caring together, caring for life.. avera eicu care: partnering icus in rural america pat herr rn,...

Caring Together, Caring for Life

Avera eICU Care: Partnering ICUs in Rural America

Pat Herr RN, CCRN – Director Avera eICU Care

Jean Winter RN – Director of Nursing Services Avera Marshall

Lois Coudron, RN CCU Lead Avera Marshall

Pat Herr RN, CCRN – Director Avera eICU Care

Jean Winter RN – Director of Nursing Services Avera Marshall

Lois Coudron, RN CCU Lead Avera Marshall

Avera System

• Our mission is to make a positive impact on the lives and health of persons and communities

• Improve health care through a regionally integrated network

• Our mission is to make a positive impact on the lives and health of persons and communities

• Improve health care through a regionally integrated network

Source: The Advisory BoardSource: The Advisory Board

DRIVING FORCES: Clinical Issues• IHI Bundles

– Ventilator Bundle– Sepsis Bundle

• Research Driven Interventions– Glucose Management

• IHI Bundles– Ventilator Bundle– Sepsis Bundle

• Research Driven Interventions– Glucose Management

Driving Forces: Changes in Healthcare Environment

• Nursing Shortages – more inexperienced nurses at bedside

• Demands on Physicians

• Nursing Shortages – more inexperienced nurses at bedside

• Demands on Physicians

VISICUVISICU

• Founded in 1998Founded in 1998

• Two Johns Hopkins Two Johns Hopkins IntensivistsIntensivists

eeI CUICU®® Client SitesClient Sites

Avera eICU Care

A comprehensive program that combines:

1. A remote, centralized, care team that assess and intervene on patients in support of the on-site caregivers

2. Use information technology tools that

transform the care process (virtual team at bedside 24 hrs/day)

PHASE 1

• Implementation September 2004• 4 Regional Facilities:– Avera McKennan Hospital (490 Beds)– Avera Sacred Heart Hospital (144 Beds)– Avera St. Luke’s Hospital (143 Beds)– Avera Queen of Peace Hospital (120

PHASE 2

• September 2005• Expansion to 4 Critical Access Hospitals– Avera Marshall, Marshall, MN– Pipestone Co. Med. Center, Pipestone, MN– Avera St. Anthony’s Hospital, O’Neill, NB– Avera St. Benedict’s Hospital, Parkston, SD

OPERATIONS: Physician Staff

• Specialty Physicians (20 hrs/day)– 2 shifts daily• 12:00 pm – 10:00 pm• 10:00 pm- 8:00 am

– Intensive Care Trained – Pulmonologists, Nephrologists, Cardiologist

• Specialty Physicians (20 hrs/day)– 2 shifts daily• 12:00 pm – 10:00 pm• 10:00 pm- 8:00 am

– Intensive Care Trained – Pulmonologists, Nephrologists, Cardiologist

OPERATIONS: eICU Staff

• Nursing Staff (24 hrs/day)– RNs• Require 3 years Critical Care Experience or

CCRN• Cross trained between eICU/ICU• Customer Service skills required

– HCAs (Health Care Assistants – 24 hrs/day)• Cross trained between eICU/ICU• Customer Service skills required

• IT – Availability 24 hrs/day

• Nursing Staff (24 hrs/day)– RNs• Require 3 years Critical Care Experience or

CCRN• Cross trained between eICU/ICU• Customer Service skills required

– HCAs (Health Care Assistants – 24 hrs/day)• Cross trained between eICU/ICU• Customer Service skills required

• IT – Availability 24 hrs/day

OPERATIONS: Licensing/Credentialing

• Physicians Licensed for each state and credentialed for each facility

• RNs licensed for each state

• Physicians Licensed for each state and credentialed for each facility

• RNs licensed for each state

OPERATIONS: Levels of Communication

• Category I – Emergency interventions; discuss care with attending prior to other interventions

• Category II – Adjust existing care plan independently

• Category III – Can develop new therapies and orders

• Category I – Emergency interventions; discuss care with attending prior to other interventions

• Category II – Adjust existing care plan independently

• Category III – Can develop new therapies and orders

OPERATIONS: Communication

• Flow of Information Vital– Daily Updates– Access to Information Systems– PACs System or method for viewing

xrays– Fax

• “Hot Line” in each facility (both ways)• eLert Button

• Flow of Information Vital– Daily Updates– Access to Information Systems– PACs System or method for viewing

xrays– Fax

• “Hot Line” in each facility (both ways)• eLert Button

OPERATIONS: Algorithms

• Algorithm Development and Sharing

• Research Based

• Examples: Potassium, Glucose Management, Pain Management, Sepsis, Vent Weaning

• Algorithm Development and Sharing

• Research Based

• Examples: Potassium, Glucose Management, Pain Management, Sepsis, Vent Weaning

Algorithms: Ventilator Weaning

• Vent Rounds daily– Bedside nurse– Respiratory therapist– eDr

• Goal is advance the weaning protocol

• Outcome – decreased vent days from 4.5/per pt. to 2.9/pt.

• Vent Rounds daily– Bedside nurse– Respiratory therapist– eDr

• Goal is advance the weaning protocol

• Outcome – decreased vent days from 4.5/per pt. to 2.9/pt.

Algorithms: Glucose Rounds

• Protocol research based

• Goal: Tight Glycemic Control for appropriate patients

• Protocol research based

• Goal: Tight Glycemic Control for appropriate patients

Algorithms: Sepsis Bundle

• Health quality initiative to reduce mortality due to sepsis by 25% (nationwide)

• Employs early identification and stepwise intervention

• Led to an order set based on protocols for step therapy

• Health quality initiative to reduce mortality due to sepsis by 25% (nationwide)

• Employs early identification and stepwise intervention

• Led to an order set based on protocols for step therapy

OPERATIONS: Teaching

• Weekly Critical Care Conference Teleconferenced to remote sites

• FCCS Course

• Newsletters

• Clinical Site for Residents, RT, Pharmacy, Nursing Students

• Weekly Critical Care Conference Teleconferenced to remote sites

• FCCS Course

• Newsletters

• Clinical Site for Residents, RT, Pharmacy, Nursing Students

Outcomes – APACHE System

• Components: Acute Physiology, Age, Chronic Health Evaluation

• Severity adjusted outcome predictions

• Overall accuracy- 0.90

• Database- over 1 Million ICU patients• Imbedded in e-ICU software

• Components: Acute Physiology, Age, Chronic Health Evaluation

• Severity adjusted outcome predictions

• Overall accuracy- 0.90

• Database- over 1 Million ICU patients• Imbedded in e-ICU software

Avera Outcomes – ICU Mortality

3rd Quarter 2005Predicted: 6.2%Actual: 1.8%

4th Quarter 2005Predicted: 5.7%Actual: 1.9%

1st Quarter 2006Predicted: 6.6%Actual: 1.0 %

Avera Outcomes – Hosp. Mortality

1st Quarter 2006Predicted: 11.0%Actual: 7.0%

Avera Outcomes – ICU LOS

3rd Quarter 2005Predicted: 2.9 DaysActual: 2.22 Days

4th Quarter 2005Predicted: 2.85 DaysActual: 2.19 Days

1st Quarter 2006Predicted: 2.9 DaysActual: 2.19 Days

Avera Outcomes – Hosp. LOS

Critical Access Hospital Goals

• Different than DRG Hospital Goals

• Keep more Patients in Home Community

• Assist with Triage/Decision Process (decreased costs, increased safety)

• Different than DRG Hospital Goals

• Keep more Patients in Home Community

• Assist with Triage/Decision Process (decreased costs, increased safety)

Avera Marshall

• Critical Access Hospital– 25 Beds

– 4 Bed ICU

– 2 eICU Beds

• Critical Access Hospital– 25 Beds

– 4 Bed ICU

– 2 eICU Beds

Rural Hospital Benefits

• Keep More Patients in Home Community

• Enhanced Community Confidence

• Recruiting

• Access to Specialty Physicians

(Pulmonology, Nephrology, Cardiology)

• Keep More Patients in Home Community

• Enhanced Community Confidence

• Recruiting

• Access to Specialty Physicians

(Pulmonology, Nephrology, Cardiology)

On-Site Physician Benefits

• Attending Physician– Retains control (Selects levels 1-3)– Retains billing (No individual patient charge

for eICU coverage)

• Relief from recurrent night calls

• Peer availability

• Attending Physician– Retains control (Selects levels 1-3)– Retains billing (No individual patient charge

for eICU coverage)

• Relief from recurrent night calls

• Peer availability

Typical Diagnosis Affected

• Acute Renal Failure• Complicated Pneumonia• Electrolyte Abnormalities• Septic Shock• Congestive Heart Failure• Diabetic Ketoacidosis• Overdoses• Cardiac Arrhythmias

Patient/Family Benefits

• Case Scenarios• Case Scenarios

Nursing Benefits

• 24 hr Peer Resource

• Pharmacy Resource

• Assistance with Transfers

• 24 hr Peer Resource

• Pharmacy Resource

• Assistance with Transfers

Technology Issues

• Need T1 Line for transmission of information

• Need compatible cardiac monitors for interface to eICU software

• Other interfaces optional (lab, ADT)• Access to Hospital Information System• Easy to use at remote site

• Need T1 Line for transmission of information

• Need compatible cardiac monitors for interface to eICU software

• Other interfaces optional (lab, ADT)• Access to Hospital Information System• Easy to use at remote site

Financial Issues

• Start-up Costs– Approx. $30,000/bed for initial

equipment–Mobile Equipment slightly more

expensive

• Monthly Service Fee

• Start-up Costs– Approx. $30,000/bed for initial

equipment–Mobile Equipment slightly more

expensive

• Monthly Service Fee

Obstacles

• Trust Building

• “Big Brother” Factor

• Individual Resistors

• Lack of Standardization of processes, equipment

• “Camera Shy”

• Trust Building

• “Big Brother” Factor

• Individual Resistors

• Lack of Standardization of processes, equipment

• “Camera Shy”

Future Expansion

• USDA Grant

• Additional Sites

• eCare Mobile

• eSearch

• USDA Grant

• Additional Sites

• eCare Mobile

• eSearch

CONCLUSIONS

• The electronic ICU will provide additional supervision of patients

• The electronic ICU allows specialists (in short supply) with greatest experience in care of seriously ill patients to be used as a resource for all hospitals participating in this program

• Proven benefit to patient outcomes while reducing costs and increasing safety/quality

• The electronic ICU will provide additional supervision of patients

• The electronic ICU allows specialists (in short supply) with greatest experience in care of seriously ill patients to be used as a resource for all hospitals participating in this program

• Proven benefit to patient outcomes while reducing costs and increasing safety/quality

Contacts

• pat.herr@mckennan.org

• jean.winter@averamarshall.org

• lois.coudron@averamarshall.org

Questions?

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