It's just after 7 p.m. and Dr. Daniel Sterman is starting his
rounds through the surgical intensive-care unit at the Hospital of
the University of Pennsylvania.
Dressed in green scrubs and holiday red socks, Sterman checks
first on William Kinney, 50, who was hit by a car while riding his
bike. His long list of injuries includes a perforated lung and
fractured pelvic bones.
Sterman takes a look at Kinney and the monitors tracking his
breathing, heart rate, blood pressure, heart rhythm, and blood
oxygen saturation.
He's doing OK, Sterman concludes - sitting five blocks away from
the hospital.
Sterman is at the controls of the "eICU," a remote monitoring
system that allows him to simultaneously track dozens of patients by
way of computers, cameras and audio hookup.
The technology is part of a telemedicine movement that is
transforming health care, allowing patients the expertise of doctors
even several time zones away.
For the next 12 hours, Sterman and two nurses in a command center
at 34th and Market Streets will keep watch over not only 24 patients
in HUP's surgical ICU, but also 27 more people in three ICUs at
Pennsylvania Hospital on the other side of town.
As real-time data from bedside equipment pour into their banks of
computers, Sterman and his team will look out for worrisome signs,
review electronic medical records, consult with nurses and residents
in the wards, and occasionally "ring the doorbell" and zoom in to
talk to a patient.
With a click of a mouse, they assess a gunshot victim at HUP one
moment and a muscular-dystrophy patient at Pennsylvania Hospital the
next. Later that night, another patient says he finds the technology
a little impersonal.
The system, made by Baltimore-based Visicu, is programmed to
track trends and spot even subtle changes in a patient's condition.
It registers a color-coded "smart alert" on the computer screen if
blood pressure or other vital signs deviate from an acceptable
range.
The Penn health system has spent close to $3 million for the
technology at HUP and Pennsylvania Hospital and will spend an
additional $1 million to bring Presbyterian Medical Center online,
according to Dr. C. William Hanson, medical director for the eICU
project.
The idea is not to replace the workers in the ICU, but to lend
another set of expert eyes - especially at night, when medical
staffing is thin.
Research shows that deaths in the ICU drop when care is overseen
by highly trained critical-care doctors called intensivists. The
eICU allows those doctors to give their expertise in multiple
places.
It "adds another dimension to patient care. Small interventions
can make a big difference in outcomes," said Sterman, 41, a
pulmonologist and critical-care specialist who once a week mans the
Penn center. Some staff think of it as "the box" - a stark,
windowless room that's empty except for a few desks and clusters of
computers.
Penn, which began phasing in the system last month, is among a
small but growing number of hospital systems turning to remote
monitoring.
"The idea that physical presence is necessary for care is going
to evaporate," said Dr. Arnold Milstein, a quality expert for the
Leapfrog Group, a Washington-based consortium of large companies
seeking to improve medical quality.
According to Milstein, the eICU has tremendous potential to save
both lives and money.
"This is the first time I've seen a single intervention generate
such results," he said.
At Sentara Norfolk General Hospital in Virginia, which started an
eICU in 2000, hospital deaths among ICU patients fell 25 percent in
the first year of operation, and the average length of stay declined
17 percent, according to independent auditors.
"By being on top of things and being able to respond quickly to
problems, we believe we are reducing morbidity," or complications,
said Dr. Steven A. Fuhrman, medical director for Sentara's eICU.
The cumulative payoff for such technology could be huge,
considering that each year in the United States about five million
people are treated in ICUs, and at least 10 percent of them die.
ICU mortality is about 40 percent lower when care is directed by
intensivists, rather than by doctors of varying specialties who come
in to see patients amid other duties, research shows.
Most hospitals don't have intensivists directing the care of
their sickest patients. Pennsylvania Hospital is just beginning to
put them in charge of medical ICU patients. Other hospitals, such as
HUP, have intensivists present only on the day shift.
And the nation's supply of those doctors isn't large enough to go
around anyway, said Brian Rosenfeld, a former Johns Hopkins
critical-care doctor who helped invent the eICU system and is a
cofounder of Visicu.
"In most community hospitals, doctors make the rounds in the
morning, and then they are pretty much gone, and nurses communicate
with them by phone," Rosenfeld said.
"In academic hospitals, you've got residents and interns, and
they are not always adept at making decisions. The minions are left
there at night and on weekends, and things don't always go the way
the senior doctor would prefer."
Concerns over cameras
It is Sterman's fourth turn in the eICU, and a couple of patients
worry him.
One is a cancer patient at Pennsylvania Hospital who shows signs
of a massive bloodstream infection and is having trouble
breathing.
Before the night ends, a resident from Pennsylvania Hospital will
call Sterman, and they agree to put the patient on a ventilator.
Other patients aren't so vulnerable. Turning on the camera above
bed No. 19 in HUP's ICU, Sterman asks: "Hi, Mr. Anderson. This is
Dr. Sterman in the virtual ICU. How are you feeling today?"
"Horrible," shoots back a feisty James Anderson.
The 56-year-old man from Oxford was home from heart bypass
surgery for six days when he bled so severely from a stomach ulcer
that he passed out and landed back in the hospital. He needed 20
units of blood.
Anderson later confesses he isn't wowed by the remote monitoring
system.
"It's nice to have someone show concern," he says of the nurse in
his room.
"But that thing," he says, gesturing at the camera on the wall,
"will never show concern."
Leslie Moore, the head night nurse in the unit, said her
colleagues have mixed opinions on the eICU.
"At times we feel like it's very good... especially if you have
two things happening at once in the unit," she said. Other times,
nurses "feel it's an intrusion on their independence to be able to
handle an issue."
Catherine Pavlov, whose father is in Pennsylvania Hospital's ICU
for heart failure, said she worried the hospital might use the
system to cut back on staffing.
"My first concern was that it was going to change the
patient-to-nurse ratio. Is the nurse going to be responsible for
more patients then? And they said, 'Absolutely not,' " she said.
She said her 82-year-old father, Charles Cramer, is happy
"knowing he could go to sleep and someone is there with him."
