Dr. Elizabeth Raitz Cowboy spent a recent night making her rounds, checking on critically ill patients in intensive care.
"You're looking much better today," Cowboy told a 69-year-old man with congestive heart failure, who waved a greeting and requested a snack.
As the doctor promised to check his dietary restrictions, a worried nurse interrupted: A recently admitted patient was showing a welcome drop in blood pressure but a worrisome rise in heart rate.
Cowboy peered at the new patient, quizzed the nurse, reviewed the medical chart, then switched the blood pressure medicine.
It was a routine evening in the intensive-care unit - except the patients and the doctor weren't in the same hospital, or even the same ZIP code. The congestive heart patient was in Alexandria, Va.; the other was more than 20 miles away in Fairfax. And the doctor was in a sleek suite in an office tower in Falls Church.
From the suite, the doctor kept watch via a remote monitoring system pioneered by VISICU Inc., a Baltimore company founded in 1998 by two Johns Hopkins intensive-care specialists.
The remote monitoring site at Inova Health System, which operates four hospitals in Northern Virginia, is one of about a dozen that went live last year as VISICU expanded.
From one control center that monitored 65 beds at the start of 2003, VISICU now has 20 electronic intensive-care units, or eICUs, from New York to Hawaii (none yet in Maryland), monitoring 1,318 beds. And with orders for nine more systems, that number will about double by year's end.
"It's definitely gaining momentum," said Dr. Jay Cowen, an ICU consultant and director of critical care at Northwest Community Hospital near Chicago. "It's impossible to ignore."
Driving the growth is a shortage of intensive-care specialists and the incentive for hospitals to turn over ICU beds as quickly as possible.
Patients do better when attended by these specialists and spend less time in the intensive-care unit, studies show. But these specialized physicians, known as intensivists, care for only about a third of patients in ICUs nationwide.
The shortage is expected to get worse. A growing elderly population will increase demand for critical-care beds, and the number of training slots for intensive-care physicians is limited.
"There's no conceivable way to staff ICUs adequately, given the number of intensivists," said Dr. Brian Rosenfeld, one of VISICU's founders and its executive vice president and chief medical officer.
VISICU began as a way to leverage the available supply of critical-care doctors to cover more beds, "not a way to cut personnel," said Rosenfeld.
Many hospitals don't have intensivists at all. For the most part, hospitals with the VISICU system do have the specialists, but not round-the-clock. For example, Inova's four hospitals did not have an intensive-care physician on regular duty at night, although ICU nurses could call on other doctors in the hospital.
Now, one Inova intensivist and two certified critical-care nurses remotely monitor up to 84 patients from 7 p.m. to 7 a.m. Critical-care physicians continue to staff Inova's ICUs during the day.
The system also can raise an alarm, flagging on a screen any patient who has had a rapid change in condition or whose vital signs have slipped into the danger zone.
Looking at a bank of six large monitors, the eICU clinicians can track alarms, look at vital signs in real time or track them over the past few hours or days. They can also call up medical records and charts, write orders for medicines, or "camera in" to look things over.
The VISICU system has mechanisms to minimize errors. For example, Rosenfeld said, since a doctor may be watching several patients at once, a box pops up on the screen to ask the doctor to confirm which patient should receive a medication that's ordered.
The system also includes redundant fiber-optic data lines and computer servers, Rosenfeld said. As a result, he said, down time has been "nominal." The longest, he said, came when a backhoe cut all communications into one eICU, causing a disruption of about two hours.
Even in such a worst-case scenario, he said, eICU doctors and nurses are available by phone, so the situation would be analogous to his pre-VISICU days at Hopkins, where a nurse might call him for a consultation in the middle of the night.
Hospitals find the system appealing because it offers the prospect not only of improving patient safety, but also of paying for itself in a fairly short period and adding to revenue.
If VISICU can reduce complications, hospitals can send the patients home - or to a less intensive, less expensive level of care - sooner, cutting its cost of care for that patient and opening beds for new ones.
