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Avera eICU Care: Partnering ICUs in Rural America

. 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. Avera System.

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Avera eICU Care: Partnering ICUs in Rural America

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  1. .

  2. 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. 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

  4. Source: The Advisory Board

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

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

  7. VISICU • Founded in 1998 • Two Johns Hopkins Intensivists

  8. Avera eICU Care

  9. 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)

  10. 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)

  11. 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

  12. 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

  13. 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

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

  15. 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

  16. 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

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

  18. 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.

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

  20. 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

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

  22. 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

  23. 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 %

  24. Avera Outcomes – Hosp. Mortality 3rd Quarter 2005 Predicted: 11.4% Actual: 5.0% 4th Quarter 2005 Predicted: 10.6% Actual: 5.7% 1st Quarter 2006 Predicted: 11.0% Actual: 7.0%

  25. Avera Outcomes – ICU LOS 3rd Quarter 2005 Predicted: 2.9 Days Actual: 2.22 Days 4th Quarter 2005 Predicted: 2.85 Days Actual: 2.19 Days 1st Quarter 2006 Predicted: 2.9 Days Actual: 2.19 Days

  26. Avera Outcomes – Hosp. LOS 3rd Quarter 2005 Predicted: 9.16 Days Actual: 6.79 Days 4th Quarter 2005 Predicted: 9.04 Days Actual: 6.66 Days 1st Quarter 2006 Predicted: 9.34 Days Actual: 6.89 Days

  27. Critical Access Hospital Goals • Different than DRG Hospital Goals • Keep more Patients in Home Community • Assist with Triage/Decision Process (decreased costs, increased safety)

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

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

  30. 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

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

  32. Patient/Family Benefits • Case Scenarios

  33. Nursing Benefits • 24 hr Peer Resource • Pharmacy Resource • Assistance with Transfers

  34. 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

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

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

  37. Future Expansion • USDA Grant • Additional Sites • eCare Mobile • eSearch

  38. 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

  39. Contacts • pat.herr@mckennan.org • jean.winter@averamarshall.org • lois.coudron@averamarshall.org

  40. Questions?

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