How a Not-So-New Concept Buoyed Mayo, Advocate Aurora Amid a Crisis

Virtual care has helped health systems solve a myriad of problems during surges of the COVID-19 pandemic. Not only did digital healthcare help organizations care for patients outside their hospitals, but it also helped enhance critical care within the four walls of their facilities.

About 13 percent of hospitalized COVID-19 patients were admitted to an ICU during the Omicron period, according to the Centers for Disease Control and Prevention. Though this percentage was lower than the ICU admission rate in winter 2020–21 (18.2 percent) and the Delta variant (17.5 percent) periods overall, the Omicron wave still strained US health systems. 

Health systems with established electronic intensive care unit programs were able to support severely ill patients despite shrinking resources and financial pressures resulting from the different phases of the pandemic.

"[Our eICU service] has played a major role in Mayo Clinic's response to the COVID-19 pandemic," said Prathibha Varkey, MBBS, president of Mayo Clinic Health System, in an email. "Connections were quickly stood up to support ICUs across Mayo Clinic that were reaching capacity."

eICUs allowed health systems to both provide specialized critical care to patients wherever they were in the facility and support overworked care teams as cases surged.

Establishing electronic ICUs

Electronic or tele-ICUs are by no means a new concept. Advocate Health Care, now Advocate Aurora Health, set up its tele-ICU program in 2003.

"We were actually the second site in the country to have a formal tele-ICU program," said Michael Ries, MD, medical director of the tele-critical care program at Advocate Aurora Health. "And initially, there wasn't much known about the tele-ICU program. It was just a concept, and leadership felt that when they heard about the program, they felt that it could improve clinical outcomes, decrease mortality, decrease length of stay, and reduce costs."

At the onset of the program, the health system set up a camera and audio system at every ICU bed. As the system grew, it brought in mobile carts with cameras and audio systems that could be rolled over to patient beds, even outside the ICU.

"That served us a great benefit during COVID because during the COVID pandemic, especially in 2020, we increased the number of ICU beds in our system by 400 beds," Ries said. "Now, obviously, we couldn't put cameras in every one of those, but we have mobile carts, and we created workflows."

Like Advocate Aurora Health, Mayo Clinic's eICU service, dubbed Enhanced Critical Care, has been operating for years. It was established nearly a decade ago in 2013 and provides Mayo Clinic Health System's 16 hospitals 24/7 access to a Rochester, Minnesota-based team of specialized critical care physicians, advanced practice providers, and registered nurses, Varkey said.

"An integrated medical record and additional specialized software allows the Enhanced Critical Care team to identify the sickest and most acute patients, and then high-fidelity audio-visual equipment is used for real-time interactions with patients, their families, and bedside care teams," she said.

Over the years, Mayo Clinic has also shifted from installing cameras and audio equipment at every ICU bed to mobile carts.

When establishing its e-ICU, Mayo Clinic worked closely with on-site staff at its 16 hospitals both in the lead-up to the launch and the months following to ensure strong working relationships.

"Enhanced Critical Care experts partnered with local champions and listened to concerns shared by nurses, providers, and local administrators," Varkey said. "The time spent listening and learning about concerns from the staff at these hospitals paid dividends."

Benefits of e-ICUs during COVID

The Enhanced Critical Care service helped standardize intensive care across Mayo Clinic hospitals, which helped as the facilities became overwhelmed with COVID-19 cases. During surges, hospitals had to set up temporary units for critical care as demand rose dramatically.

"When critical care services couldn’t be isolated to one unit, the fully equipped mobile carts helped ensure patients were getting the right level of care, no matter their location in the hospital," Varkey said.

Advocate Aurora Health used its mobile carts to offer critical care in other units, like the medical-surgical unit and emergency department, during coronavirus spikes, including the most recent Omicron wave.

"Our emergency departments just got overwhelmed with patients, and we had at times over 150 patients in the emergency department waiting for a bed," Ries said.

The health system began deploying its e-ICU mobile carts to the EDs and had its tele-critical care team consult and care for those patients while waiting for ICU beds to open. The team estimated that about 25 percent of patients improved and didn't end up needing an ICU bed.

"So I think…that the whole purpose of tele-critical care is what can you do to provide better care to the patients throughout the hospital?" Ries said. "What can you do to offload some of the work from the bedside physicians, the bedside nurses, the bedside respiratory therapists?"

The pandemic was marked by healthcare worker shortages, with some getting infected with COVID-19 and others leaving the healthcare system entirely due to stress. Additionally, nurses increasingly left full-time jobs at health systems to become travel nurses, mainly for the higher pay.  

Amid this scarcity, the e-ICU program helped provide specialized critical care across the health system without straining those already overwhelmed with the demand for care, Ries said.

For example, Advocate Aurora Heath virtually connected respiratory therapists to support rounding on patients who were on ventilators, thereby alleviating on-site respiratory therapists.

As a result, the health system decreased patient length of stay and days spent on ventilators, which resulted in cost savings and fewer adverse events.

"We [also] found that with tele-critical care, we reduced claims and medical liability because you now have an extra set of eyes and ears watching every patient in the ICU," Ries said.

Not only did e-ICUs help health systems support staff within their organizations, but it also enabled them to extend help to overwhelmed systems in other parts of the country.

In the early months of the pandemic, when New York City faced massive numbers of COVID-19 cases, Mayo Clinic's Enhanced Critical Care service supported clinical care teams at Columbia Presbyterian Hospital, according to Varkey.

"For three weeks, Mayo Clinic critical care experts volunteered to provide their expertise and moral support as they made rounds with the local providers caring for an overwhelming number of patients on ventilators," she said.

New focus for e-ICUs

As COVID-19 cases decline, health systems are thinking about other ways to use the e-ICU model to enhance clinical care.

For example, Advocate Aurora Health is leveraging its e-ICU program to target sepsis. The health system had created an early warning alert for sepsis with its EMR, and it is now bringing that alert to its e-ICU systems across 25 hospitals, Ries said.

The alert prompts physicians to check on the patient, enabling them to identify sepsis earlier and start treating it earlier.

"Just within three months, the number of patients who died went down significantly, almost to zero," Ries said. "The number of patients who needed to be transferred to the ICU went down, the length of stay went down, the cost for these patients went down, and when the patients were ready for discharge, more patients could be discharged home than to nursing homes and skilled nursing facilities because they didn't get as sick."

Mayo Clinic also has several plans to grow its e-ICU service, including by building connections with medical-surgical units, researching and investing in mobile solutions, and developing workflows for tele-critical care expertise.

"There is already support for the development of a Mayo Clinic-owned multi-patient viewer to allow patient oversight not only on the Rochester campuses but also across Midwest," Varkey said. "This technology will help create a logistics center for the Mayo Clinic Critical Care practice in the Midwest."

Though telehealth and remote patient monitoring services will continue to grow and evolve, health systems can lean on tried-and-true concepts like the e-ICU to help them face unprecedented crises.    

"Tele-critical care is here to stay forever," Ries said.