Virtual ICU Rounding: Involving Patients’ Loved Ones Through Video

Podcast Transcript

Raed Dweik, MD:

Hello, and welcome to the Respiratory Inspirations Podcast. I'm Raed Dweik, Chairman of the Respiratory Institute at the Cleveland Clinic. This podcast series of short, digestible episodes is intended for patients and families, and covers topics related to respiratory health and disease. My colleagues and I will be interviewing experts about timely and timeless topics in the areas of pulmonary, critical illness, sleep, infectious disease, and related disciplines. We will share with you information that will help you take better care of yourself and your loved ones. I hope you enjoy today's episode.

Hassan Khouli, MD:

Hello everyone, and welcome to the Respiratory Inspirations Podcast. I am your guest host, Dr. Hassan Khouli, chair of the Department of Critical Care Medicine in the Respiratory Institute at the Cleveland Clinic. My guest today is Dr. Adi Gerblich. Dr. Gerblich is a physician staff in the Department of Critical Care Medicine at the Cleveland Clinic and he's the division chief of pulmonary at Hillcrest Hospital. We will be talking about virtual ICU rounding today. Adi, welcome to the program.

Adi Gerblich, MD:

Thank you, thank you. I'm so excited to be here.

Hassan Khouli, MD:

Thank you. Let's maybe set the stage for our audience today and if you can share with us, what is the ICU environment is like?

Adi Gerblich, MD:

The ICU environment is a special place in the hospital, where the sickest patients are treated. Most people getting in there will be a little bewildered. You have advanced equipment that fills the room. High-tech monitors, screens with displays of heart rate, oxygenation, important information about the patient's health condition. You can see specialized medical staff, respiratory therapists, dialysis technicians, specialized nursing dealing with the patient. You can see IV lines, different tubes coming into veins, into the mouth, into the chest cage. All to support the life of patients. You can see monitors with medical records showing, all the time, the patient's condition, the medications, what the physician said. You can see areas of restricted access because of sterility issues that we want to keep the patients safe or isolation from the environment.

You can find family waiting areas where families often wait until they can see the patient or wait until the procedure is done. You can see a lot of emergency equipment. Dialysis machines, crash carts, intubation, ventilators, defibrillating machines. So, all kinds of devices to maintain life and resuscitate patients.

Hassan Khouli, MD:

Thank you. Thank you, Dr. Gerblich for sharing this vivid vision of what the ICU environment is like and for many of us, who are, you know, live in that environment often, day in and day out, we take it for granted. For the patients we care for, for the families of these patients that we care for, certainly this could be a big shock in introduction to them. So, communication will become even very important to really share with them what that environment is like and then what their loved one is going through as well. So, maybe you can share with us some communication modalities, types of communications that we tend to use in the intensive care unit between the ICU team and the family that are caring for that patient.

Adi Gerblich, MD:

So, as I described, the environment is sort of bewildering and chaotic. So, it's akin to a war zone. The war is now the patient medical condition and team, the physicians and everybody around trying to win that war. So, communication is done in multiple ways. First of all, we have in-person communication, where the family is at the bedside or in the waiting room. And we communicate with them directly about a patient's condition. We can make phone calls to the family if they're not available. We have the modality of having video conferencing with families that cannot be at the bedside and would like to have information about a patient. We can do it with the whole team or not. We can have scheduled meetings with family at their request. We can have designated liaison communicating with the family. We have interpretive services to people who don't have fluent English language or have other language or are more comfortable as other languages. And, we have pamphlets, supportive resources to communicate with families. So, multiple modalities.

Hassan Khouli, MD:

That's certainly true and for our audience it's good to have these options, really to know that you're not limited. Either I have to make a phone call, or I have to come into the intensive care unit to be able to learn about what's going on with my loved one, and how I can participate as a family member in the discussion there too.

Now, in the ICU, we talk about the team, and we talk about how this is really a team sport that we all work on together. So, if you don't mind, maybe you can share with us what it is like usually, you know, to be round with that team. Who's usually on that team to start off with?

Adi Gerblich, MD:

So, the way that we work in the ICU is that every patient gets daily, at least once a day, a visit by a comprehensive team of caregivers. That team of caregivers includes the intensivist or the physician who specializes in critical care. There is a practicing nurse, nurse practitioner who specializes in intensive care unit. There is a bedside nurse in this team. There's a pharmacist whose specialty is critical care. As well as a nutritionist and dietitian. And, many times, also palliative care services or social services or other consultants like cardiology or nephrology or gastroenterology or whatever the case of the patient may be.

That team, on a daily basis, rounds on the patient. At least once in the morning and, if necessary, see them multiple times during the day. As the clinical situation necessitates.

Hassan Khouli, MD:

Excellent. It's a big team.

Adi Gerblich, MD:

It's a big team, it's complicated. Especially in an arena like that, but we take our time. It takes several hours to go through all the cases that we have. But we go one by one, sometimes in sequential fashion. Sometimes depending on the acuity of the case. We might jump from place to place, but everybody gets the attention that is needed based on the clinical condition.

Hassan Khouli, MD:

Right. So, Dr. Gerblich, during that ICU environment that you just described, the ICU rounding, you know, that you just shared with us, with the team. Maybe kind of explain to our audience what is, you know, that protocol of video communication with the family or what is the difference between that and in person or other modalities of communication.

Adi Gerblich, MD:

So, sometimes the family cannot be at the bedside. But, I think, the visual experience, seeing the patient, seeing the whole team members communicate about a loved one has a positive effect on the interaction between the family and the team. And that is done with a video conferencing program where we dial in the number of the family POA, and they communicate with us by video, and they can see the whole team and we discuss the case with the family present. We like the family to be present in all our round interactions.

Hassan Khouli, MD:

Excellent. And this would be a time I would say, maybe, you can share with us the history of this program. How did this come about as a pioneer of this program, as the one who really started us here at the Cleveland Clinic. Was this well before COVID? Love for our audience to hear from you directly.

Adi Gerblich, MD:

Yeah, it started before COVID. There was an effort by the Cleveland Clinic to increase its reach via telecommunication. The idea was to do consultations on an outpatient basis or between hospitals, between consultants. And I sort of felt that the ICU arena should be one that we can communicate with families because I was feeling that if families are not involved in the critical evaluation of the patient, I'm missing something. And I would like to have them participate, so it was important to have the video and the family connected together with us in the cases where the family was not able to be at the bedside.

Hassan Khouli, MD:

And what a great idea.

Adi Gerblich, MD:

So, then as it turned out, when COVID hit, suddenly we were already on that mode of function and the video communication was the protocolized way, that we do it was already standard in the unit. So, when the COVID epidemic happened, it was a great benefit for the families because this time they were not able to come the bed at all and they were sort of in the dark as to what's happening to their loved ones. So, that made the whole difference in the way that they felt about their loved one. They saw them. They saw the data. They saw the treatment team and they sort of were with us even though not physically.

Hassan Khouli, MD:

Thank you, thank you for sharing that history and perspective of the program to our audience. We can move on to a different set of questions in this segment. How does the video conference help the treatment team and the family of the patient from your experience here?

Adi Gerblich, MD:

I think the major advantage is that the diction is, "Seeing is believing." If you see things, you can better relate to them. It's not just hearing; you involve all your senses in the interaction. You get much more insight into nonverbal communication, not just the verbal communication as to what's happening between the team, the patient, and the family. So, as you know, you can look at somebody and you can tell right by looking at a person, does he look good, or he doesn't look good. How do we decide it? We decided by vision. So, vision is an important aspect of communication, especially in a sick person. So, you can say he looks better, or he doesn't look better. That's important for the family to see. Not just the family, treatment with team as well. So, I think, in that sense, the video adds that piece of communication that is not available otherwise.

Hassan Khouli, MD:

I agree and if you think about that, you talked about some of the advantages of doing this. Are there any disadvantages that you can think about for that video rounding with the family?

Adi Gerblich, MD:

Technology's just technology. It can fail. So sometimes the connection is not good, but most of the time, more than 95 percent of the time, we don't have any problems. If there's an internet connection, communication goes excellent. The video quality is good, the voice is good. If there is no internet connection, it's more problematic. You can do it on a 5G or a 4G network. But I would not advise it. It's a little choppier. Otherwise, there's, you know, like when you dial on the phone and you wait for the phone to answer, the same thing is happening with video. You put the number of the POA or the family, it takes time for the connection to happen, so that takes about a minute. Short of that, I don't see a limitation for the video conference.

Hassan Khouli, MD:

Thank you. So, you mentioned already, some of the steps that take place. Maybe you can share with the audience, let's say I am a family member and I want to, you know, learn more about what's going on with a family member that I have in the ICU, and I want to join you during rounds. How does that work in the program that you lead?

Adi Gerblich, MD:

So, the only thing I need is for you to have an iPhone or another cell phone that is internet connected and has video capability or a camera. And once you give me your number, through the program that I have, I can connect to your number. On your screen will show up has my name and the Cleveland Clinic and we're going to have a video conference. You'll have to put your name in and make sure that you agree to the terms of the conference. That it's HIPAA protected and then if you click "Okay," then we get connected and you see me on the phone or the desktop. You can do it from the desktop the same way. And then, we communicate, sort of like FaceTime on iPhone basically.

Hassan Khouli, MD:

Excellent. You know, you make it sound simple. And it is simple because of all the work that you and the team have done really to simplify it and to make it easier to use, user-friendly.

Adi Gerblich, MD:

Yeah, it was important for us to make it as simple as possible for the recipient, for the family. Because, I mean, the family doesn't want to download the software and stuff and also that was in the beginning, we had difficulty with that, but then we found a company that was able to have a software that is available on the internet that they just hook up and immediately connect it. So that works very well.

Hassan Khouli, MD:

Nice breakthrough there. How do you ensure that all family members who want to participate can be involved simultaneously?

Adi Gerblich, MD:

Yeah. So, in video mode I don't have a limitation. I can add many people from many locations together. They'll all see each other on the screen. So, one can be in Cleveland and one can be in Florida, this other can be in Europe. It doesn't make any difference as far as the video is concerned and we've done that many times. And I'm not limiting who should participate. I leave it to the family to decide. They best know the family structures and who is important for the loved one that cannot participate in the conversation at that time. Most of the time we do it in patients who cannot communicate. So, they decide who is participating. I leave it to my family. I always want the POA to be there obviously. If there's no POA then whatever the legal structure is, if they're just kids then the majority of the kids have to be. So, if there's three kids, at least two have to be there. Many times, all three of them are there at the conference and so forth.

So, sometimes if there's no POA, you have to assign a POA. We have done that as well. Sometimes there's only next of kin, you know? We have seen that too. So, it depends on the situation.

Hassan Khouli, MD:

And for our audience here, the POA is the power of attorney.

Adi Gerblich, MD:

Yeah, the power of attorney has skill.

Hassan Khouli, MD:

Or, right, thank you.

Adi Gerblich, MD:

The one is able to make medical decisions. Because the patient cannot at that time.

Hassan Khouli, MD:

You know, being involved as a family member, in that discussion. How do you feel that that will impact or has impacted the decision-making process?

Adi Gerblich, MD:

You know, medicine is complex. It's changing all the time. It's complicated and the concepts are a bit complicated. Physiology is difficult to explain. So, the more explanation you have, the more interaction you have. The more you show, the more you visualize the CT scan or the biopsy or the X-Ray or the patient himself and how is he doing, the better the family can understand the gravity of the situation and the medical condition. And help them make the best decision for the patient. Your job is to guide them, to tell them what's the best mode that you think from a medical standpoint, but the final decision is always the family because they represent the wishes of the patient.

Hassan Khouli, MD:

That's true. And if we talk about how important communications, delivering information in a different way to families, or your loved one in that complex environment that you shared with us. So, what strategies or what are the ways that you used to make that communication compassionate, caring, and useful one for them?

Adi Gerblich, MD:

Yeah. Several strategies. First of all, you've got to listen. Listening is extremely important. You have to listen to the scope of the difficulties that they have. You listened to what happened to the patient the last couple of days, how he was behaving, what happened to the condition that brought him along. Did he take his medication, did he not take his medication, did the legs swell up, how was the breathing and so forth. So, listening alleviates some of the concerns. Give the family a feeling of participation that provides important information to the team. That helps the team understand the medical condition, which is the case.

The second strategy is you want to be totally honest with the family. You want to be totally unbiased with the family. You want to present the pros and cons in a simplified way, so they can see that you are thinking about all the conditions that are evolving here. And you want to show them that your aim is really to get the patient in better condition. And that's your ultimate game. That's your ultimate aim. And once they have that sense, that's really your aim. They feel comfortable with it, they give you confidence and they follow your guidance.

Hassan Khouli, MD:

That's very much true and I appreciate you sharing for our audience over here how important it is for us to listen to family and then, for them, really to have the courage and the comfort of speaking up and sharing with us, the care team, the patient's wishes, how they live their lives, what are their values. I find it, you know, when I'm rounding and I'm communicating with families to kind of really guide us. There's a lot of art and there's a lot of compassion in what we do in that environment.

Adi Gerblich, MD:

Yeah, I think basically your function is to translate, to be like a dictionary, to translate the medical condition from what you know, from what you see, from the labs, from the X-Ray, from the CT scan to a sentence or a structure or piece of information that they can digest and understand. So, this is taking that complex information that you know, that you learned all your life, that you're up to date with and transforming it in a simplified way to the family. That's the communication function that you have.

Hassan Khouli, MD:

And with the modality that you're describing here, the virtual video, you're allowing several family members to be together, sometimes when it's important for several people to give their perspective.

Adi Gerblich, MD:

Yeah, yeah.

Hassan Khouli, MD:

And to be in real time joining the ICU care team and then sharing these perspectives about the values, about how the patient lived their life, in which he or he, want or don't want.

Adi Gerblich, MD:

Yeah, because we don't know the personality of the patient most of the time. You know, they come to us, most of the time they aren't responsive, so we don't know them as people. We have to have the family to guide us, what are their wishes, what do they want from life, what do they like, how would they have behaved in this condition and so forth. So, sharing and communicating, you can see the different family members with different experiences, different backgrounds, which come to light. Some have medical knowledge; some don't have medical knowledge. Some have legal knowledge. So, you have to sort of gauge the information based on the family's structure and the information that they have.

Hassan Khouli, MD:

So, with that process you described and how technology is part of it too and how communication is as important, what kind of resources and training resources available to the ICU staff to ensure that this communication with the family is taking place in the right way?

Adi Gerblich, MD:

Yeah, so we have an ongoing program where we update the team all the time at bar, the way we protocolized way present the case. Because the discussion has to be structured discussion. In other words, you have to know what the information is and present it in a sequential, logical way so that we can make a decision, a medical decision about the condition. So, you cannot talk about an X-Ray before you present the clinical condition and the events. You cannot talk about the X-Ray before you tell me what the amount of oxygen the patient has is, how he breathes, what was his night, did he have a bowel movement, did he eat, is he hungry, is he not hungry, so forth.

So, everything is ordered in that presentation and that way of presentation is protocolized and very effective for the team to have all the information in an organized and succinct manner, so a decision can be made, and a plan can be devised from it.

Hassan Khouli, MD:

From your vast experience, what is your preferred mode of communication?

Adi Gerblich, MD:

I think best is in person. Short of in person, is video conference. Statistically, when we scored with different questions, the families, it stacks very close. I mean, very difficult statistically to show the difference between the two. I think the least effective is just phone conversation. Other than video or in person. So, in my experience phone conversation should be done only as a follow-up visit, but not as the main way of communicating with families.

Hassan Khouli, MD:

Yeah, and I'm maybe gonna add a little bit of my perspective over here, what the video communication offers the families are that convenience of, you know, today I cannot see them come to the ICU as I have done it in the past seven days or so. It is a good effective option to do that and in being able to bring other family members who may be living somewhere else. That is not possible to do when, you know, with the in-person way to communicate, so.

Adi Gerblich, MD:

Sure.

Hassan Khouli, MD:

So, what you have described to us is a very valuable and unique advantage over maybe some of the other effective modalities like being in person when you want family members to be around and make a critical decision. You know, sometimes it's about life and death.

Adi Gerblich, MD:

Absolutely.

Hassan Khouli, MD:

So, thank you for pioneering this and for being really a trailblazer in this area well before COVID when people started thinking about saying, well it's a necessity and we have to do this.

Adi Gerblich, MD:

Thanks a lot.

Hassan Khouli, MD:

Okay. Thank you, Dr. Gerblich and thank you everyone for listening to our podcast today. I am your guest host Dr. Hassan Khouli, chair of the Department of Critical Care Medicine in the Respiratory Institute at the Cleveland Clinic. My guest today was Dr. Adi Gerblich. Dr. Gerblich is a staff physician in the Department of Critical Care Medicine at the Cleveland Clinic and he's the division chief for pulmonary medicine at Cleveland Clinic Hillcrest Hospital. Thank you for joining us today and we conclude our podcast.

Adi Gerblich, MD:

Thank you.

Raed Dweik, MD:

Thank you for listening to this episode of the Respiratory Inspirations Podcast. For more stories and information from the Cleveland Clinic Respiratory Institute, you can follow me on Twitter @RaedDweikMD.