Sutter Widens Use of Remote Tech to Tend Patients August 4th, 2003 Kathy Robertson Staff Writer Dr. Daniel Ikeda cranes forward for a closer look. An elderly patient in Sutter General's intensive-care unit is having trouble breathing. Her breaths are labored, but she doesn't seem to panic. Ikeda pulls up her medical history and checks a recent chest X-ray. Pneumonia prior to hip surgery. "We may need to intervene," he says, looking over her lab results. He checks on the patient several times in the next few hours. She looks better, but remains high on the watch list. This patient was one of more than 35 in the intensive-care units at Sutter General and Sutter Memorial on a recent weeknight. Ikeda is board certified in internal medicine, infectious disease, pulmonary medicine and critical care. He can see the patients, check their medical history, order treatment changes -- but he can't touch them. Ikeda was "in the box" at Sutter Health's new electronic intensive-care unit. The first of its kind on the West Coast, the unit is housed in a 30,000-square-foot data center in midtown Sacramento, blocks -- or miles -- away from the patients it serves. Sutter is spending $30 million on new technology to improve monitoring of patients in intensive-care units. The "e-ICU" went live for Sutter General's ICU in January. Sutter Memorial was added in late June. Sutter Davis and Auburn Faith hospitals will be next, most likely by October or November. Sutter Roseville will follow. Eventually, remote doctors in up to three e-ICUs may monitor sick patients in Sutter's 432 intensive-care beds systemwide. The idea is to add an extra safety net for intensive-care patients. About 13 percent typically receive around-the-clock care, due to manpower shortages and other demands. At most local Sutter hospitals, critical-care doctors generally check their patients once in the morning and once at night. "This challenges the old process and really improves patient care," says Sutter CEO Van Johnson. "This stuff makes sense. It will be a monumental day when all of Sutter Health is linked to this." System saves lives, sleep: One of the recommendations of the Leapfrog Group, a national consortium of businesses working to reduce medical errors, is for hospitals to have a critical-care specialist in the ICU around the clock. But there's a national shortage of these doctors. The e-ICU offers an alternative. Baltimore-based Visicu Inc., the company that developed and markets the system, claims it has reduced ICU mortality by 20 percent in participating hospitals. The reason: Added monitoring allows doctors to identify problems and treat them earlier. A study in the Journal of the American Medical Association concluded that increased use of intensive-care doctors could dramatically cut the 500,000 deaths in ICUs nationwide each year -- and save some of the $1.8 billion spent annually on intensive care. The UC Davis Health System is looking into the technology, but has no plans to use it at this time, said Dr. Stephen Tharratt, professor of pulmonary medicine and critical care. Catholic Healthcare West, parent company to the local Mercy hospitals, is always looking for new ways to improve care, spokeswoman Jill Dryer said without further comment. Kaiser thinks it has a better approach. The HMO and health system has an inpatient specialist on site with back-up around the clock, said Dr. David Herbert, director of the intensive care at Kaiser's Sacramento and Roseville hospitals. "We're not convinced having a patient on a TV screen replaces a physician in the room," Herbert said. "We've put our time and resources into having a physician available." Reservations aside, the new Sutter system has saved lives. It's also changed the lives of some local doctors. A critical-care specialist for 18 years, Ikeda can count on one hand the times he slept through the night while on call. Now there are nights when he or his partners can sleep uninterrupted. Virtual rounding: Dressed in a Hawaiian shirt and khakis, a forgotten stethoscope still slung across his neck, Ikeda showed up for rounds at the e-ICU last week promptly at 4 p.m. An acute-care registered nurse and healthcare assistant had been there all day. His first task: Figure out the problem patients, talk to the nurse and assistant about who's likely to come in or out of the units, and get a sense of the condition of those already there. On a dashboard of five screens, he looks for "smart alerts" that indicate a potentially dangerous trend in patient vital signs. An uptick in blood pressure. An increase in the pulse rate. The elderly patient with breathing trouble is new to Ikeda. Others may be his own patients, visited in the hospital hours earlier. He orders medicine for one, transmits the message electronically to the nurses' station, and types a note into the medical record about what he just did. "I have to manipulate five different mouses for five different screens," he grins among the wires. The notewriting tool is a pain because he has to type -- but his orders are easier to read. "Aaach," he says. A sore back. Doctors aren't used to sitting down for long periods of time, so the electronic dashboard can be elevated for use while standing. Ikeda moves it up and down several times during his shift. The work is simultaneously more focused and more open-ended. Ikeda can delve deeper into the patient record to look for clues. If he's unfamiliar with a certain health condition, he can tap into "The Source," an online medical reference system with synopses of the best way to treat this or that. There's no time pressure to move onto the next patient unless there is a crisis. Nobody grumbling in the waiting room. "Here, the stress level is much less," says Ikeda, comparing his job as an e-ICU doctor to that of a lifeguard. There are kids out there who can't swim very well. He watches to make sure no one flounders. There have been some rescues. An 81-year-old man was admitted to the ICU at Sutter General with intestinal bleeding. He was sent to surgery and back to the ICU. In the hours that followed, the patient's blood pressure started to climb. So did his heart rate. The e-ICU picked up the problems, called the surgeon, and the patient headed back into the operating room late at night. "We marshaled forces to take the patient back into surgery after midnight on a Friday night," Ikeda says, "rather than waiting until the next day." Not enough docs: Sutter's e-ICU depends on Pulmonary Medicine Associates, a group of 15 local doctors, to staff the place. A partner in the group, Ikeda is also medical director of the e-ICU. As the system works now, there's one doctor on duty at the e-ICU from 7 p.m. to 7 a.m. daily. The doctors get a weeklong night shift once every 14 weeks. The shifts end on a Friday morning to give physicians a weekend to reorient to day work. A second doctor comes in from 4 to 7 p.m. weekdays. The group would like to extend the hours, but needs more doctors to do so. Pulmonary Medicine Associates is hiring, but it's tough to woo critical-care doctors to Sacramento when they can make more money in other markets. This may change. The e-ICU has brought some surprises. More sleep. Less burnout. "Demand has gone up and up and up," Dr. Richard DeFelice, a member of the group, says of his profession. "It's not the best lifestyle, but the e-ICU is taking some of the burden off." Relief comes from less night and weekend calls because a partner is on duty in the e-ICU looking out for the patients. "It will actually allow most of us to stay in practice longer," Ikeda says. The ultimate payout will be use of the new system as a recruitment tool. The doctors collect an additional 10 percent to 15 percent compensation for staffing the e-ICU. They can also market cutting-edge medicine to prospective doctors. "I haven't heard anybody say a negative about it," Bill Sandberg, executive director of the Sierra Sacramento Valley Medical Society, says of the e-ICU. "And Pulmonary Associates is one of the most interesting, rapidly changing group practices in the area." Changing of the guards: By 7 p.m., Ikeda prepares to get out of "the box." He briefs the guy on night shift, Dr. Amit Karmakar, on the patients. What worked and what didn't. Which patients to look out for. Karmakar settles in. "I like the fact that we can oversee patients, troubleshoot, be a little bit proactive -- and prevent disasters," he says.