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Implementation of Critical Care Telemedicine – the eICU July 22, 2010

Posted by Eric Rivedal in SINI2010.

Presented by: Margaret Mullen-Fortino, MSN, RN; Joseph DiMartino, MSN, RN; Nicole Coles-Williams; Frank D. Sites, MHA, RN; and C. William Hanson, MD

This presentation was on the implementation of a system at the University of Pennsylvania. It was recommended that intensivists directly monitor all ICU patients. However, there was a finding that patients do better when they are able to stay near their homes. This is especially true for patients in critical condition being cared for in rural locations. The program was started to provide access to clinical expertise to rural settings.

Implementation required the installation of a camera, microphone, speaker and computer in every monitored room. In some ways, the technology overshadowed the availability of clinical expertise.

The system installed (VisiCu) includes decision support that provides users with information on changes expressed in percentage points and alerts them to changes in patient condition. Cameras are very good, but only one to two beds can be viewed by a user at a time.

Implementation occurred in a phased approach that brought up one unit at a time. It included education for staff nurses that covered history of telemedicine and the basic functions that could be done by the system. There were representatives of the telemedicine program on site providing go-live support.

There was some resistance from staff as they were concerned that Big Brother was coming and that the system would be used as a disciplinary thing. Some didn’t want help – they felt they had enough expertise to care for the patient. There was a period when poor interactions between telemedicine and floor staff were documented. In an effort to educate floor staff, they were invited to watch the telemedicine staff working. New hires were introduced as part of their orientation. Unit councils were formed to discuss issues – many process fixes occurred on the spot. The introduction of two-way video helped with communication as well (this was also beneficial to patients). Pizza and snacks were also helpful in the acceptance of telemedicine. Bringing some staff nurses onto the telemedicine team and allowing them to work in both has also improved acceptance by staff.

Challenges to the implementation included differences in standards of care across the multiple facilities being monitored. The eICU nurses had to become familiar with policies at each facility and learned to ‘back off’. Frequent downtimes during early operations made it difficult to attain confidence. Lack of partnership with all the stakeholders (staff nurses, IT staff, etc.) also slowed the implementation.

Benchmark reporting on patient conditions was used both to inform staff nurses of whether the eICU was making a difference and to demonstrate the efficacy of eICU monitoring. The eICU helped by tracking compliance with care standard monitors. This helped both by seeing the results and by remembering that the camera was watching for compliance. Reporting was carried on for Ventilator Acquired Pneumonia, Blood Transfusions, etc. Many of the reporting projects resulted in changes to process that improved patient outcomes. These reporting data are made known to floor staff through a variety of interaction strategies including meetings, publications and posters.

There is a data warehouse that the eICU staff use to do reporting with. There is a three day latency in data extraction/transformation/loading. The U Penn school of engineering works on this data and other methods to provide decision support for nurses. They have had success with extracting data from multiple monitoring systems and providing that information to clniicians in real-time. They continue to work on projects that will present data in better formats that makes it easier for clinicians to see what the real story is.

In conclusion, introduction of eICU didn’t change processes – it was the data that came from it that did so. Presentation of data to floor staff at the grass roots level made real changes that improved patient outcomes.



1. erdley - July 23, 2010

Thanks, Eric & Peter. Content sounds a bit more than typical pragmatic of previous years. Appreciate your respective efforts. Miss the blogging corner .

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