Roshanmanasia.weebly.com



Virtual ICU Care Model: A Remedy to Prevent Adverse Events and Deaths in Adult Intensive Care UnitsRoshan Jan Muhammad The Johns Hopkins University School of Nursing “On my honor, I pledge that I have neither given or nor received any unauthorized assistance on this assignment”. RJMHealth Issue: Preventable Adverse Events and Deaths in Intensive Care UnitsIntensive care unit (ICU) is an integral entity in the health care system. In United States, ICUs manage almost 6 million critically ill patients per annum that comprise of high number of geriatric population (NEHI, 2010). Cutting edge technology, advancement in medical science and evidence based practice has gifted us longevity and improved clinical outcomes. However, in 1999, the release of report “To Err is Human” by Institute of Medicine, confronted us with bitter fact. The report revealed that significant number of patients die each year in hospitals as a result of preventable harm and adverse events. Since then, prevention of adverse events has become a particular focus of quality and safety in the health care system. According to Landrigan et al. (2010), about 18% of patients sustain harm during hospitalization and many of these adverse events are serious or even fatal. Intensive care units are not immune to this adversity. On an average, every patient admitted to ICU suffers 1.7 potentially life threatening medical errors every day (Gorman, 2011). Department of health and human service (2009) reported that hospital associated infection (HAI) is a significant cause of morbidity and mortality in hospital patients and in ICU patients in particular. The report revealed that on a national scale, four categories of HAIs including ventilator associated pneumonia (VAP), central line associated blood stream infections (CLABSI), urinary tract infections (UTI) and surgical site infections (SSI) account for 87,925 deaths per year. Most of these infections and related mortalities are preventable. These HAIs incur an estimated $28 to $33 billion excess healthcare cost each year. ICU care costs nearly $107 billion dollars per year which is 4.1% of nation’s annual health care spending (NEHI, 2010). Experts have estimated that as many as 50,000 lives and $ 4.3 billion might be saved annually in the intensive care units by improving care processes and by preventing adverse events (Young, et al, 2011). A preventable adverse event in ICU is a result of serious gaps in health care system and shortage of trained intensivists and critical care nurses. Lack of trained nurses and intensivists in ICU is associated with higher errors, more complications, longer length of stay and increased mortality rate (Camire et al. 2009 and Landrigan, 2010). NEHI (2010) speculates that by 2030, US health care system would need ICU capacity to cater 54 million case days per year. This number is three time higher than figures reported in 2006. Nevertheless, by 2020, shortage of nurses would rise over 400,000 and scarcity of intensivists is predicted to escalate upto 35% (Rincon et al., 2011). Intensive care is a complex 4 legged stool that demands right care, at right moment by right people in a safe way. Adverse events in ICUs and related financial statistics are staggering. Thus, quality and safety challenges demand a shift form outmoded system of work in intensive care units, where care processes are transformed and technology is integrated to leverage available expert human resources. Tele-ICU Care ModelI believe, novel care model of virtual ICU or tele-ICU is a solution to the problem. Tele-ICU is a technology based systemic model, designed to compliments expertise of intensivists and critical care nurses, stream line care process and improve outcomes. In this model, expert ICU physicians, critical care nurses and support staff, situated at command center, remotely work with onsite clinical teams at satellite hospitals. Technology serves a central role in the process by providing remote access to clinical information system, clinical trends, laboratory results, medications and bedside monitoring system of ICU patients to tele-ICU team. Tele-staff have real time communication with onsite staff through microphones. Simultaneously, high resolution remote cameras provide visual access to patient, equipment and environment to facilitate care delivery to critically ill patients. Moreover, sophisticated monitors have built in protocols and feature of treatment reviews that guides the need of change in clinical management. The system is sensitive to flag red zone situations and trigger remote help from expert professionals. Thus, it provides continuous supervision of intensive/expert critical care nurses, reduces response time to alarming conditions, decreases time to life saving interventions and enhances coordination and communication (Myers et al., 2008).Tele-ICU program has potential to positively influence quality of care and safety of ICU patients. In a study, Lilly et al. (2011) has reported that tele-ICU is associated with higher compliance to clinical practice guidelines for prevention of ventilator associated pneumonia, deep vein thrombosis, stress ulcer and cardiovascular protection. In another study, Rincon et al. (2011) has reported that tele-ICU intervention has caused statistically significant improvement in early identification and adherence to evidence based surviving sepsis bundle. Lilly et al. (2011) has also reported statistically significant decline in preventable complications, ventilator associated pneumonia and central line associated blood stream infections rates in ICU patients after implementing virtual ICU model. Above all, supporting software, electronic data display at site, and computer based decision-support tool coupled with round the clock coverage of intensivist and critical care nurse has caused substantial reduction in ICU mortality and ICU length of stay (Breslow et al., 2004; lilly et al., 2011; Thomas et al., 2009; Young et al., 2011; and NEHI, 2010). As a result, 20% reduction in ICU cost per patient and $122 million benefit per year to the payer is reported through virtual ICU program (NEHI, 2010). Above all, tele- ICU model effectively leverage expertise of intensivists and critical care nurses across various hospitals.Outcomes of tele-ICU are promising. However, it has some limitations as well. Major barrier that impedes its adoption is financial implication. NEHI (2010) reports that, only capital investment for installation of command center is around $ 6 to $8 million. In addition, each hospital satellite installation adds $ 300,000 to $500,000 to the total cost. Moreover, operating, maintenance and training cost further increases the budget. On the other hand, this program necessitates that nurses and physicians at afferent and efferent limb of system are acquainted with sophisticated state of art technology. Lack of related skills may not only limit optimal utilization but would potentially hamper its positive outcomes as well. Advanced Nursing Practice: A Key To The Success of Tele-ICU Model.Along with intensivit, E-nurse is the backbone of tele-ICU care model. By virtue of training and clinical expertise, clinical nurse specialist (CNS) with acute/critical care subspecialty training can make a significant contribution to the success of this endeavor. Core competencies of CNS are a true match to what is expected of E-nurse. The role demands E-nurse to perform as an expert clinician, who oversees clinical condition of critically ill patients, monitors trends, proactively identifies clinical deterioration, manages clinical emergencies and facilitates clinical decision making using critical thinking and best practice guidelines. CNS in a consultant capacity, through her advanced knowledge and skill, and focus on evidence based practice would justify and nurture the E-nurse role. Considering the demand, ICU will always have Influx of novice nurses who need mentoring and facilitation in critical thinking, clinical decision making, and management of critically ill patients. Once again, CNS, in the capacity of educator and coach can contribute to competency development of novice nurses through remote consultation. CNS’s are key players in any health care setting to initiate, design, implement, and evaluate quality improvement endeavors and evidence based practice guidelines. Being E-nurse, CNS would be in a unique position to identify variances in the care, design reports on specific patterns of observed variation and trigger performance improvement initiatives in lieu of current evidences. Above all, CNS’s would serve as a medium and catalyst to enhance the implementation of quality improvement initiatives and standardization of care across multiple units and hospitals. Benefit of virtual ICU is infinite. CNS in a capacity of visionary leader can take this innovation to the level of excellence. References Breslow, M. J., Rosenfeld, B. A., Doerfler, M., Burke, G., Yates, G., Stone, D. J., . . . Plocher, D. W. (2004). Effect of a multiple-site intensive care unit telemedicine program on clinical and economic outcomes: An alternative paradigm for intensivist staffing. Critical Care Medicine, 32(1), 31-38. doi:10.1097/M.0000104204.61296.41 Camire, E., Moyen, E., & Stelfox, H. T. (2009). Medication errors in critical care: Risk factors, prevention and disclosure. CMAJ : Canadian Medical Association Journal = Journal De l'Association Medicale Canadienne, 180(9), 936-943. doi:10.1503/cmaj.080869 Department of health and human services. (2009.) Action plan to prevent health care associated infections. Retrieved from , M. N. (2011). The future of Tele-ICU: An insider’s perspective. Retrieved from of Medicine (IOM). (1999). To Err is human: Building a safer health system. Retrieved from , C. P., Parry, G. J., Bones, C. B., Hackbarth, A. D., Goldmann, D. A., & Sharek, P. J. (2010). Temporal trends in rates of patient harm resulting from medical care. The New England Journal of Medicine, 363(22), 2124-2134. doi:10.1056/NEJMsa1004404 Lilly, C. M., Cody, S., Zhao, H., Landry, K., Baker, S. P., McIlwaine, J., . . . University of Massachusetts Memorial Critical Care Operations Group. (2011). Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes. JAMA : The Journal of the American Medical Association, 305(21), 2175-2183. doi:10.1001/jama.2011.697 Myers, M. A., & Reed, K. D. (2008). The virtual ICU (vICU): A new dimension for critical care nursing practice. Critical Care Nursing Clinics of North America, 20(4), 435-439. doi:10.1016/ell.2008.08.003 New England Health Care Institute (NEHI). (2010). Critical care, critical choices: The case for tele-ICU in intensive care. Retrieved from , T. A., Bourke, G., & Seiver, A. (2011). Standardizing sepsis screening and management via a tele-ICU program improves patient care. Telemedicine Journal and e-Health : The Official Journal of the American Telemedicine Association, 17(7), 560-564. doi:10.1089/tmj.2010.0225 Thomas, E. J., Lucke, J. F., Wueste, L., Weavind, L., & Patel, B. (2009). Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay. JAMA : The Journal of the American Medical Association, 302(24), 2671-2678. doi:10.1001/jama.2009.1902 Young, L. B., Chan, P. S., Lu, X., Nallamothu, B. K., Sasson, C., & Cram, P. M. (2011). Impact of telemedicine intensive care unit coverage on patient outcomes: A systematic review and meta-analysis. Archives of Internal Medicine, 171(6), 498-506. doi:10.1001/archinternmed.2011.61 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download