A virtual pediatric intensive care unit?

There is a shortage of intensivists in the US, both pediatric ones and those who care for adults. Intensive care nurses are in short supply, too. Yet the demand for intensive care services is growing. Part of the demand for adult intensivists is driven by our aging population, but what about children? Why aren’t there enough pediatric intensivists to go around?

I think the principal reason is that our national standard of care for children has changed over the past decades. When I trained in pediatrics over 30 years ago, only the largest children’s hospitals had PICUs. That has changed. The expectation these days is that medium-sized hospitals provide a much higher level of pediatric care than they did in the past, and that includes care of critically ill or injured children. Sometimes this means having a regional transport system so that such children can be rapidly flown to a larger center. But more and more it means that we need to have PICU capability in more places, and that means we need more pediatric intensivists.

Many have wondered if part of this problem can be solved by spreading the expertise of intensivists over a wider area, by taking advantage of all the communication and monitoring capability we have — that is, by establishing what has been labeled a “virtual ICU.” The idea has been gaining ground in adult practice; here is an example of what it means.

How could that work? What most people mean by a virtual ICU is that intensive care doctors (or nurses) can sit in a room and monitor the vital signs, lab results, x-rays, etc., of patients in ICUs in another location. The monitoring doctor could see the patients with a video camera, too. The patients aren’t alone, of course — there are doctors and nurses at the bedside, just not intensivists. When the intensivist monitoring the situation spots something, or if the doctor on site needs advice, there’s the telephone.

Can this work? I have a friend who is an adult intensivist and who has done this for years. He’s enthusiastic about the concept. I’m not so sure about children, though. Maybe I’m a dinosaur, but there’s a fair amount of research that shows that the best way of determining if a child is really, really sick is to have an experienced person say that child is sick. Tests and monitors help, but the sixth sense that an experienced person brings to the bedside is invaluable.

Still, I think some version of virtual ICUs are in the future for children, too. The technology does keep improving, and we simply don’t have enough pediatric intensivists to go around. Looking at the number of pediatricians training to become intensivists, this situation isn’t going to change anytime soon.

The concept of a virtual PICU can also have another role — that of intensivists exchanging information and collaborating with each other. Children’s Hospital of Los Angeles has been running a site intended to do that for several years now.