Every CIO knows that success in any transformation project requires three key ingredients. First, you require a great team working together. Secondly, you have to incorporate a set of best-in-class processes. And thirdly, you need enabling information technology as the glue. In the Health Care industry, any transformation project is focused on improving the quality of health care. We all know that there is nothing more valuable than a human life. Lehigh Valley Health Network(LVHN), a thousand-bed, three-time Magnet-designated hospital in Allentown, Pennsylvania, leveraged information technology coupled with revised processes and teaming skills to drive down mortality rates and increase patient outcomes in their 6 Intensive Care Units (ICU) or 141 critically ill adult patients. They developed an Advanced ICU capability, using telemedicine and other health information technologies, that statistically saves 1 additional life for every 15 patients who required ICU medical care. That amounts to over 240 lives saved over the course of a year.
Dr. Matthew McCambridge is chief of LVHN’s division of critical care medicine. “We serve our community and strive to provide the best medical care we can offer.” The success of the Advanced ICU includes a great group of nurses, doctors, and technicians working and communicating as a team, a set of best-in-class processes that drive results, and a set of enabling technologies that provide important clinical information. How did they do it? Read on to find out to find out how ICU telemedicine started, the journey at LVHN, and three success factors that made it all possible.
In 1998 Dr. Brian Rosenfeld was medical director of two critical care units at The Johns Hopkins Hospital. He observed that during the day, critical care patients received excellent care, but during night time hours of 7pm-7am, only a handful of physicians were available. For critical care patients, this can be devastating. So Dr. Rosenfeld set up a computer at his home where he could monitor critical care patients and connect with physician specialists and nurses to administer needed care immediately when he observed anomalies in patients’ vital signs. Lives were saved. Dr. Rosenfeld then founded the company, Visicu, which was acquired by Phillips. Telehealth for Intensive Care Units was a reality.
In 2000 Harry Lukens, CIO at LVHN, and a team of physicians and nurses began looking at ways Intensive Care outcomes could be improved. They heard about the telehealth approach and Dr. Rosenfeld’s work; but at the time, there was only one telehealth ICU in the US. After in-depth research and site visits in the Netherlands, LVHN acquired their first telehealth clinical information system from iMDSoft. During the next 10 years, trained teams of critical care physicians (intensivists), and nurses improved the processes by which they cared for critically ill patients. So the combination of People, Process, and Technology are at the cornerstone of the Advanced-ICU Center at Lehigh Valley Health Network that now monitors 141 critical care patients during the hours of 7pm-7am every night of the year at an off-site facility,4.5 miles east of the network’s largest campus. The combination of a trained telehealth nursing staff and critical care physicians (intensivists) working with on-site physicians, nurses, and technicians coupled with a re-engineered process for caring for ICU patients, and leveraging technology was blended for success.
Lehigh Valley Health Network Advanced ICU (AICU)
The Lehigh Valley Health Network has 988 acute care beds in their Cedar Crest, 17th and Muhlenberg hospital sites. These hospitals admit approximately 70,000 overnight admissions a year and 15%, or about 10,000, are admitted as critical care patients. The offsite Advanced Intensive Care Unit monitors 141 critical care patients, nightly.
The LVHN Advanced ICU (AICU) is a remote facility located 4.5 miles from the Lehigh Valley Hospital Cedar Crest site – the largest of the network’s hospitals. Affectionately known as the “Doc in the Box,” the AICU is a square room approximately 25 feet wide and 25 feet long. The facility includes four “computer pods”. Two rows of four computer monitors are connected to provide the same information that is available at the patient’s bedside. One nurse manages each of the three pods while the fourth is for the Advanced ICU critical care physician. In addition, a clerical team member in the AICU triages and prioritizes ancillary communications. This team of 5 performs miracles each and every night.
Each nurse, experienced in critical ICU care, monitors approximately 35-45 patients – thus the three nurses can monitor the 141 intensive care beds at LVHN. At the center pod sits the intensivists, a board-certified critical care physician who is specially trained and coordinates care for ICU patients during the 7pm-7am shift. The nurses and doctor practitioners rotate between the hospital ICU and the remote AICU on a regular basis. This enables them to effectively partner with hospital nurses, doctors, residents and advanced practice clinicians to provide the ultimate care for each of the ICU patients.
The nurses and doctor can display any piece of information on any screen and even adjust their working Pod table up and down, electrically, to provide them with the most ergonomically oriented position. The eight computer monitors provide the following information for the AICU team to provide medical care for each ICU patient:
|Patient’s Medical Records||Blood Pressure, Heart Rate, Electrocardiogram, Test Results, Medication Doses and Rates, etc.|
|Picture Archiving and X-Rays||X-rays and other medical picture records of patient|
|Audio Visual Monitoring System||Ability to visually examine patient symptoms such as dilated pupils, Skin color, etc.|
|Medication Administration Record||Ability to view patient medicine history and order medicines electronically that are prescribed for the patient.|
|Administrative Information System||Listing of All ICU patients, their room numbers, doctors, etc.|
How the AICU Provides Life Saving Results – Three Success Factors
I had the opportunity to see first-hand how the LVHN Advanced ICU operates during two visits. The first visit was during the day when ICU care is administered at the bedside at each of the hospitals. Four key players in AICU provided me an overview of the facility (Harry Lukens, CIO, Joe Tracy, Vice President of Telehealth Services, Nancy O’Connor, IT Director and Lorraine Valeriano, Manager of Advanced ICU at Lehigh Valley Health Network (LVHN)). I learned about the history of the Advanced ICU, how it functions, and the enabling technology. But to really understand how it functions, I was invited to see in action one evening.
I arrived at about 8pm one evening for my 1 hour tour. Dr. McCambridge, the Intensivist, was at the center pod listening to voicemail updates from each of the daytime ICU physicians. Each of the nurses, Nancy Long, Rich Riccio and Dara Patton, were monitoring their individual pods. Lorraine Valeriano, the ACIU manager, greeted me and introduced me to Dr. McCambridge and the nurses.
Dr. McCambridge and the nurses described how they can access various databases to display patient data on the monitors. They explained how the data can be displayed in different formats, and how they manage the care of 141 patients each and every night from 7pm to 7am.
To show me how the unit interacts with ICU patients, Dr. McCambridge explained to me how he can access a patient’s medical history, current vital signs and x-ray images for an ICU patient, all of the same information accessible at the bedside. He can connect to an ICU room via the two-way audio and video remote monitoring system to both see and talk to the patient. In turn, the patient can also visualize and communicate with the physician on a monitor screen in the ICU room. Dr. McCambridge explained to me that earlier in the evening he was observing a patient and was able to answer some questions from the family members who were visiting the ICU patient. During the conversation, he reviewed some of the recent xrays and noticed that a PICC line was in need of repositioning for more efficient medication administration by the nurse. Dr. McCambridge immediately called the resident on duty to discuss the corrective action that needed to occur to reposition the line. The AICU nurse was also able to speak with the bedside nurse to update her on the situation.
Dr. McCambridge also explained to me that the resident also mentioned a distress situation with another patient. Dr. McCambridge immediately reviewed this patient’s x-rays and discussed a course of action with the resident physician. These are two case examples of how critical care was administered in minutes instead of having to wait for multiple return phone calls or even until morning when the day shift physicians made ICU rounds. Critical time was saved because of the Advanced ICU care provided to the patient.
Actually seeing how the AICU operates, real-time, is an eye opener. I asked Dr. McCambridge and the nurses why they work at the AICU as part of a rotating nursing assignment for critical care patients. For Dr. McCambridge the answer was simple. “It’s my passion to help people and critical care patients represent a population where urgent care administered 24 hours a day will save lives.”
The nurses, each with 20-35 years of critical care experience had similar answers.
- Dara, with 34 years of critical care nursing experience told me that “the AICU has proven to be very important in helping the newer RN’s who are mostly on night shift with troubleshooting problems with their patients, and guiding them through difficult situations”.
- § Richard, with 20 years critical care experience, finds that “one of the major values of the Advanced ICU nurses is that we act as a ‘second layer of protection’ for all patients, especially those whose caregivers are neophyte critical care nurses. We offer assistance to these nurses by helping them critically think when appropriate.”
- Nancy, with 25 years of critical care nursing experience works at the AICU because ” I feel I have an advantage to gain more knowledge by listening to the different cases, and challenges in caring for critical patients. I feel it personally is a “win-win” deal for me. I can use this knowledge daily in my job, and help others when difficult situations arise through the experiences that I gained working in the AICU”.
- Lorraine, the AICU Manager, a critical care nurse for 27 years certified as a Neuroscience Registered Nurse, views the AICU as “.. an extra layer of care in monitoring patients and an external resource for bedside clinicians”.
The care these professionals provide ICU patients requires passion, focus, and experience. They actually save lives incorporating three best practices that make the AICU successful.
Three Best Practices That Make the AICU Successful – Great Teamwork, Improved Processes, Enabling Technologies
Dr. McCambridge described to me what he considers the three critical success factors and some examples of each that led to the improved mortality rates in the LVHN intensive care units in the presence of an AICU..
- Great teams don’t just happen. It’s hard work and skill.
- The team of specialty trained physicians, nurses and technicians who work together at the hospital ICU and rotate to the Advanced ICU.
- Knowing your team members, their skills, and the experience of working together builds a great critical care team that is focused on improving patient outcomes.
- People communicate well with each other.
- Every team member knows their role, capabilities, and skill levels.
- Every team member knows when to ask for help.
- During the past 10 years we’ve honed our Advanced ICU and hospital ICU processes.
- We enclosed each and every ICU room to maintain a sterile environment.
- We set rigorous standards of experience for each critical care nurse and intensivist that works in the Advanced ICU.
- We defined roles and skills required for each team member.
- We make sure that we rotate, on a regular basis, between the hospital ICU and the Advanced ICU to make sure that we never lose sight of our hands-on caring skills.
- Since the ICUs are “closed ““ICUs,” the Advanced ICU Intensivist is either an attending or consulting physician for an ICU patient and therefore, can write orders, prescribe medications, and coordinate care with physician specialists as required during the overnight hours.
- A medical information system that integrates key data that can be accessed by any team member both at the bedside and from a remote monitoring location.
- Electronic ordering of medicines results in patients receiving their drugs within 60 minutes of the electronic order entry.
- Provide automated notifications to Advanced ICU nurses when medical parameters are reached (temperature, blood pressure, heart rate, and laboratory data, etc.)
The best real-life experience of how the Advanced ICU saved a life. In 2005, Stephanie Heater was home experiencing what appeared to be flu like systems. After 2 days, her parents brought her to the local hospital emergency room in the evening where the physician immediately knew from previous experience that she was suffering from “toxic shock” and immediately transferred her to the LVHN ICU. Dr. McCambridge was the intensivist on call that evening and monitored her condition at the Advanced ICU. Alarms on the computer monitors at the Advanced ICU were triggered all evening as Dr. McCambridge worked with on- site hospital residents and nurses through a set of complex procedures, via the visual and audio monitoring capability, to stabilize Stephanie’s condition. Dr. McCambridge never left Stephanie’s virtual bedside as he monitored her vital signs the entire night. Stephanie stabilized and returned home a few weeks later. She didn’t remember much of what happened but she wanted to meet the Doctor that helped her. She visited the Advanced ICU. She told Dr. McCambridge that the two-way video “was really cool”. Before she left the AICU she walked towards Dr. McCambridge and “..hugged him for giving me my life back“.1
Doctors and nurses working as a team, practicing critical care medicine, using a stringent set of best-practices enabled by technology saved Stephanie’s life. This trilogy of transformation enablers apply in business as well. We can all learn from health care practitioners who apply these principles each and every day.
1 Reader’s Digest, May 2007, pp 162-165
Phil Weinzimer is president of Strategere Consulting working with clients to develop business and IT strategies that focus on achieving business outcomes. Previously Mr. Weinzimer was Managing Principal-Professional Services for IT Business Management at BMC Software. He has also held Managing Principal positions in the Professional Services organizations for ITM Software, CAI, and Sapient.
Mr. Weinzimer has written a book concerning customer value entitled “Getting IT Right: Creating Customer Value for Market Leadership” and has a forthcoming book, “The Strategic CIO: Creating Customer Value, Increasing Revenue, Enhancing Shareholder Wealth”, will be available in 2013.
Mr. Weinzimer can be contacted at firstname.lastname@example.org