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Service Delivery Innovation Profile

Clinicians in Tertiary Hospital Monitor Critical Care Patients in Rural Facilities via Telemedicine, Leading to Reductions in Mortality, Length of Stay, Patient Transfers, and Costs


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Snapshot

Summary

Clinicians at Avera Health System, which operates hospitals in five largely rural states, continuously monitor critical care patients in the system's rural facilities from a remote location and intervene as needed. From an operations center at Avera McKennan Hospital (a large tertiary hospital), physicians, nurses, and other support staff monitor these critically ill patients through cameras and computers that continuously collect and analyze clinical information. The computers transmit this real-time information to the operations center via secure, high-speed data lines, allowing the monitoring clinicians to recognize changes in patients' conditions quickly and to intervene, as needed, in coordination with physicians and nurses at the rural sites. The program led to reductions in mortality, length of stay, the number of patients requiring transfer to a tertiary facility, and costs. Clinicians at both the remote sites and the operating center report high levels of satisfaction with the program.

Evidence Rating (What is this?)

Moderate: The evidence includes pre- and post-implementation comparisons of mortality, length of stay, and transfers, along with post-implementation clinician satisfaction survey data and cost savings estimates; the 2.5-year study (from early 2005 through mid-2007) included 5,146 patients who received program services, roughly half of whom were at Avera McKennan (site of the operating center) and the other half at the 14 remote locations.
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Developing Organizations

Avera Health Systems
Sioux Falls, SDend do

Use By Other Organizations

The following hospitals are parallel users of similar telemedicine programs:
  • Sutter Health, Sacramento, CA
  • UMass Memorial Health Care, Worcester, MA
  • University of Pennsylvania Health System, Philadelphia, PA
  • Advocate Health Care, Chicago, IL
  • Provena Health, Chicago, IL
  • Resurrection Health Care, Chicago, IL
  • Banner Health, Denver, CO
  • Via Christi Health System, Wichita, KS
  • OhioHealth, Columbus, OH
  • Sentara Healthcare, Norfolk, VA

Date First Implemented

2004
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Patient Population

Vulnerable Populations > Intensive care unit patients; Rural populationsend pp

Problem Addressed

A shortage of critical care doctors in rural areas can compromise patient care, putting critically ill patients at increased risk for death and complications. These complications can also lead to higher costs, as patients may need to spend more time in the intensive care unit (ICU) and/or be transported to the nearest tertiary hospital for more specialized care.
  • Shortage of critical care doctors: Rural areas in the United States are home to nearly one-fourth of the population but have only 10 percent of the physicians. Specialists remain in particularly short supply in rural areas; on average, there are only 40.1 specialists per 100,000 residents in rural areas, less than one-third of the 134.1 specialists per 100,000 residents in urban areas.1
  • Leading to potential for poor quality, higher costs: Critical care specialists (also known as intensivists) know how to respond when a patient's condition deteriorates and hence can reduce the risk of death2; yet few rural areas have an adequate number of intensivists. As a result, critically ill patients in rural areas often end up staying in the ICU longer, at a cost of between $1,200 and $2,000 per day.3 They may also require transfer by helicopter or ambulance to a tertiary hospital that is better equipped to handle their care, which further drives up costs and often creates logistical difficulties for families.

What They Did

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Description of the Innovative Activity

Clinicians at Avera Health System continuously monitor critical care patients in the system's rural facilities from a remote location and intervene as needed. From an operations center at Avera McKennan Hospital (a large tertiary hospital), physicians, nurses, and other support staff monitor these critically ill patients through cameras and computers that continuously collect and analyze clinical information. The computers transmit this real-time information to the operations center via secure, high-speed data lines, thus allowing the monitoring clinicians to recognize changes in patients' conditions quickly and to intervene, as needed, in coordination with physicians and nurses at the rural sites. Key elements of the program are outlined below:
  • Operations center monitoring multiple remote facilities: The operations center at Avera McKennan is comparable to an air traffic control room, with physicians and critical care nurses constantly monitoring patient conditions at multiple rural facilities. During the 2.5-year study period, the center monitored patients in 14 remote facilities, including two community hospitals that collectively have fewer than 100 beds, three regional hospitals with 26 total ICU beds, and nine critical access hospitals (each with fewer than 25 beds). Center staff also monitor patients onsite at Avera McKennan's 24-bed ICU. Since the study ended, the program has expanded to cover 19 remote sites (as of January of 2010).
  • Round-the-clock monitoring, with intervention support as needed: A critical care nurse, with the assistance of a clerical support person, monitors patients in remote facilities 24 hours a day, 7 days a week. A physician with expertise in critical care (e.g., intensivist, cardiologist, nephrologist, pulmonologist) also participates in this monitoring 20 hours a day (all hours except between 7 and 11 a.m.), and is available at other times in case of an emergency. (The physician is typically engaged in rounding on his or her own patients at Avera McKennan between 7 and 11 a.m., and hence can be summoned quickly if necessary). Services include general monitoring, management of emergencies, and consultations, as described below:
    • General monitoring: Computers continuously transmit patients' vital signs, medications, and laboratory and radiology test results to clinicians at the center who view the information on a screen. Through real-time cameras, monitoring clinicians can also see the patients' electronic medical records and the patients themselves. Staff at the center and the remote site can discuss the patients' conditions using built-in, two-way microphones. Nurses and physicians can also use high-resolution bedside cameras to zoom in on the affected patient, even viewing the pupils of the eye if necessary.
    • Management of emergencies: If a significant change in a patient's condition occurs (e.g., a spike in blood pressure or body temperature), an alarm sounds in the center and staff immediately notify the attending physician at the remote site. If necessary, a physician at the center assists onsite critical care staff in responding to the situation by supervising administration of cardiopulmonary resuscitation, providing guidance on medications, and/or recommending tests to be performed. If the patient's attending physician is not available at the remote site, the physician at the center takes the lead role in managing the emergency.
    • Patient consultations: Staff at the center also respond to requests from nurses and physicians at the remote sites to consult on individual patients.
  • Privacy safeguards: Several system features help to ensure patient privacy. For example, while audio and visual monitoring occurs on a real-time basis, no recordings are made. In addition, patients and family members always have the option to request that cameras be temporarily deactivated. Scrambling, secure passwords, secured lines, and other technologic safeguards also help to prevent unauthorized access to data transmitted between the remote facilities and the monitoring center.

Context of the Innovation

Avera Health is a regional health system that operates more than 235 facilities (including 36 hospitals) in South Dakota, North Dakota, Minnesota, Iowa, and Nebraska. Because the system's patient population is dispersed over a large geographical area, specialty staffing has been concentrated at Avera's large, urban hospitals, and even these facilities have a limited number of critical care practitioners. The challenge of delivering critical care in rural areas, along with the high transportation costs associated with transferring critically ill patients to larger hospitals, led Avera Health leaders to explore more efficient ways of providing critical care in rural hospitals.

Did It Work?

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Results

The program led to reductions in mortality, length of stay (LOS), the number of patients requiring transfer to a tertiary facility, and costs. Clinicians at both the remote sites and the operating center report high levels of satisfaction with the program.
  • Fewer deaths: Overall mortality at one of the three remote regional hospitals decreased from 9.6 percent 2 years before implementation to 5.9 percent afterward; mortality rates at the other two regional hospitals did not change. The ICU mortality rate at the regional hospitals was not calculated because low mortality rates prevented accurate estimation of baseline severity-adjusted mortality. At Avera McKennan, the overall hospital mortality rate decreased from 0.62 percent to 0.56 percent after implementation, while the ICU mortality rate decreased from 0.63 percent to 0.26 percent. (The small number of critical care patients at the remote community and critical access hospitals precluded their inclusion in this analysis.)
  • Lower LOS: The severity-adjusted ICU LOS decreased in all three remote regional hospitals after program implementation from 1.43 days to 0.88 days, 1.35 days to 0.92 days, and 0.96 days to 0.88 days, respectively. At Avera McKennan, severity-adjusted ICU LOS decreased from 1.05 days to 0.58 days, while overall LOS decreased from 0.92 days to 0.75 days. Overall, the program prevented an estimated 6,825 ICU days and 821 other inpatient days (versus the expected number of days if performance remained at the level observed during the baseline period), with Avera McKennan accounting for approximately two-thirds of the saved ICU days and three-fourths of the other saved days. These improved outcomes were likely due to the increased presence of intensivists at Avera McKennan.
  • Significantly fewer transfers: Because the program improved the ability of the community and critical access hospitals to handle critical care patients, the number of patients requiring transfer to another facility decreased by an estimated 37.5 percent.
  • Substantial cost savings: Program leaders estimate that the reduction in ICU days across all facilities saved approximately $8 million, while the reduction in transfers saved approximately $1.25 million (each transfer costs between $6,000 and $10,000 due to the high costs of using a helicopter).
  • Positive clinician response: Surveys suggest that most staff at the remote sites find the system easy to use, feel it has made them more comfortable in caring for critically ill patients, and believe it has improved the quality of care for their sickest patients. Physicians in the operations center generally believe that the program has not adversely affected their patients, practices, or ability to perform other clinical duties; that it has improved care across the health system; and that it offers the potential to extend their critical care careers.

Evidence Rating (What is this?)

Moderate: The evidence includes pre- and post-implementation comparisons of mortality, length of stay, and transfers, along with post-implementation clinician satisfaction survey data and cost savings estimates; the 2.5-year study (from early 2005 through mid-2007) included 5,146 patients who received program services, roughly half of whom were at Avera McKennan (site of the operating center) and the other half at the 14 remote locations.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Task force development and research: Approximately 6 months before beginning the telemedicine program, Avera Health formed a task force consisting of senior administrators and physicians to serve as a steering committee and explore ways of more effectively providing critical care in rural hospitals. Task force members viewed a presentation on ICU telemedicine at a medical conference, reviewed research findings suggesting that the utilization of such technology can improve patient outcomes, and visited Sentara Norfolk General Hospital in Norfolk, VA, to see the use of telemedicine in action. After this visit, Avera contracted with a vendor to purchase and install the system.
  • Policy development: The task force created policies for each of the participating hospitals to explain the types of interventions that would be appropriate for monitoring staff to perform depending on the situation. For example, they defined interventions that would be automatic for life-threatening emergencies that were observed, interventions that would be helpful to reduce burden on the remote physicians, and interventions that required input from the remote physicians for major changes in the care plan and additional consultations.
  • Staff training: Task force members chose the staff who would participate in the monitoring center. These staff members underwent Web-based tutorials to learn the software and telemedicine capability for electronic note writing, electronic order writing, and manipulation of the video and audio devices. For the first few sessions, the lead nurse and medical director provided onsite mentoring to the nurses and physicians staffing the monitoring center.
  • Launch and expansion: The program launched in September of 2004 at Avera McKennan, followed within a month by implementation at three remote regional hospitals. The remaining 11 remote hospitals included in the initial study joined the program over the following 2 years. As noted, the program now includes 19 remote hospitals.

Resources Used and Skills Needed

  • Staffing: As noted, the center is staffed by one critical care nurse and one clerical support person 24 hours a day, 7 days a week, and by a physician 20 hours a day, 7 days a week. Critical care physicians staffing the center include four board-certified intensivists, one critical care physician, and six other specialists from nephrology, cardiology, and pulmonology.
  • Start up costs: Program start-up costs (e.g., build out of facilities, hardware/equipment, and software) ran about $2.8 million, while ongoing operating costs average roughly $2.3 million a year.
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Funding Sources

U.S. Department of Agriculture
The U.S. Department of Agriculture provided start-up grants totaling approximately $30,000 per site as part of its Distance Learning and Telemedicine loan/grant program. Operating expenses come out of the health system's internal operating budget.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Build off existing critical care team: Physicians who work at the telemedicine center need to be comfortable with technology and the concept of telemedicine. At Avera Health, task force members met individually with private practitioners affiliated with Avera McKennan to gauge their interest in participating.
  • Choose vendor carefully: Find out as much as possible about potential vendors before choosing one to install and maintain the system. To that end, visit one or more other hospital systems that already use this approach, and talk to hospital administrators, physicians, nurses, and other staff about their experiences with it and their vendor.

Sustaining This Innovation

  • Monitor and correct problems: Make sure avenues exist for staff at all participating hospitals to raise and resolve any problems they may experience. For example, Avera Health holds monthly teleconferences with each remote hospital to discuss any issues and how they can be corrected, along with weekly meetings of clinical staff to analyze the center's performance.

Use By Other Organizations

The following hospitals are parallel users of similar telemedicine programs:
  • Sutter Health, Sacramento, CA
  • UMass Memorial Health Care, Worcester, MA
  • University of Pennsylvania Health System, Philadelphia, PA
  • Advocate Health Care, Chicago, IL
  • Provena Health, Chicago, IL
  • Resurrection Health Care, Chicago, IL
  • Banner Health, Denver, CO
  • Via Christi Health System, Wichita, KS
  • OhioHealth, Columbus, OH
  • Sentara Healthcare, Norfolk, VA

More Information

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Contact the Innovator

Edward T. Zawada Jr., MD, MACP
Medical Director
Avera eICU Care
1001 E 21st Street, Suite 300
Sioux Falls SD 57105
Phone: (605) 322-5800
E-mail: edward.zawada@avera.org

Innovator Disclosures

Dr. Zawada has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile

References/Related Articles

Zawada ET Jr, Herr P, Larson D, et al. Impact of an intensive care unit telemedicine program on a rural health care system. Postgrad Med. 2009;121(3):160-70. [PubMed]

Footnotes

1 Rural Health People. Southwest Rural Research Center. 2010. Available at: http://www.srph.tamhsc.edu/centers/rhp2010/publications.htm
2 Pronovost PJ, Angus DC, Dorman T, et al. Physician staffing patterns and clinical outcomes in critically ill patients. JAMA. 2002;2088(17):2151-62. [PubMed]
3 Engoren M. The effect of prompt physician visits on intensive care unit mortality and cost. Crit Care Med. 2005; 33(4):727-32. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: September 01, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: January 15, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: September 10, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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