While the high startup costs associated with telemedicine programs have presented a barrier to many rural hospitals, data suggests they contribute to lower costs and lower mortality rates
Since the first programs were launched in the early 2000s, telemedicine has become a staple of nearly every area of care in the healthcare industry. But one area where it is just beginning to carve out a niche is intensive care.
ICU beds account for about 7% of total acute care hospital beds in the United States but generate 13.4% of total spending, with the cost of an inpatient stay ranging from $2,500 to $4,000 per day, According to the Society of Critical Care Medicine.
The evolution of tele-ICU programs is detailed in a report from the New England Healthcare Institute (NEHI), a health policy group that promotes the expansion of telemedicine. The report notes that, as of late 2012, there were 54 civilian and government tele-ICU monitoring centers in the U.S. While most were operated by academic medical centers, others were run by a mix of providers that included "regional hospitals, health plans, commercial firms, and the Veteran's Health Administration."
While tele-ICU programs have shown promise, however, high startup costs associated with the plans have presented a barrier to many rural hospitals that could benefit the most from such programs, the report suggests.
But "most indicators suggest that use of tele-ICUs is on the threshold of major change" and increased competition among providers is likely to "push tele-ICU care toward a more scalable and potentially more widely available technology," the report says.
Tele-ICUs are also being promoted as a way to expand the ICU capacity of hospitals to accommodate an aging U.S. population. "It could go a long way to addressing a major problem in that there are not enough intensivists in the health system to care for an aging population of baby boomers," says NEHI's Nick King, one of the authors of the report.
Startup costs an issue
Like most ventures rooted in high tech, tele-ICU programs can be expensive. The NEHI report estimates that per-hospital startup costs range from $100,000 to $200,000, with added expenses for equipment such as mobile carts.
"The upfront costs can be an issue, but we've demonstrated that health systems can see a return on investment from tele-ICU programs in as little as nine months," says NEHI president Wendy Everett.
Standard tele-ICU systems use a central monitoring station staffed by clinical staff around the clock. Each ICU room is equipped with a high-definition video camera and an audio hookup to allow physicians and nurses in the monitoring station to visually check on patients and communicate with nurses in the room.
Physicians also make their standard rounds between rooms each day to check on patients. Everett says round-the-clock monitoring of patients allows physicians and nurses to catch minor problems before they become major health issues.
Lower mortality rates
"If you have someone sitting in front of a screen monitoring a patient's vital signs 24/7, you're going to catch things other hospitals might miss," she says. "It's like flying a plane manually compared to flying a plane with instruments."
UMass was able to reduce its ICU patient mortality rates by 30% during the first year of its program; it also reported a reduction in hospital-acquired infections and other complications that often result in longer hospital stays.
John Muir Health, which operates two acute care hospitals in northern California, launched its tele-ICU program in 2007 and has produced even better results.
After 18 months, John Muir reported a 45% reduction in ICU mortality rates and a 54% reduction in the average length of stay (LOS) for ICU patients. "Those results show that the quality of care improved dramatically and resulted in fewer complications, shorter ICU stays, and better patient outcomes," says Carol Olff, who manages John Muir's tele-ICU program.
John Muir established a remote monitoring station at its administrative offices to track ICU patients at its hospitals in Concord and Walnut Creek. The monitoring station is staffed round the clock by a team of 34 nurses and 14 medical specialists. To help with patient monitoring, each patient bed is equipped with Smart Alert software that alerts providers to any changes in vital signs that could signal a problem.
"The software monitors trends unique to each patient and analyzes the data to detect problems before they develop," says Olff. "For instance, if a patient's blood oxygen levels are suddenly a little off, we can intervene and treat a respiratory problem that could quickly develop into pneumonia."
Many tele-ICU programs have been developed at academic medical centers as part of demonstration projects; the challenge now is to expand them to rural hospitals.
Rural adoption
Of the 54 tele-ICU monitoring centers in the United States, only 21 involve rural or critical access hospitals. The report notes that "the two key impediments to tele-ICU coverage of rural and critical access hospitals have been the costs of extending and maintaining coverage to a limited number of ICU beds and a lack of bedside clinicians in these hospitals to implement care directed from the tele-ICU."
But that is starting to change. The NEHI report notes that Missouri-based Mercy Health System, which currently has one of the largest tele-ICU programs in the U.S. covering 480 beds, recently received a federal grant to extend coverage to 24 rural hospital beds.
Mercy's program, launched in 2007, has produced a 30% reduction in ICU mortality rates and a 20% drop in patient LOS that saves an estimated $25 million per year.
Templates for rural success
Though rural tele-ICU networks are rare, there have been several successful networks that could provide a template for success. In Maine, Maine Health had eight rural hospitals coordinating ICU care through a program established in 2005 (though it was successful, the program was shut down in October 2013 when it ran out offunding).
Avera Health in Washington also operates a rural tele-ICU program as part of its innovative suite of telemedicine programs.
Extending ICU programs to rural hospitals has benefits beyond cost savings. "It also helps the patient and the patient's family," says Everett. "It's difficult enough for someone to be hospitalized in an ICU and even worse if a patient's family and friends have to travel two or three hours to visit them because the local hospital doesn't have the resources to care for them."
The NEHI report predicts that "in the future, Tele- ICU technology should be able to transition from a capital-intensive technology with modest dissemination to a more affordable and scalable technology that can reach hospital settings such as county,
public, rural, and critical access hospitals across the country."
John Muir's tele-ICU program, for example, is still confined to its acute care hospitals, but may soon branch out to serve some of the many rural hospitals in remote Northern California towns.
"It's something that's been discussed and would seem to be the next logical extension of our program," says Olff.