Big Medicine is on the way, according to celebrated author and Harvard professor, Atul Gawande, In a major article in the New Yorker, Gawande describes the new frontier of ICUs as ones where patients may be monitored not from a telemetry station within the hospital but from a remote command center filled with high-tech screens and armies of highly-trained technicians that could be miles away and serve multiple hospitals.
Gawande cites the example of Dr. Armin Ernst, who is responsible for Steward Health Care’s ICU operations at the system’s 10 hospitals, serving approximately 8,000 patients annually. “He sees it (the ICU) as the temporary home of the sickest, most fragile people, Gawande writes. ”Nowhere in healthcare do we expend more resources. Although fewer than one in 4,000 Americans are in intensive care at any given time, they account for four percent of healthcare costs. Ernst believes that his job is to make sure that everyone is collaborating to provide the most effective and least wasteful care possible.
Ernst’s ICU command center is a one-story building that contains millions worth of technology, banks of computer screens carrying cardiac-monitor readings, imaging scans, and lab results. Special software sends an alert when it detects patterns that raise concerns. Doctors and nurses operate consoles where high-definition video cameras zoom into any ICU room and talk directly to the staff or to the patients themselves. Soon, the tele-ICU team will monitor the care for every ICU patient in the Steward system.
The experience was eye-opening for Gawande. After five minutes of observation, I realized that the remote ICU team wasn’t exactly in command; it was in negotiation, Gawande writes. Sometimes the bedside staff resist resolving problems that the E-ICU staff identify. You have got to be careful from patient to patient, Gerard Hayes, a tele-ICU doctor, explained. Pushing hard has ramifications for how it goes with a lot of patients. You don’t want to sour whole teams on the tele-ICU. Several hospitals have decommissioned their systems; clinicians have placed gowns over the camera, or torn the camera out of the wall.
Despite some opposition, there is good reason why hospitals are adopting the E-ICU model. Remote monitoring is a high-tech solution to a sticky problem facing hospitals: how to care for the sickest patients amid a worsening shortage of intensive-care physicians. Currently, only one third of ICU patients receive care from an intensivist. The Department of Health and Human Services believes that demand for intensivists will outstrip supply over the next 30 years. Initial results from the E-ICUs have been dramatic: Mortality rates are 30 to 40 percent lower when physicians provide 24/7 care to prevent complications and minimize errors. A University of Massachusetts Medical Center study of 6,400 patients in seven adult intensive-care units monitored by E-ICU showed substantial benefits in reducing both costs and mortality, according to the hospital’s director, Craig Lilly. The hospital saved $5,000 per case, mostly because the system lets intensivists in the remote-command center “detect instability and bring new treatment to the patient before they would have received it in a typical ICU.