Big hospitals adding remote monitoring for ICU patients

When resident Neha Vagadia, DO, first heard her hospital was going to install an e-ICU system, the prospect of a video camera in every intensive-care patient's room seemed intrusive.

Having a physician in another location watching her patient's vital statistics, lab results and other data left Dr. Vagadia wondering if she would be constantly second-guessed.

"I was extremely nervous about having someone always looking over my shoulder," said Dr. Vagadia, chief internal medicine resident at the University of Massachusetts Memorial Medical Center.

To date, e-ICU systems have been adopted at seven academic medical centers, according to VISICU, which appears to be the only company that sells this type of system. Overall, more than 200 hospitals use it to monitor 250,000 patients a year.

The introduction of electronic and video monitoring of hospitals' sickest patients has physician educators concerned.

Though only a small number of teaching hospitals have e-ICUs, more are likely to adopt them as patient safety initiatives and physician shortages build, physician educators said.

Critics caution that e-ICU systems will stunt residents' sense of independence, which is critical to their development as physicians. Supporters say that the monitoring gives residents easy access to a second opinion and ensures that the most vulnerable patients get the best care possible.

"Patients should not suffer for residents to train," said Craig Lilly, MD, e-ICU director at the University of Massachusetts Memorial Medical Center. And residents should be able to leave the hospital without wondering if they made the right decision for an unstable patient.

Although initially skeptical, Dr. Vagadia was pleasantly surprised once the e-ICU system was introduced, with coverage from 7 p.m. to 7 a.m.

"It's there as immediate help when I need it, but [e-ICU staff] are less intrusive than I imagined," she said.

The e-ICU team is staffed by critical care physicians and nurses from the hospital system. The team works at stations surrounded by six to seven computer screens, and has access to each patient's electronic medical record and real-time vital signs. Computer programs alert staff to significant alterations in a patient's oxygen saturation, among other vital information. E-ICU doctors can pick up the phone and step in to direct patient care in order to prevent a crisis.

Patients benefit from extra eyes

Since his Massachusetts hospital rolled out its e-ICU system in June 2006, pneumonia rates have declined to half the national average, Dr. Lilly said. Deaths have dropped by 9%, length of stay has shortened, and ventilator-associated pneumonia rates have fallen to a quarter of the national average.

Residents used to have to wake a physician if they had a problem at night, Dr. Lilly said. They would give the physician a patient's information over the phone, and the doctor would try to piece it all together and get an overall feel for the situation. Now residents can call a physician who is awake and alert, who sees all of the patient's information in real time, and can focus on treatment recommendations.

Michael Ries, MD, e-ICU medical director at Advocate Health Care in the Chicago area, reported similar improvements.

Advocate's eight hospitals, with a combined 250 intensive-care beds, have seen mortalities fall from 6.8% in 2005 to 6.4% in 2006. Dr. Ries did not directly link this decline to the e-ICU, because other patient safety initiatives have been under way, but he did claim other successes. For example, tracking of best practices for preventing ventilator-associated pneumonia has cut the number of incidents from 110 in 2004 to 32 in 2006, resulting in savings of $2 million.

Advocate runs one central e-ICU station, which covers all of its hospitals and operates 24 hours a day, seven days a week, with two physicians on each shift alongside seven nurses.

Dr. Ries said that while an e-ICU has the potential to be intrusive, at Advocate the patient's attending physician establishes the level of intervention the e-ICU team may execute. Many attendings permit e-ICU physicians to intervene when they see fit, though some only want the e-ICU team to take action if there is an emergency. When e-ICU physicians do step in, they first check with the attending or resident on duty.

"We act as a second pair of eyes," Dr. Ries said. "Our goal is to help the bedside team carry out their care plan."

Laura Maursetter, DO, a third-year internal medicine resident at Advocate Lutheran General Hospital in Park Ridge, Ill., said her experience reflects Dr. Ries' goals. She taps the e-ICU team once or twice a week for second opinions on difficult cases during her intensive-care rotations. Sometimes the e-ICU physicians use her questions as a springboard for bedside teaching.

Marc Zubrow, MD, ECARE director at Christiana Care Health System in Wilmington, Del., wants to know whether the e-ICU can also be used to trim residents' work load. Nurses contact ECARE physicians for mundane requests, allowing residents to focus on admissions and critical management decisions, he said.

Christian Coletti, MD, in his third year of a dual emergency and internal medicine residency at Christiana, said this is working, so far.

"Instead of trying to get ahold of us about electrolyte replacement while we are resuscitating a patient, the nurses can get a quick answer from the e-ICU," Dr. Coletti said.

This is all well and good, according to Deborah DeMarco, MD, past president of the Assn. of Program Directors in Internal Medicine and associate dean of graduate medical education at the University of Massachusetts Memorial Medical Center. However, she still has reservations.

"Our residents are left alone to make decisions a lot less than they used to be," Dr. DeMarco said. "Some would argue that's a good thing, but how are residents going to learn to make decisions with that constant looking over your shoulder?

"Ultimately the e-ICU is great for patient safety," she said, "but how will residents learn to assess a patient and formulate their own differential diagnosis when they can turn to the camera and say, 'What do you think?' "