Reinventing the ICU

Research suggests that physicians specially trained to address the complex nature of critical care patients - intensivists - provide the best patient care for this population. Patient safety organizations have called for full-time intensivist staffing in ICUs as a means of saving an estimated 50,000 lives per year.

But intensivists are in short supply; approximately 5,400 physicians across the country are certified in critical care, enough to provide dedicated intensivist care for only 13 percent of the nation's ICU patients. The problem is not going away. Current projections estimate that critical-care specialist hours will exceed supply by 22 percent by 2020, and 35 percent by 2030. Nurse vacancies in critical care stand at 20 percent and continue to grow.

The intensivist shortage is one reason why many hospitals employ an open staffing model in the critical-care environment with a cadre of clinicians including surgeons, family physicians and cardiologists orchestrating care in a somewhat fragmented fashion. This model, however, is far from ideal. It can be difficult for clinicians to access all of the data they need to make decisions about critical patients because physiologic data, lab results, medication information and imaging studies are housed in disparate systems. 

A number of hospitals across the country have employed new technology to bring together various ICU decision-making elements and create a virtual ICU that leverages the limited number of intensivists and critical-care nurses. These hospitals are realizing dramatic improvements in multiple parameters in their ICUs.

• Sentara Norfolk General Hospital in Norfolk, Va., shortened the length of stay for intensive care patients by 17 percent and reduced ICU mortality rates by 25 percent. Per patient costs dropped $2,150 based on reduced patient expenses and increased ICU capacity.
   
• Health First Inc. in Rock Ledge, Fla., has seen a 16 percent reduction in mortality risk. The average number of codes per month has nearly halved, and survival rates following a code have increased from 51 percent to 75 percent.
   
• Borgess Medical Center in Kalamzoo, Mich., has decreased the amount of time spent searching for patient data by 75 percent.

These hospitals have implemented virtual ICU systems in conjunction with conventional patient monitoring systems like Philips Medical Systems IntelliVue, GE Healthcare's Unity and Spacelabs Ultraview patient monitoring systems to create improve ICU operations.


The virtual ICU at a glance

One option for the virtual ICU is VISICU Inc.'s eICU system, which serves as a centralized 24-hour ICU surveillance solution for several hospitals. "The eICU program entails a remote, off-site monitoring station for ICU patients staffed by critical-care nurses and intensivists," explains Ralph Koenker, MD, medical director of radiology for Novato Community Hospital in San Francisco. Location is a non-issue; current eICU centers serve hospitals as far as 180 miles away from a virtual control center.

The model replicates and centralizes conventional physiologic monitoring of ICU patients and adds access to other key clinical data like images. Critical-care nurses view blood pressure readings, EKG, oxygen saturation, central line monitoring and all other data available on a traditional bedside monitor. The difference is that the nurse is stationed offsite in an office building; a video camera enables the remote nurse to see into patient rooms. At the same time, on-site ICU nurses continue to enter patient data such as intravenous medication infusion.

The real benefit of the approach is that it allows a group of hospitals to leverage the expertise of a single intensivist, who staffs the eICU center along with critical-care nurses. "eICU serves as surrogate for a full-time intensivist," explains Jim Shaffer, MD, medical director of Health First VitalWatch in Rockledge, Fla.

"Intensivists on-site at the eICU center can make decisions more rapidly than in a conventional setting, where the critical-care nurse must call a physician at home," sums Koenker. What's more, the intensivist has access to an array of data not available to an on-call physician. At Novato's Bay Area eICU, this includes real-time data from Philips' bedside patient monitoring systems and medical images via Siemens Medical Solutions MagicWeb PACS.

"Critical care is a very data-driven process. Minor changes in parallel areas like respiration, temperature and lab results can alert a physician to a problem 24 hours before it may be heard through a stethoscope or seen on an x-ray," explains David Kapaska, MD, senior vice president of medical affairs, for Avera Health McKennon in Sioux Falls, S.D. The eICU model combines all of the disparate digital elements to provide the off-site specialists with a clear, real-time snapshot of the patient.

Borgess Medical Center in Kalamazoo, Mich., employs a similar model, relying on Cerner Corp.'s INet Virtual to enable remote ICU patient monitoring. Remote virtual ICU staff relies on two way audio/visual monitors and physiologic monitors. Critical-care staff use workstations to access the INet critical care information system. Cerner's PharmNet and Millennium systems connect the lab, pharmacy and ICU data. What does it mean? If a lab result indicates that a certain parameter - such as the patient's creatine level  - has risen or fallen outside certain area, the system immediately alerts clinicians, so that they can take the appropriate action.

These systems represent a stark contrast to conventional ICU care. In a conventional ICU, when a nurse notices abnormal heart rhythms, she needs to determine when it is appropriate to phone the on-call cardiologist at home. At that point, she verbally relates parameters like potassium levels, hemoglobin and oxygen saturation, and the cardiologist can order medication to correct the arrhythmia. In this situation, the physician is roused from bed and forced to make a decision based on verbal information without analyzing physiologic data like rhythm strips. An on-call physician may have access to some of the digital data via a web-based PACS or clinical information system; however, it tends to be too fragmented for true clinical utility.

It can be equally difficult for physicians on-site at the hospital to access the complete library of patient information. "Physicians can access some monitoring data on PCs throughout the hospital, but they can not readily access medications or other data," explains Jason Szabo, MBA, RN, director of nursing at Bay Area eICU in San Francisco. It makes more sense to rush to the ICU to access the complete picture. The virtual approach eliminates the lag time as the physician gets to the ICU. "No matter how hard you work or how smart you are, you cannot be in two places at one time," says Kapaska.

The technology provides a support mechanism to leverage clinical staff. Nurses in the eICU center have continuous access to physiologic data like cardiac rhythms. If an alarm sounds, the eICU intensivist can immediately review the cardiac data and access other physiologic data like potassium levels, hemoglobin, hematocrit, oxygen saturation and blood pressure with a single mouse click. "All of the data are at the fingertips of the treating intensivist, as if he were right there in the actual ICU," explains Koenker. Thus, the intensivist can make a more informed decision than a conventional on-call specialist.

"This is a limitless connection to ICU data that leverages expertise of critical-care specialists. We don't need to be at the bedside because all of the information is in front of us," explains Steven A. Fuhrman, MD, medical director of eICU for Sentara Healthcare in Newport News, Va.

Many hospitals demonstrate real gains in patient care and cost control with the technology. "There are non-measurable results, too," Shaffer says. "This is more than a software/hardware solution. There is a change in attitude at the ICU bedside."

The eICU system can serve as a quality initiative and facilitate low-cost, high-gain practices. For example, prior to implementation, only half of ventilator patients had the bed head elevated to the recommended degree. Post-implementation compliance is 100 percent.


Supporting structures

IT is heavily involved in eICU development. At Inova Health in Alexandria, Va., the system interfaces with monitoring systems from six different vendors including Philips Medical Systems IntelliVue patient monitoring system, GE Healthcare's Unity patient monitoring system and IDX's Carecast HIS. The process begins with bedside nursing documentation into Eclipsys' computers on wheels (COWs). Bedside monitoring systems and lab results also feed into the system.

Maggie Cornett, director of IT applications for Inova Health, explains the interface process. "VISICU sends technical specifications so various devices can be tested." At Inova, most devices passed the initial test. One system required a custom interface, which the IT department developed. Another monitor vendor sold the hospital the required interface functionality.

Data are sent from the physical ICUs to the eICU system over a high-speed private network, and the eICU facility includes a back-up generator, which enables 24/7 operation in disaster scenarios.

Inova did encounter some IT challenges - mainly on the speed front. "There's a perception that anything that seems slower than paper is too slow," notes Cornett. Initially, documenting into COWs was slow, but the IT department fixed application codes to make the process more efficient.

Other upfront IT tasks include camera placement and cabling methodology as the eICU system relies on video cameras in individual ICU rooms.

Cornett offers some advice for her IT colleagues. "Make sure the network is robust, and plan to frequently cross paths with biomedical engineers. The other biggie is buy-in from physicians and nurses. Once you get through the initial hurdles, the process rolls. This is not the most complicated system in the hospital."

 

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