INTRODUCTION

The UCSD Health System (UCSDHS) is an academic medical center with an integrated care network located at one of the most populous sections of the US-Mexico border area. UCSDHS is situated in a section of this border area with two sister-city regions, San Diego-Tijuana and El Centro-Mexicali, over a distance of roughly 110 miles from west to east.

PUBLIC HEALTH AND THE BORDER REGION OF THE US

The public health importance of this border area is well recognized given its population density and social, economic, and political importance [1]. The interdependence of these cross-border regions is characterized by high traffic across the US-Mexico border, particularly at the San Ysidro Land Port of Entry (the busiest border crossing in the Western Hemisphere) [2], as US citizens and legal residents reside in Mexico for lower costs of living but maintain employment in the US. Legal border crossings at the San Ysidro and Otay Mesa border normally exceed 130,000 daily and initially decreased to 40,000 daily with governmental COVID-19 travel restrictions in March 2020 but eventually returned to 80,000 daily by June 2020 [3]. During this time, more than 90% of crossings were by US citizens or legal permanent residents of the US. As noted by the US-Mexico Border Health Commission: “…it is important to understand the border region as a microcosm where bilateral relations and prevailing implications are considered when developing targeted solutions to address public health challenges.” [1]

COVID-19 AND THE URGENCY FOR MULTI-INSTITUTIONAL COLLABORATION

In March 2020, southern California and the Baja region of Mexico began experiencing case surges of severe COVID-19 illness (rapidly progressive respiratory and multi-system organ failure due to SARS-CoV2 viral infection requiring critical care support, including invasive mechanical ventilation) [4] that quickly saturated hospitals serving these sister-city regions, resulting in a domino effect, as Mexican hospitals looked to US border hospitals for help, and US border hospitals looked to other US hospitals for assistance. The geographic proximity between the sister-city hospitals, as well as to UCSDHS, encouraged the development of a collaborative program (see Figure 1). Ultimately, regional healthcare leaders from the US-Mexico border reached out to San Diego County Public Health Services and UCSDHS for guidance.

While the Baja region of Mexico did not officially report high rates of COVID-19 until mid-to-late April (approximately one month after SD), public health measures implemented in SD County alone quickly proved inadequate to contain the regional needs across the Mexican border and in Imperial County in California. Furthermore, public health forecasts and models indicated that cases would escalate well into the summer months of 2020 and that the large US expatriate population (~250,000 in Baja California and Baja Sur, ~75,000 of those in Mexicali) would seek care not only locally in Mexico but also across the border in the US. True to predictions, the regions of SD and Imperial Counties still continue as some of the “hottest” for COVID-19 infections in the US) [5, 6].

Given longstanding missions that focus primarily on tertiary clinical care, teaching, and research, academic health centers may sometimes be viewed as out-of-step with the needs of community health [7, 8]. However, most agree that healthcare delivery for all US citizens and residents involves a basic Hippocratic imperative that obligates healthcare providers to intervene strategically for those at highest risk and whose condition also may affect public health and safety. As a result, a call to academic centers has been made during this pandemic to take decisive action to advance regional and national health and mitigate healthcare disparities [9]. Upon this principle, UCSDHS engaged to address the COVID-19 pandemic in our border region.

TELEMEDICINE AND CROSS-CULTURAL CONTEXTS

While telemedicine has shown utility in developing nations and other underserved contexts, technologies vary widely and largely involve non-critical care patients [10]. Furthermore, despite augmented global interest in telehealth during the COVID-19 pandemic, there are notable barriers to its adoption and implementation [11].

Existing telemedicine-based critical care solutions (“Tele-ICU”) are differentiated into centralized and decentralized systems [12, 13] based on the presence or absence of a remotely located “hub” of ICU personnel that receives patient data and directs care management. Standalone Tele-ICU systems (centralized and decentralized) have improved access to critical care in underserved populations but with mixed efficacy due to variations in technology platform, study design, and patient characteristics [14]. We created a hybrid program for the border hospitals utilizing both in-person support and a Tele-ICU platform. An independent, direct care-oriented Tele-ICU clinical service line was launched in the US-located hospital (ECRMC), while a case-conference-styled, educationally-focused Tele-ICU model was used in the Mexican hospitals (HGT, HGM) (see Table 1).

We detail our interventions and outcomes to date (through July 2020) as we enacted a hybrid in-person/Tele-ICU service to address ICU needs of several US-Mexico border hospitals – one US hospital (ECRMC), located in El Centro and two Mexican municipal hospitals, located in Tijuana (HGT) and Mexicali (HGM).

INTERVENTION

We strategized a hybrid, two-phase intervention based on our prior success in launching community-based critical care outreach programs elsewhere in the UCSDHS network.

EVALUATION OF IMPACT

Institutional Review Board approval was not sought, because this initiative was quality improvement related to COVID-19 and not research per se.

At ECRMC, we assessed effects of Tele-ICU through the following: 1) tele-intensivist physicians marked any specific areas of management (in which evidence-based practices were recommended due to observed deviations) on an electronic (Excel) spreadsheet shared through a secure, cloud-based server (see Appendix 1); 2) qualitative, structured surveys (see Appendix 2) were distributed by email via electronic survey link (Survey Monkey®) by V.R. to all nurses (30), hospitalist (7), and respiratory therapy (14) staff who cared for ICU patients exactly two months after Tele-ICU launch (ECRMC), addressing staff satisfaction with the service, confidence in care, and identification of areas for improvement. Spreadsheet audits were conducted daily by V.R. to ensure 100% compliance during the study period. Requests to staff to complete surveys was done upon distribution and follow-up three days after distribution, with all responses collected within one week of distribution. Results were blinded to response results but unblinded regarding number of specific staff within each group who responded (i.e. hospitalist physicians, nurses, respiratory therapists). All survey results were reviewed by V.R. and analyzed using application-based software (SurveyMonkey®).

At HGT/HGM, UCSDHS staff performed direct reviews of inventories and equipment and nine qualitative interviews with hospital leaders and frontline ICU staff in English and Spanish with official translators as required. Direct, quantitative measurement of impact in HGT and HGM was not possible for several reasons. Most important, the urgency of the need prioritized organization and implementation of existing resources over other considerations. As UCSDHS staff were volunteers, streamlining tasks was necessary, and our assistance was intended as a humanitarian and collegial gesture to improve quality rather than an investigational exercise. The need for basic equipment and staff numbers presented clear gaps in care delivery that made equipoise difficult. Finally, logistic challenges (e.g. WiFi strength, scheduling, etc.) and cultural differences (e.g. language barriers) made data collection more challenging.

RESULTS

SPECIFIC FEEDBACK ON THE INITIATIVE INCLUDING STAFF CONFIDENCE

At ECRMC, of the 51 surveys sent out, 27 individuals returned responses (seven physicians, 10 respiratory therapists, and 10 nurses), corresponding to a response rate of 100% for physicians, 71% of respiratory therapists, and 33% of nurses (total response rate 53%). Nineteen percent more patients received evidence-based practice as a result of Tele-ICU (61.8% to 80.6%) (p < 0.0001 assuming paired t test; 2-tailed; standard deviation 25.3 vs 21.7), 78% of staff were more confident in caring for COVID-19 patients in the ICU (26% were definitely more confident or 100% confident), and 63% of staff were more confident (22% definitely more confident or 100% confident) in the care of non-COVID-19 ICU patients (see Figures 2 and 3). Highest value was attributed to enhanced care of mechanically ventilated patients (63%) and the ability to ask medical questions to an intensivist (19%). Regarding program improvement, 37% desired better consistency of plan between tele-intensivists and onsite physicians (eg. ECRMC hospitalists), while 72% requested more Tele-ICU coverage hours.

Figure 2 

Percentage of ICU patients perceived to be receiving evidence-based care at ECRMC by respiratory therapy, nursing, and physician staff at ECRMC, as a result of Tele-ICU adoption. Before Tele-ICU refers to prior to April 6, 2020. Survey conducted on June 28, 2020.

Figure 3 

Change in confidence level of 7 physicians, 10 respiratory therapists, 10 nurses at ECRMC, as a result of Tele-ICU adoption. Note that confidence levels increased even in the care of patients without COVID-19 illness, who almost never were seen by Tele-ICU service, indicating a cross-over effect.

One-on-one unstructured interviews with hospital leaders (nursing, physician, and respiratory therapy) at all three hospitals demonstrated various qualitative gains of Tele-ICU service:

1. Increased comfort and confidence with prone positioning in routine practice (ECRMC, HGT, HGM)
2. Increased confidence in safely extubating patients (ECRMC)
3. Enhanced targeting of specific areas for quality improvement (e.g. titration of neuromuscular blockers and dexmedetomidine in ventilated patients, concentration of drips for enhanced fluid management, enteral feeding-based nutrition goals, optimal timing of ancillary testing, etc.) (ECRMC, HGT, HGM)
4. Improved access to advanced life-saving therapies (i.e. ECMO [extracorporeal membrane oxygenation]). Two patients even received onsite cannulation via a new “mobile ECMO” service at UCSDHS [19] (ECRMC)

DISCUSSION

We describe our experience at UCSDHS as we responded to requests of one US and two Mexican hospitals in the US-Mexico border area seeking assistance with COVID-19 by deploying a hybrid program of in-person as well as telemedicine services. Our experience highlighted the following:

• Collaborative public health programs in border regions are crucial for the health of both communities.

The COVID-19 pandemic accentuated the public health implications of the San Diego-Imperial-Baja region, known for fluid movement between counties and countries. As commercial and non-commercial traffic continues to cross “closed” borders legally at high volume, essential workers in lower income social strata who live and travel frequently and in close proximity remain particularly prone to viral transmission and disease.

We found that institution of our program improved care such that quality of care – and perhaps more important, perception of care – was improved in the eyes of community healthcare providers. As our results showed that 78% of local healthcare providers felt more confident to care for critically ill COVID-19 and 63% were more confident with non-COVID patients, the UCSDHS intensivist program demonstrated putative impacts upon improved morale and work performance [20]. As community members themselves, local healthcare workers also contribute to increased public willingness to seek healthcare in nearby, rather than distant, hospitals and medical centers. Indeed, while data are still accruing, we expect that trends to date will continue, indicating that fewer patients from the border region require transfer to other US hospitals, thereby reducing displacement of patients from their families as well as burdens and costs upon transportation agencies and other hospitals.

• An academic center can feasibly and rapidly create a program to support low-resource community hospitals during a pandemic or other medical crisis.

Despite fears of bureaucratic hurdles and high costs of engaging academic services, we demonstrated both feasibility and quick implementation of a cost-effective program that won universal support. Contracts and agreements were created expeditiously (within days) despite the existence of public lockdowns, employee furloughs, and widespread stress during the pandemic. Of note, all involved staff (nurses, therapists, physicians, and interpreters) participated on a volunteer basis in the Mexican hospitals, such that longer sustainability will require expansion of the volunteer pool.

Others have indicated that use of implementation and team science is required for innovative change and process improvements in critical care [21, 22, 23, 24], including relations building between academic medical centers and community ICUs [25]. However, few have described the experience of launching such a collaboration in a cross-border context with the unprecedented urgency of COVID-19 pandemic. While our experience is particularly relevant to health centers at US-Mexico border, academic and community centers can leverage collaborative in-person and telemedicine services in other cross-cultural challenges in critical care delivery (e.g. urban and rural contexts). Our experience demonstrates that partnerships are possible despite short timeframes and various operational stresses attributed to COVID-19 such as lockdowns, employee furloughs, and restricted travel.

• Programs that combine in-person and telemedicine systems are likely synergistic to generate the best outcomes.

Hybrid systems offer complementary advantages: in-person involvement allows for direct sharing of ideas, enhanced collegiality, and morale building while telemedicine (Tele-ICU) platforms leverage cost-effective technology. In addition, in-person visits permit direct observation of nursing, infection control, and other institutional practices that impact ICU outcomes but fall outside of traditional workflows. The time saved through virtual rounding – as opposed to traveling to sites in person – also allows broader participation of academic providers with competing responsibilities. Furthermore, these benefits appear synergistic, as stronger relationships between the remote and onsite providers lead to higher usage of telemedicine systems [26, 27], which we believe are directly responsible for our positive results. At ECRMC, we expect further improvements as we have added an in-person, onsite intensivist service.

We found that awareness and implementation of evidence-based practices of critical care in COVID-19 [28] increased considerably over the course of the program, between launch in early April 2020 through June 2020. At ECRMC, interventions addressed adherence to recommendations regarding advanced ventilator management, vasopressor selection, sedative selection, election of specific COVID-19 specific agents, and recommended fluid and diuretic management.

Perhaps more important, the ECRMC Tele-ICU service increased staff confidence in COVID-19 care. While less pronounced, ICU staff also reported increased confidence regarding patient care for non-COVID-19 ICU patients (for whom the Tele-ICU service was not involved). One interpretation of these findings supports the presence of cultural osmosis, but further study is required.

In all three hospitals, our Tele-ICU case discussions led to idea sharing between academic and local hospitals that was fulfilling to both parties. The HGT and HGM hospital staff not only felt reassured that our recommendations generally matched their own clinical instincts, but also expressed interest in learning how to “fine-tune” their approach to advanced ventilator management (eg. assessment of “recruitability,” pleural pressure, transpulmonary gradient, prone positioning techniques/duration, etc.), use of sedatives and neuromuscular blockade, and other advanced ICU concepts. Concurrently, UCSDHS staff found the experience valuable, appreciating firsthand the strong knowledge base and experience of HGT/HGM practitioners and engaging in active discussions about medical evidence. Furthermore, UCSDHS tele-intensivists gained familiarity with challenges faced by seasoned practitioners managing patients with similarly high acuity of illness as in academic centers, but with severe resource limitations. In fact, UCSD intensivists experienced less stress in home campus ICU shifts due to enhanced appreciation of the efforts of community health providers and the involvement of UCSD colleagues in the program (personal observations).

In addition, our GoFundMe campaign raised ~$40,000 in funds successfully in June 2020 that were allocated to the purchase of ventilator parts (e.g. active humidification systems, oximeters, bedside monitors), and other equipment and supplies for HGT and HGM. Thus, we found that crowdfunding is an effective tool to address equipment and supply shortages in humanitarian settings, in addition to other strategies such as philanthropic and charity-based funding and donations. Keeping these strategies in mind for the longevity of our program itself, we are actively seeking philanthropic and foundation-based support for the continuation of our initiative.

LIMITATIONS

There were several limitations to our experience and findings, primarily due to the rapidity of the efforts during this crisis. First, our data were purely observational and did not include robust study design, leading to various risks of bias when interpreting our results (e.g. selection bias, sampling bias, observer bias (non-blinding), immortal time bias, and confounding). Definitive conclusions about interventions require proper controls and epidemiologic study design. Second, our local results pertain to the US-Mexico border, such that generalizability of results is unclear. Third, each site (HGT, HGM, and ECRMC) had unique circumstances, needs, and historical relationships with UCSDHS that create challenges in comparing each experience to each other. Future evaluations are underway to create more standardized processes such that a more rigorous understanding of this initiative can provide more representative conclusions.

CONCLUSION

We highlight our COVID-19 experience at UCSDHS regarding ICU regional needs at the US-Mexico border. We found that 1) public health approaches are important to address clinical concerns on both sides of the border, 2) an academic-community ICU partnership could be devised and executed in a short time frame under stressful pandemic conditions, and 3) implementation of a hybrid (in person and Tele-ICU) critical care program generated synergistic value. While the experience at each hospital was slightly different, common principles of team building, idea sharing, and adherence to evidence-based ICU practice were prominent. We feel that our experience can serve as a guide for other academic and community centers looking to build collaborative programs to address public health emergencies in cross-cultural contexts.

ADDITIONAL FILES

The additional files for this article can be found as follows: