Preventing the “PREVENTABLE” in the ICU

By: Mary Jo Gorman, M.D., MBA, CEO of Advanced ICU Care
Future Healthcare

What do payment policy changes, such as the ones announced by the Centers for Medicare and Medicaid Services (CMS), mean for hospitals?
There has been much discussion about the CMS announcement that, beginning in October 2008, it will no longer reimburse hospitals for the extra costs to treat eight preventable conditions. Reimbursement policy changes could follow for other hospital-acquired conditions, such as ventilator-associated pneumonia.

In all likelihood, these payment policy changes are just the tip of the iceberg. More CMS payment reforms are anticipated and private insurers also are apt to implement similar policies. While the new payment policy has been both criticized and applauded, it - and others like it - could be a boon to patient safety, prompting hospitals to explore a number of approaches to improve patient care.

The announcement already has accelerated many hospitals' existing process improvement programs - and jumpstarted new ones. Take, for example, pressure ulcers, one of the eight preventable conditions cited by Medicare. Many hospitals are visibly advocating prevention and overall system changes now more than ever, with new processes ranging from meticulous admission screenings to strict policies for repositioning patients.

What is technology's role in quality improvement?
Technology-based tools have long been part of the solution for a number of patient safety- related issues, and likely will play a larger role as new government and private payment policies come into effect. We know that preventing patient care complications requires established, evidence-based standards of care and the elimination of variability. Technology tools can be essential not only in establishing standards of care, but also in ensuring compliance with key care processes. Technology is also instrumental in reporting, tracking and benchmarking results - activities that support continuous quality improvement.

One example of how hospitals are employing technology to improve patient care and safety is telemedicine, specifically telemedicine intensivist programs for hospital ICUs. These eICU® programs combine clinical management software with patient data and video feeds to enable intensivists and critical care nurses to monitor ICU patients from an outside monitoring center. Not only do these programs leverage a centralized group of experts, but they also standardize care processes across the system, employ best practice tools and provide customized reporting and benchmarking of metrics. The technology, developed by VISICU to help address the intensivist shortage and improve patient care and safety in the ICU, also includes alerts which signal eICU intensivists to intervene as patient vital signs or other physiological data change, or as evidence-based care guidelines dictate.

Advanced ICU Care® uses this eICU technology, along with its board-certified intensivists and critical care nurses, to provide 24/7 ICU patient monitoring. Hospital ICUs are linked with Advanced ICU Care's eICU Operations Center in St. Louis, Missouri, allowing Advanced ICU Care's intensivists and critical care nurses to work in collaboration with the hospital's clinical staff to care for and continuously monitor critically ill patients, hundreds of miles away.

How important are these programs to patient safety, and how can they "prevent the preventable?"
Studies show that these programs save lives. At St. Mary's Health Center in Jefferson City, Mo. - where the Advanced ICU Care program is used - ICU mortality dropped by 24 percent after one year. Cardiac arrests plunged by 69 percent and ICU patient total length of stay fell by 14 percent.

Technology-based programs also help to improve health care processes. For instance, the technology includes an automated reminder for vascular catheter replacement - a critical task in reducing vascular catheter-associated infections. The technology also helps to establish compliance with best practices. For example, since the inception of the Advanced ICU Care program at St. Mary's, the hospital has seen zero cases of ventilator-associated pneumonia (VAP) - a proposed Medicare preventable condition, no doubt due to its high associated mortality rate and costs (VAP adds about $40,000 to a typical hospital admission).1

Key to the St. Mary's result is the "ventilator bundle" - four best practice interventions related to ventilator care that, when implemented together, have been shown to reduce VAP. While the VAP bundle is nothing new to ICU nurses and physicians, establishing 100 percent compliance with each of the measures can be difficult without technology. As part of the Advanced ICU Care program, the VAP bundle is measured multiple times a day and orders are submitted to maintain compliance. At St. Mary's, compliance with all four VAP interventions has risen considerably since implementation of the program. Other results have been impressive as well. Before implementation, the average days on ventilator was 8.2; with the Advanced ICU Care program, the average days on ventilator now average 4.8 - a remarkable 58 percent drop. The technology also helps hospital staff substantiate key "before" and "after" results, which are critical to measuring and reporting safety improvements.

How will hospitals balance increased quality standards with costs?
Hospitals face the daunting task of needing to balance increased quality standards with rising costs. Intensive care units in particular face significant economic challenges, given mounting costs of care, high patient acuity and clinical complications. Literature shows that patient care in the ICU accounts for at least 20 percent, if not more, of hospitals' operating budgets.2

However, implementing technological tools to improve care processes and patient safety need not be cost-prohibitive. The Advanced ICU Care program provides standardized care processes, continuous monitoring and faster interventions, which means that outlier stays can be shortened, complications prevented and costs reduced.

Sentara Healthcare, which implemented an eICU program in 2000, reported that variable costs decreased, attributable to a decrease in length of stay and lower daily ICU ancillary costs.3 Costs associated with staff turnover also have dropped in hospitals employing eICU programs. After one year of using the Advanced ICU Care program, St. Mary's saw a 67 percent reduction in nursing turnover, leading to lower nursing recruitment costs.

What does the future hold?
Technology-based tools are likely to become more prominent as hospitals adapt to the new payment policies and strive to improve care processes. As an officer of Advanced ICU Care, I have the benefit of witnessing firsthand just how well technology can improve patient care and safety. As a physician, however, I know how difficult change processes - like the ones brought about by the CMS payment policy - can be for clinicians to accept. By bringing together key change advocates within their organizations, plus the right care processes and the technology to support them, hospitals can, and will, continue to improve patient care. FH

REFERENCES
1 Rello J, Ollendorf DA, Oster G, et al. VAP Outcomes Scientific Advisory Group. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest. 2002 Dec;122(6):2115-2121.

2 Jacobs P, Noseworthy TW. National estimates of intensive care utilization and costs: Canada and the United States. Crit Care Med 1990; 18: 1282-1286.

3 Breslow MJ, Rosenfeld BA, Doerfler M, et al. Effect of a multiple-site intensive care unit telemedicine program on clinical and economic outcomes: an alternative paradigm for intensivist staffing. Critical Care Medicine 2004 Jan;32(1):31-38. eICU® is a registered trademark of Visicu, Inc.