More eyes in the ICU September 15th, 2003 BY LORILYN RACKL Daily Herald Health Editor It's a Tuesday afternoon, and Dr. Michael Ries is making his rounds through Advocate Lutheran General Hospital's intensive-care units. He's dropping in on patients, checking their vital signs, writing orders, reviewing lab results, consulting with nurses - the usual stuff. The unusual part is that Ries isn't actually in the Park Ridge hospital. In fact, he's not even in the same county. He's sitting in front of a bank of computers in a fluorescent-lit office in Oak Brook. Welcome to the eICU®, an innovative way of caring for the sickest of the sick. The concept of the electronic ICU is simple, even if the technology behind it is not: Critical-care specialists constantly monitor ICU patients from a remote location with the help of high-tech computer software and real-time telemedicine. With a few clicks of the mouse, Ries can see if an ICU patient's potassium levels need tweaking at Lutheran General and seconds later be 18 miles away at the virtual bedside of a critically ill person at Advocate Good Shepherd Hospital in Barrington. "The only thing we can't do is touch the patient," Ries said. The amount of patient information at the "e-doctor's" fingertips is staggering. On one screen, he can pull up a bedside monitor that tracks the patient's heart rate and other vital signs. He can prescribe a drug and a few strokes on the keyboard will tell him if the patient is allergic or on other medications that might pose dangerous interactions. He can see medical records, care plans, X-rays, lab results, trends in temperature and white blood cell counts - and the patient. Each ICU room is outfitted with a camera, microphone and speaker. When the doctor wants to drop in, he rings a doorbell that lets the patient know there's a virtual visitor. "Hi, it's Dr. Ries from eICU®," the physician said into his headset as an elderly patient's face appeared on the screen. The camera can zoom in close enough for the doctor to check a patient's pupils or read the settings on a bedside infusion pump. "You're much better than you were yesterday," Ries told the woman, who managed a wan smile for the camera. "I hope you feel better and go home soon." The first hospital system in the Midwest to start an eICU® program, Advocate brought Lutheran General's 34 adult intensive-care unit beds online this spring. Good Shepherd soon followed. By the middle of next year, all 212 adult ICU rooms throughout the Advocate network are expected to be online, starting next month with Good Samaritan in Downers Grove. "We think this or something like it will become the standard of care," said Dr. Martin Doerfler, vice president of clinical services for Visicu Inc. The Baltimore-based company developed the concept of the eICU®, a registered trademark of Visicu Inc. Officials stress that electronic ICUs aren't a replacement for doctors and nurses at the bedside; staffing levels within hospital walls remain the same. The eICU® serves as an added safety net, a way to reduce medical errors and improve outcomes in a patient population whose average mortality rate hovers between 12 and 17 percent, according to a study in the American Journal of Respiratory & Critical Care Medicine. "Care really becomes 24-hour care," said Dr. Rod Hochman, chief medical officer at Sentara Healthcare, a six-hospital system in Virginia. Sentara created its eICU® in 2000, making it the first in the country to try the technology. "The results speak for themselves," Hochman said. "In one of the ICUs at Norfolk General, we had an almost 30 percent reduction in mortality over a year. In that one unit, that meant that more than one person every week walked out of the hospital that ordinarily would have never walked out of the hospital. That's a pretty telling statistic. Few things in medicine give you a change in mortality of that magnitude." Research has shown that ICU patients fare much better when they're cared for, at least in part, by "intensivists," or physicians who have extra training in critical-care medicine. Problem is, there aren't enough intensivists to go around. Not by a long shot. "If you wanted to put one intensivist in every ICU around the country, 24 hours a day, seven days a week, you'd need about 35,000. There are only about 5,800 in active practice," said Dr. Brian Rosenfeld, who co-founded the eICU® concept while working as an intensivist at Johns Hopkins Hospital. Experts say the dilemma is only going to get worse in the coming years as aging baby boomers fill more ICU beds. Electronic ICUs make the most of the few intensivists out there by having them monitor and treat dozens of patients in different locations. At Advocate's eICU® in Oak Brook, an intensivist, a critical-care nurse and a health-care assistant keep track of 44 ICU patients - with the help of a sophisticated computer system that tips them off to potential problems. An alert popped up on the screen when one patient's blood oxygen levels started to drop. Ries went in to investigate. He rang the doorbell and turned on the camera in the patient's room, where he could see that the man had removed the device on his finger that monitors oxygen levels in the blood. All it took was a quick call to the on-site nurse to rectify the situation. The eICU® program is designed to look for subtle trends, picking up potential problems - and ideally solving them - much earlier than they might get detected in a regular ICU. For example, someone's heart rate might have gone up 40 percent in an hour but still fall in the "normal" range, thereby not triggering an alarm in your typical ICU. But that would be enough to set off an alert in the eICU®, giving staff an early chance at trouble-shooting. "People don't like all the noises going off in the ICU; it's distracting," Rosenfeld said. "So they set their alarms at very critical levels. Well, I want to know before a patient gets to those levels." If a problem is spotted, the eICU® intensivist might deal with it himself by giving treatment orders to someone on site. Or he might pass it along to be handled by that patient's doctor. These details are worked out ahead of time with the attending physicians so there aren't too many cooks in the proverbial kitchen. At Sentara, Hochman said most doctors have been happy to relinquish full control to the eICU®. "That's not to say they don't want to know what's going on (with their patients)," Hochman said. "But they know these are trained professionals who know what they're doing." Since most ICUs aren't staffed with physicians around the clock, the e-doc can be an especially valuable resource during those off hours when there might be just one M.D. in the entire hospital. Instead of having to call a physician at 2 a.m. because a patient's condition changed, the on-site nurse can press a button and get an awake and alert intensivist with full access to that patient's information. Even so, eICU®s don't always get a warm reception from on-site hospital staff. "Initially, they thought this was Big Brother watching us," said Denise Cole, a critical-care clinical nurse specialist at Lutheran General. "But now they're more used to it and they see it as another safety net." Carol Rue, a critical-care nurse with Advocate who works in both the eICU® and the regular ICU, said she finds it comforting to know there's an extra set of eyes on her patients. "You're pulled in a lot of different directions in the ICU," Rue said. "I like being in Room 2 and knowing someone is watching my other patient." And what do the patients think? And their families? "They love it," Hochman said. "Think if it was your mom or dad in the hospital and you had the opportunity to have a doctor or nurse looking in on them all the time. Would you want that? I think the answer is yes." Electronic ICUs also have proven healthy for hospitals' bottom lines, resulting in fewer costly complications and shorter ICU stays. (Because Medicare reimbursement is based on a patient's diagnosis rather than length of stay, less time in the hospital translates into bigger profits.) A study soon to be published in the Journal of Critical Care Medicine found that Sentara's eICU® more than paid for itself, producing a savings of $2,150 per patient.