Case Study | February 18, 2015 | Ellen McEvoy Gaining Physician Support for a Tele-ICU Program Background A mid-sized regional medical center (RMC) in the southeast evaluated their internal programs in pursuit of continuous performance improvement and found that their intensive care unit (ICU) operations could be elevated through additional specialized patient care. Critical care in the RMC’s ICU was provided by primary care physicians and staff physicians, which included hospitalists, a pulmonologist and an endocrinologist. Clinical leadership believed the level of ICU care provided was reliable, but supplementing existing coverage with specialized intensivist expertise would improve overall ICU patient outcomes. Furthermore, medical leadership sought a solution which would also allow staff physicians to maximize their time with non-ICU patients while remaining confident that their critical patients were well cared for. This led hospital leadership to conclude that the RMC could best serve its ICU patients by adding Advanced ICU Care’s around-the-clock Tele-ICU service. With the ICU bedside team as the “first line” of patient care at the hospital, the Advanced ICU Care intensivist physicians and critical care-trained nurses would provide an extra layer of specialized care via tele-technology. The Challenge: Integrating Two Teams Leadership of both organizations recognized the need to address potential concerns of integrating the two clinical teams, including: How will the addition of Advanced ICU Care’s tele-intensivists, nurse practitioners, and nurses impact the role and status of the bedside teams with patients, families and within the hospital? How should the Advanced ICU Care team be most effectively integrated within established workflows such that patient care is enhanced and not disrupted? To address these and any other questions arising it was essential to establish a culture of constant, collaborative communication and transparency between the two clinical teams to build the knowledge and trust necessary to effectively deliver cooperative care once the program went live in April of 2012. The Solution: Collaborative Goals, Improved Results Honed through extensive experience and success with other partners nationally, Advanced ICU Care has developed a systematic implementation program. The RMC and Advanced ICU Care teams collaboratively established goals and determined priorities at regular meetings throughout the process. The leadership teams collectively identified glucose management and mechanical ventilation as initial areas where the addition of intensivists and the broader critical care experience of Advanced ICU Care’s clinical teams, algorithms and protocols would most positively impact patient care. Glycemic Control The RMC already had an established general glycemic control protocol, but wanted to enhance their insulin drip (non-DKA) protocol. The Advanced ICU Care clinical team met on-site regularly with their RMC colleagues to present updated research on glycemic control best-practices and share insights gained from successful glycemic control initiatives at other client facilities. The clinical leadership from both organizations, along with input from the hospital’s Endocrinologist, collaboratively designed the formal insulin drip protocol which was implemented in the 1st quarter of 2013. The redefined goals, additional focus and combined efforts of both teams resulted in improved management of patients’ glucose levels. The Advanced ICU Care nurse practitioners (NPs) identified patients whose daily glucose readings reached a certain threshold, further investigated underlying causes for the elevated glucose levels and then collaborated with their counterparts at the bedside to determine the best course of treatment. 18 months of complete data demonstrate significant results of the insulin drip protocol: Percentage of patient days with average daily glucose greater than 180 decreased 38% from an average of 24% prior to implementation to 15%, the collaboratively established goal in the third quarter of 2014. Average daily glucose fell 11.8% from 152 mg/dL to 134 mg/dL, which is below the ADA’s definition of hyperglycemia. Ventilator Best Practices While the ventilator settings used in the ICU were safely within accepted standards, updated research supported revised best practices. Slight adjustments to ventilator protocols and the addition of around-the-clock coverage in the ICU were expected to notably influence the number of days ICU patients spent on mechanical ventilation. The clinical teams at the RMC and Advanced ICU Care, including the RMC’s staff pulmonologist and respiratory therapists (RTs), thoroughly discussed how best to better manage mechanically ventilated patients. In a series of on-site and virtual meetings, the two teams came together and reviewed current research and reached consensus on joint goals, benchmark guidelines, and logistical details. As part of the joint initiative, the multidisciplinary team would collect and streamline pertinent data to be reviewed by Advanced ICU Cares tele-intensivists. The Advanced ICU Care team would then collaborate with the bedside team to review and as necessary modify ventilator settings as well as discuss the patients readiness to be removed from ventilation. Comparing data prior to the protocol to complete months since the measure was instated, the collaboratively planned, Advanced ICU Care executed initiative drove the following results: Average Ventilator Days: 24% decrease Saved a total of 224 ventilator days compared to APACHE predictions There has been a steady downward in the average numbers of average ventilator days, from 5.2 days to 2.8 days, or a 46 decrease. Prior to around-the-clock intensivist oversight, average monthly ventilator days fluctuated significantly: there was no consistent/predictable pattern, with the longest average monthly duration reaching seven days. Attaining Outstanding Results By partnering with Advanced ICU Care, the RMC added clinical expertise and robust analytic resources. This partnership drove increased productivity and attention to performance metrics, which in turn, enabled particular focus on priority clinical initiatives, including glycemic drip and ventilator protocols. These expanded efforts drove meaningful reductions in average length of ICU stay (LOS) as well as the hospital LOS for patients admitted to the ICU. ICU Length of Stay Hospital Length of Stay Baseline 3.85 days 10.64 days With Advanced ICU Care 3.04 9.15 days Percent Reduction in LOS 21% 14% *The above chart uses data from the first full quarter of the partnership as baseline. Another measure which illustrates the effectiveness of the partnership is how the actual LOS compares to what was predicted. Variables, including age, chronic health conditions, vital signs, and lab values, are collected for each patient and are used in conjunction with the APACHE algorithms to make predictions for expected patient outcomes across a variety of areas. Prior to Tele-ICU implementation, the average patient was in the ICU for a slightly longer duration than was predicted. However, after the Tele-ICU was implemented, the actual LOS was reduced by 21% and patient stays in the ICU were now shorter than the algorithms predicted. Predicted ICU LOS Actual ICU Actual:Predicted Ratio Baseline 3.85 days 10.64 days 1.02 With Advanced ICU Care 3.04 9.15 days .85 Continuous Tele-ICU: Peace of Mind Patient Care With the program up and running successfully, RMC staff physicians in a variety of disciplines benefit from the partnership, including those with varying experience and comfort treating ICU patients. Readily accessible partners (now very much colleagues) with extensive critical care expertise give RMC doctors flexibility and confidence in caring for patients both within and outside the ICU, and comfort in knowing that Advanced ICU Care is always there monitoring RMC ICU patients. Outcomes Initial skepticism regarding the effectiveness of the new Tele-ICU program and concern about how the bedside team’s work would be affected was anticipated. Advanced ICU Care’s current best-practice knowledge and track ecord of success with other clients provided the RMC staff initial encouragement. Regular transparent conversations and on-site meetings provided a forum to collaborate on mutual objectives and integrate Advanced ICU Care’s Tele-ICU team into the existing ICU workflows. Advanced ICU Care’s Medical Director and Client Services team provide ongoing support to RMC via regularly collaborating with bedside team members and hospital leadership, leading grand rounds on current critical care trends, and reporting performance data on a quarterly basis. Most importantly, the patient outcomes have been great. Any initial uncertainty was more than overcome by the positive patient care results generated. The bedside physicians and staff now welcome the heightened level of support and appreciate the elevated level of care their patients receive in the ICU due to the partnership.