key: cord-0894598-un6muaai
authors: Ramnath, Venktesh R.; Hill, Linda; Schultz, Jim; Mandel, Jess; Smith, Andres; Holberg, Stacy; Horton, Lucy E.; Malhotra, Atul; Friedman, Lawrence S.
title: Designing a critical care solution using in-person and telemedicine approaches in the US-Mexico border area during COVID-19
date: 2021-08-11
journal: Health Policy Open
DOI: 10.1016/j.hpopen.2021.100051
sha: 79fb7d4f5f1685079d5ba4cc173d754a8e9bf9d4
doc_id: 894598
cord_uid: un6muaai

BACKGROUND: UC San Diego Health System (UCSDHS) is the largest academic medical center and integrated care network in US-Mexico border area of California contiguous to the Northern Baja region of Mexico. The COVID-19 pandemic compelled several UCSDHS and local communities to create awareness around best methods to promote regional health in this economically, socially, and politically important border area. PURPOSE: To improve understanding of optimal strategies to execute critical care collaborative programs between academic and community health centers facing public health emergencies during the COVID-19 pandemic, based on the experience of UCSDHS and several community hospitals (one US, two Mexican) in the US-Mexico border region. METHODS: After taking several preparatory steps, we developed a two-phase program that included 1) in-person activities to perform needs assessments, hands-on training and education, and morale building and 2) creation of a telemedicine-based (Tele-ICU) service for direct patient management and/or educational coaching experiences. Findings A clinical and educational program between academic and community border hospitals was feasible, effective, and well received. CONCLUSION: We offer several policy-oriented recommendations steps for academic and community healthcare programs to build educational, collaborative partnerships to address COVID-19 and other cross-cultural, international public health emergencies.

The UC San Diego Health System (UCSDHS) is an academic medical center and integrated care network in the southwest area of the United States within the US-Mexico border area where San Diego-Tijuana and El Centro-Mexicali are two sister-city regions. Tens of thousands of US citizens and legal residents live in Mexico for lower costs of living but are employed in the US and cross the US-Mexico border daily in these areas. Because of this intertwined relationship of communities on both sides of the border from social, economic, and political standpoints, strategies to promote public health in the US-Mexico border area are essential [1] .

In March 2020, cases of COVID-19 escalated in southern California and the Baja region of Mexico. On the US side of the border (San Diego and Imperial counties), local community hospitals, such as El Centro Regional Medical Center (ECRMC), were filled by US citizens crossing the border from homes in Mexico to seek health care in the US. On the Mexican side of the border, local demand for healthcare exceeded supply of equipment and personnel. A cascade of consequences occurred where Mexican hospitals looked to US border hospitals for assistance, and US border hospitals looked to other US hospitals. Furthermore, public health projections indicated increasing COVID-19 case rates into mid-2020, as US expatriate populations (~200,000 in greater Tijuana area and ~300,000 in Mexicali) sought care both locally in Mexico and across the border in the US. A collaborative program between UCSDHS and Mexican hospitals was necessary especially given the geographic proximity (see Figure 1 ). 

While academic health centers have traditionally focused on specialized clinical care, teaching, and research, suboptimal alignment with community health practice [2] , [3] 

While implementation and team science-based approaches are needed to achieve quality improvement in critical care settings, [4] - [7] including relations-building between academic medical centers and community ICUs, [8] there is scant guidance around urgently designing and launching multi-modality critical care initiatives in cross-border contexts. Our experience particularly applies to other health centers in the US-Mexico border area dealing with COVID-19, but academic centers and community sites internationally would benefit from updated approaches to the utilizing and integrating in-person and telemedicine services in critical care, especially in any cross-cultural (e.g. geographic, ethnic, economic) context. This document aims to improve understanding and provide guidance for developing and implementing critical care collaborative programs between academic and community hospitals.

Our recommendations are based on preparatory and implementation-based experiences through July 2020 as we enacted a hybrid in-person/Tele-ICU service to address critical care needs of 7. Efforts were made to identify onsite Tele-ICU champions to assist execution. We identified program champion(s) at each hospital (from physician staff, nursing, respiratory therapy, and administration).

We launched a hybrid, two-phase intervention that mirrored a model used in other communitybased critical care outreach programs in the UCSDHS network. 

Our initial in-person assessment assessed gaps in infrastructure, equipment, web connectivity, supplies, coverage schedules, personnel, and technological capability for Tele-ICU. A decentralized Tele-ICU system, in which tele-providers remotely connect to patients from places of convenience (e.g. home, office, or via mobile devices) rather than from a centralized hub [10] , [11] , was selected.

At ECRMC, the Tele-ICU program provided direct patient management in conjunction with onsite hospitalist physicians. At HGT/HGM, we initiated regular case conference-style, education-based Tele-ICU sessions. In all sites, we focused on building trust and integrating with existing rounding schedules and shift-changes to enhance involvement of the clinical teams.

We created a high quality, consistent, reproducible Tele-ICU "product" to engender immediate value upon launch through:

 Careful vetting of tele-intensivist candidates based on known performance of bedside manner, communication, evidence-based practice, openness to feedback, and collegiality.

We deployed few intensivists to grow familiarity and minimize practice variations.

 Multiple on-boarding workflow-building sessions to answer questions and share tips;

 Clear expectations for tele-intensivists: 1) detailed documentation of care plan; 2) strict adherence to evidence-based practices; 3) mandatory communication with ECRMC onsite providers via phone calls to hospitalists at the end of rounds;

 Multiple pre-launch meetings with ECRMC nurse/respiratory therapist/hospitalist physician staff to clarify details of the Tele-ICU "product" including schedules and expectations.

We found that several preparatory and implementation-based strategies were necessary and feasible for UCSDHS, an academic medical center network, to assist one US and two Mexican hospitals in the US-Mexico border area with COVID-19 critical care through a hybrid program of in-person and telemedicine services (see Table 1 ).

Objective/Rationale Table 1 . Action items for initiating a successful cross-border program to improve critical care delivery As in other launches of enterprise-level telemedicine solutions, [12] , [13] successful execution was augured by significant pre-implementation efforts in rapid, targeted needs assessments and selection/vetting of participating providers (at all engaged hospitals). As we addressed healthcare needs across international borders, we obtained sanction from political leaders [14] prior to formal engagement. Operationally, formal UCSDHS governing bodies integrated necessary individuals and skill sets, utilizing onsite champions [15] early to facilitate necessary bureaucratic processes (e.g. obtaining official letters, contracting, scheduling), encourage participation of local providers, and promote adoption of practice recommendations. Consequently, quickly clarified value propositions led to agreements in unprecedented time (i.e. within days, despite employee furloughs and lockdowns) and a clear path to successful execution. Notably, all UCSDHS team staff (nurses, therapists, physicians and interpreters) engaged on a volunteer basis in Mexican hospitals.

between UCSDHS and local hospitals, as staff felt reassured of intrinsic clinical instincts and incentivized to learn advanced skills in ventilator management (e.g. assessment of "recruitability," transpulmonary gradient), sedation, and other critical care areas. Concurrently, UCSDHS staff appreciated first-hand the strong knowledge base and experience of HGT/HGM practitioners, gaining familiarity with challenges of severe resource limitations.

3. Tele-ICU must foster team building between tele-intensivists and onsite providers.

We focused team-building efforts through pre-and post-implementation periods as much as during the initial rollout itself to build collegiality and trust. Internal meetings within the teleintensivist group, hospitalists, nursing, and other staff occurred weekly to identify opportunities for further impact. For example, at ECRMC, when the UCSDHS team shared concerns about fluid balances in ventilated COVID-19 patients, joint tele-intensivist-nursing-pharmacy teams formed, concentrating medication infusions within days.

Periodic on-site visits served to reinforce further the already strong spirit of collaboration and morale and allowed for serendipitous meetings with local community leaders. All participants have expressed interest in maintaining a long-term relationship in support of border health issues.

Partnerships were successful only once parties had deadlines to execute contractual agreements. At HGT/HGM, creating a strong ROI was challenging in our primarily advisory/educational capacity. Ongoing plans include onsite visits and mentorship of Mexican physicians at the UCSDHS campuses, trainee exchanges to foster medical learning opportunities. As cases surge, however, UCSDHS clinicians face mounting pressure regarding primary responsibilities, reducing time to devote to volunteer activities. Without alternative avenues of sustainability (e.g. philanthropy, foundation-based grants), the gains at HGT/HGM to date may fade.

Strengths include involvement of multiple health centers in an internationally important, crossborder region with highly fluid movement representative of other cross-cultural contexts. In addition, consistently high COVID-19 case numbers in these hospitals over months facilitated reliable execution of policies. Limitations were primarily due to rapid efforts to provide critical clinical services in hospitals in desperate need of assistance. Each site (HGT, HGM, and ECRMC) had unique needs, infrastructure, and historical relationships with UCSDHS that complicated unified approaches allowing adequate comparisons. Ongoing evaluations are underway with more standardized processes for more detailed, comprehensive, and valid evaluations of this initiative.

We detail preparatory and implementation-based aspects of our recent experience at UCSDHS in addressing requests of three hospitals in the US-Mexico border region of southern California and northern Baja region of Mexico for critical care support during the COVID-19 pandemic. A partnership between an academic center and resource-limited community hospitals was feasible, rapidly executable, and effective in generating clinical, operational, and educational value that is also cost-effective. Common themes that engendered success included team building, idea sharing, and adherence to evidence-based practice in critical care. Our experience serves as a blueprint for other academic and community centers looking to build collaborative partnerships to address international public health emergencies.

product" as clinical deliverable that emphasizes "customer comes first" approaches, consistent evidence-based practices, and uniform expectations positively brands in-person and telemedicine services and quickly builds trust

Focus on standard process was calming to ECRMC nurses and staff, as variations of onsite ICU personnel background and skill sets (e.g. hospitalist and Emergency Department (ED) physicians, federal/state Disaster Management Assistance Team members from neonatal ICU andED

advanced ventilator management, vasopressor selection, etc.) and enhanced staff confidence in critical care plans (manuscript in submission). Furthermore, ICU staff reported increased confidence caring for non-COVID ICU patients (for whom the Tele-ICU service was not involved), suggesting a cross-over, "osmosis" effect. We experienced similar gains in HGT/HGM

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All authors had access to the data and a role in conception, data acquisition, and/or editing the manuscript. All have approved the final version to be published and have agreed to attest to the accuracy of the work. Venktesh Ramnath: Conceptualization; Data curation; Formal analysis; Investigation;