A Dramatic Care Transformation in the ICU
“We couldn’t keep the majority of our pulmonology cases here without someone with vent training to manage the settings. We would go into the unit and talk to the bedside teams about how sick the patients were. We knew that in order to grow the business we needed to retain those patients, and in order to keep those patients, our care had to improve”
Experienced Onsite Hospitalist
Walking into a Turnaround
There is a 154-bed hospital regional medical center in a small but beautiful town in the heart of the Smokey Mountains. Back in 2016, when the medical center’s new CEO and CNO arrived, they faced a challenging situation. The medical center’s CMS star rating was a 3. Even more troubling, their most recent Leapfrog Hospital Safety Grade had fallen to a D.
With two tertiary care facilities located within 30 minutes of the hospital, it was difficult to compete for talent and recruit experienced critical care nurses. ICU oversight was distributed among a handful of physicians in an ad-hoc capacity with inconsistent roles and responsibilities. As a result, many of the patients who started at the hospital were ultimately transferred to another facility—along with a significant amount of revenue. One experienced onsite hospitalist explained, “We couldn’t keep the majority of our pulmonology cases here without someone with vent training to manage the settings.”
Both the incoming CEO and CNO have critical care backgrounds. “We would go into the unit and talk to the bedside teams about how sick the patients were. We knew that in order to grow the business we needed to retain those patients, and in order to keep those patients, our care had to improve,” said the hospitalist.
Planning an Evolution
The leadership team put together a comprehensive plan to improve quality, reduce transfers and transform the organization. “We wanted to implement telemedicine from the very beginning, but there were so many things that we needed to do that we put it on the back burner for a little while—until our one pulmonologist retired and we knew we had to move very quickly,” said the incoming CNO.
She had previous experience working with telemedicine at a health system in another state, and was familiar with the ICU “bunker model,” but didn’t believe it would be a good fit. “In some cases, staff start to rely on the bunker clinicians to monitor their patients so they’re not as vigilant. If my team is relying on someone else to watch the vital signs or urine output, I’m not helping them develop their critical thinking skillset,” she said.
Instead, the hospital was seeking a telemedicine partner that would providearound-the-clock ICU coverage and simultaneously upskill the team. SOC’s dual ICU workflows including proactive patient assessment via SMARTRounds and intensivist support on-demand, fulfilled the hospitals requirements. They also sought council from experts within the broader health system. “Initially the clinical leadership team was wary and suggested we bring in experts to evaluate the concept. After our first collective meeting, one important decisionmaker said that he would definitely support a teleICU pilot, and we agreed to keep him updated on the progress that we have made,” explained the CNO. The board quickly approved the program and implementation began shortly thereafter.
An All-Hands Effort
The entire medical center team played a role in the implementation of telemedicine and the transformation of care. New standards of care and order sets were developed and implemented. Hands-on staff training focused on complex care, pulmonary disease, vents, and caring for patients who were hemodynamically unstable. New protocols and workflows were introduced and a dedicated team focused specifically on how to efficiently incorporate telemedicine into their current clinical practice. The CNO explained, “We worked through all of the necessary steps up front so that when we did go live with SOC Telemed, we would be prepared to provide enhanced levels of care using the telemedicine platform.”
Anticipating Patient Needs The ICU care team spent time learning how to interact with the SOC teleintensivist team—from using SMARTRounds for more proactive routine follow ups, to requesting emergency evaluations when necessary. Led by an SOC virtual intensivist, the entire care team (nursing, pharmacy, respiratory therapy, PT, dietary and several other physicians and clinicians who find the interactions invaluable) engages to discuss each patient, evaluate the current plan of care, anticipate challenges and proactively plan on how to handle the current situation. “This is our opportunity to dig into the deep details of what is going on with our ICU patients. We hold our rounds on the back of the unit and the nurses are required to come prepared. They share an overview of what’s been happening with the patient, and then the intensivist asks the bedside team multiple questions. It is a great learning opportunity,” explained the CNO.
“There are definitely patients here now that I would not have kept in our hospital before the teleICU program. Those critically ill patients can now benefit from an intensivist who has had an extra four years of fellowship training and experience.”
Experienced Onsite Hospitalist
Increase in Patient Acuity
As staff became comfortable with the support from remote intensivists, they gained valuable experience caring for more complex patients including ventilator patients and patients who were hemodynamically unstable. “We regularly engage in discussions with our SOC intensivists around best practices and new care models that they are seeing in their work across the country. Our physicians benefit from the latest thinking,” says the CNO. As a result, the hospital’s Case Mix Index (CMI) increased by approximately four percent.
Return on Investment
Before its partnership with SOC Telemed, the ICU transferred an average of 78 patients per month. Post implementation, the number of patient transfers was reduced by 15%, allowing the hospital to retain 144 additional patients annually.
Using a conservative per-patient reimbursement average of $8,251, and an assumed contribution margin of 50 percent, the hospital estimates that the reduction in transfers led to a revenue increase of more than $1,188,000 and $594,000 in annual incremental profits.
The 4% increase in CMI resulted in an additional $442,021 in annual profits. When taken together, the hospital conservatively estimates they have achieved a 257% ROI from their telemedicine program.
Developing and Retaining Top Nursing Talent
Before embarking on their quality journey, the hospital found it very difficult to recruit experienced critical care nurses. The CNO explained, “There are wonderful tertiary care facilities nearby. When ICU nursing is your passion, you want to provide care to patients that are sick and on ventilators and see them turn around. At this facility, we were transferring all of those patients out. Initially we had many young, novice nurses that really didn’t know how to be more aggressive with care, but they were smart, enthusiastic and eager to learn.”
Even though the hospital began their ICU transformation with a relatively inexperienced nursing team, as soon as they went live, the team began to transform. The CNO continued, “The SOC intensivists actually teach and coach our nurses. They discuss why they think it is best to order certain medications or recommend various clinical interventions. That teaching has really elevated the knowledge level of the team.” The hospital is now 18 months into their teleICU journey and executives like their CNO believe that a significant part of this evolution is due to their partnership with SOC. “The skillset and experience of our nursing team is significantly higher than it was before we partnered with SOC. Even our hospitalists – who are very experienced providers – enjoy conversing back and forth with SOC’s teleIntesivists about the latest and greatest practices and interventions.” SOC Telemed is the first provider of acute clinical telemedicine services to earn The Joint Commission’s Gold Seal of Approval.
The Impact of COVID 19
Although the impact of COVID-19 has been minimal to date, the hospital is grateful that telemedicine is already incorporated into the workflow. “As we worked with the broader health system to discuss our COVID-19 preparation strategy, the one thing that our CEO and I were confident about was the talent and the skill that we have access to with the SOC team. We know that they will have access to the latest and greatest knowledge and be able to guide us when and if we begin to see a surge of ARDS cases.”
“This past spring we had quite a few young patients that were extraordinarily sick and SOC was instrumental in their care. All have been discharged alive and well.”
“As we worked with the broader health system team to discuss our COVID-19 preparation strategy, the one thing that our CEO and I were confident about was the talent and the skill that we have access to with the SOC team. We know that they will have access to the latest and greatest knowledge and be able to guide us when and if we begin to see a surge of ARDS cases.”
Experienced Onsite Hospitalist
It’s All About Trust
“Our physicians enjoy that they work with consistent providers, so even though they may be 1000 miles away there’s still that rapport which is so important for building trust.” To sum it up, the CNO concluded, “We have been very happy with our decision.”
SOC Telemed is the first provider of acute clinical telemedicine services to earn The Joint Commission’s Gold Seal of Approval.