You're having a busy night as usual in the cardiothoracic intensive care unit. You're helping a colleague with her near-arresting patient when you receive a call on the "hot phone."

It's the nurse from the ReSCU (remote specialized care unit) alerting you to check your own patient, who has developed a sudden rise in pulmonary artery pressures with decreasing oxygen saturation. She picked up on this change while reviewing and trending patient data more quickly than you would have, and is able to notify you immediately.

The ReSCU nurse has also contacted the ICU attending physician, who meets you at the patient's bedside. You suction the patient, place him on 100 percent oxygen mask and draw an ABG. You also feel lucky that this was identified so quickly.

There is a new type of critical care monitoring (eICU®) that is now becoming available in select hospitals throughout the country. Sometimes referred to as an electronic or virtual intensive care unit, the ReSCU at NewYork-Presbyterian Hospital (NYPH) is changing the way patient care and monitoring occurs in ICU and stepdown units.

A New Frontier

In February 2003, NYPH's Columbia Presbyterian Medical Center campus became the first medical center in the New York area to open this type of unit. NYPH has recently opened another unit at the NewYork Weill Cornell Medical Center campus. Each ReSCU is located outside of the main hospital building. Our current equipment allows us to monitor up to 48 patients at any one time.

The concept for the ReSCU is fairly new. It came from two intensivists from Johns Hopkins Hospital who were targeting the nationwide shortage of intensivists, physicians trained in intensive care. These two founded a company with the idea that they could combine information technology with real-time telemedicine to improve patient outcomes and control costs. A pilot study published in Critical Care Medicine revealed that implementation of this type of unit with increased intensivist coverage resulted in a decreased in length of stay, severity-adjusted ICU mortality, ICU costs and the incidence of ICU complications.¹

While NYPH already has 24/7 intensivist coverage in the ICUs, it wanted to expand the intensivist coverage in the stepdown units (SDU), particularly on nights and weekends. The hospital also wanted to improve outcomes for its ICU patients.

"Our intensive care units have incredibly talented, highly skilled teams caring for the nation's sickest patients," said Bernadette Miesner, BSN, RN, director of the cardiovascular service line. "Employing unique and advanced technology can further our already excellent patient outcomes."

'We Have the Technology'

The ReSCU consists of several workstations, each equipped with 5 monitor screens. One screen displays real-time bedside monitor information (including ECG, arterial line and pulmonary artery pressure waveforms), while another screen provides access to all of the hospital's traditional computer systems such as electronic nursing documentation and radiology films.

A third screen displays even more patient data, which is entered by the data assistants and available for ReSCU clinician's review, including medications, laboratory results and physician progress notes.

The fourth screen alerts the nurse and physician in the ReSCU to changes in the patient's condition. Such alerts are triggered by analysis and trending of the patient's physiologic parameters such as heart rate, respiratory rate and pulmonary artery pressure.

This alert system is different than that of continuous telemetry monitoring. Instead of alarming to only very acute events, this system alerts caregivers about changes in a patient's heart rate or blood pressure. For example, a patient's heart rate may be trending upwards or downwards outside the recent range for that patient.

By alerting clinicians early, the system allows caregivers to quickly address the problem before the situation becomes critical. The system can also alert clinicians to changes not seen on the ECG monitor, things such as changes in labs and creatinine clearance values.

The fifth screen provides an audiovisual (camera and speaker) link into each patient's room. Nurses and physicians in the ReSCU use the cameras to perform audiovisual assessments of patients when changes in trends are noted and to communicate with staff in the room. The quality of the camera is clear enough that the ReSCU staff is able to zoom in on machinery in the room and read IV pumps and ventilator settings.

The remote unit at each NYPH campus is able to monitor up to 48 beds at this time. Columbia Presbyterian is monitoring two ICUs and three SDUs, and the ReSCU at NewYork Weill Cornell is monitoring two ICUs and one SDU.

Patient Perspectives

The cameras are used for assessment of the patient only, and there is no videotaping of any information. When the cameras are turned off they face the wall and a red light turns on, so it is obvious to anyone in the room. The ReSCU clinician rings a doorbell when videoconferencing into a patient room to alert those in the room to the ReSCU staff's presence. The camera moves to focus on the patient and the red light turns to green indicating that certain activity is in progress.

Patients receive education about the ReSCU upon admission to any ICU/SDU that is being monitored. Once the system is explained to them, they are pleased that even when their own nurse is not in the room another nurse is monitoring them.

"I sleep better at night knowing someone is watching me," said one patient recovering from cardiac bypass surgery.

ReSCU Workflow

Each ReSCU is staffed with a critical care nurse and data assistant 24 hours a day. Physicians also staff the unit on nights and weekends, during times when there are fewer medical staff in the hospital.

If the ReSCU nurse detects a patient problem during the daytime, the ICU/SDU staff can be notified immediately by special "hot phones" located in each unit. During the nights and weekends, the ReSCU nurse and ICU/SDU nurse can immediately receive the support of the ReSCU physician, who is able to electronically write orders on patients if needed.

"The use of the ReSCU in the ICU and SDU allows the staff to implement innovative tele-nursing approaches in the care of patients while in the acute care setting," said Hussein Tahan, DNSc, RN, CNA, director of nursing, cardiovascular services at Columbia Presbyterian. "It also facilitates the development of a peer-mentoring relationship between expert and less experienced nurses.

"In addition, the creation of the ReSCU ensures the highest standards of quality care and opens new career opportunities for nurses."

The Knick of Time

Nurses in the ReSCU routinely monitor certain parameters at specific time intervals based on patient acuity. A patient is classified as red, yellow or green by the nurses and physicians based on the patient's condition and whether the patient is a new admission or recently post-operative.

Red patient data is reviewed at least hourly, yellow at least every 2 hours and green at least every 4 hours. Patients are assessed even more frequently when the ReSCU nurse is alerted to changes in trends by the computers.

The ReSCU provides an extra layer of monitoring that was not present before. It is not replacing any care that is at the bedside. Jennifer Bianchi, RN, ReSCU nurse at NewYork Weill Cornell, said working in the ReSCU provides a different perspective on critical care nursing and enables her to support the ICU/SDU staff.

"I noticed a patient was off the cardiac monitor," she explained. "Already knowing this was a confused patient, I quickly videoconferenced into the room to find the patient was out of bed standing by the window and pulling out his lines. I alerted the ICU staff and they immediately went to the room, probably preventing this patient from falling.

"If you think about it, when staff are busy on the unit, a patient's monitor may be alarming leads off, and it may take some time for staff to respond if they are busy in other rooms, only to find this patient on the floor later," Bianchi added.

Donna Burchie, RN, ReSCU nurse at Columbia Presbyterian, had a similar experience. When the computer alerted her to an increase in a patient's heart rate, she videoconferenced into the room to find the post-op patient was waking up from anesthesia and reaching for his endotracheal tube. She was able to speak to the patient through the camera, asking him to stop, and also to notify the nurses in the unit immediately via the hot phones.

Backing Up Nurses

Bernadette Khan, MSN, RN, CNA, patient care director at NewYork Weill Cornell, said she is particularly excited about using the ReSCU to monitor patients in the SDUs.

"The ReSCU can have a great effect in the SDUs where there are many new nurses, especially on the night shift," she said. "The SDU nurses won't have to wait for someone to answer a page or for a colleague to be available to assist them. They can just pick up the phone and have the ReSCU nurse and physician as a resource to support them."

The ReSCU nurses themselves have said they are learning more about other areas of critical care nursing since they are monitoring many different specialty units. When working with a physician, they also have the opportunity for one-on-one teaching and consultation about different patient conditions and treatments.

Discussions are underway as to where to expand next. Critical care nurses said they look forward to using this new technology to improve patient care.

"Having the ReSCU is like having a third eye," said Woodley Perpignan, RN, a SICU nurse at Columbia Presbyterian.

"The more people monitoring the patient, the better."

Reference

1. Rosenfeld, B., et al. (2000). Intensive care unit telemedicine: Alternate paradigm for providing continuous intensivist care. Critical Care Medicine, 28 (12), 3925-3931.

Jennifer Sullivan is nurse manager of the remote special care units at NewYork-Presbyterian Hospital, NewYork Weill Cornell Medical Center and Columbia Presbyterian Medical Center.