A partnership between Emory Healthcare in Georgia and the Royal Perth Hospital in Australia is using technology to move night intensive care work into daylight hours. Delivering healthcare from the other side of the world.

No beds, no drip stand, no privacy curtain, no smell of disinfectant or machines constantly beeping. Welcome to the Emory Electronic Intensive Care Unit (eICU) Center in Atlanta, Georgia. This is the physician office building outside the hospital. But at any given time, the medical staff working here are taking care of at least 160 remotely situated patients from different hospitals, all of whom require continuous monitoring to prevent deterioration
or organ failure. The revolutionary system, developed by Cheryl Hiddleson, director of the Emory eICU Center and Dr Timothy Buchman, Medical Director of the eICU service of Emory Healthcare, allows Emory physicians and nurses to deliver care from the other side of the globe by working in daylight hours in Australia to cover night-time hours in Atlanta.  Most eICUs operate on a hub-and-spoke model. The hub refers to a central location containing many workstations that are staffed to serve several hospitals. In these workstations,
medical staff face monitors hosting information coming from patients’ bedsides in the ward as well as details obtained from the electronic medical records (EMRs).

At Emory, this data is multi-varied, with about 200 features ranging from test results, radiographs and electrocardiograms, to the uninterrupted flow of vital signs such as blood pressure and heart rate. The data is fed into a system with algorithms alerting the staff, should any patient deviate from the expected trajectory. Conversely, the spoke is a respective hospital in which each patient’s room is equipped with a camera, a monitor, a speaker and a microphone. At the click of a button, staff in the hub will be able to see the patient and talk to their family or caregivers.

At its core, eICU is the incorporation of telemedicine into critical care, which can be regarded as an additional layer to what the patients are already receiving in the ward. But Buchman and Hiddleson had the vision to turn night into day. By placing healthcare providers in a time zone with a 12-hour time difference, the providers come to work in Perth, Australia at 7am but cover the night shift remotely in Emory Healthcare ICUs in Atlanta beginning at 7pm. The time change transforms the experience for healthcare providers working at night, reversing two of the largest drawbacks of critical care night staffing: a shortage of senior clinicians willing to cover the night shifts and the toll that working nights takes on caregivers and their attention levels. “A typical ICU accounts for 15% of hospital beds and 30% of the costs in the US,” says Dr Buchman. “It is inevitably a high risk and high value part of medical services.” Yet, the country is facing a dangerous shortage of intensive care unit-trained medical staff. The majority of the experienced workforce are reaching retirement age and aren’t being replaced by younger staff. This shortage of manpower is aggravated by an ageing population. “As many as 10,000 Americans are turning 65 every day,” Dr Buchman warns.

“So it won’t be long before critical care services experience significantly increased pressures.” To overcome the increasing scarcity of intensive care unit-trained, training programmes are helping to turn practitioners into advanced practice providers. Technology and telemedicine is also helping to cope with demand by reallocating some of the tasks normally required by onsite clinical staff, so that physicians and nurses in the ICU itself, can be used to best advantage. However, this still doesn’t spare medical staff from having to cover night, weekend and holiday shifts, especially in an ICU where surveillance and continuous expertise are mandatory. Indeed, Dr Buchman worked 185 nights in the first year that the Emory eICU center opened – sometimes for up to 18 nights in a row without day duties. That was when Buchman and Hiddleson decided to implement a wider support system to prevent staff fatigue and sent a medical team over to Australia.

In 2016, the concept was tested during a six month trial in Sydney, Australia. Sydney, one of the largest Australian cities, is 14-16 hours ahead of Atlanta, depending on the season. Utilising the time difference, Dr Buchman stationed some of Emory’s staff there to provide night coverage during the daytime hours in Australia. “The benefits were immense, for both provider and patient,” says Buchman. “The providers worked more efficiently and felt better because they were working during daylight hours in Australia, reducing burnout and keeping more professionals satisfied in the critical care medicine field. Patients benefitted from the project by having focused, around-the-clock management of care, both during day and night hours.” The experimental concept proved so successful that the team of staff was eventually moved to Perth, where there is a 12 to 13-hour time difference, to better suit the night shift hours in Atlanta. Dr Buchman and Hiddleson were careful to reassure the Australia Medical Association and Australia Nursing Association that the project would only involve patients in Atlanta. “I want to be very clear. We are only providing care to our own patients,” says Hiddleson. “We don’t have Australian physicians providing care to our patients and we are not providing care to Australian patients.” Recently, the Emory eICU Center has also ventured into the use of machine learning (ML) to reduce alarm fatigue in the ICU. According to Dr Buchman, there is often a tidal wave of alerts and alarms in critical care units which can overwhelm medical staff.

In addition, recent years has also seen a huge increase in the amount of data streaming into the ICU system. ML is thus employed to create real-time classifiers that give early insights on the outcomes of the patients. Known as ‘DeepAISE’, the algorithm allows medical staff to work over the time horizon; to be four, six, eight or even 12 hours ahead in time, to identify patients who are showing the earliest signs of having sepsis, long before physicians notice something is not right about a particular patient. The tool also has the potential to detect other types of deterioration like impending respiratory failure. “Care providers know that they cannot be at the bedside all the time because there could be different emergencies occurring at once,” explains Hiddleson. “So, if they know that they are being supported by a technology like this, it will decrease the level of stress and burnout while they are caring for patients.”

Deep AISE received close to $700,000 funding at the start of the year from DRIVe, part of the US Department of Health and Human Services, to “accelerate the development of availability of transformative technologies”. So, both Dr Buchman and Hiddleson are positive about the benefits that DeepAISE or new technologies can bring to eICU. “I believe that any tool that is developed in healthcare specifically, using AI or advanced analytics, is going to be aimed at increasing quality and saving patients’ lives,” says Hiddleson.

“AI has already brought significant advantages to many areas of our lives. It’s now poised to do that in medicine and healthcare with technology bringing huge benefits for the patient.”