An experienced critical care nurse is busy at work in front of six monitors at Christiana Care Health System in Wilmington, Delaware. She's watching the patients' heart rate, blood pressure and ventilator-assisted breathing in the intensive care unit (ICU), focusing on a monitor where the patient's vitals are displayed. She concentrates on a reading and quickly changes one of the screen's views to seek further clarification of her suspicions.

The patient's (physiological vital signs) are fluctuating or trending into a potential critical situation. It's not a good sign.

She lifts the telephone handset and calls the nurses' station, letting the patient's nurse know that the patient in room 2 is showing this slight clinical change. Within seconds, a nurse arrives in the patient's room, and the remote critical care nurse can see the nurse's entry from the eICU video monitor. At this time, the remote critical care nurse and the patient's nurse can collaborate and evaluate the significance of the clinical change.

If this same vital sign trend was to occur when the remote specialized critical care physician (intensivist) was working, the remote nurse would escalate this concern and would get another expert to evaluate the situation.

A large room at Christiana Care Health System houses five telemedicine workstations manned by many experienced critical care clinicians bringing technology and critical care expertise together and leveraging a new approach to critical care medicine delivery. According to Marc T. Zubrow, MD, director of critical care medicine at Christiana Care and the medical director of Maryland eCare, a collaborative effort between six hospitals in rural Maryland, what the remote critical care clinicians are able to view on each computer screen leads to improved care for the critically ill patient.

Maryland eCare
The six non-aligned hospitals, which are collectively known as Maryland eCare, recently decided to implement a solution to address patient safety and the staff shortage in critical care medicine. In the spring of 2009, the hospitals that are a part of the Maryland eCare will begin implementing VISICU's eICU technology through a $3 million grant from CareFirst Blue Cross Blue Shield. The eICU Program brings medicine and technology to rural ICUs, an area facing shortages in specialized intensive care physicians.

VISICU, a Baltimore-based company and division of Philips, was developed by two former Johns Hopkins critical care physicians. The eICU system is being used by more than 200 hospitals nationwide, primarily within large health systems.

Maryland eCare is a collaborative effort among Atlantic General Hospital in Berlin, Md.; Calvert Memorial Hospital in Prince Frederick, Md., Civista Medical Center in LaPlata, Md.; Peninsula Regional Medical Center in Salisbury, Md.; St. Mary's Hospital in Leonardtown, Md.; and Washington County Health System in Hagerstown, Md. The hospitals collectively admit more than 67,000 patients each year, and will be the largest collaboration of independent hospitals in the country to establish this model of care for its patients.

(Editor's note: Click on this link for further details about the project on Christiana Care's Web site: http://www.christianacare.org/body.cfm?id=66&action=detail&ref=285.)

The system lets critical care physicians and nurses monitor patient conditions remotely, through video and audio technology combined with intelligent software and alarm systems. In an ICU, a patient's condition can change quickly. The eICUs remote center closely monitors patients for any physiologic changes, immediately alerting the caregivers and at times recommending corrective action. The eICU system preserves patients' privacy.

CareFirst President and CEO Chet Burrell states, "CareFirst aims to serve as a catalyst for improving health care throughout Maryland. Our support of the eICU initiative will foster better patient care at the most critical moments."

Christiana Care's Expertise
"Bringing this technology to rural Maryland means patients and families will have better care, closer to home," Dr. Zubrow said. "The eICU program enables us to act quickly and hopefully prevent medical complications, leading to improved patient outcomes and getting patients home with their families more quickly and safely. In addition to patient care, safety and satisfaction, the eICU program provides ICU nurses with access to critical care physicians during off hours," Dr. Zubrow said.

(Editor's note: To learn more about the project, watch Dr. Zubrow's recent conversation with ADVANCE.)

"Telemedicine offers different options, and Christiana Care will monitor the ICUs of the Maryland hospitals by providing the technology in what we term an additional set of eyes," Dr. Zubrow said. "If it's safe to have five sets of eyes watching a patient, wouldn't it be better with six sets of eyes?"

Anita Witzke, RN, CCRN, a critical care nurse and eCare's operations manager, said that the remote critical care nurse at Christiana Care's eCare unit can provide IV pump confirmations and remote monitoring in those situations when nurses are called away from the patient's room. For example, a coding patient in the ICU usually requires many of the ICU resources to be focused on that critical situation. The remote critical care nurse can oversee (via the camera and the alerting system) the other patients, therefore, providing an added layer of safety and proactive care that hopefully prevents other crises from occurring.

For issues such as critical care, smaller hospitals often face financial constraints when having to transfer such patients. "However, we believe that if they could keep 50 of the patients in the hospital [in Maryland], then they could save money," Dr. Zubrow said. "CareFirst's grant is paying for providing them with this expertise, and they felt that it was in their patients' best interest to contract with a proven system, such as VISICU."

The eICU physician can ask the nurses in the ICU to confirm what they're seeing on the screen. "These interactions make patient care much more beneficial," Witzke said. The system, with its built-in alerts, can lead to reductions in mortality rates, Dr. Zubrow added. At our Wilmington Hospital, there was a 12 percent reduction in mortality rates in the ICU after the technology was implemented. Dr. Zubrow, who worked the first evening that the eICU technology went live at Wilmington Hospital's 8-bed ICU, said that within the first two hours of his shift, he had assisted on a case of apatient who had "coded." Using the eCare technology, Dr. Zubrow remotely monitored theother patients in the ICU while nurses and critical care physicians attended to the patient who had coded.

Maryland Project
Witzke and Dr. Zubrow are working on the Maryland systems' functionality now, assessing the technology the Maryland hospitals have in place, what additional resources will be needed, and which resources are currently available. "We're learning what challenges exist so that we do not create further problems or significant changes in their workflows when we begin the implementation," Witzke said. She said it is "truly a collaborative effort".

A physician, nurse, outcomes coordinator, and IT team member have been working on the project, with groups of key stakeholders from each of the facilities. Witzke said, "We will not make any changes or take the next step that has not been collaboratively discussed and decided on by implementation teams at both Christiana and the Maryland hospitals. This provides a level of cohesiveness throughout the implementation process and prevents disruptions from occurring at the hospital and among its staff."

Dr. Zubrow and the rest of the eCare team have been conscientious about the perceptions surrounding such technology. They do not want there to be a perception that eICU technology will eliminate anyone's job. They also work hard to address any negative perceptions that the technology is something that is being "inflicted upon the staff," he said.

The experiences that Dr. Zubrow gained during the Wilmington Hospital eCare implementation and later throughout the entire Christiana Care system came from his taking lumps along the way. "I was naïve, though," Dr. Zubrow confessed. "I sat with the doctors and let them yell at me regularly; they complained that the electronic medical record part of the process took too long, that they had to log into four different programs. Cumulatively it probably took one minute, but I sat with them; then after they had calmed down, I would take the time to walk them through the process."

Dr. Zubrow noted that his experience as a physician helped him convince other doctors that the technology would be beneficial to them in the end.

Mr. Mitchell is managing editor of ADVANCE for Health Information Executives.