Telemedicine Implementation in a Hospital for Use by the ICU - Research Paper Example

For the last 30 years, the demand for ICU services has continuous increased in the United s. The average life expectancy has risen, with data indicating that the American population over the age of 65 will increase by about 50% come 2020, and 100% in 2030. As noted by Macdoff, et al (2010) with the increase of, care services. Dow (2011) notes that in 2008, the Leapfrog Group, an American healthcare advisory board, forwarded evidence-based recommendations aimed at improving and enhancing health-care quality, reducing mortality and cutting down on healthcare expenditure. One of the recommendations was to introduce Tele-ICU, to provide a chance to leverage latest technology to deliver the limited resources of intensivist physician as well as nurse know-how to underserved ICU facilities. Tele-ICU system is a reserve that enlarges by making use of technology to improve population based critical health-care delivery in the face of growing giver shortages. Implementation of tele-ICU is been found out to improve the care of ICU patients, reduce mortality rate and the patient stay in hospitals. However, some studies have shown that implementation of ICU-may not necessary result in low mortality rate in ICUs. Hospitals have also to be aware of a number of challenges that accompany the implementation of tele-ICU. Tele-ICU continue to evolve, and a number of programs have shown improved outcomes, while using tele-ICU to monitor and implement specific best guidelines, and the technology is expected to be taken up by more hospitals. The paper discusses in length implementation of tele-ICU and concludes that ICU is a vital technology in improvements of care for ICU patients. Introduction In the United States, over 5.7 million patients are admitted in ICUs every year. According to Macdoff, et al (2010) this costs the government nearly $ 67 billion yearly. Data indicate that the mortality rate average of 10% to 15%, which represents approximately 540 000 deaths annually Macdoff, et al (2010). It is clear that there is need to improve care of these patients. For example, data indicate that clinical outcomes are superior with dedicated intensivist model and yet between 85 to 90 % of hospitals in the United Sates do not use this model even at daytime. Many national patient advocacy groups such as Leapfrog Group identified ICU intensivist staffing as a way of reducing mortality rates. Data clearly indicate that more than 53,000 deaths in the ICU could be reduced if hospital managements implement intensivist standards in all urban hospitals. Currently there is a shortage of intensivists, and this is major obstacle to adopt this care model in most hospital. However, there is high demand for ICU care because of rapid growth as the supply of intensivist is expected to remain constant and this leads to greater shortage of telemedicine systems. These insufficient telemedicine systems make it difficult to meet the new standards of care that were proposed. Experts suggest the use of telemedicine in the ICUs because they view it as a potential way of leveraging present intensivist shortage. Breslow, et al (2004) in their study concluded that implementation of a telemedicine program played a major role in improving economic as well as clinical outcomes. The authors realized that implementation of tele-ICU in the study hospital increased the patient outcomes significantly and this decreased the mortality rate in the hospital’s ICU. There was also a reduction in time that a patient stayed in a hospital’s ICU, and this enabled ICUs to accommodate more patients as compared to before the implementations of tele-ICU. Further, as a result, it increased throughput, hospitals were able to increase revenue because payment of a patient is based upon the diagnoses and not the total number of days that the patient takes in a hospital (Breslow, et al, 2004). The tele-ICU in program was cost saving because the hospital realized more revenue and was able to recover costs of incorporating tele-ICU program. This study paper critically examines the implementation of tele-ICU in a hospital. The paper will begin by explaining telemedicine; it will further examine how the technology can be implemented, the practical challenges, benefits and the future of tele-ICU. Telemedicine Tele-ICU was first described by Grudy et al in 1982, where telemedicine was introduced as an available option way of networking critical care physicians and other care consultants, in hospitals that lacked intensivists (Berenson, et al. 2009). From that time tele-ICU has developed into the systematic application of a continuous monitoring as well as sharing of information and data between the bedside physicians and the monitoring center, using a two-way interactive computer audio-video technology to connect remote tele-ICU technology. Today, there are a number of tele-ICU technology providers among them is Philips-VISICU, that presently has a tele-ICU technology system comprising of 42 health systems, covering 5,900 beds (ranging from 28 to 406 beds). Latest studies show that in America as at 2009, over 1 million patients had been cared though tele-ICU. Staffing and Workflow Though differences in organizational and staffing systems exists among tele-ICU centers in hospitals, the fundamental structure comprises of a central communication center, also referred to as “command center,” installed with high-speed, reliable connections to a number of remote ICUs. Edward (2011) explains that the command centre is staffed and controlled by critical care physicians, critical nurses, physician, extenders and/or administrative support staff. However, at some tele-ICU centers, they have a critical care pharmacist to provide remote ICU pharmacy support (were). As explained by Edward (2011) the number of staff remotely managing and controlling the tele-ICU varies depending on the quality of the critical care beds under the tele-ICU. According to Edward (2011) smaller networks (less than 70 beds), could be covered by just one physician and one critical nurse. Extra staff is added in where beds monitored are more than 70 (Edward (2011). Majority of tele-ICUs offer around the clock nursing services, and physicians are available varying from night presence alone to 24/7 availability. All tele-ICU workstations comprises of numerous monitor screens, enabling clinician to access real-time information and data, that include, bedside monitor data, radiographic imaging, laboratory studies, ventilator parameters, nursing and respiratory therapy flow graphs and physician documentations (Glenn (2006). Through regular rotation, tele-ICU clinicians’ advances “best practice” care, evaluate early symptoms of clinical decompenation as well as assisting with performing care plans as outlined by bedside providers. Extra consultation and management of patients is offered to improve bedside care, for example reviewing and offering education to homecare staffs and those clinicians with less experience. As explained by Love and Whitten (2005) Tele-ICU rounding is prioritized depending on the level of acuteness, with highest acute patients reexamined at least hourly, while patients with lower acuteness are reexamined less regularly. Audiovisual equipments are combined with decision support resources, that include real-time automatic alert systems that outline abnormalities and tendencies in laboratory examinations and physiologic measures (for example, vital signs, urine discharge, renal functioning). Alerts that are collected are evaluated y the tele-ICU clinical staff, and further review is done through the communication with bedside providers. The clinical information of the patient is accessible by the tele-ICU staff as well as the hospital care team (Love and Whitten, 2005). In many combined programs, a single computerized health record is used at the bedside as well as the tele-ICU. Nonetheless, a lot of programs use different documentation systems (paper records included), and thus, depend on fax transmissions together with other ways of sharing information. Glenn (2006) notes that Tele-ICU and hospital clinicians make a contribution to the computerized documentation, entering and evaluating orders and updating progress information, flow sheets and graphs and care plans. A fundamental aspect of tele-ICU is that regular rounding and attention given to recognize “best practice” care could assist avoid deterioration of conditions of critical patients and avoid ICU complications. The degree of involvement of tele-ICU in an a patient’s management is directed by the patient’s degree of acuity, the willingness of the hospital staff taking care of the patient, and decision of the hospital clinical team (Breslow, et al 2004). Bedside physicians could decide to permit the tele-ICU to intercede before getting direct communication during an emergency, or take action as required, under proper documentation of care being given and after looking at the facts. Past experience has shown that outcomes regarding tele-ICU are better in patients whose bedside nurses or physicians agree to higher degree of input as well as management from tele-ICU. As observed by Breslow, et al (2004) tele-ICU is not meant to replace bedside patient care; they notes that bedside providers remain important and necessary. This is because not each intervention can remotely be delivered to the patient, for example medication, placement of endotracheal tube or any other life-saving processes. Tele-ICU is meant to act as adjunct equipment for enhancing patient safety as well as contributing to better cost-effective population-based and individualized healthcare to ICU patients (Breslow, et al 2004). Evidence of the Effect of Tele-ICU on Outcomes In a study carried out by Michelle, et al. (2010) in 2009, it reviewed the results of patients in a 15-bed surgical ICU following implementing a remote intensivist monitoring program. The researchers established a 45% reduction among the severity adjusted ICU mortality, 25% reduction in hospital mortality rate and length of stay (LOS). There was also a 15% decrease in cost. Another study carried out in two hospitals in Sentara and published in 2004 (Michelle, et al. 2010), that examined the application of tele-ICU in medical and surgical ICUs, comparing results among 1300 patients admitted in the baseline period and other 700 patients in the intervention period following the implementation of tele-ICU. The results from this study found out that hospital mortality reduced by 26%, and average length of stay reduced by 15%, while costs reduced by 24%. Edward (2011) explains that in 2004, tele-ICU was established in a rural community in Avera Health System, and its results were published in 2009. In this study, hospitals included a huge tertiary care facility, two community hospitals, four rural regional hospitals and critical access hospital housing 5,100 patients. The study established that in small and critical care hospitals, tele-ICU was able to reduce patient transfers by 37% (to hospitals offering higher degree of care), with nearly $1.25 million being saved. Within the regional hospital, the study established that mortality levels did not change in the two hospitals, but decreased by 5% in third and fourth hospitals. When was severity-adjusted, length of say was decreased in a severity adjusted ICU mortality, reducing the general hospital length of stay. When the results from the tertiary facility and community hospitals, the stay established that tele-ICU implementation reduced length of stay in both ICU and hospital stays. Tele-ICU was implemented by the University of Pennsylvania Health System in its academic surgical ICU, which had 2800 patients that has been managed for over 3 years. Tele-ICU in this university health system reported reduced hospital mortality of 4% (from 11% to 6%). The length of stay in ICU was as well reduced by 3.5 days, while hospital length of stay reduced y 4.4 days following the implementation of tele-ICU. Though tele-ICU was seen to work in the above studies with significant results, two recently studies published in 2010, failed to show a significant result s of tele-ICU implementation. This lack of positive results was attributed to various factors. For example, Macdoff, et al. (2010) explains that one reason could be due to poor integration of tele-ICU into bedside care. In Macdoff, et al. (2010) study, they concluded that in cases where bedside clinicians ’preference was followed, the tele-ICU was limited in its provision of care, and this resulted in the poor results. In a study done by Health Science Center of Texas University based in Houston, referred to Association of Telemedicine for Remote Monitoring of Intensive Care Patients with Mortality, Complications and Length of Stay. The study was done in six ICUs in 5 different hospitals. This study analyzed the records of over 2,000 patients before implementing an ICU telemedicine program as a major health system in the United States and the records of more than 2, 1000 critical patients after its implementation (Michelle, et al., 2010). The results showed that there was no significant overall change in mortality rates, the frequency of complications, or an ability of a patient to leave the ICU at an earlier time. However, they found out that survival rates for adversely affected patients improved in all the studied ICUs. These findings were in contrast with the outcomes in a study of 2004, which indicated that death rates and average lengths of staying a hospital reduced in two adult ICUs in a big tertiary care facility. This was after the hospital adopted a telemedicine system. According to Michelle, et al., (2010), the system they studied consisted of a remote office that was located at the administrative offices in the health system and it was separate from all the hospitals. This system was equipped with audiovisual monitoring equipment and staffed by two intensivists and each was working with two nurses as one technician monitored ICU beds. Computer workstations gave real-time vital signs accompanied with graphic trends, early-warning signals regarding abnormalities in status of a patient, audiovisual connections to rooms of a patient and access to imaging studies and medication administration proceedings. The team of Thomas identified three factors that they believed had an influence on the effectiveness of a telemedicine system in ICU. They included, how to use remote intensivists to change care in the monitored units apply the program, its acceptance by physicians in the monitored unit. Lastly, they considered integration of the telemedicine program and information systems of units that they monitored. For instance, in the research program, most of physicians who were responsible for taking care of patients in the monitored units had to retain control of decisions after affecting their patients but did not let the remote monitors have an authority of intervening situations that were threatening life of their patients. The physicians faxed progress notes from monitored units to the telemedicine system and telemedicine recorded orders into the computer workstations and hence printed in the monitored units (Michelle, et al., 2010). Generally, when telemedicine technology was implemented it did not integrate well with EMRs as it is done in other places. Michelle, et al., (2010) states that another issue for an individual ICU is to look at telemedicine that they have to integrate with other current record systems or if they will require an additional task such as simple printing or faxing. This is a serious issue because physicians and nurses do not have extra time when they skepticism about the value arises. According to Michelle, et al., (2010), a broader definition of telemedicine means anything from consultations of a telephone, video conferences to audiovisual connections at the bedside and real-time vital monitoring signs. For hospitals that consider telemedicine systems for their ICUs, must analyze every study based on its individual merits before fully use it. The physicians in charge must not look it for the first time and conclude that it is good without considering the negative effects it has on ICU operations. Lastly, the barriers that exist are those that prevent telemedicine from realizing its full potential. They are privileging, cross-state licensing and reimbursement. The current health reform legislation and federal communication commission, which have a broadband plan, are likely to make some improvements in this sector. If this issue of reimbursement is addressed, then telemedicine will expand to urban and suburban areas. They are focusing keenly on the issues of shortage physicians, an aging population, and bundled payments that aim at keeping patients healthy. These reduced payments will be a tool of motivating doctors to be a position to find proper ways of giving healthcare (Michelle, et al., 2010). Practical Aspects of Implementing Tele-ICU According to Breslow, et al (2004) the introduction of an external entity into the current care paradigms has numerous challenges that accompany its implementation, maintenance and effecting collaboration from all stakeholders. Careful planning and extensive implementation with all personnel has a great role in influencing the implementation of tele-ICU. Effective engagement of tele-ICU leadership is very important at clinical, information level and administrative levels. The implementers must identify and involve different staff from various department of the hospital. This will enable tele-ICU to be of great value in initial acceptance and ongoing success of this system. This will require frequent provision of outcome data and feedback administrators and bedside clinicians. Mair and Whitelen (2000) state that tele-ICU systems in the United States have an association with large health-care organizations that help in distributing this system to other affiliate hospitals. This is because small hospitals may not have funds and technological knowledge to develop and administer their programs. Networking of small institutions with large hospitals has promoted centralized functioning of tele-ICU program. This defines organization structure for administrative functions, surveillance of program, financial consideration as well as reviewing of health-care practices. The organizations that are using tele-ICU have started to an investigation that target to reach nonaffiliated institutions. However, it is vital to appreciate the difficulty of introducing a significant number of participants to such institutions. A streamlined and uniform use of telemedicine privileges greatly improves efficiency in health-care to reduce waste. For the administration to initiate and maintain an effective tele-ICU program, then it must employ an unprecedented partnership between clinicians and information technology services and it must also involve dedicated-program personnel, and a 24 hour centralized technical support among other issues. In addition, operators do not record all audio or video communication of tele-ICU, and they must maintain strict standards for privacy of a patient at all tele-ICU systems. In addition, to implement a tele-ICU system, the administrator must consider the technology and the scope that will have to cover to clearly plan for it. According to Mair and Whitelen (2000) for technology that is commonly used, the begin cost range from about $30,000 to $50,000 for every ICU bed. A study carried out indicate that a yearly operating cost to cover overhead, staffing, and maintenance are estimated to be approximately 20% of start-up costs (Macdoff, et al. 2010). Currently, there is now a mechanism for patient or assurance billing and compensation for tele-ICU physician services irrespective of prospect from stakeholders that this model will initiate change as the role of telemedicine expands further and mature with time. The affiliated hospitals or health systems must meet the cost of all tele-ICU personnel. Reimbursement for nurses, physicians as well as physician extenders is at an hourly rate but the management can employ full-time tele-ICU providers on a salary basis. Cost savings of a health-care can primarily reoccupy the start-up and operational cost of a tele-ICU program. Edward (2011) in the Sentara health care study indicated a 24.6% reduction in variable cost after implementing a tele-ICU program. According to Edward (2011) there reports, which indicated that for an expenditure of $500,000 for every affiliated tele-ICU bed within their system. This implied that a hospital would save $1,202,379 in its first 25 years after implementation of this system, because it will reduce the need for transfer from rural hospitals to tertiary care facilities. Edward (2011) note that, the University of Massachusetts studied 6,400 patients and they realized a cost saving of $5,000 per patient after implementing of a tele-ICU system. Edward (2011) further explains that the implementation of tele-ICU program in the surgical ICU at the University of Pennsylvania enabled the hospital to reduce its cost by 10% in the ICU lowering of stay. The estimate indicates that the ICU saved $706,272 to $941,697 and $2,134,339 to $2,842,840 for the hospital. Further, as Edward (2011) states, the University of Pennsylvania produced a report, which indicated an increase in revenue after implementing the tele-ICU program. This outcome relates to the role that electronic health record while capturing complexity of a patient and physician activity. However, Edward (2011) recommends that those facilities should consider the severity illness of a patient and quality that the care unit provided. The physicians must think widely about the efforts needed to increase quality in the ICU and not to implement the most expensive technology. There are no better ways to improve on quality in the ICU. Some of the equipments are cheaper with good evidence that accompany them. It is therefore advisable for people to consider other options and all things they can use in order to improve the quality of care in the ICU without implementing telemedicine. The results that hospitals realized after implementation of tele-ICU are stimulating since both surgical and medical ICUs realized improvements. However, this program has number major challenges that it is important to be understood. The use of computer systems and decision support tools and an increased focus on ICU after installing of tele-ICU program is a likely cause that affected results. The clinical impact on hospitals that completely lack intensivist coverage is not likely to be the same. Lastly, small hospitals that have fewer ICU beds because of economies of scale cannot realize financial benefits due to smaller of patients admitted (Breslow, et al (2004). According to Breslow, et al (2004), the resistance of physicians and lack of insurance reimbursement for medical care that use telemedicine pose a great resistance to widespread acceptance and application of telemedicine in the ICU. In addition to this, lack of understanding or recognition for the need of more ICU intensivist staffing made physicians uncomfortable or unfamiliar with this technology. Since health system or the hospital pays all staffing and operating costs of tele-ICU, cash layout for a tele-ICU system is seen as expensive and unnecessary venture in the short-term run. Regardless of these concerns, more than 100 hospitals countrywide have implemented and are using tele-ICU program while on the other hand, others are considering expanding these programs to other high-risk areas in the hospital like step-down units. Future directions for Tele-ICU The extent of tele-ICU continues to evolve, and a number of programs have shown improved outcomes, while using tele-ICU to monitor and implement specific best guidelines. As noted by Mair and Whitelen (2000) The Sutter Health Systems employed tele-ICU as a way of screening severe sepsis, monitoring and facilitating compliance with the surviving sepsis campaign bundles. In Sutter study, they admitted 266 patients to the ICU, and diagnosed with sepsis and they shared management between hospital practitioners and clinicians of tele-ICU. After the incorporation of tele-ICU, administration of antibiotic increased within two hours to 79% from 51% (Mair and Whitelen, 2000). They measurement of lactate increased from 49% to 55% and frequency of baseline laboratory blood drawn increased to 84% from 78%. Further, frequency of blood cultures drawn before conducting antibiotic increased to 74% from 63%. Such improvements in processes of healthcare are associated to previous observation from the same institution. They indicate that implementation of tele-ICU reduced ICU mortality by 21.2% resulting from sepsis with an estimate of saving 56 lives. According to Mair and Whitelen (2000) the Baptist health in Little Rock had a pilot program that utilized tele-ICU to find out patients ready for ICU discharge to facilitate the transfer process. When they this with baseline data, the implementation of this program enabled ICU LOS to reduce by 30% that saved an estimated cost of approximately $3 million. The implementers have incorporated tele-ICU systems into other programs of standardized best practice of care that include sedation practice and blood transfusion policy. These innovative programs indicate the potential role of a coordinated tele-ICU in improvements of a systematic process for large a large population in ICUs at multiple sites. Tele-ICU is also the start of extending to micro systems beyond the ICU such as a rapid response teams, EDS, long-term acute care hospitals and high-risk labor and delivery units. They implemented this system in intermediate care and care units because these departments deal with patients with high levels of acuity that need ICU services. Early communication with intensivists facilitated the extension of tele-ICU technology to other areas. This improves outcomes and hence lowering mortality rate. Further, implementers have extended the tele-ICU to e-hospitals. Macdoff, et al (2010) cites that the International Virtual e-Hospital program that participated in the introduction of e-health education within the public health infrastructure of developing countries like Kosovo. Tele-ICU can influence outcomes in public health emergencies like mass casualty or epidemics. For example Macdoff, et al. (2010) states that the Inova Health System completed a simulation exercise the response of tele-ICU to mass casualty. The framework of tele-ICU was optimal for networking tele-ICU intensivists. On the other hand, trauma surgeons to bedside and on-site providers stabilized the situation of an ailing person from a remote location that is outside the direct area of emergency impact. Effective tele-ICU to respond to disaster provides a potential way for surgical management across many locations in a large geographical coverage. Further, tele-ICU has a potential role in prospective early identification of pandemics. This technology is also best suited in some applications such as tele-pharmacy and tele-stroke systems. The researchers warranted further experience and study with regard to the extension of tele-ICU into these areas. The management is incorporating tele-ICU program into critical care training programs, simulation-based education programs and nursing education. The widespread use of tele-ICU model will have an advantage on learned clinicians with awareness of the role of tele-ICU from both sides of the camera. Conclusion Presently, there is a shortage of intensivists, and this is major obstacle to adopt this care model in most hospital. However, there is high demand for ICU care because of rapid growth as the supply of intensivist is expected to remain constant and this leads to greater shortage of telemedicine systems. Experts suggest the use of telemedicine in the ICUs because they view it as a potential way of leveraging present intensivist shortage. Tele-ICU system is a reserve that enlarges by making use of technology to improve population based critical health-care delivery in the face of growing giver shortages. This technology is a potential mechanism that improves clinical outcomes, reduce health-care costs as well an optimizing efficiency of service providers. Numerous studies have shown the importance of tele-ICU in the hospitals. However, other studies have asserted that the impact of tele-ICU does not necessary improve on above stated benefits. For example, Michelle, et al., (2010) claims that telemedicine is not necessary the best method of resolving specific issues in a particular ICU mostly when the administration considers the cost of technology. This is because it is expensive to adopt and use telemedicine system. They point out that studies have indicated that making proper use of checklists has been effective in preventing catheter-related infections and ventilator that relates to pneumonia that is a less cost solution as compared to implementing of telemedicine. References Berenson, R., Grossman, M., & November, E. (2009): Does telemonitoring of patients- the eICU-improve intensive care? Health Affairs, 28(5), W937-W937-W947: Retrieved from http://login.ezproxy1.lib.asu.edu/login?url=http://search.proquest.com/docview/8 52799410? Accountid=4485 Breslow, M., et al (2004): Effect of a multiple-site intensive care unit telemedicine program on clinical and economic outcomes: an alternative paradigm for intensivist staffing. Crit Care Med, 32:31–38 [1]. Dow, J. (2011): The picture of Health: With critical-care specialists in short supply, remote monitoring offers a high-tech solution: The Wall Street Journal: Edward, A. (2011): The continuing need to investigate the nature and content of teleconsultation communication using interaction analysis techniques: Journal of Telemedicine and Telecare: Royal Society of Medicine press Ltd Glenn, L. (2006): The Moultrie Observer. CRMC marks telemedicine success. Retrieved on 18/09/2011 from: http://moultrieobserver.com/local/x1131433107/CRMC- marks-telemedicine-success Landro, L. (2009): Health care (A special report) - the picture of health: With critical- care specialists in short supply, remote monitoring offers a high-tech solution. Wall Street Journal, pp. R.4-R.4: Retrieved from http://login.ezproxy1.lib.asu.edu/login?url=http://search.proquest.com/doc view/399131147? Accountid=4485 Love, P and Whitten, P. (2005): Patient and provider satisfaction with the use of telemedicine: Overview and rationale for cautious enthusiasm: J. Postgrad.Med.51 (4):294-300 Mair F. and Whitelen P., (2000): Systematic review of studies of patient satisfaction with telemedicine: BMJ; 320 (7248): 1517-20 Macdoff, C., West, B., and Harvey, S. (2010): Nursing Standard, Harrow-on-the-hill. Telemedicine in rural care, Assessing the wider issues: Retrieved on 20/09/2011 from: http://proquest.umi.com/pqdweb?did=72671446&sid=5&Fmt=3&clientld=44044 &RQT=309&VName=PQD Michelle G., et al., (2010): Telemedicine and e-Health: 16(04): 472-479. doi: 10. 1089 tmj. 0169 Read More