Advanced ICU Care | Technology Brings Virtual ICUs to Smaller Hospitals

With technology making it possible for off-site clinicians to watch over critically ill patients miles away, a virtual ICU may soon become reality at your hospital or a facility near you.

It’s 3 a.m., and a critical care nurse and physician sit in a small room, keeping an eye on a number of computer monitors. The screens provide crucial data on patients in intensive care units at several different hospitals in their facility’s network. The nurse and the doctor—a critical care medicine specialist known as an intensivist—have been working with bedside staff at a facility 35 miles away to wean a 75-year-old patient from a ventilator. Their team effort, made possible by telemedicine and specialized software, will make it possible for the attending physician to extubate the patient during morning rounds.

Suddenly, an alert pops up on one of the computer screens, commanding the clinicians’ attention to the elevated heart rate of another patient at another facility. With a click of a mouse, the “e-nurse” directs a camera in the patient’s room to zoom in and finds him in moderate respiratory distress. The virtual ICU staff quickly contacts the bedside ICU nurse, who is attending to the needs of another patient. Within minutes, the bedside ICU nurse is able to call respiratory therapy in to reintubate the patient, thus sparing him from respiratory failure.

A little later, the intensivist gets a call from another ICU nurse, requesting that he confirm placement of a central line in a patient needing a blood transfusion. With another click of the mouse the physician reviews the patient’s chest Xrays and gives the bedside nurse approval to proceed. Finally, as dawn approaches, an inexperienced ICU nurse at yet another hospital contacts the e-nurse to request guidance as she removes a catheter. The remote e-nurse watches on the video camera, ready to give instructions as needed, while the bedside nurse performs the procedure.

These scenarios sound like science fiction, but they’re typical of a night shift at a virtual ICU. These remote facilities can already be found in California, New York, Texas, Virginia, Illinois, and Florida, and new operations are being planned or implemented all across the country.

As the virtual ICU makes inroads into the mainstream delivery of healthcare, it’s not far-fetched to envision a remote team overseeing the care of well over 100 patients during a single shift. That provider-patient ratio may not seem so shocking once you learn more about remote ICUs and their potential to improve the care of critically ill patients.

The evolution of the virtual ICU

Each year, more than 4 million patients are admitted to intensive care units in the United States and about half a million die in ICUs.1,2 Many of those deaths can be traced to preventable medical errors, according to the Institute of Medicine and the Leapfrog Group, an influential coalition of more than 150 large public and private organizations that is leading the drive for patient safety and improved outcomes. Both groups have focused heavily on the ICU, where studies suggest that about one death in 10 could be avoided if intensivists managed patient care. 3,4

The problem: With an estimated 6,000 intensivists nationwide, there aren’t enough of them to go around. A possible solution: The virtual ICU.

The remote ICU is the brainchild of two intensivists from Johns Hopkins Hospital—Brian Rosenfeld, MD, and Michael Breslow, MD. Their idea is to use technology to leverage the
scarcity of intensivists over multiple ICUs and give bedside nurses who care for the sickest patients around-the-clock support.

Using voice, video, and data software and hardware, a remote staff assembled by a healthcare system can monitor the heart rates, blood pressures, and oxygen saturations of patients in the system’s various ICUs. This staff can also check ventilator settings and wound dressings; review X-rays, lab results, and care plans that have been input or transferred electronically; and interact with patients and caregivers.

The eICU® Smart Alerts® software, designed by Baltimore-based VISICU (a company co-founded by Rosenfeld) is capable of identifying dangerous trends, such as a decreasing oxygen saturation that’s combined with an increasing respiratory rate, and alerting remote staff, who can evaluate the alert and contact bedside caregivers as needed. The software is sensitive enough to detect subtle changes that the nurses and doctors at the bedside might miss.

To picture how it works, imagine an air traffic control tower. The remote ICU staff, like those in the control tower, monitor, advise, issue warnings, and provide orders. But it’s the bedside staff—like the airline pilots who fly the planes—that actually provide the hands-on intervention.

Although virtual ICUs—called eICU centers by VISICU—are typically staffed by nurses 24/7, intensivists generally provide coverage 19 hours a day. “E-doctors” usually take off between the hours of 7 a.m. and noon, when attending physicians make hospital rounds.

Nurse buy-in is key to success

Like anything new, acceptance of the remote ICU can take some time. Nurses’ concerns that “big brother” is watching to see whether they wash their hands or start an IV correctly must be addressed.

“We had to make them understand that the remote staff aren’t assessing the nurse, they’re assessing the patient,” says Bobbi Hartman, RN, director of operations of the virtual ICU at Advocate Health Care System, in Oakbrook, IL. “Quickly getting in and getting out [is key],” says Hartman. She’s referring to the fact that the cameras in the ICU rooms are turned off and pointed toward the wall when not being used to monitor a patient.

To address privacy concerns of nurses and patients alike, the remote nurse “rings a doorbell,” taking the time to announce herself before pointing the camera toward the patient. Emergency situations are, of course, an exception. To further alleviate staff resistance, the remote nurses work closely with the bedside nurses to determine when it is appropriate to look in on a patient. A staff nurse can request that the remote staff refrain from performing a video assessment during bath time, for instance, or when the patient’s family is visiting.

Fears of reduced bedside staffing must also be addressed, those involved with virtual ICUs say. But it’s not a model to reduce staffing, it’s a safety net, according to Janine Mazabob, RN, BSN, CCRN. Mazabob is director of clinical operations at Memorial Hermann Southwest Hospital in Houston, which implemented a virtual ICU in March. “It’s another set of eyes that can watch your patients,” she says. “The bedside nurses are the hands, and the remote nurses are in the background to help them.”

What’s more, the remote ICU has relieved bedside nurses of “secretarial duties” like paging a physician three or four times to clarify an order, reports Kathy Beddingfield, RN, CCRN, a bedside educator at Memorial Hermann Southwest Hospital. Now the staff nurse can call the remote ICU for the information she needs instead.

The virtual ICU at Sutter Medical Center Sacramento (CA), which “went live” in February 2003, may also be helping to reduce turnover. A policy allowing qualified nurses to rotate between two weeks at the remote facility and two weeks at the bedside has eliminated much of the burnout seen among critical care nurses, reports Kim Meyers, RN, MSA. She is administrative director for Sut-ter’s Sierra Region virtual ICU, which monitors about 100 beds. “It’s let us keep our more veteran or seasoned nurses, without losing their experience,” she adds.

Sutter’s staff nurses are also finding that the remote ICU has helped improve bedside care. They are increasingly likely to call the virtual facility, where they know someone is awake, alert, and ready to provide support when needed, Meyers says.

Those involved say the extra support benefits nurses in various stages of their careers. Novices may find a mentor in the remote nurse, who typically has several years of experience and is certified in critical care.

Seasoned staffers can also benefit from the support of the virtual staff. “If I had a patient to take down to X-ray, I could call the virtual ICU to ensure that someone else was monitoring my other patients,” says Carol Rue, RN, who worked in critical care for 32 years before becoming a full-time virtual ICU nurse at Advocate. “It’s an extra layer of monitoring that’s a comfort.”

Patients and families reap the benefits

Knowing that someone is keeping a continuous, watchful eye on them can also be a relief to patients and to their families.

At Memorial Hermann, for example, Mazabob recalls a mother who was keeping vigil at her 14- year-old son’s bedside. She agreed to go home to rest only after she realized that her child would be continuously monitored by critical care specialists in a remote location. “Here was a mom who knew she had not only a nurse, but a doctor” keeping tabs on her son, Mazabob says.

Education about the remote operation helps alleviate many patient concerns. At Advocate Health Care, for instance, patients receive an information sheet or a brochure describing the remote operation. It explains that the system is part of the standard of care for all intensive care patients, just as cardiac monitoring or pulse oximetry would be, Hartman notes.

That standard of care seems to be paying off for patients. Studies led by Rosenfeld and Breslow have found a decline in mortality rates and a drop in the length of stay in ICUs when bedside care is supplemented by remote critical care staff.5,6 That also translates into monetary savings. Another of Rosenfeld and Breslow’s studies found that the shorter stays and lower ancillary costs resulted in an average saving of nearly 25%, or $2,556, per case. 6

But setting up a virtual ICU, which includes sophisticated telemedicine equipment, extensive training, and technical support, is not a cheap endeavor. Although costs vary considerably depending upon the needs of the facility, the cost for a health system to install an eICU system in four 12-bed ICUs, for example, would be more than $2 million, according to Rosenfeld. Moreover, the time to train staff in the use of the equipment in
the remote ICU and camera etiquette at the bedside must be factored in. And protocols out-lining workflow processes, such as how often virtual assessments should be made or when lab results can be downloaded, also take time to develop.

In the end, many facilities are concluding that it is worth the effort. Since 2000, 21 health systems encompassing over 100 hospitals across the country have implemented, or are in the process of installing, eICU technology, a VISICU spokeswoman says. And some facilities are considering using the technology to monitor patients in EDs and on stepdown units as well.

The technology that opens the door to these possibilities also offers opportunities to nurses. Opening your mind to new ways of practicing may allow you to expand your career while enhancing patient care. RN

Technology brings virtual ICUs to smaller hospitals