Case Study – United General Hospital ICU Expansion Case Study

Overview

United General Hospital is a 15-year-old, 220-bed hospital built to serve a suburban community of 90,000 residents, 60 miles outside Des Moines, Iowa. Of the beds, 10 are in the intensive care unit (ICU). Over the last 15 years, the community has grown to over 190,000 residents, who are supported by United General and four urgent care facilities. With the urgent care facilities able to address many of the population’s non-emergency issues, there is an increase in the ratio between the use of the hospital’s non-ICU facilities and its ICU facilities. In a typical week, the ICU operates at 120% capacity and 40% of patients experience a six- to eight-hour delay transferring to the ICU. The patients remain either in the emergency department, creating an overcrowded emergency department, or in post-op, causing overcrowding and delays in scheduled surgeries.

The hospital has just received $15 million in funding and is considering expanding the ICU; however, the CEO is not convinced that expanding the ICU department is the right solution for the hospital. The analysis is to include options that combine expanding the ICU department with using remote ICU monitoring.

The ICU senior staff brought you, Raul Hemply, in as a consultant to build a business case to support the decision to expand the ICU and use remote ICU monitoring. You will work with the ICU’s senior staff to build a business case and present it to the CEO and board of directors for final consideration. There will be great emphasis placed on data and analyses that support your recommendation. Because of this, you need to use data derived from informed or objective sources, or evidence-based data, to build the recommendation. The CEO will want to know the sources, validity, and reliability of the evidence presented.

As you create your business case, there are several options to consider: 1. Subscribe to remote ICU monitoring services with a per usage model so that you only pay for

services as they are rendered. 2. Expand the ICU with a combination of ICU beds and regular beds managed by a combination of

bedside and remote ICU monitoring. 3. Expand the ICU with ICU rooms managed by bedside teams. 4. Expand the ICU and subscribe to remote ICU monitoring for rooms that will serve patients with

more serious conditions.

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Excerpts of a conversation with George Mallory, the senior staff representative

George: Hello, Raul; it is good to meet you. We are looking forward to working with you on this business case to expand the ICU. We have already completed some research on the right size of the ICU, and we will share that with you over the course of your investigation. Raul: Hi George, I appreciate you taking the time for this interview. This will help me in my research of how much to expand the ICU; I am also considering the use of remote ICU monitoring service as a complement to expanding the ICU. George: Remote ICU monitoring services is a topic that will cause a lot of consternation here at United General. We have a number of staff members that fear that a remote service will put them out of a job, so I would touch lightly on that subject. Raul: Has your group done any research on remote ICU monitoring services in the area? George: We started to but realized that it was so controversial that it was not really an option. If you do look into a remote service, please make sure to take the staff into account in the analysis. Raul: What caused the controversy with the idea of remote ICU monitoring? George: Physicians were reluctant to cede authority to a remote operation, and nurses were concerned about a loss of autonomy. During a staff meeting, a couple of nurses voiced concerns because their colleagues complained of a poorly executed implementation. Raul: Thank you George, I will. Can you tell me who on your staff has the research on the remote ICU monitoring services? George: That would be Frank. Frank looked at the services from the standpoint of patient and staff benefits and cost savings, as well as how the services help the patient. We suggested that he speak to staff in hospitals that have implemented these services to get their reaction to the change, but he never went through with that because the staff here was so set against it. It will be a hard sell to the staff. Raul: Thank you for the heads up. Was there any other research completed about expanding the ICU that I may be able to use? George: I cannot think of anything else. You may want to check with other hospitals that use these services, as part of your study. Raul: Thank you, George; I think I have enough to get started. I will check back with you if I need any help.

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Excerpts of a conversation with Frank Bellamy, a senior ICU staff member Raul: Hi, Frank. My name is Raul, and I would like to talk to you about your research on remote ICU monitoring. I am working on a business case to expand the ICU and to couple it with the use of remote ICU monitoring services. Frank: Sure, I would be happy to talk with you about the research I have completed. Let me start with three general benefits of these remote ICU monitoring services. Telemedicine is able to link a single physician to multiple clients using remote computer technology, leveraging the specialist’s cognitive skills over multiple patients. However, it also mandates significant process changes in how we provide ICU services. In short, the remote ICU represents a “re-engineering” of how we provide ICU care, expanding the reach, scope, and availability of intensivists’ expertise. The re-engineering occurs through a number of ways. First, the telemedicine connection is continuously available in a pro-active fashion that provides “twenty-four seven” coverage. Secondly, the system utilizes computerized clinical intelligence algorithms with direct electronic links to physiologic, laboratory, and pharmacy data as well as patient diagnoses to focus attention on potential adverse outcomes or trends in individual patients and to notify caregivers before trends manifest as adverse outcomes. Third, the traditional physician, nurse, and patient relationship is substantially augmented when there is an ICU physician immediately available to address issues in patient care, particularly at night, when physicians are less likely to be present at the bedside. Raul: During your research, did you speak with any staff members from hospitals currently using remote ICU services? Frank: Yes, I spoke with Mark Panther from Practitioner Hospital in Indiana about their use of remote ICU monitoring. I can tell you what he said, or you can give him a call for firsthand information. Raul: Thank you Frank. Please do not be offended; I think I will give him a call directly. The information will be more valid coming directly from the source. Frank: I understand the need for a firsthand account. Here is his contact information.

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Excerpts of a conversation with Peter Bella, United General Hospital’s chief financial officer Raul: Hi, Peter. My name is Raul, and I am working on a business case to address the potential expansion of the ICU department. I understand that you have completed some research that may help me with the analysis for the business case. I am investigating the addition of ICU beds and the use of remote ICU monitoring services. What has your research shown in these areas? Peter: Hi Raul, I am glad to help in your research. As far as remote monitoring costs are concerned, it costs $25,000 to $30,000 per ICU bed per year to equip each room. In my research, I have seen a 30% reduction in the ICU length of stay (LOS) numbers. Overall, the savings for the hospital is about $4,000 per patient. Raul: What have you uncovered in regards to staff and patient benefits? Peter: One benefit we expect is for physicians who are tired due to long hours or stress. They are less prone to making avoidable mistakes with the second set of eyes provided by the addition of a remote ICU service’s clinical surveillance and support. Raul: What about benefits that you might expect to see in in regards to patient satisfaction? Peter: We expect patient satisfaction to increase because of their added confidence that both bedside staff and remote ICU monitoring service will adequately cover them. Raul: Thank you for the information, Peter; how do you see this applying to an expansion of the ICU department? Peter: If we expand the ICU department, one thing that you may want to consider is to expand the department and start with regular beds tied to remote monitoring. We pay $4,000 a day for an ICU bed and $1,700 a day for a regular bed. If we add the $500 per day cost of remote monitoring to the cost of supporting a regular bed, we will be able to provide ICU services to a larger number of patients without incurring the full cost of an ICU bed. By starting patients in a non-ICU bed and only transferring patients if necessary, we can provide similar benefits at a fraction of the cost.

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Excerpts of a conversation with Mark Panther, senior ICU staff member at Practitioner Hospital Raul: Hi, Mark. My name is Raul, and I am researching remote ICU monitoring services for possible use at United General Hospital. I spoke with Frank Bellamy, and he told me that you have some good information on remote ICU monitoring since your hospital has implemented these services. What can you tell me? Mark: Hi, Raul; I am glad to help. For the most part, the idea of the services frightened many of the staff because they felt that they would lose their positions if we subscribed to a remote ICU monitoring service. The nurses and physicians fought the idea for a while, and we even found some sabotaging it when it was first implemented here. However, once we got through the first six months, people started accepting it, and the service is now running more smoothly. Raul: What did you find to be the benefits of remote monitoring? Mark: One benefit is collaborations. An example was between a new nurse and an experienced nurse in the remote center. The new nurse, just off orientation, prepared to transport a patient to radiology for a CT scan. The patient had two chest tubes, and the new nurse felt uncertain about how to safely disconnect the chest tubes from suction and prepare the patient for transport. The nurse brought the experienced remote monitoring nurse in by camera to assist. The remote monitoring nurse coached the ICU nurse through the steps to prepare the chest tubes and the patient for transport. The bedside nurse felt relieved, confident, and supported in caring safely for the patient. Raul: What type of changes have you seen within the local operations at your hospital? Mark: Interestingly enough, we have seen improvements to our pre-existing in-house intensivist care model with the addition of the remote ICU monitoring. The reasons for this are that it provides proactive and hourly remote “virtual rounds” on the most critically ill patients, and our ICU physicians use its computerized algorithms when triaging patients. These algorithms are processes that are programmed into the system to guide physicians and nurses during ICU intake. We also find that it supports our staff decisions, thereby reducing the number of errors in our critical care unit. Raul: How did you address the cost of implementing the remote monitoring system? Mark: During our research, we uncovered that remote monitoring was most effective for patients with a Simplified Acute Physiologic Score over 50. We initially implemented remote monitoring in a small number of rooms, to take advantage of this benefit, and found that constant remote and computerized monitoring reduced our mortality rate by 25% for these patients. Raul: Thank you for helping me research remote ICU monitoring services. Is there anything else that would be helpful in my research? Mark: You may want to talk to our hospital administrator Becky Walters. She helped with the research and is currently monitoring the benefits. She may have time to fit you into her schedule. I will give her a call and let her know that you might be calling. Raul: Thank you, Mark. May I use you as a reference in my report? Can I give people at United General your name if they have any questions? Mark: Sure, Raul; I am glad to help. I know the remote ICU monitoring services have provided both staff and patient benefits here, and I hope United General adopts them as well.

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Excerpts of a conversation with Becky Walters, administrator at Practitioner Hospital Raul: Hi, Becky. Mark Panther thought you might have some insights that would help me build a business case to expand the ICU department at United General with the use of a remote ICU monitoring service. Becky: Sure, Raul. We count on remote ICU monitoring services to keep track of patients in areas that enhance our own capabilities. Even though we have a well-staffed and well-trained ICU department, the remote ICU monitoring services alerted us to an early symptom of sepsis in one of our patients before a nurse would have identified it, and we were able to remove a central line before it resulted in an infection in the blood system. In another case, an intensivist at the remote command center detected instability in a patient, alerted the bedside team to the issue, and identified a new treatment before the bedside staff would have recognized the issue. So far, in the first two years of implementation, we have seen a 10 to one ratio of these types of interventions that have benefitted the patient. Raul: How has the staff reacted to these interventions? Becky: Initially, the staff resisted the remote ICU monitoring services and the interventions, but, after the first six months, the staff started to see the benefits to the patients and welcomed the collaboration with the remote center resources. Raul: Are there any other benefits that Practitioner is seeing from the remote ICU monitoring services? Becky: We had a great example of collaboration earlier this year. A nurse called the remote ICU monitoring service at 1 am to describe a patient’s leg wound, which appeared to be worsening. The remote physician connected via cameras in the patient’s room, visualized the patient’s leg, and realized the urgency of facilitating an immediate intervention. While the remote nurse assembled and reviewed the patient’s lab results, the bedside nurse prepared the patient for the OR, and the remote intensivist collaborated with the surgical team to activate the OR team for the emergent procedure. Raul: That is a great example of collaboration that I can use in the study. Are there any productivity benefits you have noticed? Becky: We have been able to increase the number of patients under care. Prior to subscribing to the service, an intensivist was able to oversee about 10 patient beds. With the addition of the service, we have been able to take advantage of one intensivist and four nurses in the remote command center to oversee the care of 50 to 75 beds. We have seen a drop in the average length of stay of an ICU patient by 24%, or an average of five days. This reduces our costs by about $5,000 per patient because we can move them to a regular hospital bed sooner.

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You found through various discussions that one of the challenges to implementing a remote monitoring system is the resistance to the system by ICU physicians and nurses. To dig deeper into this resistance, you request an interview with the head ICU nurse. Excerpts of a conversation with Francine Mueller, head ICU nurse at United General Hospital Raul: Hi, Francine; I would like to discuss your thoughts on using a remote ICU monitoring service to augment an expansion of the ICU department. Francine: Sure, Raul; we are in support of the expansion because we are experiencing a significant increase in patient wait times for admission into the ICU. It would be to the patients’ benefit to address this problem as soon as possible. Raul: What are your thoughts on implementing a remote ICU monitoring service to help defray cost by reducing the number of ICU beds that the hospital would need to add? Francine: There are positives that we believe would result from using such a system, such as enhanced collaboration with remote physicians and nurses and constant monitoring. However, that same collaboration raises our concern over a loss of autonomy and heightened scrutiny. Without a remote system, we consult with local physicians about care and, sometimes, have in-depth discussions about the advice for care. We would not look forward to adding another source of contradictory advice. That advice would be coming from a source with which we are unfamiliar. Raul: Francine, it sounds like you have reasonable concerns about a remote ICU monitoring service. How would you consider addressing these concerns? Francine: I would want to have the nursing leads very comfortable with the people providing the remote ICU monitoring services. It would be critical for us to we understand their background, and for them to understand and respect our knowledge. Moreover, because I would worry about a potential service or equipment malfunction, I would want all staff members fully trained on the system prior to implementation. Raul: That sounds like a good suggestion and something that I need to include in any implementation plans. What would you say if I told you that Mark Panthers from Practitioner Hospital stated that, once the hospital staff accepted the remote monitoring system, they measured a significant increase in positive patient care? Would you believe that 96% of the patients and 80% of staff stated that patient care quality increased because of their remote ICU monitoring system? Francine: Thank you, Raul, for listening to our concerns, and I am looking forward to reading your business case. I am going to be especially interested in the implementation plans.