Virtual Reality With e-ICUs

Cutting-edge telemedicine technology improves care in the ICU.

Five million patients are admitted to ICUs each year and, of those patients, an estimated 10 percent die while in the ICU. One way to reduce that number, and save an estimated 162,000 lives annually, would be for hospitals to have a full staff of intensivists. Unfortunately, an intensivist shortage exists, just like the nursing shortage. Only one in five ICUs has intensivists on staff, according to a 2006 article in Critical Care Medicine.

"People are turning to remote ICU monitoring programs because of the national shortage of critical care physicians," explained Sandi Aubuchon, BSN, RN, associate director of operations at Advanced ICU Care, a St. Louis company that provides such telemedicine.

Many facilities turn to virtual technology to provide an improved quality of care in their ICUs after intensivist recruitment has failed. That's where remote monitoring programs come in and show quick results. According to a study published in a 2004 issue of Critical Care Medicine, when telemedicine is used, it can dramatically reduce hospital mortality rates for ICU patients by 27 percent and ICU length of stay by 17 percent, while also providing significant cost savings. In addition, job satisfaction and retention rates have been shown to increase among hospital nurses working with an eICU, according to that study.

Flipping the Switch

After unsuccessful attempts to fill intensivist vacancies, St. Mary's Health Center in Jefferson City, MO, turned to Advanced ICU Care for help in 2006. The hospital outfitted 10 of its 13 ICU beds with technology that provides 25 full-time RNs and six prn nurses with an additional level of assistance through 24/7 monitoring of ICU patients by experienced intensivists and critical care nurses.

"The nurses really appreciate the added resource, particularly the night and weekend staff," explained Jane Dozier, MBA-HM, BSN, RN, director of the ICU at St. Mary's. "They're more attached because they don't have to wake someone up in the middle of the night or deal with the time delay waiting for somebody to respond to a phone call. You have instant support."

Investing in eICU technology was just one of St. Mary's commitments to quality improvements that extended far beyond that ICU. The hospital jumped to the top 1 percent in the Centers for Medicare & Medicaid Services core measures, as measured by HealthInsight.

How It Works

St. Mary's ICU is linked with Advanced ICU Care's virtual ICU Center in St. Louis through telemedicine technology that combines clinical management software with remote care tools, such as bedside cameras and microphones. This allows nurses and physicians to provide 24/7 monitoring of patients through tracking their vital signs, medications, laboratory results and general condition from the center in St. Louis.

"Generally, the ICU nurses initiate contact with eICU when a patient's condition deteriorates rapidly, resulting in destabilization where time is of the essence," explained Donna Bell, RN, CCRN, manager of St. Mary's ICU. "The ultimate goal is to prevent respiratory or cardiac arrest. eICU may be called upon for timely airway management, fluid resuscitation or other hemodynamic interventions at a moment's notice."

For example, last month a patient arrived in the unit following an out-of-hospital cardiac arrest. Despite being placed on a ventilator upon arrival, he remained hypotensive and failed to adequately oxygenate. The eICU physician was notified, came online via camera, assessed the situation and ordered changes to the ventilator settings, as well as initiated additional vassoactive medication to increase the blood pressure within minutes of being called, preventing further deterioration.

Had the hospital not had the virtual ICU technology in place, the outcome may have been compromised due to time delays. Instead, an ICU physician from 100 miles away at the monitoring center in St. Louis worked collaboratively with the ICU nurse to facilitate a positive outcome.

"A unique feature of the software is the 'dashboard' - the patient profile that provides vital information we need to know about the patient in real time: 4-hour vital sign trends, physiological data, lab results and so on," Aubuchon said. "Most people ask, 'How can you watch up to 35 patients?'The software sophistication with alerts built into their hemodynamic system tells us if the patient is having a heart rate, oxygen saturation, or blood pressure issue - all in real time."

The technology is very sophisticated - so much so that the off-site nurses can see the ventilator settings, read the ingredients on the side of an IV bag and view how fast tube feedings are.

"Sometimes the sophistication of the technology surprises nurses, as well as getting accustomed to someone coming into their room remotely. This all can take some getting used to," Aubuchon said. "It's somewhat of a futuristic concept and there's an element of communication adjustment the ICU staff needs to prepare for."

To allow for privacy, the virtual ICU nurse activates the camera viewing when conducting a clinical assessment each shift, when observing any changes in the patient's condition requiring notification of the ICU nurse or intensivist, and when called to the bedside for emergent situations. Advanced ICU Care staff is also able to have a private, face-to-face conference via video with bedside staff and family members in a location outside the patient's room. This is particularly helpful if a staff nurse wants to seek counsel from the remote ICU nurse or physician.

"Each room has a camera in place, a direct line telephone and a call button, which we jokingly call an 'EASY button' since it is a big red button similar to what you see on commercials," Dozier explained. "If you're in a hurry you push that button and you're on; you can hear a voice overhead and get assistance or use the phone."

Making a Connection

Nurses at both settings connect on a regular basis through interaction during patient care. The virtual ICU staff also does regular reporting on patients and charge nurse rounds where the two groups can share a summary of how things are going. Respiratory rounds are also part of the daily process, which has enabled St. Mary's to decrease the days patients are on the ventilator by 1 day.

"We have a very good relationship with the nurses and physicians at Advanced ICU Care," Dozier explained.

Advanced ICU Care also visits St. Mary's each quarter to sit in on the monthly critical care meeting. That meeting includes an Advance ICU Care quarterly report where the team is able to look at how they are doing on predicted and actual mortalities, length of stay, severity scores and number of admissions.

"We also look at benchmark reports for ventilator days, deep vein thrombosis and stress ulcer prophylaxis, as well as average daily blood glucose and blood transfusions. Our predicted and actual results are based on national values from the Cerner APACHE IV Outcomes algorithm, which measure and manage ICU performance. We also utilize Press Ganey and the Hospital Consumer Assessment of Healthcare Providers and Systems to track customer perception of their ICU experience," Dozier said. "This gives us a snapshot of everything from customer satisfaction to core measures. We're very much data-driven."

Remarkable Results

And the data continues to show significant improvements in a variety of areas, since the virtual ICU program was installed:

• ICU mortality dropped by 24 percent after 1 year;
• cardiac arrests plunged by 69 percent;
• ICU patient total length of stay fell by 14 percent;
• zero cases of ventilator-associated pneumonia since program inception;
• drop in central line infections (just two in 3 years since program implementation);
• median days on ventilator fell by a full day; and
• standardization of glucose management.

"These results are due to the 24/7 monitoring by experienced critical care clinicians, consistent communication and relationship built between the ICU and the virtual ICU staff, and a unique software program. That's what leads to proactive interventions," Aubuchon explained. "We can anticipate patient issues prior to the patient actually being in distress, which is a marvelous advantage."

The results strengthen the staff's faith in this technology and encourage higher morale. Each team member sees this tool as a supplementary resource, not intended to replace the bedside care.

"It's a tremendous team effort. When nurses need to get answers, confirm their clinical assessment or obtain physician's orders quickly, they can do so: it's closing that time gap in providing care," Dozier said. "This technology offers nurses an extra level of clinical resource and patients and family members' reassurance that our patients are receiving exceptional care.

Sarah Lebo is a frequent contributor to ADVANCE.