By Mary Jo Feldstein
ST. LOUIS POST-DISPATCH
05/30/2008
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| St. Mary's Medical Center nurse Tracy McCarty, right, tends to patient Veronica Leyva in the ICU of the Jefferson City, Mo. hospital under the watchful eye of a St. Louis doctor who is watching via the camera mounted on the wall. (L.G. Patterson/AP) |
Mark Van Patten doesn't remember much about the 25 days his wife Regina spent in the intensive care unit at St. Mary's Health Center in Jefferson City. Fatigue, stress and anguish have blurred those long hours by her bedside.
But there are a few moments he recalls quite clearly, including one only hours after she arrived, when he heard a voice from above.
"Mr. Van Patten, please step away from the monitor," said the voice. The person speaking was a St. Louis physician who specializes in caring for intensive care patients.
St. Mary's is one of dozens of community hospitals around the country that wanted to keep their intensive care units but couldn't find the specialists — called intensivists — to staff them.
Research has consistently shown intensivists can lower mortality rates and move intensive care patients out of the hospital sooner than more generally trained physicians. But there are too few of these physicians, particularly in less populated areas.
So hospitals including St. Mary's are contracting with companies based in larger areas, including Advanced ICU Care in Creve Coeur. The firms hire intensivists to share their skills remotely through monitors, television screens and other technologies.
In the two years since implementing Advanced ICU Care's program, St. Mary's has seen cardiac arrests in the ICU plunge by 67 percent, according to research by Advanced ICU Care. The number of ICU patients who left the hospital alive improved by 24 percent, the research found.
A broader study funded in part by Visicu, which supplies the technology, and published in a 2004 issue of the journal Critical Care Medicine, also found improved patient care with the use of remote intensivists. More recent research by Baltimore-based Visicu found intensive care patients at its hospitals had a 29 percent lower mortality rate than the national average.
"I wouldn't say I was surprised by the magnitude (of the improvement)," said Dr. Mary Jo Gorman, chief executive of Advanced ICU. "What's becoming very clear is we can do a lot better than we're doing in caring for ICU patients."
The results don't surprise Dr. John Lucio, vice president of medical affairs at St. Mary's. He said the hospital had "very significant issues" with some complex cases.
"We had expertise here, but we didn't have enough to go around," Lucio said. "When you have an intensivist present, the patients don't get to the point where they are about to go off the cliff."
Van Patten said his wife proves the statistics. She was admitted to the hospital with an e-coli infection that had spread to her blood. She left about six weeks later and returned this month to her job as a science teacher.
"I can tell you those cameras and those 'doctors in a box,' as the nurses call it, saved her life a few times," Van Patten said. "She'd crash. Everything would just start failing and in 10 or 15 minutes she'd be stable again. It would have taken that long to get a doctor out of bed."
Before St. Mary's signed on with Advanced ICU Care in 2004, nurses would often have to wake physicians in the middle of night to change medications, get permission for a test or make other changes to patients' care, said Kristy Huenink, a registered nurse in St. Mary's ICU for four years.
The process could take as a little as a few minutes or as long as a couple of hours, Huenink said. And, she said, the nurses were often contacting on-call physicians who weren't familiar with the patient's medical history and were often reluctant to make significant changes.
With Advanced ICU, Huenink said, the physicians often spot problems early and can explain the philosophy behind the treatments they recommend.
"If there's something I've never encountered or have a question about, they're always there," Huenink said. "That improves what I can do for that patient."
Advanced ICU doctors also generally care for many of the same patients for long shifts over several days. One of Regina Van Patten's physicians felt so connected to her, the doctor traveled from St. Louis to Jefferson City to meet her after she was feeling better.
Nursing turnover at the hospital is down, and the fact there are fewer nighttime phone calls has boosted physician satisfaction, Lucio said. He credits Advanced ICU.
Still, the transition hasn't been without its challenges. Attending physicians at the hospital don't always appreciate the extra help, and differences of opinion can arise, Lucio said. Huenink agreed.
"We have some physicians who really utilize them and some physicians who, unfortunately, don't give them the benefit of the doubt," Huenink said.
Then, there's the $1 million a year price tag for St. Mary's. It's a cost, Lucio said, that isn't adequately reimbursed by government payers or insurers.
Lucio said insurers say they are willing to pay for better quality, but they're not willing to raise payments for teleintensivists, despite the research showing their value.
It's "just doubletalk," Lucio said. "You should reward those entities willing to go out on a limb and spend that money."
Advanced ICU Care thinks teleintensivists should save money by reducing the amount of time patients spend in the hospital and limiting medical errors. As Medicare and insurers stop paying for several types of mistakes — including a couple that are concentrated in intensive care units — ensuring quality will guarantee revenues, Gorman said.