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Journalism of Courage
Nina Bernstein
High in a Manhattan skyscraper near Grand Central Terminal,80 critically ill patients in intensive care units scattered from Georgia to New Jersey were being monitored,remotely,by a doctor scanning a dozen computer screens.
More than a decade ago,this kind of tele-ICU command centre was trumpeted by its creators as the new standard in critical care,a way to save lives and money by stretching the skills of an inadequate pool of intensivists to help oversee more of the countrys sickest patients. Today,with the growth of such systems stalled at about 10 per cent of ICU patients nationwide,and wildly contradictory studies about the results,no one can say with authority if,or under what circumstances,tele-ICUs deliver on their promises.
In New York,in a sense,this is a second act for the tele-ICU. It was developed in 1998 by intensivists at Johns Hopkins,who later sold their company to Philips Electronics of the Netherlands,which now licenses the software as eICU. NewYork-Presbyterian Hospital adopted the technology with great fanfare in 2003,but only two years later,deactivated it. At Kaleida Health,a large Buffalo-based hospital system,the tele-ICU lasted no longer. At least three other hospital systems,in Michigan,Texas and Kentucky,have also unplugged command centres installed in 2004 and 2005.
The eICU was a marketing success,but theres still legitimate concern about whether theres any improvement as far as patient care, said Michael P Hughes,a spokesman for Kaleida. We studied it,and there was no statistically significant improvement in the mortality rate and complication rate over a 12-month period. We discontinued it,and moved that personnel back to the bedside.
Proponents of tele-ICUs suggest that poor implementation,and the reluctance of physicians to cede authority to remote intensivists,explains the disappointing results in some places and some studies.
If or when tele-ICUs pay off financially is also disputed. Medicare and many insurers typically pay hospitals a bundled rate for a particular diagnosis,whether the patient spends two days or 12 in the ICU,where as much as 40 per cent of hospital spending takes place. By intervening before a patient crashes,or reducing complications like ventilator-induced pneumonia,watchful intensivists significantly improve the hospitals bottom line by helping patients improve and leave the ICU faster,proponents say.
Round-the-clock access to intensivists also allows smaller hospitals to safely keep sicker,more lucrative patients rather than sending them to distant medical centres,said Dr Mary Jo Gorman,founder and president of Advanced ICU Care,a St Louis-based company with a branch in Chennai,India,and since 2011,the office near Grand Central.
The company licenses the software from Philips and provides services to 26 individual hospitals typically without the deep pockets to spend 6 million to 8 million to establish their own command centers. Gorman estimates that hospitals reap an extra 2,000 to 3,000 per patient after paying annual fees ranging from 750,000 to 2 million.
But researchers at the University of Iowa found little public data and sharp disparities when they combed past studies evaluating the financial impact of tele-ICUs,said Dr Gaurav Kumar,the lead author of the review study,published this year in the medical journal Chest. Costs ranged from 50,000 to 100,000 a bed the first year,they estimated. Three previous studies linked to vendors had reported increased hospital profits of up to 4,000 per patient,while two without such links had found no return or losses.
That has not stopped the growth of Advanced ICU,which is now expanding its Manhattan centre,and has wooed away half a dozen members of Mount Sinai Medical Centers ICU team,starting with Dr Corey Scurlock,the former director.
It was like the first few minutes of Saving Private Ryan every day for me, recalled Scurlock,40,who assumed responsibility for intensive care at Mount Sinai after a critical care fellowship at Harvard,and earned an MBA in 2010. As far as Mount Sinai was concerned,I was still going to be running that ICU when I was 80,and working around the clock. Instead,while on vacation in the Caribbean,he read about Advanced ICU,he said,and contacted the company,which hired him to open the New York branch.
