The increasing cost of health care and the challenges set forth by health care reform make it imperative that new and innovative models of care delivery are developed to meet the demands of our aging population and to compensate for the inadequate numbers of intensive care physicians.1,2 Quality care delivery in the intensive care unit (ICU) accounts for a large portion of a hospital's operating budget. However, perhaps even more stressful to a health system is the recruitment and retention of staff trained to care for the most complex and highest-acuity patients in our hospitals. Despite the proven benefits of a comprehensive intensivist-led team, consisting of specially trained critical care nurses and board-certified intensivists, only 10% of US hospitals meet the standards for coverage as established by the Leapfrog Group.3,4
The use of telemedicine in the ICU assists in bridging the gap of an intensivist-led team. Leveraging tele-ICU technology in large major medical centers, regional hospitals, and small rural facilities can ease the resources and expenses related to recruitment and standardize care delivery throughout a geographical region, which ultimately decreases length of stay and mortality rate.5 Tele-ICU centralizes care for a region's most critically ill patients by effectively using scarce resources to solidify the care-delivery process into standardized, best-practice modalities. Tele-ICU grants regional medical centers and rural hospitals access, via 2-way audio and video, to an intensivist-led team, enabling patients to remain close to home, while receiving specialty physician and nursing oversight. The benefit specifically to rural hospitals and critical access facilities is access to an intensivist team that would otherwise be difficult to recruit and retain.
Work environment differences between the bedside and the tele-ICU make staff education and buy-in important to the success of a tele-ICU program. The environment of the traditional critical care unit typically has frequent interruptions in workflow. The bedside nurse must try to balance the many necessary tasks that must be completed for each patient, while trying to monitor trends and interpret changes in the patient's physiology. The frequent interruptions and alarms can lead to alarm fatigue and increased error rates.6
The environment in the tele-ICU is quiet and less chaotic, primarily because the monitors do not emit auditory alarms. The tele-ICU staff is able to focus on immediate changes in patient physiology, as well as evolving trends in vital signs and laboratory values. This contrasting atmosphere creates an environment in which the tele-ICU staff is able to recognize subtle changes more rapidly because of less frequent interruption and immediate access to patient data. The tele-ICU team is able to assist the bedside team by providing an additional level of support and clinical surveillance.7 Tele-ICU augments care processes and provides a second set of eyes on each patient in the ICU.
Tele-ICU programs have been able to demonstrate reductions in mortality rate and length of stay. A sentinel study published by Breslow et al8 in 2004 demonstrated a 27% decrease in severity-adjusted mortality rate (APACHE [Acute Physiology, Age and Chronic Health Evaluation] III), a 17% reduction in severitya djusted ICU length of stay, and a 13% reduction in severity-adjusted hospital length of stay. As a result, the hospital's revenue increased secondary to improved throughput.
Despite the proven benefits to decrease mortality rate, length of stay, and complications that have been documented throughout the literature,8-10 widespread adoption of tele-ICU technology continues to be limited by many misconceptions surrounding the purpose and use of tele-ICU technology. This article explores the outcome data published and some of the common "myths" (Table 1) encountered before and after the implementation of a tele-ICU.
Review of Outcomes
Breslow11 provided the historical review of tele-ICU technology, as well as the benefits and improved clinical outcomes. Many patient care improvements, including an Ohio hospital that observed a 38% decrease in severity-adjusted mortality rate, were discussed in this publication.11 A Texas health system observed decreases in severity-adjusted mortality rate in all 5 ICUs, while also experiencing increases in case-mix index, a qualifier for patient severity and a basis for Medicare reimbursement. Finally, a Seattle-based hospital was able to significantly improve ventilator bundle compliance and experienced a drop to zero in ventilator-associated pneumonia (VAP) cases. Other facilities tracked the number of cardiac arrests and were able to report reductions in the overall number of arrests.11 A recent publication in May 2009 concluded that in addition to a reduction in actual-to-predicted ICU and hospital mortality rate and length of stay according to APACHE III methodology, the use of tele-ICUs also resulted in substantial cost savings of nearly $1.25 million, related to fewer transfers, reduced readmissions, and reduced length of stay.10
In contrast, in a study of more than 4000 patients representing 2 community hospitals, Morrison et al12 concluded that no reduction in mortality rate, length of stay, or hospital cost could be attributed to tele-ICU technology. Further examination of this study showed that the level of involvement of the physicians working in the tele-ICU might not have been comparable in terms of level of involvement in patient care as in previous studies. According to the study, "almost 80% of physicians opted for low tele-ICU intervention during wave one compared to approximately 50% during wave two of the study."12(p4) This result has a significant impact on the outcome of the study, because primary care physicians, by virtue of choice, were not allowing the tele-ICU physician the opportunity to provide early intervention and required the tele-ICU physician to contact the primary care physician before delivering or prescribing care.
Separate from mortality rate and length of stay data, substantial outcome data can be collected and reported from a tele-ICU program. Outcome reports such as glycemic control, aggregate ventilator days, vein thrombosis prophylaxis, and blood transfusion data can be collected to assist a tele-ICU program, monitoring many ICUs in the performance-improvement process. Despite the excellent data tools and quality outcomes that are notable in the tele-ICU program, many practitioners have doubts and misunderstandings about what the tele-ICU does and what types of tools it has to offer. The following are a few examples that attempt to separate myth from reality.
Myth:Tele-ICU is "watching" via the camera 24 hours a day, 7 days a week.
Myth Buster:Tele-ICU staff members only use the camera on an as-needed basis or as requested.
One common misconception of bedside staff is assuming the tele-ICU functions as "big brother," watching over their work 24 hours a day, 7 days a week (24/7).13 In addition, some bedside staff may feel that tele-ICU has been implemented to report care gaps and offer no other support in executing the plan of care. This particular myth can lead to lack of buy-in from bedside staff. Hospitals that want to implement tele-ICU into their care models should aim to clearly articulate the purpose and goals of the program to maximize acceptance, use, and patient safety.
The tele-ICU registered nurse (RN) is able to monitor data from many patients simultaneously but is able to visualize only 1 patient at a time with the camera. The technology works by installing equipment into each ICU room. This equipment enables 2-way audio and video, allowing real-time communication between tele-ICU staff and bedside staff, all while vital patient information from the bedside monitor and the medical record is interfaced in the tele-ICU clinical operations room (COR). The data interface depends solely on the types of information systems and technology being used in both the COR and the ICU to be monitored. These systems include, but are not limited to, the type of patient bedside monitor, the type of electronic medical record (if there is one), and the system that the tele-ICU has chosen for monitoring purposes. The data are analyzed for subtle trends, and when a predetermined threshold is met, a visual alarm alerts the tele-ICU staff. The tele-ICU RNs investigate these alarms and, when indicated, relay the information to the intensivist and/or bedside staff. Alerts are also available for abnormal laboratory values, changing creatinine clearance, and sepsis screening.
The ability to have an experienced, intensivist-led team with easy access to patient data provides the bedside staff with a reliable backup. The typical configuration in the tele-ICU allows the care team to view 6 monitors (Figure 1) at once, facilitating the ability to view all relevant patient information at one time. The advantage to this configuration is that the tele-ICU staff is able to assist the bedside staff by quickly and reliably accessing needed patient information, enabling an informed decision to be reached more efficiently. This approach enhances team collaboration, as the tele-ICU RN is able to provide needed information to his or her bedside partner, ultimately improving patient outcomes. For example, the tele-ICU RN receives an alert that a patient's laboratory values are deranged. Having the ability to view the laboratory data, nursing flow sheet, latest progress note, and the patient monitor can help the tele-ICU RN decide quickly about the next step to take. In addition, having access to the appropriate patient information and keeping the tele-ICU RN informed make it easier for the tele-ICU team to provide timely care.
Professional collaboration and communication to facilitate patient care are key elements in defusing the myth of "big brother" watching.7,14,15 Overcoming the resistance that may perpetuate the "someone is watching me" element begins with education, knowledge sharing, and open dialogue between bedside staff and tele-ICU staff. The use of 2-way video communication, available at newer sites, also helps to alleviate fears as face-to-face communication allows the bedside staff to see who is supporting them and realize that they are fellow professionals, perhaps even acquaintances. Openly encouraging visitation between the tele-ICU and the on-site ICUs allows bedside staff to observe, ask questions, and understand the unique workflows in the tele-ICU as well as the opportunity for tele-ICU staff to understand the work environment differences in the on-site ICUs, which may have the most significant effect on alleviating fears.
Myth:Tele-ICU is simply a telemetry unit.
Myth Buster:Tele-ICU is a complex network of data integration and clinical expertise.
Another common misconception is the belief that the tele-ICU has a bank of monitors that displays all patients' rhythms and a technician or nurse is watching around the clock. Although the tele-ICU depends on the ability to retrieve and interface information from bedside monitors, only the bedside monitors of some of the highest acuity patients are continuously displayed in the tele-ICU. Other bedside monitors for less acute patients are interfaced with the software and responded to when an alert is triggered. Again, the situation depends on the setup of the particular tele-ICU and the unit that is being monitored.
Most ICUs have staffing ratios of 1 nurse for every 1 or 2 patients, whereas most tele-ICU programs staff 1 tele-ICU RN for every 35 patients.7,15,16 Although the "ideal" staffing model for the RN in the tele-ICU continues to evolve, the tele-ICU RN can be responsible for monitoring upward of 50 to 60 patients at one time, depending on the tele-ICU program goals and scope of tele-ICU involvement in care. The tele-ICU RN staff members spend much of their shifts interacting with the bedside staff as well as intervening on alerts triggered by the system and reviewing patient charts for care gaps. The priority of tele-ICU RN responsibilities would make it difficult for the tele-ICU to function as a telemetry unit, which is not the purpose of the tele-ICU.
Typical business intelligence tools included in the tele-ICU software are built on adult algorithms and are continuously analyzing vital signs directly from the patient's bedside monitor. This alerting system focuses on patients' vital signs and trends, including changes in heart rate, mean arterial pressure, oxygen saturation, and respiratory rate. Changes in patient data described previously trigger an alert not only once the value is outside a set parameter but also when there is a change in vital sign trends. Note that the values are unvalidated, and the waveform morphology of both the heart rate and oxygen saturation is not analyzed by the system; therefore, analysis and interpretation are part of the tele-ICU RN's interrogation of patient data.
Finally, tele-ICU RNs have limited ability and utility in viewing the patient's bedside monitor. Depending on the bedside monitor manufacturer and remote viewing capabilities, the capacity to view the monitor in the tele-ICU may be limited to only 1 patient monitor at a time. Consequently, a tele-ICU RN who is responsible for several ICUs may have the capability to view only 1 patient monitor at a time. For all of the reasons stated previously, the tele-ICU is not a telemetry unit or extension thereof.
Myth:Tele-ICU is only a crisis-intervention tool.
Myth Buster:Tele-ICU is both a crisis-intervention and a crisis-prevention tool.
When notified, the tele-ICU can be effectively used to intervene during emergencies and also prevent a crisis from occurring. The intensivist may serve as the code captain until the bedside code team arrives by assuming control of the room and directing communication and interventions. If the crisis occurs during a time when the tele-ICU is not staffed with an intensivist, the tele-ICU RN is able to make appropriate phone calls to bedside providers and assist with data retrieval so that the bedside staff can concentrate on providing lifesaving interventions.
Tele-ICU programs have been successful at preventing crisis through early detection of physiological instability, prevention of complications, and reliable implementation of best practices.11,17,18 In addition to responding to alerts for changes in patients' physiology, the tele-ICU staff interprets a graphical trend in patients' vital signs (Figure 2). The technology allows the tele-ICU staff to easily visualize and respond to subtle changes in a patient's condition that is progressing slowly and may otherwise go unnoticed. This type of vigilance was illustrated from the outcome data following implementation of a tele-ICU program in a Florida Health System that saw a significant reduction in cardiopulmonary arrest.11
The tele-ICU is also used to detect and emphasize compliance with evidence-based practice guidelines. Assigning responsibility of best-practice compliance to the tele-ICU staff can lead to high rates of compliance and improved outcomes for the patient.11 Examples of improved best practice include compliance to a VAP bundle, sepsis protocols, peptic ulcer prevention, and venous thrombosis prevention.18,19 The tele-ICU staff review the patients' medical chart routinely to ensure that patients are receiving stress ulcer prevention, VAP bundle interventions, and venous thrombosis prevention when indicated. At-risk patients are also screened for sepsis, and associated treatment protocols are initiated when necessary. Several health systems have been successful in improving outcomes using tele-ICU programs to comply with best-practice guidelines. Hospitals in both Seattle and Chicago observed 95% to 99% compliance with VAP bundle adherence and significant reductions in VAP cases using tele-ICUs to review care bundles and best-practice compliance.7,11 Vendors and health systems have also partnered to begin using tele-ICU programs to initiate automated screening of physiological data to detect early sepsis and deploy sepsis intervention protocols in an attempt to improve protocol compliance and patient outcomes.
The Tele-ICU is an essential tool for both crisis intervention and crisis prevention. The tele-ICU staff is immediately available to assist during a crisis. In addition, the ability to investigate complicated scenarios with minimal interruptions, implement best-practice guidelines, and use physiology trends to monitor patients allows the tele-ICU staff to anticipate a potential crisis and intervene preemptively.
Myth:Tele-ICU decreases bedside staffing needs.
Myth Buster:Bedside staffing does not decrease and, in some instances, may increase after implementation of the tele-ICU.
The Leapfrog Group estimated that providing a dedicated intensivist-led team would save more than 54 000 lives annually in the United States.3 Despite the proven benefits of a comprehensive intensivist-led team, consisting of specially trained critical care nurses and board-certified intensivists, only 10% of US hospitals meet the standards for coverage as established by the Leapfrog Group.3,4 The number of trained critical care staff continues to decline; however, projections indicate that demand will increase over the next several years.20 Leveraging these highly skilled providers and their specialized skill sets through the use of technology will broaden the coverage a team can provide. Traditional models indicate that an intensivist-led team could cover 1 to 2 ICUs in a single facility. Using tele-ICU technology, an intensivist-led team can provide oversight of upward of 100 patients located in several facilities.11,21 Bedside staff may have concerns that implementing tele-ICU technology will reduce the number of staff members at the bedside. The inverse is actually true because tele-ICU, as a quality initiative, was designed to provide a second set of eyes and vigilance monitoring. Geisinger Health System implemented tele-ICU technology in January 2010 and has since added full-time equivalents (nursing positions) to each ICU and the tele-ICU (Figure 3). Essentially, this increase in staff is a result of the increased acuity as determined by APACHE IV results and patient census, which continues to trend upward (Figure 3). As tele-ICU programs are implemented, support staff positions often increase to provide clerical support and dataentry support. As indicated previously, tele-ICU staff can be leveraged over several facilities to add an additional layer of care and bring the intensivist-led team to hospitals that otherwise would not have had this type of resource. Outreach hospitals will need to maintain current levels of bedside staff and ensure that a qualified practitioner is available for bedside procedures, such as intubation and central catheter insertion. Tele-ICU technology also provides hospitals with an opportunity to have virtual mentorship programs and one-on-one consultation as needed, which is especially important for new graduates recently completing orientation.
Myth:Tele-ICU clinical roles are clearly defined and understood.
Myth Buster:Tele-ICU is a new subspecialty, and roles are in a state of evolution.
Staffing models for tele-ICU programs vary nationally. Generally, command centers operate on a 24/7 basis with critical care nurses and support staff. The variation in staffing is mainly attributed to the physician coverage that exists. In some programs, the tele-ICU intensivist (physician) is on site 15 to 20 hours per day. In other programs, the intensivist covers only the night shift.7 Other models exist in which coverage in the tele-ICU is accomplished through midlevel providers such as nurse practitioners or physician assistants. Specifically, the University of Massachusetts is staffed 24 hours a day by mid-level providers, including nurse practitioners and physician assistants, and the staffing is complemented at night by an attending-level intensive care physician, which replicates previously described RNstaffed models.22
The physician, often referred to as the ePhysician or tele-ICU physician, is often board certified or board eligible in critical care medicine or surgery and is credentialed at each hospital that is equipped with tele-ICU technology. A single physician can have oversight of 60 to 125 patients, depending on acuity and level of involvement.11,21 The variation in staffing for physicians is primarily related to the ability of the hospital to recruit and retain physician coverage at the bedside. A common shift duty for the tele-ICU physician begins with virtual rounding to conduct a broad assessment of each patient. Following this rounding, many different tasks must be completed by the tele-ICU physician, such as order entry, changes in the plan of care, admitting and discharging patients, rounding with the bedside care team, and intervening in patient care events.
In most cases, a model is chosen in which the RN monitors patients 24/7. The nurses working in the tele-ICU typically have a minimum of 5 years of bedside critical care experience and are preferred to be certified by AACN Certification Corporation as certified critical care registered nurses, but this is not a requirement for employment in most tele-ICUs. The estimated number of patients that 1 tele-ICU RN can monitor is between 30 and 40 at one time.7,15 Nurses typically work 12-hour shifts and do various activities, such as alert evaluation, data collection, and identification and closure of care gaps. The tele-ICU environment allows nurses to remain focused on details with few interruptions.7
Although traditional bedside clinical roles are well outlined and relatively similar, in the tele-ICU, the actual tasks and thought processes are much less defined and continue to evolve. The tele-ICU staff walks a fine line between intervention and interruption. The finesse of intervention significantly affects the relationship between the bedside and the tele-ICU staff. Each patient care unit may have a unique set of service expectations with regard to the tele-ICU program. Even more complex is that individual nurses may have unique expectations as well. To be most effective, the tele-ICU staff must have clear and unambiguous expectations, including clinical decision pathways and evidence-based protocols that must be in place to avoid role confusion, duplication of work, and, worse yet, care gaps. Although the hard work of conclusively defining the roles in the tele-ICU and defining the collaborative relationship with the bedside staff has begun through work groups assembled by the American Association of Critical-Care Nurses, to date each tele-ICU program and hospital system must individually set expectations and build the relationships between the tele-ICU staff and the bedside staff, which is most effectively accomplished through shared governance councils or work groups including the bedside staff and tele-ICU staff.
Myth: Tele-ICUs are not cost-effective.
Myth Buster:Tele-ICUs have a return on investment (ROI) that is based on cost avoidance.
The decision to spend millions of dollars to implement a tele-ICU is based on providing high-quality care rather than earning profits. Although tele-ICU implementation is costly (Geisinger Medical Center experienced an estimated initial investment of $5 million to $7 million to build the COR and place equipment in all ICUs), the savings realized by improved quality of care delivered makes it a cost-effective strategy in the care of critically ill patients. Tele-ICU care enhances the quality of patient care provided at the bedside. The ROI is based on cost-avoidance strategies, because the Centers for Medicare & Medicaid Services has not yet allowed billing of services for critical care medicine in tele-ICU settings; it has, however, provided current procedural terminology codes to track critical care services delivered, although these are not reimbursed at this time.
Institutions should have significant commitment and investment to begin a tele-ICU program. The challenge is to understand the ROI for the initial investment, the ongoing program operating expenses, and cost for program growth. Cost-avoidance strategies encompass many variables, specifically the expected decrease in length of stay and decrease in mortality rate, which also transcend the overall decrease in hospital length of stay and mortality rate.
The most commonly demonstrated ROI is to decrease the length of stay and mortality rate of critically ill patients. The New England Healthcare Institute and the Massachusetts Technology Collaborative recently published Critical Care, Critical Choices: The Case for Tele-ICUs in Intensive Care.22 This 65-page analysis of tele-ICU technology suggests that "if tele-ICU systems were broadly implemented in Massachusetts the potential benefits to payers could amount to approximately $122 million annually."22 In addition to payer benefits, total implementation costs ($7 120 000) were recovered within 1 year, solely through reductions in length of stay. Furthermore, the net contribution margin by $5400 per case increased as a result of a 20% decrease in average cost per case and several other factors such as a reduction in fee-based payments. On the basis of the increase in contribution margin, University of Massachusetts Memorial Medical Center realized an estimated $25 million ($5400 x 4600 annual cases) return as a result of tele-ICU technology and associated fringe benefits.22
Additional cost avoidance is realized by decreasing the number of patient transfers from community hospitals to large tertiary care centers. Many patients are transferred by helicopter or ground transport to a tertiary center, because many community-based hospitals do not have the expertise or technology to care for complex patients. With a tele-ICU program in place, transfers are avoided with care rendered at the community-based hospital. This strategy serves the tertiary care center by not requiring construction of additional beds and similarly the community-based hospital, because they are able to retain higher acuity patients at their facility. Significant dollars are saved by avoiding the costs of transporting patients by ambulance or helicopter.
Geisinger Medical Center has been able to demonstrate both a clinical and financial ROI after implementing tele-ICU technology. Severity-adjusted data show a decrease in variable costs and an increase in the number of lives saved across 3 critical care units. This analysis is limited by 2 factors: first, the average variable costs are a snapshot in time and can change frequently, and second, several physiological factors that could affect the total expected ICU length of stay data depend on interoperator reliability (consistent data entry). Despite these limitations, a solid platform exists by which to gauge both the clinical and financial ROI. Although Geisinger Medical Center's experience is slightly behind the return experienced by University of Massachusetts Memorial Medical Center, sufficient data embedded in this analysis exist to conclude that the financial ROI is significant if a strong business case is established and there is stakeholder buy-in for investment in this technology.
Financial ROI is not limited to cost avoidance. Many health systems have demonstrated success by using tele-ICU technology as a mechanism to provide outreach to smaller, community-based hospitals. In an outreach contract, community hospitals pay a per-bed fee that incorporates the tele-ICU physician, nursing, and nonclinical salaries as well as the equipment and vendor maintenance fees. The intent is to place the right patient in the right location for the right care. The community hospital's ROI is based on the examples previously provided in regard to length of stay, decreased mortality rate, and the number of transfers avoided. In addition, this contractual relationship often builds referral relationships for critically ill patients, thereby increasing volumes in the tertiary care facility as well as increasing the Medicare case-mix index. Increasing the case-mix index has a positive effect on reimbursement revenue to the hospitals.
Conclusion
The dynamic interfaces that occur within organizations that implement tele-ICU technology are complex. Tele-ICU nurses and physicians are required to become knowledgeable about the technology and must have the ability to assist bedside staff in troubleshooting technology issues. As health care reform becomes a reality, the use of technology-based programs such as tele-ICU may have the ability to enable large health care organizations to reach out to communities that otherwise would not have had access to high-level critical care resources, so that patients would have been required to travel great distances for care. Tele-ICU technology and other telemedicine platforms not only assist in providing effective care but can potentially bend the health care cost curve. Similar technology platforms should be developed to deliver care in other high-risk settings such as obstetrics, pediatric intensive care, neonatal intensive care, and disaster management. Decision-support tools such as those embedded in current software products can become the staple of electronic health records in every health care organization, thereby reducing unnecessary variation and reducing error rates in health care.
Tele-ICU technology has demonstrated a significant, positive effect on patient outcomes, delivery of service, and innovative, cost-effective design. The authors have addressed several myths that surface when implementing remote technology. Although there are certainly other myths surrounding tele-ICU technology, with consistent communication and education, myths surrounding tele-ICUs can be dispelled. Myths aside, the current community of users of tele-ICU technology believe that it adds value to patients and bedside staff when effective and collaborative relationships are nurtured. A unified approach to patient care should be achieved with unrecognizable differences between the bedside staff and the tele-ICU staff. In addition, the value of keeping specially trained, experienced nursing staff and intensivists involved in patient care is paramount to increasing quality outcomes. Last, although the financial ROI is composed of a soft financial return, the return is easily linked to increased quality of care. These myths and fear of the unknown frequently discourage many service providers from deploying strategies that are of significant benefit to critically ill patients.
REFERENCES