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Background: Tele-critical care (TCC) adoption has been slow since its emergence in the early 2000s. The COVID-19 pandemic has renewed interest in telemedicine and may spur expansion or development of new TCC programs. This narrative addresses the Cleveland Clinic TCC service, (eHospital) to promote exchange of ideas to continually optimize the practice for current and future users. Methods: A descriptive narrative methodology is used in this report. Results: Cleveland Clinic's eHospital was established in 2014 to support nighttime critical care across system hospitals. It encompasses a tiered system of two-way audiovisual communication, telemetry, software platform that integrates the electronic health record, and a proprietary risk stratification algorithm for targeted electronic surveillance. The TCC team includes intensivists, advanced care providers, and registered nurses. Three coverage models evolved depending on onsite clinician availability. More than 133,000 patients have been served by eHospital to date, and span the typical spectrum of critical illness. Along with universal monitoring, ∼18% of patients received active interventions, the most common of which are categorized. Patterns of activity, typical workflows, and adaptations of bedside best practices are also described. Bookending the work shift are sign outs focused on pending critical issues, unstable patients, and those who can be triaged out of the intensive care unit. In between, TCC teams round periodically and interact with bedside teams. Conclusions: TCC adoption has proceeded slowly. Some acceleration is anticipated in a post-COVID-19 pandemic world. Our experience highlights operational practices that can facilitate successful TCC practice.