One of the highlights of the Healthcare Informatics Executive Summit in San Francisco was the presentation of the first Healthcare Informatics/AMDIS IT Innovation Advocate Award, which was sponsored by the Association of Medical Directors of Information Systems (AMDIS) and Healthcare Informatics. On Friday, May 13, Cecilee Ruesch, R.N., the team lead for the Providence Alaska Medical Center’s eICU Team, which was awarded first place in the award program, accepted the statuette representing the award, from Howard Landa, M.D., vice chairman of the board of directors of AMDIS, and Mark Hagland, Editor-in-Chief of HCI.
Necessity: Mother of eICU Invention
Out of necessity, because of staffing-related transitions affecting the core physician intensivist group at Providence Alaska Medical Center, Cecilee Ruesch, R.N., and her colleagues in critical care at the 320-bed hospital in Anchorage, Alaska, decided to pursue a rarely tried strategy: supporting their hospital’s intensive care units (ICUs) with nurse-staffed remote monitoring via their new electronic ICU (eICU) capability (their vendor is the Baltimore-based Philips Visicu).
In the typical intensivist-led model of ICU remote monitoring an intensivist staffs the eICU function. To make a nurse-led model work, Ruesch and her colleagues carefully created a multi-stage plan that would launch the hospital’s eICU as nurse-led, with the option of switching the model to being collaboratively intensivist- and nurse-led when the intensivist resources became available.
The program launched in January 2009 with nurse-only eICU staffing. Importantly, the initiative was able to document significant patient safety and care quality gains. From January through October 2009, Providence’s adult critical care unit posted the following improvements: a 15 percent decrease in average length of stay; a 14-percent decrease in mortality (20 lives saved); an 8-percent increase in compliance with the ventilator bundle standard of care provision; and a 100-percent improvement in documentation compliance.
Because of the Providence Alaska Medical Center’s eICU team’s ability to document strong patient care improvement gains through solid planning, good execution, and innovative leadership, the CMIO and CIO judges representing Healthcare Informatics and AMDIS awarded the Providence Alaska team its first-place award in the first Healthcare Informatics/AMDIS IT Innovation Advocate Award program earlier this month.
Following her in-person acceptance of the award on May 13 in San Francisco, Cecilee Ruesch spoke this week with Mark Hagland regarding the development and ongoing management of this innovative clinical informatics/care management initiative. Below are excerpts from that interview.
Tell us about the origins of the initiative and your team’s core strategy in creating it?
It really evolved forward out of necessity. We knew, as we were activating our new eICU, that there would be a time when our intensivist group was trying to recruit new physicians, and wouldn’t be able to fully support the [ICU] unit and the eICU. So we knew that there would be a period of time when the eICU would be staffed by nurses only; so this came purely out of necessity. Given the situation, we made the decision as an implementation group to just go ahead and activate. We had planned for five months of nurse-only-staffed eICU, but it ended up being eight months during which we were nurse-staffed only—from January 22 through September 1, 2009.
What were some of the potential challenges involved, and how did you handle those challenges?
We identified some things we were looking at, including acceptance among bedside staff, as well as looking at patient outcomes, especially around mortality, length of stay, ventilator bundle compliance, several factors we mentioned in our submission to the awards program. And we weren’t sure whether or not we’d make a difference at all. And some things we saw an impact in, and others we didn’t. But all the advances we’ve made in care management and outcomes have come out of everyone working together—the bedside caregivers, including the intensivists and ICU nurses, plus the eICU team, and physical therapy, respiratory therapy, and pharmacy.
Had you reviewed the literature on eICU development?
Yes, we had looked at some of those studies, and took some of those metrics, and looked at the eICUs structured with intensivist and nursing support, so we looked at some of those metrics—lengths of stay, mortality ratios.
Cecilee Ruesch, R.N., and HCI Editor-in-Chief Mark Hagland at the IT Innovation Advocate ceremony.
What turned out to be the most difficult elements in your initiative?
I think that probably the most difficult things were building those relationships of trust, and trying to figure out how to work in the eICU as part of the team. We tried to not impact workflow at the bedside, but doing so does require a bit of extra effort, including improving communications—it requires calling with updates and communicating between the two sides.
Where were the nurses located who were monitoring electronically and remotely?
They’ve been working out of the physician offices on campus, about a five to 10 minute walk from the adult critical care unit.
Let’s talk about the staffing of the ICU and eICU. How many clinicians are involved in each?
We started our electronic monitoring with the 28-bed meg/surg ICU for adults—and the normal ratio in that unit was about 2 patients to one nurse. Usually, we had around 14 or so nurses. And then we had one nurse in the eICU doing the monitoring.
Where do the intensivists come in?
Typically, we have one intensivist in the ICU itself at any one time. That’s enough to support care at the bedside, but not enough to staff the eICU as well.
How did you achieve the positive outcomes in decreases in mortality and length of stay, etc.?
It really was just having that extra set of eyes—just making sure, did the patient have their DVT prophylaxis, or stress-ulcer prophylaxis, with both of those procedures being part of the ventilator bundle of care—in other words, is the patient receiving the level of care indicated in the evidence? And it’s also about the whole team working together. We know that the eICU was one piece of that team.
When did you know that this was working well?
As we continued to go throughout the year, improving the communication and team collaboration, and started to look at adding in the intensivists when it was possible to bring them into the eICU management, we saw improvements, such as an increase in ventilator bundle compliance, over time. And after the physicians came on board in September 2010, we saw further improvements.
What has the biggest lesson learned been?
That everybody can make a difference, that working together as a collaborative team, the bedside clinicians, ancillary staff, eICU, everyone working together can improve the lives of our patients. That’s what all this technology is there for—improving patient outcomes.
Howard Landa, M.D., vice chairman of the board of directors of AMDIS
What would your message be for CIOs, CMIOs, and VPs of clinical informatics?
Just that you should innovate with technology, and make the technology work for what you have.
What’s the total size of your clinician team?
We have about 80 staff in the adult critical care unit—altogether, about 100-plus people were involved in this collaboration.
In terms of intensivist and nurse coverage of the eICU, what is the arrangement?
The intensivists primarily work in the eICU at night, with one intensivist per nighttime shift, while there is nurse staffing in the ICU 24/7. In other words, the nurses are still doing what they had been doing; now, intensivists are involved as well. And we’ve added eICU units to Providence Kodiak Island Medical Center, in Kodiak, Alaska, and Providence Seaside Hospital. in Seaside, Oregon, as well. Those are both critical access hospitals, with about 25 beds each.