Telemedicine is a tool hospitals and health systems can use to improve patients' access to care as well as the organization's access to specialists. Preliminary research suggests that telemedicine may improve patient outcomes. Initial findings in a United Kingdom study, for example, showed telemedicine interventions can reduce patient mortality rates by 45 percent. In addition, the American Telemedicine Association recently sent a letter to CMS urging changes to Medicare's conditions of participation for hospitals that would accept telemedicine staffing for intensive care and other areas. Here is a case study of Ministry Saint Clare's Hospital in Weston, Wis., which achieved high-quality outcomes by using telemedicine in its ICU.
The problem
Rating organizations such as the Leapfrog Group have set a standard of care that hospital intensive care units should have continuous coverage by intensivists. When Ministry Saint Clare's Hospital was preparing to launch in 2005, it was able to recruit only one intensivist due to a shortage of physicians in critical care medicine. However, the hospital wanted to meet the standard of care, as studies that have shown that 24/7 intensivist coverage is associated with better patient and financial outcomes. In addition, the hospital needed to provide appropriate staffing in the ICU to be competitive in the market.
The solution
To provide this coverage, Ministry Saint Clare's partnered with Advanced ICU Care, which was also launching in 2005, to connect to intensivists via telemedicine. Under the agreement, Advanced ICU Care provides intensivists and support staff from its center in St. Louis to monitor patients and provide interventions 24/7. By 2010, the hospital's ICU mortality rates were 33 percent better than predictions by the scoring metric APACHE IV. Compared to APACHE predictions, hospital mortality was better by 26 percent and ventilator days were better by 40 percent. Similar results were found for hospital and ICU length of stay. In addition, Ministry Saint Clare's reported success in nursing recruitment and retention due in part to the tele-ICU program.
How it was accomplished
1. Continuous monitoring and measurement. One of the key elements of success of the tele-ICU program was the continuous monitoring and measurement of patients in the hospital, either by clinicians physically present or those located remotely who were linked via video. This coverage ensures quality care for the patient and support for the physicians, nurses and staff at the hospital. "You can't manage what you can't measure," says Mary Jo Gorman, MD, CEO of Advanced ICU Care. "[The] ability to bring the measurement tools and change management program to hospitals allows them to enhance their performance in the ICU." Continuous measurement enables the clinicians to respond immediately when a patient is in need. As an example, Dr. Gorman says if a nurse stepped out of a patient's room and a remotely-located nurse measured an increase in blood pressure and pulse in the patient via telemedicine, the remotely-located nurse could determine the appropriate intervention and immediately contact the hospital nurse to return to the room and deliver the intervention.
The support of other physicians and nurses in ICU care contributes to successful physician and nursing recruitment and high retention, according to Larry Hegland, MD, CMO of Ministry Saint Clare. "Physicians are recruited here because we have telemedicine for them," he says. "It allows them to have a better lifestyle in a setting where we only have two [intensivists on site]. They can better maintain a balanced family life and professional life, yet know that patients are getting really good patient care."
This support is valuable to nurses as well because when they are responsible for ICU patients they may have difficulty reaching a physician quickly in an emergency situation. "[Through telemedicine], they have immediate access to an intensivist who knows the patient, can intervene and give orders they need right away," Dr. Gorman says. "Once a nurse experiences that kind of security, the nurse does not want to leave that," she says.
2. Quality staff. Another essential component of the tele-ICU program is the quality of staff on both sides — the clinicians who work on-site at the hospital and those who are linked in via telemedicine. In fact, Ministry Saint Clare's credentials all physicians Advanced ICU Care provides to ensure all physicians have a similar background and training in ICU care. "The success of a tele-ICU program really depends upon the team that is implementing the tele-ICU," Dr. Gorman says. "It's very important that anybody considering telemedicine identifies an experienced, qualified team to work with [to] best leverage tele-ICU for clinical and financial results."
3. Strong relationships. The tele-ICU program at Ministry Saint Clare's also owes its success in large part to the strength of the relationships between the hospital-based and remotely-based clinicians. Dr. Hegland says when the hospital began the program, the physicians provided by Advanced ICU Care came to the hospital to meet the hospital physicians they would work with. In addition, the hospital ICU team visited Advanced ICU Care's command center in St. Louis to meet other staff at the company and better understand how the program would run.
Seeing the resources the remotely-located physicians have — such as monitors tracking all vital signs and decision-support systems — also helps to reassure hospital-based physicians that their patients will receive top-grade care, Dr. Hegland says. "It's not an easy relationship to launch into because you're giving up control, and you want to make sure those physicians are of a caliber that you would trust them to be your partner," he says. To strengthen the relationship between the hospital team and the Advanced ICU Care team, the company assigns a number of its physicians to the hospital, providing a stable group that allows the physicians to build trust and understanding. Furthermore, Advanced ICU Care physicians and nurses are considered full members of the hospital's medical staff.
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The problem
Rating organizations such as the Leapfrog Group have set a standard of care that hospital intensive care units should have continuous coverage by intensivists. When Ministry Saint Clare's Hospital was preparing to launch in 2005, it was able to recruit only one intensivist due to a shortage of physicians in critical care medicine. However, the hospital wanted to meet the standard of care, as studies that have shown that 24/7 intensivist coverage is associated with better patient and financial outcomes. In addition, the hospital needed to provide appropriate staffing in the ICU to be competitive in the market.
The solution
To provide this coverage, Ministry Saint Clare's partnered with Advanced ICU Care, which was also launching in 2005, to connect to intensivists via telemedicine. Under the agreement, Advanced ICU Care provides intensivists and support staff from its center in St. Louis to monitor patients and provide interventions 24/7. By 2010, the hospital's ICU mortality rates were 33 percent better than predictions by the scoring metric APACHE IV. Compared to APACHE predictions, hospital mortality was better by 26 percent and ventilator days were better by 40 percent. Similar results were found for hospital and ICU length of stay. In addition, Ministry Saint Clare's reported success in nursing recruitment and retention due in part to the tele-ICU program.
How it was accomplished
1. Continuous monitoring and measurement. One of the key elements of success of the tele-ICU program was the continuous monitoring and measurement of patients in the hospital, either by clinicians physically present or those located remotely who were linked via video. This coverage ensures quality care for the patient and support for the physicians, nurses and staff at the hospital. "You can't manage what you can't measure," says Mary Jo Gorman, MD, CEO of Advanced ICU Care. "[The] ability to bring the measurement tools and change management program to hospitals allows them to enhance their performance in the ICU." Continuous measurement enables the clinicians to respond immediately when a patient is in need. As an example, Dr. Gorman says if a nurse stepped out of a patient's room and a remotely-located nurse measured an increase in blood pressure and pulse in the patient via telemedicine, the remotely-located nurse could determine the appropriate intervention and immediately contact the hospital nurse to return to the room and deliver the intervention.
The support of other physicians and nurses in ICU care contributes to successful physician and nursing recruitment and high retention, according to Larry Hegland, MD, CMO of Ministry Saint Clare. "Physicians are recruited here because we have telemedicine for them," he says. "It allows them to have a better lifestyle in a setting where we only have two [intensivists on site]. They can better maintain a balanced family life and professional life, yet know that patients are getting really good patient care."
This support is valuable to nurses as well because when they are responsible for ICU patients they may have difficulty reaching a physician quickly in an emergency situation. "[Through telemedicine], they have immediate access to an intensivist who knows the patient, can intervene and give orders they need right away," Dr. Gorman says. "Once a nurse experiences that kind of security, the nurse does not want to leave that," she says.
2. Quality staff. Another essential component of the tele-ICU program is the quality of staff on both sides — the clinicians who work on-site at the hospital and those who are linked in via telemedicine. In fact, Ministry Saint Clare's credentials all physicians Advanced ICU Care provides to ensure all physicians have a similar background and training in ICU care. "The success of a tele-ICU program really depends upon the team that is implementing the tele-ICU," Dr. Gorman says. "It's very important that anybody considering telemedicine identifies an experienced, qualified team to work with [to] best leverage tele-ICU for clinical and financial results."
3. Strong relationships. The tele-ICU program at Ministry Saint Clare's also owes its success in large part to the strength of the relationships between the hospital-based and remotely-based clinicians. Dr. Hegland says when the hospital began the program, the physicians provided by Advanced ICU Care came to the hospital to meet the hospital physicians they would work with. In addition, the hospital ICU team visited Advanced ICU Care's command center in St. Louis to meet other staff at the company and better understand how the program would run.
Seeing the resources the remotely-located physicians have — such as monitors tracking all vital signs and decision-support systems — also helps to reassure hospital-based physicians that their patients will receive top-grade care, Dr. Hegland says. "It's not an easy relationship to launch into because you're giving up control, and you want to make sure those physicians are of a caliber that you would trust them to be your partner," he says. To strengthen the relationship between the hospital team and the Advanced ICU Care team, the company assigns a number of its physicians to the hospital, providing a stable group that allows the physicians to build trust and understanding. Furthermore, Advanced ICU Care physicians and nurses are considered full members of the hospital's medical staff.
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