Critical Care Plus: Doing More With Less: The Advantages of an E-ICU’ 

Intensivist-designed system making inroads 

By Julie Crawshaw

Nationally, it’s estimated that patients need the services of 30,000 intensivists. since only about 6,000 board-certified intensivists are available, there’s a big gap to be filled, and one company offering online clinical services has started filling it.

Begun in 1998 by Brian Rosenfeld, MD, and Michael Breslow, MD, former intensivists at Johns Hopkins Hospital, VISICU, Inc. in Baltimore, offers an online comprehensive clinical services program that the company says enables healthcare organizations to save lives, improve outcomes, and reduce costs. The company’s Continuous Expert Care Network (CXCN) recently became the first commercialized offering to meet patient care safety standards set by the Leapfrog Group, a consortium of Fortune 500 companies and other large private and public healthcare purchasers organized to reward hospitals for higher standards for patient safety.

About 500,000 patients die every year in U.S. ICUs, according to Leapfrog’s physician staffing report. The group’s recently announced ICU patient safety standards call for full-time staffing by certified intensivists as a way to save more than 50,000 patient lives annually, nationwide. Rosenfeld’s and Breslow’s initial e-ICU research showed huge reductions in risk-adjusted mortality, length of stay and costs.

Sentara Healthcare, a Norfolk, Virginia-based not-for-profit health care organization that serves Southeastern Virginia and Northeastern North Carolina, began using CXCN on its patients in June 2000 after a year of preliminary work. In its first year of using CXCN, Sentara says it accomplished a 26% reduction in severity-adjusted ICU mortality, a 23% in severity-adjusted hospital mortality for those ICU patients and reduced ICU length-of-stay by about 17%.

"We’ve found that the magnitude of change has been maintained through time discharge," says Gene Burke, MD, Sentara’s medical director for its e-ICU.

Sentara’s six-hospital system, which serves a community of one and a half million residents, has fewer than 20 board-certified medical intensivists and a handful of surgical intensivists, to serve its 150 ICU beds. "We obviously have a huge need," Burke says, Sentara launched CXCN in a 10-bed, tertiary medical-surgical ICU, followed by an eight-bed, tertiary vascular post-operative ICU and two 16-bed community hospitals with combined CCU/ICUs.

Long-Distance Monitoring

CXCN’s technology works from a remote e-ICU site outfitted with a VISICU network and database. Clinicians use the CXCN’s telemedicine technology and smart alarms to monitor and manage ICU patients. There are three parts to VISICU’s program: telemedicine, outcomes analysis and decision support.

The telemedicine, real-time audio-video communication with the bedside and nursing station are monitored through secure landlines into an electronic ICU. One eICU computer screen contains the patient’s medical records, another acts as a slave to a monitor at the patient’s bedside, and one serves as audio-video communication in the patient’s room. "I can do a pupillary exam on the patient even though I’m 20 miles away," Burke says. "I can be wired to 50 ICU beds, nowhere near a hospital."

Burke refers to a fourth monitor as smart alarms, a collection of software programs designed to look at constant, real-time monitoring of vital signs. "If a patient has a significant drop in pulse-oximetry saturations, either an absolute level or a trend from what has been the baseline, the software automatically alerts me and draws my attention to that patient."

The system has similar alarms for heart rates, both for absolute and trends. Other alarms, including one for a small-magnitude drop in blood pressure accompanied by an increased pulse rate and another for creatinine-level changes, are under construction.

CXCN is based on an electronic medical record proprietary to VISICU constructed for critical care units. It has a variety of screens that allows users to see summaries of patient data broken down by organ systems. All laboratory, X-ray and trend analyses remain available on the system, allowing retrospective data analysis to help determine clinical change, a capability Burke points out is not available at the bedside.

"Looking at the monitor in a hospital room, you see only about the last 10 seconds, and that’s it." Burke says. "And once it’s off the screen you can’t call it back."

CXCN, Burke says, can store months’ worth of data, useful for trend analysis. The system also keeps the intensivist physician in communication with other physicians, nurses, respiratory therapists, nutritionists and pharmacists who are at the bedside.

Better Outcomes Analysis

The complexity of the medical database is so great, Burke says, that most hospital systems have not put a lot of money into software tools for analyzing clinical outcomes. "It’s a rare hospital with a system the physician can ask to show how much resource is being consumed for care of an ICU patient with a given diagnosis," Burke says. "Most systems can’t tell you your cost-of-care or complication rate, yet we need those data to understand where we do things well and where we need to do better."

Burke says CXCN uses APACHE III software, a predictive tool for critical care that allows assessing a collection of patient problems to ascertain the most probable outcomes. "We look at our performance compared to that prediction, try to find places where our performance is not what it could or should be," Burke says. "That’s a huge assist."

Burke says that through using CXCN, Sentara has found opportunities for shortening length of stay and significant financial savings. "We are trying to bring evidence-based medicine to the critical care environment," Burke says. "About 92,000 people per year die of avoidable medical complications."

Decision-Support Tool

The Source is VISICU’s proprietary name for the third component of its system, a collection of algorithms and suggested guidelines for frequently occurring critical care problems.

Asking five physicians about a problem will likely result in at least three different answers, Burke says, noting that variability decreases outcomes and increases costs. To counter this, VISICU hired a collection of experts in various organ disciplines and asked them to write succinct literature-based guidelines.

"I have a collection of algorithms available to me in this computer," Burke says. "I enter specific patient data and the program walks me through the decision process, helping me come to the best practice."

Burke also uses the Source as a teaching tool for Sentara’s interns and residents, who can use its bibliography to access articles via the Internet. Thus a resident encountering a problem with a patient in the middle of the night can do a quick read with a selective bibliography and show up for rounds on the following morning with an article pertinent to that problem. "It really facilitates graduate education," Burke says.

(For more information contact Gene H. Burke at [757] 461-0241, or Cheryl Isen at VISICU, [425] 222-0779.)