Providing Quality Nursing Care From A Distance September 9th, 2002 by Linda Childers In a typical day Leslie Martin, BSN, RN, provides care to 49 intensive care patients. This superhuman patient load is possible because the veteran critical care nurse is hooked into an elaborate network of cameras, monitors and two-way communication links. Martin works at Sentara Healthcare, the first chain of medical centers in the nation to introduce the concept of an "electronic ICU" (eICU®). This cutting-edge technology allows physician specialists and critical care nurses to use telemedicine to monitor and treat critical patients in five ICUs at three different Sentara medical centers in southeastern Virginia. Though the technology is still relatively new, hospitals such as Sentara have discovered that these eICU®s not only allow hospitals to leverage critical-care expertise in the midst of a shortage, but the technology even saves lives. These eICU®s are part of the larger world of telehealth. This technology gives nurses and physicians the freedom to assess a patient's medical needs from a distance using real-time video and audio links, electronic stethoscopes, and advanced life monitoring equipment. Although all patients in Sentara ICUs have a hospital-based critical care doctor assigned to them, the physicians aren't in the units all the time, or at night. This is where the eICU® comes in handy. The electronic command center provides a watchful eye around the clock. The only time it shuts down is between 7 a.m. and noon, when ICU hospital-based physicians are conducting rounds. Each patient has a main computer screen that displays data in ways that make trends easy to identify. Visual alarms sound when vital signs, lab test results and other data deviate from a patient's baseline. By monitoring this data vigilantly, the eICU® can assist in diverting life-threatening situations. Nurses in the eICU® begin their shifts by assessing patients and setting up a plan for the critical care physicians. At the outset of her day, Martin evaluates a patient's vital signs for the past 24 to 48 hours. "When the physician arrives in the eICU®, I will direct him to any area requiring immediate attention," she says. The Sentara eICU® staff works as a team with their hospital-based counterparts who provide on-site care. "Telemedicine isn't a replacement to bedside care," says Martin. "We're here to offer another layer of support to ICU staff and patients." In a typical day, Martin interacts regularly with the hospital-based staff. If, for example, she notices a patient's blood pressure rising, she'll contact the bedside nurse. If the blood pressure increase is related to pain, the patient may be receiving pain medication to alleviate it. "If that's the case, I will monitor that patient's progress, and if it appears the medications are not working in the appropriate length of time, we'll do a video assessment with the bedside nurse to see if other intervention is needed." On any given shift, the eICU® staff monitors at least three or four patients who are very active and a lot of intervention. "One of our ICUs is a very active vascular ICU with a steady supply of post vascular patients whose conditions can alter very rapidly from one end of the spectrum to the other," says Martin. The approach seems to be working According to Sentara officials, an independent study performed by Cap Gemini, Ernst and Young (CGEY), shows the eICU® reduced intensive care mortality rates at Sentara Norfolk General Hospital by 25 percent and shortened the average length of stay for these patients by 17 percent. At Sentara Hampton General Hospital, mortality in the ICU has been reduced by 18 percent. "Critical care physicians and nurses are in short supply in the United States," says Sarah Darwin, RN, director of patient care services at Sentara Norfolk General Hospital. "The eICU® allows us to leverage the services of these specialists across several different medical facilities." Feedback from families and staff has also been positive. "Families like the reassurance the eICU® provides," says Darwin. "Our studies have shown that this technology is saving lives. At least one patient a week now leaves the hospital who wouldn't have been alive two years ago." Telemedicine also offers nurses new challenges and growth opportunities. After working as a critical care nurse at the bedside for 20 years, Leslie Martin was ready for a change. "I felt that I had gone as far as I was going to go as a bedside nurse. It was a grueling job, and I even considered leaving the nursing profession," she says. "The eICU® has given me the opportunity to use my expertise in a different way to help a wide variety of patients." In Michigan's Upper Peninsula, patients who live in rural areas are also utilizing telemedicine to access clinical specialists without spending hours traveling to an appointment. "Many of our patients would need to drive several hundred miles to see a specialist," says Susan Makela, BSN, MPA, RN, director of the Office for the Advancement of Telehealth for the Marquette General Health System (MGHS) in Marquette, Mich. "Our telehealth project allows patients to access medical specialists by traveling a short distance to a local hospital or clinic and using the telemedicine equipment at that site. This benefits the rural organization by allowing the necessary lab tests and X-rays to be completed and billed locally." "We have a lot of success stories," says Makela. "We had one patient who had quadruple bypass surgery and was able to conduct his two-week follow-up visit using videoconferencing with his cardiovascular-thoracic surgeon, saving him a 240-mile trip." For the follow-up surgery appointment, the surgeon used an electronic stethoscope and headphones to listen to the patient's heart. A small, hand-held video camera allowed him to get a close-up of his patient's incisions. In the MGHS Home Health program, patients have audio and video devices in their residences, allowing them to interact with home health nurses. "We use telehealth technology to augment our regular home health visits," says Makela. "Because we serve a rural area, our nurses often spend hours driving from one location to another. Using this technology, a nurse can often check in with 15 to 20 patients a day, as opposed to only five or six if that would be conducted in person." Telemedicine and reimbursement issues Physicians and nurses praise telemedicine, yet few medical centers across The country have access to the technology. "Not all insurers reimburse for all telehealth services and that has the spectrum to the other, prevented telemedicine from becoming more widespread," says Nancy Sharp, RN, MSN, FAAN, who serves as a telehealth consultant to the American College of Nurse Practitioners. "We need to persuade insurers and government agencies to reimburse health care providers for each patient consultation, whether it transpires in an office or by video phone." Under current Medicare coverage, reimbursement is permitted in rural health professional shortage areas (HPSAs), while the Medicaid program leaves each state the option of permitting reimbursement for services delivered via telemedicine. Some private insurers have begun reimbursing for telehealth services, but there are no standard guidelines and coverage varies from state to state. Sharp, who serves on the federal Joint Working Group on Telemedicine, says major telehealth legislation recently introduced in both the House and Senate may improve access to telemedicine. Current legislation being considered would require that Medicare pay physicians the same fee for remote monitoring of patients' vital signs that they are paid for a face-to-face encounter. Other bills seek to expand services to skilled nursing facilities, assisted living, board and care homes, and school and community health clinics. The future of telemedicine Those who work in telemedicine claim that it's the wave of the future for health care. "Widespread use of telehealth could potentially assist us in addressing everything from the nation's shortage of nurses and medical specialists, to how we deliver health care to the nation's growing number of elderly patients," says Susan Slater, BSN, RN, a Telehealth Nurse Specialist for American TeleCare Inc. in Minnesota. She envisions homes of the future with technology that would allow older patients to be wired into their physician's office. This could give patients the freedom to live independently in their homes and still receive medical care. Schools are also exploring the possibilities of using telehealth technology to augment the shortage of school nurses. "By using telehealth, schools could utilize a single nurse to work with several different schools to monitor students with chronic conditions such as asthma and diabetes," says Slater. According to Slater, who teaches a telehealth class at the University of Pittsburgh, Penn. to senior nursing students: "It's imperative that we teach future nurses how telehealth can be used to augment bedside care," she says. "As a nurse, I look forward to the day when all nurses can use this technology to assist patients in a variety of settings."