Virtual ICU

Published Nursing Spectrum Magazine 3/13/2003
By Carol Lindsay

By allowing intensivists and experienced critical care nurses to treat more patients, the eICU provides specialized care to patients who would not
otherwise have access.

A patient lying in a bed in an ICU reaches for his endotracheal tube and starts to pull. A voice comes out of nowhere - "Mr. Smith*, you really don't want to do that." Startled, the patient looks around the room, but there is no one there. Seconds later a nurse walks in the room. She reminds him that he has two nurses caring for him - herself and a virtual nurse located at a remote location. It was his virtual nurse who reminded him not to pull out his endotracheal tube.
The virtual ICU, also known as the eICU, is a combination of telemedicine, teleconferencing, and integrated clinical information technology. The system allows experienced RNs and hospitalists to work at remote sites as a team with the bedside staff to manage numerous ICU patients at numerous hospitals.
While the country needs 30,000 intensivists to care for critically ill patients, currently there are only 6,000 board certified intensivists practicing. There is also a shortage of critical care nurses across the country. By allowing intensivists and experienced critical care nurses to treat more patients, the eICU provides specialized care to patients who would not otherwise have access.
The eICU systems were created by two intensivist physicians at John Hopkins in Baltimore, MD. The idea behind the eICU is to add an extra layer to the ICU system. eRNs and eMDs at a remote site monitor a patient's labs, vital signs, cardiac rhythms, medications, and bedside information. They also have the ability to "look in" on the patient via camera and listen to activity in the room. A critical care eMD is available to the hospital ICU nurses immediately via a special emergency phone. This prevents common delays involved in paging a hospital physician. Because the remote sites are staffed 24-hours-a-day, the nurse is assured of speaking with an eMD who has up-to-the-minute information about the patient.
Tina Kennedy Schlegal, RN, MSN, CCRN, CNS, is the eICU director for VISICU, an eICU in Virginia. Schlegal believes there are many advantages to working in an eICU. "Working in the eICU is being able to do one of the best parts of ICU nursing - the thinking part," says Schlegal. The eRN is able to review all the patient information, such as labs, progress notes, results from CTs, MRIs, and other tests. The eRN is able to assimilate this knowledge and understand the patient's care plan and give input about different directions of patient care.
Requirements for nurses who work in eICUs include a minimum of three years of adult ICU monitoring at the bedside, plus experience with pulmonary artery catheters, monitors, pumps, and specialized equipment. These nurses must also have the technical abilities to learn to operate the eICU computer system and have the ability to manage up to 50 patients at a time. "We are no longer acting as just a critical care nurse, but more as an advanced practice nurse, reviewing charts, following vital signs, and working to prevent the urgent situations from occurring, as well as responding to urgent situations when they do occur," says Linda Rettig, RN, a clinical eICU nurse and trainer.
Patients are possibly seen by their attending physician and consulting physician only twice during the day, even though their condition changes minute by minute. Through the eICU the patient is seen 24-hours-per-day by an eMD intensivist and constantly monitored by a critical care eRN. This ensures that urgent situations are dealt with immediately, and the nonurgent issues are responded to promptly as well. "When a physician is paged, he or she must rely on his or her memory, and the nurse must answer many questions to bring him or her up to speed on the status of the patient at that time. The eICU staff has up-to-date information in front of them. This means the patient has a fully informed eMD making prompt decisions about urgent critical situations," says Rettig. The eICU does not replace the bedside nurse or the bedside physician. It is simply an adjunct to improve the outcomes of patients and decrease mortality and morbidity.
The advantages for an eRN working in an eICU include a decreased noise level, fewer interruptions, and the availability of a critical care physician the entire shift. Nurses do not have to stockpile their questions waiting for the physician to make rounds. "I have time to ask questions while I'm going through charts in the course of the day," says Rettig.
The technology is outstanding, but eRNs admit there is always a challenge when they are not the one standing at the bedside listening to the heart sounds and feeling the rigid abdomen directly. There is a definite team effort between the eICU nurse and bedside nurse.
The eICU can also be a benefit for nurses who are no longer physically able to work at the bedside but want to continue to use their critical care knowledge and skills to help patients. This allows the newer nurse at the bedside the advantage of having a seasoned eRN available for consultation. Rettig's vision for the future of eICU nurses includes a certification similar to the CCRN, which is currently available to bedside nurses, perhaps an eCCRN. She would also like to see nursing schools located near eICUs include nursing rotations and eICU critical care internship education.
So far the eICUs are reporting favorable outcomes. A 2001 Cap-Gemini, Ernst & Young study documented the following results: A 25% reduction in severity-adjusted hospital mortality at Sentara Norfolk General Hospital, a 17% reduction in ICU length of stay, and a savings in healthcare costs of $2,150 per patient or $3 million in program costs.



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