Case Study | March 31, 2015 | Ellen McEvoy Together, Intensivists and Tele-Intensivists Achieve Better Results Advanced ICU Care’s Tele-ICU service, where critical care-trained physicians and nurses remotely monitor ICU patients 24 x 7 x 365, can improve patient outcomes and drive operational efficiencies and productivity in the ICU regardless of whether the ICU staffs intensivists at the bedside. Even with intensivists at the bedside, the impact of complementing care provided bedside with additional specialized expertise in an around-the-clock, collaborative care model is readily apparent. The Leapfrog group put the importance of 24/7 care by an intensivist in the spotlight when they established their ICU Physician Staffing (IPS) standard in 2000, citing reductions in both ICU mortality and length of stay (LOS). Advanced ICU Careâ€™s Tele-ICU presents hospital leadership who have intensivists at the bedside an opportunity to bridge the gap between their current level of staffing and the constraints of best practice standards. Direct, Quantifiable Results As a Tele-ICU partner, Advanced ICU Care provides ICU bedside teams with instant access to additional skilled, trained and US board certified/eligible physicians, critical care nurses and robust data collection and analysis. Cooperative care between bedside intensivists and Tele-intensivists drives improved patient outcomes while data accurately measures the direct impact of the collaborative efforts. Advanced ICU Care analyzed the effect implementing their 24/7/365 Tele-ICU model had on their hospital clients that staff intensivists. Comparing measures of the hospitals’ performance prior to the Tele-ICU (baseline) to the first year after the program started, one can gauge the rapid impact additional, around-the-clock intensivist oversight has on patient outcomes and ICU operations. Mortality Length of Stay Case Volume Average Change 22% Reduction 26% Reduction 13% Increase Mortality and LOS In the continuous care 24/7 Tele-ICU model, there is a constant stream of patient data exchanged between Advanced ICU Care and client hospitals. Advanced ICU Care intensivists and critical care nurses continue to monitor patients and carefully track data even when there are intensivists actively providing care at the bedside. This enables the identification of trends in patient conditions, which drives proactive patient care and allows earlier intervention before patient conditions deteriorate further. This active, 24/7 involvement drives reductions in mortality and LOS. In the first year after Tele-ICU activation, Advanced ICU Care clients with intensivists on staff experienced, on average, a 22% reduction in mortality and a 25% decrease in length of stay. As just one example, a mid-sized customer hospital located in the northeast experienced particularly exceptional improvements in mortality and LOS rates by embracing the integration of Advanced ICU Care’s Tele-intensivists with their new intensivist program. The exchange of real-time patient data and ongoing consistent, transparent dialogue drove a collaborative focus on data-centric patient care. In the initial year of the Tele-ICU program, the customer’s mortality and LOS rates decreased by more than 40% and 50% respectively. After the first year of their partnership, the client and Advanced ICU Care continued to deepen their collaborative, proactive approach to patient care and not only maintained the considerable initial impact on mortality and LOS, but continued to experience ongoing annual reductions in mortality rates and length of stay. As further confirmation of the enhanced outcomes, these results were achieved without any adverse impact on overall hospital LOS. Case Volume When patients are in the ICU for shorter periods of time, it is often the case that the ICU will be able to care for a greater number of patients. In addition to the obvious capacity utilization benefits, there are other means by which implementation of a tele-ICU program can serve as a catalyst for case growth. Awareness of the Tele-ICU service in the community can bolster the hospital’s reputation and lead patients to choose the hospital with a Tele-ICU over its competitors. Furthermore, the additional specialized manpower of a Tele-ICU has often provided physicians in other disciplines, namely surgeons, enhanced confidence that their critical patients receive optimal, around-the-clock care and can attract them to provide their services at a hospital with a Tele-ICU. Overall, Advanced ICU Care clients that staff intensivists experienced, on average, a nearly 13% increase in case volume within the first year of the partnership. As another example, an Illinois-based facility saw their case volume increase a remarkable 62% in the first 12 months after implementing Advanced ICU Care’s Tele-ICU program. Advanced ICU Care instantly provided this 22-bed ICU client with the additional specialized clinical power that allowed enhanced collaboration and workload balancing, as well as access to ICU-specific performance data that was not previously available to them. The data and Advanced ICU Care’s experienced focus on best practice measures served as a rallying point for the bedside ICU and Tele-ICU teams to roll up their sleeves together, streamline operations and realize significant clinical and operational benefits. Through continued collaborative focus, even after the initial year of the Tele-ICU partnership, the client continued to experience annual case growth. Enhancing Best-Practices The rapid and subsequent sustained impact of a Tele-ICU on mortality, length of stay and case volume, while significant, is only a portion of the program’s portfolio of extensive benefits. Additional positive results of around-the-clock intensivist monitoring come to fruition with an ongoing collaborative focus on process improvement and further integration of mutually agreed upon evidence-based practice protocols. Advanced ICU Care’s augmentation of its hospital partners’ ICU bedside staff with critical care-trained intensivists and nurses, also contributes more manpower to execute the initiatives. As one example, Advanced ICU Care intensivists work closely and collaboratively with hospital intensivists, pulmonologists and respiratory therapists to manage the care of mechanically ventilated patients. Continuous monitoring by Tele-intensivists prompts the earlier identification of patients’ readiness to be weaned from ventilation and then work with appropriate bedside staff to remove patients from ventilation, reducing the risk of pneumonia and lung damage as well as higher rates of mortality and ICU LOS. Glycemic Control A 24/7 overlay of critical care physicians and nurses enables an acute focus on managing patients’ blood glucose. Advanced ICU Care’s Tele-ICU team support clients’ ICU bedside staff by running reports that flag patients with 2 blood glucose readings over 180 mg/dL. The Advanced ICU Care practitioners investigate underlying causes of the elevated glucose levels and then, together with their counterparts at the bedside, determine the best course of treatment. Better glucose management reduces the risk associated with high blood glucose, including increased rates of infection and sepsis, longer length of stay and periods of mechanical ventilation, and greater risk of mortality after heart attack or cardiac surgery, kidney injury and poor wound healing. Low Risk Monitor While ICUs represent only 10%-15% of a hospital bed census, they comprise a disproportionate percentage of acute care hospitals’ costs, roughly 40%. The high cost of patient care in the ICU is a significant motivator for hospital administration to ensure that their ICU resources are appropriately allocated to the most critical patients. Among the many measures upon which Advanced ICU Care collects data and reports is Low Risk Monitor, which gauges the percentage of patients whose conditions do not warrant an ICU stay. A low Low Risk Monitor indicates the hospital is not misallocating resources to patients that should be cared for in other units. When the Data Tells a Different Story Sometimes the data tells a nuanced story. A 24-bed ICU in the Mid Atlantic area saw a first year decrease in case volume of 21% while mortality rose 22%. While this is not what the average hospital should expect, analysis reveals an extremely positive narrative for the ICU. A decrease in case volume was beneficial for this particular client in the context of a reduction in Low Risk Monitor and ICU Readmissions. The reduced Low Risk Monitor indicates that the ICU was previously treating patients whose conditions did not warrant an ICU stay. By ensuring their ICU resources were appropriately allocated to more critical patients, they admitted fewer, low risk patients into the ICU. The average acuity of the ICU patients on a go-forward basis increased materially, confirmed by increasing APACHE severity scores that measure a number of variables, including age, chronic health conditions, vital signs, and lab values – so the patients that they did treat in the ICU, were truly the client hospital’s sickest patients. Intrinsic Value Other benefits of a Tele-ICU are not as easily quantified, but are nonetheless valuable and can profoundly influence the operations of a finely-tuned ICU, including: Patient/Family Experience: Patients and their families are comforted by the security an extra layer of care provides Bedside Team Satisfaction: Advanced ICU Care’s Tele-ICU deepens a hospital’s bench of ICU staff. Simply put, there is more manpower to do the work, alleviating some of the constraints from the bedside team, allowing for a more fulfilling, lower stress work experience Collaborative Culture: Bedside nurses can avoid disturbing hospital intensivists when they are not on site by collaborating with readily available Advanced ICU Care Tele-intensivists. Advanced ICU Care’s Tele-presence reinforces the work and objectives of the bedside team, supporting the efforts of staff nurses while giving bedside intensivists peace of mind that their patients are well cared for when they are away from the hospital. Conclusion Advanced ICU Care’s 24 x 7 x 365 collaborative care approach to Tele-ICU drives documented improvements in patient care and ICU operations when care is provided in cooperation with intensivists at the bedside, including on average, 13% growth in case volume, 26% reduction in LOS and 22% decrease in mortality. Advanced ICU Care’s around-the-clock model assists client hospitals in achieving The Leapfrog Group’s ICU Physician Staffing standard of 24/7 care by an intensivist, which is right for the hospital, and most importantly, best for their critical patients.