caring together, caring for life.. avera eicu care: partnering icus in rural america pat herr rn,...
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Caring Together, Caring for Life
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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
Caring Together, Caring for Life
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
Caring Together, Caring for Life
Caring Together, Caring for Life
Caring Together, Caring for Life
Caring Together, Caring for Life
Source: The Advisory BoardSource: The Advisory Board
Caring Together, Caring for Life
Caring Together, Caring for Life
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
Caring Together, Caring for Life
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
Caring Together, Caring for Life
VISICUVISICU
• Founded in 1998Founded in 1998
• Two Johns Hopkins Two Johns Hopkins IntensivistsIntensivists
Caring Together, Caring for Life
Caring Together, Caring for Life
eeI CUICU®® Client SitesClient Sites
Caring Together, Caring for Life
Avera eICU Care
Caring Together, Caring for Life
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)
Caring Together, Caring for Life
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
Beds)
• 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
Beds)
Caring Together, Caring for Life
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
• 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
Caring Together, Caring for Life
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
Caring Together, Caring for Life
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
Caring Together, Caring for Life
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
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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
Caring Together, Caring for Life
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
Caring Together, Caring for Life
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
Caring Together, Caring for Life
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.
Caring Together, Caring for Life
Algorithms: Glucose Rounds
• Protocol research based
• Goal: Tight Glycemic Control for appropriate patients
• Protocol research based
• Goal: Tight Glycemic Control for appropriate patients
Caring Together, Caring for Life
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
Caring Together, Caring for Life
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
Caring Together, Caring for Life
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
Caring Together, Caring for Life
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 %
3rd Quarter 2005Predicted: 6.2%Actual: 1.8%
4th Quarter 2005Predicted: 5.7%Actual: 1.9%
1st Quarter 2006Predicted: 6.6%Actual: 1.0 %
Caring Together, Caring for Life
Avera Outcomes – Hosp. Mortality
3rd Quarter 2005Predicted: 11.4%Actual: 5.0%
4th Quarter 2005Predicted: 10.6%Actual: 5.7%
1st Quarter 2006Predicted: 11.0%Actual: 7.0%
3rd Quarter 2005Predicted: 11.4%Actual: 5.0%
4th Quarter 2005Predicted: 10.6%Actual: 5.7%
1st Quarter 2006Predicted: 11.0%Actual: 7.0%
Caring Together, Caring for Life
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
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
Caring Together, Caring for Life
Avera Outcomes – Hosp. LOS
3rd Quarter 2005Predicted: 9.16 DaysActual: 6.79 Days
4th Quarter 2005Predicted: 9.04 DaysActual: 6.66 Days
1st Quarter 2006Predicted: 9.34 DaysActual: 6.89 Days
3rd Quarter 2005Predicted: 9.16 DaysActual: 6.79 Days
4th Quarter 2005Predicted: 9.04 DaysActual: 6.66 Days
1st Quarter 2006Predicted: 9.34 DaysActual: 6.89 Days
Caring Together, Caring for Life
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)
Caring Together, Caring for Life
Avera Marshall
• Critical Access Hospital– 25 Beds
– 4 Bed ICU
– 2 eICU Beds
• Critical Access Hospital– 25 Beds
– 4 Bed ICU
– 2 eICU Beds
Caring Together, Caring for Life
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)
Caring Together, Caring for Life
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
Caring Together, Caring for Life
Typical Diagnosis Affected
• Acute Renal Failure• Complicated Pneumonia• Electrolyte Abnormalities• Septic Shock• Congestive Heart Failure• Diabetic Ketoacidosis• Overdoses• Cardiac Arrhythmias
• Acute Renal Failure• Complicated Pneumonia• Electrolyte Abnormalities• Septic Shock• Congestive Heart Failure• Diabetic Ketoacidosis• Overdoses• Cardiac Arrhythmias
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Patient/Family Benefits
• Case Scenarios• Case Scenarios
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Nursing Benefits
• 24 hr Peer Resource
• Pharmacy Resource
• Assistance with Transfers
• 24 hr Peer Resource
• Pharmacy Resource
• Assistance with Transfers
Caring Together, Caring for Life
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
Caring Together, Caring for Life
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
Caring Together, Caring for Life
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”
Caring Together, Caring for Life
Future Expansion
• USDA Grant
• Additional Sites
• eCare Mobile
• eSearch
• USDA Grant
• Additional Sites
• eCare Mobile
• eSearch
Caring Together, Caring for Life
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
Caring Together, Caring for Life
Contacts
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Questions?