Critical Care, Critical Choices: The Case for Tele-ICUs

New England Healthcare Institute – Massachusetts Technology Collaborative
Cambridge, MA

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Background

Intensive care units (ICUs) are a vitally important component of health care in U.S. hospitals, treating six million of the sickest and oldest patients every year. The choices about how to manage ICUs carry high stakes: ICUs have both the highest mortality and the highest costs in health care, accounting for 4.1 percent of the nation’s $2.6 trillion in annual health care spending, or nearly $107 billion per year.

Problem

Adding to the complexity of these ICU management decisions is the collision of two strong trends: the increasing number and severity of critical care patients as the U.S. population ages, and the decreasing supply of critical care physicians (known as “intensivists”) available to manage the growing number of ICU patients. The obvious result of these colliding trends is a shortfall of intensivists, just as the need for critical care increases.

Physicians and nurses who are not certified in critical care medicine can also work in ICUs and, in fact, represent the majority of the clinicians in those units. However, research indicates that ICU patients have lower risks of death and shorter ICU and hospital stays when an intensivist physician is on duty in the ICU to oversee patient care. The presumption is that when intensivists are available to manage and monitor ICU care, patients’ problems are identified sooner, leading to more rapid and complete interventions and lower mortality rates. The mortality reduction attributed to intensivist staffing varies among research findings, ranging from 15 to 60 percent lower than in ICUs where there are no intensivists. Similarly, costly ICU and hospital length of stays for ICU patients have been observed to be shorter in units staffed with intensivists.

Hospital standards set by The Leapfrog Group, a leading national health care quality association, call for full-time intensivist staffing as a way to reduce ICU deaths by an estimated 50,000 lives per year. However, in 2006 there were reported to be fewer than 6,000 actively practicing intensivists in the U.S. with less than 20 percent of ICUs staffed with intensivists.

Solution

There is a potential solution for addressing the critical care staffing shortage: a telemedicine technology, known as tele-ICUs, which puts intensivists and other specialists in a central “command center” to remotely monitor, consult to, and care for ICU patients in multiple and distant locations. Tele-ICUs hold great promise to improve the care of ICU patients, save lives, lower costs, and increase both the productivity and the reach of specialists in critical care medicine.

A single tele-ICU command center can provide care for up to 500 patients, with staffing constellations of one tele-intensivist, four advanced practice nurses and a pharmacist to care for 75 patients. By increasing the number of ICU patients that critical care teams can manage, tele-ICU technology can effectively extend both the productivity and the reach of intensivists, other critical care specialists and nursing staff.

Although tele-ICU technology holds promise to expand ICU capacity and solve the mismatch between the supply and demand for intensivists, a number of barriers has contributed to its slow adoption nationally. These include:

• Physician resistance to using the technology
• Technical compatibility issues
• Capital costs
• Regulations regarding cross-institution and cross-state physician licensing and credentialing
• Lack of Medicare reimbursement for tele-health services
• A lack of documented clinical and financial outcomes of the benefits of tele-ICU care

As of 2010, approximately 250 hospitals had implemented a tele-ICU program in the U.S. (including 42 tele-ICU command centers) representing just 7.6 percent of U.S. hospitals with adult ICU beds or 6.8 percent of adult ICU beds.

Costs

Given the barriers described above, the adoption of tele-ICU technology by hospitals in Massachusetts and nationally has been slow and uneven despite its potential to provide remote intensivist coverage to critical care patients. It is against this backdrop that NEHI and MTC determined that a demonstration project was warranted to assess the benefits of tele-ICUs. The study analyzed two metrics, ICU mortality and ICU length of stay. According to these metrics, tele-ICUs would prove they had significant clinical and financial value if they could demonstrate a 10 percent decrease in ICU mortality rates coupled with an average decrease of 12 hours for an ICU length of stay.

The University of Massachusetts Memorial Medical Center (UMMMC) was an ideal site for the demonstration project because it had installed the only tele-ICU command center in Massachusetts and was extending coverage to both the medical center’s seven adult ICUs and to two outlying community hospitals’ adult ICUs (covering a total of 116 beds). Data were collected for a six-month period both prior to and following implementation of tele-ICU coverage, thus enabling a determination of whether patient outcomes as measured in mortality and length of stay improved.

Implementation of the tele-ICU command center at UMMMC entailed substantial capital expenditure and one-time operating costs ($7,120,000) and requires an increment of annual operating costs of $3,150,000. For each of the community hospitals implementation required capital and one-time operating costs of approximately $400,000 and incremental annual operating costs of about $400,000.

Positive Outcomes

The NEHI-MTC demonstration project resulted in a report, “Critical Care, Critical Choices: The Case for Tele-ICUs,” released in December 2010, with the following key findings:

• Tele-ICUs save lives. At UMMMC, patient ICU mortality decreased by 20 percent and total hospital mortality rates (which is time spent in ICU plus the remainder of their hospital stay) declined by 13 percent. At one of the community hospitals, ICU-adjusted mortality rate decreased 36 percent.
• Tele-ICUs shorten ICU stays. Patient ICU stays were reduced by 30 percent or an average of two days in the academic medical center. Community hospital stays were also reduced.
• Tele-ICUs save money. Hospitals recovered the up-front investments for tele-ICU in approximately one year. Health insurers saved $2,600 per patient treated in the academic medical center. Tele-ICUs also enable community hospitals to care for a substantial portion of patients instead of transferring them to teaching hospitals (as is common practice). Retaining these patients in community hospitals saves the payers approximately $10,000 per case.
• Tele-ICUs should be implemented statewide. Given the clinical and financial benefits, NEHI and MTC recommend that all academic medical centers implement tele-ICUs by the year 2014 and that all community hospitals in Massachusetts implement them by 2015.

The report concluded that if tele-ICU systems were broadly and effectively implemented in Massachusetts, more than 350 additional lives could be saved each year, the hospitals would benefit financially, and the potential savings for payers would exceed $122 million annually. If these results were realized on a national scale, the clinical benefits and savings would be considerable and significant.

Funding

The funding of tele-ICU technology is at the discretion of a hospital system. Although access to capital can be a recurring problem for many community hospitals, the short-term (approximately one year) payback period for tele-ICU capital and operating costs significantly reduces the impact of this perceived barrier. For the full promise of tele-ICU to be realized on a national scale, hospitals will need to embrace the technology and implement it into practice. While legislation or executive orders aren’t a necessary pathway to widespread implementation, tele-ICU technology has enough market benefits to compel innovative institutions to adopt it. Since the release of our report, the Steward Healthcare System (formerly Caritas) approved funding in February 2011 to implement a tele-ICU initiative and five community hospitals have also expressed interest in adopting tele-ICUs.

In terms of regulation, NEHI and MTC have been working with Massachusetts Public Health Commissioner John Auerbach to license hospitals in the state and give them credit for improved patient safety standards. Additionally, NEHI and MTC are working with The Leapfrog Group (which provides patient safety ratings for hospitals) to identify ways to encourage hospitals to adopt tele-ICUs.

Expansion

Since the report was released in December 2010, NEHI and MTC have expanded the program to include all academic medical centers and community hospitals in the state. NEHI has partnered with the Massachusetts Council of Community Hospitals and the Massachusetts Hospital Association for an outreach effort to community hospitals statewide.

Due to the success of the program in Massachusetts, NEHI was awarded a grant from the California HealthCare Foundation to study the potential of using telemedicine to improve the care delivered in ICUs in California. The grant is being used to assess the state’s current ICU capacity and examine whether tele-ICU technology can expand the availability of trained critical care specialists in California.

Up until now, there has been slow adoption of tele-ICU technology in Massachusetts and across the country. Since the release of the NEHI-MTC report, there has been a growing interest in the technology. As for current practices nationally, as of 2010 there were 42 installed and active tele-ICU command centers across the country.

Future Goals/Conclusion

The goal of NEHI and MTC’s research project is to provide decision-makers with evidence-based data on the clinical and financial benefits of tele-ICU technology. Given what has been learned about the promise of tele-ICUs to improve patient care and reduce costs, the case for implementing the technology is compelling. As a result, NEHI and MTC recommend that all academic medical centers in Massachusetts implement tele-ICUs by the year 2014 and that all community hospitals in the state implement them by 2015. On a national level, our goal is to change hospital standards to encourage the use of tele-ICU across the country.

The clinical and financial benefits of a fully implemented tele-ICU system offer a win-win-win opportunity for patients, hospitals and payers across Massachusetts. Now that tele-ICUs are gaining a strong reputation based on clear evidence, we must seize the chance to speed adoption of this valuable technology in hospitals around the country.

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