What problems or challenges does it address? (Pat/David)
Challenge #1: Physician Resistance
1) The lack of availability of intensivists to provide 24 hour coverage for ICU patients by monitoring many beds, at different sites with one ICU team--the need for intensivists is lessened, and all the patients have intensivists care around the clock. This is increasingly important, and has become a standard required by safety monitoring groups such as Leapfrog.
2) It is improved quality of life for the doctors who won't be taking overnight call because they have E-ICU monitoring the patients. Also hopes to improve early detection of problems like pneumonia by computerized algorithms which detect subtle changes in vital signs which might otherwise be missed. By preventing problems or intervening early--it hopes to shorten ICU time for patients--saving money and improving outcomes.
3) ICU physician and nurses have to be accustomed with new technology under eICU systems.
4) Physicians tend to be more resistant to eICU intervention than nurses, because there are prevailing concerns about their expertise being questioned, turf conflicts, and a dislike of other physicians caring for their patients. eICU administrators consider this to be an unavoidable challenge that all hospitals must confront.
Challenge #2: Slow to Show Significant Improvement
1) Creating metrics for quality improvement is difficult and many uncontrollable factors influence patient mix and acuity. Consequently, measurable improvements in the quality of ICU care will not be immediately apparent. Administrators can expect to rely on trends toward lower LOS and improved outcomes for several years before determining whether the eICU has significantly improved patient care.
Challenge #3: High Financial Outlay
1) The eICU– whether purchased from VISICU or built independently– requires hospitals have millions of dollars (2M-5M) available to purchase equipment, and software, as well as to fund physician and nurse salaries. Gaining a full return on investment is highly unlikely, so the eICU will become a cost sink. For smaller community hospitals or health systems the expense can prove to be a hurdle difficult to surmount.
2) eICU bed cost up 100, 000 per one unit. An eICU center is a multi-million dollar investment, and except in very limited circumstances, reimbursement is currently unavailable. That said, “soft” returns in terms of physician, nurse, and patient satisfaction, not to mention improved clinical quality, have been substantial.
Challenge #4: Lack of Reimbursement
1) Compounding the financial hurdle is a current lack of reimbursement for eICU services. Hospitals must pay for all eICU operations out of their operating budgets without expecting financial returns from payers. Administrators anticipate that reimbursement is in the pipeline, and the Society for Critical Care Medicine is currently requesting a CPT code dedicated to eICU services, but it is unclear when reimbursement will be determined.
2) Lack of reimbursement from insurance for eICU services.
Challenge #5: Systems Integration
1) Integrating the eICU systems with the existing ICU systems is a challenge.
2) eICU systems can’t work effectively with existing ICU systems.
How will it solve the challenge? (Pat/David)
1) Open Communication Channels
To ensure that physicians and nurses on the floor will implement eICU technologies, administrators and doctors must be open to discussing concerns or problems.
Additionally, clear guidelines about which situations eICU intensivists may intervene in are key to avoiding turf battles and confusion.
2) Collaboration Between eICU, Bedside
Uncooperative physicians and nurses on the floor may actually lower the quality of ICU care, and eICU intensivists who intervene without physician permission can interfere with floor staff’s work. All parties must work together when setting up and implementing the eICU to reach a consensus about the level of care the eICU team will provide.
3) Physician and Nurse Advocates
Physicians and nurses will never universally accept the eICU. However, on units where a strong physician or nurse leader enforces the eICU rules, cooperation between eICU administrators, physician, and nurses is significantly better than on those units with no champion to unify the staff.
4) Financial Security
Hospitals with eICUs must finance them without any support from insurers or additional charges to patients. Consequently, the hospital or health system with significant funds that can be allocated to new technology is more likely to maintain a successful eICU.
5) Clear Division of Tasks
Avoiding confusion between the eICU and the floor is critical to a functional eICU and clearly delineating when and in what situations the eICU physician will take over for the attending physician or nurse. Clarity is a key to maintaining strong communication and collaboration between the eICU and the physicians.
6) Patience
Many early adopters have found identifying significant improvements in quality is difficult to measure when the eICU has been up and running for less than two years. Additionally, physicians and nurses may require a significant amount of time to “win over.”
References:
Koppenheffer, M. (2006). The eICU: Beyond the Hype. Retrieved April 18, 2010 from
Miller, M. & Fifer, S. (2007). Tele-ICUs Interim Findings about Remote Monitoring and
Management of Patients in Intensive Care Units: A FAST Initiative Technology Analysis. Retrieved April 18, 2010 from http://www.healthpolcom.com/Tele-ICU-DiscussionDRAFT-condensed-0707.pdf.
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