How can the sickest patients in the hospital be
cared for remotely?
While it may sound heretical, critically ill patients can be cared for
quite effectively in this manner. Clinical decisions in the ICU are often
based on a large and continuous stream of data (physiologic, laboratory,
radiographic, etc) and these data can be communicated electronically in
real time. Informed caregivers can then perform the cognitive decision-making
remotely. Remote management of ICU patients has been evaluated in two
clinical studies, both demonstrating a 25 percent to 30 percent reduction
in hospital mortality for ICU patients.1
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Who does procedures/emergency procedures if they are needed?
All hospitals have processes in place to deal with common emergency
procedures. These include dedicated in-house personnel (physician assistants,
critical care nurse practitioners, house physicians, hospitalists,
anesthesiology personnel, and emergency department physicians) or specialty
physicians on call from home (cardiologist for pacemaker, etc.). These
processes remain in place, except that the call for the procedure would
likely be initiated by the eICU intensivist, after discussion
with the attending physician. If surgical evaluation is required, the eICU
intensivist contacts the surgeon requested by the attending physician. eICU
intensivists coordinate these activities, maintaining the nurse at
the bedside.
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What about patient privacy?
Patient information is secure and confidential. The technology provides
the highest level of electronic data security and meets the latest security
and privacy recommendations of the federal government (HIPAA). While there
is a camera, speaker and microphone in each room, this communication system
is only activated by request from the bedside nurse or during prescribed "virtual
rounds.” It is readily apparent when the camera is activated (it moves
from pointing at the wall to pointing at the patient's bed) and an audio
signal is used to alert the nurse who may be in the patient's room. There
is no capability for recording video or audio and patient privacy is respected
when virtual rounds are required.
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How does the Advanced ICU Careprogram affect the way bedside
nurses take care of their patients?
The Advanced ICU Care program helps nurses provide better patient care
and reduces situations of fear and conflict. Nurses have a specialist available
with immediate access to them, their patients and their charts and records.
Nurses no longer need to find the right doctor on call, wake them up, or wait
for them to return a page. With the program, nurses can reach the eICU
doctor immediately.
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Who staffs the eICU facility?
The Advanced ICU Care eICU Operations Center is staffed
by on-site intensivist physicians, critical care nurses and health care
assistants. Our critical care nurses have an average of 20 years of critical
care experience. Our intensivists are fellowship-trained and board-certified.
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How do attending physicians coordinate with the eICU
team?
Two categories have been created to respect attending physician autonomy
in the care delivery process and enable attending physicians to become
accustomed to the eICU care model.
| Categories of eICU
Care |
Category A |
Category B |
The eICU physician
actively carries out the attending physician’s care plan and initiates
new therapies as needed. The eICU physician notifies the
attending physician of major changes in patient status.
Initiate new therapies as needed (i.e.,
evaluation and therapy of new fever, ventilator
weaning and adjustments, volume resuscitation,
initiate and titrate vasoactive regimens).
ICU Best Practices
- DVT Prophylaxis
- Stress Ulcer Prophylaxis
- Sepsis Management Bundle
- Ventilator Associated Pneumonia Bundle -Increased Head of Bed
-Sedation Vacation -Weaning Trials
- B Blockers in Acute MI, when not contraindicated
- Low Tidal Volume Ventilation for ALI
- Glucose Control
Notify attending physician and/or appropriate consultants immediately
of major changes in patient’s condition. |
The eICU physician intervenes for life threatening emergencies
and evidence based care, and contacts the attending physician for
all other medical conditions.
Maintain therapies outlined in
existing patient care plan (i.e.,
ventilator support, weaning plan, fluid
support, vasoactive medications).
Initiate minor non-emergent therapies (i.e.
potassium, magnesium replacement, maintaining
O2 saturations).
ICU Best Practices
- DVT Prophylaxis
- Stress Ulcer Prophylaxis
- Sepsis Management Bundle
- Ventilator Associated Pneumonia Bundle -Increased Head of Bed
-Sedation Vacation
-Weaning Trials
- B Blockers in Acute MI, when not contraindicated
- Low Tidal Volume Ventilation for ALI
- Glucose Control
Notify attending physician and/or appropriate consultants immediately
of all other situations. |
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As a bedside nurse, who do I call first if I have a problem?
Beside nurses should call the eICU and the eICU physician
will call the attending of record or the appropriate consultant to discuss
any issues. This effectively gives the bedside nurse “one stop shopping”
and removes the confusion of who to call, the fear of calling, or the
interrogation that can follow. If house staff is covering the patient
and they are assigned in the unit, nurses should call them first. If they
are not in the unit and the situation is emergent, nurses should call
the eICU first and then try to reach the house staff.
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How do x-rays get to the eICU facility?
If the eICU physician needs to view a patient’s x-ray and a PACS
system is not available, nurses may be asked to scan the x-ray to the eICU
facility. This requires just one push of a button and the technology does
the rest.
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How much time does it take for nurses to document in eCareManager®?
eCareManager is designed to have little or no impact on nursing
workflow. Nurses may be asked to update the patient care plan (one to
two minutes per patient), but much of this information is also used to
create the nursing sign-out report, which will print in the ICU at change
of shift. This sign-out report provides a more accurate and efficient
exchange of information to the next shift nurse.
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What is the training time for nurses on the system?
Bedside nurses require two to four hours to be trained on the system.
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Will the Advanced ICU Care program affect nursing-to-patient
ratios?
The Advanced ICU Care program is not designed to replace anyone and in
fact it adds a layer of care. Data has shown that reducing nursing-to-patient
ratios has negatively impacted patient care. Advanced ICU Care’s goal
is to help health care systems manage costs through quality improvements,
not personnel reductions.
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What is it like to work in an ICU networked to an eICU
facility?
According to Sarah Darwin, RN, MSN, CCRN, director of patient care services
at Sentara Southside Hospitals, “The technology gives my staff immediate
access to intensivists and experienced ICU nurses any time of the day
or night. My nurses’ job satisfaction has increased considerably since
they are now able to remain focused on the patient and not have to spend
valuable time calling for help when a situation arises. This program is
also attracting RNs to work in my ICU due to its cutting-edge technology.”
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How is the house staff supported by this program?
The eICU intensivists are readily available to provide guidance
and consultation to the house staff. The system is designed to support
the house staff in learning and implementing best practices for critically
ill patients.
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1 Rosenfeld
et al: ICU Telemedicine - An Alternate Paradigm for
providing Continuous Intensive Care. Critical Care Medicine.2000;28;3925-3931.
Breslow et al: The Effect of a multi-Site ICU Telemedicine Program
on Clinical and Economic Outcomes: An Alternative Paradigm for Intensivist
Staffing “ accepted for publication in Critical Care Medicine. |
