Learn about one recent success as published in the Journal of Physician Executives

Physician Executive Journal

July/August 2010

by John Lucio, DO, FACHE, CPE and Isabelle Kopec, MD, FACP, FCCP

In this article...
Discover the quality improvements and revenue increases that officials at a hospital in Missouri credit
to the implementation of a tele-intensivist program in the ICU.

Five million patients are admitted to intensive care units (ICUs) each year, and an estimated 10 percent die there. The daily cost per bed for critical care services is in the range of $2,300 to $3,000 and length of stay averages between six and nine days.

Not surprisingly, ICU patient care accounts for at least 20 percent of hospitals' operating budgets, often even more. With all that is at stake, we as hospital administrators need to make sure we get it right in the ICU. And if we can improve quality and save costs in an area that poses so many challenges, will hospital-wide improvements follow?

Our answer is a resounding "yes." St. Mary's Health Center, an SSM Health Care facility in Jefferson City, Missouri, invested in quality and technology to improve patient care and safety in the ICU. The hospital implemented a virtual ICU program along with its in-house program in January 2006, and results show significant improvements in ICU mortality, length of stay and quality measures.

While our goal was focused on the ICU, quality improvements extended far beyond. The hospital jumped to the top one percent in the Centers for Medicaid and Medicare Services (CMS) core measures, as measured by Health Insight.

24/7 care
Early on, St. Mary's recognized the need for 24/7 intensivist care in the ICU to improve patient outcomes. The Leapfrog recommendations on ICU physician staffing were clear: full intensivist staffing would save 162,000 lives each year and $3.4 billion annually in the U.S.

While ICU specialist coverage was available on call and for consults, St. Mary's was concerned -- like many hospitals -- about the lack of coverage during office hours, or competing priorities for consulting physicians, especially at night and on weekends.

St. Mary's identified areas for improvement, particularly around physician availability in emergency situations and rounding limitations among key consultants. The hospital was also experiencing high ICU nursing turnover, partly due to delays in reaching physicians. Additionally, St. Mary's wanted to differentiate itself in the marketplace and improve perception within the community.

After in-house intensivist staffing proved to be difficult to complete given St. Mary's relatively rural location, the hospital launched a virtual ICU program. Our goals for the program were focused on quality and safety, consistent with SSM's system-wide commitment to quality. The virtual ICU program provides 24/7 intensivist care, supported by telemedicine technology and a continuous process improvement program. The technology combines clinical management software with patient information and remote care tools, enabling the remote monitoring and care of ICU patients by intensivists and critical care nurses.

While the program focus was on the ICU, St. Mary's was also making quality improvements beyond the ICU. In 2008, St. Mary's moved to the top 1 percent in CMS core measures around heart attack, heart failure, pneumonia, and surgical infection prevention.

While many of the measures are not ICU-specific, the process improvements and best practices associated with the tele-intensivist program helped contribute to quality improvements throughout the hospital.

For example, controlled blood glucose is a standard in cardiovascular surgery patients, and a component of the CMS core measures as well as the CMS Surgical Care Improvement Project for better surgical outcomes and fewer wound infections. There was no standardization to glucose management in 2005, before implementation of the tele-intensivist program, and average daily glucose was 146. Alan Rauba, MD, St. Mary's chairman of Internal Medicine and an endocrinologist, worked to institute standardized glucose management protocols on all ICU patients. The tele-intensivist team supported his initiative by presenting glucose quality management results as a driver for change, providing data on the impact of improving glucose control and on the safety of the protocol, and -- by actively managing these patients -- successfully instituted his protocol, thereby meeting best practices.

Two years after program implementation, overall average daily glucose fell to 131. Levels fell to as low as 125, with no increase in hypoglycemia. This example also highlights the collaboration between the tele-intensivist team and local clinicians.

The tele-intensivist team is not a replacement for care, nor do they serve as the "control" center or in a "big brother" capacity. Rather, they work closely with the local team to establish standards of care and ensure compliance. The team also helps support local caregivers through 24/7 proactive monitoring, availability, interventions as needed, and institution of best practices.

Other improvements in ICU
This customized benchmarking and outcomes data, with APACHE IV acuity-based predicted to actual outcomes and national eICU comparative data, drive process improvement and improved patient care and safety.

In the three years since the program was implemented, St. Mary's ICU has had only two central line infections. The program software tracks when and where invasive lines are placed, along with the patient's white blood cell count over time and temperature curve. Remote intensivists monitor this data continually for signs of developing infection.

St. Mary's also has seen tremendous process improvements among patients with adult respiratory distress syndrome (ARDS) and acute lung injury. Using low tidal volume ventilation in these respiratory patients has been an accepted process for many years, yet many pulmonologists across the country do not follow the guidelines.

This held true at St. Mary's before implementation of the teleintensivist program. Through proactive interventions by remote intensivists, collaboration with St. Mary's pulmonologists and respiratory therapists, St. Mary's patients now benefit from low tidal volume ventilator settings as well as active management of protocols to liberate patients from mechanical ventilation.

The median days on ventilator fell by a full day. Benchmarking data show that St. Mary's has been a nationwide leader in this best practice among all 200-plus virtual ICU program monitored hospital ICUs.

Customized patient care data to drive best practices, along with the proactive interventions of teleintensivists when lapses occur, have driven results.

After one year, mortality rates dropped 23 percent. After two years, mortality rates plummeted 63 percent from pre-program 2005 levels, and year three saw a 34 percent drop from pre-program levels, with actual mortality far less than predicted.

Cardiac arrests plunged 69 percent after one year, due to 24/7 monitoring and proactive interventions when patient warning signs occur. Length of stay in the ICU fell steadily since program implementation, dropping by 36 percent after three years. Hospital length of stay of ICU patients also fell dramatically, falling by 45 percent after three years, as patients who have fewer complications in the ICU do better when transferred into other areas of the hospital.

Quality and the bottom line
Quality improvements such as length of stay have led to better patient throughput and, as a result, better financials. St. Mary's has seen a 30 percent increase in volume in the ICU and total hospital case volume has increased by seven percent.

The improved throughput and volume has allowed St. Mary's to expand operating room suites into what was previously a stepdown/ICU overflow space. In turn, revenues have ticked up dramatically.

In year one, there were 88 new cases in the ICU. In year two, St. Mary's added 143 new cases. At $12,000 in revenue per case, this equals $1.7 million in new revenue. Fixed costs in the ICU are high, so much of this revenue falls to the bottom line.

In conjunction with an aggressive revenue cycle management process improvement project, hospital case mix index (CMI) increased as well, partly due to improved documentation from the ICU-specific EMR and the ability to treat more severely ill patients. The CMI for full-year 2005, before program implementation, was 1.38. Full-year 2007 CMI was 1.56, an increase of .17 or 12 percent. Given that each .1 in CMI represents approximately $500 per case, this is significant.

Also, decreased nursing turnover in the ICU led to a drop in recruitment costs. Consider in 2005 St. Mary's ICU nursing turnover was at 30 percent. It fell to just 6 percent in 2007, helped by improved nurse satisfaction levels given the 24/7 support by remote intensivists and experienced critical care nurses.

Implementing a shared vision
For a program such as this to be successful, a process change is required. The key for St. Mary's was in developing a shared vision and a shared ownership with all involved in the process -- from physicians supporting the ICU to bedside nurses and ancillary staff.

Administrative, physician and nursing leadership support for the program was clear from the beginning. And early on, key users in the ICU were engaged in the process, and champions were identified to help promote the system and train others.

By embracing technology-based programs, hospitals can recognize significant process improvements, resulting in better quality and safety of care, improved financials, and strong partnerships among in-house staff and remote specialists to drive quality care.

For St. Mary's, an investment in technology and quality in the ICU has provided far-reaching results across the care continuum. Results such as these, coupled with an economic stimulus package at hand that includes billions of dollars for health care information technology, may give more hospitals more reasons than ever to consider new technology- based programs to improve care.

John Lucio, DO, FACHE, CPE, is vice president of medical affairs at St. Mary's Health Center in Jefferson City, Missouri.

Isabelle Kopec, M.D., FACP, FCCP, is vice president of medical affairs with Advanced ICU Care in St. Louis, Missouri.