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> The open access and latitude granted to attending physicians in the ICU raised some sensitive political issues at first, as does any new technology when a diverse group of private-practice physicians is involved. Some doctors were comfortable with allowing eICU® physicians to make decisions and take actions on their behalf, but others preferred to continue making some or most patient-care decisions themselves. To ease community physicians into the concept of the eICU®, Burke says they could opt for four levels of eICU® care depending on the extent to which they agreed to put the care of their patients in the hands of other hospital-based doctors. The community doctors included the usual distribution of early adopters and laggards associated with all new technologies, he notes. Initially the bulk of the community physicians chose the lower two levels of care, but now most are going with the higher levels, he says. "Doctors always go to bed at night thinking they provided great care, and we were going to show them a way to give even better care," Burke says. Before the eICU® was wired to four ICUs at three Sentara hospitals, Burke counted six intensivists in his group. To staff the eICU®, the system needed to hire four more intensivists, and working remotely was a condition of the employment. But to date only two new intensivists have been recruited, a fact Burke attributes to the workforce shortage and Sentara’s exacting standards. The group of eight split the eICU® shifts with a dozen or so community intensivists who were interested in the program and, of course, are paid by Sentara to cover the shifts. The number of additional nurses needed was nominal, Rosenfeld says. A staff of 12 nurses has been trained to work in the eICU® with four of them working exclusively at the remote location and eight dividing their time between the hospital and the remote location, he says. As part of its agreement with Sentara, VISICU has borne the additional nursing costs, but the system will assume those expenses in July, he says. The eICU®, whose neighbors include a software company, an insurance office and a state agency, is staffed with three people: an intensivist, a nurse and a clerical support person. The team covers two shifts over 19-hour days, shutting down the remote operations from 7:00am to noon, when the doctors are routinely in the ICU making rounds. Each of the ICI staff divide time between the hospital and the remote location. For example, Burke could work four 12-hour overnight shifts in one week. In another week, he might work three seven-hour day shifts in the eICU® and two days in his office seeing patients. In the meantime, his partners will be in the hospital doing bedside consultations, he says. Backing up the front lines
From the eICU®, physicians can see the patient, monitor information
about the patient and communicate with staff, all at the same time.
"It’s the virtual equivalent of walking in to a patient’s bedside with my hands in my pocket," Burke says. "I simply can’t put my hand on the patient." But Burke can watch as he asks a bedside nurse to, for example, touch a patient’s abdomen or shine a light in the eyes. He also works from an electronic medical chart – the only area systemwide where the medical charts are electronic. Cameras and microphones at the nurse's station also offer an opportunity for family conferences. Perhaps the biggest difference between then and now is that the eICU® physicians have the time and ability to look for trouble before it happens. "The whole point of this thing is, we don’t come to the bedside and change the diagnosis and plan; we simply work it in frequent, little intervals," Burke says. "We don’t let little things become big things. That’s where we save lives, complications and money." As for how the intensivists view the eICU® Burke says if you ask the eight members of his group how they feel about working in it, you will get eight different answers. Burks says he really likes it: It has all the mental challenges of critical-care medicine without the physical challenges. "I get to address questions sitting there and (information on) 50 patients is electronically funneled to me, and I don’t have to run around a nine-story building with an ICU on four different floors," Burke says. "I just sit there and everything comes to me." Burke says he’s been told that the average burnout age for an intensivist is 47 years old. "I’m 52, and I’ve been doing this for 22 years, and in my group there are five over the age of 40. I see this as an important tool that is going to keep us from burning out," Burke says. Rosenfeld says the same principle holds true for ICU nurses, whose job demands are perhaps even more physically challenging.
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