What Tele-ICUs Mean For Health Care In Critical Moments

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0:31In August 2024, 26-year-old Connor Hilton checked into Bridgeport Hospital in Connecticut with severe abdominal pain. Overnight, he was transferred to critical care where he died. Only after did his family find out that Connor was treated at what's known as a tele-ICU. Connor had a lot to live for. Connor worked very hard to get where he was. And to have that taken away from us the way it did doesn't sit well with me. That's Connor's father, William Hilton. We'll hear more from him later in the hour. Connor's story puts a spotlight on a practice that's been around for two-plus decades, but still lacks substantial research, hospitals using telemedicine critical care, or tele-ICUs.

1:17They vary widely, but what they have in common is that at least part of the patient care is handled off-site by remote doctors, nurses, or specialists. Up to a third of ICU beds in the U.S. are in tele-ICUs. That's according to a study using data from the American Hospital Association. Take Wisconsin. As of May 1st, critical care physicians are no longer physically present in the ICUs of several Ascension satellite hospitals. They remain available via video call to help bedside nurses and on-site hospital medicine doctors known as hospitalists who do not specialize in critical care. Tele-ICUs do present an opportunity to expand and improve the health care people receive, but what are the risks of providing remote care in the most critical life-or-death moments?

2:04I'm Jen White. You're listening to the 1A Podcast. We'll be back with more after a short break. Stay with us.

2:15Welcome back to the 1A podcast. We're talking about the use of tele-ICUs in hospitals and the kind of care patients can expect. Joining us from Chicago is Dr. Nandita Nadig. She's a pulmonary and critical care physician and associate professor at Northwestern University's Feinberg School of Medicine in Chicago. She's researched and worked inside tele-ICUs. Dr. Nadig, welcome. Thank you for having me. Joining us from Orlando, Florida is Paul Melito. He's an RN and the Director of Nursing Services for eMedicine at the University of Alabama at Birmingham Health System. He helped build UAB's virtual nursing program.

2:52He also serves on the American Telemedicine Association's Acute and Critical Care Special Interest Group. Paul, welcome to 1A. Hey, thanks for having me. And we have Julia Kolak with us from Garrison, New York in the Hudson Valley. She's a Ph.D. trained bioethicist and philosopher who's currently the Assistant Director of Research at the Hastings Center for Bioethics. That's a think tank. She also worked as a clinical ethicist in ICUs. Julia, welcome to the program. Thanks for having me. So Dr. Nadig, help us better understand what a tele-ICU is and what it isn't, because that term can cover a lot of ground.

3:27Yeah. You know, as you, you know, alluded in the show earlier, tele-ICU really refers to healthcare delivery for critically ill patients, right, by an intensivist from a remote location using electronic transfer of information. And it typically involves, you know, interactive, audiovisual platforms or systems. And I think in layman's terms, I think the way to best explain tele-ICU is it's an extension of critical care expertise, but not a replacement for bedside care. It allows ICU teams to support patients, bedside clinicians, hospitalists, most often in real time. particularly when critical care resources are unevenly distributed.

4:25You use the term intensivist. Just explain what kind of training that doctor gets. Yeah, so an intensivist is typically a physician who has had either training in internal medicine, anesthesia or surgical specialties to start off, And then on top of that undergoes, you know, subspecialty training in critical care medicine. So essentially taking care of, you know, patients in an intensive care unit where, you know, patients are typically connected to heart-lung machines or breathing machines or require, you know, support, you know, significant support. So, you know, in simple terms, I would say, you know, the sickest of the sick in the hospital are typically taken care of in an ICU.

5:18Now, Paul, you built and run a virtual nursing program at UAB. What does it look like when a tele-nurse is involved at an ICU? I think people most often think about nurses as being very hands-on. Absolutely. You know, I tell people the easiest way to visualize it is if you've seen the movie Iron Man. When Iron Man's in his suit, he has the AI technology Jarvis, right? And Jarvis will put all this stuff up on his visor. He can tell him where he's hurt, make predictions, make phone calls, and give him all data information. But Iron Man does all the physical work. That's really the relationship the virtual team has with the bedside team.

5:56The virtual team is Jarvis for the bedside team being Iron Men and Women. So the nurses, the non-nurses, physicians, they utilize computer intelligence technology and sometimes an AI overlay, depending on where they are in the program, that uses algorithms to pull data from different platforms, from vital science software, from trending software, from different places like that. And it gives them real-time visual alerts for things that are outside the norm. These are experienced nurses, usually 10, 20 years of experience, that are able to look through that data and those alerts and pull up those programs and say, okay, is this patient's oxygen dropping because they're wiggling their finger and they've got a bad connection to the device, or is this truly an acute change in their condition?

6:42When they have gone through that and they've looked through the chart, then they'll initiate a two-way audio-video experience, a camera assessment, to where the patient, the patient's family, the clinicians at the bedside can see and hear the virtual nurse, and the virtual nurse can clearly see all of them. And the technology is very sharp. They can zoom in so tight they can see the pupils on a patient's eyes. So it's very clear. And they get a global view of what's going on. they communicate in real time, it allows all the clinicians involved to be more proactive in care than reactive. Well, Dr.

7:11Nadik, you've worked as a critical care doctor in a tele-ICU setting. What does the job look like for tele-doctors compared to working on site at an ICU? You know, there are certainly aspects of it that are, you know, similar, right? I mean, you're taking care of critically ill patients, right, in an ICU, albeit remote, right? But there is a lot of information that can be obtained, right, from electronic health records. While you're reviewing these patients, right, in the ICU, you have the ability, as Paul mentioned, right, to call in and talk to the patients, the family, right, the clinicians at the bedside, the nurses at the bedside.

7:53But I think, you know, the aspects that are, I would say, are unique are, It depends what the level of involvement of a tele-ICU physician is. There are certain models that are continuous models where the tele-ICU physician is involved 24-7 versus some others that are intermittent overnight or something along those lines. And then, as Paul was saying, there's the proactive model where there is continuous assessment using risk prediction algorithms and so on, or they're reactive, right? When called upon, right, you know, you intervene. And then in terms of scope as well, right, there's full autonomy, right, where you have a collaborative model with the bedside team and, you know, are involved in the day-to-day decisions of, you know, the patient, where, you know, there are some models that are in minimal discretion.

8:46So it really depends on what the partnership looks like between the local bedside hospital or ICU and the remote tele-ICU team. Well, we got this text from one of you. My 83-year-old mom had a tele-visit one time when she was in the hospital with pneumonia. It was very impersonal, and if I wasn't there, she probably would not have understood what was happening. We all need advocates when we are being treated for a serious illness. The telehealth guy for my mom basically came on a screen and looked at her, didn't even talk, and I had to ask him, what's up? I think I scared him because he wasn't expecting me to be there.

9:23Julia, as an ethicist who really studies ethical questions in medicine, what are the questions that come up for you around telehealth, especially in a critical care case? Yeah, so I think tele-LCUs are neither inherently ethical nor unethical. Like many tools and innovations in medicine, the facts do not determine or settle the ethical questions, but they're certainly contributory to the ethical analysis. And I think what's so tricky about tele-ICUs, as I see it at least, is that there are a number of foundational empirical questions about how they're defined, how they operate, what their safety profile is relative to standard ICU care that have not been sufficiently answered to meaningfully weigh whether there are potential harms incurred with respect to their adoption and how those tradeoffs should be weighed ethically relative to their prospective benefit.

10:12I think there's also a number of commitments firmly ingrained in the foundations of medical ethics, like informed consent, autonomy, and privacy, that require careful analysis and reflection to determine how they translate to the tele-ICU setting. As that audience member just reported, I think a lot of people, when they know that their loved one is in a hospital, in an ICU, they immediately assume certain things about the level of care being received, how it's being delivered. And I think patients can feel betrayed, sometimes confused about what tele-ICU care delivery means in terms of what they have a right to expect from their physicians.

10:50Well, we have to go to a break. But coming up, we hear from the father of Connor Hilton, a 26-year-old who died while being treated in a tele-ICU and was pronounced dead by a remote doctor. That's just ahead.

11:07Welcome back to the 1A Podcast. William Hilton, a dentist based in Connecticut, was in the room when his son Connor was pronounced dead. But it wasn't a doctor in person who did so. Rather, a face on a screen, a doctor working remotely in what's known as a tele-ICU. Connor Hilton died in August 2024 at 26 years old, a day after being admitted to the hospital with severe abdominal pain. This March, his family sued the hospital where he was treated in Milford, Connecticut. It's part of the Yale New Haven Health System. The case raises questions about standards of care in tele-ICUs, which account for up to a third of U.S.

11:46ICU beds. We spoke to William Hilton and his attorney, Joel Faxon, earlier this week. Here's Dr. Hilton. I took Connor to the hospital August 14th, and two days prior to this, he wasn't feeling good. We thought it was a stomach bug because that was kind of going around my house. so we decided well actually he called me when i was at work and he's like will you take me to hospital really don't feel good and that's just what kid wants his dad to take him to hospital so i went home and picked him up we decided to and this is in north haven where i live north and we decided to take him to milford hospital um because well number one is a yale facility so So we assumed we would get great care.

12:37And also, we thought that we'd have less of a wait time. We got there just after 11 in the morning. And we were there pretty much the entire day. My wife and I, visiting hours were over that day at 7. He got his dinner around 6.30. We were talking about dental school starting the next day and about his getting a parking pass. And so I left at 7. It's the last time I saw him alive. The medical malpractice lawsuit you filed in March accuses the hospital of negligence, specifically in its use of an intensive care unit overseen remotely by an off-site doctor. When did you learn your son was being treated by a doctor who was not on site?

13:23We found out afterwards. I mean, you have to imagine, like we were shocked at so many different things, right? uh i've had nothing but time to look at what has happened in the past and uh the more time that goes by the more it's unsettling because we never we never would have allowed this to happen so number one we had no idea that that connor was you know decompensating and was was getting worse around me we had no idea and the thing is this connor was at that point he was in pain so connor was incapacitated. Conor had no ability to make any decisions for himself. What do you do in that situation?

14:07We needed to be called. We were never called. So he goes in the ICU just after midnight and he's in there for four hours. He's never seen by a doctor. No physician ever saw him until he coded. I would think there was time enough in four hours, time they probably could have let us know that our son was in the ICU. But no, I got a call at 4.45 in the morning, basically telling me that this is it. And I just, I mean, so no, I didn't know this was a tele-ICU. We were never told it was a tele-ICU. We were never told that he was getting worse. There's no way in the world that we would have ever said sent him to an unmanned ICO.

14:56And as I have found, this model is so flawed because, in my opinion, it's a father. Because not only is it remote, but their first responder is a hospitalist. So you have somebody who crashes, who maybe needs an airway, And their first responder is a hospitalist who doesn't intubate. For those unfamiliar, just explain what is a hospitalist. A hospitalist is basically like an internal medicine doctor. They're not really critical care trained, so they don't really intubate. So, you know, the people that are ER docs, those are the guys that are usually the ones who intubate. In this model, the responding doctor can't render life-saving airway management to my son.

15:49They have to then call a second person who is the ER doc who is qualified to intubate. So there are built-in double delays. I don't know how you would call that a true ICU. out. We did reach out to Bridgeport Hospital, part of Yale New Haven Health System, for a response to the lawsuit. Here's what they shared with us in a written statement. Our priority has been and remains providing safe, high-quality care to our patients. We remain committed to continuous review and improvement of patient safety practices. Because this is active litigation, we cannot comment on specific allegations, and we'll address the claims in the appropriate legal forum.

16:32Joel, I'd like to bring you in here. What is the legal case you're making in the medical malpractice suit against Bridgeport Hospital? This is, again, a suit you filed at the beginning of March. Yeah, so there's two components to it. One is the malpractice element, which is a failure of the hospital to render an appropriate level of care to patients. And in this particular case, Connor Hilton. And also, the second part of it is lack of informed consent, because at a very basic level, there's no patient or family of a patient that would consent to sending a critically ill person to an intensive care unit that doesn't have a doctor.

17:16And from Bill's perspective, all he needed was information so that he could make a decision for his son. And that information was never forthcoming. So just for some context, Yale is in New Haven. Milford is about 10 miles from New Haven. And then Bridgeport Hospital is down the road a little further in Bridgeport. So there are two fully staffed intensive care units owned by the same hospital system that are within less than 10 minute ambulance ride either side of Milford Hospital. So there is no need for what I've called a fake ICU in the middle. If a person decompensates to the point where they need that level of care, it's incumbent upon the hospital to provide that level of care and at a very minimum at least disclose to the patient that the care that they're going to get if they stay at Milford Hospital is going to be substandard or inadequate or potentially life-threatening because of the fact that they don't have adequate staffing.

18:22But that information was never provided. What kind of remedies are you seeking in this case? Well, I think there's many things that can come out of this lawsuit. And I think Bill can speak to this, but I think the main thing that he wants to accomplish here is to shed light on the fact that there is a growing area of medical care where you really don't get any medical care. So there's important areas that legislatures across the country could participate in here to mandate minimum staffing requirements and minimum disclosure requirements. So that's position number one. Obviously, in a lawsuit, unfortunately, the only remedy that the legal system provides in all 50 states for something like this is a financial payment.

19:08But I think from the perspective of the Hilton family, they would just simply forego any kind of financial payment if there could be a structural change where a hospital tells the patient exactly what the medical care is going to be, tells them that it's going to be on a screen so that they can make a decision, and furthermore, that there should be intervention by public policy makers, lawmakers, about these kind of disclosures so people can make informed choices. Bill, I'd love to hear from you as well. I'm hearing two things from Joel. One, increased transparency for patients around treatment at ICUs, these telehealth ICUs.

19:53But what other remedies would you like to see? Well, I will tell you, the way I guess I would respond is, if I back up, I've learned, I mean, I didn't think before this happened, that I would have to be such an advocate. I mean, you always want to be an advocate for your loved one. But I guess I didn't ever think that I would have to ask basic questions about basic levels of care. But I was floored that I now know that I have to. This happens again, and we're in the hospital. I have a whole list of questions I'm going to ask. I'm going to ask who's there, who's covering, what is the treatment plan.

20:35So I want this whole thing to change. If this hospital can't handle a patient who has to go to the ICU, well, you transfer them. But before then, you have to let the family know that there's even a situation brewing. I mean, it seems very basic to me that the hospital should have to tell the family what's going on with their loved one, Especially if, you know, at Conor's lowest point, Conor had like zero voice for himself. Like it breaks my heart. Not only did he have no voice for himself, we had no voice either. Were we given a chance, you're darn straight we would have had him transferred right away.

21:18They have specific ambulances that can transport people from ICU to ICU. There's things that could have been done. And I do think the whole informed consent thing is so important to me because that did not happen with us. We've spoken a lot about that final, those final hours of Connor's life. But Dr. Hilton, how would you like people to remember your son? I mean, tell us about him. Connor was a kid who had so many dreams. Like he basically picked out a house that he wanted to buy when he had grown up money after he became a dentist. right he wanted to be a room criminal specialist so he had a car picked out as well connor had a lot to live for connor worked very hard to get where he where he was and to have that taken away from us the way it did doesn't sit well with me well i want to thank you both for speaking with us and sharing your story with us we appreciate it thank you thank you very much That was William Hilton and his attorney, Joel Faxon.

22:26They spoke to us from Connecticut earlier this week. Now, an investigation by the Connecticut Department of Public Health in July 2025 found Bridgeport Hospital, quote, failed to ensure quality medical care was provided. That's according to the Harford Current. The Connecticut Hospital Association told the Current this about tele-ICUs, quote, different than telehealth and other care settings, it is designed to enhance care for critically ill patients by adding another layer of expert oversight, not replacing bedside care, end quote. Let's return to our guests. We're here with Dr. Nandita Nadig, pulmonary and critical care physician and associate professor at Northwestern University, Paul Molito, director of nursing services for e-medicine at the University of Alabama at Birmingham Health System, and Julia Kolak, assistant director of research at the Hastings Center for Bioethics.

23:15So we just all heard from William Hilton about the night his son Connor died at a tele-ICU without knowing more specific details. And of course, we're not asking any of you to litigate the case. What went through your mind hearing that story, Paul? Yeah, I think we need to be transparent. We need to communicate and let people know that patients know exactly what's going on, that our physicians and the virtual team are just like you said, a supplement. We're not a replacement, but in those cases where you don't have the physical hands, you help. You give your expertise and then you work as a team, just in any other case.

23:54So I think that's one thing that we want to make clear to our patients and our community is none of us are here to replace. The virtual team is not a replacement. It's adding that extra layer of support to enhance the care. And, you know, we all want the same thing. We want the best for our patients. Dr. Nadek, your thoughts? You know, I'd say that a majority of the ISUs now have, you know, of some intensivist involvement, right? But the truth of the matter or the reality is, you know, only about 40, 50 percent of, you know, ICUs, right, in the United States, right, meet the leapfrog, you know, group standard.

24:29And, you know, what the leapfrog group is, you know, it's a national nonprofit organization, right, that collects information about, you know, hospital performance and quality and safety and sort of so on and grades hospitals, right, based on, you know, a number of things. And one of the things that they look at is, you know, the intensity model of, you know, intensivist coverage for all of their patients. And, you know, the reality is only about 40, 50 percent of hospitals in the United States actually, you know, meet, right, the grade A level of, you know, intensivist coverage. And so I think tele-ICU is there to help expand, right, access, right, for, you know, those 50 percent of hospitals that don't have it, but clearly not, you know, does not, you know, replace, you know, bedside care.

25:12like bedside care, bedside protocols, or communications. We got this email from Ruth who says, I'm a nurse practitioner working in telemedicine in an ICU with limited access to ICU-trained physicians on site. As I live in a rural area of South Dakota, sometimes weather does not permit transfer of patients in critical condition. I have found the access to telemedicine essential. But Dr. Nadig, it does raise the question, in a tele-ICU setting, if there's a specific procedure required, that would be handled by an intensivist, but that intensivist is remote, who handles that procedure? Yeah, no, that's a very important question, right?

25:47I mean, you know, if there are interventions, procedures that need to be done, and I think this is sort of where it's important to think about, right, how the partnership between the remote, you know, intensivist or the tele-team and, you know, sort of the bedside has been, you know, organized. You know, I think there needs to be tele-ICU protocols, right? If there needs to be an intubation, right? Who is your go-to person, right? If there needs to be a procedure, you know, those need to be spelled out during the onboarding process and the implementation process, right? Communication, right? You know, sort of, you know, what is our communication pathway, right?

26:27And as, you know, mentioned earlier, right, we need to be transparent about, you know, the tele-team that does, you know, interact with the patient and family. So it really comes down to collaborative rounding models, agreement on triage systems, agreement on escalation pathways between the local hospital and the tele-team. Julia, we heard William Hilton saying neither he nor his son consented to his son's treatment at a tele-ICU. You mentioned informed consent. What should that look like in practice? Yeah, so I would start off by saying that the legal and ethical concept of consent is related, but it's not identical, right?

27:14So classically, you can have satisfied the legal standard of informed consent by issuing disclosures about risks, benefits, and alternatives, even if the patient potentially misunderstands what they're agreeing to. Whereas I would argue you have a pretty austere ethical obligation that goes above and beyond the legal obligation to ensure patients really process and comprehend what you're saying to them so they can assess whether or not they want to participate in treatment. And I think, you know, as a mediator, I can imagine patients or family members feeling betrayed about not being given an opportunity to opt out by requesting transfer.

27:50We have a standard of what a reasonable person would want to know. I think in this case, the reasonable question is, am I going to have care delivered through an ICU? We have to take another quick break, but before we go, we got this text from one of you. Telehealth for ICU and ER care presents opportunity and risk. When used as part of a system with well-designed support and guardrails, they can offer assistance in the delivery of excellent care. I did, however, hear a director of nursing say at a meeting that new ER nurse practitioners did not require intubation competency because they could be monitored during intubation via telehealth.