June 8, 2009

Overnight Sensation
By Lindsey Getz
For The Record
Vol. 21 No. 12 P. 16

Technology allows doctors to remotely monitor ICU patients around the clock.

It used to be that hospitals facing a physician shortage or lacking the funds to maintain round-the-clock staff in critical care were merely at a disadvantage, without a lot of options to improve their situation. However, new technology is allowing these hospitals to monitor their intensive care unit (ICU) patients electronically. Although the initial reaction to the idea may have been uncertainty, the results thus far have been positive, and the technology is rapidly gaining popularity among patients and staff.

While electronic ICU (eICU) programs have been launched throughout the country, a program known as Maryland eCare is of particular interest because it connects seven hospitals that would otherwise be competing against one another. The organizations, which together form the nation’s largest collaboration of independent hospitals, are using the eICU program developed by Baltimore-based medical technology company VISICU.

The system, which recently went live in the first hospital, will allow a critical care doctor based at a command center at Christiana Care Health System in Wilmington, Del., to oversee the overnight care for the hospitals’ ICU patients. The system is capable of monitoring more than 150 beds. “It allows us to provide the same level of care in the middle of the night as a patient would receive during the day,” explains Marc T. Zubrow, MD, director of critical care medicine at Christiana Care who doubles as Maryland eCare’s medical director. In that latter position, Zubrow will oversee the program’s remote monitoring center along with a team of Christiana Care critical care nurses and physicians.

While Maryland eCare has only recently gone live, Christiana Care has already established expertise in utilizing the technology since it first implemented eICU in its two hospitals back in 2005. With the establishment of Maryland eCare, it has become the first health system in the United States to monitor unrelated hospitals in a rural setting.

Christiana Care uses eICU to monitor critically ill patients in the hospitals’ emergency departments and postanesthesia care units—the first facility in the nation to use monitoring in these areas. Its experience with the technology has helped eliminate any unforeseen hiccups during the adoption process for the Maryland eCare program. “Every once in a while, we may run into a technical speed bump, but we had a very steep learning curve when we first went live at Christiana Care, so we’ve made a concerted effort not to make the same mistakes twice,” says Zubrow. “It has certainly been advantageous that we’re veterans at implementation. This is not new for us—just a new location.”

Maryland eCare was made possible through a $3 million grant provided by CareFirst Commitment, the nonprofit sector of BlueCross BlueShield that aims to address healthcare needs within the community. “One of the key things we aim to do with CareFirst Commitment is increase access to healthcare by helping to fund programs that remove obstacles to care,” says Michael P. Sullivan, a CareFirst spokesperson. “We also look for programs that can be catalysts to change healthcare for the better. And when we looked at the eICU program, we felt that it fit those criteria. You’re looking at a series of hospitals that would not otherwise have access to the intensive care physicians that are needed.”

“Our support of the eICU initiative will foster better care at the most critical moments of recovery for CareFirst members and others who receive care in the participating hospitals,” adds CareFirst President and CEO Chet Burrell.

Improved Care
It is expected that the eCare program will have a huge impact on patient safety, especially considering that the hospitals involved did not previously have intensive care doctors on staff at all hours. These hospitals relied on on-call doctors, with only nurses on staff to check on patients during overnight hours. With eCare, a doctor is always available.

Zubrow says the program will improve safety in other ways as well. It means that patients get the benefit of a second pair of eyes protecting their well-being on even the most routine matters. “For instance,” he says, “there’s always a second check on all IV pump infusions. If the nurse at the bedside programs a pump, then we can camera-in to read the pump and ensure it is hooked up correctly and the patient is getting the right medication. Without eCare, there wouldn’t be a double check.”

Similarly, Zubrow adds, labs can now be reviewed right away. “If an abnormal lab test came back at 3 am, many nurses might just wait until the doctor is in at 7 am to have it reviewed,” he says. “But with eCare, we can take a look and determine what should be done immediately. Say a patient’s potassium is low. We can react immediately and prevent a cardiac arrhythmia. Essentially, with this program, we’ve instituted proactive care—getting minor problems taken care of before they can become major problems.”

There’s little doubt that the program is beneficial to patients, but what about the staff? With the double checks and mounted cameras, do nurses feel like Big Brother is watching? Zubrow says that’s not the case. “Many people have this security camera idea in their mind like we’re watching all the time, but that’s not how it works,” he explains. “The camera is not on at all times, and we have strict rules about not surprising anyone. We call ahead if we’re going into a room, or we ring an electronic doorbell to notify we’re in the room.”

In addition, no audio or video is recorded. “We have real-time interaction with the caregivers, but we have no record of it,” explains Zubrow. “Once patients and staff understand that, it eliminates 99% of their concerns.”

Nurses also appreciate the ability to get immediate answers and have a doctor not only happy but eager to help in the middle of the night. “I tell nurses, ‘How many times have you called a doctor at 3 am and he was happy to talk to you?’” says Zubrow. “But at eCare, we’re always excited to talk to the nurses. We like it when people are asking us questions or for help with a patient because that’s why we’re there.”

As for others on staff, Zubrow says he has spoken with doctors at each of the seven sites to answer questions and allay fears. He says that once the process is well understood, the majority are in favor of implementation. “There are always a small minority that are not interested in change, and that’s primarily just because change can be painful,” he says. “But once I start to explain to the doctors that this program can save them from phone calls every night and they realize they will now be able to get a better night’s rest, which allows them to take better care of their patients the next day, they realize this change is about their lifestyle, too. That tends to be their ‘a-ha’ moment.”

Having well-rested doctors is another plus in the patient safety category, something that made CareFirst interested in funding the grant. “We have supported other programs that focus on patient safety, and this is certainly one of them,” says Sullivan. “These doctors work long hours and are under tremendous strain. By providing the 24/7 care that is necessary for the patient while still allowing the doctors to get a full night’s rest, eCare allows hospitals to have a fresher staff.”

eCare Elsewhere
While Maryland may boast the largest collaboration of nonaligned rural hospitals involved in this type of care, it is not the only state where eICU plays a significant role in patient care. In fact, the technology has been adopted by more than 200 hospitals nationwide as the shortage of critical care doctors has continued to grow.

The University of Wisconsin Hospital critical care physicians and nurses are one such group that has implemented eICU technology. Known as the e-Care of Wisconsin program, it has helped provide round-the-clock care for critically ill patients. Based in Madison, the e-Care Center monitors two hospitals: the University of Wisconsin Hospital and Clinics and Saint Joseph’s Hospital.

So far, so good in the Badger State, as doctors have embraced the technology as a catalyst to providing better care. “There is a serious and growing shortage of critical care doctors and nurses,” says Kenneth Wood, DO, director of critical care medicine in the trauma/life support unit at the University of Wisconsin Hospital and Clinics. “e-Care allows us to continue high-quality care despite workforce challenges. And it will help us recruit and retain critical care physicians and nurses, too.”

For staff or patients who have expressed concerns that their privacy may be compromised, Wisconsin officials have responded in much the same manner as their Maryland counterparts: by providing complete education on how the system works. Similar to Maryland’s program, the monitoring is never done in secret. A bell and a green light on the camera alert those in the patient’s room that the camera has become active. Also, anyone in the room is able to contact the e-Care monitoring center at any time by simply pressing a button.

In addition, the program has taken measures to protect patient data. “First, all patient data is encrypted until the information reaches either the e-Care Center or the hospital,” explains Wood. “Second, cameras are turned off except when data shows that a patient should be checked. Also, any patient who declines to be on camera would not be required to do so, but to date, we have not had that happen because patients are grateful for the extra level of care the system can provide. Finally, the images are not recorded; they are simply transmitted between sites.”

Wood adds that physicians and staff have jumped on board with the program. The benefits of having a doctor available at all times gives critical care nurses some relief in what can be a stressful job and has made the process of learning about the new system worth any changes. “There is always a learning curve when a new technology is introduced,” says Wood, “but we were careful to do it step by step to make sure the staff was as comfortable as possible. The units on which we have initiated the eICU program have been enthusiastic.”

A Greater Good
The implementation of eICU programs nationwide could have a huge impact on patient safety at hospitals that may otherwise be understaffed. Critically ill patients are known to develop complications and can rapidly take a turn for the worse. But with more hospitals having access to 24-hour, physician-staffed critical care, these complications may be avoided entirely. “One of the many outstanding features of e-Care is an early warning system, which alerts staff of potential patient complications,” says Wood.

In Maryland, the opportunity to better serve its patients has actually brought competing hospitals together for the greater good. “Five of these seven hospitals are in head-to-head competing markets,” says Zubrow. “Some of them even share doctors, so they are competing for the same patient population. But they clearly get it. They understand that they can only improve the quality of their ICU care by supporting the patients and their physicians with these sorts of processes—and that requires coming together.”

As more hospitals find the means to fund this sort of remote technology, it is expected to become more widespread. Notes Zubrow: “It is remarkable how much can be done for a patient without being right at the bedside. It’s a traditional belief that you have to be right there, next to the patient. But besides the social aspect, most of the things we do in person can be done remotely as well. And that will ultimately allow us to better serve the patient.”

— Lindsey Getz is a freelance writer based in Royersford, Pa.