The crew of Medic 46 is asked to return to headquarters because their unit was flagged by a hospital_s infectious disease surveillance software system, identified as being involved in the transport of three patients to their facility, later found to have MRSA. The rig is pulled from service and placed in a special enclosure to saturate it with hydrogen peroxide vapor to completely disinfect it.
Before placing Medic 24, their replacement rig, in service, the crew sprays an invisible solution on the interior surfaces of the unit, turns on a black light and sees fluorescent areas on the steering wheel, switch panels, microphones, grab rails and defibrillator handle that had not been properly sanitized. They clean those areas and go in to service.
The crew is then dispatched to a hospital 35 miles from an urban specialty center to transfer a patient with complications from an emergency C-section. En route to the transferring hospital, the crew logs on to the Regional Hospital System database and reviews the current and past medical history of their patient, complete with medications, allergies, current vital signs and up-to-the-minute treatment. They then sign on to the regional electronic intensive care unit (eICU) system and request transfer orders and special equipment needed for the care/transfer of the patient.
After transferring the patient to their ambulance, the crew re-establishes eICU contact and is connected to a special audio/video/monitor link with an intensivist and nursing team located at a central monitoring facility. The crew sets the cardiac monitor to send continuous diagnostic parameters to the eICU throughout the transfer.
Without warning, the young woman_s vitals degrade to a level inconsistent with her age, condition and past medical history. It_s not readily apparent to the paramedic in the unit or the eICU staff, but the sophisticated software processing and comparing all the complex parameters recognizes the problem immediately and sets off alarms to alert the staff.
The intensivist helps the solo paramedic quickly stabilize the patient, and the patient is transferred to the receiving hospital without further incident. The eICU staff continues to monitor the patient in her new ICU bed.
You might think that the technology and processes described here are fictitious, cost-prohibitive, taken from a scene from Star Wars III, or decades away from a health-care system near you. But it_s all real and, with a few tweaks and financial incentives offered to hospitals by Medicare and the new health-care regulations, I believe many EMS systems will be involved in similar programs in the future.
Remote Viewing Adds toMedical Oversight
In its Oct. 27 edition, theWall Street Journalprofiled the role of eICUs and the other procedures and processes in a special "Health Care Report on Innovations in Delivering Health Care." A staff of eICU intensivists (critical-care physicians trained to care for life-threatening conditions) and critical care nurses, currently sit at consoles in specialized command centers throughout the U.S., remotely monitoring patients in multiple ICUs.
Sophisticated software tracks patients_ vital signs and instantly registers any changes in their lab test results or physical condition, enabling the eICU staff to spot warning signs that a patient is crashing, advise on-site ICU staff to give medications and treatments, and point out potential errors or oversights.
Mortality rates are 30-40% lower in hospitals where intensivists are providing round-the-clock care, preventing complications and minimizing errors. And, while a hospital-based intensivist can oversee only 10 patient beds, one intensivist and four nurses in a remote virtual ICU can oversee the care of 75-100 patients.
In 2008, electronics giant Philips Electronics NV purchased Visicu, the leading provider of eICU software systems, and now supplies the technology to 42 health systems covering 5,900 bedsƒabout 10% of the nation_s ICU beds. The eICU software can identify when a patient_s heart rate is too high for a particular condition and also identify signs of a deadly infection, such as sepsis, before the symptoms might be obvious.
A University of Massachusetts Medical Center study of 6,400 patients in seven adult ICUs monitored by an eICU showed that almost 200 interventions were made at the request or suggestion of the offsite monitoring team for every one made at the request of a bedside team. That equals a sobering interventional impact of approximately 200:1.
And the appropriateness of these additional interventions seems supported by mortality data from the Sioux Falls, S.D.-based Avera Health System_s eICU system, which covers 72 intensive-care beds in 18 hospitals spread over a five-state region, some as many as 350 miles apart. Since implementing its eICU, Avera hospital system_s ICU mortality rate has been 65-80% lower than predicted by a ratings scale used to measure how well patients will fare once they arrive in the unit. According to Ed Zawada, the eICU medical director for Avera, that decrease in mortality rate translates into about 400 lives being saved.
If you take the eICU concept to the next level, a remote intensivist could watch over the sickest prehospital and interfacility transfer patients in a health-care system like a shepherd watches over a large flock of sheep. They would serve as an extra brain trust to assist EMS crews. It adds a whole new meaning to medical command, oversight and control.
Other Areas of Progress
In the area of infection control, we know that some of the most vicious vectors of infection can survive for weeks on medical equipment in hospital patient rooms and ambulances. As many as one in 10 patients hospitalized in the U.S. currently get an infection, close to 100,000 die, and it costs hospitals up to $6.5 billion to manage so they are hungry for solutions to curb infections.
Data mining software, such as CareFusion Corp._s MedMined Data Surveillance, now allows hospitals to track hospital admission, discharge, transfer data and laboratory results and pick up on spikes in infections in specific areas of a hospital. Watching for these spikes allows staff to identify problem areas, disinfect equipment, check for defective items and zero in on staff and areas, such as stretchers or ambulances, most at risk.
And, in Michigan, hospitals were able to lower patient bloodstream infections by 66% by having staff routinely follow a standard five-step checklist and process when inserting a catheter to deliver IV drugs and fluids.
In a similar effort to reduce exposures, particularly by identifying areas not cleaned during sanitizing efforts, an epidemiologist at Caritas Carney Hospital in Dorchester, Mass., developed an invisible solution with fluorescent markers in it that light up when a black light is shined on them. Any missed spots will have a fluorescent glow. After showing crews the results and improving training and their cleaning processes, compliance with proper cleaning techniques rose from 44% to 77%. The fluorescent solution and a training program have now been licensed to Ecolab Inc., a global sanitation company.
When the Databases Are Loaded
All of these advanced systems require medical records to be digitized, allowing agencies and patients to become linked through common databases. The U.S. government is spending nearly $20 billion in stimulus funding to help hospitals and doctors switch to digitized records. What_s important for EMS agencies is the fact that Medicare will start penalizing hospitals that don_t use the digitized records in a meaningful way by 2015.
Doctors and nurses at more than 1,400 Veteran_s Administration (VA) facilities can now share a patient_s medical history via an integrated digital system that_s been carefully implemented. The system enables caregivers to not only maximize their assessment and care capabilities, but also avoid medical errors and the repeating of unnecessary tests. Health-care advocates are saying the VA_s experience shows this technology, combined with quality measurements, can work on a large scale.
This massive working model implemented successfully by the VA, coupled with the financial pressure that will be placed on hospitals to digitize and use records across all spectrums of health care, including EMS, should help us break down the walls that have existed for decades between hospital and prehospital data systems.
These technological breakthroughs have the potential to bring hospitals and EMS systems together in a computerized marriage: We might see a future of monitoring systems for infectious diseases, vital signs and patient condition diagnostics, all complemented by a team of specialists remotely monitoring, and acting on system alerts as well as providing consultative services.
EMS involvement in such systems will mean not only access to past patient histories, allergies and vital sign parameters, but also final outcome data that would assist us in evaluating, studying, improving and expanding EMS systems and their capabilities.JEMS
- Landro L: "The Picture of Health: With critical-care specialists in short supply, remote monitoring offers a high-tech solution. Health Care: The Journal Report." The Wall Street Journal. Oct. 27, 2009. p. R4.
- Simon S: "Ten Steps to Preventing Infection in Hospitals: Too many patients get sick in the very places that are supposed to heal them. Health Care Report." The Wall Street Journal. Oct. 27, 2009. p. R6.
- Goldstein J: "Easy as 1-2-3? Checklists can reduce infections dramatically. The trick is getting doctors and nurses to use them. Health Care Report." The Wall Street Journal. Oct. 27, 2009. p. R6.
- Zhang L: "The Digital Pioneer: Veterans hospitals have already fought this battleƒand offer plenty of lessons on how it can be done." The Wall Street Journal. Oct. 27, 2009. p. R5
A.J. Shares more thoughts:jems.com/heightman