Hospitals faced with challenges in ICU staffing often compare two virtual options: bunker model vs. teleICU. What are the differences between the bunker model and teleICU, and how should hospitals compare them depending on use cases? This blog addresses the many factors hospitals should consider when choosing one over the other.
History of Virtual ICU Care
On April 6, 2000, the Baltimore Sun ran a story: Telemedicine business is launched by 2 doctors. It was about two Baltimore-area intensivists. Drs. Brian Rosenfeld and Michael Breslow had just inked a deal the day before with Sentara Healthcare to set up a bunker model at two hospitals in Norfolk.
As the Sun reported, intensivists at the hospitals “will still staff their ICUs the old-fashioned way in the morning. But each of the specialists will also spend a few nights a month at an electronic command center… supervising patients during hours when there is no intensivist on the unit.”
Thus was born the bunker model for virtual ICU care. The Sentara unit was the first of its kind in the country. The Sun was breaking news on a brand new model, birthed in response to a persistent shortage of critical care physicians. That model remains today in heavy use and to good effect for health systems—but there is another model of delivering virtual care to the most critically ill patients: teleICU.
What is the Bunker Model?
The bunker model for virtual critical care essentially seeks to recreate the in-person care team, but remotely. The traditional bunker setup puts a critical care physician with nurses, respiratory therapists, and pharmacists together in a room called a “bunker.” That room is virtually connected to patient rooms throughout a hospital ICU or across multiple hospital ICUs. Each of the rooms is wired with video and audio capability to enable real-time monitoring and patient care. This team can round as they would in person but much faster while providing critical care coverage to multiple facilities.
What is teleICU?
In contrast, the teleICU model connects remote critical care physicians with in-person care teams to provide expertise, guidance, and support for making life-saving patient care decisions. TeleICU physicians conduct rounds on patients with the on-site care teams via telemedicine carts and are available rapidly for consultation in emergent situations. In this model, there is no centralized bunker. Instead, teleICU is a distributed network of critical care physicians who can work from nearly anywhere. This model isn’t trying to recreate an entire care team remotely but provides 24/7 coverage of critical care physicians and surge capacity while proactively integrating into the existing ICU workflow at each hospital site.
Differences in Cost
The Bunker Model requires a significant upfront investment to connect each patient room. A report from Philips estimates the cost of implementing an ICU bunker model at $2-5 million.
According to Access TeleCare’s Dr. David Fedor, a critical care physician who has worked extensively in both settings, the bunker model is most appropriate for a mid-sized health system with multiple sites, especially one that employs its own physicians. Once hospitals make the initial capital investment, they can utilize their clinicians to work shifts in the bunker, as in the original Sentara example.
The distributed teleICU model typically requires very little upfront investment. Access TeleCare’s Telemed IQ telemedicine platform can run on existing hospital infrastructure and legacy carts or other mobile devices.
Differences in Flexibility
A teleICU model will naturally provide greater flexibility and accessibility than a bunker model with wired hospital rooms on the ICU floor. This is because telemedicine carts can be wheeled into any area of the hospital, including inpatient floors or the emergency department.
“Have Wi-Fi, will travel,” Dr. Fedor says of the teleICU model. “Anywhere you can wheel the cart, we can go to provide care.”
Additionally, not every hospital needs an entire rounding team. The teleICU model is more appropriate than the bunker model for sites that only need the expertise of a critical care physician to fill intermittent gaps, cover nights or weekends, or handle surges in demand.
Differences in Accessibility
This small footprint on the technology side also makes teleICU more accessible for small hospitals, rural hospitals, or facilities not part of a large system.
In those cases, it rarely makes sense to invest in a bunker-style virtual ICU system. Instead, these facilities can rapidly deploy a teleICU program that uses existing devices and utilizes a distributed critical care physician workforce.
Nurse and Physician Satisfaction
In 2015, Becker’s Hospital Review published a retrospective look back at the Sentara system. One of the doctors at Sentara’s Medical Group, working with Sentara’s bunker model since its inception, talked about the skepticism they confronted in the beginning. Dr. John Bowers explains, “Most pushback came from individual bedside clinicians who weren’t convinced of the value of telemedicine and were a bit afraid their role was going to be either eclipsed or second-guessed by this other application.”
Fedor says this hesitation remains today. In-person care teams have a pride of ownership over their roles. They are also sometimes hesitant to work in rooms with cameras trained on them 24/7. “The bunker model cameras are always available,” Fedor says, which can lead clinicians on the ground to suspect that they are constantly watched.
In contrast, the teleICU model tends to set everyone’s mind at ease because, “If you don’t put the cart in the room, there’s nothing the virtual team can do.” There is still skepticism about virtual care, but when delivered on a device or cart that the in-person clinician controls themselves, it goes a long way toward promoting greater acceptance.
At hospitals without intensivists on staff, critical care nurses and hospitalists like the teleICU model because they don’t want to transfer critically ill patients out of their care. Hospitalists appreciate that the teleIntensivist expertise feels more like a consultation from a colleague than someone taking over their patient. And critical care nurses benefit from structured collaboration, which provides an opportunity for both parties to ask questions and build a care plan together.
Bunker Model vs. TeleICU: The Verdict
These models are, of course, not mutually exclusive. A health system could adopt the bunker model for several sites and use a distributed platform supplement to handle other use cases or service other parts of the hospital which are not wired for access by the bunker.
Ultimately, hospitals, health systems, and other care providers must consider the use cases they seek to address, the pluses and minuses of each model, and the long-term implications for flexibility, accessibility, satisfaction, and cost. To summarize:
The Bunker Model:
- Suitable for medium-sized and larger health systems that employ their own clinicians
- Replicates an entire care team in a virtual setting
- Requires significant upfront capital investment
- Can be met with skepticism by in-person care teams
- Confined to the ICU floor where each patient bed is wired for remote monitoring
The TeleICU Model:
- Suitable for a more diverse set of use cases
- Provides specialists on-demand to handle gaps in coverage or surges in utilization; some hospitals have no intensivists on staff, and telemedicine physicians are the singular provider for the ICU
- More mobile as the telemedicine cart can be wheeled throughout the hospital
- Requires little upfront investment; can make use of existing, legacy devices
- Integrates into existing hospital workflows, promoting acceptance by in-person teams
- Can bolster critical thinking skills for on-site providers because they are collaborating with a critical care physician for patient care
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