MEDICAL TECHNOLOGY

IT'S EARLY EVENING and a 63-year-old patient who’s breathing with the help of a ventilator in a Health First Intensive Care Unit shows a low blood oxygen level.  Dr. Sarah Neilly checks in, looking over other vital signs and taking a look at the patient to make sure there’s no turn for the worse.

It’s no routine physician visit to the ICU.  Dr. Neilly is miles away at the non-profit healthcare system’s corporate office in what’s known as the Clinical Operations Room or COR.  She’s working the night shift in the VitalWatch eICU® program, an electronic clinical surveillance and management system that essentially puts a critical care expert, also called an intensivist, at the bedside around the clock in all 78 intensive care unit rooms in Health First’s three Brevard County hospitals.  It’s an extra layer of monitoring and clinical care vigilance that augments the care provided by the patient’s attending physician and the bedside care team.

A computer tracks all the encrypted patient data fed in over private, high-speed, dedicated fiber optic lines.  Remotely operated cameras and microphones stationed in each ICU room allow doctors and nurses in the COR to talk with a nurse or look in on a patient if they need to, even zooming in to check eye movement or read a monitor.  The software is designed to constantly check each patient’s condition, comparing it against accepted medical standards and signaling a warning, known as a Smart Alert, if a patient starts to stray from normal.

“If the patient is going downhill we intervene,” explains Dr. Neilly, an anesthesiologist and critical care expert, who came to the Health First eICU® after 15 years working and teaching in the Harvard Medical School’s teaching hospital system. “The fact you’re alerted when things are changing is the key to timely reaction.  Sometimes it’s not anything significant, but what you really want is to be alerted when something’s not right.  Often the bedside nurses can let you know that there is a change in a patient’s status, and other times the eICU® system alerts fire — It all works together for more timely management.   I can’t imagine the hospitals without this.”

That collaboration between technology, the bedside caregivers and the VitalWatch critical care physicians and nurses is at the heart of the eICU®, which came online in June 2004, at that time the first such remote ICU monitoring system in the Southeast and only the ninth in the nation.  The eICU® concept was developed in 1998 by two Johns Hopkins intensivists, Dr. Mike Breslow and Dr. Brian Rosenfeld who compared it to America’s air traffic control system, which allows a relatively few highly trained experts to monitor and manage the safety of airline travel.  They incorporated their idea under the name VISICU and hold a copyright on the term eICU®, installing their first commercial system in 2000 at the large non-profit Sentara Healthcare system in Virginia.

Health First Executive Vice President & COO Larry Garrison heard about the idea from a Sentara colleague and invited him to present the idea to Health First’s Board of Directors.

“The cost involved was substantial, but everything we read and understood from the few other hospitals that had an eICU® at the time was that it really enhanced the overall care of patients,” recalls William T. Brennan, now the Board’s chairman.  “The proof is in the outcomes.  Data would indicate that it has decreased the mortality rate and how do you put a price on that outcome?”

That data is tracked by pulmonologist and critical care expert James Shaffer, who’s been the VitalWatch Medical Director and also its chief cheerleader since its inception.  In the five-year period starting the year before VitalWatch began and running through fiscal year 2007, the mortality rate in all Health First intensive care units decreased.  At Holmes Regional Medical Center, home to four Intensive Care Units, including one for heart surgery patients, the ICU mortality rate fell 2 percent.  Cape Canaveral Hospital’s 12-bed ICU saw 19.3 percent fewer deaths, with a 35 percent lower mortality rate at Palm Bay Hospital’s ICU.  During that same time period there was a big jump in the seriousness of the ailments that landed patients in the ICU as measured by what the Medicare system refers to as “Severity of Illness.”  About 70 percent of all Health First ICU patients are now at an acuity level 3 or 4, categories which reflect the highest severity of illness.

“Our code rate, that’s the number of people who actually have cardiac arrest in the intensive care units, has dropped. How much is that worth? If it’s your mother, father, husband, son, whoever — that’s worth a ton,” says Health First CEO Mike Means.

“This is a cost effective way to help our sickest patients and they’re quickly becoming a larger majority of our patients,” says Dr. Shaffer, who in addition to working multiple shifts in the VitalWatch COR, continues to treat critically ill patients at the bedside.  “I feel like a mini Paul Revere, and so do many of my colleagues, running through the day trying to spread the word, do your job well and sell the concept.”

Winning Over Physicians And Nurses
Dr. Shaffer’s first sales effort was aimed at his colleagues at the bedside, some of whom were initially skeptical. “What’s helped make the difference with physicians who use the units and interface with the eICU® is time and patience,” explains Dr. Shaffer, who has been recognized nationally for clinical results and operational/adoption success of the VitalWatch program. “We weren’t going to take over their patients, we weren’t going to cost them money and we weren’t watching over them and writing up a report.”

Dr. Peter Spies, a kidney specialist with Brevard County’s largest physician group MIMA, was won over almost immediately.  “I was a little bit hesitant in the beginning because it was a new system, but I gave them the benefit of the doubt,” he says, admitting that a huge benefit is not being awakened in the middle of the night with a call from an ICU nurse.  “Even if I’m on call and know the patient, I have to go back and forth with the nurse to get the information I need, while the intensivist in the COR has the information right there to make the decisions. You get to the ICU the next morning and you see that what was done in the middle of the night by the eICU® was very appropriate and helped your patient, and you were able to sleep through the night without intermittent calls and worries.”

Ask nurses about contacting some physicians after hours or at night and mixed in with the stories of reaching cooperative doctors you’ll hear tales of pages that went unanswered, calls that took too long to be returned and even about times they were yelled at for bothering a doctor with something he or she considered minor.

“There have been many situations when a patient has started to worsen and because we can contact the eICU for an immediate real-time response I know we’ve prevented some code situations,” says Barbara Seymour, RN, who works three overnight shifts each week in the Cardiovascular ICU at Holmes Regional Medical Center.  “At first you kind of wonder how effective can this be with them looking in on a camera or talking over a microphone, but those first times you use it and you see how engaged and helpful the eICU staff is, all that goes away.  It’s an indispensable tool for us to have.”

Cape Canaveral Hospital ICU nurse Bob Deamer, RN says the quality of patient care is enhanced because the eICU serves as a double check.  “They might be looking through lab work and see a level that’s off and they’ll call us to see if it was addressed,” says Deamer.  “They have called us before and asked us to check a patient who they might have seen via the camera trying to climb out of bed, even before it triggers the bed alarm.”

Both long-time nurses say the eICU physicians are invaluable when they have what nurses refer to as “a bad feeling,” a trend that concerns them, but not enough to wake up a doctor.  It’s a lot easier to make that call to an intensivist in the COR who’s being paid to be awake and alert overnight.  “You call the eICU intensivists and they’re very open to what you’re telling them about the patients,” says Seymour.  “It’s not just that we trust the doctors and nurses who are there, but it’s that they trust us.  It’s a wonderful professional interaction.”

Nurse Retention Tool
Nurses on the day shift also sing the praises of VitalWatch.  Elena Hamant, RN, BSN, now works the 7 a.m. to 7 p.m. shift at Palm Bay Hospital after working overnight at another hospital that did not have an eICU®.  “At my previous hospital, every night  it was necessary to start a to-do list for the day shift,” recalls Hamant. “You don’t really like to do that, but unless you call the patient’s doctor in the middle of the night to get orders, you don’t have a choice.”

“Here at Palm Bay Hospital, I come in each morning and electrolytes are replaced, DVT prophylaxis has been started (to prevent blood clots), all those things are done in a timely manner at night, and it just makes my day so much easier,” said Hamant.

Plus that stepped up level of overnight intervention enhances the quality of care for patients.  “It is the combination of dedicated clinical and operational expertise and the specialized VISICU clinical software features that makes the Health First VitalWatch service unique.  The software can detect subtle changes, particularly those changes for the worse, which might be so subtle that we wouldn’t pick them up. At the bedside it may take time to detect a change because you’re not looking with a human set of eyes at every parameter, every minute of every day,” says Mike Means.  “Most of the ICU patients go downhill very slowly and that’s where the danger comes in because nurses are deciding whether to wake up the doctor at home for this or should I watch it for another couple of hours.  With immediate access to an intensivist in the eICU® the nurses don’t have to grapple with those types of decisions.”

During the daytime hours, from 7 a.m. until 5 p.m. when the patients’ doctors and critical care specialists are readily available in the hospitals, experienced critical care nurses handle eICU® monitoring, a staffing decision Hamant appreciates.  “Sometimes you see something curious or you just have that gut feeling that something’s going on, but you don’t necessarily have anything to call a physician about because there’s not real, tangible evidence. So we’ll punch the button and we’ll get the nurse working that day and ask what they think.  It’s like having another experienced nurse in the unit at all times,” says Hamant who also says that she would now never work at a hospital without an eICU®.

Dr. Shaffer surveyed bedside ICU nurses, asking them to rank such things as whether they thought the eICU® had improved the quality of patient care, plus whether it has improved nursing morale in their ICU and made their job less stressful. On a scale of 1 through 5, every nurse who responded picked the highest ranking of 5.  “Nurses truly drive the plan of care,” says Dr. Shaffer.  “As physicians we can write orders and request treatments, but it’s nurses who make that happen.”  Physicians on staff at all three Health First hospitals also gave VitalWatch near perfect ratings when they were asked about its effectiveness and value.

“Data would indicate that it has decreased the mortality rate and how do you put a price on that outcome?”

— William T. Brennan, Health First Board of Directors

Evidence-based Medicine In Action
The Smart Alerts and trending analysis built into the eICU® are based on what’s called evidence-based medicine, which essentially means treatment processes that are influenced by the latest, best practices proven to work through medical research and clinical practice. The goal is consistent, high quality care provided to every patient, every time.

“With the eICU® you’re able to get the same standard of care throughout all of our ICUs and that standard is very high,” says critical care nurse Mike Gavigan, RN, who recently became the VitalWatch Operations Manager.  “It’s really changed the way we practice.  Before the VitalWatch program, on the ICU night shift we pretty much just tried to keep people alive until the day shift came in and the doctors came in.  Now they’re actually able to implement and direct the plan of care at all hours. We implement a lot of new therapies and evidence based medicine a lot of times during the night.”

One example of that is managing patients who are breathing with the help of a ventilator.  Although a life-saving process, research has shown that mechanical ventilation increases the chance of developing pneumonia.  The evidence-based standard is now to wean patients from the machine as soon as their condition allows.

“If you call an ICU at 4 a.m. and speak to the respiratory therapist assigned to that unit and ask if there is anybody who can come off the vent, it’s like fishing and you’ll get a couple of definites and some maybes, and all you need to do is tee them up with a weaning trial.  If you start that at 6 a.m. you can potentially have them off the vent a whole 12 to 18 hours sooner,” explains Dr. Shaffer.  “The majority of physicians are delighted that we’re helping expedite care.  It’s not always that I’ll give an order to take them off the vent.  In fact, it’s not good practice to remotely take them off the vent and then go home.  What I’ll do is help to set the stage for the patient to come off the vent so when their bedside physician comes in they have met the clinical criteria and they’re ready to come off.”

Starting that process overnight has helped to decrease the risk of ventilator complications like pneumonia, and also saved Health First money.  Ventilator utilization started dropping as soon as VitalWatch came online, and in 2008 it declined another 5 percent, adding up to as much as a 50 percent reduction in ventilator usage in some Health First ICUs.  Dr. Shaffer says a conservative estimate of the savings is $1,000 for each day a patient is off the machine, which equaled a $100,000 savings last year and $600,000 in the four years prior.

“It’s hard to quantify, but it is very evident that those interventions are getting the patient out of the hospital sooner or getting them off a ventilator one or two days earlier and those things are huge differences,” says Gavigan. “Critical care is about those small, minute details that all together add up to whether somebody makes it out of the ICU or not.”

Combining Evidence And Clinical Expertise
As evidence-based medicine becomes the norm in healthcare settings, there is still the commitment to integrate the individual clinical judgment of physicians and other caregivers, avoiding what critics sometimes call “cookbook medicine.” VitalWatch and its intensivists have come to be the clearinghouse for critical care treatment standards throughout the Health First system. They have a long list of accomplishments in that role, including helping to develop infection prevention standards, implementing a new cold therapy for Sudden Cardiac Death survivors (CLICK HERE FOR STORY) and coordinating the Fundamentals of Critical Care Support class (FCCS), which teaches healthcare workers who’re not critical care experts the basics of caring for these sickest of patients.

One of the first physicians to sign on as a VitalWatch intensivist was Dr. Jon Johnson, a trauma surgeon at the Holmes Regional Trauma Center and a critical care expert who still treats ICU patients at the bedside in addition to working an average of 14 overnight shifts each month in the eICU®.

“I was interested in getting involved in what I considered cutting edge technology from the beginning and I really believed in it as a way of helping the most patients that I could given the fact that I’m only one person,” says Dr. Johnson. “Essentially what I can do is help the nurses and other bedside caregivers at three different hospitals almost at the same time. Within a five or 10-minute period you can take care of patients at all three hospitals. You could never do that in a real life situation. A lot of times we’re affecting lives and decreasing mortality and not necessarily knowing about it because we’ve prevented something that never happened.”

Dr. Johnson routinely teaches the FCCS class and vividly recalls a weekend session attended by several physician assistants and nurses who work in the Trauma Center. He’d talked about watching for the unexpected complication and mentioned a rare abdominal syndrome that can be fatal. The next day when the students returned to work a motorcycle crash victim came in with two broken legs, but began to suffer cardiac arrest.

“They called me into the room on the camera from the eICU,” recalls Dr. Johnson. “All he had was two broken legs. One of the nurses said his belly’s getting firm and one said let’s measure it because that’s what we were taught in the course the day before. We measured it and the surgeon came in and opened up his abdomen and allowed it to expand and that man went home two weeks later. The course had been developed as part of the eICU training so it all kind of came together in that one night.”

Outsourcing The Vital Watch Concept
In early 2009, Dr. Shaffer and his team of more than two dozen eICU® doctors, nurses and administrative staff will begin marketing the service to other hospitals, a practice already common in other areas thanks to the technological advances of electronic medicine.

“In my home town of Covington, Ind. there’s a hospital being monitored by experts at a hospital in Chicago three hours away,” says Health First eICU® nurse Heidi Hutchens, RN, BSN, who believes in the ability of VitalWatch to save lives. “This is crisis prevention instead of crisis intervention.”

The VitalWatch electronic ICU program costs Health First about $2 million each year.  If it could generate revenue from other hospitals it would obviously help offset those costs, which CEO Mike Means says would be nice but not mandatory for the system, which as a not-for-profit, community-based organization takes a different approach to profit and loss decisions.

“To me that’s a wonderful luxury because it allows you to make decisions that you know in your heart are the right thing for the community, but maybe they don’t have a huge return,” says Means. “There are lots of other programs like OB and neonatal ICU programs — those don’t make money and never have, but what would a community be like if we didn’t have a safe place for mothers to deliver babies and to save babies that weren’t full term?”

It will be a complicated process, with the need to integrate the information technology systems so clinical data can be shared in the same secure, safe way that protects the privacy of Health First’s hospital patients. Dr. Shaffer sees it as the necessary future of critical care medicine because there simply are not enough intensivists to meet the needs. Experts estimate staffing all American ICUs with specially trained intensivists would save almost 54,000 lives, but that would require about 30,000 critical care doctors and there are only about 8,000 now certified.

“There’s going to be a shortage for some time even if you dramatically increase the numbers,” says Dr. Shaffer, who adds that he takes pride in the impact of the eICU® on the entire approach to critical care medicine at Health First. “Going forward I truly believe that this paradigm will be one of the key players in the way we leverage human, technologic and financial resources to help salvage and maintain the quality of healthcare in America.”

Mike Means says this is the year to explore the partnership opportunities, but vows the team has time to find those potential new revenue sources.  “I’ll tell you one thing, forget the dollars, forget the length of stay and all those other things,” he says.

“Our Vital Watch Program has elevated the quality and safety of critical care management at Health First to a new dimension that is now an imbedded component of our organizational culture, and distinguishes us from other systems. Yes, it’s costly, but it’s made a huge difference for our patients, their families, our physicians and nurses,” said Means.

CLICK HERE FOR RELATED STORY: The eICU®: A Patient’s Perspective

Palm Bay, Florida retiree Leo DuFault had survived a quadruple heart bypass operation 12 years ago so he thought he was playing it safe by exercising indoors with a daily walk inside his local Walmart store.

Related posts:

1. The eICU®: A Patient’s Perspective
2. Harris Corp, Health First Form IT Partnership
3. Health First Family Channel Features VitalWatch
4. Health First’s Dr. Jim Shaffer Featured In The Wall Street Journal
5. Foundation Supported By Strong Community Participation

Tagged as: Andrea Capps RN, Antonia Santos, Barbara Seymour, Bob Deamer, Brian Rosenfeld, Cape Canaveral Hospital, Cindy Lavery HUC, Dr. Jon Johnson, Dr. Mike Breslow, Dr. Peter Spies, Dr. Sarah Neilly, eICU®, Elena Hamant, Health First, Heidi Hutchens RN, Holmes Regional Medical Center, HUC, Jackie Brink RN; Leslie Forrest HUC, Jon Johnson MD, Larry Garrison, Lisa Goetz HUC, Mark Pessa MD, MEDICAL TECHNOLOGY, Melissa Haynes RN, Mike Gavigan, Mike Mean, MIMA, Palm Bay Hospital, Robin Cook, Sarah Neilly MD; Mike Gavigan RN, Tammy Dejarnette, Trauma Center, Velda Humeston RN; James P. Shaffer MD, VISICU, VitalWatch eICU®, William T. Brennan