A white paper recently published by the Society of Critical Care Medicine’s (SCCM) Tele-ICU Committee notes that between 10% and 20% of all hospital beds are devoted to critical care, accounting for 30% of overall acute care hospital costs.(1) Those costs are expected to increase as the U.S. population ages and illnesses become increasingly complex. At the same time, the nation faces a growing shortage of critical care physicians and nurses, and the demand for intensivists outstrips the supply by five- to six-fold.(2) Although the telemedicine concept is gaining traction, strong, published evidence related to patient outcomes is still scarce, and Medicare and other health payors currently do not reimburse for such services. A recent study from the December 2009 Journal of the American Medical Association even points to evidence that remote monitoring of patients in intensive care units (ICUs) is not associated with an overall improvement in the risk of death or length of stay in ICU or hospital. Critical of the telemedicine trend, study authors from the University of Texas Health Science Center at Houston recognize that telemedicine extends the reach and availability of intensivists in the face of a workforce shortage. However, they note that while “remote monitoring may be a partial solution for the intensivist shortage … it is expensive, its use is increasing, and there are few data in the peerreviewed literature evaluating its effect on morbidity and mortality."(3) Some ICUs have experienced this reality first hand, removing tele- ICUs after outcomes failed to justify the costs. Even so, several individual hospitals report success in using telemedicine to achieve various goals, and these positive experiences offer insight into the potential benefits of this technology.
“There are 5,500 intensivists in the United States – not enough for each hospital to have one, and many hospitals could use more than one,” noted Teresa Rincon, RN, Sutter Health Sac-Sierra eICU nurse director and current chair of SCCM’s Tele-ICU Committee.
“The tele-ICU is a tool to leverage critical care resources, but it is not meant to take the place of bedside clinicians. It is meant to leverage expertise that a hospital may not have. We want the same level of care for all patients; telemedicine meets disparity issues.”
“If you look at the intensivist shortage, it’s significant,” agreed Herb Rogove, DO, FCCM, president of a telemedicine consultation firm. “Where there is a shortage of specialties and in rural areas, time is life.”
The term “telemedicine” is used broadly to describe medical services delivered over distances using communication technologies. As practiced in the intensive care unit (ICU), telemedicine comprises networks of audiovisual communication and computer systems that link hospital ICUs to intensivists and other critical care professionals at a remote location. These networks can be used to store and forward data (such as medical records), to conduct remote real-time monitoring of vital signs or chronic conditions, or to facilitate staff interactions via video, phone or online computer. Video cameras near the ceiling of an ICU patient room can zoom to see equipment and monitors, even a patient’s eyes or nails. Cameras typically have an electronic “doorbell” to announce that tele-ICU staff are in visual contact to share observations and care recommendations with bedside caregivers. Data on multiple patients can be tracked on screens at the remote location with sentry alarms alerting tele-ICU staff when a monitored measurement starts to change in an unusual or dangerous way.
As an example, Rincon relates the story of a new mother in a rural hospital who needed an operation to stop postpartum bleeding. After the late-night procedure, the tele-ICU nurse saw that the patient needed blood faster than the normal transfusion time and recognized a postoperative hemorrhage. She alerted the bedside nurses to speed up blood and fluid delivery and identified the nearest available trauma center, while also connecting the patient’s doctor and the trauma surgeon in the tele-ICU. Quick action and coordinated transport saved the woman’s life. “Decisionmaking tools may come up on the computer that show you what to do, what to look at,” Rincon said. “It’s all designed for rapid assessment and intervention for a large volume of critical care patients.”
Via Christi Health System’s tele-ICU operation in Wichita, Kansas, covers 150 ICU beds across five hospitals, comprising 35% of all ICU beds in the state. Three to four critical care nurses watch approximately 30 patients each around the clock. From 7 p.m. until 7 a.m. daily, a physician with one or more critical care specialties monitors all beds. Medical director Elizabeth Cowboy, MD,, former chair of SCCM’s Tele-ICU Committee, came in four years ago to help create and run the program.
“We did it to increase access to critical care physicians statewide and to achieve economies of scale,” Cowboy said. Of 67 board-certified critical care physicians in the state, all but 10 practice in three counties. Through telemedicine, we transport them to where the patient is. Pure demographics led to this decision.” Cowboy noted that Via Christi has tracked more than 200 patients who were able to stay in their local hospitals rather than be transported by helicopter to the system’s main facility in Wichita or elsewhere. “The cost of the helicopter ride alone would have cost them their farm,” she said.
The whole system, including technology and salaries, costs approximately $3.5 million. To see how the investment is paying off, Via Christi uses a balanced scorecard to look at LOS, throughput, expected patient severity and mortality. Cowboy said they have seen a 33% reduction in hospital and ICU deaths, and throughput has increased from 11,000 to 14,700 patients a year – a 24% increase.
Covering seven acute care hospitals and a long-term care facility outside Chicago, Resurrection Health Care in Des Plaines, Illinois, introduced telemedicine into its 14 ICUs in 2007. Twenty-four hour monitoring from a tele-ICU “command center” in Resurrection’s Holy Family Medical Center promotes proactive intervention, including “trended alerts” that show incremental changes in such factors as blood pressure, oxygen levels and drip rates. Intensivist physicians in the center also can see subtleties in patient status, often mentoring bedside residents.
“This has organizationally transformed the way we do critical care,” says Rebecca Rufo, program operations director for the system’s telemedicine program. “There is an immediate resource for bedside staff available at a moment’s notice.” She added that the tele-ICU system “has forced Resurrection to see how we operate. It focuses ownership and accountability in a whole new way.”
From “day one” of the its tele-ICU operations, Rufo said, Resurrection leadership wanted to know how the system was going to prove its return on the $7 million investment spent to set up all 14 ICUs systemwide simultaneously. Rufo distributes quarterly balanced scorecards showing what the tele-ICU can do, using national and international best practice benchmarking standards (including nine benchmarks from the private telemedicine company and an Acute Physiology and Chronic Health Evaluation [APACHE] score), stratifying data into high, medium and low risk. These data help each ICU optimize its performance and have been instrumental in educating skeptics on the hospital floor. She stresses that success comes from one source: “It boils down to organizational direction and leadership. You have to have a clear vision.” In short, a health system’s executive team needs to fully understand the benefits of a tele-ICU program or it won’t trickle down to the rest of the organization. “You can’t start at the bottom. ‘Successful’ stems from leadership buy-in,” she explained.
In a slightly different organizational approach, UMass Memorial Health Care in Worcester, Massachusetts, pairs nurse practitioners and physician assistants with intensivists in its tele-ICU, rather than critical care nurses. “It’s hard to recruit critical care nurses – that was the driving force behind our decision,” explained Shawn Cody, associate chief nursing officer at UMass Medical Center, one of the system’s five hospitals. “We thought we could have affiliate practitioners be more proactive in getting and writing orders according to clinical best practice guidelines.”
Open since 2006, UMass’ tele-ICU system has been deployed to 126 ICU beds in 10 different units and provides constant monitoring. “We go into the room 10 times for every time a floor nurse calls us,” Cody said. “Telemedicine allows extra eyes and ears 100% of the time so nothing falls through the cracks.”
Like Rufo, Cody emphasized the importance of buy-in from all ICU leaders through its critical care operations committee. This governing body comprises the medical center’s medical director and nurse manager, as well as all critical care physician leaders. “Our administration thought it was very important that critical care be a unified force and evidencebased medicine be the way we worked,” Cody said. “[The committee] allows us to bring together experts in the field, so we can agree on how to treat really sick people and iron out how to do all ICU nursing the same way. We create order sets that allow for the best possible care every time.”
Based on the feedback he received while training staff on tele-ICU software, Cody adapted a curriculum for nurses “that was more integrated into the UMass way of doing things,” he said. “We had nursing supervisors teach their own nurses; they were much more receptive to learning from their colleagues.” ICUs were brought up one at a time over the course of a year, with staff evaluating what worked and what needed to be changed as each unit went live. So far UMass has met or exceeded all of its goals for the system, Cody said, adding “we’re coming up with new ideas all the time.” LOS, complications and costs per case are down. “It’s not the technology [that matters] so much as the whole program. The system gives us real-time feedback, oversight, report cards. It allows us to benchmark against all e-ICU patients nationwide,” he said.
Other hospitals provide telemedicine services using a robot model rather than an in-room camera system, making the system transportable anywhere in the hospital. Rogove, who owns a company that provides clinical services for telemedicine facilities using the robot model, describes it as “a vehicle with information technology support.” This model is less expensive than a remote monitoring model because there is no offsite complex or widespread cameras and wiring. Rogove estimates robots are utilized in approximately 250 locations worldwide, predominantly in rural and urban ICUs within the United States. Often used in the emergency room, the robot is “paged” along with the physician on call. Laboratory data, electronic medical records, computed tomography scans, some magnetic resonance images and radiographs may be run through the robot’s software. The robot also has a stethoscope, a post for ultrasound scanning, and the ability to look in eyes and ears, “everything except palpitation,” Rogove explained. Robots are brought into the room only with the patient’s permission and with remote physicians and nurses participating in bedside examinations.
“We can drive the robot anywhere. We make ICU rounds, teaching rounds, go with rapid response teams. But we don’t try to replace physicians; we supplement them,” Rogove explained, adding that the robot’s average response time is 20 minutes from when a call is made until it “sees” the patient.
To determine whether a hospital might benefit from a robot or remote monitoring model, Rogove suggests that hospital leadership examine the approach to patient care. “[A robot] leverages the nurses on site to provide watchfulness. It learns to recognize the signs to bring to the attention of staff,” Rogove said. “A monitoring system provides an extra layer of protection. You have to sit down and look at both products. [In either case], it doesn’t change care at the hospital; it’s a way to have intensivists on site. The telemedicine model is a collaborative model. It’s good for physicians, but also for nurses if they can’t reach the doctor they need.”
It is critical that any ICU considering telemedicine weigh the evidence for and against such technology. It is not ideal or even possible for every hospital and the implications of an unsuccessful telemedicine venture are costly. Like any new protocol or process change, implementing a telemedicine program requires buy-in from all levels. It represents a significant culture shift and must be presented and planned with care.
2. Society of Critical Care Medicine. The Critical Care Physician Workforce: An Update from SCCM. Critical Connections. 2009; 8(3):1
3. Thomas EJ, et al. Association of Telemedicine for Remote Monitoring of Intensive Care Patients With Mortality, Complications, and Length of Stay. JAMA. 2009; 302:2671-2678.