Caring Together, Caring for Life
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Caring Together, Caring for Life
Avera eICU Care: Partnering ICUs
in Rural America
Pat Herr RN, CCRN – Director Avera eICU Care
Jean Winter RN – Director of Nursing Services
Avera Marshall
Lois Coudron, RN CCU Lead Avera Marshall
Caring Together, Caring for Life
Avera System
• Our mission is to
make a positive
impact on the lives
and health of
persons and
communities
• Improve health care
through a regionally
integrated network
Caring Together, Caring for Life
Caring Together, Caring for Life
Caring Together, Caring for Life
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Source: The Advisory Board
Caring Together, Caring for Life
Caring Together, Caring for Life
DRIVING FORCES: Clinical Issues
• IHI Bundles
– Ventilator Bundle
– Sepsis Bundle
• Research Driven Interventions
– Glucose Management
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Driving Forces: Changes in
Healthcare Environment
• Nursing Shortages – more inexperienced
nurses at bedside
• Demands on Physicians
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VISICU
• Founded in 1998
• Two Johns Hopkins
Intensivists
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Caring Together, Caring for Life
Caring Together, Caring for Life
Avera eICU Care
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A comprehensive program that combines:
1. A remote, centralized, care team that
assess and intervene on patients in
support of the on-site caregivers
2. Use information technology tools that
transform the care process (virtual
team at bedside 24 hrs/day)
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PHASE 1
• Implementation September 2004
• 4 Regional Facilities:
– Avera McKennan Hospital (490 Beds)
– Avera Sacred Heart Hospital (144 Beds)
– Avera St. Luke’s Hospital (143 Beds)
– Avera Queen of Peace Hospital (120
Beds)
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PHASE 2
• September 2005
• Expansion to 4 Critical Access Hospitals
–
–
–
–
Avera Marshall, Marshall, MN
Pipestone Co. Med. Center, Pipestone, MN
Avera St. Anthony’s Hospital, O’Neill, NB
Avera St. Benedict’s Hospital, Parkston, SD
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OPERATIONS: Physician Staff
• Specialty Physicians (20 hrs/day)
– 2 shifts daily
• 12:00 pm – 10:00 pm
• 10:00 pm- 8:00 am
– Intensive Care Trained –
Pulmonologists, Nephrologists,
Cardiologist
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OPERATIONS: eICU Staff
• Nursing Staff (24 hrs/day)
– RNs
• Require 3 years Critical Care Experience or
CCRN
• Cross trained between eICU/ICU
• Customer Service skills required
– HCAs (Health Care Assistants – 24 hrs/day)
• Cross trained between eICU/ICU
• Customer Service skills required
• IT – Availability 24 hrs/day
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OPERATIONS:
Licensing/Credentialing
• Physicians Licensed for each state and
credentialed for each facility
• RNs licensed for each state
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OPERATIONS: Levels of
Communication
• Category I – Emergency interventions;
discuss care with attending prior to other
interventions
• Category II – Adjust existing care plan
independently
• Category III – Can develop new therapies
and orders
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OPERATIONS: Communication
• Flow of Information Vital
– Daily Updates
– Access to Information Systems
– PACs System or method for viewing
xrays
– Fax
• “Hot Line” in each facility (both ways)
• eLert Button
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OPERATIONS: Algorithms
• Algorithm Development and Sharing
• Research Based
• Examples: Potassium, Glucose
Management, Pain Management, Sepsis,
Vent Weaning
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Algorithms: Ventilator Weaning
• Vent Rounds daily
– Bedside nurse
– Respiratory therapist
– eDr
• Goal is advance the weaning protocol
• Outcome – decreased vent days from 4.5/per pt.
to 2.9/pt.
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Algorithms: Glucose Rounds
• Protocol research based
• Goal: Tight Glycemic Control for
appropriate patients
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Algorithms: Sepsis Bundle
• Health quality initiative to reduce mortality
due to sepsis by 25% (nationwide)
• Employs early identification and stepwise
intervention
• Led to an order set based on protocols for
step therapy
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OPERATIONS: Teaching
• Weekly Critical Care Conference
Teleconferenced to remote sites
• FCCS Course
• Newsletters
• Clinical Site for Residents, RT, Pharmacy,
Nursing Students
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Outcomes – APACHE System
• Components: Acute Physiology, Age,
Chronic Health Evaluation
• Severity adjusted outcome predictions
• Overall accuracy- 0.90
• Database- over 1 Million ICU patients
• Imbedded in e-ICU software
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Avera Outcomes – ICU Mortality
3rd Quarter 2005
Predicted:
Actual:
4th Quarter 2005
Predicted:
Actual:
1st Quarter 2006
Predicted:
Actual:
6.2%
1.8%
5.7%
1.9%
6.6%
1.0 %
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Avera Outcomes – Hosp. Mortality
3rd Quarter 2005
Predicted:
Actual:
4th Quarter 2005
Predicted:
Actual:
1st Quarter 2006
Predicted:
Actual:
11.4%
5.0%
10.6%
5.7%
11.0%
7.0%
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Avera Outcomes – ICU LOS
3rd Quarter 2005
Predicted:
Actual:
4th Quarter 2005
Predicted:
Actual:
1st Quarter 2006
Predicted:
Actual:
2.9 Days
2.22 Days
2.85 Days
2.19 Days
2.9 Days
2.19 Days
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Avera Outcomes – Hosp. LOS
3rd Quarter 2005
Predicted:
Actual:
4th Quarter 2005
Predicted:
Actual:
1st Quarter 2006
Predicted:
Actual:
9.16 Days
6.79 Days
9.04 Days
6.66 Days
9.34 Days
6.89 Days
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Critical Access Hospital Goals
• Different than DRG Hospital Goals
• Keep more Patients in Home Community
• Assist with Triage/Decision Process
(decreased costs, increased safety)
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Avera Marshall
• Critical Access Hospital
– 25 Beds
– 4 Bed ICU
– 2 eICU Beds
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Rural Hospital Benefits
• Keep More Patients in Home Community
• Enhanced Community Confidence
• Recruiting
• Access to Specialty Physicians
(Pulmonology, Nephrology, Cardiology)
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On-Site Physician Benefits
• Attending Physician
– Retains control (Selects levels 1-3)
– Retains billing (No individual patient charge
for eICU coverage)
• Relief from recurrent night calls
• Peer availability
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Typical Diagnosis Affected
•
•
•
•
•
•
•
•
Acute Renal Failure
Complicated Pneumonia
Electrolyte Abnormalities
Septic Shock
Congestive Heart Failure
Diabetic Ketoacidosis
Overdoses
Cardiac Arrhythmias
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Patient/Family Benefits
• Case Scenarios
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Nursing Benefits
• 24 hr Peer Resource
• Pharmacy Resource
• Assistance with Transfers
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Technology Issues
• Need T1 Line for transmission of
information
• Need compatible cardiac monitors for
interface to eICU software
• Other interfaces optional (lab, ADT)
• Access to Hospital Information System
• Easy to use at remote site
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Financial Issues
• Start-up Costs
– Approx. $30,000/bed for initial
equipment
– Mobile Equipment slightly more
expensive
• Monthly Service Fee
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Obstacles
• Trust Building
• “Big Brother” Factor
• Individual Resistors
• Lack of Standardization of processes,
equipment
• “Camera Shy”
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Future Expansion
• USDA Grant
• Additional Sites
• eCare Mobile
• eSearch
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CONCLUSIONS
• The electronic ICU will provide additional
supervision of patients
• The electronic ICU allows specialists (in short
supply) with greatest experience in care of
seriously ill patients to be used as a resource for
all hospitals participating in this program
• Proven benefit to patient outcomes while
reducing costs and increasing safety/quality
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Contacts
• pat.herr@mckennan.org
• jean.winter@averamarshall.org
• lois.coudron@averamarshall.org
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Questions?