Remote Monitoring

As the name suggests, people in intensive care need round-the-clock care. Even a tiny dip or rise in heart rate could mean the difference between life and death. Yet most ICUs are hectic environments where doctors and nurses juggle multiple cases and interruptions at a time. That's why certain hospital systems, such as California-based Sutter Health and Virginia-based Sentara Healthcare, are now using electronic ICU software at eICU centers to provide critically ill patients with an extra layer of care.

The eICU system is part of an effort to bring specialists called intensivists to the bedside of every intensive care patient at all times. Studies show that patients in ICUs that have 24-hour care by intensivists—who are board-certified physicians with a certification in critical care—experience better outcomes. Yet few ICUs are managed by intensivists all day, every day. One reason is that these specialists are in short supply, particularly in rural areas.

An eICU system, however, is a way to allow one or two intensivists to oversee hundreds of patients at one time. An eICU center is an off-site monitoring unit staffed by an intensivist and specially trained nurses. At Sutter's eICU hubs, staff can provide additional support or expertise by using early-warning software, and video and electronic monitoring devices designed specifically for intensive care patients. By carefully watching the patients and tracking their blood pressure and other vital signs, the eICU staff can pick up changes from afar and assist the hospital staff in the care of these fragile patients.

"The chances of a patient coming out of the ICU alive and healthy are much higher with an eICU monitor or a full-time intensivist on site," says Daniel Ikeda, MD, medical director of the Sutter Health's eICU program in Sacramento, which was established in 2003 and oversees more than 100 patients in five hospitals. "Through the eICU, we can now see early warning signs, proactively intervene and thus prevent severe outcomes."

A study published in January 2004 in Critical Care Medicine found that eICU programs were associated with a nearly 30 percent reduced risk of death, as well as shorter patient stays and cost benefits. This reduced death rate is similar to that seen in ICUs that are managed by intensivists.

"If there was a drug that reduced mortality by 30 percent and 80 percent of patients weren't getting it, there would be uproar," says Peter Pronovost, MD, medical director for the Johns Hopkins Center for Innovations in Quality Patient Care in Baltimore.

One patient who had the benefit of an intensivist is Jim Hamilton, a 60-year-old Sacramento resident who was in the ICU at Sutter Memorial in Sacramento for two weeks following two, successive heart attacks last year. Hamilton and his wife, Ruth, say that the staff took the time to carefully explain the presence of the camera and monitoring equipment, and that he and Ruth were comforted by the knowledge that both the ICU staff and the eICU staff were watching him.

"When the doctors or nurses have to leave the room, you feel like you're being left alone," Hamilton says. "But when it was explained that I was also being monitored remotely [by the equipment in the room], I found it extremely reassuring."

Ruth agrees. "A group of people knew what was happening [with Jim] instead of one person, who might miss something," she says. "He could turn over, and they knew it."

Teresa Rincon, RN, CCRN, is an eICU nurse manager in Sutter Health's eICU program in Sacramento, which monitored Jim Hamilton. Rincon is an experienced clinician who now spends her time at a bank of screens off-site in the eICU hub.

She explains that those screens not only monitor but also graph vital signs, and that alarms go off when a patient's heart rate, for example, seems to be trending up or down. That way, health care providers have the option of intervening before the heart rate drops or rises into a dangerous zone.

The eICU nurses also have time to assess what those trends might indicate about a patient's overall health.

"When the nurses are looking at the screens, they don't have the noise, tasks and interruptions they do in the ICU," Rincon says. "They have the time to use their critical thinking skills."

Once the eICU staff obtains permission from the ICU nursing staff, it can also use the video and audio equipment to virtually enter a patient's room and observe and talk to them. Rincon recalls a late-night respiratory emergency an intensivist quickly diagnosed from the eICU using the patient's vital signs and by observing his breathing pattern, allowing the lifesaving procedure to get underway immediately.

Patients at all of Sutter Health's 26 hospitals will be connected to an eICU hub by the end of 2006.

Of course, not every nurse and doctor working in an ICU immediately welcomes the extra sets of eyes that seem to be monitoring their behavior as well as their patient's. Even though the admitting physician still has primary responsibility for the patient's care, the eICU intensivists may hold discussions with the attending physician and nurses to review care. And the admitting physicians are encouraged to delegate the initiation or modification of care to eICU intensivists.

"It's a huge culture shock," Rincon says. "One of the biggest obstacles is getting physicians to talk to each other."

Yet Rincon believes that the eICU system ultimately makes hospital staff more careful and more comfortable.

"It helps us retain physicians and nurses," she says. "It allows physicians to sleep at night by turning over some of their late-hour care by phone to the intensivists. And it helps us keep older nursing experts who we don't want to lose but who might find it difficult to do physical, bedside care on a regular basis." Rincon explains that most eICU nurses work part-time in the eICU center and part-time in the ICU, so the work is less physically demanding.

The biggest benefactors of such collaboration, these experts say, are the patients. Not only does eICU staff have the time to critical assess individual patient care, they also collect data that can be used to compare care given at different hospitals. Care can then be standardized, so patients everywhere can benefit from the approach that works best.

"I am very passionate about the eICU system," Rincon says. "It puts an additional set of expert eyes on a patient who is critically ill…and it improves the care of patients by helping us combine data, as well as our knowledge and assessment skills, to put together the best practices."

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