TeleICU And What It Means To You

Transcription

1 Vanderbilt Department of Anesthesiology TeleICU And What It Means To You Dr. L. Weavind MBBCh Associate Professor Anesthesia and Surgery Director Critical Care Fellowship Vanderbilt University Former Director eicu Memorial Hermann Texas Vanderbilt Medical Center

2 Goal: Discuss use of Telemedicine in the ICU environment Objectives: Define Telemedicine and it s use in the ICU Re-iterate need for this tool Address outcomes and barriers to utilization of TeleICU

3 Medical services delivered over distance using communication technologies. When did it begin? Einthoven (1906) ECG transmission over phone lines 1960 NASA and Lockheed used audiovisual technologies to create STARPAHC (Space Technology Applied to Rural Papago Advanced Health Care) Papago Indian reservation in Arizona linked to health care specialist utilizing microwave technology

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5 Leverage People Centralized intensivist led care team Specialty services (transplant, ECMO, burn) Senior Critical Care nurses Pharm D Technology The tool Process Standardized protocols and best practice Improve patient safety through checklists, redundancy, critical decision making in real time, timely intervention Consistent and continuous monitoring Data collection

6 Virtual ICU workflow Leveraging scarce resources

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8 Inconsistent care processes Data availability Medical errors Clinical throughput problems Clinical Staffing High costs Payors/patients demanding quality

9 Intensivist Presence in the ICU Reduced mortality Reduced complications Reduced length of stay Greater throughput Reduced costs JAMA 252: Chest 96: JAMA 260: JAMA 276: AJRCCM 157: AnnSurg 229: MayoClinProc 72: CCM 27: JAMA 281:

10 Physicians 35,000 Intensivists serving >4 million patients 1 Dedicated Intensivists in < 20% of US ICU s 1 Projected worsening gap between Intensivist supply and demand 2 Nursing 40% of US workforce > 50 years old 3 Nursing shortage to exceed 1 million by Nurse shortage impacts patient time, perception that quality impacted Provonost Crit Care Med 2006; 34(3): HRSA Report to Congress Wisdom at work/rwjf HRSA website 5. Buehans. Health Affairs 2007: 837.

11 SCCM Vision SCCM envisions a world in which all critically ill and injured persons receive care from integrated teams of dedicated experts directed by trained and present intensivist physicians We will need technology to facilitate timely, safe, effective and efficient patient care Dr. Angus asks if we can meet the requirements of an aging population? Angus, D. C. et al. JAMA 2000;284:

12 Adopters: Perception of increased quality and safety Quality and innovation Leverage the intensivist coverage of more patients Outreach relationships with small hospitals Non-Adopters: No buy in from bedside staff Limited ROI with substantial capital and operating cost Berenson Health Affairs 2009: 28:937 47

13 68% in Severity Adjusted ICU Mortality 33% In Severity Adjusted Hospital Mortality 44% Incidence of ICU Complications 34% in ICU LOS 33% in ICU Costs Rosenfeld CCM 2000; 28: Breslow CCM 2004; 32:31 38

14 Rural Healthcare 40% of US hospitals in rural area 25% of population 10% of physicians Sub-specialist Care Urban 134.1/100,000 Rural 40.1/100,000 Study Hospitals 1,000,000 pts over >1,550 sq. miles 1 tertiary care hospital (506 beds) 3 Regional Hospitals (10,6,10 ICU beds) 2 Community Hospitals (< 100 total beds) 9 Critical Access Hospital (<25 beds) Zawada ET Post Grad Med 2009: 121;

15 37.5% reduction in number of patients requiring transfer Decreased ICU mortality and LOS (3.79 days days) Decreased Hospital LOS (10.08 days 7.81 days) $ 10 mil cost savings from transfer costs, ICU and hospital costs driven by LOS Zawada ET Post Grad Med 2009: 121;

16 Upenn eicu monitored patients 64% ICU relative mortality reduction (8.4% to 3.1%) 46% Hospital relative mortality reduction (11.1% to 6%) 50% ICU relative LOS reduction Kohl CCM 2007; 35: A22 Sutter Health eicu diagnosis and management of sepsis protocols 53% ICU relative mortality reduction (41% to 19%) CCM 2006; 34: A108

17 Reduction in sepsis mortality driving best practices 1 Improvement sepsis protocol 2,3 Protocol compliance improvement DVT, VAP, PUD 4,5 Improved glycemic control 6 Decreased cardiac arrests 7 1. Ikeda CCM 2006; 34(12)A Patel CCM 2007; 35(12)A Ricon CHEST 2007; 132:557S 558S 4. Young CHEST 2006; 130:226S 5. Gessel CHEST 2007; 132:444S 6. Aaronson CHEST 2006; 130:2276S 7. Shaffer CCM 2005; 33(12):A5

18 ROI Cost avoidance VAP cost avoidance Leveraging of scarce resources Pharm D s Renal dosing Appropriate and therapeutic ABX regimens Avoiding ADR Am J Health Syst Pharm 2006;65: Reis International Anesth Clin 2009;47:

19 Why isn t everybody doing this?

20 Study ICU s Academic Tertiary Care Center 16 MICU beds 11 Shock Trauma beds Urban Hospital ICU s 32 Med-Surg beds Community Hospitals 12 med Surg beds 66% minimal delegation and 33 % full delegation Thomas JAMA 2009: 302:

21 ICU Mortality (9.2% to 7.8%) SAPS > 44 decreased mortality rate post eicu SAPS < 44 increased mortality rate post eicu Hospital Mortality (12% to 9.91%) SAPS > 39 decreased mortality post eicu SAPS < 39 increased mortality post eicu ICU Complications the same post intervention ICU and Hospital LOS the same post intervention Thomas JAMA 2009; 302:

22 No significant effect on ICU and hospital mortality when severity adjusted Increased LOS with low eicu involvement 2.6 days to 3.2 days Increased cost with low eicu involvement $22, 430 to 23,210 Morrison CCM 2004: 38;2 8

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24 Start up cost $45-50,000/bed Annual budget $28-32,000/bed licensing fee 90% of Operating Costs: Physician Salaries Nurse Salaries IT Support Reis International Anesth Clin 2009;47:

25 Culture Vision, leadership and willingness/need to change Technology Integrated EMR, radiology, labs, CPOE and pharmacy Reimbursement None, but not for lack of trying Regulation State must have license to practice medicine in the state that the hospital is being monitored. Hospital credentialing nightmare Malpractice

26 Tele-ICU model of care can facilitate delivery of safe, timely, efficient, equitable, effective and patient centered care - IOM Technology alone cannot bring significant changes in outcomes Complex technology in dysfunctional environments can lead to unintended outcomes Does benefit outweigh significant cost (financial and cultural) and can we wait to find out?

27 Questions?