Written by Lou Silverman, CEO, Advanced ICU and Manu Varma, Head of Strategy, Philips Hospital to Home | December 28, 2015
Originally appeared in Executive Insight online
The introduction of the tele-ICU has proved powerful in generating substantive clinical and efficiency improvements in hospital Intensive Care Units (ICUs) nationwide, beginning with saving lives, reducing length of stay (LOS) and decreasing infection rates and ventilator duration. A key 2013 study1 published in CHEST examined patients who received care at an ICU with eICU technology and highlighted several key takeaways. These patients were:
- 26% more likely to survive the ICU
- Discharged from the ICU 20% faster
- 16% more likely to survive hospitalization and be discharged
- Discharged from the hospital 15% faster
The tele-ICU can also deliver significant operational benefits, such as improved protocol compliance, streamlined workflows and reduced care costs. Tele-ICU can enable hospitals to achieve Leapfrog gold-standard 24/7 coverage by intensivists – doctors specially trained in critical care medicine – despite the growing shortage of such talent.
Enabled through technology that remotely provides patient data and adds analytical data that are often more extensive than those available within the hospital, intensivist-led tele-ICU clinical teams partner with their bedside counterparts on patient care. The ability to extend intensivist expertise outside of the four walls of an individual hospital makes this specialized set of skills available where or when it otherwise might not be. Smart alert technology analyzes patient data in real-time and alerts tele-ICU clinicians to specific patient issues and urgent care concerns. Further, the data analysis enabled through the tele-ICU technology provides a basis for on-going clinical and operational process improvements.
The ROI (Return on Investment) of a tele-ICU program has consistently ranged from 3:1 to 6:1 across a range of implementations. However, achieving this ROI is not as simple as installing remote monitoring technology and watching the financial benefits and clinical outcome improvements flow. Several key areas of attention are critical to achieve the desired goals. Successful tele-ICU programs are dependent on a strong technology base, collaborative and expert staffing, clear process development and close collaboration between the hospital and tele-ICU partner.
Technology is critical, but not sufficient
Technology provides the critical underpinning to a successful tele-ICU, as the engagement of remote clinicians is enabled through the data access and communication tools. The most widely-used tele-ICU technology enables the remote clinician to review patient vital signs, access the patient’s care plan and review test results and medications from afar. Integrated video capabilities can allow the remote clinician to interact in real-time with the patient, the patient’s family and bedside staff, as well as to observe a patient’s physical characteristics and the in-room environment. An accomplished tele-ICU service provider will integrate additional proprietary technology to support a collaborative care model and also enable a range of hospital-customized process workflows.
Leveraging video communication, predictive analytics and data reporting, this comprehensive set of tele-ICU technologies can offer the onsite care team on-demand access to critical care specialists and to specialized comparative data beyond what they might otherwise have available, as analytics and alerting provide key additional capabilities. It also enables the remote care team with real-time access to all the information they might access if they were on the floor. For all stakeholders, this combination can mean reduced mortality rates, reduced risk of in-hospital infection and shorter length of stay.
Collaboration and staffing mix are essential
The availability of board-certified intensivists, supported by the appropriate mix of other critical care clinicians (e.g., advanced practice providers, nurses), is critical to tele-ICU success and thus ROI. Partnering with an experienced service partner provides a hospital access to an existing team of clinicians, accelerating the onboarding process and expanding intensivist resources more quickly than undertaking a recruiting process for incremental bedside staff. Drawing upon multiple tele-ICU operations centers also makes it easier for the partner to meet the staffing challenge and drive ROI, as it avoids reliance on a single geographic talent pool.
Collaborating on patient care plans includes weaving the bedside and tele-ICU teams into a coordinated team, a critical means of delivering the desired care and achieving the targeted benefits. Standard processes, such as managing transfers out of the ICU or ordering tests and medications, must be defined for both on-site and remote teams. Specialized protocols, such as those for sepsis and glucose management, also need to be identified, coordinated and prioritized for tele-ICU monitoring.
As an example, there are more than 750,000 patients treated for sepsis2 each year. Predicting when these patients are at risk for this potentially fatal infection is an around-the-clock job for the bedside care team, and recent Centers for Medicare and Medicaid Services (CMS) guidelines define 3-hour and 6-hour protocols that are challenging to monitor and meet. With the help of a tele-ICU monitoring center and the highly-automated alert prompting that it can enable, the full team can monitor trends, help identify at-risk ICU patients and prevent patient deterioration.
Possibly most important in achieving the desired outcomes and ROI in a teleICU is the care and feeding of a partnership, stemming from hospital leadership and radiating through the clinical, technology and client relationship teams. Successful partnership begins with executive sponsorship that chooses a tele-ICU partner with both clinical and operational goals in mind and then facilitates the launch of a collaborative relationship. A successful implementation includes processes that bring the two organizations together with unified goals.
Ongoing prioritization, measurement and refinement of joint outcomes is critical to retaining a collaborative effort while also objectively assessing results. Tele-ICU partners that have extensive (50+ hospitals) experience in implementing and partnering for collaborative service provide a great advantage to guiding the entire process, especially when this experience is developed across a diverse mix of client hospitals.
Tele-ICU partnership yields clinical and administrative benefits
The most important benefit of a successful tele-ICU partnership is the reduced mortality rate. Measurement is typically based on actual ICU performance compared to APACHE (Acute Physiology and Chronic Health Evaluation)-predicted results, an industry standard which projects anticipated outcomes based on the acuity of patients. Leading partners can see mortality rate reductions as high as 40% vs. APACHE-predicted rates. A second key benefit is a significant reduction in ICU LOS. Not only does the patient benefit from a shorter ICU stay, but, at a cost of $1,200 per day, a 30-bed ICU can save $1.8 million per year by reducing ICU LOS by one day across its 1,500 annual patients.
Another example of the potential for significant improvement in clinical and operational outcomes arises when tele-intensivists assist in focusing on identification of patients ready and able to be removed from mechanical ventilation. Tele-ICU teams can work with staff and respiratory therapists at the bedside to extubate the patients sooner and eliminate unnecessary ventilation days. For example, based on previous findings, improving ventilator management in a 30-bed ICU at a hospital realizing $2,700 per ventilated day could save 794 vent days annually, which translates into over $2.1 million in cost avoidance.
Tele-ICUs can also boost overall ICU performance in other ways. In many cases the addition of a tele-ICU program has resulted in increased ICU bed utilization and the ability to attract and treat higher acuity patients, driving improvements in case mix index (CMI).
Technology + Staffing + Processes + Collaboration = Success
Tele-ICU solutions are increasingly being chosen to improve clinical outcomes while simultaneously addressing the shortage of intensivists, and reducing the cost of ICU care. A successful tele-ICU partnership requires a robust technology platform, a means of providing trained and credentialed intensivist-led teams around the clock, process integration and customization, close collaboration, and both launch and continuing client relationship management. Outcomes can be improved significantly by working with experienced partners who can offer the benefit of previous implementations and the resulting best practices.
