Virtual Intensive Care Can Improve Patient Care and Reduce Costs
Laura Iding, RN, BSN, MBA
Froedtert & Medical College of Wisconsin Critical Care Nurse; Director, Trauma/Surgical/Medical/Virtual ICU Nursing
In October, Froedtert & Community Health along with partners ThedaCare in Appleton and Bellin Health System in Green Bay launched their Virtual Intensive Care Unit (ICU), a remote system of monitoring ICU patients at multiple sites. The Virtual ICU uses technology to add an extra layer of monitoring for the hospitals' sickest patients.
Q. What is the Virtual ICU?
The Virtual ICU (also known by its brand name, eICU®) is basically an added level of care for ICU patients using software and other electronic technology. We are able to watch a fair number of patients and have a lot of information right at our fingertips with this software. We can see the actual monitor, we can see all the lab values, and we can see the patient with cameras. It's really a way to provide an extra layer of care for those patients. It doesn't necessarily change anything they do at the bedside, but it does provide an extra set of eyes to look at things and watch trends and maybe catch some things quicker than they would have in a traditional ICU. It will never replace bedside ICU nursing or bedside ICU physician care. It truly is only a way to enhance what we are currently doing.
Q. How does it work?
The Virtual ICU software has smart alerts built into it so it can flag trends. For example, it will show if the patient's heart rate is trending up or down or if blood pressure is trending up or down. It's not that the heart rate or blood pressure are abnormal, but they are trending differently. There are sometimes things that you can do ahead of time, before a patient's blood pressure gets to a critical level, if you know that they're trending down or up.
The software can sometimes tell a different story because you see all the information together. It will show you, for example, a spike in a white blood cell count, and maybe the start of a low grade fever, and maybe a little bit of a drop in urine output. When you put all those together, you may have a serious infection going on. You may not have picked that up as quickly without the software. It's taking that step back and watching the patients from a more global perspective.
When the Virtual ICU was launched, we were watching 74 ICU beds at Froedtert and the two ThedaCare hospitals — Theda Clark Medical Center and Appleton Medical Center. When we add Bellin Hospital and Community Memorial Hospital in early 2006, we'll be up to 129 beds.
Q. Who staffs it?
The Virtual ICU is staffed by a board-certified critical care intensivist, a physician who specializes in critical care medicine, and by experienced ICU nurses along with administrative staff. We know that the best outcomes result from having an intensivist available 24 hours a day, seven days a week, whether that intensivist is here on site or at a remote site like the Virtual ICU.
Part of the benefit of the Virtual ICU results from having an intensivist staffing it during the overnight hours. Generally, ICU nurses do not call an attending physician at home late at night unless it's very important. What might often happen is that the nurses would keep track of all the little issues that came up during the night, wait until the morning and then tell the doctor and implement his or her orders then. So, the whole concept here is to give the patient all the care that they need around the clock so that there is no lag time. With the Virtual ICU, the goal is to treat the patients continuously, shorten their length of stay, and get them out of the ICU quicker.
Q. How will this impact patient care and outcomes?
We are confident that it will positively affect patient care and outcomes. According to the company that created the software, other hospitals that have put this into place have seen a drop in ICU mortality and a drop in ICU length of stay. It is a quality approach to managing ICU patients. This isn't something where you're going to see a huge impact in the first month, but over time, you'll definitely see the impact. If you take better care of your patients 24 hours a day, you can only improve patient care and improve outcomes.
Q. What kinds of benefits have you seen already?
At this point, we’ve seen little things that will add up over time. If we see a patient’s heart rate shoot up to the 170s, and we look in the room and there’s nobody there, we get in touch with the nurse. She may have been tied up in another patient’s room and didn’t realize that patient’s heart rate had suddenly spiked. This way, she’s able to take care of that issue right away.
In one case, a patient began to have respiratory distress, and the intensivist ordered a non-invasive mask as a way to support respiration. In that case, we avoided intubating the patient. In another case, we caught a 10-point drop in the hematocrit, which indicated bleeding. One patient had a breathing tube that was slightly out of position, so we contacted the resident and the tube was checked and repositioned.
A lot of the little things can add up, and at the end of a year, you’ll see that drop in the length of stay and other positive changes.
Q. Does it work the same in every ICU?
The basic system does work the same in every ICU, but the physicians actually have the choice of how much interaction they want the Virtual ICU to have with their patients. The physicians can choose to make their patients a Level I, Level II or Level III Virtual ICU patient.
At Level I, the Virtual ICU simply communicates trends and issues and may intervene in a life-threatening emergency. At Level II, the Virtual ICU physician can actually give orders to keep patients within certain parameters, but if they do anything major, like intubate a patient or start certain medications, they would have to call the physician on-site. The intensivist at the Virtual ICU communicates all his orders in writing. He can write the order in the system, and push “print” and it prints out at the respective hospital.
At Level III, the Virtual ICU physician will take care of the patient as if it were his or her own. An intensivist staffs the Virtual ICU during the nighttime hours from 6:00 pm to 6:00 am, so it’s that extra layer of care. The on-site physicians still come in every day, they still make rounds, they still do the plan of care for their patients. It’s just that, while they’re not there, they can hand the care of the patient over to the Virtual ICU, which can manage the patients overnight.
Q. Will this increase healthcare costs?
From what we can tell, the Virtual ICU should decrease healthcare costs. Again, it’s not going to happen within a month, but anytime you improve patient quality, decrease the amount of complications, decrease their length of stay, and decrease mortality, you will see a decrease in healthcare costs.
In the long run, it’s going to pay off. That is what the other customers have seen. One CEO said that within the first year of having an eICU®, they had already saved enough to pay for the program. It’s hard to compare because we don’t know how many beds they’re watching or how many of those hospitals are teaching hospitals. But generally, if you have better quality care and better outcomes, you will have decreased healthcare costs, so that’s the goal.
Q. What motivated the development of the eICU® here?
Our driving force was two-fold. One was to take better care of our ICU patients, and, in addition to that, we were looking for some way to partner with some of the outside hospitals. This project made sense on both fronts.
Q. Are patients comfortable with cameras in their rooms?
Most of the patients like it. They like knowing that somebody else is watching over them. Some staff might get a little concerned about someone watching over their shoulder, but it’s not a way to spy on the nurses or doctors to make sure they’re doing things the way they’re supposed to. It really is there to augment the care that’s being given. ICU patients are very sick and it can never hurt to have an extra set of eyes watching the patients. It’s not meant to be a Big Brother approach. It’s really meant to help the caregivers at the bedside. And it’s cool technology.
Q. What makes this unique compared to what some other healthcare systems are doing?
We are the first customer of this software company to implement a Virtual ICU across independently owned and separately operated healthcare systems.
Q. Do you see this approach becoming more common in ICUs?
If you can leverage having one critical care intensivist watching a number of patients during the nighttime, when everybody else is sleeping, I think that’s huge. I think Virtual ICUs will become the rule more than the exception by far.
Q. Do you see this technology being used in other capacities in the future?
I think there is some potential in the Emergency Department area, especially for outlying hospitals.
Another possibility is using this technology, still in the ICU area, but changing the focus toward donor management. Organ donation and organ recovery is a big issue across the United States because there are not enough organs available for everyone who is on the list. Sometimes we lose organs because hospitals don’t manage them well — that is after a patient is declared brain dead and the family has agreed to donate their organs. They don’t keep the blood pressure high enough, or they don’t run the right lab work.
There are a number of institutions in Wisconsin that are very interested in that and concerned about improving the success rate. Even if we increase the number by just a couple of donors a year — each donor can possibly give up to three or four organs — think about how many lives that could change or save.
We have noticed once in a while that some centers are maybe not as quick to ask about donation when they could. Maybe they don’t pick up on the brain death signs right away. That is something the Virtual ICU might be able to help with as well. The families would still have to agree, but they can’t agree if you don’t even ask the question.