Essential and Expensive

"We have large wall posters, which are seen by the families of patients, and we report measures like our VAP rates and explain what we're doing to improve things. We view accountability and transparency as a major component of our quality improvement program," says Douglas.

Now that conditions such as catheter infections and ventilator-associated pneumonia have been targeted by CMS as "never events," measuring outcomes and implementing protocols for reducing complications on a daily basis is more important than ever.

Success Key No. 4: Subspecialize, if you can
Some strategic considerations can also affect the quality and efficiency of ICU operations. ICUs come in all shapes and sizes—there are neonatal ICUs, pediatric ICUs, neurological ICUs, coronary ICUs, trauma ICUs.

Subspecialized units tend to improve quality through familiarity—physicians and nurses working exclusively on cardiac patients, for example, will be more efficient and efficacious than counterparts who perform the same procedures only periodically in a general medical-surgical ICU.

So when is it advantageous to segment an ICU or add a subspecialized unit? The answer will vary from hospital to hospital and usually depends on volume. For facilities like large academic medical centers, subspecialized units have become standard, whereas smaller hospitals may not have the volume to support a separate unit.

But that isn't always the case. In 2003, Aspirus Wausau Hospital, a 250-staffed-bed level two trauma center in north-central Wisconsin, pulled cardiac cases out of its general ICU to form a small, eight-bed cardiac intensive care unit.

The driver of the change was the cardiovascular service line, says Deb Karow, director of cardiac nursing, who oversees the coronary ICU team. "We are considered a part of the cardiac service line; I report directly to the cardiac service line administrator," she says. "It puts a bit of a different emphasis or imperative in goal setting when you look at contributing to a defined outcomes for a patient population."

Initially the change simply served to segment the existing critical care patients, but over time the coronary critical care patient population grew with the service line. That specialized unit played a major role in national recognition the heart and vascular institute has received, Karow says.

The subspecialization has also been popular with staff, particularly physicians. "If we talked about blending these units back together again we'd have a revolt on our hands. Physicians were instrumental about driving the concept forward. They like the dedicated staff, expertise, the level of trust, the understanding that we're all on the same page looking for the same outcomes."

The electronic intensive care unit is often likened to air traffic control. From a single command center, an operator is fed information on dozens of patients in multiple locations and can make split-second decisions to keep the unit running smoothly—or, when necessary, react to a pending disaster.

At UMass Memorial Medical Center in Worcester, MA, a physician and critical care nurse practitioner monitor 10 ICUs at five campuses 24 hours a day via Visicu's eICU program, which includes full audio and visual feeds of every patient bed. The software constantly collects and analyzes data and can detect minor changes in a patient's condition early, and it sends out critical alerts when a patient suddenly takes a turn for the worse—going into congestive heart failure, for instance.

The plethora of data and time-saving features of the eICU have resulted in a shortened length of stay and an overall improvement in mortality rates since its implementation in 2006, says Walter Ettinger, president of the 771-staffed-bed tertiary care center.

Yet most hospitals have been reluctant to adopt eICUs, in part because they believe the costs outweigh the perceived quality improvement benefits. In some cases, particularly for hospitals with smaller ICUs, they may be right.

But the eICU at UMass Memorial has proven to be remarkably sustainable economically, Ettinger says. "In the ICU, hours are important. Because we shortened length of stay, we increased our bed capacity and were able to take more patients. That is what drives the economics of eICU. You're able to get more throughput and in turn bring in more revenue."

Even with a favorable business plan, however, eICU adoption can be a long and potentially divisive process if all parties—boards, leadership, physicians—aren't on the same page. The change at UMass Memorial was driven by a critical care operations committee chaired by a senior critical care physician. One of the committee's goals was to improve quality by ensuring intensivist attendings were available around the clock for patients. There simply weren't enough doctors to pull that off, however, and the committee decided to investigate the eICU as a way of doing more with less.

As shortages of both physicians and nurses trained in intensive care become worse and recruitment becomes challenging, that argument may persuade more hospitals to reconsider eICU technology.