Pressures converge in the ICU Hospitals turn to IT and process changes to improve outcomes and satisfaction December 1st, 2003 By Richard Haugh The intensive care unit is one of health care's most complex medical systems. ICU patients are among the sickest in the hospital, and adverse events are a constant danger. Statistics show that in an adult ICU, as many as one in five patients will die, not because of errors but because of their extreme medical condition. "You mix all of these conditions together, and even on a good day you have a relatively volatile environment," says John Penrose, chairman and CEO of Paradigm Health, a Concord, Calif.-based ICU staffing firm. Hospitals are turning to a variety of solutions to improve patient care in the ICU. Some are high tech, such as using telehealth technology to provide 24/7 remote monitoring of several ICUs. Others are decidedly low tech, such as standardized patient care forms and regular team meetings. The intensive care unit has the highest rate of mortality and complications in the hospital. Of the 5 million patients treated each year in an ICU, about 500,000 will die--a rate of 10 to 20 percent in most hospitals, says the Leapfrog Group. ICUs also make up a lion's share of hospital costs. While they account for only 5 to 15 percent of total hospital beds, ICUs generate as much as 30 percent of the average hospital's costs. Patients, Responses Shift There's been a sea change in the type of patients being treated in ICUs, says Timothy Buchman, M.D., president of the Society of Critical Care Medicine, Des Plaines, Ill. "We no longer are seeing critical care delivered as a response to an acute illness," says Buchman, who also is co-director of the surgical ICU and director of the trauma center at Barnes-Jewish Hospital, St. Louis. "Rather, it's a response to an exacerbation of chronic and unremitting disease." Aided by technology and research, hospitals and industry groups have made strides in improving ICU care. Yet mortality rates remain stubbornly high because of challenging patients--older, immunosuppressed, and recovering from more invasive, technically sophisticated procedures. "On one hand, we're developing better technology and better ways of taking care of patients. At the same time, they're getting sicker," says Eric Dobkin, M.D., director of the surgical ICU at Connecticut's Hartford Hospital. "It should be no surprise that there isn't going to be very much of a change in mortality or length of stay. We're probably pretty close to where we're going to be." That doesn't deter employer groups from seeking change. The Leapfrog Group has made the ICU one of its top goals for improvement. It is prodding hospitals to adopt the intensivist model, in which physicians highly trained in critical care medicine focus exclusively on treating ICU patients. Fewer than 15 percent of the nation's hospitals have full-time intensivists, but research shows that using intensivists can save as many as 50,000 lives each year. Moreover, a recent study shows that using intensivists can save 10 times the cost of implementing the program. "There's no ambiguity on this point," Buchman says. "The best thing for you as a patient, the thing that has the greatest likelihood of getting you out of the ICU healthy and whole and safe, is an intensivist-led, multiprofessional team focusing their many specialty lenses on your care." Hospitals Take Action While research groups study ways to improve ICU care, some hospitals actively pursue change on their own, both high and low tech. One of the more ambitious strategies addresses the shortage of specialty ICU physicians. Using telehealth techniques, 10 hospital systems--among them, Advocate Health Care, Oak Brook, Ill., Sentara Norfolk General Hospital in Virginia, New York-Presbyterian Hospital and California's Sutter Health System--remotely monitor multiple ICUs from one central location. In Chicago, Lee Sacks, M.D., Advocate's chief medical officer, says the system's "electronic ICU," designed by Baltimore-based Visicu, allows the central monitoring of 212 adult ICU beds across Advocate's eight metro-area hospitals. The system uses cameras, microphones and software linked through a high-speed Internet connection to monitor patients from a central Chicago location. From there, physicians can quickly spot changes in patient conditions and immediately discuss them with a physician at the hospital. "Now there's a physician instantly available, literally 24/7," Sacks says. Electronic ICUs also can reduce costs. After Virginia's Sentara Norfolk installed an e-ICU, a Cap Gemini Ernst & Young study showed ICU mortality rates fell by 25 percent and lengths of stay dropped by 17 percent. Sentara also saved $2,150 per patient--about $3 million overall in the first year--by reducing patient care expenses and increasing ICU capacity. Technology can be used to free up nurse and clinician time for patient care. A study partially funded by the Agency for Healthcare Research and Quality at a Veterans Affairs medical center found that an automated clinical documentation system reduced the time ICU nurses spent on documentation to 24 percent of their time from 35 percent. It also increased the time they spent on patient care to 40 percent of their time from 31 percent. Sharp Healthcare, San Diego, installed such a system developed by CliniComp, also of San Diego. Sharp CIO Bill Spooner says the system began working with CliniComp in the mid-1980s to develop automated nurse charting, and decided early on that the intensive care unit was the best place to start. "That's where the most intense care is going on, the most data is being collected and the fastest decision-making is required," Spooner says. Studies by the system's nurses have documented a clear FTE savings. Spooner says the number of nurses needed has dropped--a bonus in a state as strapped for nurses as is California. "It's a great recruitment tool, too," he says. "Nurses like to work in an automated environment and physicians view it extremely favorably." Other technology has the potential to improve efficiency and patient care in the ICU. Computerized physician order entry, bar-coded medication administration and pharmacy robotics, and PACS all are in various stages of implementation around the country. Many hospitals, however, are reluctant to make the leap into still-evolving technology such as bar coding. "We're looking at medication administration bar coding but haven't made any decisions yet," says Advocate's Sacks. "We want to let the technology evolve a little bit and make sure it integrates with our clinical data systems." Other solutions are more down-to-earth. The 2,200-member hospital alliance VHA Inc., Irving, Texas, recently launched a program called "Transformation of the ICU." Fourteen member hospitals and 25 ICUs around the country study ways to make incremental changes in the way they deliver care to improve outcomes and patient and family satisfaction--all at little cost. Reworking clinical processes and boosting teamwork appears to be paying off. Early results: a 20 percent decrease in mortality, which translates to nearly 1,000 saved lives, says Stuart Baker, M.D., VHA's executive vice president of clinical affairs. In addition, the hospitals have shortened lengths of stay, and improved patient care by reducing infections and getting patients off ventilators more quickly. "The program really is about role definition, process improvement, culture change, communication and practicing evidence-based medicine," Baker says. "You can do that with low tech." Hartford Hospital is also participating in the VHA program. Dobkin says the key was to start small. ICU team members made changes they thought would improve patient care and safety, such as having each caregiver use a standardized patient care form. At first, the change would be introduced into the care of one patient. If the change produced measurable positive outcomes, it was then expanded to another patient, and then another. Outcomes were monitored each step of the way. "The biggest thing is getting people to understand that measuring what we do is important--just as important as taking care of the patient," says Dobkin. "If we don't measure what we do, we have no idea whether what we're doing is beneficial."