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An Alternative Approach to 24/7 ICU Coverage

June 21, 2012
by John DeGaspari
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Can tele-ICU monitoring fill the intensivist shortage?
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For High Point (N.C.) Regional Hospital, telemedicine has helped to fill a gap in staffing its intensive care unit, while helping the provider to significantly reduce its mortality rate as well as the lengths of stay for its patients. 

Like many hospitals, High Point Regional has struggled with a persistent and long-standing staffing problem: a shortage of intensivists to man their ICUs. A report released in 2006 by the Department of Health and Human Services’ Health Resources and Services Administration projected that by 2020 there will be a 35-percent shortage of intensivists by 2020, partly resulting from an aging population that is more likely to use hospital ICUs. 

Greg Taylor, M.D., High Point Regional Medical Center’s chief operating officer, describes the hospital’s decision to move to tele-monitoring of its ICU as an eight-year journey, the beginning of which coincided with his arrival there as the organization’s first chief medical officer. “When I arrived, one of the first things the CEO asked me to do was to look at the length of stay and outcomes in our ICUs,” he says, adding that the hospital was an outlier on the negative side on both measures. 

The challenge was to begin to benchmark the hospital against state-of-the-art critical care medicine. That was in 2004, at a time when the critical care unit was essentially run by two pulmonologists, who shortly after moved on from the facility. With their departure, Taylor says the hospital saw a need to recruit an intensivist to run the ICU, rather than depend on physicians dividing their time between practicing their specialty and critical care medicine. It did succeed in hiring an intensivist, who left shortly after; and then hired a replacement intensivist, Peter Brath, M.D., who is medical director of High Point Regional’s intensive care unit and respiratory therapy. 

Yet even with a full-time intensivist on board, the hospital faced significant staffing costs, relying on locum tenens physicians, at considerable expense. The hospital spent $2 million in the 2007-2008 fiscal year on ICU labor costs of the intensivist and ancillary clinicians to provide 24/7 ICU coverage, he says. 

A Search for a Partner

That proved to be a watershed moment, which prompted the hospital to look for an alternative, and more affordable, ICU staffing model. The hospital considered two possibilities. One was to collaborate with a neighboring hospital in Greensboro, N.C., which had installed an electronic ICU monitoring system. The hospital had enough beds in its ICU to justify it, but was interested in covering High Point Regional’s ICU beds as well, to help defray its investment costs, Taylor explains. The other was a tele-ICU service provider (supplied by Advanced ICU Care, St. Louis, Mo.). 

In making the decision, Taylor said that hardware and software costs were identical, whether from the neighboring hospital’s ICU or the service provider. The deciding factor was coverage: 12 hours per day from the neighboring hospital’s ICU versus 24 hours a day by the third-party service provider. “We realized that we had an intensivist on site, but he was just one person, and we understand that other emergencies come up, and vacations and illnesses,” he says. 

Nonetheless, a major concern of either option was interoperability, Taylor says. High Point Regional uses Alpharetta, Ga.-based McKesson Technology Solutions as its primary IT vendor, which provides solutions for nursing documentation and pharmacy orders and physician orders. Taylor says a major concern was compatibility issues between the hospital’s McKesson solutions and the hardware and software for the remote monitoring of the ICU (supplied by VISICU, Inc., Baltimore, Md.). He notes that Advanced ICU (which maintains it is vendor neutral) had prior experience with both of those systems. This was an important factor in the final decision to sign on with the tele-ICU service provider, Taylor says. 

Smooth Implementation

In August 2008 High Point Regional negotiated a contract, which it signed toward the end of the year. Go-live was scheduled for July 1, 2009. The vendor arrived at the hospital in April with a technology team, an operations team, and a clinical team to begin implementation. The hospital supplied counterpart teams from its own staff. 

Taylor says the implementation went smoothly. “They basically came in with a roadmap for implementation, and they led us through it. They told us up front what we were going to need and what we needed to do,” Taylor says. When connectivity issues arose, both the vendor team and its hospital counterpart teams worked through theproblems, consulting with McKesson when necessary, Taylor says. He adds that the vendor’s prior experience working with McKesson was a big advantage, because it removed potential roadblocks during the implementation process. 

The clinical teams were focused on uploading the hospital’s clinical protocols.”Dr. Brath had been here long enough so he had several protocols,” Taylor says. “It’s not [a case of] us adapting to Advanced ICU’s protocols; it was quite the reverse. Advanced ICU adapted to our protocols. By July 1, when we went live and the night staff was calling Advanced ICU, they knew exactly what our weaning protocols were, what our ventilator protocols were,” he says. 

Night and Day

Even an on-site intensivist can’t be available 24 hours a day, and Taylor says the tele-ICU monitoring system works well to fill in the gaps. 

During the day, Dr. Brath is able to handle the majority of management tasks involving patients and their families, answering questions, developing plans of care, and speaking with physicians, Taylor says. At the same time, data is being continuously fed to the tele-ICU monitoring center in St. Louis, which is manned by intensivist at all times. If Dr. Brath is tied up with another emergency or needs assistance with another patient who is beginning to deteriorate, he can get immediate access to the intensivist in St. Louis. 

The intensivists at both locations, on-site and off-site, can communicate via audio and high-resolution video. “The intensivist in St. Louis has a bank of computer screens and can bring up the ventilator setting, the heart rate, medications, problem lists, vital signs, nurses’ and physicians’ notes—whatever they need they have instantaneously in front of them,” Taylor says. 

The tele-ICU monitoring center takes over primary management of the hospital’s ICU between 7 p.m. and 7 a.m., Taylor says. “During the nighttime hours, if there is a change in ventilator settings or if there is low potassium or a change in blood pressure, that dialog and the patient management comes from St. Louis,” Taylor says. He notes that that the tele-ICU monitoring software is capable of early detection of a change in the status of the patient. “The software is so sensitive that it frequently picks up things before the clinical staff at the patient’s bedside has even noticed,” he says. According to Taylor, the hospital’s ICU typically averages 40 phone calls with the tele-monitoring center in St. Louis during a 24-hour period. Most of those calls take place at night. 

One thing that the off-site intensivist can’t do is an intervention, Taylor says. For that, the hospital maintains a hospitalist and anesthesiologist in-house, and the intensivist and/or pulmonologist are on call. During the day, Dr. Brath works with a physician assistant as well as a team of specialists, Taylor says. 

High Point Regional has a total of 20 beds that are monitored remotely: eight in its medical ICU; eight in its intermediate ICU; and two in its surgical ICU, which is the hospital’s open heart unit; and two in its critical care unit. It also has two remote units that can be deployed anywhere in the hospital; one on the floor with the critical care beds and the other in the ED. 

Overall, how does the tele-ICU system stack up? Over one quarter, High Point Regional saved over 200 patient days, which resulted in significant cost savings, Taylor says. “It would be wonderful if we had 24/7 intensivists, but our volumes are not sufficient to support that, and nationally there are not enough intensivists and critical care physicians to cover all of the critical care beds,” he says, adding that the tele-ICU system is the next best thing.


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