By Merin C. MacDonald
The eICU program at UMass Memorial Health is leading exciting new efforts to improve efficiency and patient outcomes in intensive care units across Central Massachusetts. Also known as the ICU telemedicine program, the eICU launched in 2006 and currently electronically monitors over 150 adult ICU beds at UMass Memorial Medical Center, Marlborough, Harrington, and HealthAlliance Hospital, the PACUs at UMMC, and ICU beds at non-UMass sites including Heywood, Milford Regional, and Tobey Hospital. Beds are monitored 24/7, from a remote support center, by attending intensive care physicians who are assisted by critical care nurse practitioners or physician assistants. The eICU is led by Bruce Greenberg, MD, MBA, interim medical director of the eICU and medical director of the Memorial CCU, critical care physician, and assistant professor of medicine in Pulmonary, Allergy, and Critical Care, and Eric Cucchi, MS, PA-C, director of eICU operations, critical care physician assistant, faculty in the Program in Digital Medicine, and instructor in the Tan Chingfen Graduate School of Nursing. The primary goals of the eICU include direct support of and interventions to help ICU patients in conjunction with the bedside providers, review and optimization of recently admitted patients, co-managing triage and patient flow, and providing population health outreach.
One of their chief objectives is to enable clinicians to be as efficient and effective as possible. Because they are staffed with two to three clinicians each shift and they monitor over 150 patients, the eICU depends on electronic tools to help guide them and ensure that they are not missing critical issues. They utilize a specialized alerting and alarming system that helps them focus their attention on sicker or less stable patients that might be decompensating so that they can intervene. They have also developed handoff tools that facilitate communication from the bedside to the eICU and vice-versa, enabling easy communication among the teams. Innovative technology and tools used in the eICU are critical to the management and care of our ICU patients.
For their most recent innovation, eICU leadership developed a clinical decision support tool within Epic that addresses about 25 patient metrics. Beginning in the summer of 2021, the metrics and particularly the supporting electronic medical record analytic logic were developed from the ground up. Dr. Greenberg and Mr. Cucchi sought input from physicians and critical care leaders, worked to match all the algorithms precisely with UMMMC clinical practice guidelines, and worked iteratively to optimize the tools. It took over a year to fully develop and validate the tool and in October 2022, under the leadership of Dr. Greenberg and the support and assistance of the Critical Care Committee and hospital quality leadership, the eICU began its implementation. Two ICUs were added each month until all UMMH Epic ICUs were on the system. The tool was developed and refined to align with how providers practice critical care at UMass and, with about 98% accuracy, is able to identify critical care patients that need at least one of the metrics addressed, whether by action or conversation and consideration. The eICU team has incorporated the tool deeply within the critical care workforce workflow including with both eICU and bedside providers.
Currently, each morning during rounds, the bedside team is recommended to use a patient census view that incorporates the eICU population health recommendations as part of routine rounds. In the afternoon, the eICU clinical team will go through the report and review patient charts to evaluate whether items that are still flagged need further evaluation by the bedside team. If further evaluation is required, the eICU clinical team will reach out to the bedside team to have conversations about specific metrics which can then lead to actionable items and in turn improvements in patient care. Through decisions made from these types of conversations, preliminary data has shown that UMass is already starting to see a decrease in the amount of time that intervascular lines are in place. Initial data is also showing a downtrend in the duration of mechanical ventilation. More data are needed, but these preliminary results indicate that using this tool is having a significant impact on ICU patients. “I would say we’re justifiably proud of this effort,” said Dr. Greenberg. “It took a couple of years of work and rework to get fidelity so our rules and logic synchronize as close to perfect or, really, perfectly, with our established standards. It was a huge effort and an enormous amount of coding, mostly by Eric [Cucchi]. This tool may be among the most sophisticated of any Epic installation, certainly of anything we know of.”
Ongoing adjustments to the tool can be made in accordance with stakeholder feedback or changes in clinical practice guidelines. “A great thing about this tool is that the eICU owns it fully, so as clinical practice guidelines change we can make changes on the fly and have new or revised metrics out on the front line very quickly without having to rely on a vendor to build the tool for us,” said Mr. Cucchi.
Beyond its use in the eICU at UMass, Dr. Greenberg and Mr. Cucchi envision this tool will be exportable to other institutions. While specifics will vary from institution to institution because of differences in how Epic is set up at each individual site, the concept is transferrable. They are currently preparing a paper to share their findings with the national and international communities. More immediately, many aspects of this tool can be exported for use with non-ICU patients at UMass for relevant metrics. Current discussions with the anticoagulation group are ongoing to explore how to implement DVT algorithms into their acute care workflows and there are validation efforts going on in that area. The eICU team has also had conversations about exporting their nutrition support decision logic for the hospital nutritionists.
This incredible effort by the eICU and multiple other supporting groups has made a significant impact on the workflow of eICU providers and bedside teams. Ultimately, this tool improves efficiency and allows caregivers to offer more effective care to ICU patients. The benefit of this tool has already been seen and more data will likely continue to reveal the overall impact to those who are cared for in the UMMH ICUs that they serve.