Monday, March 19, 2018

The nurse will see you now — remotely (w/video)

ST. PETERSBURG — Wearing a headset with a microphone, her gaze fixed on a panel of computer screens, Chris Smith looks more like an air traffic controller than a critical care nurse.

But tending to the sick is how she will spend the next 12 hours.

Her screens are full of real-time data from the most fragile patients at five Tampa Bay area hospitals. With a few clicks, she can see their heart rates, breathing rates and oxygen levels. A few more clicks and she can pull up X-rays and lab results, or connect with the patients in their rooms.

Like most of her shifts, this one begins as the sun sets. Smith combs through the data, looking for anomalies. Low oxygen. A slightly elevated heart rate. The smallest blip can portend a problem.

It isn't long before something catches her eye: a 71-year-old patient at Morton Plant North Bay Hospital with higher-than-normal blood pressure. Her gut tells her to "camera in" for a closer look.

"Ms. O'Brien?" she says, using a program like Skype to connect with the woman in real time. "This is Chris from eCare."

Smith is part of BayCare Health System's new eCare Unit, a team of doctors and nurses who help monitor the critically ill patients in five of BayCare's hospitals. They work remotely from a suite in a St. Petersburg office park, an outpost known as eCare Central, using advanced technology to assess each patient's condition and help the staffers at bedside.

The program is an around-the-clock operation. But eCare is busiest at night, when staffing levels are low in most ICUs.

"There aren't enough doctors to be at the bedside 24 hours a day," said eCare medical director Dr. Devendra Amin. "That's where we come in. We can use technology to be that extra safety net."

BayCare isn't alone. Hospitals nationwide are making better use of technology to treat patients remotely — a practice known as telemedicine. The concept has been around for decades. But as the technology advances, its uses are evolving.

• • •

There are 111 patients to help care for on this Monday night.

Rosalie O'Brien, 71, is being treated for pneumonia and high blood sugar at Morton Plant North Bay Hospital in New Port Richey, about 30 miles north of eCare Central.

O'Brien is resting in her bed when Smith connects into the room. A doorbell sounds and a few seconds later, the beige camera facing the wall swings around and points in her direction.

Smith's image appears on a screen.

"How are you?" the nurse asks. "Doing better?"

O'Brien nods.

Smith adjusts the camera from her computer in eCare Central. She zooms in on the machine displaying O'Brien's heart rate and blood pressure, then on her IV pump. The resolution is so high Smith can read the tiny words on the IV bags.

She focuses the camera back on the bed and notices the patient is short of breath.

"I'm going to check back in later, OK?" she says. "I hope you feel better."

When the video feed cuts off, Smith turns to Amin, at the next work station. She shares her observation and asks if O'Brien has had a recent chest X-ray.

Amin, a veteran pulmonologist, says he will follow up.

The sun has now set, and the screens cast a dim glow across Smith's face. She checks in on her patients, one after another, like a nurse doing rounds at the bedside. She looks the part, wearing blue scrubs and comfy shoes.

For Smith, the routine has a familiar feel. She has been a nurse for more than 15 years and still works in a hospital at least once a month. There are some differences. While Smith assesses her patients remotely, the software pulls in data and determines which are in the worst shape. Alerts pop up on her monitors like instant messages, letting her know about the slightest changes in body temperature and blood pressure.

She doesn't dare get up from her console.

"If you walk away, you come back and you have a screen full of things to investigate," she said.

Amin, meanwhile, is busy helping admit new patients to ICUs that are 10 and 15 miles away. He works at a standing desk, his white lab coat draped over the empty chair.

• • •

It took more than a year to build the infrastructure for the eCare system. Engineers outfitted eCare Central with state-of-the art hardware and software. They connected 147 beds at five hospitals: Morton Plant North Bay, Morton Plant in Clearwater, Mease Dunedin, Mease Countryside in Safety Harbor and St. Anthony's in St. Petersburg.

The $5 million investment was substantial, said Lisa Johnson, vice president of patient services at Morton Plant Mease. But she believes the program will save money over time.

"The whole goal of this is to bring best-practice, evidence-based medicine to the critically ill patient," Johnson said. "By doing so, it's been proven that (we can) reduce the length of time a patient has to stay in a critical care setting."

The program also could generate savings if it keeps patients from being readmitted. Medicare fines hospitals if too many patients return within weeks of their release, a policy created under the Affordable Care Act.

BayCare has not, however, cut costs by reducing the number of doctors and nurses working on the front lines in the ICUs.

"This supplements care," Johnson said. "It does not replace care. Nothing can replace the person at the bedside."

Since its debut on Nov. 11, eCare has been well-received by patients.

Allen Suban, who was at Morton Plant recovering from open heart surgery two weeks ago, said he was initially thrown off by the camera mounted in his hospital room.

His first reaction: "Uh, oh. Big Brother is watching."

But after the eCare nurses checked in on him, the 74-year-old retired engineer from Clearwater said he came to see the technology as a useful tool.

"It's like having a nurse in your room all the time," he said.

Administrators of eCare say they have fielded more than a few questions about privacy. They work hard to allay concerns.

"There aren't other people looking into their room, and it is not being recorded," Johnson said.

While the actual interactions are not saved, the doctors do record the steps they take to improve a patient's health. That's deliberate, Johnson said. They're hoping to build each patient's electronic medical record.

• • •

Just before 8:30 p.m., eCare Central is silent except for the sound of keystrokes and mouse clicks.

Nobody uses the treadmill or step machine intended to help team members stretch their legs during grueling 12-hour shifts. The doctor, three nurses and administrator all focus on their screens.

The silence is broken when a patient from Mease Dunedin uses the "eLert" button in her room to connect with eCare. Barbara Bernier, 80, is being treated for a blood clot in her leg and is in pain. She wants a few pills to help her sleep.

The nurse jots down the request on a slip of white paper the size of a smart phone. She hands the "ticket" to Amin, who puts in an order online for some sleeping medication.

The low-tech system of delivering notes is a key part of the operation, Amin says later. It lets the nurses get up from their work stations and ensures the physician sees the request.

"There's already enough information on the screens," he said.

Amin likes another aspect of the ticket system: It creates a paper trail.

• • •

BayCare hopes to expand eCare to its hospitals in Hillsborough and Polk counties by the end of 2016. The project isn't expected to cost quite as much as the first phase of the program, but the price tag will likely be in the millions.

Other area hospitals are embracing the concept, too.

Florida Hospital Carrollwood and Florida Hospital North Pinellas, both part of the Adventist Health System, have launched similar programs in their ICUs. But instead of having their own central command, the hospitals contract with a St. Louis company, Advanced ICU Care, for patient monitoring.

"Telemedicine is the wave of the future," said Robin McGuinness, Florida Hospital Carrollwood's chief nursing officer. "It's been a solution for rural communities for a very long time and is clearly moving into urban settings and all settings."

It is too soon to tell if the programs have improved patient outcomes or shortened the lengths of ICU stays. The hospitals are waiting on data they can compare to older figures.

BayCare expects its program to yield positive results.

At 9:27 p.m., Bernier calls back to ask for two more sleeping pills. The nurse brings a ticket to Amin, who approves only one.

"It's a balance between doing the right thing and keeping the patients comfortable," he said.

Just before 10 p.m., he heads to the break room for coffee. The overnight shift isn't the most glamorous, he muses, and this night in particular has gotten off to a slow start.

But that can change in an instant. Nine hours to go.

Contact Kathleen McGrory at [email protected] or (727) 893-8330. Follow @kmcgrory.

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