Intensive care from afar: Caregiver versus patient watcher

A recent NPR story by Michael Tomsic recounted the remarkable story of how the Carolinas HealthCare System monitors ICU patients in 10 of its hospitals from a remote "command center"-like facility. Several critical care specialists staff the center; nurses are present around the clock and doctors work nights. Command center staff also spend time at the hospitals they monitor.

The system began doing this roughly two years ago and have since found that the quiet atmosphere of the command center ("none of the bells and whistles going off that most ICUs need to alert nurses and doctors down the hall that they're needed") allows medical staff in the center to maintain a constant focus on patients. The approach seems to be working for the system: They've observed a higher patient volume, lower mortality rate, and decreased length of stay since opening the center (though, as the article describes, such improvement likely isn't due solely to the remote monitoring program).

The issue of alarm fatigue is recognized as an important patient safety issue, so the idea of placing a group of specialists outside the immediate patient environment for monitoring purposes has a strong rationale. What I found most interesting about the article, however, was revealed in remarks from two nurses interviewed. One observed that "There are things that I'm able to view here [in the command center] — trends that I'm able to view here — that I'm not able to view at the bedside", while another noted that since the command center staff has easy access to patient data, handoffs are better and issues are less likely to be missed.

Assuming that these ICUs are not fundamentally different from ICUs in other facilities, the story highlights an issue that is endemic far beyond this particular set of hospitals: the frequent failure to bring data to the bedside in an effective way. This is ironic, as the big data and IT revolution brags -- incessantly, it sometimes seems -- about delivering data and analytics to the point where they can be most useful. That isn't consistent with the remarks from healthcare workers in this article.

Is caregiving versus patient monitoring an either-or proposition? I doubt it, as I've seen data-driven intensive care delivered reliably over long periods of time. Rather, I think the question is how to make data actionable through delivery to the right people without disrupting their workflow. It's a question for all clinical environments beyond the ICU. We need to make more effective use of routine clinical data.

(image source: Wikipedia)

No room for complacency: Doing more for patient safety

I've had significant encounters with the US healthcare system over several years, since a close friend was initially diagnosed and hospitalized with a life threatening disease. I won't go into the details of that illness other than to say that it involved many prolonged stays in intensive care environments in multiple capable institutions, followed by a long, complex, and ultimately successful convalescent period. All in all, I was impressed at the time with the quality of care they received and with the amount of evidence-based practice that was incorporated into the care.

Accompanying my friend to a series of follow up appointments at one institution recently was, as always, a rewarding experience. They are doing very well in the aftermath of their illness and treatment, and the professionalism and warmth of the original caregivers continues to be evident as the years go by. Between appointments that day I reflected on how the clinic rooms had changed over the years. They were still the same bright colors. They were still spotless. They still had sinks and motion-detection towel dispensers, and they still had alcohol-based hand rub bottles at the doorway. Every last healthcare provider on the visit, as always, utilized correct hand hygiene practice before each and every procedure, and providers asked for name, DOB, and other relevant information.

The thing that struck me as new, however, were posters, buttons, and reminders everywhere regarding patient safety. Five years ago, there was the usual painting or informational poster on walls in examining rooms and common areas. They served to inform the patient and also to break up the sheer monotony of the healthcare experience. Today, in addition to those, interventional wall coverings grace the rooms and doors. They are colorful and efficient at delivering information to patient and HCW alike. They address hand hygiene and other facets of patient safety in constructive and actionable ways.

It's nice to see, especially in an institution that is a leader in quality of care to begin with. In my friend's case, the quality of care was high at all hospitals where they stayed, though the push to improve safety wasn't as outwardly visible at one of them. I wonder how meaningful safety metrics (e.g., changes in the incidence of HAI or dosing errors within the same patient population -- as opposed to the aggregate data usually available online -- over time) would compare between institutions with similar campaigns?

(image source: CDC)