Some good news and some bad news about hospital intensive care units September 8th, 2003 BY MARTIN STROSBERG The ICU (intensive care unit) is one of the most expensive parts of a hospital, and for good reason. It is the place where highly skilled and dedicated doctors and nurses, using sophisticated technology, care for patients who are at risk of sustaining or who have sustained acute, life-threatening conditions. On average, an ICU has approximately 12 beds. Americans, more than other people, are particularly enamored with ICUs and are willing to pay the price. But are we getting value for our money? There is mounting evidence from national studies showing that deficiencies in coordination and in staffing levels compromise patient safety and lead to increased complications, deaths and cost. The good news is that the Fortune 500 is on the case. The Leapfrog Group for Patient Safety, part of the Business Roundtable (whose membership includes the major corporations) is using its economic leverage on behalf of the purchasers of employee health insurance to encourage hospitals to adopt safety practices and meet safety standards. Leapfrog's ICU physician-staffing standard calls for specially trained and certified physicians, called intensivists, to help coordinate care for ICU patients and to be readily available 24/7 for timely intervention. Evidence shows that when this standard is met, there are fewer complications, better outcomes, fewer number of days spent in the ICU and lower costs. The bad news is that hospitals, especially the smaller ones, find it too expensive to maintain in-hospital coverage by intensivists. And to make matters worse, there is a national shortage of intensivists. Leapfrog estimates that, nationwide, only 10 percent of hospitals meet their standard. The good news here is that there may be a cost-effective solution on the horizon. Are we ready for the e-ICU? A Baltimore-based company named VISICU has developed innovative information systems that enable an off-site intensivist and multi-disciplinary team to manage the care of patients at two or more ICUs in the same geographical area. When an intensivist cannot be physically present (e.g., during the night shift), one can be virtually present through telemedicine. The off-site intensivist, ever vigilant, is continuously monitoring the vital signs of patients "wired" for transmission of data to a remotely located, but nearby, e-ICU. Zoom-in cameras are also used. Of course the bedside nurse is always physically present and has instant access to the intensivist through video-conferencing. Together, when alerted to a problem, the off-site intensivist and the on-site nurse (and other health care professionals generally located in the hospital) can quickly and proactively intervene to prevent serious complication. The e-ICU is not necessarily meant to be a substitute for existing ICU practices or to replace the attending physician. It is meant as a supplement. In fact, hospitals may need to engage the e-ICU only during the night. During the daytime there can be business as usual. The e-ICU has been tried in several locations throughout the country. Thus far, the research studies evaluating performance have been favorable from a medical and economic perspective. Critical-care nurses, in particular, seem to like it. They work in stressful, complex and fragmented settings. Frequently, they face conflicting demands from a variety of attending and consulting physicians. They find it beneficial, especially in the middle of the night, to be able to turn to an intensivist who is on top of the case. Is the e-ICU or something similar a model that could be implemented in the hospitals of the Capital Region? We have almost a dozen hospitals, some of which do not meet the Leapfrog standard. Here is a way for two or more hospitals to share their resources and expertise for the betterment of the critically ill. At minimum, the concept should be explored. We may find that it is too expensive to wire up the ICU beds, purchase the necessary software and hardware and hire the appropriate personnel. Or perhaps it will be too difficult to convince the hospital's attending physician staff of the soundness of the idea. Perhaps we are not ready. But then, just how will we meet the Leapfrog standard? This is a question that all purchasers of health insurance, including the businesses of the Capital Region, should want answered.