Collaborating across the miles

ICUs, hospitalists, intensivists improve outcomes for the critically ill.

Richard Bailey, FACP, medical director of inpatient care and hospitalist services at Saint Clare's Hospital in Weston, Wis., was called to the emergency department in the middle of the night to see a man with a drug overdose. Dr. Bailey intubated and stabilized the patient and got ready to admit him to the 12-bed intensive care unit (ICU).

He called an intensivist on duty—a doctor stationed at a remote ICU (eICU) command center more than 500 miles away in St. Louis. “I was able to call the command center, have them ‘meet’ me [on camera] in the patient's ICU room and immediately join me in the management of the patient,” said Dr. Bailey, a hospitalist.

Doctors at some eICU command centers can enter patient orders remotely
Doctors at some eICU command centers can enter patient orders remotely.

Saint Clare's is one of a growing number of hospitals in the U.S. that are using remote monitoring systems to help oversee the care of critically ill patients. The trend is being driven by a number of factors, including the tight supply of intensivists to staff ICUs and a desire to improve care while reining in costs. Proponents of the systems say that eICUs can reduce complications, length of stay and mortality rates. Community hospitals that have eICU backup also are able to keep critically ill patients rather than transfer them, which can bring in added revenue and is often more desirable for the family.

But implementing an eICU isn't as simple as installing equipment and software. Administrators and physicians said it takes extensive planning and coordination to establish a good working relationship between the doctors and nurses on the ground and those in the eICU.

“We're there to serve the bedside physician and the patient,” said David Rein, MD, medical director of the eICU for Aurora Health Care in Milwaukee, Wis. It needs to be made clear that the role of the eICU is not to take away from the doctor–patient relationship, he said, but rather to come out of the conversation with better plans for patients' care.

ICUs link to command center

Saint Clare's contracts with Advanced ICU Care, which runs an eICU control center in St. Louis staffed by board-certified intensivists and CCRN-certified critical care nurses who oversee about 90 ICU patients at nine hospitals in five states. The doctors and nurses in the command center work alongside staff at the bedside via technology that provides real-time information on vital signs, access to test results, and video and audio hookup to patient rooms.

“It really is a partnership and it is important we work together,” said Isabelle C. Kopec, FACP, vice president of clinical services for Advanced ICU Care, which went live with its first hospital in January 2006 using the patented eICU system sold by Baltimore-based VISICU. Dr. Kopec, an intensivist, said staff in the eICU monitoring center track data that look for subtle changes in a patient's condition, picking up potential problems before they develop into full-blown crises.

Doctors at the central Advanced ICU Care command center in St. Louis can also enter orders for patients in the ICUs, cutting down on the lag time that can normally occur when a doctor is not immediately available. In one recent case, a physician in the command center used the stream of incoming data to pick up signs that a patient had a pulmonary embolism, intervening immediately to treat the condition, said Dr. Kopec.

Aurora Health Care's eICU near the Milwaukee airport oversees 253 ICU beds in the 13-hospital system, Dr. Rein said, using 38 hours of physician manpower and an average of 108 hours of nursing manpower per 24 hours. On one recent day, the eICU's patients included a young man with acute respiratory distress syndrome who had just been transferred from a medical-surgical ward to the ICU at one of Aurora's smaller hospitals. When various measures indicated the patient was deteriorating, the eICU fine-tuned his care plan, including making adjustments in ventilation and sedation, Dr. Rein reported.

But Dr. Kopec and other doctors stress that there's much more to an eICU than gadgetry. “You have to look at this aside from the technology, the cameras, the computers, the speaker,” said Dr. Bailey. “The fact of the matter is that there is someone on the other end of the line who is human.”

Addressing a shortage

The shortage of intensivists is expected to grow along with a demand for ICU beds as the population ages. According to The Leapfrog Group, a nonprofit organization that focuses on improving health care quality and safety, research shows that hospital mortality rates go down as much as 30% and ICU mortality rates decline 40% when ICU patients are managed or comanaged by board-certified intensivists. Yet it's estimated that only about 15% of U.S. hospitals with ICUs have dedicated intensivists; larger hospitals are more likely to have them.

Research on eICUs (sometimes called tele-ICUs) likewise shows that they can help bring down mortality rates. Sentara Healthcare, which primarily serves southeastern Virginia, was the first hospital system in the U.S. to implement an eICU, beginning in 2000. Steve Fuhrman, ACP Member, the eICU's medical director, said a study of the eICUs's first year of operation found that hospital-based mortality for those patients who required the ICU during their hospitalization went down 25% when compared with the time period before the system was put in place. Sentara has since expanded its eICU, which now covers 101 beds at five of its seven hospitals. Dr. Fuhrman said that in 2006, hospital-based mortality for patients who used the ICU was 13%—significantly lower than the 16% mortality rate predicted by patients' APACHE III scores. In addition to lowering mortality rates and lengths of stay, the eICU has helped Sentara recruit hospitalists, who like the idea of having the backup of critical care specialists.

At Aurora Health Care, Dr. Rein said the system has not led to the sizable drop in mortality or length of stay reported by others, but there have been improvements in measures such as ventilator-associated pneumonia, as well as length of stay (from 19.6 to 15.2 days) and cost of care for ICU patients with sepsis.

Building relationships

To enhance the relationship between Aurora's eICU and the various units it oversees, doctors who work at the bedside rotate through the command center if it's geographically possible. Venkata Anne, FACP, a pulmonary critical care intensivist at St. Luke's Medical Center in Milwaukee who also works at Aurora's eICU, said that a “different learning curve” was required to work at the command center. It took time to get comfortable evaluating patients from afar and absorbing information flowing into the center, he said. It also took practice to learn how best to communicate with on-site staff.

“Even if you're right and they're wrong, you have to keep it very friendly and use a certain tone,” he said.

Craig Lilly, FACP, who heads the eICU for UMass Memorial Health Care in Worcester, Mass., agreed. “The key to success is communication and collaboration,” he said. He avoids using the term “command center” to describe the eICU in part because it denotes a “hierarchical, military-style approach.” Instead, he said, the central hub operates as a “support center predicated on the fundamental concept that our bedside physicians and nurses have put together the best possible care plan and the eICU supports those plans.”

UMass Memorial recently connected one of its affiliated community hospitals, UMass Memorial Marlborough Hospital, to the eICU and soon will hook up two other community hospitals. Dr. Lilly said he expects to encounter different challenges working with community hospitals, including the difficulties some well-established physicians have integrating electronic tools into their workflow.

Wendy Everett, president of the New England Healthcare Institute, a nonprofit research organization in Cambridge, Mass., said her group is starting a study with UMass Memorial on the impact of tele-ICU care at the community hospital level. Most of the reports on decreased mortality came from large integrated health systems, she noted, and the dramatic results reported in early studies have not been replicated independently. Also, not much is known about the potential benefit to community hospitals.

“Even though the full spectrum of evidence is not quite complete,” Dr. Everett said, “the early results are very promising. We're extremely optimistic about the potential of tele-ICUs to save lives and save money.”