Why Haven’t More Hospitals Jumped on the eICU Bandwagon?

Carrie Vaughan, for HealthLeaders Media, June 11, 2008

I have written a lot about hospital partnerships lately, and for good reason: These collaborations are a key factor in keeping healthcare costs down and ensuring that patients receive the right care at the right place at the right time. One example in Maryland shows how a hospital partnership can both improve the quality of patient care and increase access to critical-care physicians through an electronic ICU program.

I have heard of eICUs being utilized within a hospital system, but what is unique about Maryland eCare is that it links six independent community hospitals in Maryland with Christiana Care Health System in Wilmington, DE, and has the support of CareFirst BlueCross BlueShield. Small community hospitals are hard-pressed to recruit and retain critical-care doctors to their intensive-care units because of their size. For example, the ICU at Calvert Memorial Hospital, a 123-licensed-bed hospital in Prince Frederick, MD, and a Maryland eCare member, is a 10-bed unit that averages only four to six patients a day, says President and Chief Executive Officer James Xinis. Even if facilities like Calvert Memorial could recruit critical-care docs, it is often cost prohibitive to staff that number of beds with around-the-clock intensivist coverage. Yet such facilities still want to provide their patients with the same quality of care that they can receive at larger hospitals.

To that end, Maryland eCare will link the ICU at Calvert Memorial and other community hospitals to a remote ICU monitoring center at Christiana Care through Visicu's eICU software technology. Christiana, which has already been using the technology at its two hospitals since 2005, will employ nurses to monitor the community hospitals' ICUs 24/7 and offer critical-care physician coverage at night (7 p.m. to 7 a.m.) and on weekends. "We are supporting their physicians, not trying to replace them. We are here when they are not there," says Marc T. Zubrow, MD, Christiana's director of critical care medicine and the medical director of Maryland eCare.

Nuts and bolts
So what does the system entail? First, there is a continuing data stream from the bedside monitors at the participating hospitals to the remote center through T1 lines that provide data on things like heart rate and blood pressure. Second, the software has smart alerts, which notify caregivers of subtle changes in care that may be easy to miss but could mean the patient is deteriorating. For instance, a 10% change in blood pressure may trigger an alert. "Every alert that goes off may not be important, but every now and then you pull a fish out of the barrel," says Zubrow. "Maybe the patient is trending downward. Maybe he's septic or bleeding. You catch the patient early, so it is proactive care, not reactive care," he says. The program also uses cameras so the remote staff can offer additional support to the bedside team. For example, an eICU nurse can work with a bedside nurse to confirm that a patient is receiving the correct medication, dose, and amount at the correct time. This saves the local caregiver the time it would have taken to track someone down locally to corroborate the order. Lastly, the critical-care doctors are able to assess new patients that come in at night or on weekends, and can redirect patient care, if needed.

Christiana will provide one experienced nurse (meaning at least five years of work experience) for every 30 patients. The physician ratio is still being determined, but it will likely be somewhere between 120 to 150 patients per physician.

Then there is the question of who pays for what. The technology for the remote center—software, licensing fees, and additional monitoring equipment—is being acquired by Christiana and is being partially funded by a $3 million grant from CareFirst. In addition, Christiana has the cost of hiring more intensivists and nurses to staff the center. Each hospital in the collaborative is responsible for the costs to integrate their clinical data information systems with the remote site.

So why aren't more people using this type of technology?
With the advances in technology over the past several years, I would think there would be more of these types of collaborations in regards to ICU care. But that has not been the case. One of the main hurdles is getting the different boards, leadership, and medical staffs of the independent hospitals to agree on the business plan, says Xinis. "It was one of the reasons why it took us over two years to put the program together." According to Zubrow, the biggest challenge for these types of programs is usually getting physician acceptance of the standardized treatment protocols. Maryland eCare had an advantage in this regard, because most Maryland hospitals participated in an ICU collaborative two years ago to create standard protocols for different types of diagnosis in the ICU, says Xinis.

Bringing this technology into the hospital setting and integrating it with existing care management systems and organizational structures is no simple task, either. For example, Christiana is developing a dashboard just to keep track of the log-on passwords for all of the participating hospitals' enterprise systems, PACs, and eCare systems, says Zubrow. In addition, he has to train his staff on how to use all of the different systems—not to mention the task of actually building the interfaces, which he estimates will take about nine months. The first hospital should be online around January or February 2009 with plans to phase in another hospital every three months after that, he says.

The future of eICU care
Despite the obstacles, both Xinis and Zubrow foresee more hospitals utilizing the eICU care model in the future. The shortage of critical-care physicians and hospitals' desire to improve patient safety and quality of care are key drivers of this model of care—not too mention the financial benefits for smaller hospitals that are able to treat more patients locally. And hospital systems in competitive markets can benefit financially, as well, by creating larger referral bases, says Zubrow.

Speaking as a healthcare consumer, I would like the comfort of knowing that my loved ones are being monitored around the clock by nurses and critical-care physicians in addition to the local providers. After all, a second pair of eyes can never hurt.

Carrie Vaughan is editor of HealthLeaders Media Community and Rural Hospital Weekly. She can be reached at cvaughan@healthleadersmedia.com.

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