Emory eICU Technology Addresses Provider Shortages

Unexpected benefits from the program bolster advanced practice provider training, improve retention, address burnout, and reduce sleep deprivation.

As more hospitals adopt remote ICU monitoring to improve patient outcomes and lower costs, Emory Healthcare in Atlanta is leveraging this same technology to address an industrywide challenge in critical care: provider shortages.

The intensivists and critical care nurses behind Emory's eICU cameras play a role training a new generation of advanced practice providers (APP) enrolled in the Emory Critical Care Center Nurse Practitioner/Physician Assistant Post Graduate Residency Program. At the same time, the positions in the control room help retain seasoned clinicians who might otherwise retire or quit.

Because of the way Emory has structured its program, there are other unexpected benefits. Some of the clinicians elect to work eight- to 12-week stints in Australia, when the day shift half a world away occurs during the night shift in Atlanta. As a result, program directors and employees say this approach diminishes job burnout, and eliminates the sleep deprivation associated with a higher risk of medical errors and safety issues.

The experts behind Emory's eICU and APP residency program shared with HealthLeaders how they achieved even greater benefits from a tool designed to improve patient care.

1. Build on a History of Success

Emory has a history of success employing Philips' eICU technology. It launched its initial program in 2012 with a $10.7 million Health Care Innovation Award from the Centers for Medicare & Medicaid Services to develop a collaborative network to remotely support ICUs in Georgia hospitals.

In 2014, the eICU program began serving critical care units at four of Emory's hospitals in metro Atlanta (the system has seven in Georgia), plus a small community hospital in Statesboro, Georgia, that contracted with Emory to provide eICU services. Experienced critical care nurses monitor the five hospital's ICUs 24/7 from control rooms at Emory Saint Joseph’s Hospital in Atlanta, as well as from Royal Perth Hospital in Perth, Australia. On nights and weekends, when doctors are not usually present in the ICUs, intensivist physicians also are available in the control room.

Over a 15-month period from April 2014 to June 2015, the health system achieved the following results across 136 beds at five hospital sites:

• Saved an estimated $4.6 million—a $1,486 reduction in average Medicare spending per patient
   
• Discharged more patients to less expensive home healthcare services (+4.9%) rather than more costly nursing homes or long-term care hospitals (-6.9%)
   
• Decreased 60-day inpatient readmission by 2.1%

In addition, within six months of providing live monitoring for the Statesboro hospital, which has no intensivist on staff, the mortality rate decreased by 54%.

2. Prepare the Next Generation of APPs

About the same time Emory started monitoring its own eICUs, the health system launched a yearlong residency program for nurse practitioners (NP) and physician assistants (PA) to help address a nationwide shortage that is expected to grow. CCUs are relying more heavily on these APPs as the number of intensivists declines.

Using clinicians behind the camera to help train the residents was not intentional. As trainees, APPs must always have a supervisor—another NP, PA, or physician—on the unit. But that person is not necessarily nearby, and in most ICUs, physicians rarely work at night. The convenience of having a physician in the room with the resident at the touch of a button changed the training dynamics.

Heather Meissen, ACNP, MSN, CCRN, co-director of the residency program, explains that many health professionals in training are "afraid to call a physician at night who might be sleeping." They may fear the situation is not urgent enough to awaken the doctor, or they may not realize the urgency of a matter, she says.

But when a physician is watching from a monitor, trainees aren't hesitant to reach out, she says. They may just want to bounce an idea off of someone, but if the patient is in trouble, they are able to institute a plan of care much more quickly.

"Nighttime is where you're going to see the biggest advantage to training," says Meissen. "A lot of times patients fall off a trajectory at night, and they need immediate assistance. Your time to get that physician collaboration is much quicker when you have an eICU."

Because they are constantly monitoring patients, the professionals in the control room also serve as a second set of eyes, even when trainees don't ask for assistance. And, in an academic medical center, there are numerous health professionals in training. The eICU provides another layer of protection and feedback because "when you are in a learning environment," says Meissen, "mistakes can be made."

3. Evolve and Expand the Scope of Training

The Emory program is an accredited Practice Transition Program by the American Nurses Credentialing Centers Commission on Accreditation and has graduated nearly 50 APPs. It is doubling the number of residents this fall, and those now entering the program will have an opportunity to do a rotation inside the control room before they graduate.

Providers working in the eICU have to review "large amounts of data and assess it quickly," says Aimee Abide PA-C, MMSc, who serves as program co-director with Meissen. "To be on [both] sides of the camera will create a comprehensive training program and make the APP resident uniquely well-rounded in multiple aspects of medicine and medical technology."

The medical director also has plans to add a permanent APP position in the eICU to supplement the work of the nurses and physicians.

Emory also is using eICU physicians as part of a formalized core competency documentation process to evaluate APPs already on staff and ensure they can properly perform certain procedures, such as putting in central or arterial lines. Once again, having a physician available on the spot to witness procedures while they are in progress—even viewing live images on the ultrasound screen that guides the process— has proved to be a valuable asset, says Abide.

4. Create a Training Program That Multiplies

There's yet another way Emory's program will help address shortages: It is designed to inspire graduates to perpetrate the training process. 

"There are not enough critical care providers in the nation to support the need of an aging population," says program medical director Timothy Buchman, MD, PhD, FACS, FCCP, MCCM, who also serves as director of the Emory Critical Care Center, professor of surgery and anesthesiology at the Emory University School of Medicine, and chief of critical care services at Emory Healthcare.

"I want not only to train critical care providers, I want to create the next generation of leaders," says Dr. Buchman. After completing the residency program, he expects graduates to work in critical care for three to five years, then set up their own training initiatives. About four graduates are in the process of launching programs in other states.

5. Focus on Retention of Seasoned Practitioners

While the eICU is helping to train new practitioners, it also addresses retention at the other end of the spectrum.

"We have an aging workforce," says Cheryl Hiddleson MSN, RN, CENP, CCRN-E, director of Emory's eICU Center. "The average age of a bedside nurse right now is around 55, and we are losing nurses who have years and years of experience and expertise."

The eICU program helps Emory retain some of these seasoned professionals.

"I have a nurse who is 68 years old, and every year she comes to me and says, 'I'm going to work one more year in the eICU,' " says Hiddleson. "She loves being able to provide patient care; that's why she got into nursing. She [also] loves being involved in something that's new and innovative, and it's not hard on her body the way it is at the bedside when you're lifting, and stooping, and bending."

After multiple back surgeries, a different nurse was using a walker and no longer able to work on the unit. He now works in the eICU and is able to walk unassisted.

"I have extended the careers of a couple of nurses who might otherwise be disabled or just left this path altogether," says Hiddleson.

Physician retention is another asset of the eICU. Not only is it difficult to find new ones; it's expensive. When the costs of recruiting, start-up, and lost revenue generation are calculated, the cost to replace a single employed physician often exceeds $500,000, according to The Studer Group.

6. Address Quality of Life

Dr. Buchman says that establishing the Australian outpost added another appealing dimension to working in Emory's eICU. He came up with the idea after working one night near his sixtieth birthday. Exhausted, he realized he no longer had the resilience he did when he was younger, and knew his colleagues had similar issues. He turned to Hiddleson and said, "We have to find a way to turn night into day," and the search for a solution began.

"We wanted to find a way to mitigate the deleterious effects of working the night shift," says Hiddleson. "We want to bring better quality of life and joy to our clinicians' lives. There's high turnover in critical care due to the emotional and physical stress of taking care of these patients. If we can retain one physician and one nurse a year [by offering an opportunity to work from Australia], it pays for the program."

Explore the Trends

The following resources provide further information into the issues and trends that an eICU can help address:

• The United States will face a shortage of between 40,800 and 104,900 physicians by 2030, according to a study commissioned by the American Association of Medical Colleges (AAMC) and released March 14, 2017.
   
• A 2015 AAMC study indicated of 10,159 critical care physicians, 8,849 were actively involved in patient care.
   
• An article published by Advanced Healthcare Network on May 29, 2014, which calculated even fewer numbers of practicing intensivists, cautioned that "With only about 7,000 practicing intensivists in the U.S. and more than 7,000 ICUs in the nation, the math translates to about one intensivist per ICU, clearly not enough for 24/7 coverage."
   
• Burnout is also an issue. According to a 2016 statement jointly issued by four critical care organizations, up to 45% of the nation's 10,000 critical care physicians and nearly a third of the 500,000 critical care nurses report symptoms of severe burnout syndrome.