Author: ROBERT S./Monday, January 07, 2019
by Bryan Maier • firstname.lastname@example.org
BJC | Barnes-Jewish Hospital’s Tele ICU, located at the Meridian building in Richmond Heights, is leading the way in BJC’s virtual care presence. Since its launch in July 2016, Tele ICU coverage has expanded from 36 surgical beds at BJH to 148 beds at BJH, Barnes-Jewish West County, Progress West, Barnes-Jewish St. Peters and Christian hospitals. Along the way, the Tele ICU physician and nursing team has partnered with ICU bedside staff to improve patient outcomes and identify ways to standardize critical care delivery.
“We expanded our full-coverage model to Progress West Hospital in September 2018 and to Barnes-Jewish St. Peters and Christian hospitals in November 2018, adding 42 beds to our current coverage,” says Lisa Konzen, Tele ICU director. “This will be followed by further expansion in 2019 at BJH and other BJC facilities. Missouri Baptist Medical Center, Missouri Baptist Sullivan Hospital and Parkland Health Center will partner with the Tele ICU during the first quarter of 2019, adding another 42 beds to the full Tele ICU coverage model.”
A “full-coverage” model refers to full interface of patient data from Epic, bedside monitors and hardware in every patient room to allow audio/visual connection at a moment’s notice. An “eICU light” mobile cart version has been developed as a bridge in select facilities prior to full implementation.
The timeline of Tele ICU coverage expansion includes:
“Our focus is on integrating the Tele ICU with the bedside ICU care to create a high-performing critical care delivery network for BJC and the region,” says Walter Boyle, MD, Washington University School of Medicine professor of anesthesiology and surgery, an original architect of the Tele ICU program and executive medical director. “Tele ICU is not intended to replace bedside care, but rather to support it. It provides an additional layer of safety and oversight, much like an air traffic controller supports a pilot flying a plane.”
The concept at BJH got started about six years ago, following a visit to see another Tele ICU in action.
This was followed by a more thorough investigation and visits to other Tele ICUs. John Lynch, MD, chief medical officer of clinical operations and chief operations officer at BJH, along with Dr. Boyle, spearheaded this original discovery work. “A lot of time and research went into our decision to move forward with this. We tested the concept of Tele ICU coverage against a control group with no Tele ICU coverage, to validate the improvement in patient outcomes,” Dr. Lynch says. “Quality measures, including patient safety indicators and complications, improved in the units with Tele ICU coverage.”
According to data gathered both before and since the Tele ICU launch, this extra layer of Tele ICU coverage continues to improve patient outcomes. As an example, in just six months, the mortality rate in a patient population identified to have higher mortality than expected dropped a whopping 33 percent — down to the expected level of mortality — since Tele ICU coverage was added. Another example is adherence to ICU best practices intended to prevent complications. This has improved in units with Tele ICU coverage, which has led to a drop in complications in these units.
How it works
The Tele ICU center has four “pods,” each with three workstations. Each workstation features seven large monitors. “The monitors give us direct visual access to all the patient data, as if we were actually at the bedside,” says Patti Crimmins-Reda, executive director of the heart and vascular program at BJH and executive director of the Tele ICU.
The four pods were designed to have a combined capacity to monitor all the ICU patients in BJC’s hospitals, or up to 300 ICU patients. The Tele ICU nurses and physicians monitor patients remotely, or virtually, 24/7, using sophisticated clinical software that provides real-time access to all electronic medical record data, including data from the bedside monitoring devices, and lab test results. This data also is used to provide automated multi-organ acuity scores and trends that enable the Tele ICU staff to focus on the sicker patients and quickly detect negative trends.
While not physically present in the patient’s room, Tele ICU staff can be virtually present using high-resolution tilt and zoom cameras that see every angle around the room whenever needed, upon request or if a potentially important issue is detected. “We can zoom in to readily assess the patient, and even read a patient’s wristband or the list of additives in the fluids being infused,” Crimmins-Reda says.
Each room also has a monitor mounted on the wall for face-to-face conversations between the bedside caregivers and the Tele ICU team. The ICU bedside staff can push a button requesting the Tele ICU staff at any time. Once the button is pushed, the Tele ICU staff are notified of the request and respond immediately.
“Clinical engineering and IS have been terrific partners,” says Konzen. She adds that optimal connectivity and technology provided by the partnership with Philips Healthcare, the vendor of the technology, has been outstanding.
Also outstanding, says Konzen, has been the collaboration between the Tele ICU staff and ICU bedside staff. “We use an integrated staffing model of almost 30 experienced ICU nurses who opt to work all shifts in Tele ICU or rotate in from bedside ICU teams. We also offer shifts to three BJH acute care team nurses. This voluntary split fosters the one-team approach and retains some of our most experienced ICU nurses.
“All of our Tele ICU nurses must have at least five years of ICU experience and critical care nurse certification,” Konzen adds. “Our critical care physicians, who also provide 24/7 coverage, rely heavily on the technology and our nurses’ ability to detect early change and triage quickly. We are all truly dedicated to this care delivery model.”
Using “big data” to improve patient outcomes
The partnership between the Tele ICU and the bedside staff works well because the Tele ICU staff can focus solely on patient data. “The next frontier in critical care delivery is decision support with real-time data analytics, rather than waiting for compiled patient data reports to identify issues and trends,” says Dr. Boyle. “That helps us identify areas for improvement. We are using real-time analytics of our clinical data to provide minute-to-minute support of quality and safety. This enables us to identify outliers that need immediate attention and to provide additional support for both the ICU patients and the bedside providers. We are using this, for example, to ensure our best practices and protocols are being followed. We can then immediately address any gaps in our goal of delivering consistent high-quality care across all of our ICUs.”
In addition, says Crimmins-Reda, “We are able to take the various data points we receive and quickly identify patients at high risk, and conversely, those patients who are ready for discharge from the ICU.”
Not only can the data help providers in real-time — it can also be used to predict future outcomes. “This is going to continue to revolutionize how we deliver patient care for the foreseeable future,” says Crimmins-Reda.
The Tele ICU staff can also see and help manage ICU bed utilization systemwide. This is important to ensure ICU resources are used as efficiently as possible. Dr. Boyle adds, “We want to have options for patient care — if one of our ICUs is full, perhaps another nearby BJC ICU has capacity.”
The goal is to eliminate unnecessary transfers away from BJC facilities by matching patient needs with ICU capability and capacity, particularly in underutilized community hospitals.
Embracing the change
At PWH, permanent Tele ICU equipment was installed in September. “Initially, there was a lot of skepticism from our team about the concept of a Tele ICU,” says Josh Estes, PWH patient care services manager. “But within a week, they embraced it. For our nurses to have the additional resources 24/7 is amazing, especially for a newer nurse. To be able to talk directly with a Washington University critical care physician overnight is terrific for them, and for our patients.”
Sicker patients are staying at PWH, which is energizing and engaging the nursing staff. “Our community and the patients we serve want to remain in our hospitals when possible,” says Lauren Beckmann, chief nursing officer at PWH and BJSPH. “The Tele ICU allows us the access to specialists and advanced ICU care that otherwise would not be possible within the community hospitals. Additionally, our ICU nurses want exposure to more intensive patient care. Our care teams at PWH and BJSPH are energized and excited to learn and develop their practice.”
Estes couldn’t be more pleased with the program and the technology. “Thus far, the technology has been terrific — great connectivity and response from the Tele ICU. I have more issues with my cell phone than with this technology.”
While the total investment thus far for the Tele ICU program has been substantial, the improvement in critical care delivery and the associated efficiencies have already made for a successful return on the investment. “Ultimately, we want to standardize practices in our ICUs across the system where it makes sense. The rich supply of data we receive, real time, in our Tele ICU will guide us in our decisions,” Dr. Lynch says.
Dr. Boyle adds, “The goal is for bedside and Tele ICU teams to see the same data the same way at the same time. This is vital to our pace of innovation and improvement. So is sharing the Tele ICU resources across the system. This will create additional efficiencies and, ultimately, improve patient outcomes. Providing the best care possible is why we all went into medicine and that’s what this is all about.”
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