Remote ‘eye in the sky’ keeping tabs on VA hospital patients

IOWA CITY - Scanning a bank of monitors from the Veterans Affairs Medical Center in Minneapolis, intensive care Dr. Tariq Janjua reviews the vitals and lab results of a surgical patient in Iowa City.

“We are looking at all the numbers and analyzing all the data, and I will talk to the bedside doctor to make sure we have a plan for the night,” Janjua, a critical care doctor at the Minneapolis VA hospital, said through a monitor perched above a patient bed in the intensive care unit of the Iowa City Veterans Affairs Health Care System.

Through the Veterans Affairs new Tele-ICU program, which has included the Iowa City VA since December, doctors like Janjua are able to monitor as many as 75 ICU patients at one time around the clock.

“I think it's incredibly important to be able to use the data we get about a patient's breathing or heart rate or lab tests in real time, so we're not just responding to it in the morning when we are doing our rounds,” said Karl Thomas, chief of primary and specialty care in Iowa City's VA Health Care System. “The essence of critical care medicine is being able to respond on a minute-to-minute or hour-to-hour basis.”

The VA's Tele-ICU program is based in Minneapolis, where one doctor and two nurses at any one time are stationed in front of a bank of monitors tracking ICU patients in seven VA hospitals across the Midwest, including Iowa City. The team assigned to the Tele-ICU unit tracks patient progress, analyzes test results and identifies potential problems.

If something comes up, a tele-doctor or nurse rings into a patient's room and participates via monitor in a conversation with the patient and bedside doctor.

“The idea is that we can transmit that information about every patient ... to a central monitoring area,” Thomas said. “Personnel are watching that data in real time, primarily during times when hospitals don't have boots on the ground at the bed side.”

The Tele-ICU program supplements the Iowa City VA's pool of 22 ICU doctors and 24 ICU nurses. Before the Tele-ICU's debut in Iowa City, doctors and nurses did morning and afternoon rounds and reacted to problems when they arouse, Thomas said.

“That's not very proactive,” he said.

Now, in addition to having a doctor and two nurses monitoring patient vital signs 24 hours a day, the computers are programmed to track trends, store data and send alerts to doctors if an alarming change happens, according to Thomas.

“It's hard to see heart rate changes with the human eyes and brain - you have to remember what the heart rate was two hours ago,” he said. “If you're a computer, you can see a trend and say, ‘This is an alarm that I need to generate now.'”

The Tele-ICU program doesn't replace bedside nurses and doctors and it has not decreased the number of times a patient sees a real person, Thomas said. Some patients have expressed concern about the technology, he said, but many people - and their family members - appreciate the second set of eyes.

“Lots of patients are reassured that, just because a doctor is not at their bedside, it doesn't mean we're not watching,” Thomas said.

The Tele-ICU program cost the VA millions of dollars, and officials are analyzing the program to determine whether its benefits outweigh its costs. Preliminary research shows patients overseen by the Tele-ICU program spend less time in the hospital and have lower death rates, according to Thomas. A secondary benefit, he said, could be an overall reduction in health care costs.

Robert Bonello, medical director of the VA Midwest Health Care Network Tele-ICU program and doctor of internal medicine at the Minneapolis VA Health Care System, said Tele-ICU programs exist in some private hospital networks, but the Midwest region was the first VA network to experiment with the system. The Iowa City VA is the only hospital in Eastern Iowa with a Tele-ICU.

Bonello, one of the Tele-ICU doctors in Minneapolis, said his VA pulls from a pool of 14 doctors and about 10 nurses who trade shifts in the monitoring room. Most of the doctors they interact with virtually have been receptive to the new technology, even though it's “somewhat unusual” to interact via camera.

Robert Zeman, assistant nursing administrator for primary care and specialty medicine in Iowa City's VA Health Care System, said his staff has appreciated the oversight and additional monitoring.

“There is a more comfortable level of nurses now in the ICU,” he said.

PROS

• The Tele-ICU program aims to provide a proactive style of care by watching a person around the clock and alerting doctors to potentially problematic trends or issues when the doctors are seeing other patients or off the clock - like in the middle of the night.

• Studies of Tele-ICUs suggest they might save lives. Bellin Memorial Hospital in Green Bay, Wis., saw a 34 percent drop in the death rate of ICU patients after it implemented a virtual ICU. From 2007 to 2008, it also saw the number of ICU patient days drop by 29 percent.

• Tele-ICUs could save money by providing support hospitals need to keep up with rising care demands without increasing staff, by cutting patient days in the ICU and by decreasing mortality rates.

CONS

• The Tele-ICU program cost the VA system millions to implement.

• Some patients have expressed concern that the electronic monitoring will result in less one-on-one time with a bedside doctor or nurse.

• Some patients are skeptical of the new technology and the potential “Big Brother” atmosphere of having cameras mounted in the corner of every VA hospital ICU room in the Midwest.

Sources: Robert Bonello, medical director of the VA Midwest Health Care Network Tele-ICU program, Karl Thomas, chief of primary and specialty care in Iowa City's VA Health Care System, and McClatchy Tribune Newspapers