ED uses 'Virtual ICU' to improve patient care

Resuscitation continues as docs, nurses help others

A program that provides "critical care without walls," originally intended solely to support the intensive care units (ICUs) at Christiana Healthcare in Wilmington, DE, has been adapted to support the care of critically ill patients in two of the system's EDs. The staff assert that the program, called eICU for electronic ICU, has enhanced quality of care and speeded the resuscitation process.

The program, provided by VISICU of Baltimore, includes the eCareMobile unit, staffed by intensivist physicians and nurses and two mobile cameras inside the ED. "I believe we are the first ED in the country to use eICU," says Marc Zubrow, MD, FACP, FCCP, FCCM, medical director of eCare and director of critical care medicine for the health system.

When this program was created, it was not designed for an ED setting, says Karen Toulson, RN, MSN, CEN, nurse manager of the ED at Christiana Hospital, Wilmington. "But we felt it had merit, and we have found it really does," Toulson says.

The program was implemented in November 2005. The ED staff use the program to implement therapies such as early goal-directed sepsis care, tight blood glucose control, and normalized blood pressures in neurology patients while the patient still is in the department. The approximate $2.5 million program is funded through the information systems budget.

Intensivist care needed

One of the reasons such a program was needed is that it was difficult providing intensivist coverage for two hospitals: Christiana and Wilmington Hospital, Zubrow recalls. (Full-time intensivist coverage is one of the requirements of The Leapfrog Group, of Washington, DC, which publicly reports on the safety performance of hospitals.)

"We were boarding critical care patients in the ED all the time, and it was clear we needed to improve our continuity of care," Zubrow says. While the ED docs did a great job evaluating and handling initial resuscitation, he says, they were very busy. "Sepsis resuscitation, for example, takes about four to six hours, and they have to move on to the next patient," Zubrow says.

The mobile unit is located right across the street from Christiana. "The critical care nurse sits at a table with a bank of computers, getting patients' real-time physiological data," explains Anita Witzke, RN, CCRN, the operations nurse manager of the eCare virtual ICU. "They can pick up changes in condition earlier than ED nurses, who may be too busy to pick up on them."

Zubrow recalls: "I had an 18-year-old female asthmatic patient one night. She was intubated and stable on the ventilator, but I was watching her through the camera and saw her ventilator flows were getting better." He was able to wean the patient and extubate her, he says, and she was discharged from the ED 12 hours later and "never saw an ICU."

The critical care nurses, who staff the virtual ICU 24/7, all have at least five years of critical care experience, Witzke notes. The board-certified intensivists are scheduled from 7 p.m. to 7 a.m., seven days a week.

Staff are pleased

Toulson says the ED staff "can't live without" the eICU, although it was not that way at first. "The nurses were at first a little hesitant to see the benefits, but we marketed it well with the ED staff and showed what the benefits were," she notes. "Now, they call the eICU staff on their own and say, 'I see this — do you?' or, 'Can you double-check this drip?'"

There was some staff training involved, she recalls. "They were basically taught how the system worked," says Toulson. "The nurses learned what the cameras did and also learned a computer program they can [access] and see what the e-staff sees: trends of vital signs, lab results, and so forth."

Zubrow says the ED has realized most of the anticipated benefits of the program. "There used to be a gap in care between initial resuscitation and when the patients got to the ICU, and we're trying to make that gap go away," he says. "These patients may still stay in the ED as long as they previously did, but they are further along in care." A percentage of those patients now have their conditions downgraded sufficiently so that when beds open, they can go to a regular hospital bed instead of the ICU, he says.

There is also some hard data that show the eICU has helped improve patient safety. Witzke says that as part of the patient safety initiative, there are intravenous medication rounds designed to prevent errors. "In the first six months, we prevented 34 major medication errors," she says.

Sources/Resource

For more information on using a virtual intensive care unit to boost ED performance, contact:

  • Marc Zubrow, MD, FACP, FCCP, FCCM, Medical Director of eCare, Director of Critical Care Medicine, Christiana Care Health System, Wilmington, DE. Phone: (302) 623-0616.
  • Karen Toulson, RN, MSN, CEN, Nurse Manager, Emergency Department, Christiana Hospital, Wilmington, DE. Phone: (302) 733-1629.

For more information on the eICU, contact:

  • VISICU, Baltimore, MD. Phone: (410) 276-1960. Fax: (410) 276-1970. Web: www.VISICU.com.