Feature / US study tour: Virtual reality for ITU

In response to pressures to cut costs while improving quality, the Geisinger Health System (GHS), Pennsylvania, has invested heavily in telemedicine for its intensive treatment unit (ITU), writes Phil Taylor. Its experience may well be of interest to UK hospitals facing the same quality/cost challenge.

GHS is an integrated health service including provider facilities, a large physicians practice and managed care companies. It is, in effect, a vertically integrated system, with a single organisation collecting the funding and providing primary and secondary care. Unusually for the US – but similar to the UK – the physicians are directly employed rather than independent practitioners.

It serves a mainly rural population from a base in Danville, Pennsylvania. The Geisinger Medical Centre has about 400 beds, including 42 intensive care beds. There are a similar number of beds at two other campuses, including a 12-bed ITU, community facilities and three ambulatory surgery centres.

In a September 2010 speech to Congress, President Obama cited GHS as a model for the health industry. ‘Even within our own country, a lot of places where we spend less on healthcare actually have higher quality than where we spend more,’ he said. ‘We have to ask why places like Geisinger Health System in rural Pennsylvania ... can offer high-quality care at costs well below average, but other places in America can’t. We need to identify the best practices across the country, learn from them and replicate the success elsewhere.’

In the US, while hospital facilities overall have shrunk, critical care has continued to grow. Between 2000 and 2005 the number of general hospital beds fell by 4.2%, while critical care beds increased by 6.5%. Over the same period, the number of hospital inpatient days rose by 5.1% compared with an increase in critical care inpatient days of 10.6%.

The demand for critical care services is linked to an ageing population and is expected  to increase sharply after 2010, when the baby boomers hit 65. Demand is then likely to increase until 2030 before stabilising.

With severe shortages of critical care nurses and consultants, meeting this demand will be challenging. Workforce projections show a widening gap between the supply and demand for intensive care consultants. Currently 50% of US ITUs lack dedicated consultant coverage and only 26% were considered to have high-intensity coverage. In nursing, there is an anticipated shortage of at least a million nurses by 2020 (all nursing, not just ITU).

Evidence shows high-intensity ITU staffing reduces both hospital and ITU mortality and length of stay. Under a US intensive care standard,  ITUs should be managed by consultants who are present during the day and provide clinical care exclusively in the ITU, and when not present return a call by pager within five minutes 95% of the time.

 The GHS response to the pressures has been to invest in telemedicine – phase one for its in-house ITUs and phase two for surrounding hospitals. As with other hospital systems, recruitment of critical care consultants is a challenge for Geisinger – even though it is a major research and training facility. The move to e-ITU was motivated by a desire to improve quality and patient safety. Savings from reduced complications and length of stay (LOS) were not the main reasons. However, the business case shows it is a sound investment. The financial projections made were:

• Capital investment of $7m
• Internal rate of return of 29.1%
• Net present value of $168,000 over 10 years (using a 20% discount rate)
• Payback period of four years.

The development was planned over two phases. The planned bed coverage for telemedicine and cost/benefits are shown in the table below. The analysis shows cost benefit – cost savings through length of stay and variable cost reductions – as the main factor, rather than increases in income. These benefits are based on ITU LOS reductions of 15% at two of the existing units and 8% at the other.

Significant reductions in variable costs of 75% per day were also projected. Evidence that this level of saving had been made elsewhere was included in the business case.

The system chosen for Geisinger was already used across the US in more than 200 hospitals and the aggregate results were impressive (see table right). In individual hospitals, the results can be even more striking. One university hospital treating more than 2,800 patients in ITU over a three-year period achieved:

• ITU mortality reduction from 8.4% to3.1%
• Hospital mortality drop from 11.1% to 6%
• ITU LOS fall from 7.53 days to 3.78 days.

In another case, a hospital showed a 53% reduction in ITU mortality over a 30-month period, saving an estimated 56 lives.

The business case for telemedicine in ITU at GHS cited similar evidence and was accepted in 2008. The model involves ITU consultants and nurses at a central monitoring station using visual and electronic monitoring to track care across a number of ITUs in several hospitals.

The central staff use remote control communications to see and hear activity around the patients and talk to bedside staff. Visual display units allow staff to view patients’ vital signs fed from the bedside monitors, lab results and other systems, and to view the patient and clinical activity from the bedside camera. This allows them to advise clinicians.

The equipment was impressive. The bedside cameras give a clear view and can zoom in to great detail. Unlike the UK, the beds are mostly in single rooms, but the monitoring equipment at each bed is familiar except for the remotely operated video camera and voice system.

The central command centre is located away from the ITUs and is operated by highly experienced critical care consultants. It has a number of desks, each surrounded by the many monitoring screens. It is a quiet and calm environment away from the hustle and bustle of the operational units. When they or the bedside nurse have a problem, they discuss the patient details and provide advice, ensuring critical decisions are taken promptly.

It is too early to draw definitive conclusions from the Geisinger implementation, but the early results are better than anticipated in the business case for mortality and length of stay.

Could it work in the NHS? The number of intensive care beds in England has surged in recent years, from 2,240 in March 1999 to 3,662 in July 2010. Yet there are still shortages most winters. With similar interests in reducing mortality, length of stay and cost, it may be time for the NHS to examine the potential of telemedicine in intensive care.

• Phil Taylor is a management consultant