A suite tucked into a corner of an ordinary-looking building in Aurora is the unlikely home of an intensive care unit.
There are no beds, IV lines, syringes, pumps or tubes. There are no hospital rooms. There aren’t even any patients – at least at first glance.
But in fact, the patients are there – not in the flesh but rather on the screens of large computer monitors that occupy much of the suite’s open space. They are 30-some miles away, at the six-bed ICU at UCHealth Longs Peak Hospital in Longmont and a few miles north at the nine-bed Burn/Trauma ICU at UCHealth University of Colorado Hospital.
Welcome to UCHealth’s Virtual ICU. It is part of the Virtual Health Center, a project launched earlier this year to give direct-care providers on the ground help from afar in keeping tabs on patients. In the Virtual ICU (VICU), that involves experienced critical-care nurses who monitor patients on camera for tell-tale signs of declining health. They keep an eye on their vital signs and look for adverse trends or acute changes, using electronic tools that assess the severity of their condition, said Frank Newsome, registered nurse and director of patient services for the Virtual Health Center.
A VICU nurse who sees a problem crop up – a sudden drop in blood pressure, for example – while a patient’s bedside nurse is in another room or occupied with a task, can quickly call attention to it, potentially saving precious response time. If the problem is serious enough, physicians in the VICU can direct treatment in real time, Newsome said.
Extra pairs of eyes
The fundamental goal is to improve patient care while making the most efficient use of resources, said Dr. Benjamin Scott, medical director for the Virtual Health Center.
“It’s a layer of surveillance support for nurses, residents and attending physicians, and a layer of safety for patients to make sure that any deterioration they have is recognized and addressed as rapidly as possible,” Scott said.
In addition, Scott said, the VICU assists the bedside team by providing “continuous clinical evaluation” of patients in real time. That includes looking for signs of agitation, checking Alaris medication pumps, reviewing orders, and ensuring proper delivery of oxygen to patients on ventilators, to name a few.
The idea of the VICU is to put extra eyes on patients, not to look over the shoulder of providers at the hospitals – the “big brother phenomenon,” as Scott put it.
“The VICU nurses are looking for patterns with the patients,” he said. “It can be helpful to have someone doing that who is not caught up with bedside activity.” Providers can benefit from having access to an intensivist away from the site who can “think more slowly and come up with suggestions for care,” he said.
“We’re all working toward the same goal,” said RN Brett Fisher, nurse manager for the Virtual Health Center. “Every nurse wants better patient care and we’re here to help with that.”
Fisher, who joined UCH four years ago and worked in the Medical Intensive Care Unit, said he was attracted to the Virtual Health Center’s “intersection of data analysis and nursing” – the place where providers use technology to complement their clinical skills and improve patient outcomes.
Humans and machines unite
On a November afternoon, Jen Dessauer, RN, stood at that intersection. Dessauer, who joined UCHealth last January, puts her nearly 15 years of nursing experience – 10 in critical care – to use in the VICU. On this day, she watched a bank of six large computer monitors, one showing an ICU patient at Longs Peak, others displaying blood pressure, pulse rate, oxygen levels and other vital signs for each patient in the unit. Dessauer could also see at a glance the severity of each patient’s condition – red indicating the most concerning, green the least, and yellow in the middle. She was 30 miles away but intimately involved in their care.
“On the clinical side, it’s the same as being a bedside nurse,” she said. “You get to know the patients,” adding that she makes virtual safety rounds on those with the highest severity scores every hour.
“It’s a little like being an air traffic controller,” Newsome said. “We’re looking for adverse trends,” such as plunging blood pressure, sudden changes in heart rate, signs of respiratory distress and gradual signs of decompensation that may be difficult to detect.
“This is not replacing the bedside nurses,” he added. “Rather, we are adding a member to the care team.”
Dessauer said she keeps a close eye on each patient’s numbers, but she also relies on high-definition images from the cameras trained on the patients. For example, she said, signs of skin tightening around a breathing tube could trigger a call to consider repositioning the tube.
Team building across the miles
RN Joe Gerardi, chief nursing officer for Longs Peak Hospital, said the hospital and the Virtual Health Center use “relationship building” to build collaboration among care givers. For example, Longs Peak nurses visit the VICU to meet their counterparts, and the two teams have “ongoing dialogue” about monitoring procedures and review cases that resulted in the VICU making calls. The VICU nurses also participate remotely in bedside rounds at the hospital to familiarize themselves with the patients they’ll be watching.
Debbie Voyles, UCHealth’s director of Virtual Health, said collaboration between providers is essential to UCHealth’s “strategic plan’’ for delivering a variety of telehealth services. That means, for example, keeping the operation home-grown: no outsourcing to third-party “docs-on-call” services.
“We made a decision to use our own providers and our own medical records,” Voyles said. She noted that all virtual health services – workflows, schedules, documentation, and so on – are embedded in the Epic electronic health record, ensuring that every virtual health provider sees a complete medical chart and has the resources necessary to deliver the same level of care as a provider in the hospital or exam room.
“The idea is that a telehealth visit through UCHealth is equivalent to a face-to-face visit,” Voyles said.
The Virtual Health Center is only one part of UCHealth’s burgeoning Virtual Health program. It provides telestroke services to more than a dozen hospitals both in and out of the system, while a growing number of ambulatory clinics offer patients remote visits with providers. Patients also can schedule Virtual Urgent Care visits for selected non-emergency conditions through My Health Connection, the Epic patient portal.
In addition to the VICU, the Virtual Health Center handles telemetry monitoring for cardiac patients and provides “Safety View,” which is a remote or “virtual sitter” program for monitoring of patients who are confused or have safety needs such as preventing them from falling or removing necessary medical lines or tubes.
Safety View is live at Longs Peak Hospital, UCHealth Memorial Hospital North and Memorial Hospital Central in Colorado Springs, and at Poudre Valley Hospital and Medical Center of the Rockies in northern Colorado. University of Colorado Hospital in metro Denver is slated to go live in January 2018, Voyles said.
It all requires a significant financial commitment. Voyles said UCHealth invested about $1 million in the Virtual Health Center alone. Work that began in January 2017 included hardwiring the suite, installing a generator to ensure 24-hour patient coverage, purchasing equipment, remodeling, and providing adequate staffing.
“We built the space from scratch,” said Newsome, who credited collaboration between providers and the Facilities, Biomed, IT, and Epic teams for the success.
The completed build-out puts UCHealth and the Virtual Health Center in position to meet the challenges of delivering medical care in the 21st century, Newsome said. He noted that the Virtual Health Center will likely serve new UCHealth hospitals in Highlands Ranch and Greeley, but he doesn’t see the growth stopping there. A national shortage of intensivists, for example, promises to increase the importance of services like the VICU, particularly in hospitals serving rural communities.
“This is the future of medicine,” Newsome said. “Telehealth extends our reach to smaller community hospitals.”
Scott saw the benefits of telehealth during his residency and fellowship at the University of Pennsylvania, which he said was one of the first medical centers to implement the concept. Penn wired its surgical intensive care unit with cameras and microphones, installed round-the-clock nursing coverage, and provided a telemedicine intensivist to support the bedside ICU team, Scott said.
He experienced the system as a physician monitoring patients and working with bedside staff to deliver the best possible care. Doing that, he realized how “a second pair of eyes” could ease pressure on staff in a large academic medical center caring for growing volumes of acutely ill patients. He said virtual health services can help providers in Colorado meet another kind of challenge: caring for patients who might be a couple of hundred miles or more away from an intensive care specialist.
“We have a very large catchment area at UCHealth,” he said. “When I came here, I had a strong sense that we could use telehealth to benefit our patients.”
Demonstrating that benefit is an important part of Newsome’s job. He documents all interventions that VICU nurses initiate based on their observations.
It’s early days, but Gerardi said the system is working well. “We’ve had early interventions initiated by the VICU, where they have called in on something like a change in blood pressure and alerted the nurse here to go to the bedside,” he said. “We know we have eyes on our patients at all times.”
Scott said that in addition to documenting interventions and saves, the team has a “more ambitious” data collection plan in development. That effort would document core quality measures, including fall rates, central line infections, hospital-acquired infections, length of stay, and ventilator use among all patients monitored.
The VICU will ultimately be judged on its performance, just as all other programs are, Voyles said. But she sounds an optimistic note.
“Cost will be one measure we use to evaluate it,” she said. “We will do more evaluations with Longs Peak and the Burn/Trauma ICU to see if we have identified interventions sooner and to see if we’ve made a difference in patient safety. We’ll figure out the costs and the benefits. We’ve started small, but I don’t think that will be for very long.”