Matthew McCambridge, MD, is chairman of critical care medicine at the three-hospital Lehigh Valley Health Network (LVHN) in Bethlehem and Allentown, PA, which uses an advanced ICU system to monitor about 120 ICU beds from 7 p.m. to 7 a.m.
An LVHN study compared the outcomes of 954 patients who received care in the ICU for 16 months prior to the remote ICU launch and 959 who received care from intensivist physicians using the remote ICU. Mortality dropped from about 21% to nearly 15%. In other words, McCambridge says, "for every 15 patients we admit, we're saving one additional life."
The LVHN remote ICU, which includes an EMR, a computer-assisted physician order entry system, medication bar-coding, and a picture archiving and communication system, costs about $1.7 million a year—an expense that is not reimbursed. But the three-hospital system breaks even, in part due to reduced mortality and length of stay and also because the network can admit more critical patients from eight surrounding hospitals—patients who continue to receive care at LVHN when they are discharged from the ICU, generating downstream revenue.
One reason the results of the LVHN study, which was published in the April 12 Archives of Internal Medicine, differed from those in the JAMA study was that LVHN uses a "closed" model, meaning the entire patient population is cared for by remote and on-site clinicians day and night, McCambridge says. In the JAMA study, physicians could choose whether to use remote caregivers—and about half chose not to. One reason for low adoption rates may have been that physicians and even nurses feel threatened or perceive that they?rather than the patients—are being monitored.
If a remote ICU program is to succeed, the teams "on the ground and in the air" must work together, says McCambridge and others. The patient must be the first, second, and third priorities, he says. "It doesn't matter what bells and whistles you put on top, the patients must be taken care of by the doctors."
Resurrection Health Care, a six-hospital system in Chicago, monitors 182 beds in five of its hospitals and one long-term actute-care facility as well as two other local hospitals. Rebecca J. Zapatochny Rufo, RN, eICU operations director, says another reason the JAMA study didn't show positive outcomes was that the ICU physicians in the study had a limited degree of treatment authority delegated to the eICU by the majority of attending physicians. The authors acknowledge that the lack of acceptance and integration are contributing factors to their undesirable results.
Rufo works closely with the organization's' medical director, Neil Rosenberg, MD, and enjoys "enormous" support from the organization's leaders "for the pure purpose of saving lives, enhancing quality, and driving organizational transformation for performance outcomes."
"Everybody has to share the same vision. [If] you have naysayers in the group, that's a problem," she says. "These are our coworkers and our peers that we work with and we partner together."
Staff from several different departments?from nurses to dieticians to respiratory therapists—use the system.
"We integrate from a multidisciplinary standpoint, at the bedside and in the ICU itself." She says. "The application is very dynamic. Everybody who touches the life of that patient needs to be involved. So everybody's got access to the same data fields."