, another US company iRobot (vendor of the robotic household vacuum, Roomba) set up a Healthcare Robotics division in 2009.
In 2011, iRobot and InTouch Health announced an alliance targeting healthcare. The next year they unveiled the RP-VITA (Remote Presence Virtual + Independent Telemedicine Assistant), a robot which went beyond simply providing remote interactive capability between a clinician and patients to a hugely-enhanced navigation capability, based on sophisticated mapping and obstacle detection and avoidance technologies tailored to a hospital environment. Its aim was to free the clinician for clinical tasks.

FDA clearance
The most revolutionary capability of RP-VITA was autonomous navigation, which was submitted to the the US Food and Drug Administration (FDA) for 510(k) approval. In January 2013, the FDA cleared RP-VITA, making it the first autonomously navigating telepresence robot in healthcare, with clearance for use before, during and after surgery and for cardiovascular, neurological, prenatal and psychological as well as critical care. 

Demand driven by range of factors
The key drivers of demand for ICU robots today include time factors (urgency in ICU cases) and access (unavailability of ICU expertise) in remote areas. Both these are compounded by staff shortages.
There are fewer than 6,000 practising intensivists in the United States today and more than 5 million patients admitted to ICUs annually. A few years ago, Teresa Rincon, chair of the Tele-ICU Committee of the Society of Critical Care Medicine (SCCM) noted that the number of intensivists in the US was “not enough for each hospital to have one.” Indeed, it is estimated that only about 37 percent of ICU patients in the US receive intensivist care, although trained intensivists in the ICU correlates to better outcomes and decreased length of stay – both in the ICU and hospital.

The challenge of coma
In terms of urgency,  the SCCM notes that up to 58% of emergency department admissions in the US result in an ICU admission. 
Following admission, one of the major drivers of demand for ICU robots is coma. The reliable assessment of comatose patients is always critical. A hospital needs to quickly identify clinical status changes in order to determine and implement appropriate interventions.
In January 2017, the prestigious Mayo Clinic published results from a 15-month study of 100 patients, which is reported as the first to look specifically at telemedicine in assessing patients in coma. The results suggest that patients with depressed levels of consciousness can be assessed reliably through telemedicine.
Another urgent complication is delirium. Delirium incidence has been estimated at over 80% in critically ill patients. This is accompanied by a threefold increase in mortality risk, according to an oft-cited study in an April 2004 issue of the ‘Journal of the American Medical Association’.

Clinician availability
Medical emergencies like coma and delirium require the presence of highly qualified clinicians, but as discussed previously, real-life constraints limit their availability round-the-clock.
Access is another crucial consideration. Most hospitals simply lack the patient volume to employ full-time intensivists in fields like neonatology, while their availability is limited for the same reason in remote rural locations. 

The tele-ICU
The first attempts to address such challenges were centred on telemedicine or Tele-ICU care, involving continuous surveillance and interactive care by offsite clinicians. This was achieved by video observation of the patient and interrogation of equipment, along with instructions conveyed to other ICU staff.
Although more studies are needed, there is evidence of an association of the Tele-ICU with lower mortality and shorter length of stay in both the ICU as well as the hospital.  Another benefit is that a Tele-ICU enables stricter adherence to guidelines.

US leads the way
Europe was a relative latecomer to ICU telemedicine, with a near-total focus on teleconsultation and almost-total reliance on the US experience.
For example, Britain’s NHS refers extensively to US studies on ICU telemedicine in its own Technology Enabled Care Services (TECS) Evidence Database, while the University of Pittsburgh Medical Center has opened a Tele-ICU centre in Italy, which allows US physicians to perform remote consults for Italian ICU patients.

From telemedicine to robotics: business model turned around
In many senses, ICU robotics have been a natural successor to the Tele-ICU, albeit with a significant reversal in its operating model.
The Tele-ICU functions centrally. Rooms are hard-wired with high-resolution cameras and transmit data to a remote command centre staffed by an intensivist (tele-intensivist). The intensivist, who typically covers multiple ICUs, has access to the same clinical information (e.g. vital signs, lab values, notes, physician orders etc.) as the ICU bedside team consisting of nurses, respiratory therapists, non-ICU physician and transfers instructions to them via a two-way communication link. Robotics, driven by advances in technology and mobility, have made it possible for the Tele-ICU care model to become decentralized. The ICU robot is controlled wirelessly by the tele-intensivist, who is freed from a dedicated command centre, and can indeed be just about anywhere. The robot moves from room to room, examining patients based on instructions from the intensivist and interacting as required with staff. The latter interaction is now seen to be far more efficient, since it occurs only after the intensivist has given instructions on the procedures which need to be performed on a patient.

The cost factor
ICU robots seem to also address another major  limitation of Tele-ICU, namely cost. Most studies on Tele-ICU have found that though the technologies deployed have been adequate, they have also been much too expensive.
In the US, some hospitals collided with reality, quickly and harshly, “removing tele-ICUs after outcomes failed to justify the costs.” A study in December 2009, in the prestigious ‘Journal of the American Medical Association’ also questioned a key maxim of the Tele-ICU, pointing to evidence that remote monitoring of patients in ICUs was not associated with an overall improvement in the risk of death or length of stay in the ICU or hospital.
Perspectives have been similar in Europe. For example, a Dutch study published in 2011 in the ‘Netherlands Journal of Critical Care’  concluded that hospitals were unlikely to see the “enormous” investment entailed by a tele-ICU as being cost-effective. Concerns about Tele-ICUs were also echoed the same year in Canada, where critical care clinicians, writing in the ‘Journal of Critical Care’ expressed scepticism regarding the ability of a Tele-ICU to address challenges of human resource limitation or even deliver quality care.

The personal touch
While a conclusive answer to the question of cost-effectiveness of OCU robots will require a larger user base, one powerful advantage seems to be the ability to target the eventual subject of the healthcare process, the patient. According to Paul Vespa, a neurosurgeon at UCLA’s David Geffen School of Medicine patients “interact with the robot as if it is a person.”

Steps to realize full potential
Before there is growth in numbers of ICU robots, some of the factors which will need to be addressed have been identified in a ‘Journal of Critical Care’ article in December 2013 by the Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City, US.
These consist of formal training and orientation, identification of roles, responsibilities, and expectations, needs assessment, and administrative support and organization. Failure to adopt these, say the authors, will mean ICU robots may not see their full potential realized.

Point-of-care testing (POCT) is typically described as a clinical test which is done at, or close to, the physical location of a patient. This could be at a patient’s home, in a pharmacy, a GP’s office or an in-hospital bed site. POCT typically consists of portable devices and instruments, which return results quickly. As a result, POCT permits immediate intervention or treatment.
POCT can also be defined usefully by specifying what it is not. In this case, a POCT is simply a test that is not analysed in a laboratory. POCT short circuits many steps involved in the latter. It eliminates the need to collect a specimen, transfer it to the lab, perform the test, and transmit results back to the provider.
POCT is increasingly used to diagnose and manage a range of diseases, from chronic conditions such as diabetes to acute coronary syndrome (ACS). Recent additions include genetic tests.

Driven by miniaturisation
The POCT era is considered to have begun in the 1970s, with a test to measure blood glucose levels during cardiovascular surgery. In 1977, a rapid pregnancy test called ‘epf’ became the first POCT for use wholly outside a hospital.
Since the late 1980s, one of the key drivers of POCT has been product miniaturization, with increasingly sophisticated and ever-smaller mechanical and electrical components integrated onto chips that can analyse biological objects at the microscale. The pace of miniaturization has accelerated at a breakneck speed in recent years, to mobile handheld and wearable POCT devices. These can be inte-
grated with other applications within a healthcare facility, or aid patients in monitoring and self-management of chronic conditions.

Wide product range, but handful of tests dominate
The most widely-used POCTs include “blood glucose testing, blood gas and electro-
lytes analysis, rapid coagulation testing, rapid cardiac markers diagnostics, drugs of abuse screening, urine strips testing, pregnancy testing, faecal occult blood analysis, food pathogens screening, haemoglobin diagnostics, infectious disease testing and cholesterol screening.” Nevertheless, just three tests – urinalysis by dipstick, blood glucose and urine pregnancy – are believed to account for the majority of POCT.

Comparisons with the lab
Beyond definition, the relationship of POCT to a laboratory is close for a very good reason. Most clinical cases for POCT use lab testing as a comparator. In other words, the first question that comes to many people when using POCT is whether its results match those of a laboratory. Although evidently quicker to obtain, is POCT as reliable? Another topic for comparison consists of the cost of POCT versus lab tests.

Costs: a vexed question
Even in the heady early days of POCT, there was awareness about potential cost downsides. One of the first efforts to address this question was a US study, published in 1994 in ‘Clinical Therapeutics’. [1] The study, by the Office of Health Policy and Clinical Outcomes at the Thomas Jefferson University Hospital in Philadelphia, sought to determine time and labour costs for POCT versus central laboratory testing on a cohort of 210 patients presenting to the emergency department.
The patients had blood drawn for a Chem-7 profile (sodium, potassium, chloride, carbon dioxide, blood urea nitrogen, glucose, and creatinine), or for cell blood count (CBC). Largely due to much quicker turnaround time (TAT), physicians reported that POCT would have resulted in earlier therapeutic action for 40 of 210, or 19 percent of patients. Costs for POCT were, however, over 50 percent higher, and also showed significant variability, depending on test volume. The authors speculated that increasing volumes of POCT would reduce costs “substantially.”

Volumes lower cost
The perception that POCT is much more expensive than a centralized laboratory persists. There are several reasons for this. Consumables generally cost more than tests done with automated laboratory instruments. On its part, POCT simply cannot achieve the scale economy associated with the latter. It also requires more staff downtime.
However, right from the early stages of POCT use, it seemed likely that unit costs could be reduced by increasing test volumes, as anticipated in the 1994 study by Jefferson University Hospital.
POCT was also to quickly demonstrate enhanced utility for certain kinds of tests. In 1997, a study at an Indiana hospital reported a near-halving in unit costs of panels, from USD 15.33 to USD 8.03, following POCT implementation for blood gases and electrolytes [2].

Levelling the field of play
One of the biggest hurdles in making cost comparisons of POCT with lab tests is the difficulty of levelling the playing field. It is also difficult to use such an exercise to draw generalised conclusions, since key conditions often vary significantly from one care facility to another. POCT is also complex to manage, and it is especially challenging to maintain regulatory compliance, especially in large institutions.
Though the cost of consumables is straightforward to determine, this is hardly so for labour.
Labour costs for a lab test are not limited to staff in the laboratory. They also include costs of staff in the pre-analysis phase, for phlebotomy, nursing and other services. Many of the latter entail administrative overheads. Typically, these would consist of formalities in the collection of phlebotomy supplies, the completion and submission of a test request, the labelling of tubes, specimen packaging and despatch.
In contrast, POCT eliminates most pre-analytic steps, along with associated staff costs and overheads. POCT can be undertaken by personnel who are not trained in clinical laboratory sciences.

Cost versus value
Although it seems to be common sense that POCT labour costs are significantly less than for a laboratory test, calculating this precisely requires a complex time-and-motion study which takes account of differences in wages and other costs for phlebotomists, nurses, administrative staff and medical technologists.
Unit product cost therefore reflects only a part of the overall equation, as far as justifying the case for a test is concerned. Indeed, many experts now urge for making assessments based on unit value rather than unit cost.
The role of TAT
With POCT, faster TAT promises better treatment, reduced patient stay, superior workflow and improved clinical outcomes. POCT is however less about reducing TAT than making results available in an optimal and clinically relevant time frame. This, in turn, is frequently dictated by conditions for which care is targeted as well as the setting in which it is delivered.
Delayed test results also impact upon cost in indirect ways. For instance, radiology departments use creatinine POCT before administering contrast agents, since patients with impaired renal function can develop contrast-induced kidney injury. This allows for quick decisions about patients and efficient use of costly CT scanners. If physicians had to wait for test results from a laboratory, the scanner would risk having to idle in a stand by status.

POCT can sometimes be only choice
Some tests have to be performed at point of care since there is no choice, in terms of time for transport to a lab.
One good example is an activated clotting-time test. This is used to monitor cardiac patients undergoing high-dose heparin therapy, whose blood immediately starts to clot after collection of a sample. Another is a POCT glucose test, where a quick result is crucial in determining insulin dosage for diabetic patients.
Elsewhere, whole blood cardiac-marker POCT tests in an A&E facility allow physicians to make rapid decisions on patients with acute coronary syndromes in terms of triage and disposition for observation, catheterization or transfer to a cardiac ICU.
Yet another example is a rapid flu test, used to identify patients who could benefit from antiviral therapy requiring administration as soon as possible after infection, in order to reduce symptomatic intervals. None of the above permit the wait times required for a lab test.

The grey zones
Still, there are grey zones where lab tests have advantages, which are non-negotiable under certain conditions.
One example is routine monitoring of international normalized ratios (INR) for patients on warfarin. The latter is used for prophylaxis against stroke and systemic embolism in patients with atrial fibrillation or mechanical heart valves. The goal of testing is to ensure that anticoagulant levels are appropriate. Over a certain threshold, there is a risk of bleeding, while below it, there is the danger of clotting.
While warfarin toxicity can result in life-threatening risk of bleeding, inappropriate warfarin dose reduction can lead to inadequate protection from a stroke or systemic embolism.
Lab-based testing entails the patient travelling to a GP, or having a caregiver come to take blood at the patient’s home, and doing this regularly. However, even a one-day TAT for the lab test can be a major problem in terms of warfarin dosage. The utility of POCT here seems clear. The GP can know the results and adjust the medication dosage immediately. In addition, POCTs can enable certain categories of patient to self-test and manage warfarin therapy.

Lab tests as gold standard
However, POCT tests can vary significantly from laboratory analysers. In the case of warfarin monitoring, this happens as INR values rise. Correction factors are also typically device- and institution-specific. They cannot be uniformly applied across institutions. Many clinicians therefore require POCT INRs which are greater than 5.0 to be confirmed with a venipuncture sample and a lab test.
Lab tests therefore remain a gold standard. Instrumentation in a laboratory provides robust analytics during a test, and includes a host of quality controls, from test strengths and timings to testing accuracy. These are incorporated into a laboratory information system (LIS) and stored in a patient case file. POCT simply cannot provide such a depth of information.

Gaps being closed
In brief, both POCT and laboratory testing have pluses and minuses. POCT provides definite advantages and reduce risk in some situations.
However, laboratory testing is more advanced, more closely follows scientific process and is fully integrated with the kinds of technical redundancies necessary to ensure greater accuracy and validation of records.
Nevertheless, gaps between the two are being closed, especially through software technology.
Some hospitals now have dedicated satellite labs in emergency rooms and outpatient facilities equipped with POCT.

[1]  https://www.ncbi.nlm.nih.gov/pubmed/7859247
[2] Bailey TM, Topham TM, Wantz S, et al. Laboratory process improvement through point-of-care testing. Jt Comm J Qual Improv 1997;23(7):362–80

Doctors working in the eight-bed Pediatric Intensive Care Unit at the Ramón y Cajal University Hospital in Madrid use point-of-care ultrasound extensively to evaluate the condition of critically ill children, and find it essential to their work. Dr José Luis Vázquez Martínez, Head of UCIP at Hospital Ramón y Cajal, with over 25 years’ experience in pediatric intensive care medicine, explained.

Point-of-care ultrasound (POCUS) is used extensively in our unit, allowing comprehensive, head-to-toe assessment of critically ill children, including respiratory, oncology and post-operative cardiac patients, as well as those being treated for sepsis or multiple trauma. The POCUS approach allows not only an initial diagnosis, but also routine monitoring of treatment to see whether or not a patient’s condition changes, enabling alternative strategies to be implemented if there is no improvement.

POCUS helps pediatric doctors in many ways. For example, ultrasound scans enable evaluation of a patient’s hemodynamic state, looking at their heart function and blood volume to see if these factors are contributing to respiratory failure. Conversely, doctors can see if a lung problem, such as pneumonia, is affecting the heart. For a patient in a coma due to multiple trauma, ultrasound is used to look for signs of bleeding – a potential cause of unexplained anemia – and to assess the intracranial pressure. It is also used to monitor kidney function in children with blood pressure problems, and visualize intestinal indications of sepsis. In addition, ultrasound guidance can be used for endotracheal intubation. In short, broader applications that we did not anticipate until very recently.

We have used ultrasound in our PICU for more than a decade, and have always had SonoSite systems, upgrading them as new technology is introduced. In the beginning, when my knowledge was more limited, the aim was to perform clinical echocardiography but, when the SonoSite representative showed me the linear probe and the various techniques available, it was as if I was being shown electricity after using candles! It was amazing, a real turning point in the use of ultrasound, and everyone recognized it as a step forward in the pediatric intensive care world. For the patients, a major benefit of ultrasound is that exposure to radiation can be reduced. Before ultrasound, X-ray examinations were performed two or three times in the first few days after admission to try to establish the cause of the problem, often with limited success. With ultrasound, we can scan the patient as often as necessary, implementing treatment and monitoring its effect without exposing the child to more radiation.

In PICU, we consider an ultrasound system essential – there is nothing else that gives us so much information, so quickly and non-invasively – and today we have a dedicated Edge II ultrasound system with linear, including hockey stick, and adult and pediatric cardiac transducers. It is in constant demand and is a perfect fit for our work, fulfilling all our expectations. All my colleagues use it, and we are very satisfied with it. The system is high quality and ergonomic, and strikes a good balance between image quality and ease of use. It is also quick to boot up, which is crucial for an instrument that is frequently moved between different beds in the unit. Robustness is vital too; if a patient deteriorates, we may have to move any equipment surrounding the bed very quickly to create space to treat them. However careful you are, there is always the risk of unintentional knocks to the system.

A while ago someone said to me that they ‘sell ultrasound machines but don’t offer training’, but this view isn’t enough – it’s very short-sighted – training is very important. Ramón y Cajal pioneered the use of ultrasound in PICUs across Spain, and was the first hospital to offer external training courses for doctors from other facilities, initially focused on clinical echocardiography. Over time, this has expanded to include neuromonitoring, respiratory and abdominal monitoring. I acquired my ultrasound experience through a combination of external training in adult ultrasound and practical, hands-on learning, and am largely self-taught. If courses like these had been available when I started using ultrasound, I would have saved so much time.
FUJIFILM SonoSite is clearly committed to organising and supporting ultrasound training, and this is unquestionably a great benefit to the scientific community – long may it last!      

Today, we are seeing a boom in the use of ultrasound in pediatric care, as it non-invasively provides immediate information in situations where time is of the essence. Our advice to people attending our training courses who do not have – or have to share – an ultrasound system is to tell their hospital managers that, just like a ventilator, it is an essential piece of equipment for an intensive care unit.

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