Healthcare executive leaders are faced with an ongoing nationwide shortage of critical care physicians and nurses, otherwise known as intensivist clinicians, and many healthcare leaders project that the workforce gap will only intensify as acuity of illness, complexity of care and healthcare costs continue to rise.
With an increase in the number of critically ill patients, the challenge of meeting this need for comprehensive critical care medicine is being felt at Atlanta-based Emory Healthcare as it is as most major hospitals and health systems across the country.
“The environment in which critical care is delivered is highly technical, IT-rich, and the people who deliver critical care, that would be intensivists physicians and critical care nurses, and also allied health personnel, such as respiratory therapists, critical care pharmacists, nutrition support specialists, they all have had much additional training and are technically very advanced,” Timothy Buchman, Ph.D., M.D., founding director of the Emory Critical Care Center, says.
However, there are a number of forces at work creating challenges for critical care, Buchman notes. “We are running out of experienced professionals. The experienced critical care nurse at the bedside is no longer 30 or 40 years old, and many are now approaching retirement age as are the physicians,” he says. “To make matters worse, those experienced people are mal-distributed and tend to congregate in major cities and it leaves the smaller hospitals in suburban and rural areas relatively thin on that level of experience. If you go 50 miles outside of Atlanta, there are plenty of hospitals that have ICUs, but zero to one ICU physician and the majority of the nurses who work in the ICU may not have specialist critical care training.”
Healthcare leaders at Emory Healthcare, the largest health system in Georgia with six hospitals and 16,000 employees, launched its eICU Center in March 2013 at Emory University Hospital to provide round-the-clock ICU monitoring, and the eICU service has since expanded to all hospitals in the health system. Seeing the success of tele-ICU technology, Cheryl Hiddleson, MSN, R.N., director of the Emory eICU Center and Buchman decided to take this program a step further, about 9,000 miles further. This past July, Emory Healthcare, through its Emory eICU Center, collaborated with Sydney-based Macquarie University’s MQ Health program and technology vendor Philips to roll out a project that delivers remote intensive care services from critical care specialists stationed in Sydney, Australia.
Timothy Buchman, M.D., and Cheryl Hiddleson, R.N.
Referred to as the “Turning Night into Day” program, it’s a three-way partnership using remote monitoring to bring 24/7 eICU care to Emory Healthcare patients in Atlanta. Emory Healthcare critical care physicians and nurses based at workstations at Macquarie University’s MQ Health in Sydney use Philips’ eICU technology to provide additional patient monitoring in the ICU.
The pilot program aims to improve the outcomes of high-risk patients in greatest need of constant observation. Combining daytime critical care coverage in Atlanta with night-time coverage from Sydney provides focused, 24-hour-a-day management of ICU patients by critical care specialists, potentially decreasing the risk of complications and shortening patients’ length of stay, according to Buchman.
By using providers in a complementary time zone –– in this case, Sydney –– to cover the Atlanta eICU night shift, it reverses two of the largest drawbacks of critical care night staffing: a shortage of senior clinicians willing to cover night shifts, and the toll that working nights takes on caretakers and their attention levels, Buchman and Hiddleson contend.
“The senior nurses prefer weekday day shifts. You’re just not as sharp at 3 a.m. as you are at 3 p.m. And at nighttime, it’s usually the newest graduates, the least experienced nurses, the ones who need the most guidance and mentorship,” Buchman says.
He adds, “In any healthcare organization, the most valuable resource that we have is our people. If you look at the medical specialties that are out there, the top of the burnout list is critical care. So, we believe that the efforts we’re making in improving the work-life balance and work-life integration of our caregivers will pay the greatest dividends for our patients.”
Citing the success of Emory Healthcare’s eICU Center, Buchman says, “At one point, we said, ‘What if we were to take our entire eICU operation, the hardware, software, the physical environment, and create a copy of it in Sydney Australia, and then rotate for a period of six to nine weeks, a physician and a nurse down to Sydney, and literally allow them to turn night into day, to deliver care back into the Georgia nighttime from the Sydney daytime?,” Buchman says.
The program is set up to have one physician and one nurse working remotely from the Sydney workstations three or four days a week and working concurrently with two nurses on staff in the ICU in the Atlanta hospitals.
“Thanks to our eICU program we can continuously monitor Atlanta-based patients from MQ Health in Sydney and support the bedside team by recognizing adverse physiology, making critical diagnoses and intervening before those issues become significant problems,” Hiddleson says.
According to Buchman, the cross-global remote monitoring program enables healthcare providers to deliver care to critically ill patients that is more timely as well as more effective, accurate and precise.
While Emory Healthcare’s eICU Center has been in operation for three years, for this particular project, there were considerable logistical challenges had to be overcome, primarily technical and legal challenges, Hiddleson says. “Basically we went through a six month process—concerns about our staff practicing medicine in another country, and whether that involves licensure and credentialing. And, there were concerns about the various liabilities, the health insurance, the liability coverage for practice, all those sorts of legal considerations because it’s an international project, and there are different laws and rules that govern each country.”
She continues, “There were also considerable IT concerns, primarily around security and HIPAA [Health Information Portability and Accountability Act], and protecting PHI [protected health information] for patients, and how we could best make that happen. We wanted to make sure data wasn’t transmitting from here to Australia and somehow living in Australia, or being transferred to some document repository there.”
According to Hiddleson, the solution to that particular challenge was creating a multiprotocol label switching (MPLS) circuit that is end-to-end for a high-performance telecommunications network. “Emory configured both of the circuits, their sort of like routers, so they configured both of them, and the routers are both ours. So the program in Australia is on the existing Emory network to ensure the privacy of all the patients and their information,” she says. “There were logistics challenges about getting that circuit up and built. It took four months to make that happen. This is not something that’s done every day, to get all the parties in the same place, to understand this is the goal and what we’re doing. It took a lot of coordinating, persistently saying, yes, we’re going to do it.”
Hiddleson says she is confident that the remote monitoring and consulting from Sydney is as secure and effective as the remote monitoring system in the eICU Center in Atlanta.
“The providers at the eICU workstations have what I call population level views where they are seeing high-level abstractions of 100 or so patients that they are caring for at a time,” Buchman says. “Those abstractions include alerts, such as out of range lab values, and new admissions coming into the various units. They can drill down, through these population level views, to get very detailed information about each patient that they are caring for. And, literally, at the touch of a button, they can go into high resolution audio and visual communication with the patient and whatever family and caregivers are in the room. We have immediate access to the EMRs and to the PACs systems. If there is an electronic system active at a hospital, then we have it.”
The physicians and nurses on staff in Atlanta have reported seamless interaction with the specialists in Sydney, Hiddleson says. And, she adds, “The primary responsibility still falls on the team members at the patient’s bedside. We’re there as a second set of eyes, with the added benefit of being able to speak directly to the bedside staff, patient and family.”
Project leaders are testing the efficiency of Emory clinicians practicing in Australia as well as the program’s impact on patient well-being. Project leaders also want to evaluate how the initiative improves the lives of the senior personnel, the critical care specialists, who are working remotely in Sydney so there are ongoing efforts to track sleep cycles, mood changes as well as clinician stress as measured by cortisol levels, and overall quality of life, says Hiddleson.
While program leaders do not yet have the results of those studies, Hiddleson says she is receiving positive feedback from the critical care specialists who have worked from Sydney and she has observed improvements in critical care clinicians’ quality of life.
Additionally, program leaders have received positive feedback from hospital staff at the bedside in the Atlanta hospitals. “We’ve gotten feedback such as ‘This physician in Australia had the time to talk to us and gave us an education on a particular drug and how a patient would respond,’” she says.
Future plans may include expanding outreach coverage, and possibly extending the international options for Emory clinicians working in the eICU, Buchman says.
“The notion of a global eICU network is an interesting one,” Buchman says. “I am having some ‘what if’ conversations with colleagues on what it would take to put critical care professionals shoulder to shoulder around the world, local and “visiting expatriates,” so that everyone’s home night-time care could be delivered from somewhere that is daylight. And, when you have critical care professionals working shoulder to shoulder with one another, they tend to exchange information, approaches and ideas, and help to spread the ideas around best practices. In our view, this project is not just about delivering nighttime ICU care during the day, it’s also about some pioneering efforts toward globalizing information exchange around best care for critically ill patients.”
He adds, “To be able to move senior personnel to a bedside anywhere more or less at the touch of a button is really remarkable. When you are thin on personnel, this is a very efficient way to deliver care. And, when you have experienced staff who are approaching retirement and they are saying, ‘We can’t do this anymore,’ even preserving three, four or five years of work productivity has an enormous impact on the nation’s ability to care for this rapidly growing group of patients.”