Michael J. Breslow

VISICU, Inc.

This presentation describes a broad-based effort to redesign a complex clinical environment, the intensive care unit (ICU). ICUs account for about 10 percent of inpatient beds nationwide, although in tertiary-care centers the percentage is higher. ICU patients have the highest acuity of all patients in the hospital; their mortality rate exceeds 10 percent, and their daily costs are four times higher than those of other inpatients. As a result, the ICU represents an ideal target for quality initiatives. ICU patients experience a high incidence of medical errors (1.7 per patient per day in one study), and because of their inherent instability, they are particularly vulnerable to harm from suboptimal care (Donchin et al., 1995). Improvements in care delivery can lead to substantial improvements in outcomes, both clinical and financial.

ICUs also provide major support for other areas of the hospital. Many key functional areas (e.g., emergency department, operating room) send patients to the ICU. If ICU patients are not well enough to leave the ICU, the unit becomes a bottleneck—a common problem in many urban centers—and the operation of other service areas is adversely affected. Thus, improving clinical outcomes in the ICU can improve the overall efficiency of the hospital.

Several trends in ICU care suggest a need for new systems. First, the number and acuity of ICU patients is increasing rapidly, driven primarily by the aging of the population. It is estimated that the number of patients requiring ICU care will double in the next 10 to 15 years. These changes in ICU volumes and the severity of problems are increasing demands on care providers and adversely affecting the operating effectiveness of ICUs and the throughput of patients. At the same time, there are major problems with the clinical workforce. The number of nurses choosing to work in ICUs is decreasing, and the average level of experience of the nursing force is lower than in years past.

In addition, physician coverage is inadequate to meet patient needs. ICUs with intensivists in constant attendance have been shown to have clinical outcomes superior to those of ICUs with other staffing models. The value of these specialists derives both from their expertise and from their constant monitoring and altering of care plans in response to changes in patients' clinical status. Intensivists also serve as the leaders of care teams, coordinating the activities of the many different physicians and ancillary staff who contribute to the care of ICU patients with complex conditions. Despite the clear advantages of this staffing model, less than 15 percent of U.S. hospitals have dedicated physicians in the ICU. There are many reasons hospitals do not have dedicated intensivist staffs, but the biggest problem is a severe shortage of these specialists. Fewer than 6,000 intensivists are currently in active practice. Staffing ICUs nationwide, 24 hours a day, seven days a week, would require 30,000 intensivists. Therefore, most ICUs depend on nurses to detect new problems, assess their severity, identify the appropriate physician, track him or her down, and communicate the nature of the problem—just to get a treatment order.

Despite the shortage of intensivists, the Leapfrog Group, a health care purchasing organization created by Fortune 500 companies to improve the quality of health care, has called for dedicated intensivist staffing for all nonrural U.S. hospitals within the next two years. Leapfrog estimates that broad implementation of this staffing pattern would save 50,000 to 150,000 lives annually. Although the call for intensivist staffing is controversial—after all, how can hospitals meet this performance standard if the resources aren't there—the corporate leaders of the Leapfrog Group want to change behaviors and expectations by sending a strong message that businesses do not trust the health care system to maintain the health of their workers and control the costs. Don Berwick, of the Institute for Healthcare Improvement and a longtime proponent of fundamental changes in health care, put it this way, “Every system is perfectly designed to get the results it achieves.”

There are many points of failure in our current system. The Institute of Medicine (IOM) created quite a stir with the publication in 2000 of To Err Is Human, a report that estimated there were as many as 100,000 deaths each year in American hospitals from medical errors. IOM focused almost exclusively on errors of comission. In ICUs, errors of omission outnumber errors of comission by a large margin. When these errors are included, the number of unnecessary deaths is even higher. Crossing the Quality Chasm, the follow-up report by IOM in 2001, outlined the need for fundamental changes in the way health care is delivered. The basic message was that outcomes will improve only when new systems of care are introduced.

In the remainder of this presentation, the eICU solution, a systematic reorganization of ICU care focused on improving patient safety and operating efficiency, is described. The reengineering of ICU care was initiated by two intensivists (the author and Brian Rosenfeld, the other founder of VISICU, Inc.) who ran a large tertiary-care center ICU for almost 20 years. The eICU solution has two main components. First, technology is used to leverage the expertise of intensivists. A telemedicine-type application bridges the manpower gap by creating networks of ICUs and linking them to centralized command centers (eICU facilities) that are continuously staffed by intensivists and support personnel. eICU care teams, led by intensivists, provide continuous monitoring and timely interventions when intensivists cannot be available on site. The second feature of the eICU solution is the use of technology tools to help both on-site and remote intensivists do their jobs better, more safely, and faster. Specifically, information technology systems are used to identify problems, guide decision making, and improve operating efficiency.

Figure 1 is a schematic drawing of an eICU network, which usually links multiple hospitals within an integrated delivery system (or any geographically proximate aggregation of hospitals) to an eICU facility. The participating hospitals generally care for different types of patients, and the availability and sophistication of on-site physicians and the organization of their ICUs vary. Tertiary-care centers usually have multiple ICUs with very high acuity patients and some dedicated intensivist presence during daytime hours. They frequently have step-down units with unstable patients but minimal physician presence. They also often care for similar patients in the emergency department, at least until they can be transferred to the ICU. Community and rural hospitals generally have fewer ICU beds, less acutely ill patients, and fewer intensivists. Rural hospitals, which often do not have sophisticated ICU resources, attempt to stabilize sick patients and transfer them to larger hospitals. All of these sites may be included in an eICU network, but their needs are different, and the role of the off-site team varies accordingly.

FIGURE 1

Remote-care architecture.

The physical network connecting an eICU to participating hospitals and ICUs must be secure and robust and must have adequate bandwidth to support real-time video. Some hospitals already have such networks, but most do not. In the absence of an existing network, dedicated T-1 lines can be used. Each patient room has a high-resolution camera and a two-way audio system so the eICU care team can see the patient and communicate directly with on-site personnel. In addition, “hot” phones provide ICU staff with immediate access to the intensivist-led staff in the eICU. Other equipment in the eICU includes real-time bedside monitor viewers, an electronic data system, note-writing and order-entry applications, an alerting system, and a computerized decision-support tool. High-resolution scanners are used for x-rays and other images, unless a digital x-ray system is already in place.

Some have suggested that it would be helpful to provide remote patient access to physicians in their offices or at home. We see many advantages to a dedicated staffing center instead. When I (as a physician) am at home, in my office, or on the golf course, I am doing something else, and the staff person in the ICU (usually a nurse) has to detect a problem and decide whether or not to contact me. I then have to stop what I am doing to address that problem. Once the problem has been dealt with, I probably will return to my preferred activity, without providing follow-up. Acutely ill patients need continuous monitoring by people who have the expertise and the authority to initiate therapies and who have nothing to do but oversee the care of patients in the network.

Experience suggests that eICU personnel often detect patient problems before the on-site nurses. We have noticed that nurses in traditional ICUs often are reluctant to ask for help—usually because they don't want to “bother” the physicians (a reaction that may be conditioned by prior inappropriate physician responses to such calls). In addition, ICU nurses today are less experienced than they were in the past, and they may not recognize problems early. Prompt detection is very important because appropriate interventions at an early stage often can restore stability and prevent complications.

The eICU program uses a suite of information technology tools to support the remote team and the on-site team. The core information system collects data from a variety of sources and reconfigures it to optimize data presentation and facilitate physician work flow. The goal is to organize data in a format that makes the information easily accessible so clinicians can see temporal and other associative relationships. As part of this application, we provide note-writing and order-writing applications that allow physicians to initiate therapies and document their actions. We also provide real-time decision support designed for succinct data presentation and real-time use in guiding patient care decisions. Computer-based algorithms provide patient-specific assistance. These decision trees solicit key clinical information and, based on the data entered, provide clinicians with concrete recommendations suited to the situation. Another major focus has been on the creation of an early warning system that provides timely alerts designed to ensure that appropriate actions are initiated as soon as problems begin to develop. The goal is to move away from a system in which correct decisions depend solely on flawless behavior of busy clinicians.

Four key applications have been developed to achieve these goals. The first, called eCareManager, is a physician-focused ICU electronic medical record and tool set for executing routine tasks (e.g., monitoring, note and order writing, care planning, communication, etc.). eCareManager was designed to support the key functions of an intensivist, on site or off site. Data display screens are organized by organ system to provide context, and data are formatted to show changes in key parameters over time. The data density is high to highlight important relationships. Other screens show more detailed information (e.g., laboratory results, medications, etc.) with icons that announce the presence of new information. The overall acuity of the patient is prominently displayed, and this is tied to specific care processes. For example, the most acutely ill patients are reviewed comprehensively at least once every hour by the eICU team. Another screen contains all details of the care plan. ICUs have many different caregivers (e.g., intensivists, consultants, nurses, nutritionists, respiratory therapists, pharmacists, etc.) all providing care to the same patients. Often each member of the care team carefully documents his or her activities, but other members of the team do not take the time to process the information. As a result, communication and coordination are less than optimal. For better integration, we created a single site to document the inputs of team members. The goal is to facilitate information transfer. Our decision support tool, called The Source, was created with the assistance of more than 50 physicians around the country. The Source, which includes approximately 160 acute medical problems, provides succinct summaries of the literature, with an emphasis on diagnosis and therapy. Links to source material are provided for additional detail, but the primary goal is to provide real-time assistance with decision making.

A second important feature is the presence of clinical algorithms that help physicians deal with a specific patient. These algorithms are generally based on published best practices or, if evidence is not definitive, major consensus reports, such as recent publications by the American Thoracic Society and the American Society of Infectious Diseases on the empirical treatment of hospital-acquired pneumonia. These comprehensive review articles have been deconstructed and a series of decision trees created. Based on physician-provided, patient-specific answers to key questions, the user is directed to appropriate recommendations for prescribing antibiotics.

The third major application, Smart Alerts, functions as an early warning system. Remember that all relevant clinical data (e.g., vital signs, laboratory results, medications, etc.) are being stored in a relational database. Whenever new data are entered, they are run against a complex set of rules to determine whether the ICU team (on-site or remote) should be notified of an impending problem. These rules can identify values that are out of range or parameters that have changed by a predetermined amount over a fixed period of time. One example flags patients on heparin if their platelet count drops. The rationale is to alert clinicians to the possibility of an infrequent (but life-threatening) complication.

The fourth application, Smart Reports, also capitalizes on the robust information stored in the database. Smart Reports provides detailed information about outcomes, practice patterns, resource utilization, and clinical operations. For example, a report on the use of deep-venous thrombosis prophylactic therapies identifies the population at risk, shows when preventative treatments were begun during the ICU stay (if at all), and shows which agents were used. These reports, which can detail individual physician practice patterns, become an effective tool for managing change.

The eICU solution is currently being used in five health care systems. The impact on outcomes has been studied formally at Sentara Healthcare, a six-hospital system in Virginia, where the program has been up and running for two years. This detailed study showed a 25 percent reduction in hospital mortality, a 17 percent reduction in ICU length of stay (LOS), and a 13 percent reduction in hospital LOS. The decrease in ICU LOS is attributable entirely to a reduction in the number and LOS of the outliers, which strongly suggests that early, appropriate interventions can prevent complications that prolong ICU stay and lead to outliers.

Cap Gemini Ernst & Young, which performed a detailed analysis of the financial impact of the program, found that hospital revenue went up because of the reduction in ICU LOS, which made room for 20 percent more patients to be admitted to the ICU. Costs of care also fell, through a combination of decreased LOS and improved use of resources. Practice standardization and a reduced illness burden, as a result of fewer complications, are thought to have contributed to the latter benefit. A number of ancillary benefits were also noted: nursing turnover was lower; intensivist lifestyle improved; and the hospital was able to market an innovative patient-safety initiative.

In conclusion, ICUs represent an ideal target for quality improvement efforts because of the high acuity of ICU patients and the high cost of caring for them. Substantial improvements in outcomes are possible, but they require a comprehensive reorganization of existing systems of care. Technology solutions can provide meaningful increases in operating efficiency and quality if they can be integrated effectively into physician work flow. The eICU Solution represents a new paradigm for ICU care that treats the management of acutely ill patients as an enterprise-wide priority and uses a suite of technology applications to reduce errors, standardize practice patterns, and improve operating efficiency. Early results suggest promising changes in clinical and economic performance.