1. Caring Together, Caring for Life.

2. Avera eICU Care: Partnering ICUs in Rural America
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

3. 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

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7. Source: The Advisory Board
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Source: The Advisory Board

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9. DRIVING FORCES: Clinical Issues
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DRIVING FORCES: Clinical Issues
IHI Bundles
Ventilator Bundle
Sepsis Bundle
Research Driven Interventions
Glucose Management

10. Driving Forces: Changes in Healthcare Environment
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Driving Forces: Changes in Healthcare Environment
Nursing Shortages – more inexperienced nurses at bedside
Demands on Physicians

11. VISICU Founded in 1998 Two Johns Hopkins Intensivists
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Founded in 1998
Two Johns Hopkins Intensivists

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14. Caring Together, Caring for Life
Avera eICU Care

15. A comprehensive program that combines:
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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)

16. PHASE 1 Implementation September 2004 4 Regional Facilities:
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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)

17. PHASE 2 September 2005 Expansion to 4 Critical Access Hospitals
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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

18. OPERATIONS: Physician Staff
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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

19. OPERATIONS: eICU Staff
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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)
IT – Availability 24 hrs/day

20. OPERATIONS: Licensing/Credentialing
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OPERATIONS: Licensing/Credentialing
Physicians Licensed for each state and credentialed for each facility
RNs licensed for each state

21. OPERATIONS: Levels of Communication
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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

22. OPERATIONS: Communication
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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

23. OPERATIONS: Algorithms
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OPERATIONS: Algorithms
Algorithm Development and Sharing
Research Based
Examples: Potassium, Glucose Management, Pain Management, Sepsis, Vent Weaning

24. Algorithms: Ventilator 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.

25. Algorithms: Glucose Rounds
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Algorithms: Glucose Rounds
Protocol research based
Goal: Tight Glycemic Control for appropriate patients

26. Algorithms: Sepsis Bundle
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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

27. Caring Together, Caring for Life
OPERATIONS: Teaching
Weekly Critical Care Conference Teleconferenced to remote sites
FCCS Course
Newsletters
Clinical Site for Residents, RT, Pharmacy, Nursing Students

28. Outcomes – APACHE System
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Outcomes – APACHE System
Components: Acute Physiology, Age, Chronic Health Evaluation
Severity adjusted outcome predictions
Overall accuracy
Database- over 1 Million ICU patients
Imbedded in e-ICU software

29. Avera Outcomes – ICU Mortality
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Avera Outcomes – ICU Mortality
3rd Quarter 2005
Predicted: 6.2%
Actual: 1.8%
4th Quarter 2005
Predicted: 5.7%
Actual: 1.9%
1st Quarter 2006
Predicted: 6.6%
Actual: 1.0 %

30. Avera Outcomes – Hosp. Mortality
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Avera Outcomes – Hosp. Mortality
3rd Quarter 2005
Predicted: 11.4%
Actual: %
4th Quarter 2005
Predicted: 10.6%
Actual: %
1st Quarter 2006
Predicted: 11.0%
Actual: %

31. Avera Outcomes – ICU LOS
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Avera Outcomes – ICU LOS
3rd Quarter 2005
Predicted: Days
Actual: Days
4th Quarter 2005
Predicted: Days
Actual: Days
1st Quarter 2006
Predicted: 2.9 Days

32. Avera Outcomes – Hosp. LOS
Caring Together, Caring for Life
Avera Outcomes – Hosp. LOS
3rd Quarter 2005
Predicted: Days
Actual: Days
4th Quarter 2005
Predicted: Days
Actual: Days
1st Quarter 2006
Predicted: Days
Actual: Days

33. Critical Access Hospital Goals
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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)

34. Avera Marshall Critical Access Hospital 25 Beds 4 Bed ICU 2 eICU Beds
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Avera Marshall
Critical Access Hospital
25 Beds
4 Bed ICU
2 eICU Beds

35. Rural Hospital Benefits
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Rural Hospital Benefits
Keep More Patients in Home Community
Enhanced Community Confidence
Recruiting  
Access to Specialty Physicians (Pulmonology, Nephrology, Cardiology)

36. On-Site Physician Benefits
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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

37. Typical Diagnosis Affected
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Acute Renal Failure
Complicated Pneumonia
Electrolyte Abnormalities
Septic Shock
Congestive Heart Failure
Diabetic Ketoacidosis
Overdoses
Cardiac Arrhythmias

38. Patient/Family Benefits
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Patient/Family Benefits
Case Scenarios

39. Nursing Benefits 24 hr Peer Resource Pharmacy Resource
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Nursing Benefits
24 hr Peer Resource
Pharmacy Resource
Assistance with Transfers

40. Technology Issues Need T1 Line for transmission of information
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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

41. Financial Issues Start-up Costs
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Financial Issues
Start-up Costs
Approx. $30,000/bed for initial equipment
Mobile Equipment slightly more expensive
Monthly Service Fee

42. Obstacles Trust Building “Big Brother” Factor Individual Resistors
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Obstacles
Trust Building
“Big Brother” Factor
Individual Resistors
Lack of Standardization of processes, equipment
“Camera Shy”

43. Future Expansion USDA Grant Additional Sites eCare Mobile eSearch
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Future Expansion
USDA Grant
Additional Sites
eCare Mobile
eSearch

44. Caring Together, Caring for Life
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

45. Contacts pat.herr@mckennan.org jean.winter@averamarshall.org
Caring Together, Caring for Life
Contacts

46. Caring Together, Caring for Life
Questions?