Program Design Discussion: The Program Life Cycle and Resource Justification

A Health System-Based Critical Care Program with a Novel Tele-ICU: Implementation, Cost,

and Structure Details

Spyridon Fortis, MD, Craig Weinert, MD, MPH, Robyn Bushinski, MA, NE, PHN, RN, Alison Greiner Koehler, MHA, Greg Beilman, MD, FACS

BACKGROUND: Improving the efficiency of critical care service is needed as the shortfall of intensivists is increasing. Standardizing clinical practice, telemedicine, and organizing critical care service at a health system level improves outcomes. We developed a health system Critical Care Pro- gram based at an academic medical center. The main feature of our program is an intensivist who shares on-site and telemedicine clinical responsibilities. Tele-ICU facilitates the stan- dardization of high-quality critical care across the system. A common electronic medical record made the communications among the ICUs feasible. Combining faculty from medical and surgical critical care divisions increased the productivity of intensivists.

STUDY DESIGN: We retrospectively reviewed the administrative database data from 2011 and 2012, including mean census, number of transfers, age, sex, case mix index, mortality, readmissions, and financial data.

RESULTS: The Critical Care program has 106 adult ICU beds; 54 of those beds can be managed remotely using tele-ICU based at the main University hospital. The mean midnight census of the system for 2012 was 69.44 and total patient-days were 34,406. The capital cost of the tele-ICU was $1,186,220. The annual operational cost is $1,250,112 or $23,150 per monitored ICU-bed. Unadjusted mortality was 6.5% before and 4.9% after implementation (p < 0.0002).

CONCLUSIONS: We describe a novel health system level ICU program built using “off the shelf” technology based on a large University medical center and a tele-ICU with a full degree of treatment authority across the system. (J Am Coll Surg 2014;219:676e683. � 2014 by the American College of Surgeons)

Management of critically ill patients by intensivists im- proves outcomes1 including mortality2,3 and ICU length of stay.4,5 The Society of Critical Care Medicine recom- mends that an intensivist, usually unit-based, have the authority to intervene and directly care for critically ill patients in urgent and emergent situations 24 hours per day, 7 days per week.6

The demand for critical care services in the United States is anticipated to increase due to aging of the

Disclosure Information: Nothing to disclose.

Received February 11, 2014; Revised April 15, 2014; Accepted April 29, 2014. From the University of Minnesota Medical Center-Fairview (Fortis, Weinert, Bushinski, Koehler, Beilman), Critical Care and Acute Care Surgery Division (Fortis, Beilman), and Pulmonary and Critical Care Division (Fortis, Weinert), University of Minnesota, Minneapolis, MN. Correspondence address: Spyridon Fortis, MD, University of Minnesota Medical Center-Fairview, 420 Delaware St SE, MMC 276, Minneapolis, MN 55455. email: [email protected]

676 ª 2014 by the American College of Surgeons Published by Elsevier Inc.

population and the 35% shortfall of intensivists that is anticipated by 2030.7 New methods are needed to improve the efficiency of critical care service delivery and increase the number of critically ill patients that can be managed around-the-clock per each intensivist. Recent innovations have the potential to improve the

efficiency of care for patients in the ICU. These include the electronic medical record (EMR), computerized physician order entry, and use of standardized proto- cols.8,9 Another technological development with potential for improving care is the use of telemedicine that can remotely provide care to critically ill patients located in community hospitals.10

Military traumas systems have improved their clinical performance mainly by using evidence-based practice guidelines and telemedicine under the umbrella of a large trauma system.11 Evidence-based guidelines have reduced the variation in clinical practice in military trauma, and

http://dx.doi.org/10.1016/j.jamcollsurg.2014.04.015

ISSN 1072-7515/14

Abbreviations and Acronyms

CMI ¼ case mix index EMR ¼ electronic medical record FHS ¼ Fairview Health System MICU ¼ medical ICU SICU ¼ surgical ICU UMMC ¼ University of Minnesota Medical Center

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telemedicine allows the providers to discuss their patients across the continuum of care.11 Trauma patients are trans- ferred within the trauma system from the battlefield to the tertiary hospital when necessary to escalate their care. Civilian hospitals are increasingly organized in verti- cally integrated systems to improve care but also to align with economic and regulatory incentives to reduce health care costs.12

The Fairview Health System (FHS), like many others, has increasingly moved toward a stronger interaction be- tween hospitals of the system to improve economies of scale and to share lessons learned about best practices in patient care and other areas. As the ICUs of the FHS became increasingly busy, and as more patients were cared for by one group of intensivists, both administrators and intensivists believed that there were considerable ben- efits to be gained by efforts to more effectively use the ICU resources across the system. Using the example of the US Military Joint Theater Trauma System,13 in which patients are cared for within one system across 3 conti- nents, we sought to set up, although on a much smaller scale, an ICU program to provide needed patient care at the appropriate level across the FHS. This program included components that allowed appropriate optimiza- tion and standardization of patient care through multidis- ciplinary team efforts. We will describe its components.

METHODS

Critical Care Program hospitals

The Fairview Critical Care Program includes 5 hospitals and 7 ICUs in FHS. Fairview operates 7 hospitals in

Table 1. Characteristics of Fairview System Intensive Care Un

Hospital ICU beds, n Da

UMMC-E 52 Daytime acad

UMMC-W 6 Nurse practit

Lakes 10 Hospitalist þ Northland 4 Hospitalist þ Ridges 12 Hospitalist þ Southdale 22 Intensivist þ UMMC-E, East bank campus of University of Minnesota Medical Center (m Medical Center.

Minnesota with 22,000 employees, 74,649 acute care admissions in 2012, and annual revenue of $3.22 billion. The hospitals of the program are Lakes, Northland, Ridges, Southdale, and the East and West bank campuses of University of Minnesota Medical Center (UMMC-E and UMMC-W). The UMMC-E is the primary teaching hospital of the University of Minnesota Medical School and is operated by Fairview and administratively linked with the UMMC-W. The hospital characteristics are in Table 1 and the components of the Fairview Critical Care Program are summarized in Table 2.

History of Critical Care Program development to current state

For many years, the ICUs of FHS, apart from those in UMMC-E, functioned without fellowship-trained inten- sivists. Fairview-employed hospitalists and private prac- tice internal medicine, general surgery, or subspecialty physicians managed ICU patients. At UMMC-E, medical ICU (MICU) and surgical ICU (SICU) were staffed by traditional academic teams including medical students, residents, and fellows and were led by a faculty attending during the day. At night, residents managed ICU patients with fellows or attendings taking call from home and coming to the hospital if needed. In 2008, Southdale Hospital contracted with University of Minnesota Physi- cians (ie, a faculty practice plan of the Medical School) to provide dedicated intensivist services from 7 AM to 11 PM with intensivist call from home after 11 PM with rapid ability to return to the ICU to deliver face-to-face care if needed. Hospitalists are also available to provide care for emergencies. In 2009, Ridges Hospital contracted with University of Minnesota Physicians to provide on- site intensivist services for 4 hours in the morning and 24-hour availability by phone and return when needed. All intensivists were full-time faculty from the Depart- ments of Medicine and Surgery at University of Minne- sota with fellowship training in medical or surgical critical care. In 2011, all FHS hospitals started using a common EMR (Epic). In October of 2011, an in-house

its

ytime care model Nighttime care model

emic intensivist þ trainees On-site intensivist ioner þ intensivist Tele-ICU open ICU Tele-ICU

open ICU Tele-ICU

Intensivist Tele-ICU

open ICU Tele-ICU

ain hospital); UMMC-W, West bank campus of University of Minnesota

Table 2. Components of the Fairview Critical Care Program

Component Roles/representation

Critical Care Program leadership Medical director of the Fairview ICU system, medical and nursing directors of tele-ICU, nursing directors of medical ICU and surgical ICU at UMMC-E and project manager

Physician leadership group Chiefs of Divisions of pulmonary and critical care and surgical critical care at UMMC, directors of ICUs from all hospitals

Steering committee Critical Care Program leadership, CNOs from all hospitals, presidents of Southdale and UMMC-E, VP nursing of UMMC-E, medical directors of medical ICU and surgical ICU at UMMC-E

ICU physician group Peer review, practice issues, guidelines, break down specialty barriers

Tele-ICU Active patient monitoring at all sites, data gathering for PI, nurse, and physician education, “eyes on ground”

Medical informatics Quality measures, technology management (eg, Epic, cameras, computer issues)

Critical Care Program working group Multidisciplinary, multisite working group, data sharing, PI, protocol, and order set development and implementation

Research and education ICU for hospitalist course, anesthesia rotations, pulmonary and surgical critical care fellowship programs, funded ICU research

CNO, chief nursing officer; PI, performance improvement; UMMC, University of Minnesota Medical Center; UMMC-E, East bank campus of University of Minnesota Medical Center (main hospital); VP, Vice President.

678 Fortis et al Health System-Based Critical Care Program J Am Coll Surg

intensivist service, staffed by faculty alternating every week between the 2 departments, began serving as the admitting attending for both MICU and SICU at UMMC-E from 6 PM to 7 AM. The need for intensivist direction in the other ICUs

within Fairview, especially at night, became apparent. At that time, the two options were to contract for tele- ICU coverage from an out-of-state vendor or build our own tele-ICU program. To reduce the per-bed tele- ICU cost to the remote hospitals, at the end of 2011, the nighttime intensivist at UMMC-E started serving as the tele-intensivist using a newly built tele-ICU hub. Costs to the remote ICUs were lowered because 66% of the nighttime intensivist compensation is paid by UMMC-E and the program did not have to use a com- mercial tele-ICU care management program in addition to the existing EMR, thereby avoiding licensing fees. All critical care providers have educational responsibil-

ities at UMMC through residency or fellowship programs and many of them work at the bedside in 2 or 3 of the Fairview ICUs. They also share nighttime ICU duties at UMMC-E and tele-ICU responsibilities. Combining the staff of the departments reduces the nighttime call commitments to 1 to 3 in-house nights per month and 2 nights per month taking call from home with availabil- ity to come to the bedside at Southdale or Ridges for new admissions or for issues requiring direct intensivist presence.

Critical Care Program leadership

The medical director of the Fairview ICU system, the medical and nursing directors of the tele-ICU, the

nursing directors of MICU and SICU at UMMC-E, and the project manager of the Fairview Critical Care program meet twice a month. The ICU leadership com- municates with the individual ICUs and reports to the hospital and system leadership group.

Physician leadership group

The ICU leadership meets every 3 months with the physi- cian leadership from all the hospitals (Division Chiefs of pulmonary and critical care and acute care surgery/critical care at UMMC and ICU directors from all hospitals) to discuss the practice of critical care medicine, staff, and contract issues.

Steering committee

The ICU leadership brings issues for discussion to the steering committee, which meets every 3 months. Hospi- tal and system executives and ICU leadership constitute the steering committee (Table 2), which is responsible for the management of financial aspects and approves the decisions of ICU system leadership.

Intensive care unit physician group

The ICU physician group is composed of academic phy- sicians from the Departments of Anesthesiology (n ¼ 1), Medicine (n ¼ 21), and Surgery (n ¼ 10) in the Medical School and convenes every other month. The goal of this group is to minimize differences in clinical practice by adopting common diagnostic and treatment protocols. This is especially important as the training history and clinical practice of medical and surgical intensivists can result in different approaches to clinical problems that

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could confuse the users of the tele-ICU program. They also share their expertise to optimize protocols.

Critical Care Program working group

The meeting site for this group rotates among all the tele- ICU hospitals to facilitate face-to-face communication and to gain familiarity with the physical layout of the monitored ICUs. To improve and standardize critical care practice throughout the system, ICU leadership as- signs tasks to multidisciplinary working groups composed of physicians, nurses, pharmacists, nutritionists, and administrative employees from the hospitals. Topics have included standardizing vasoactive medication dosing, glucose control, mechanical ventilation bundle, sedation protocols, pain assessment, and ICU admission order sets. The group regularly monitors “customer satis- faction” by surveying the medical and nursing staff that interacts with the tele-ICU program.

Tele-intensive care unit program

The cornerstone of our Critical Care Program is the tele- ICU, which provides support to the ICUs of 5 Fairview hospitals, but not for UMMC-E ICUs (Table 1). The tele-ICU command center (hub) is a 444-square foot room located adjacent to the SICU at UMMC-E. A tele-ICU registered nurse (tele-RN) is in the hub 24 hours per day and does not have bedside patient care re- sponsibilities when in the hub. All tele-RNs maintain active bedside ICU practice at other times. The main duties of tele-RNs are patient monitoring every 2 or 4 hours, depending on severity of illness, updating patient lists, and phone call assistance for nursing issues or triag- ing to tele-intensivists for medical issues. Because of lower patient care needs during the daytime, the tele-RN also has quality-improvement duties, such as abstracting compliance data from the EMR as requested by the work- ing group. The tele-intensivists are full-time faculty in the Medical

School and have ongoing bedside critical care practices at the ICUs within FHS. The daytime tele-intensivist is either the MICU or SICU attending, who is also leading the traditional fellow-resident-student team. Because there is an on-site intensivist for all the ICUs except two (Lakes and Northland), the tele-intensivist work load is low during the day, allowing the MICU or SICU attending to have this dual role. At night, the intensivist also has two roles: admitting and attending physician for both MICU and SICU (assisted by over- night medical or surgical residents with fellows taking call from home) and tele-intensivist for the rest of the sys- tem’s critical care beds. Based on a work-frequency anal- ysis we performed for 2 weeks in 2013, the UMMC-E

and tele-ICU time commitment is split about equally throughout the night. The tele-intensivist has permission for full “treatment authority” for all patients in the moni- tored ICUs and can call the at-home intensivist to come to the bedside for issues that cannot be managed remotely. Mechanisms for provision of needed services (eg, intubation, central-line placement) vary between each site. We have identified mechanisms to provide these services 24 hours daily. The back-up intensivist can be physically present for unstable patients and new ICU admissions.

Medical informatics

An important element of the Critical Care Program is the common EMR (Epic), which allows immediate access to vital signs, flow sheets, medication lists, laboratory results, and radiology images in the same EMR that clinicians use during bedside care and ambulatory care. We created a tele-ICU module within Epic that aggregates patients from all the Fairview ICUs (except for UMMC-E ICUs) into a single patient list with flow sheets that have simple “one-click” buttons indicating when a tele- ICU patient was reviewed and which interventions were performed. There is also a free-text progress note section that is prominently titled as “Tele-ICU” so the daytime clinicians can read about patient care issues overnight and the interventions made by the tele-ICU. Fifty-four ICU rooms have moveable and zoom-

capable cameras (Video Guidance) controlled from the hub. When the video system is on, the patient’s television monitor displays a video image of the tele-ICU clinicians, allowing two-way video and audio conversation between the tele-ICU and patients, family, or bedside nurses. Real-time ECG telemetry, blood pressure, respiratory rate, and oxygen saturation are also displayed in the tele-ICU hub (SpaceLabs monitors) with capability to re- view ECG recordings for up to 24 hours in the past. Tele- ICU staff use 3 Epic workstations, 2 monitors for viewing patient rooms remotely, and 1 high-resolution radiology monitor.

Education and research

Apart from sharing clinical responsibilities, the Depart- ments of Medicine and Surgery organize education activ- ities, such as critical care fellowship rotations and the combined monthly medicine-surgery critical care confer- ence for staff, fellows, residents, and students. Our Crit- ical Care Program also provides education for clinicians outside of the departments. In the last 2 years, >50 prac- titioners have participated in a 4- or 5-day “Critical Care for the Hospitalist” course. In addition, for the last 12 years, there has been a joint, 1- or 2-day, annual

Table 3. Mean Daily Census and Total Patient Days per Year Monitored by the Tele-Intensive Care Unit Physician in 2012

Hospitals Mean ICU census, n

Total patient-days per year

Tele-ICU (off-site) 32.64 16,973

Northland 1.46 865

Lakes 4.32 2,413

Ridges 8.48 4,654

Southdale 15.97 7,705

UMMC-W 2.4 1,336

UMMC (on-site) 36.81 17,433

Total 69.44 34,406

UMMC, University of Minnesota Medical Center (main hospital); UMMC-W, west part of University of Minnesota Medical Center.

Table 4. Capital and Annual Operational Cost of Tele- Intensive Care Unit

Cost, $

Capital cost

Spacelab monitors (vitals, ECG, etc) 323,000

Facilities (build out of the hub) 290,000

Cisco systems for the hub (cameras in the hub) 4,000

Computer monitors (hub) 8,000

Video guidance charges (set up, maintenance) 1,277

Video guidance 54 cameras in ICU rooms 414,456

Network costs 144,000

Imaging computers 1,487

Total 1,186,220

Total cost per ICU bed 21,967

Operational annual cost

Tele-ICU nurse 550,200

Intensivist* 547,675

Administrative cost 152,237

Total 1,250,112

Total cost per ICU bed 23,150

*The tele-intensivist cost was subsidized by 66% from medical ICU and surgical ICU for on-site service at the East bank campus of University of Minnesota Medical Center (main hospital). Tele-ICU nurse is in the tele- ICU hub 24 hours per day.

Table 5. Patient Outcomes Across Fairview Intensive Care Units

Outcomes 2011 2012 p Value

ICU admissions, n 6,063 6,097

Age, y, mean � SD 58.1 � 19.2 58.2 � 19.7 0.9774 Female, n (%) 2,876 (47.4) 2,894 (47.5) 0.6258

CMI � SD 5.69 � 6.1 5.89 � 6.01 0.0559 Death, n (%) 394 (6.5) 299 (4.9) 0.0002

ICU readmissions, n (%) 54 (0.89) 29 (0.49) 0.0064

CMI, case mix index.

680 Fortis et al Health System-Based Critical Care Program J Am Coll Surg

continuing medical education course that includes pre- sentations of relevance to a multidisciplinary group. The goal of these educational activities is to improve the care of critically ill patients within Fairview or other hospital systems that have hospitalists who care for ICU patients. In addition, the Critical Care Program funds 4 research projects per year ($15,000 to $20,000 each) sub- mitted by the intensivist faculty via a competitive grant process. Although, our objective is mainly to provide informa-

tion about how we built our health systemewide Critical Care Program, we reviewed administrative data of FHS to investigated whether our intervention improves outcomes across the health system.

Data analysis

We retrospectively reviewed the hospitals’ administrative database from January 2011 to December of 2012, including mean census, number of transfers, age, sex, case mix index (CMI), mortality and readmissions. Case mix index is a measure of patient acuity based on diagnosis-related group and hospital characteristics (eg, diversity of populations, hospital facilities, etc).14

Diagnosis-related group is determined by patient charac- teristics, comorbidities, and diagnoses.15 We also reviewed financial data of our tele-ICU. Continuous or scale vari- ables were compared using Student’s t-test. Categorical or nominal variables were compared using chi-square. A p value <0.05 was considered statistically significant.

RESULTS In 2012, the Fairview Critical Care program had 52 ICU beds at UMMC-E and 54 tele-ICU beds remotely (Table 1). Mean midnight census for the entire program was 69.44 and total patient-days were 34,406 (Table 3). Mean daily census of the tele-ICU program only was

32.64 patients and the total number of patient-days was 16,973. The capital cost of the tele-ICU was $1,186,220

(Table 4). The annual operational cost is $1,250,112 or $23,150 per monitored ICU-bed. The annual cost of the tele-ICU nurses is $550,200. Sixty-six percent of the cost of the tele-intensivist is paid by UMMC-E for providing in-house service, which reduces the cost for the remote hospitals for the tele-ICU physicians to $547,675 (Table 4). The ICU mortality and 48-hour readmission rates were

slightly lower in 2013 compared with 2012, although the acuity of the patients was similar, as reflected by CMI (Table 5). Two hundred and thirty-three critically ill pa- tients from Fairview hospitals were transferred in 2012.

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One hundred and ninety-five (84%) were transferred to another ICU within our system and 38 (16%) were trans- ferred for medical care in facilities outside of Fairview.

DISCUSSION This study describes the development and operational de- tails of a health care system level ICU program patterned off the much larger Military Joint Theater Trauma Sys- tem.13 To our knowledge, it is one of the few studies that provide details about the structure and the operation of ICUs at a health system level.16

Our system-wide ICU program has led to standardiza- tion of some aspects of critical care in the Fairview sys- tem. Traditionally, the decisions at a system level affect financial and organization issues, and critical care service are organized at an ICU level by the ICU directors. Here, ICU leadership participates in strategic decisions about the entire critical care service of the system. This kind of multidisciplinary approach to critical care is known to be beneficial at a hospital level.16 In addition, because all of the intensivists are in the same physician practice group and medical school, there is greater ability to adopt common critical care protocols or order sets,16 which de- creases unnecessary variation. This is not a one-way pro- cess originating only from the University hospital; UMMC-E has adopted protocols and practice standards that started in the community hospitals. Our novel Critical Care program is based on the pres-

ence of an intensivist at UMMC-E around-the-clock who also serves as the tele-ICU physician. This dual-role model would not be feasible if there were so much tele- ICU work that direct patient care was neglected or vice versa. Covering approximately 36 ICU patients at UMMC-E (with house-staff assistance) and 32 ICU pa- tients remotely makes for a balanced and busy 13-hour nighttime shift. Although the benefit of a nocturnal intensivist is

controversial,1,4,17 at UMMC-E, the severity of illness is high and there are no medicine or surgery critical care fel- lows in house overnight. Around-the-clock intensivist presence is the care model in many ICUs in the United States18 and Europe,19 and is recommended by the Society of Critical Care Medicine.6 To avoid intensivist burn out, ICU physicians from Medicine, Surgery, and Anesthesi- ology joined together to share nighttime work. Other au- thorities have reported the same approach to increase the staff of intensivists.16

Telemedicine can provide care to remote critically ill patients around the clock, thereby fulfilling the intent of the Society of Critical Care Medicine’s vision to have intensivist input into the care of critically ill patients

anywhere. Many ICUs in the United States do not have on-site intensivist assistance currently and many never will for various reasons. Telemedicine allows an intensiv- ist to review information for remote patients in the same format (ie, vitals, laboratory tests, and imaging through EMR) as if she/he were at the bedside and provide critical care through on-site provider such as staff nurses, hospi- talists, or other advanced practice providers. Some reports show that tele-ICU programs decrease

mortality and improve outcomes,10,20-24 and others have not shown a benefit.25 It is possible that the beneficial ef- fects of tele-ICU are related to the extent that the tele- ICU clinician is permitted to actually make changes in care for a patient in a monitored ICU.23,26 In the Fairview system, the tele-ICU staff is given full authority for pa- tient care by the remote sites, including medication order entry or having on-site providers perform emergency pro- cedures, such as endotracheal intubation. This authority was granted in part because the majority of tele- intensivists also maintain a bedside practice in several ICUs of the system9 and therefore have a face-to-face pro- fessional relationship with the clinicians that use the tele- ICU program. Additionally, the ICU leadership visits all hospitals served by the ICU program on a routine basis to ensure that issues are addressed in a timely fashion. A financially sustainable stand-alone tele-ICU program

is only possible when the tele-ICU monitors a large num- ber of tele-ICU beds, which might explain why many tele-ICU programs include >100 beds.27 Our program demonstrates that a smaller tele-ICU program can be sustained with low “per-monitored bed” charges to the remote facilities, if all the ICUs use the same existing EMR technology and if the cost of the tele-ICU physician is defrayed by professional fee revenue doing face-to-face ICU care at the hub hospital and also doing tele-ICU. Costs are reduced even more by avoiding licensing fees required to install a separate tele-ICU care management software program. Payment for professional work by the intensivist staff is

currently reimbursed only when provided directly at the bedside, therefore, the tele-ICU work is not reimbursed. However, indirect financial benefits, such as increased revenue from a higher CMI score; improved efficiency outcomes from 24-hour intensivist availability, and abil- ity to keep ICU patients in their local hospital (where costs are lower than in the teaching hospital to where the patient would be transferred) helps compensate for lack of reimbursement. The capital cost of a tele-ICU command center ranges

between $2,000,000 and $6,000,000.28 Fairview’s costs were $1,186,220. A recent meta-analysis reported that the estimated combined implementation and first-year

682 Fortis et al Health System-Based Critical Care Program J Am Coll Surg

operation cost per tele-ICU bed ranges between $50,000 and $100,000.29 The authors of this meta-analysis suggest that these data are of ambiguous validity due to the low quality of the accounting methodology. The investigators also reviewed data from Veterans Affairs hospitals and estimated a combined capital and first-year operational cost from $70,000 to $87,000 per tele-ICU bed. The Fairview combined implementation and first-year opera- tional cost was $45,117 and the annual operational cost for one tele-ICU bed was only $23,150. Although this study objective was not to demonstrate

that the Fairview critical care and tele-ICU program im- proves the care of critically ill patients but rather to provide information about implementation of a system-wide pro- gram, the outcomes data support its functionality. Despite the acuity of the patients admitted in 2012 being similar or higher than those admitted in 2011 based on CMI, ICU mortality was significantly lower in 2012 after tele-ICU implementation. We observed similar findings in ICU readmission rates. Eight-three percent of ICU transfers in 2012 were able to be managed within the Fair- view ICU system. However, we cannot conclude with cer- tainty that our intervention leads to reduction of mortality or other outcomes for several reasons. First, the interven- tion is a continuous process; it is still in progress and is composed of many smaller interventions.30 Second, the implementations of our system-based ICU program can affect the triage and selection of patients. For example, tele-ICU availability might have led to more judicious de- cisions about which patient can benefit from ICU. This might have been the reason that previous studies have shown a reduction in ICU but not hospital mortality.21

In addition, the improved outcomes might reflect a Haw- thorne effect.31 The ICU staff might have improved their productivity because of the implementation of the Critical Care Program, and the intervention itself has no effect on outcomes. Although, this is less likely because our inter- vention took place gradually, such a possibility cannot be excluded entirely. This does not undermine the impor- tance of our report, which describes how we built a health systemelevel Critical Care Program. Our Critical Care Program has also created a framework

that allows academic physician faculty to work closely with community ICUs and understand their patient problems. This is important because most patient-level ICU research take place in large academic centers only.32

Our study has several limitations. Although the pa- tients admitted in 2011 had CMIs similar to those admitted in 2012, mortality was not adjusted for initial severity of illness. We also did not provide outcomes data, such as ICU length of stay, need for mechanical ventilation, or transfers, for 2011, as they are not available

in the administrative database. Another limitation is that the complexity of the ICU system intervention makes it difficult to causally link one intervention to one discrete resultda problem that has been described previously.23,30

We also did not systematically collect data on clinical conflicts between the tele-ICU clinicians and the on-site clinicians. We did not examine whether our intervention has affected the clinical practice of different subspecialties or whether outcomes are different among the different specialists (ie, internists, surgeons, and anesthesiologist). These will be the subjects of future studies. In addition, we did not report the direct and indirect ICU patient care costs before and after the tele-ICU intervention, as those costs are not reliably assigned within the current Fairview cost accounting system.

CONCLUSIONS We describe building a health system level ICU program using “off the shelf” technology based at a University medical center and implementing a tele-ICU program with full treatment authority in all monitored ICUs. The tele-ICU is the “eyes on the ground” for the system and facilitates the Critical Care Program’s efforts to stan- dardize critical care practices across 7 ICUs. The tele-ICU business model is based on an intensivist who shares on-site and telemedicine clinical responsibilities, thereby subsidizing substantially the operational cost to the remote ICUs. Combining the faculty clinical effort of academically distinct departments into one Critical Care Program reduces nighttime work and creates new educa- tion and research opportunities.

Author Contributions

Study conception and design: Weinert, Beilman Acquisition of data: Fortis, Weinert, Bushinski, Koehler, Beilman

Analysis and interpretation of data: Fortis, Weinert, Beilman

Drafting of manuscript: Fortis, Weinert, Beilman Critical revision: Fortis, Weinert, Beilman

Acknowledgment: The authors are indebted to Jeff Wood for data acquisition support.

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