From the March 2007 Issue

Sticking the Quantum Leap

Remote Control Training: Case History

From a Distance: Saving Lives Through Remote Care: Case History

The Keys to the Kingdom

A Season of Change

When Consumers Drive, Physicians Don’t Have to Get Taken for a Ride


From a Distance: Saving Lives Through Remote Care

A combination of eICU technology, intensivists and in-house staffing delivers significant improvements in ICU patient care

Studies show that care by intensivists, physicians specially trained in treating critically ill patients, greatly improves the quality of care in the ICU. But demand far outweighs supply. Today, just one in five ICUs has intensivists on staff. According to The Leapfrog Group, which has identified intensivist staffing as one of its “safety standards,” more than 54,000 ICU deaths could be avoided if this standard were implemented.

For St. Mary’s Health Center in Jefferson City, Mo., the position on intensivist staffing was clear. St. Mary’s is a 167-bed facility with extensive cardiology and open-heart surgery services, and is part of the regional SSM Health Care system. Administration recognized that the ability to provide an intensivist was a best practice for improved and sustained quality of care. It could also lead to improvements in nurse recruitment and retention, as well as the ability to recruit other types of specialists. But with just 6,000 intensivists in the U.S., how easily could an intensivist program be implemented at St. Mary’s?

Supply in Demand
Spearheading the intensivist effort for St. Mary’s was Vice President of Medical Affairs John Lucio, D.O. A cross-specialty physician steering group was formed that began by surveying physician interest in an intensivist program, as well as the expected amount of involvement. Not surprisingly, the results showed wide support for an intensivist program. With physician backing and clear data on how an intensivist program could improve the quality of patient care, the steering committee quickly identified the need to recruit intensivists.

In late 2003, the committee sent out an RFP, interviewed three intensivist groups, and selected one based in St. Louis to staff its ICU with intensivists. However, the nationwide shortage coupled with St. Mary’s relatively rural location, challenged the group’s ability to find the intensivists St. Mary’s needed. After a year of searching and being no closer to their goals, the group approached St. Mary’s with an alternative: telemedicine.

Thinking Outside the Box
In 2004, after closely watching VISICU, the Baltimore-based developer of eICU telemedicine technology that combines clinical management software with patient data and video feeds, and which enables intensivists and critical care nurses to remotely care for patients, the St. Louis intensivist group formed Advanced ICU Care. They licensed the VISICU technology and set out to build a centralized operations center in St. Louis, where intensivists and critical care nurses could remotely care for patients at St. Mary’s and other community hospitals.

Studies conducted at Sentara Healthcare, a Norfolk, Va.-based not-for-profit integrated healthcare organization that had implemented the eICU program in 2000, had shown a 27 percent reduction in patient mortality and a 17 percent shorter ICU length-of-stay for ICU patients discharged from January 1 through June 30, 2001. However, VISICU’s eICU technology had previously only been installed at regional, multisystem hospitals that had in-house intensivists. Could a community hospital like St. Mary’s, which had no in-house intensivists, achieve those types of results? Advanced ICU Care believed so.

Decision Made
After considering how difficult finding intensivists had been, and convinced that they would play a crucial role in St. Mary’s ICU patient care and safety, Dr. Lucio and his team championed the concept of telemedicine and drove the implementation of the program.

In mid-2005, St. Mary’s partnered with Advanced ICU Care, to place eICU technology and board-certified intensivists and nurses in St. Mary’s ICU. The hospital selected Advanced ICU Care for the same reasons the intensivist group had won the initial RFP—its organizational fit with St. Mary’s and the experience of its intensivists, who had led ICUs at other SSM facilities.

“If we were going to adopt telemedicine technology as a solution,” said Betsy Aderholdt, president of St. Mary’s Health Center. “Advanced ICU Care was the group the physicians wanted on the monitors and the other end of the phone. The technology is great, but at the end of the day it’s the doctor and nurse interaction with our team that is most important.”

Discussions on the eICU program centered on improving the quality of patient care and safety. “While cost savings associated with lessened ICU length of stay and resource utilization were discussed, this was not a financial decision,” Aderholdt says. “It was first and foremost about patient care.”

That thought was echoed by St. Mary’s Foundation, a charitable organization seeking to invest in technology that would differentiate the hospital and improve patient care. They provided funding for the initial capital costs, recognizing that the program would further healthcare in the community by a quantum leap.

A Cultural Change
Managing the change process and formulating the rules of engagement became the steering committee’s chief mandate. They chose to implement a hybrid system using telemedicine technology, and Advanced ICU Care’s intensivists and critical care nurses, along with the hospital’s in-house staffing model. The eICU program at St. Mary’s enables attending physicians to designate the level of eICU care for their patients.

Implementation of the program took six months from start to finish. Advanced ICU Care studied St. Mary’s existing clinical procedures and protocols and integrated its services. Implementation teams at Advanced ICU Care, St. Mary’s and VISICU embedded clinical protocols into the technology and then wrote interfaces between St. Mary’s information systems and the technology infrastructure of the eICU program. The eICU technology includes software applications as well as remote-care tools, such as remote bedside monitoring and videoconferencing, which allow intensivists to simultaneously monitor multiple sites.

Advanced ICU Care’s Vice President of Clinical Services Dr. Isabelle Kopec, eICU Medical Director Dr. Dellice Dickhaus, and eICU Director of Clinical Services Christi Longnecker, as well as representatives from VISICU, were onsite to lend support during the implementation and installation process, and remained for several days after the program went live.

Testing and training were critical. Both Advanced ICU Care and VISICU were supportive and open to suggestions during the training process, which included classroom training as well as Web-based self-study, says Denise Webber, St. Mary’s ICU clinical coordinator. St. Mary’s identified super users, several nurses from different shifts who received extensive training on the program and were charged with providing support for others.

Aderholdt says the first focus was on getting the nurses comfortable with the electronic documentation. Many quickly embraced the paperless documentation system, along with the realization that this would give them an opportunity to improve patient care. However, in undertakings such as these, Dr. Lucio cautions clinicians and other caregivers not to be dissuaded by technological change. “There was a learning curve,” he says. “But once the system was underway, the feedback was very favorable.”

Newer nurses, especially those working the night shift, were particularly excited about the eICU program, says Webber. The program also has helped with nurse recruitment, especially with new graduates.

Positive Results
The clinical metrics since implementation appear to be on target. After one year of using Advanced ICU Care’s eICU program, St. Mary’s ICU has seen patient mortality drop by 24 percent. ICU length of stay has been shortened by 6 percent, and overall hospital length of stay for ICU patients has decreased 14 percent from 2005.

Webber also points to a 64 percent drop in code blue outcomes—attributed to the eICU program—along with the frequent remark, “If the eICU had not been there, the patient outcome would have been different.”

“I’m thrilled with the quality improvement, especially since we’re still operating with an open environment model,” says Aderholdt. “These results will drive continued evolution of the program.”

Introducing telemedicine technology in the ICU broke the ice for St. Mary’s, where administration and medical staff alike embraced technology. Aderholdt predicts that the physician-directed process in managing cultural change, a critical factor for success with the eICU program, could be instrumental again as other technological initiatives come to pass.

For more information on Advanced ICU Care’s eICU program,

For more information on VISICU’s eICU technology,

© 2007 Nelson Publishing, Inc