Combining telemedicine with hands-on critical care nursing has led to improved patient outcomes, created challenging professional opportunities for new and experienced nurses and raised concerns about “Big Brother” watching, but savvy clinicians have developed ways to successfully employ the technology.

“It improves patient care, because you have a decrease in variation and a second layer, a safety net to help with care and needs,” said R. Renee Johnson, RN, MBA, IT clinical project manager at Indiana University Health in Indianapolis, which uses Cerner’s INet Virtual system.

Tele-ICU typically involves intensivists and nurses working at a remote location, monitoring patients and addressing condition changes. “You have a second set of eyes watching your patients,” said Brenda Tousley, RN, MS, CNS, CCRN, a clinical nurse specialist at North Colorado Medical Center in Greeley. “In smaller facilities, there’s improved patient safety, because you have more experienced ICU nurses on the other end of the camera, especially at night when you might have less-experienced nurses [on the unit].”

The remote nurse often serves as a mentor, someone the newer nurse can bounce ideas off, said Caroline Truong, RN, BSN, tele-ICU program manager for Swedish Medical Center in Seattle, which has had a tele-ICU program since 2004. She finds newer nurses appreciate the support and it reduces the chance of errors.

“eCare provides a safety check for our patients and together [with the bedside nurse], we can make an impact on how our patients are cared for,” said Sandra Earle, RN, an eCare Central nurse with Christiana Care Health System in Wilmington, Del. “A tele-ICU in conjunction with an ICU gives you a Super ICU.”

Positive outcomes for many

When it began its tele-ICU program, IU Health nearly halved its ICU and hospital mortality rates between 2004 and 2010, something Johnson attributes to decreases in practice variation and adoption of best practices. Hence, fewer patients developed bloodstream infections, ventilator-associated pneumonia, or nosocomial infections.

Truong, at Swedish, also said greater adherence to evidence-based practices, such as deep-vein thrombosis or stress-ulcer prophylaxis, through tele-ICU monitoring has “helped us improve patient survival, shortened length of stay, reduced complications, decreased ventilator use and create collaborative relationships between our nurses and physicians.”

Tele-ICU equipment will sound an alarm to alert the team to adverse trends or changes in the patients’ conditions. IU’s tele-ICU team discovered bedside nurses were shutting off equipment alarms due to alarm fatigue. Now the hospital has set a standard that the alarms must remain on, but the nurse can change the default.
Earle said early detection of a subtle change that could indicate sepsis or a falling blood pressure enabling early intervention has improved patient safety and outcomes at Christiana’s facilities.

Those alarms not only assist with condition changes but also in fall prevention. If the patient removes the leads or tries to get out of bed, the alarm alerts the tele-ICU, and the remote nurse can talk with the patient and call for help. “[Tele-ICU] optimizes patient care, because patients don’t have to wait for a physician to arrive and write orders,” said Kathryn Palmer, RN, CCRN, charge nurse at North Colorado Medical Center. “Before eICU, night people would wait until morning, when the physicians and radiologists arrived, and read the tests. Patients would have to wait for treatment. Now they get it immediately.”

In 2000, Brian Rosenfeld, MD, founder of VISICU; Peter Pronovost, MD, PhD, FCCM; and colleagues at Johns Hopkins University School of Medicine in Baltimore, first reported in the journal Critical Care Medicine that a 16-week intervention with off-site intensivists monitoring ICU patients led to a 68% decrease in severity-adjusted ICU mortality during the intervention period as compared to one baseline period and declined 46% in the second baseline period. Both baseline periods occurred within one year of the intervention. The team also saw a decrease in ICU complications of 44% and 50%, respectively.

Michael Breslow, MD, Rosenfeld and others reported in the same journal in 2004 that the “addition of a supplemental, telemedicine-based, remote intensivist program was associated with improved clinical outcomes and hospital financial performance.” They found hospital mortality for ICU patients during the remote ICU intervention was 9.4% vs. 12.9%. Length of stay and cost also were lower.

Challenging implementation for some, mixed results for others

Despite research dating back more than a decade showing clinical benefits associated with tele-ICUs, some facilities have not obtained the same results. A team from Advocate Lutheran General Hospital in Park Ridge, Ill., reporting in Critical Care Medicine, found no reduction of mortality, length of stay or cost associated with the implementation of an eICU. Hospitals have been slow to adopt the technology, in large part due to cost, clinician resistance and legacy computer systems that do not talk to each other, according to a December 2010 white paper from the New England Healthcare Institute and the Massachusetts Technology Collaborative. Only 7.6% of hospitals, 249 facilities, have tele-ICU coverage. Five facilities have discontinued their telemonitoring programs.

The New England researchers studied the implementation of tele-ICU at the University of Massachusetts Memorial Medical Center in Worcester and two community hospitals and found mortality rates and length of stay decreased, and the hospitals recouped their one-time up-front investments within one year. In a Journal of the American Medical Association article, the UMass team reported a decrease in ICU mortality from 10.7% before remote monitoring to 8.6% after and greater adherence to best practices such as compliance with deep vein thrombosis prevention. But the process was not smooth. One physician draped his coat over the camera in the patient’s room and another ripped the camera off the wall.

Now, though, Shawn Cody, RN, MSN/MBA, associate CNO for critical care at UMass Memorial, says the tele-ICU is well accepted and well used. “We won them over one at a time,” Cody said. “Our acceptance is pretty universally good, but there are still issues that come up.”

As part of the implementation, UMass took bedside caregivers to the command center, and it phased in telemonitoring one unit at a time. All tele-ICU nurse practitioners and physicians split their time between the command center and the bedside. “We did that because you have different perspectives on both sides,” Cody said. “The program is good, but it’s really the people.”

Swedish tele-ICU nurses work half of their time in the remote location and half on the units, which helps them keep up to date with clinical skills and fosters relationships with bedside staff, Truong says. The tele-ICU charge nurse participates on ICU shared leadership councils.

Christiana also has invited bedside nurses to visit the eCare command center, and several nurses float between the bedside and eCare. “It builds morale when you are working on both sides of the camera,” said Michelle Zechman, RN, BSN, CCRN, an eCare RN at Christiana Care. “It’s fear of the unknown that makes people apprehensive about it.”

Zechman credits eCare’s success to the health system fostering a collaborative environment. “We have a good relationship with the bedside nurses and residents, and they look to us for help, especially during times of high census and high acuity,” she added.

IU Health takes dual capabilities to a new level, with some nurses working part of their shifts on an ICU unit and part in the command center. Leaders have found it fosters collaboration and educates peers on both sides of the camera. In addition, nurse managers meet regularly, nurses from the satellite hospitals visit the bunker and tele-ICU nurses take the equipment to other hospitals to educate nurses at the bedside about the program. “There’s the notion of ‘Big Brother;’ we hear that a lot from the bedside,” said Johnson, adding that IU has made an effort to dispel that through education and care providers meeting each other. “It’s much easier to talk to someone if you know who you are talking to.”

North Colorado Medical opened its ICU with the iCare electronic system installed, but nurses did not have an opportunity to get to know command center personnel, since they are in Phoenix. However, once a month, the eICU director works in the Colorado ICU, and Colorado nurses have traveled to Phoenix for a tour. “It’s viewed as a partnership at our hospital,” Palmer said. “Anytime you have a team of people working together, it’s in the best interest of the patients.”

The remote nurse can double check when the bedside nurse hangs blood, complete a central-line bundle checklist or serve as a second set of eyes to the newer nurse. “It’s a big resource for us,” said Susan Sinnwell, RN, CCRN, BSN, night charge nurse at North Colorado Medical. “It’s nice to know they are on the other side and easily accessible.”

Johnson agreed, saying without the need to focus on tasks, the ePartners nurse is free to think through complicated issues. “It has allowed the nurses to grow,” Johnson said, explaining that nurses must gain expertise across critical-care specialties.

Most of the bunker nurses have 15 years or more experience, and each monitors 30 to 40 patients. Rather than leaving the hospital and taking their skills to an insurance company, for instance, they can work in the command center. “We would have lost all that valuable information they have from years of knowledge and intuition,” Johnson said.