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    Electronic ICU monitoring: Big Brother, great friend

    Remote monitoring of patients is a boon for nurses, patients, and families

    It's a tribute to the late George Orwell that his dystopian novel Nineteen Eighty-Four, which was written in 1949, still resonates today whenever the topic turns to any type of video surveillance. The idea that "Big Brother is watching you" has found a place in the collective world psyche.

    However, a "big brother" doesn't have to be a symbol of a totalitarian regime bent on squelching thought and ensuring conformity. A big brother also can be a friend, mentor, and confidant who helps make your life easier.

    That's the idea behind electronic intensive care units (eICUs). The concept is simple: Cameras, microphones, and high-speed computer data lines come together in a central location to monitor patients in virtually any number of ICU rooms at remote hospitals. The centralized monitoring location is staffed 24/7 by intensivists and experienced ICU nurses, who are on hand to help the floor staff ensure the highest possible patient care.

    Powered by software from Baltimore-based VISICU Inc., the eICU program is designed to help hospitals and health systems deliver high-quality care when specialist resources are limited. The eICU Program is powered by the VISICU eCareManager(tm). This technology runs the gamut, from high-resolution cameras that can zoom in and examine a patient's pupils, to advanced software that automatically analyzes data about a patient's vitals, medications, lab work, X-rays, medical records, and more, helping to provide a clear overview of the patient's condition.

    VISICU reports there are fewer than 6,000 actively practicing intensivists in the United States; less than 15% of ICUs are receiving dedicated intensivist care. Centralized intensivist physicians and critical-care nurses in an eICU help bedside teams watch over their sickest patients, and prioritize and guide interventions. An eICU program staffed with an intensivist-led care team can monitor and care for hundreds of patients.

    If an eICU hasn't come to your area yet, it will: EICUs are operating in 28 states, covering more than 200 hospitals and 40 health systems. Nationwide, more than 300,000 ICU patients each year are served by eICU centers.

    Technology and nurses as allies

    Wendy Deibert, RN, operations director of Mercy SafeWatch in St. Louis, has 20 years of ICU experience. She told RN that Mercy Health System carefully examined the concept and conducted a two-year research project before instituting the program. "It has become an invaluable ally to the nurses on the floor ever since," she said.

    "We're not there to take the place of a nurse or a doctor at the bedside," Deibert said. "We're there to monitor the data and the trends—things that nurses on the floor often don't have the time to do. As a result, we're able to catch things that nurses might not normally be able to catch because they're tied up with patients or patients' families."

    Mercy SafeWatch's central monitoring area in St. Louis consists of 14 work stations, each with two computers and six monitors. Each eICU nurse generally monitors 30 to 50 patients.

    "Most people's initial reaction is, 'How can they watch that many patients,' but keep in mind that we're not physically helping patients, giving meds, or any of the other things that nurses on the floor are doing," Deibert said. "We're analyzing data and trends, and looking for ways to help prevent a code situation from developing. We are able to be proactive rather than reactive."

    In addition, the system's software makes triage relatively easy. Deibert explained that by using computer charting instead of paper charting, nurses in the core area are able to receive data in real time from each patient being monitored. The SafeWatch software then runs a variety of algorithms and rates the patients as green, yellow, or red, with the red patients being "high critical" and in the need of the most attention.

    As an example of SafeWatch's capabilities, Deibert cited a patient in whom a lab test revealed a high creatine level. "The system would alert us, look at all the meds that patient is taking, and suggest which ones we might think about re-evaluating," she said. The system's high-definition cameras can zoom in and read an IV bag, see if a patient's color looks good, or read the reaction of a patient's eyes to a light flash.

    "We round every day, just like a nurse on the floor would," Deibert explained. "Some of the longer-term patients actually come to recognize our voices, and we can carry on everyday conversations with them, or help convince confused patients to return to their beds."

    Help for staff, patients, or their families is only a button-push away. The system's two-way speaker capability gives the nurses on the floor instant access to an eICU nurse or intensivist. When the SafeWatch program began in St. Louis in 2006, it had 13 intensivists. Today, 20 intensivists provide around-the-clock support for the 10 hospitals, and all the nurses in the core area must have at least five years of ICU experience.

    The ability to receive immediate help from an intensivist or an eICU nurse is one of the program's best features, said Linda Meyer, RN, an eICU nurse with Mercy SafeWatch in St. Louis.

    "I think if you're a new or inexperienced ICU nurse, it would be great to know you can just push a button and speak with an experienced ICU nurse," Meyer said. "It's nice to be able to bounce ideas off someone else, or just say, 'Can you take a look at what I have here?'"

    Meyer moved from the ICU to the eICU in August 2007. "I wanted to come up to the eICU because I was very intrigued by it and really liked the idea of interacting with the other facilities. It's great to be able to help them," she said.

    Bob Blum, RN, is both an ICU and an eICU nurse in St. Louis. He admitted to feeling an Orwellian fear when he first heard of the program.

    "I wasn't sure exactly what to expect, but my first impression was that 'Big Brother' would be watching," Blum said. "But as it turns out, nothing could be further from the truth. As an experienced nurse, it's great to be able to run your thoughts or ideas by other equally experienced individuals, and as a new nurse, you now always have a mentor to help you.

    "There's a learning curve at first, and everybody has different expectations. But once ICU nurses get their hands on it and meet everyone else involved, they come to find that it's really just an additional level of care," Blum added.

    To assuage fears of the omniscient eye, Deibert pointed out that nothing from the cameras is taped or recorded. "Legally, nothing can be pulled from the cameras," she said. "They're simply a communications tool."

    Donna Gudmestad, RN, another of the team of eICU nurses in St. Louis, told RN she thought the eICU concept was a great idea from the beginning. "My opinion has never wavered. It's a great tool that has the potential to do even greater things than what we're doing now."

    Both Gudmestad and Blum said families love the idea of having an extra set of eyes on their loved ones. And the nurses on the floor appreciate that there's always a physician available to them. "It doesn't matter if you're a new nurse or an experienced nurse, when you want a physician to lay eyes on someone, you can call here and there's a physician who can camera in on the patient, assess the patient's information, and take the necessary steps to get the ball rolling for the nurse," Gudmestad said.

    Educating staff overcomes resistance

    The response to Mercy SafeWatch has been overwhelmingly positive in the host facility in St. Louis, and, perhaps somewhat surprisingly, the same has been the case at the remote facilities being monitored—once they understood what the SafeWatch program was all about.

    "There were many of our staff who really didn't know much about it," said Mandy Lewis, RN, a nurse at Mercy Health Center Oklahoma City, which is home to one of the Mercy SafeWatch ICUs being monitored from St. Louis. "We had a lot of people asking questions about it at first, and we met with some resistance. But I was one of the 'superusers' for implementing this technology, and knew it was going to be a great asset here. Once we started educating people about it, things went very smoothly. It's probably just human nature to be concerned about something new until you're educated about it."

    Since its implementation in September 2006, SafeWatch has been "awesome," according to Lewis. "It has been great for us at the bedside to have that extra set of eyes and ears on our patients," she said. "And now that we do all our charting on the computer, there's no longer anyone fighting over the charts. Anyone in the unit can go to a computer and pull up patients' information, without waiting for someone else to be done with the flow sheet."

    Debbie Perdue, an RN at Mercy Health Center Oklahoma City, said she was excited by the arrival of SafeWatch.

    "Any new technology that benefits our patients, and can help provide more safety to them, should be welcomed with open arms," she said.

    Even though Perdue describes herself as somewhat "old school" when it came to switching from paper charting to computer charting, she would never want to go back. "If there's a situation with a patient, I can stay right there in the room, hit a button, and SafeWatch can compare various days' lab results for me and answer my questions," she said. "I'm not pulled away from that patient at a crucial moment to go flip through several days' worth of paper charts."

    Back in St. Louis, eICU nurse Sara Stanhope, RN, pointed out that the use of Mercy SafeWatch hasn't changed the ratio of nurses to patients at the bedside, it simply has helped make nurses' bedside time more productive.

    She did admit, however, that working with remote facilities brought with it a few challenges until everyone got to know each other.

    "We did have to improve our communications skills," Stanhope said. "Just because a facility was doing something differently from the way we might have done it didn't mean their way was wrong. So you have to learn to be helpful and not judgmental. At the same time, there were best practices we wanted to convey and standardize, and I think SafeWatch has helped us do that."

    Stanhope also agreed with her colleague, Donna Gudmestad, about the technology's potential: "I think the sky's the limit," she said. "I don't see why we need to limit it to the ICU. I think someday, we could have an entire e-hospital."

    The last sentence of Orwell's novel, "He loved Big Brother," served as a chilling statement of the triumph of totalitarianism. But as evidenced by Mercy SafeWatch and a growing number of similar eICUs across the country, there's nothing inherently negative about the use of monitoring technology. In fact, there's much to love about the eICU program, and patients, families, and nurses alike share the triumph.


    Evidence Builds for eICU Programs as Lifesavers

    Hospital ICU patients are nearly one-third less likely to die, on average, when treated at hospitals using the eICU care delivery model, than they are at hospitals without eICU technology, according to results released in May by VISICU Inc. (www.visicu.com).

    Data from 185,464 patients treated in ICUs at 156 hospitals in 2006-2007 using VISICU's eICU technology show severity-adjusted hospital mortality rates over the two-year period of 9.6%, compared with the national hospital mortality rate of 13.5%.

    The Leapfrog Group (www.leapfroggroup.org) has documented numerous studies that show intensivist staffing reduces the risk of ICU mortality by up to 40%, but less than one-third of patients nationwide have access to these specialists.

    "Intensivist-led care 24/7 has become a necessity, not a luxury, and this program is the only identified way to address the growing critical-care crisis resulting from aging baby boomers and the shortage of critical-care doctors and nurses," said Dr. Brian Rosenfeld, VISICU chief medical officer. "The numbers are compelling. Patient conditions in the ICU can change in a matter of minutes, and we owe it to patients and their families to deliver the highest-quality care around the clock, seven days a week."

    Evidence Builds for eICU Programs as Lifesavers

    Hospital ICU patients are nearly one-third less likely to die, on average, when treated at hospitals using the eICU care delivery model, than they are at hospitals without eICU technology, according to results released in May by VISICU Inc. (www.visicu.com).

    Data from 185,464 patients treated in ICUs at 156 hospitals in 2006-2007 using VISICU's eICU technology show severity-adjusted hospital mortality rates over the two-year period of 9.6%, compared with the national hospital mortality rate of 13.5%.

    The Leapfrog Group (www.leapfroggroup.org) has documented numerous studies that show intensivist staffing reduces the risk of ICU mortality by up to 40%, but less than one-third of patients nationwide have access to these specialists.

    "Intensivist-led care 24/7 has become a necessity, not a luxury, and this program is the only identified way to address the growing critical-care crisis resulting from aging baby boomers and the shortage of critical-care doctors and nurses," said Dr. Brian Rosenfeld, VISICU chief medical officer. "The numbers are compelling. Patient conditions in the ICU can change in a matter of minutes, and we owe it to patients and their families to deliver the highest-quality care around the clock, seven days a week."