Telemedicine reduces ICU mortality rate at Valley Health
Valley Health, a not-for-profit health system serving West Virginia, Maryland and part of Virginia, was facing two serious challenges for which it was looking for solutions.
First, hospitals are facing critical care staffing shortages.
"There is a national problem finding enough intensivists to support an ICU," said Dr. Glen Bouder, director of valley intensivists at Valley Health and medical director of critical care at Winchester Medical Center.
"We struggled with that obstacle at the same time that we were growing the ICU program volume," he said. "We asked ourselves, 'How do we grow our program, support our existing physicians and still meet the care needs of our community?'"
And second, from an administrative perspective, the provider organization found being able to have risk-adjusted acuity data an appealing measure.
"Not many organizations have the bandwidth to have the APACHE – Acute Physiology and Chronic Health Evaluation – scoring system, or have a robust acuity-based infrastructure in order to understand what is actually going on clinically in the ICU," Bouder said. "We all say, 'Well, our patients are really sick,' but how do you validate that?"
From Bouder's perspective as an ICU director, there was a clear added advantage to have those quality measures and acuity-based measures available to see how the organization was doing and to benchmark the organization for quality improvement.
Valley Health could have tried to keep riding out the intensivist shortage by hiring locums, which is very expensive. However, the health system's Winchester Medical Center hospital president Skip Phillips had previous experience with tele-ICU, specifically, telemedicine technology and services vendor Advanced ICU Care.
Based on Phillips' familiarity with the model, he encouraged Bouder and his team to explore tele-ICU services as a potential solution to some of the health system's most pressing challenges.
"Advanced ICU Care impressed us with their breadth of clinical experience," Bouder said. "They have a strong history of working in different hospital settings and with facilities of various sizes and complexities. It inspired confidence that they knew what they were doing in terms of being able to help us."
The other value proposition with the telemedicine vendor, in addition to the physician support they provided, was the nursing component of their service offering, he added. The strength of the vendor's nursing staff and their ability to support Valley Health nursing staff, in addition to the intensivist team, was an added appeal to Bouder. In fact, it was something he had not previously thought about.
There are many vendors on the market today offering telemedicine technology, including American Well, Avizia, GlobalMed, MDLive, Novotalk, SnapMD, Teladoc, TeleHealth Services, Tellus and Tyto Care.
MEETING THE CHALLENGE
From a technical perspective, implementation was a strength of the vendor, the provider said. The vendor had broad-based experience implementing high-acuity telemedicine in a wide range of hospital settings, working with many different EHRs, the provider added.
"Integrating the tele-ICU technology with our Epic EHR platform went very well, and the vendor's depth of experience really helped the launch," Bouder explained. "The technology elements are the largest portion of the implementation process in terms of time and energy, such as getting all the hardware and software integration done."
The more difficult piece, which turned out to be one of the most critical parts of the process, was all the groundwork that had to be laid with the nursing staff, the medical staff, the administrative staff – any and all of the people who were going to be touched by the technology, not just the intensivists, Bouder added.
"Winchester Medical Center has a very good technical foundation in place that allowed us to get operational very quickly."
Dr. Glen Bouder, Valley Health
"There is an art to working through that and preparing people for tele-ICU," he said. "An administrative decision to implement tele-ICU without engaging the staff risks a lack of buy-in and success. One of the things we did upfront was take a group of our nurses, many of whom were skeptics, on a site visit to a facility that was similar in size and scope to our hospital."
Following the visit, they all came back with a positive reaction to tele-ICU, which led to them being vocal cheerleaders for the effort, he said.
On another note, after the go-live, having staff being able and available to answer any concerns caregivers may have on the back-end was also very important – it is a key component to sustainability, he said.
During the first year of tele-ICU at Valley Health, the technology helped save 125 lives, achieve a 35 to 44 percent reduction in ICU mortality rate, reduce ICU length of stay by 34 percent, reduce the sepsis mortality rate, and achieve measurable improvements on best practice compliance.
"After the first six months of tele-ICU, ICU length of stays actually got even shorter as we were able to reduce them by 34 percent," Bouder said. "This told me that there were active care interventions taking place, particularly at night, that were now getting patients out of the ICU faster. Certainly, reducing length of stay was a pleasant surprise."
On the flip side, there are areas where one might think one is doing well when in reality this is not true.
"For example, blood transfusions and glycemic control, both of which we thought were going well, were actually not up to standard," he said. "Last year we focused on improving glycemic control and we saw around a 24 percent improvement in our glycemic control, which landed us just below the Advanced ICU Care average measured against all of their hospitals."
By looking at the data and letting bedside teams know about performance, it gave the care team a cognitive awareness around the issues, Bouder stated.
"We then started to see improvements in those metrics over time," he said. "It is very helpful to have an understanding of your ICU strengths and weaknesses. No one wants their ICU to be the low performer relative to your peers."
Then there is the patient experience. How has the tele-ICU model been received by Valley Health patients and their families? Have they been open to remote care team support?
"In terms of patient experience and acceptance of tele-ICU, I would say their introduction to the care model came with an appropriate dose of healthy skepticism," Bouder reported. "But we did a lot of education upfront, for example having informational brochures in our waiting rooms, and introducing Advanced ICU Care tele-intensivists as part of our team."
Most patients are used to technology like FaceTime so the concept isn't completely foreign to them, Bouder added.
ADVICE FOR OTHERS
"You really need to avoid underestimating the importance of getting all the caregivers, physicians and nurses and respiratory therapists, to buy into tele-ICU," Bouder advised. "Otherwise, you will not achieve the goals you desire. This includes upfront communication about the program, managing of expectations, a level of necessary education, and a rapid back-end process to resolve issues – this can make or break a program."
It also is important to look at one's IT infrastructure to make sure it can support tele-ICU.
"Winchester Medical Center has a very good technical foundation in place that allowed us to get operational very quickly," he said. "For example, we were up and running in four months. We could not have done that without a strong IT infrastructure."
Another piece of the process is creating both a business and clinical case for tele-ICU with the medical staff, Bouder advised.
"We did a number of presentations and a lot of education for both the critical care committee and staff executive committee to get them on board," he said. "And finally, we really emphasized with the ICU staff that tele-ICU was in no means replacing them but rather supporting them as part of our ICU care team. Getting that mindset was key, for the current intensivists as well as the nursing staff and the rest of the care team."