Hospitals seeking to elevate their Leapfrog scores might want to look to telemedicine, especially if one weakness is intensivists or critical care-trained physicians managing patient care around the clock. A hospital in Georgia has lifted its scores this way.
Leapfrog administrators note that because death rates for patients admitted to the ICU average 10-20% in most hospitals, quality of care for these patients plays a big role in Leapfrog scores. Research indicates that staffing ICUs with doctors specializing in critical care medicine can reduce ICU mortality by as much as 40%.
“Hospitals can earn partial credit for having teleintensivist coverage 24 hours per day, seven days per week with onsite care planning done by an intensivist, hospitalist, anesthesiologist, or a physician trained in emergency medicine,” Leapfrog guidelines state. “Recent evidence suggests that teleintensivist coverage can reduce ICU mortality by 15-30%; however, the impact on patient care is not as significant as the reduction in mortality associated with on-site intensivist coverage. Thus, Leapfrog awards partial credit to hospitals with teleintensivist coverage.”
To earn full credit from Leapfrog, ICUs must be managed or co-managed by intensivists who are present during daytime hours and provide clinical care exclusively in the ICU. In addition, when they are not present on site or via telemedicine, they must return notification alerts at least 95% of the time within five minutes and arrange for a physician, physician assistant, nurse practitioner, or critical care nurse to reach ICU patients within five minutes. (A fact sheet on Leapfrog’s standards for physician coverage is available online at: .)
That is a challenging level of coverage for many hospitals. Those without that intensivist coverage are consistently downgraded on their Leapfrog scores, notes Talbot McCormick, MD, president and CEO of Eagle Telemedicine in Atlanta.
“They find it hard to accomplish Leapfrog scores of A and B. They’re hamstrung from the lack of that kind of clinical leadership and also lacking those professionals who can work in conjunction with other individuals like nurses, respiratory therapists, and hospital leadership,” McCormick says. “Their ability to accomplish some goals in patient quality and safety are hampered if they don’t have this captain of the patient’s care.”
One challenge is the lack of critical care specialists, McCormick says. There simply are not enough to be employed at every ICU in the country around the clock, every day of the year. Even if there were enough to go around, many hospitals cannot afford to employ them for uninterrupted coverage. That is especially true of hospitals with smaller ICUs that typically do not have enough volume to justify the expense. This is where telemedicine can help hospitals make the most of limited resources.
“Leapfrog recognizes the option of having an intensivist available through telemedicine and working with qualified physicians there at the hospital, giving partial credit toward that ideal physician staffing,” McCormick says. “A telemedicine ICU physician, working in collaboration with an on-the-ground attending, can accomplish reductions in mortality and improvement in scores. With telemedicine, we can have one critical care physician who can cover a number of small hospital ICUs, providing them that critical care physician engagement that makes a difference in outcomes, even if none of those individual hospitals could afford their own in-house intensivist.”
McCormick cautions that such an arrangement still requires significant coordination among the critical care physician contacted via telemedicine and the rest of the staff at the hospital. Using telemedicine is not as simple as contacting the distant physician, he says. The same level of communication and coordination is required as if the physician were in house, McCormick says.
Telemedicine was used to improve Leapfrog scores at Meadows Regional Medical Center, a 60-bed, not-for-profit hospital in Vidalia, GA, says Karen McColl, MD, chief medical officer and vice president of medical affairs. For many years, the hospital had not paid much attention to its Leapfrog scores. About five years ago, leaders realized that the scores were receiving more public attention, McColl says. Meadow Regional’s scores were not good.
“We had a revamp of our quality department and made some changes regarding hospital-acquired infections that got those rates down over the past three or four years. That helped our scores,” she reports. “But one item where we were having trouble was ICU coverage, where we were making some progress but weren’t able to get above a C grade. We have employed physicians and two intensivists for an eight-bed ICU.”
Need to Cover Off-Hours
The patient volume was not enough to warrant a third intensivist, McColl explains, and the intensivists also were pulmonologists who saw outpatients. “We were scratching our heads over how to provide that 24-hour coverage without working our two intensivists to death or going into that locums arena to get more coverage,” McColl says. “We looked at the telemedicine option. One concern was that we didn’t want to work with someone who had a great number of providers for us to interact with because that meant credentialing each one. We wanted to work with four to six providers maximum.”
Meadows Regional landed with Eagle Telemedicine, arranging for the remote intensivist to cover the ICU when the hospital’s own physicians were not available. “Our model is that we flip to our telemedicine providers when our own providers are either off or on vacation. We typically average about four to six days per month when we are on telemedicine,” McColl says. “It has worked well, and we have not received any patient complaints regarding the use of telemedicine. Our hospital staff have found it to be a help and a comfort to know that when our own intensivists are not here there is that higher level of care available for consultation and monitoring the patients who are ventilated.”
Implementing the telemedicine intensivist program required coordinating with emergency physicians, surgeons, and anesthesiologists, asking them to participate when the intensivist needed hands-on care that required their skill levels, McColl explains. “If the intensivist needs intubation or line placement of the patient, they’re hamstrung by being remote. We had conversations with each of those services, and they were willing to assist when needed,” she says. “Thus far, it’s been a good working relationship. We also brought our hospitalists into the conversation since they most likely would be the ones with the most direct interaction with the telemedicine intensivists.”
The hospital held implementation meetings monthly at first. Then, as providers were credentialed, the meetings became more frequent, McColl says. Sixty days out from the go-live date, hospital leaders were meeting at least weekly to discuss details. There was a mock go-live date in which the procedures were tested, including the use of the telemedicine device, which primarily is a cart with a computer that provides interaction with the intensivist.
“It has Bluetooth interactivity with a stethoscope and monitor with a camera that the remote physician can control. If he’s talking with the family, he can move the monitor to look at the person speaking,” McColl says. “Patients’ families have found it helpful, and the intensivists do family rounds in addition to patient rounds.”
The in-house intensivists usually sign out at noon on Friday; the telemedicine service takes over until they return on Monday at 8 a.m., McColl says. The telemedicine service might be used for several days during the week and if one of the intensivists is on vacation. After more than a year and a half with the telemedicine intensivists, the only real stumbling block has been financial, McColl says.
“Right now, we are unable to bill for the providers in our telemedicine ICU because they are not credentialed with any of the health plans,” she notes. “We try to improve the return on our investment by being more efficient with our use of the ICU and ventilator days. At some point, we’re going to have to look at how to recoup some of the costs. Telemedicine is moving in that direction with the health plans, but it might take some legislative action ... to get some of these programs billable for services other than just the teleconnection, which is a very minor charge you can bill.”