July 3, 2011

System provides ICU care remotely

Tired and lethargic, Kristopher Lee Taylor knew the moment he got out of bed one recent Monday morning that he wasn't going to work.

Taylor, 32 and a Phoenix resident, instead went to Banner Estrella Medical Center, where he was diagnosed with a potentially life-threatening diabetic reaction.

At the west Phoenix hospital's intensive-care unit, Taylor was treated remotely by a doctor in Tel Aviv, Israel, via a two-way camera installed in the patient's room.

Health-care companies such as Banner have turned increasingly to remote doctors to monitor their patients because of a shortage of critical-care specialists.

Dr. Baruch Goldstein assessed Taylor, monitored his vital signs and regularly communicated with him and his nurses, who provided hands-on care. Taylor received insulin, potassium, magnesium and fluid to treat diabetic acidosis, a condition in which a lack of insulin caused his blood levels to rise. He was out of the hospital's intensive-care unit within 48 hours and returned home that Thursday.

Taylor was satisfied that Goldstein, located half a world away, checked him several times during the day and night, even navigating a scare when Taylor's heart rate slowed in reaction to multiple needle injections. Not only could the doctor see the patient, but the patient could see the doctor.

"This was better because there was always a doctor on hand," said Taylor, comparing last month's hospital stay favorably to a previous trip.

"This one was a little more instantaneous. I felt he (Goldstein) could respond faster, rather than having to waiting for a doctor to come to your room or call a nurse back."

Banner Health is among more than three dozen hospital systems nationwide with "eICUs," which provide remote care for the most critically ill patients.

Banner's system, which began about five years ago, includes a command center at Banner Desert Medical Center in Mesa that links doctors and nurses to 15 hospitals and about 450 beds in Arizona, Colorado and Nebraska. Starting this year, doctors in Tel Aviv and Southern California also joined the system that remotely transmits critical patient information such as heart and breathing rates. The information allows the remote critical-care doctors to guide and work with doctors and nurses who actually provide the hands-on treatment.

The system, which Banner calls iCare, is available to every patient in intensive care, but patients are offered a chance to opt out when they are admitted.

By now, Banner doctors and nurses have become accustomed to working with virtual counterparts; Banner started iCare in early 2006. Medical specialists have said in the past, though, that while they welcome the help and ability for remote doctors to quickly detect problems, they worry about turning patients over to doctors they don't know.

The concept is that such remote telemedicine centers staffed by critical-care physicians and nurses can better handle the growing number of patients who require intense monitoring. There is a nationwide shortage of such critical-care specialists, known as "intensivists," so the idea is that these doctors can monitor more patients remotely than if they were on-site at a single hospital.

Banner Health's system is among the nation's largest remote telemedicine systems used for critical care.

Over the past four years, Banner said that patients have spent 26,000 fewer days in critical care and nearly 100,000 fewer days in hospital rooms. Last year, Banner estimates that the remote system saved more than 600 lives by providing more attentive care from critical-care specialists.

Banner's estimates are based on a hospital-industry measurement called Apache (Acute Physiology and Chronic Health Evaluation), which predicts outcomes of patients under similar circumstances.

Banner, based in Phoenix, has invested $11.3 million in equipment to establish its telemedicine system, and it is testing a plan to expand the program to areas of the hospital beyond the ICU. Banner is now conducting a pilot program at Banner Gateway Medical Center in Gilbert to assess whether it's feasible to use the telemedicine for medical and surgical units, too.

Banner Health CEO Peter Fine said the technology had proven its worth in the ICU because it had saved lives and reduced the time patients stay in the hospital.

"It's a more effective, efficient outcome for patient care," Fine said. "It is representative of the type of organization we want to be from a clinical-quality perspective."
Fewer fatalities

The idea of using telemedicine to bolster care at even established urban hospitals has gained momentum based on recent research.

In a May article published in the Journal of the American Medical Association, researchers found that patients at a Massachusetts hospital that operated an eICU system suffered fewer infections and fatalities. The death rate at UMass Memorial Medical Center in Worcester, Mass., dropped to 8.6 percent after the telemedicine program opened at the hospital, compared with the previous 10.7 percent.

Dr. Craig Lilly, who is director of the Massachusetts hospital's eICU program and the lead author of the study, said that the evidence showed that the telemedicine program saved lives.

Lilly said the biggest barrier to more widespread use of eICUs was capital costs for smaller hospital systems and convincing hospital staff that it was the best way to care for patients.

"Some people call it culture," Lilly said. "The hardest thing is routine, getting people to do things a little differently than they did before."

Robert Groves, Banner Health's director of critical care, said that establishing such a telemedicine program initially required a "leap of faith" for Banner.

Past studies of the benefits of telemedicine program for intensive-care units have produced mixed results. And hospital systems must grapple with not only the up-front equipment costs, but also the training costs associated with establishing such an intricate process and convincing hospital employees that it's the best way to deliver care.

Groves, however, said Banner's ICU units consistently have delivered better results in saving lives and reducing the length of hospital stays for patients.

"The most important outcome is, do you keep your patients alive, and do you provide quality care," Groves said.
Remote monitoring

Goldstein, the Tel Aviv-based critical-care physician, said he became interested in the concept of telemedicine while he was completing his medical training at a New York hospital.

At the time, he planned to move to Israel, but he also wanted to practice medicine in the United States. He investigated several hospitals' telemedicine systems before he landed a position at Banner Health.

Goldstein, who holds dual citizenship in the United States and Israel, works from a small office in Tel Aviv that includes all the remote-monitoring equipment he requires as a doctor. It also operates with redundant T1 data lines to ensure a reliable, high-speed connection.

In a typical day, Goldstein cares for dozens of patients in emergency rooms in Arizona, Colorado and Nebraska. He estimates that he receives 15 to 20 calls from nurses and doctors at Banner facilities during each shift. Otherwise, he keeps tabs remotely on the patients.

Goldstein, a New York City native, typically works during the day in Israel, which is the overnight shift at Arizona hospitals. Two doctors who are also board-certified in critical-care medicine work with Goldstein in Tel Aviv.

Goldstein, who works occasional shifts at hospitals in Israel to keep his bedside skills sharp, said he may add one more physician to the Tel Aviv office as Banner's eICU program grows.

"As long as Banner keeps growing, it is easy to find doctors willing to work with me," Goldstein said.

by Ken Alltucker The Arizona Republic Jul. 3, 2011 12:00 AM

System provides ICU care remotely

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