Remote IT Lets Docs Care for ICU Patients From a Distance

When Leo DeFault had what should have been a fatal heart attack almost three years ago, it was an alert bystander who knew CPR that kept him alive. But once he was at a community hospital, it was a critical care physician -- who was 25 miles away -- who saved his life through a remote IT system.

The electronic intensive care unit, or eICU, where Dr. James Shaffer was located allowed him to remotely instruct and watch emergency room physicians as they put DeFault into a coma using therapeutic hypothermia to lower his brain's temperature to 91.4 degrees Fahrenheit to reduce damage from loss of oxygen.

"This isn't a guy who fell down and bumped his head. He was dead," Shaffer said. "We were able to teach the bedside staff how to do the procedure. It went off without a hitch. The beauty of it is that Leo did well."

After inducing the coma, Shaffer was able to then monitor his patient for 10 days through the eICU, which allowed him to watch DeFault through a high-definition, two-way robotic camera that could zoom in close enough to detect changes in the capillaries in DeFault's pupils. Special software monitored DeFault's vital signs, and preset alerts based on DeFault's medical history alerted Shaffer to even the smallest changes in white blood cell count, oxygen levels and heart arrhythmia.

Healthcare and tech convergence

As healthcare and technology converge, more and more doctors will be able to do what Shaffer did: remotely intervene to save patients' lives and monitor their conditions from a distance. It's an advance in telehealth technology that also helps patient families.

For DeFault's wife, Barbara, having a critical care team monitor her husband 24 hours a day gave her peace of mind. "I was able to leave and come home, and maybe not rest, but I knew someone was watching him all the time," she said in an interview. "It was like having a private nurse right there. I just couldn't believe they could do this."

Even as Shaffer and two critical care nurses were remotely monitoring DeFault, they were also in charge of 60 to 80 other patients in five ICU units across three hospitals in the Health First healthcare system, which is based in Rockledge, Fla.

"The robotic cameras allow us to see and hear and talk to patients. Really, there are no walls," Shaffer said.

The system also has five mobile eICU carts, like the one used in the emergency room that initially treated DeFault. In April, the hospital system will add a fourth hospital to its eICU system and one mobile device, for a total of 102 remotely monitored ICU beds and six mobile carts.

In a typical ICU, during night shifts physicians respond only to emergencies when paged by charge nurses. The nurses can do very little, for example, if a patient experiences an irregular heart rhythm that could harm his health.

"[The nurse] can't even put in a urinary catheter without an order," Shaffer said. "So rather than paging a physician, which can take up to 30 minutes, they push a button or pick up a phone, and if I've not already seen the irregular rhythm, I'm clued in within 15 seconds."

"I'm a big fan," said Leo DeFault, referring to the eICU technology. "It's the best thing since sliced bread. My life was saved. How do you convince someone that you're foolish not to use these?"

Walking in Wal-Mart

In was on June 26, 2008, that DeFault, then 68, suffered "cardiac death" while taking an exercise walk inside the Wal-Mart across from his house. DeFault hit the floor so hard he cracked his skull and for all intents and purposes was dead. The chances of the retired construction engineer recovering without serious brain damage were slim, according to Shaffer.

But DeFault was fortunate to wind up at Palm Bay Hospital just a few minutes away from the Wal-Mart. That hospital, part of the Health First healthcare system, had an eICU remote communications cart. On the cart was a two-way camera, a high-definition computer monitor and LAN-connected health monitoring equipment that allowed Shaffer, who was located in Health First's VitalWatch eICU, to assess the situation and direct ER physicians through what was for them an unfamiliar therapeutic hypothermia procedure.

A single eICU staffed by one critical care physician and two nurses can effectively keep tabs on up to 120 patients. That's because special software, called eCareManager, monitors each patient's vital signs, providing "smart" alerts about any health-threatening changes.

Philips Healthcare said its customers are already using the eICU model to bring telehealth support to the emergency room, the surgical floor and long-term acute care facilities. Others are looking at extending telehealth support to skilled nursing facilities and even into a patient's home.

"If a heart rate changes 15 beats in a three-hour period for a particular patient, that may send up an alert for the physician or nurse," said Frank Sample, CEO of the Philips tele-ICU system. "The monitoring software offers a one-page thumbnail graphic for heart rate, blood count and all the other vital signs as they're actually happening."

Illustration: Richard Tuschman
A patient dashboard

If a patient's health moves in wrong direction, eICU physicians and nurses can bring up a profile page and dig deeper into the patient's health history to determine the cause of the problem. At that time, physicians will typically turn on the remote camera and begin watching the patient and conversing with nurses on scene.

"It creates a sense of collaboration," Sample said.

For example, if a patient goes into cardiac arrest and a nurse performs CPR, the eICU physician can monitor an electrocardiogram readout and the calibration off a ventilator to determine the effectiveness of the procedure.

Each eICU command center has five to six computer-monitor workstations that can keep track of multiple patients. Doctors and specially trained ICU medical personnel in the command center can speak with the remote ICU personnel to discuss clinical patient data and can view televised images of the patients. Direct patient care is provided by the doctors and nurses in the physical ICU, who do not have to be specially trained in intensive care procedures.

That last point is important because in recent years, the number of people needing ICU care has gone up -- without a corresponding increase in the supply of professionals trained in ICU techniques.

About 300 hospitals in 40 healthcare systems across 30 states now use eICUs. As a result, more than 300,000 patients are remotely monitored by eICUs each year -- about 10% of U.S. adult ICU patients, according to Philips. And the popularity of eICUs is growing. Last year, another 500 beds were added nationwide.

Philips provides the professional services to set up the eICUs along with the health monitoring software. The hospitals are responsible for purchasing all the hardware and finding a suitable facility with networking connectivity in which to run the eICUs.

The eICU software alone costs from $2 million to $3 million.

Expensive, but worth it

However, the cost is well worth it, according to Shaffer. Health First's VitalWatch has saved lives and money, and the patient litigation rate has dropped to zero since the hospital installed the eICU system seven years ago. "All it takes is one legal bogie, and you're talking a couple millions dollars," he said, referring to potential damages that could be awarded in a lawsuit.

The remote monitoring facility has also helped reduce the number of sepsis cases, a major problem among U.S. hospitals, as well as the amount of time patients spend on ventilators, Shaffer said. "It's not unusual for patients with sepsis to present at night when there are few physicians around," he said.

DeFault said that even if he had been taken directly to a state-of-the-art hospital in a major city, he'd still want it to have an eICU.

"If someone has a heart attack on the 24th floor, by the time you get them down to the 17th floor where they can be treated, they're gone," he said. "It was instrumental in me having lived my second life. I don't know how else to praise it."

Lucas Mearian covers storage, disaster recovery and business continuity, financial services infrastructure and health care IT for Computerworld. Follow Lucas on Twitter at @lucasmearian or subscribe to Lucas's RSS feed. His e-mail address is lmearian@computerworld.com.

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