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Impact of closer vigilance

Steve Fuhrman, M.D., an intensivist, checks on a patient's status while staffing the eICU® serving Sentara Norfolk General.

The medical team has no lack of anecdotal stories about lives saved and costs reduced by the eICU^®.

Burke relates the case of a woman in her later 30s who came to the ICU from the emergency room with a diagnosis of toxic shock syndrome. She immediately was started on treatment in the ICU, but Burke, monitoring her from the eICU^® noticed she was not responding as she should have.

He suspected she was suffering from an adrenaline deficiency and immediately started tests and treatment for that. She responded and returned home a week later.

Had he not been in the eICU^®, the doctor making morning rounds in the ICU would have found her the way she was when he left, Burke says, likely with significant lung, kidney, liver or brain damage.

"The main thing was I was awake; I had the data in front of me. The (ICU) nurse was just following instructions," Burke says.

Hochman, Sentara’s medical chief, notes that like every health system, there’s typically a backup of ICU beds. The overnight intensivist can keep things moving along to help save costs and reduce complications.

The eICU^® physician can, if appropriate, begin weaning a patient off a ventilator at 2 a.m., Hochman says; reducing the length of time patients are on ventilators has been proven to improve the patient’s survivability and reduce the length of stay, he says. Before the eICU^®, even if an intensivist were in the hospital, weaning a patient off the ventilator would have required a nurse finding the doctor. Usually the task was postponed until morning.

"The eICU^® doesn’t wait for someone to say there is a problem. That’s the difference," Burke says.

Acceptance of the eICU^® has boosted revenue for Burke’s group of intensivists, but considering the new physicians he’s had to hire, it’s been a wash, he says. The real financial impact has been in savings.

"The eICU^® stops the cash hemorrhage," Burke says.

Besides reducing length of stay and increasing availability of beds for new patients, the eICU^® presents other unanticipated opportunities, Hochman says.

For example, Sentara believes it will go a long way toward keeping ICU nurses satisfied and will help in recruitment efforts.

The eICU^® has burnished the reputation of all the hospitals in the system as well. In the past doctors were not so confident about sending patients to the ICU at 100-bed Sentara Bayside Hospital, Virginia Beach, Va., because they did not feel it was "comprehensive enough," Hochman says. But Bayside, which went live with the eICU^® enhancement about six months ago, just had its best year ever: Admissions rose 2.8% to 5,227 and surgeries, including outpatient procedures, increased 8.3% to 6,049.

"It’s no coincidence to us," Hochman says.

Hochman also gives the eICU^® credit for helping to standardize practices systemwide.
Physicians working in all the ICUs are comparing notes now. It has "put a light on critical-care medicine for us," Hochman says.

Sentara is next considering opportunities in outlying hospitals that are not part of the system but refer seriously ill patients. "This could be a win-win for rural Virginia hospitals that have three or four beds hooked up so we can co-manage patients to prevent having to ship them to Sentara," Hochman says.

Spillover effects

LEAPFROG'S 10 REQUIREMENTS FOR TELE-MONITORING         An intensivist who is physically present in the ICU performs a daily comprehensive review of each patient and establishes or revises a care plan.   A tele-intensivist is available whenever an on-site intensivist is not.   A tele-intensivist has immediate access to key patient data, including medications, bedside monitor data, lab orders and results.   Data links between tele-intensivists and the ICU are reliable and secure.   Audiovisual support is clear enough for tele-intensivists to assess a patient's breathing pattern and communicate with on-site personnel at bedside.   Written standards for remote care are established, including credentials and certification in critical-care medicine as well as explicit policies on roles and responsiblities.   Tele-ICU care is proactive, with routine review of all patients at a frequency appropriate to severity of illness.   A tele-intensivist's workload permits completion of a comprehensive patient assessment within five minutes of a request for assistance.   A written process of communication is established between a tele-intensivist and an on-site care team.   A tele-intensivist documents patient-care activities, and documentation is incorporated into the patient record.     Source: Leapfrog Group                                       MH/John Hall

As to the $3 million question: Is the eICU^® Leapfrog-compatible?

The standard was expanded last fall "to allow for the presence (of a critical-care physician) to be achieved through an eICU^®," says Suzanne Delbanco, executive director of the coalition led by a group of Fortune 500 companies.

Delbanco would not comment on how Sentara’s eICU^® complies with Leapfrog’s standards. However, the 10 key features of Leapfrog’s ICU- tele-monitoring guidelines were based partly on studies conducted by researchers led by VISICU co-founder Rosenfeld when he was an intensivist with Johns Hopkins Hospital in Baltimore. (See chart.)

Bernd says he believes the technology has great potential in other areas, such as helping with overflow in the emergency department and even in primary-care offices. The focus right now, though, is to just "make sure it works."

When all is said and done, the real return on the investment is coming from patient satisfaction, Bernd says. "The key to success is continuous quality improvement of clinical processes and driving out variations of outcomes in clinical care," he says.

"This will do more for quality patient care and financial viability than anything we can do on our business side. I think the eICU^® is one of the breakthrough technological advances that can put us where we need to be in our industry."

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