In the past several years, there have been growing concerns related to the shortage of critical-care physicians (intensivists) and critical-care nurses in the healthcare industry. In 2006, HHS reported to Congress that two-thirds of ICU patients may be receiving less than optimal care. They went on to say that “Even if only half of patients admitted to intensive-care units were cared for by full-time intensivists, there would be a shortage of critical-care physicians in the range of 25% of current supply.” The report further estimated a 35% shortage in the critical-care workforce by the year 2030. The healthcare industry is well aware of these constraints, and a limited number of health organizations have devised solutions to this dilemma by expanding upon technological advancements in telemedicine offerings that can greatly leverage the capabilities of the existing intensivists and critical-care nurses.
Baptist Health South Florida’s commitment to excellence in quality of care included the goal of decreasing critical-care patients’ mortality rates and length of stay. The stated mission became to deliver an enterprisewide critical-care solution that would decipher real-time clinical data through a series of algorithms (i.e. artificial intelligence) and provide trending alerts prior to becoming incidents. In addition to this pro-active medical approach, our mission also included the delivery of accurate, timely and relevant clinical data to allow the clinician to make informed decisions. These mandates were able to be satisfied through the implementation of a cutting-edge critical-care information solution.
Baptist Health South Florida was the first healthcare organization in South Florida to implement a critical-care patient surveillance and monitoring system. The system is composed of 22 servers. Each of our five major facilities has a corresponding server responsible for transmitting bedside vital information and facilitates near real-time waveforms that replicate the monitoring conducted at the bedside. Realizing the future demands on this information system, the system was designed to be “highly available” by duplicating the production environment with a set of secondary servers that would automatically failover in the event that the primary server(s) failed. We also leveraged the high availability architecture to include our network infrastructure and our storage area network solution. A complete set of servers were also procured to support our development and upgrade environments. The system interfaces to a series of information systems, which include the hospital information system, vital signs, laboratory results, medication orders and nursing flowsheet entries. In addition, a shared PACS station to view diagnostic-quality medical images and accessibility to all the pertinent hospital information systems is made available at our state-of-the-art multimonitor workstations.
Each monitored patient room is equipped with videoconferencing hardware that includes a high-resolution camera. The camera's resolution is so powerful that the remote caregiver can see the patient’s pupil. The audio portion includes a highly sensitive microphone and speaker to allow the remote staff to communicate with the bedside staff and the patient. A call button is also included to contact the remote center clinicians and may be used for any purpose; even to ask a simple question. The constant communication between the local and remote caregivers is one of the primary ingredients for success.
The remote staff assists the bedside with data collection for various performance improvement and monitoring projects like collection of ventilator bundle data, which is a part of the surveillance process in prevention of ventilator-associated pneumonia. Monitoring of interventions done by physicians and nurses are also documented. In a six-month period, data collection has shown that 35 patient falls, 13 medication errors and eight cardiac arrests were prevented. The remote RNs divide the patients by hospital so that each nurse monitors approximately 30-40 patients. They watch for changes in vital signs, assisted by the alarms/alerts built into the software they use. They also watch for arrhythmias and new lab results as well as provide all kinds of clinical and technical assistance to the bedside nurse. The remote MD routinely monitors all patients using the acuity system and specific alerts that could result in the need for an order.
Since the initiation of our surveillance and patient-monitoring initiatives, in conjunction with continuous improvements modalities, the severity adjusted mortality and length of stay have demonstrated considerable reductions. Based on a recent report that compared the program's initial quarterly data against the most recent quarterly data, the results indicated a 42% reduction in hospital mortality, 14% reduction in ICU length of stay and 33% reduction in total hospital stay for all ICU patients. In addition, our patients and their families have shown a substantial increase in satisfaction. However, this surveillance comes with substantial start-up—approximately $5 million not including BHSF labor—and operational costs (annual operating budget approximately $4 million). BHSF chose to absorb all costs and not charge for this service, although we are working on grants for future/expanded coverage, there are many questions as to why BHSF would even consider this investment. BHSF President and CEO, Brian E. Keeley, clearly put things in perspective when he stated: “It is all about doing the right thing for the patient.”
Armando Romero
IT corporate director
Beth Willmitch
Operations director
Baptist Health South Florida
Coral Gables, Fla.
