Just over ten thousand intensivists practice in the U.S. today, yet more than five million patients are admitted to the ICU every year, according to The Society of Critical Care Medicine. Now, with the growing elderly population in part due to medical advances that extend life expectancy, the disparity is only projected to increase.

When facilities are understaffed, it increases the likelihood of medication errors, patients being in for longer hospital stays with greater complication rates, and a list of other problems, according to a study conducted by the University of Calgary.

One solution gaining popularity in the battle against staff shortages is the concept of tele-ICUs. Tele-ICUs provide a command center made up of a team of intensivists and nurses who use audio and visual capabilities to deliver 24-hour care remotely. The team has access to patients’ vital signs, laboratory test results, radiologic images, notes and pharmacy, lab or radiology orders. They are also able to monitor patients using high-resolution cameras and microphones.

If a patient is showing signs of distress, the team can alert the bedside care team so they can intervene before the patient’s condition gets worse. In 2010, 41 command centers were deployed to cover 5,789 ICU beds in 249 hospitals, according to the New England Healthcare Institute and the Massachusetts Technology Collaborative.

Second set of eyes and ears
The origin of tele-ICUs started in the late 1990s, when two intensivists at The Johns Hopkins Hospital, Dr. Michael Breslow and Dr. Brian Rosenfeld, noticed the disparity between the number of ICU patients and intensivists who care for them.

They created a company called VISICU, Inc. and coined the term, eICU. The first system was installed in 2000, at Sentara Healthcare in Virginia.

In 2008, Philips Healthcare acquired the company for about $427 million and since then, the technology has come a long way. The original technology was relatively basic in that it only provided audio and video feeds and captured physiological monitoring data but Philips added more “smarts” to the command center.

“In essence, every ICU patient that is being monitored and supported through this telehealth center approach is caught before they get worse—that is basically the stitch in time saves nine approach,” said Manu Varma, vice president of strategy and hospital to home at Philips.

The centralized team consists of an intensivist, two nurses and a couple of other support staff who use Philips’ IntelliSpace eCareManager software to get the physiological data and EMR lab and medication data. The software then runs a range of predictive analytics to detect the acuity of the patient including whether ventilation compliance is where it needs to be and if the patient is going septic.

If something doesn’t look right, then the centralized team taps into the patient’s room through the cameras and microphones and determines if they need to alert the bedside care team.

A study conducted by the University of Massachusetts Medical School and published in CHEST Journal in December investigated the impact that eICU had on 118,990 critical care patients in 56 ICUs, 32 hospitals and 19 health systems over the course of five years. They found that the patients were 26 percent more likely to survive in the ICU and also that discharge from the ICU was 20 percent faster.

“The patients are getting discharged faster and there is the ability to use your capacity better — that has to lead to substantial savings as well,” said Varma. There are currently 50 health systems in the U.S. using eICU.

Breslow hired an independent consulting firm in 2004 to investigate the financial outcome of tele-ICUs. The firm found that there was a 24.6 percent decrease in costs per patient and it was attributed to improved clinical outcomes and shorter lengths of stay. Philips is the leader in the tele-ICU market, but Cerner Corporation and iMDSoft also have their own solutions. Cerner’s product is called Critical Care/Critical Connections, which is built around their existing EMR system and electronic charting of ICU nursing and physicians’ information.

iMDSoft’s product is called the MetaVision Suite that involves a clinical information system for ICUs called MVICU. It includes smart alarms based on their physiological parameters and tailored for each patient.

Manu believes that eventually, all health systems will have some sort of tele-ICU program in place. “I absolutely expect every health system to have a telehealth strategy for their organization,” he said. “If that is the case, some of them might not start in the ICU, but given that the highest cost area in the hospital is the ICU, you would think that a lot of them would absolutely have a similar concept in place.”

Making CT available for everyone
Many ICUs have recently been showing an interest in having their own CT in order to avoid transporting critically ill patients to their radiology departments, according to Siemens Healthcare.

In some hospitals, the ICU is on the top floor and the radiology department is on the bottom floor, which makes it a cumbersome process to transport the patients. The staff often needs to switch the patients to mobile life support equipment and a nurse or respiratory technologist has to accompany them.

They also have to schedule a time that the radiology department is not using the CT. Sometimes they even suspend regular patient imaging because they are anticipating a patient from the ICU. Even though many facilities are interested in installing a CT in their ICU, not all of them can afford it. Right now, the large academic hospitals are the most likely to make that kind of a purchase.

But Siemens is trying to change that with the introduction of their SOMATOM Scope CT, which received FDA approval in September. It has a space requirement of 130.2 square feet and the company claims it is the smallest 16-slice fixed CT system on the market today. Siemens also describes the system as “very attractively priced” and on par with the refurbished 16-slice CT scanners sold today.

They were able to price it that way since they built it on a lot of the technology that they already developed for their high-end systems. It include Siemens’ Iterative Reconstruction in Image Space technology that speeds up the image reconstruction and reduces noise and artifacts, their Adaptive Signal Boost technology that amplifies low signals when there is high attenuation and the Fully Assisting Scanner Technology and Combined Applications to Reduce Exposure applications to reduce radiation exposure and standardize the CT imaging process.

It also includes their eCockpit technology that reduces the wear and tear on the system by optimizing scan parameters, putting it into hibernation mode if it’s idle and warming up the X-ray tubes so there isn’t a substantial jump in temperature when it’s powered up for a procedure.

Until the Scope was introduced, the only CT available to the ICU were either expensive, high-end systems or portable scanners. The portable scanners are more affordable, but the majority of them are only designed to provide head imaging and most ICUs want to be able to perform head, chest and abdomen imaging.

One of the exceptions is Neurologica’s BodyTom, which received FDA approval in 2011. The system is one of the portable CT scanners that can do full body imaging in the ICU. It’s a 32-slice CT with an 85 centimeter gantry and 60 centimeter field of view.

Unlike fixed CT, the BodyTom has a lower installation cost since construction or buildout is not required. Staff members can also move it with ease to and from the ICU, operating room, emergency department and radiology department.

Reducing complications
One of the major complications in the ICU today is ventilator induced lung injury (VILI) — 24 percent of all patients who are mechanically ventilated will develop VILI. It occurs when too much volume or pressure is delivered.

GE Healthcare developed a new ventilator called CARESCAPE R860 to address this issue. It’s currently only available in Europe, but GE expects it to receive FDA approval early next year. It’s equipped with lung protection tools and it works by measuring lung volume, possible lung recruitability, the capability of the lung alveoli to open and titrating the right positive end-expiratory pressure (PEEP) —pressure that remains in the lungs after exhalation — to enable improved oxygenation.

“It’s really a way for physicians to better understand the cause and effect of not only the ventilator settings that they have, but the progress of ventilation that’s occurring,” said Paul Hunsicker, clinical manager of GE Healthcare Life Care Solutions. “Ultimately, we’re trying to find a way of providing additional information to the clinician to understand what might be the optimal settings for this patient.”

Prolonged mechanical ventilation, which CMS defines as more than 21 days of ventilation for at least six hours per day, can also lead to health complications for the patient. But GE’s ventilator has a spontaneous breathing trial mode that helps physicians determine when a patient is ready to come off the ventilation and breath on their own.

It allows them to administer trials in a consistent manner and provides continuous trending and documentation of results to assess progress during those trials. “We want to be able to ensure that patient is going to be able to breathe adequately on their own once we remove the support of the ventilator,” said Hunsicker. “To do that, often it is required that a patient be monitored with minimal support for a period of time.”

Another complication that 40 to 50 percent of patients suffer from is malnutrition. The majority of those patients are found in the ICU, with the problem ranging from moderate to severe malnutrition, according to a study conducted by the University of Sao Paulo. “Finding the right nutritional balance for each patient’s unique needs is critical in speeding up the healing process,” said Hunsicker. GE’s ventilator also has tools for indirect calorimetry measurements.

When that is integrated with the ventilator, it captures gas exchange and energy expenditure measurements and physicians can use that to customize nutritional support. Today, health care reform is holding physicians accountable for delivering the best care they possibly can. If they can catch a patient before they deteriorate, avoid transporting them down four floors to radiology and customize ventilation settings for each of them then they’re well on their way.