Saturday, December 30, 2006

Top 10 issues in hospital medicine for 2006---issue 6: outsourcing of hospital services

In a February 16 NEJM Perspective piece and an accompanying podcast interview Dr. Robert Wachter discusses new forms of outsourcing now made possible by electronic means including image interpretation, transcription and the electronic ICU (eICU). Outsourcing has been driven primarily by economic considerations and the need for night call relief for physicians. New ideas and wider forms of implementation, however, are likely to bring unanticipated benefits as well as unintended consequences and are sure to spark controversy.

Perhaps the best known forms of outsourcing are remote transcription services and remote interpretation of images. A more novel and ambitious form of outsourcing is the eICU. It is believed that the first eICU in the United States was started several years ago at Sentara Health Systems in the Hampton Roads area of Southeastern Virginia. Evidence suggests that mortality and length of stay in ICUs are improved with a dedicated intensivist model in which there is mandatory care of all patients by a critical care specialist. The Leapfrog Group and others which set standards for quality in health care recommend the dedicated intensivist model. The major problem in implementation is the shortage of critical care specialists. It is estimated that there may be fewer than half as many critical care specialists as there are hospitalists. The eICU may be a way to close this gap in implementation. Evidence that eICUs improve mortality and utilization is beginning to accumulate. This study in the journal Critical Care demonstrated that improvements in outcomes derived from the use of an eICU were similar to those reported for the dedicated intensivist model of on site critical care specialists.

How does it work? This description of the eICU at Sutter Health seems fairly representative. Critical care physicians and ancillary staff monitor electrocardiographic and physiologic data in real time, as well as laboratory data via direct computer interface from a remote location, perhaps hundreds of miles away. The eICU staff communicates with on site physicians and nurses via direct audio and video links, telephone hotlines and computer text messages. High resolution cameras zoom in to check patients’ pupils, examine the skin and read labels on infusion bags. Thanks to real time interface with the lab, the remote team will be aware of critical results before anyone else and when the contractual arrangement with the on site physicians allows, they can give orders directly to the on site nurses. Because the eICU control room is manned “24/7” by staff who are free of the competing demands of hospital rounds and the distractions of pagers the response time to abnormal lab tests and hemodynamic disturbances is shortened.

There are limitless possibilities. The eICU doctors can access physician orders, medication records and progress notes and thus can make daily reviews for compliance with evidence based quality “bundles.” Prompts from the eICU staff to the on site doctors thus have the potential to enhance compliance with DVT prophylaxis and other underutilized quality measures.

The skeptic in me realizes that bright ideas tend to be implemented, sometimes with irrational exuberance, ahead of evidence. The early promise of the eICU needs validation by more studies. In the meantime will it be viewed as a welcome practice enhancement or as something Orwellian? It all depends on your attitude.

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