Clinicians behind the eICU at UMass Memorial Health Care support critical care nurses at four hospitals within the Massachusetts health system

by Sandy Keefe, MSN, RN

Each time Lisa Thibeault-Gardner, BSN, RN, a staff nurse in the Heart and Vascular ICU at UMass Memorial Health Care, Worcester, MA, delivers expert care to critically ill patients, two teams of physicians and mid-level providers back her up. One team is stationed in the unit itself, while another is located across town in the headquarters of the health system's eICU, keeping a close eye on patient information from the cardiac monitoring system and electronic medical record (EMR).

"We frequently receive alerts from the eICU staff, usually in the form of questions," she said. "They may ask something about the patient's status such as 'Do you know your patient has had a urinary output of less than 30 cc an hour for the past couple of hours?' or pose questions such as 'Have you discussed end-of-life care with your patient?'

"They may discuss the acuity of the patient, give us sepsis alerts, or prompt us that a patient on a ventilator looks like he might need antibiotic prophylaxis. Even if we were aware of those concerns already, it's great to have another set of eyes helping out!"

Cardiac & Vascular Patients

The UMass Memorial eICU remotely monitors patients in 122 beds within nine critical care units across four hospitals within the health system: UMass Memorial Medical Center's Memorial and University campuses in Worcester; Marlborough Hospital, Marlborough, MA; and HealthAlliance Hospital, Leominster, MA.

In addition to monitors that display information about parameters such as blood pressure, oxygen saturation and cardiac output, the eICU monitoring room contains cameras that can be activated to provide a bird's eye view into each patient room.

The staffing model for UMass's eICU is designed to support bedside care providers, while providing an extra level of safety. Attending physicians, as well as mid-level providers including nurse practitioners and physician assistants, serve alternately in the eICU and on the frontlines in critical care units throughout the health system.

"We wanted the ability to write orders within our clinical practice guidelines, so we're one of the few eICUs across the country that doesn't have critical care RNs staffing the eICU," said Shawn Cody, MBA, MSN, RN, associate chief nursing officer/operations director of the eICU.

Clinical Conversations

Typically, the eICU provider will have a conversation with the bedside team when a clinical problem develops.

"For example, they monitor blood glucose levels carefully in our cardiac patients and if those levels are elevated, they'll page the nurse practitioner or resident assigned to the patient to discuss the issue," Cody described. "If it's 2 a.m. and the provider is tied up at the bedside of a more critical patient, the eICU staff member might add a note to the task list, which is a sort of an electronic sticky note, saying, 'The glucose level appears high; consider a bolus insulin dose.' If there's significant hyperglycemia that needs to be dealt with right away, the eICU staff can write an order for the insulin. But eight out of 10 times, we do end up calling the bedside provider, who will talk over the problem and write orders accordingly."

Gail Frigoletto, BSN, RN, nurse manager of the Heart and Vascular ICU at the University campus, appreciates the added support to coordinate care for the unit's complex population of cardiology, cardiothoracic surgery and vascular surgery patients.

"As a manager, I receive a rounding sheet every day that's pre-populated with information from the eICU program - whether the head of the bed is elevated for someone on a ventilator; if the patient should be getting a sedation holiday; whether a DVT protocol is in place; and highlighting the patient's glycemic control," she said. "This provides me with a user-friendly audit tool to ensure good patient outcomes."

An Extra Set of Eyes

While electronic oversight contributes significantly to patient care, the eICU staff is sensitive to issues of privacy and confidentiality.

"During our first year of operations, we made a conscious decision to limit the use of the cameras, to ensure privacy not only for the patients, but for the critical care nurses, as well," Cody said. "We developed brochures and signs for the waiting rooms that explain the eICU capabilities and added verbiage to the patient-consent forms. I have to say the response has been overwhelmingly positive."

Before activating the video camera to observe the patient, eICU providers use an audible chime to notify the critical care patient, as well as any visitors and staff in the room. Data from those observations are used to directly improve patient care.

"For example, if they see on camera that the patient is in restraints, they can check the order-entry system to see whether there's a restraint order," Frigoletto said. "If there isn't an order, they'll usually call the unit to talk directly to the provider; if that provider is busy with more urgent care issues, the eICU staff can write an order for restraints and fax that paper form to us."

It didn't take long for Thibeault-Gardner to become accustomed to the video cameras and monitoring.

"It's great to have someone on our team who can give us alerts, let us know about trends in the patient's parameters, or give us a heads-up the patient may be getting into trouble," she explained. "On nights, if I have two patients and am tied up in one room, the eICU staff is there to keep a close eye on my other patient. That's very reassuring. On those occasions when we have two codes or other emergencies at the same time, the eICU providers are able to help us out tremendously. It's a collaborative effort."

While information about urgent issues is shared immediately, eICU personnel often use e-mail to relay other messages.

"They may send a message to me and to the medical director to remind us to look at potentially dangerous situations," Frigoletto said. "They may remind us a femoral line has been in for 3 days, for example, and ask if we can discontinue the line, or move it to another site."

Breaking Down Silos

The collaboration between critical care staff at the bedside and providers in the eICU has gone a long way toward breaking down silos.

"Since all the eICU personnel rotate between the eICU and critical care units, there's a level of objectivity and understanding," Cody said. "I might have taken care of Mr. Smith last week, and this week I'm in the eICU monitoring him remotely. There's a level of understanding when I use the microphone to tell him, 'Mr. Smith, please get back in the bed - I'm sending your nurse in.'"

"The eICU experience, which requires a level of consistency and standardization, has given all of us a nice objectivity," Cody added. "The old way of thinking, 'I'm doing it my way!' has pretty much gone away."

What's important, Cody noted, are the many success stories that demonstrate the positive impact collaboration between eICU and critical care personnel has on patient outcomes.

"The other day at 5 a.m., a nurse called the eICU to say her patient's face looked asymmetrical," Cody said. "We [zoomed the camera] to do an assessment along with the nurse and sure enough, it turned out the patient had some subcutaneous emphysema that required insertion of a chest tube.

"That type of early intervention and collaboration makes a big difference in patient care."

Sandy Keefe is a frequent contributor to ADVANCE.

Making It Work

When leaders at UMass Memorial Health Care, Worcester, MA, decided to invest in a state-of-the-art eICU for remote monitoring and oversight of critically ill patients across the health system, critical care managers immediately began collaborating to establish collegial relationships to make the most of the new technology.

Collaborating & Training

"When the decision was made to open an eICU, the critical care operations committee worked with the company that provides eICU capabilities," said Gail Frigoletto, BSN, RN, nurse manager of the Heart and Vascular ICU on the University campus.

"Critical care leaders brought the company in, and we did a lot of training for our staff," she said. "We began by implementing eICU in one ICU on each campus; 4 months later we added the rest of the ICUs."

ICU nurse educator Cathy Pianka, MS, RN, described the successful efforts to ensure critical care nurses would understand and buy-in to the capabilities of the eICU.

"We had set up a training room on one of our other campuses complete with computer stations, and our nurses went there for a class on the basics of the system, as well as what documentation would be required," she said.

Lisa Thibeault-Gardner, BSN, RN, a staff nurse, recalled how the combination of hands-on training and real-life observation won her over.

"We also had a chance to go to the eICU 'headquarters' on that campus to see how things were monitored, and that gave us a good idea of how the whole thing would come together," she said. "We had our apprehensions at first, naturally, but were pleased to be part of this high-tech, cutting-edge system."

Here to Help

Shawn Cody, MBA, MSN, RN, associate chief nursing officer/operations director of the eICU, shared a very clear message with ICU clinicians.

"We provide real-time information for critical care nurses at the bedside," he emphasized. "We can help with everything from 'Why aren't my vital signs recording?' to 'What's going on with the cardiac output readings on my patient?'"

Physicians and mid-level providers at eICU headquarters across town go out of their way to facilitate data recording and monitoring for bedside nurses in each critical care unit. "We get the operating room schedule each morning, and pre-populate the system so the nurses can enter data the minute the patient is rolled into the unit," Cody explained.

"When we started doing LVADs [left ventricular assist devices], we needed to gather an additional 12 rows of data, so I worked with the nurses and lead nurse practitioner in terms of what data to gather and how to set up the flow sheet. And for our cardiothoracic team, we developed a format for balloon pump data gathering."

Thibeault-Gardner appreciates that collegial approach and support from eICU personnel.

"The minute I get a patient into a critical care bed, I'm going a mile a minute, so it's a wonderful thing to have the flow sheet already customized with the patient information, and set up to reflect an LVAD or balloon pump," she said.