Tele-ICU comes of age
By Mary Jo Gorman, M.D., December 2011
Studies, hospital five-year results validate effectiveness of the technology.
The promise of telemedicine has been the next big thing in healthcare for some years now. Over the past five years, the application of telemedicine in the ICU — known as tele-ICU — has become one of the first telehealth initiatives to prove itself in medical care as a broad solution offering continuous patient management and oversight, which works for hospitals of all sizes throughout the U.S.
And it's just in time. Eleven years ago, the Leapfrog Group identified 24/7 intensivist staffing as one of its safety standards for the ICU, estimating that more than 54,000 ICU deaths a year could be avoided if this best practice was implemented in U.S. hospitals. However, due to a severe shortage of intensivist physicians, hospitals have found that it's almost impossible to provide the recommended level of intensivist coverage. In fact, less than 20 percent of hospitals have intensivists providing around-the-clock coverage. The serious shortage of those with specialized training in critical-care medicine, combined with the aging of our population, is driving a crisis in the ICU that needs immediate attention.
Yet many hospitals have not yet responded to this alarming trend. The ICU is a difficult area of the hospital to manage well for two major reasons. The first is a lack of analytical tools in the ICU for administrators to measure the performance of the ICU. ICUs usually account for 10 percent of the beds in the hospital, yet generate 30 percent of the costs. The ICU can be a bottleneck to the ED and the OR and can seriously impact the ability of the hospital to throughput new cases, resulting in loss of revenue. But if these factors aren't measured, hospital management may have no idea of the magnitude of the problem.
Secondly, for too long, ICU management has been confused with ICU staffing. Obtaining the necessary staff members is an expensive, multi-year project that distracts from the implementation of best practices, training and performance.
However, two recent events are changing this scenario and bringing tele-ICUs to the tipping point of universal acceptance.
The first was the publication in 2011 of two major studies (one in the Journal of the American Medical Association and the second by the New England Health Institute) that confirm the positive contributions made by the tele-ICU. The NEHI study found that with tele-ICU programs in place:
• ICU mortality rates decreased 20+ percent;
• ICU length-of-stay decreased 30 percent;
• Hospitals gained significant volumes in ICU;
• Best practice compliance improved;
• Case margin improved 33-80 percent;
• Total margin increased 136 percent, considering volume growth;
• Payers realized significant savings; and
• Hospitals achieved payback within the first year.
Dr. Michael Walter, M.D., intensivist at Advanced ICU Care, and Mary Jo Gorman, M.D., M.B.A., chief executive officer and founder of Advanced ICU Care, are pioneers in the application of telemedicine in the ICU.
The second key event is the experience of the early adopters of tele-ICUs, which began about five years ago. The hospitals that implemented robust ICU-management programs with their 24/7 telemedicine programs can report solid results in improvements in clinical outcomes, financial performance, operational efficiency and acceptance of this concept by the medical staff and the nursing staff. The penetration rate of comprehensive 24/7 telemedicine programs for use in the ICU is almost 10 percent.
Hospital's five-year results validate technology
When it opened its doors a little more than five years ago, Ministry Saint Clare Hospital in Wisconsin became one of the first hospitals in the U.S. to implement a tele-ICU unit. During the planning stages for the new facility, the hospital intended to recruit intensivists to staff the ICU so that they would meet the Leapfrog Group's guidelines to have physicians trained in critical-care medicine, monitoring ICU patients 24/7. However, they found — as have so many other hospitals — that attracting intensivists was a difficult and often fruitless undertaking.
Searching for alternatives, they evaluated and selected a program offered by St. Louis-based Advanced ICU Care, which is now the largest independent provider of tele-ICU programs in the U.S. Their program combined the three elements essential to meeting recommended ICU standards:
• A remote monitoring center with real-time access to all patients' clinical data such as lab results, medical records, vital signs, video communication in patient rooms and automated alerts that notified clinicians immediately of any event or reading that needed immediate attention.
• A highly trained and experienced team of intensivist physicians and critical-care nurses available to monitor patients around the clock, able to act immediately when a patient's condition changed and before the situation escalated into a crisis or a serious problem.
• A process improvement program that consistently ensured that best practices were implemented for ongoing enhancement of clinical outcomes.
Once the tele-ICU program was in place, Ministry Saint Clare also found that it was much easier to recruit the intensivists and hospitalists who had previously been so hard to attract. The reason was the presence of the tele-ICU program promised a better quality of life: no night or weekend calls, plus the assurance that these fragile patients were vigilantly monitored even when the bedside physician was not in the hospital.
Clinically, the results of tele-ICU proved to be outstanding. As a new facility, the hospital did not have existing data against which to compare improvement. However, when compared to industry standards, results consistently improved over time. In 2010, Ministry Saint Clare was below the APACHE predictive scores in the following criteria:
• ICU mortality: 33 percent better than APACHE prediction;
• Hospital mortality: 26 percent better than APACHE prediction; and
• Ventilator days: 40 percent better than APACHE prediction.
The tele-ICU program is also credited with maintaining a length of stay lower than expected for the patient population, thereby increasing throughput to allow the hospital to operate with maximum efficiency. In 2010:
• ICU length of stay was 37 percent better than APACHE predictions; and
• Hospital length of stay was 41 percent better than APACHE predictions.
Clinically, the hospital achieved near-perfect compliance with best-practice protocols to prevent gastric stress ulcers, blood clots and minimization of time that patients spent on a ventilator. ICU complications were markedly reduced:
• Zero ventilator-associated pneumonias since opening;
• Near-zero central-line catheter infections; and
• Extremely low rates of gastric stress ulcers and life-threatening blood clots.
The administration also identified these additional positive ROI contributions from the tele-ICU:
• Program growth and new cases;
• Variable savings from ICU days saved;
• Variable savings from hospital days saved;
• Improved documentation/CMI improvement;
• Improvements in nursing recruitment and retention;
• Daytime critical care recruiting and sustainability;
• Risk management/cost avoidance;
• Reduced readmissions;
• Increase in ICU capacity; and
• Positioning for reform.
Larry Hegland, M.D., has been chief medical officer at Ministry Saint Clare since the hospital opened. Prior to that, he spent his career in facilities where the ICU was managed in the traditional way — with private-practice physicians providing daily rounds and the ICU nurses managing the patient needs when the doctors were not present.
"Doctors really want to know that their patients are getting the best care. In our program, they can have a high-quality service to supplement the care they provide so that their patients are getting the optimal care, while the physicians can have a better quality of life," Hegland says. "This model also helps to bring the nurses into the critical-care team model more effectively than what I see in other practice settings."
Julie Beeney, R.N., director of critical-care services, concurs. "The tele-ICU program has improved staff satisfaction and morale. Nurses know that at 2 o'clock in the morning, instead of paging a physician and waiting for a call back, they have instantaneous access to an intensivist."
Dr. Hegland attributes the strong clinical and operational results to three factors:
• With the tele-ICU program, patient care plans are managed 24 hours a day, as opposed to the interventions being limited to the morning and the evening, when the bedside physician was present in the traditional bedside model only. This moment-by-moment assessment of critically ill patients whose conditions are changing rapidly provides the quick intervention that is needed to prevent deterioration and stabilize them. In addition to the monitoring of patient data, the technology contains algorithms that identify and send automatic alerts when a patient's condition indicates that immediate attention is needed. If a nurse needs help right away, an emergency button in the patient's room can be pushed to summon a physician via the video in the room.
• The remote-monitoring team and the bedside team truly work together collaboratively. From the beginning, the focus was on cooperation with and support of the local physicians and the nursing staff. Because of this collaboration, the program comes together seamlessly for benefit of the patient.
• The team approach encompasses process-improvement initiatives that ensure that evidence-based medicine and best practices are instilled throughout the ICU. The results are a reduction or avoidance of most of the common complications that can occur in this high-acuity environment. For example, incidences of ventilator-associated pneumonia are almost non-existent.
In a large study of more than 10,000 patients across multiple hospitals, Advanced ICU Care demonstrated an average performance of:
• 40 percent reduction in mortality in the ICU;
• 25 percent reduction in length of stay;
• 17 percent increase in the number of ICU cases; and
• Continuous process improvement that reduces complications, increases throughput and improves patient and staff satisfaction.
"The tele-ICU combined with process-improvement programs are really the future of ICU healthcare," says Dr. Hegland. "As we go into an era of increasing physician shortages, we're going to see more and more of these kinds of innovative programs in hospitals. And physicians, nurses and patients welcome them. The intensivists and hospitalists have commented that if this program weren't in our hospital, they wouldn't be either. Making the decision to adopt a tele-ICU program is one of the best a hospital will ever make."
Mary Jo Gorman is CEO and founder of Advanced ICU Care.
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