Review Article

Tele‑Medicine, Tele‑Rounds, and Tele‑Intensive Care Unit in the

COVID‑19 Pandemic
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Pradeep Rangappa1, Karthik Rao1, Thrilok Chandra2, Sunil Karanth3, Jose Chacko4
Department of Critical Care, Columbia Asia Referral Hospital, Bengaluru, Karnataka, India, 2Department of Health and Family Welfare, Government of Karnataka, Karnataka, India,
1

3
Department of Critical Care Medicine, Manipal Hospital, Bengaluru, Karnataka, India, 4Department of Critical Care, Majumdar Shaw Medical Center, Bengaluru, Karnataka, India
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Abstract
The COVID‑19 pandemic has caused a worldwide health crisis, laying stress on existing health‑care systems and causing an unprecedented
financial crisis. In this situation, provision of homogenized, evidence‑based care by all levels of health‑care providers, including those in a
low‑resource setting, is of paramount importance. As a specialized offshoot of Tele‑medicine, Tele‑intensive care unit (Tele‑ICU) offers an
innovative solution in the care of critically ill COVID‑19 patients, by off‑site clinicians, using audio, video, electronic, and tele‑communication
links to leverage technical, informational, and clinical resources. Tele‑ICU also helps overcome the shortage of expertise like intensivists in
these settings and helps to take the clinical expert to the patient bedside by remote monitoring and supervision. Telemedicine applications
can be classified into four basic types, according to the mode of communication, timing of the information transmitted, the purpose of the
consultation, and the interaction between the individuals involved‑be it doctor‑to patient/caregiver or doctor to doctor. The benefits and concerns
of tele‑medicine have been described in detail.

Keywords: COVID‑19, COVID health care, distance health care, telemedicine, video conferencing

Introduction audio, video, electronic, and tele‑communication links to

leverage technical, informational, and clinical resources,[1] as
India is a land of diversity with a heterogeneous health‑care
shown in Figure 1. The World Health Organization defines
facility across the country. Against the background of telemedicine as “the delivery of health‑care services, where
widespread COVID‑19 infection, the goal is to homogenize distance is a critical factor, by all health‑care professionals
care across designated COVID‑19 hospitals to deliver the using information and communication technologies for the
optimal care, improve outcomes, reduce morbidity, and exchange of valid information for the diagnosis, treatment,
save lives. We need to restructure care‑processes across and prevention of disease and injuries, research and evaluation,
the district level hospitals to ensure uniform care based on and the continuing education of health‑care workers, with the
updated, evidence‑based information. We face additional aim of advancing the health of individuals and communities.”
challenges considering our incomplete understanding of the There is a shortfall of qualified intensivists to meet the growing
clinical manifestations, diagnostic dilemmas, therapeutic demands of the COVID‑19 pandemic both in the cities and in
modalities, and preventive strategies of COVID‑19 infection. district hospitals that provide care to COVID‑19 patients. Early
Administrative challenges include capacity building,
structural adjustments, creation of new standard operating Address for correspondence: Dr. Pradeep Rangappa,
procedures (SOP), and maintenance of the supply chain of Department of Critical Care, Columbia Asia Referral Hospital,
personal protective equipment (PPE). Besides, we need to Bangaluru ‑ 560 055, Karnataka, India.
ensure adequate availability of diagnostic tools, drugs, and E‑mail: [email protected]

oxygen delivery devices.

Submitted: 22‑Aug‑2020 Revised: 21-Oct-2020
Tele‑intensive care unit (Tele‑ICU) constitutes care provided Accepted: 23‑Oct‑2020 Published: 04-Jan-2021
to critically ill COVID‑19 patients by off‑site clinicians using
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For reprints contact: [email protected]

DOI: How to cite this article: Rangappa P, Rao K, Chandra T, Karanth S,

10.4103/injms.injms_100_20 Chacko J. Tele-medicine, tele-rounds, and tele-intensive care unit in the
COVID-19 pandemic. Indian J Med Spec 2021;12:4-10.

4 © 2021 Indian Journal of Medical Specialities | Published by Wolters Kluwer ‑ Medknow

 Rangappa, et al.: Tele‑Medicine and Tele‑ICU in COVID‑19

recognition of warning signs portending a possible downward availability of intensivists and increased cost of care may
spiral with clearly defined care processes leads to improved make onsite presence untenable; hence, the utilization of
outcomes in these patients.[2] Research has also shown more tele‑ICU as means to access critical care expertise appears
favorable outcomes with high‑intensity staffing models that promising.[1]
include mandatory intensivist consult.
The role of telemedicine during the COVID‑19 pandemic Tools for Telemedicine
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is two‑fold: To connect intensivists with patients and Telemedicine involves the use of multiple tools to assist doctors
to support frontline bedside clinicians, regardless of including telephone, video, devices connected over Local Area
patient location. [3,4] This is achieved by imparting best
Network (LAN), Wide Area Network (WAN), internet, mobile
practice guidelines complying with national protocols,
or landline phones, chat platforms such as WhatsApp and
optimization of oxygen delivery devices, and assistance
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Facebook Messenger or mobile applications or internet‑based

with troubleshooting crisis situations. This strategy involves
digital platforms for telemedicine. Data transmission systems
a flexible, multi‑disciplinary approach, accompanied
by rapid response and ability to improvise. The limited such as Skype and E‑mail are also useful tools. However, the
core principles underlying the practice of telemedicine remain
the same. Whichever mode of communication is used, it comes
with its own strengths and limitations, as shown in Table 1.
Telemedicine applications can be classified into four basic
types, according to the mode of communication, timing of the
information transmitted, the purpose of consultation, and the
type of interaction; this may be between the doctor and the
patient or caregiver, or between doctors,[5] as shown in Figure 2.
Mode of communication
• Video (telemedicine facility, applications, video on chat
platforms, Skype/Facetime)
• Audio (Phone, Voice over internet protocol (VoIP),
applications)
• Text based.
1. Telemedicine chat‑based applications (specialized
telemedicine smartphone applications, websites, and
other internet‑based systems)
Figure 1: Integration of clinical variables, monitored variables and
2. General messaging/text/chat platforms (WhatsApp,
investigative variables between District Hospital Physician and Expert at Google Hangouts, Facebook Messenger)
Bangalore to guide decision making 3. Asynchronous (E‑mail/Fax).

Table 1: Strengths and limitations of various modes of communication

Mode Strengths Limitations
Video Closest to physical presence, real‑time interaction Depends on high‑speed internet connection at both ends; slow
telemedicine facility, Patient identification is easier connections result in suboptimal exchange of information
applications, video‑chat Doctor can see the patient and discuss with the caregiver Privacy and security is crucial; misuse may lead to breach of
Visual cues can be perceived. Enables close examination confidentiality
of the patient
Audio Convenient and fast Nonverbal cues may be missed
Phone, VoIP, applications, Unlimited reach Not suitable for conditions that require visual inspection
etc. Suitable for urgent cases (examination of the skin, eye, or tongue), or physical touch
No separate infrastructure required Patient identification needs to be clearer; risk of imposters
Privacy ensured representing the real patient
Real‑time interaction
Text‑based Convenient and fast Besides absence of visual and physical touch cues, text‑based
Specialized chat‑based Documentation and identification may be an integral interactions also miss the verbal cues
telemedicine applications, feature of the platform Difficult to establish rapport with the patient
smartphone applications, Suitable for urgent cases, or follow‑ups, second opinions
SMS, websites provided the RMP has enough context from other sources
RMP: Reviews of modern physics

Indian Journal of Medical Specialities ¦ Volume 12 ¦ Issue 1 ¦ January-March 2021 5

 Rangappa, et al.: Tele‑Medicine and Tele‑ICU in COVID‑19

Timing of information transmitted Table 2: Benefits and concerns of tele‑intensive care unit
• Real time Video/audio/text interaction
Benefits of tele‑ICU
Video/audio/text for exchange of relevant information regarding
Adhering to best practice guidelines which is evidence‑based
diagnosis, medication, health education, and counseling
Enhanced monitoring, early identification, and treatment of critical
• Asynchronous exchange of relevant information. illness pathophysiology
Improved co‑ordination of care and implementation of SOPs
Transmission of a summary of patient complaints and
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Increased night‑time vigilance

supplementary data including images, laboratory reports, and Potential concerns of tele‑ICU
radiological investigations. This type of data may be forwarded Disruption of traditional ICU practice
to the individuals involved at any point of time and accessed Diffusion of responsibility
later as required. No impactful role (e.g., insufficient authority/expertise)
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Insufficient time dedicated between tele‑ICU hub and off‑site center

Telehealth Modalities Inability to demonstrate tangible outcome benefits

Cost‑benefit substantiation
Telemedicine communication between doctors and patients SOP: Standard operating procedure, ICU: Intensive care unit
can be classified[6] as:
• Synchronous: This includes real‑time telephone or live • Participate in physical therapy, occupational therapy, and
audio‑video interaction, typically with a patient using a other modalities, thus providing optimal health
smartphone, tablet, or computer • Monitor clinical signs and relevant data in chronic medical
• A health care provider may be able to use specialized disease including blood pressure and blood glucose
medical equipment including digital stethoscopes, measurements
otoscopes, ultrasonography, etc., with remote • Follow up with patients after hospitalization
evaluation by a specialist. • Deliver advance care planning and counseling to
• Asynchronous: This includes “store and forward” patients and caregivers to document preferences if a
technology where messages, images, or data are collected life‑threatening event or medical crisis occurs
initially and interpreted later. Patient portals can facilitate • Provide education and training for the health‑care
this type of communication between the provider and the provider through peer‑to‑peer professional medical
patient through secure messaging consultations (inpatient or outpatient) that are not locally
• Remote patient monitoring: This allows direct transmission available, particularly in rural areas.
of clinical measurements remotely to the health‑care
provider, in real‑time or as saved data. The Concept of Public‑private Partnership
The think‑tank of the health department of the Government
Benefits and Potential Uses of Telehealth of Karnataka conceptualized a public‑private partnership in
Telehealth services can complement public health strategies creating a critical care resource team including three private
during the COVID‑19 pandemic by enabling social distancing hospitals from the city of Bangalore. The team would carry out
and reduce the risk of exposure to infections. The requirement tele‑rounds as an outreach service to cover all the districts in the
for PPE can be cut down and lessen financial constraints. state providing care to COVID‑19 patients. A taskforce was set
Hence, these services are the need of the hour. These services up with consensus among specialists and COVID‑designated
have both benefits and potential concerns, as shown in Table 2. hospitals were established in all districts. The public health
fraternity stepped in to take up the responsibility and additional
Telemedicine can facilitate continuity of care by avoiding
workload. The concerning situation that evolved over time
delays in routine care. Telemedicine also enables care for
required rapid deliberation and sustainable action. Protocols
patients who are unable to either travel or have difficulty in
and SOPs had to be created to ensure homogeneity of care
accessing regular care. Remote access can also help preserve
based on an updated level of evidence throughout Karnataka
the patient‑provider relationship when a physical visit is not
under specialist supervision. The Government was ready with
feasible. Telehealth services can be used to:
frontline health‑care workers. The private establishments
• Screen patients who may have symptoms of COVID‑19 were forthcoming to work with public hospitals to lend their
and referral as appropriate multi‑specialty expertise to homogenize the care and assist in
• Provide care for non‑COVID‑19 conditions, identify complicated cases.
patients who may need additional consultation or
assessment, and refer as appropriate Tele‑Intensive Care Unit/Tele‑Medicine and
• Access primary care providers and specialists, including
mental and behavioral health care, for chronic health Tele‑Rounds
conditions and medication management Tele‑ICU is care provided to critically ill patients by off‑site
• Provide medical help and support for patients suffering clinicians using audio, video, and electronic links to leverage
from chronic health conditions technical, informational, and clinical resources. Tele‑ICU care

6 Indian Journal of Medical Specialities ¦ Volume 12 ¦ Issue 1 ¦ January-March 2021

 Rangappa, et al.: Tele‑Medicine and Tele‑ICU in COVID‑19

includes the ability to detect clinical instability or laboratory out through WhatsApp or telephonically to ensure mitigation
abnormalities in real‑time. It involves collection of additional and prevention of a downward spiral. During the tele‑rounds
clinical information regarding the patient, orders diagnostic interaction, all district hospitals are logged in and enable
testing, enables diagnosis, implements treatment, and provides active learning across 14 districts through scientific discussion.
other facets of intensive care including the management of Relevant knowledge is imparted, updated interventions
life‑support devices and communication with patients and offered, and scientific cues of a transformational nature are
bedside care providers.[3] provided. Onsite doctors are encouraged to participate in
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Tele‑ICU deals with real‑time continuous monitoring of decision‑making to achieve the best possible outcomes for
patients by off‑site physicians. Tele‑rounds constitute an the patients. Following rounds, there is an ongoing exchange
innovative middle‑path introduced by the Government of of academic insights involving the latest publications, videos,
Karnataka, as shown in Figure 3. Using this system, ward and other useful scientific material.
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rounds are performed twice daily along with district hospital There could be practical prblems during tele-medicine, when
doctors by an off‑site multi‑specialty team using audio‑visual one is wearing Personal Protective Equipment (PPE). These
aids (Zoom platform, WhatsApp,) akin to handover rounds include-
that typically occurs in the ICU. Cases are prioritized, and 1. Difficulty in having a clear line of communication
details of critically unwell patients are deliberated in great • Recognizing the person participating
detail, vulnerable trends captured, and appropriate diagnostic • Muffled speech and nonclarity of speech due to the
and therapeutic interventions are suggested. Follow‑up
mask/eye‑shield
interventions that emanate from the guidance offered are carried
• Inability to perceive the feelings/mood of the
participating health care workers.

2. Inability to participate for prolonged periods of time

• Discomfort of wearing PPE
• Frustration occurring out of the combination of
discomfort of PPE and the difficulty in communicating
the information.

3. Risk errors due to miscommunication.

Tele‑Intensive Care Unit/Tele‑Rounds Impact on

Influencing Favorable Outcome in Patients
From the available literature, [7‑15] it has been clearly
demonstrated that tele‑ICU has influenced favorable outcomes
Figure 2: Components of tele-ICU tele-rounds including reduced mortality and length of stay in ICU and

Figure 3: Tele‑medicine‑decision‑tree‑for‑COVID‑19‑patient

Indian Journal of Medical Specialities ¦ Volume 12 ¦ Issue 1 ¦ January-March 2021 7

 Rangappa, et al.: Tele‑Medicine and Tele‑ICU in COVID‑19

hospital, decreased the occurrence of critical events, and

(MD ‑0.064, CI ‑ 1.52‑0.25)

No significant change (MD

Reduced (MD ‑ 1.26, CI ‑

most importantly, ensured adherence to “Best Practice

2.49‑−0.03 in 6 studies
Reduced (15% shorter,
Reduced (HR 1.44, CI
‑ 0.27, CI ‑ 1.14‑0.59)

No significant change
Guidelines” leading to improved clinical outcomes. Studies

Hospital LOS

In 8 studies

In 6 studies
1.33‑1.56)
have also shown that by minimizing the critical events in

P<0.001)
vulnerable patients and improving clinical outcomes, cost
minimization was achieved. In the COVID‑19 scenario, recent
U. S data showed a significant reduction in PPE utilization
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by minimizing the number of health‑care personnel required

to provide bedside care.[3] Tele‑medicine was valuable in
facilitating effective communication with the patient by family

in 7 studies with 29,837 patients

Reduced (MD ‑ 0.1.26, CI ‑
Reduced (MD ‑ 0.27, CI ‑

Reduced (MD ‑ 0.62, CI ‑

members, counseling by psychologists, interaction with social

Reduced (20% shorter,

Reduced (HR 1.26, CI
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workers, and spiritual support by chaplains.[3] Tele‑medicine

2.21‑−0.30)
In 9 studies

In 7 studies
enables casting an expert remote eye that may influence

0.28‑0.17)

1.17‑1.36)

1.21‑0.04)
P<0.001)
ICU LOS
favorable outcomes.
What are the Key Requisites for the Success of
Tele‑Intensive Care Unit/Tele‑Rounds?
The degree of benefit from tele‑ICU/tele‑rounds is directly

CI: Confidence interval, ICU: Intensive care unit, LOS: Length of stay, OR: Odds ratio, HR: Hazard ratio, RR: Risk ratio, MD: Mean difference
proportional to the degree of acceptance by the involved
clinicians and a mindset to adapt to a change in process,

No change (RR ‑ 0.82, CI

Reduced (HR ‑ 0.84, CI ‑
Reduced (RR ‑ 0.74, CI ‑

‑ 0.65‑1.03) in 10 studies
Reduced (OR 0.40, CI ‑

‑ 0.73‑0.94) in 9 studies
Reduced (RR ‑ 0.83 CI

with 33,183 patients

Hospital mortality
keeping the best interest of the patients as the envisaged

In 13 studies
mission.[1] Transformative knowledge gain, shared decision

0.58‑0.96)

0.31‑0.52)

0.78‑0.89)
making, establishing good rapport and good inter‑personal
communication are quintessential for success. Tele‑rounds
specialists have to be of good academic standing with
reasonable seniority and adequate experience to address
complicated cases. Tele‑specialists typically should be active
clinicians regularly caring for critically unwell patients by the

Reduced (OR ‑ 0.80, CI ‑

Reduced (RR ‑ 0.83, CI ‑

Reduced (RR ‑ 0.79, CI ‑

Study 1: Reduced (OR ‑

0.66‑0.97) in 12 studies
Study 2: reduced (HR ‑

0.65‑0.96) in 9 studies
0.37, CI ‑ 0.28‑0.49)

0.74, CI ‑ 0.68‑0.79)
bedside and involved in tele‑medicine in addition, in contrast
ICU mortality

to carrying out tele‑work alone.[16] Good audio‑visual interface In 15 studies

0.72‑0.96)

without interruptions is also a key to facilitate adequate

Table 3: Meta‑analysis and systematic reviews of tele‑intensive care unit

compliance.[1]
The clinical success of tele‑ICU, as seen in a meta‑analysis
shown in Table 3,[17‑20] lies in capturing accurate information and
effective integration of clinical, monitored, and investigative
patients (pre/post)

6290 (1529/4761)
(156,413/35,952)

variables in establishing the diagnosis and plan appropriate

(15,587/33,870)

(15,677/25,707)
Number of

therapeutic modalities and interventions.

192,265

49,457

41,374

Experience of Tele‑Rounds so far in Karnataka

The Columbia‑Asia Referral Hospital Yeshwantpur, Bangalore,
and Manipal Hospital, Airport Road, Bangalore, have been
Number of

Study 2: 38
Study 1: 7

performing tele‑rounds for 28 Districts for the past 10 weeks.

37 (20)

35 (27)
ICUs
110

As on June 28, 2020, tele‑rounds were carried out for

9771 patients, of whom 115 died with a case fatality rate (CFR)
of 1.17%. These results were compared with the urban and rural
(2004‑2014)

(2000‑2012)

(2004‑2009)
(2011‑2014)

Bangalore hospitals that were not connected to tele‑ICU. The

Studies

19

13

Bangalore hospitals cared for 3419 patients during this period;

2

92 patients had died, accounting for CFR of 2.69%. From these

observations, we could assume that tele‑ICU, by casting a
remote eye, may facilitate more effective vigilance and diligent
2017

2016

2002
Year

2011

care. Besides, imparting of transformational knowledge, and

empowerment of the off‑site team in shared decision making,
Mackintosh

facilitation of capacity building is enabled. Integration and

et al.[17]

et al.[18]

et al.[19]

et al.[20]
Author

Wilcox

Young

more efficient mobilization of valuable resources are possible,

Chen

with support by governmental agencies. Tele‑rounds have

8 Indian Journal of Medical Specialities ¦ Volume 12 ¦ Issue 1 ¦ January-March 2021

 Rangappa, et al.: Tele‑Medicine and Tele‑ICU in COVID‑19

to optimize care. It could either be in drafting protocols,

Table 4: Checklist for the tele‑intensive care unit
to sharing practical experiences, or help one another out
Basic requirements
during times of stress, or psychological and emotional
Standard operating procedures and administrative policies
support in times of crisis, etc.
Integral part of the critical care team/ICU team
5. We recommend the use of Tele‑ICU facilities in academic
Education and training with a pathway for continuous professional
development pursuits, collating and publishing data, which would serve
as a strong evidence for later years to come for clinicians
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Adequate measures to ensure privacy and confidentiality

Adequate cybersecurity measures built into the e‑platform to draw valuable inputs in other areas of need
Adequate budgetary allocation 6. We recommend active clinicians who are teachers of
Policies and procedures to document, store and retrieve patient health Intensive Care Courses involved in onsite patient care to
records be part of tele‑ICU teams contrary to stand‑alone tele‑units
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Setting up and monitoring of appropriate quality indicators to minimize the disconnect

Appropriate technical equipment depending on the type and intensity of
service provided ‑ ensure good audio, visual clarity
Recommended processes Conclusions
Adequate autonomy to make policy decisions Tele‑Medicine/tele‑ICU is bound to revolutionize the future
Appropriate credentialing and registration as per the regulatory health care in India by homogenizing the care between public
requirements of the state
and private hospitals. Root cause analysis with corrective
Protocol and procedures to educate patient and families about role of
tele‑ICU and preventive action happens instantly in the off‑site with
Clear definition of workflow pattern, model of care, staffing, type of this model and minimizes the lag. This model is easily
patients covered implementable in acute pandemic situation and is scalable with
ICU: Intensive care unit minimal costs. Tele‑medicine/tele‑ICU provides a good space
for senior eminent medical professionals who otherwise cannot
enabled to integrate scientific data from multiple centers to impart their skills at the bedside in COVID‑19 pandemic to
initiate multi‑centric observational study. contribute their service and wisdom to serve the humanity.
Tele‑rounds have led us to develop robust state‑wide protocols Financial support and sponsorship
to manage different dimensions of COVID‑19 patients, None.
as shown in Table 4. This includes a protocol for general
hospitalized COVID‑19 patients, protocols for ventilator Conflicts of interest
management, sepsis and septic shock with COVID‑19, and There are no conflicts of interest.
management of patients with severe acute respiratory illness.
We are currently in the process of creating protocols for acute References
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10 Indian Journal of Medical Specialities ¦ Volume 12 ¦ Issue 1 ¦ January-March 2021