Founded in 1995, Health First is Central Florida's only fully integrated delivery network (IDN) and employs over 9,000 associates. It operates four hospitals, encompassing more than 1,000 beds―Health First's Cape Canaveral Hospital, Holmes Regional Medical Center, Palm Bay Hospital and Viera Hospital—which led to the system becoming an early adopter of a centralized approach to care. Linda Castelli, Supervisor, Centralized Patient Logistics and Luann Tirelli, RN, MHA, MSN, CCRN-E, NHCE, Director, VitalWatch eICU Operations share how Health First has continued to evolve their centralized approach to care.
Supervisor, Centralized Patient Logistics
Linda joined Health First in 1998 as a Registration Counselor at Holmes Regional Medical Center. Linda was promoted to Bed Control Lead in September 1999. Bed Control and the Transfer Center were combined in May of 2007, and she was awarded the new position of Supervisor, Patient Logistics. Patient Logistics was centralized in 2009 and she is responsible for patient placement at all four hospitals in the Health First IDN. The Patient Logistics Center was relocated to the Health First corporate location in January of 2010. Linda was involved with planning the Health First Transfer Access Center [TAC] to include all aspects of transferring patients within the system as well as to and from outside facilities/systems―which includes adding a Centralized Registration team to support the TAC and all centralized registration functions.
Director, VitalWatch eICU Operations
Luann is a multi-talented Registered Nurse with 37 years of critical care experience―35 of which have included administrative, teaching, and leadership responsibilities. Ms. Tirelli is currently the Director of Operations for the VitalWatch eICU®. Luann also has extensive experience with telemedicine services as well as academic involvement in continuing education having written, developed, and lectured for institution and online continuing education. Her current experience in telehealth operations include multi-factorial assessment, planning, leadership, and direction of tele-ICU services while enhancing cohesive critical care management throughout Health First.
Speaker 1: Like we're the elephant in the room. I want them as pets.
Speaker 2: I know, right? Script your answers. Just [inaudible 00:00:08].
Speaker 1: We're like, it's like a little stuffed animals.
Speaker 2: It is. It's really comfy, actually.
Interviewer: Well, welcome today. If you could both introduce yourselves and include your titles, please.
Linda Castelli: I'm Linda Castelli. I'm with Health First in Brevard County, Florida. The supervisor of centralized patient logistics and centralized registration.
Luann Tirelli: And I'm Luann Tirelli, also with Health First and I am the director of the VitalWatch eICU.
Interviewer: Great. Could you give us just a brief overview of Health First?
Linda Castelli: Well, we are a four hospital system. We have over a thousand beds. Our tertiary facility is Holmes Regional, which is the largest facility, provides the most services. That's 516 beds. The other 500 beds so are dispersed throughout the three community hospitals. And we provide everything up to a level two trauma, open heart surgery program. We do not do any type of transplants at this point. Teaching hospitals still do those, but we provide all the other services for our county.
Interviewer: Wonderful. Just to start, Health First has been an amazing early adopter of a centralized approach to care. What led to you to make that initial decision?
Linda Castelli: Funny you should ask me. I was actually in bed control. In 1998, I started. And everything was on paper. Literally if someone opened our door, all of our placement paper requests would have been all over the place. And we would have had to reorder them and reprioritize them and figure out who was what and where. We color coded each piece of paper with boys and girls and levels of care and dirty colors for the rooms. I got invited to a demo by our EVs director at the time, looking for a solution. Because the way we paged EVs was I sent a message. A little dot matrix printer printed it in another thing down the hall and then a phone got picked up. And it was just so manual and so cumbersome. So he was looking for a solution for that, saw the interaction with the bed placement and knew I was looking for a solution, invited me.
I literally walked out of the demo in the middle of it, called my director, said, "You have to come here. We have to have this". And we went live in 1999. Early 2000 is when we went live initially with the legacy version and our IT would not support it. So I ended up building a lot of the early version. And then once they saw where TeleTracking was going, we got full buy-in. We centralized. And we've just taken off with the product ever since. So yeah, we early on saw, oh, we need that bad. Even before the joint commission focused on throughput. Because we were literally, one of our vice presidents came in, sat with us and said, "If someone slams your door, we're pretty much in deep... " I said, "Yeah. We're in deep crap here." So that's what started the whole thing. And we've been coming to the client conferences since then, before we actually made the choice to purchase and ever since. And I remember coming to my second or third one and my director at the time was Mark Clemmons. He says "We're going to be presenting at these one day."
Luann Tirelli: And we presented the very next year.
Interviewer: Can you tell us, so who is in your center, your patient logistics center? What are the types of the roles in the center?
Linda Castelli: So when we first centralized, we brought registration, bed control, the transfer center, the transfer access nurses. And we also had utilization review. Utilization review, there were some shortages with, I mean, with case management at the facilities. So some of that work had to be added to where some of UR folks, so they kind of got put back out in the fields. We still have access to them, computerized, everything's electronic now. But they are no longer co-located. We still miss them because they provided a lot of help with our incoming levels of care. Making sure with the criteria that the correct beds were being used and helping with us with that utilization. eIC was already at the corporate location. That was one of the deciding factors as to moving us to corporate because we saw even back then before we realized how closely we could work with them helping us with the downgrades and making the ICU beds and utilizing our ICU beds better. So that was one of the decisions that brought us to move to that location. And now we're centralized and now they want to move us again somewhere that's more hurricane safe.
Luann Tirelli: Yeah.
Interviewer: So you're actually in a very interesting spot, right? Can you tell us about where you're located?
Linda Castelli: So we're on the Space Coast of Central Florida, which is 18 miles South of Cape Kennedy, Cape Canaveral now. I'm aging myself. Sorry. And we were first responders for the Cape, for anything that launches at any of the Cape facilities, as well as trauma level two. So we are right there in the midst of it all. That being said, we have a hospital, one of our community hospitals, is located on a barrier island. And when the wind gets just a little breezy, we have to evacuate Cape Canaveral Hospital pretty much routinely. And we just did it recently with the threat of our most recent hurricane. Using your software, two people did it in 35 minutes. It was absolutely amazing.
Luann Tirelli: What we also have at the Cape is we also have one of the busiest ports in the nation, so we see a lot of patients that present from cruise ships-
Linda Castelli: Oh, yeah. We do have-
Luann Tirelli: And they're usually very, very critical. So again, it takes the coordination of the teams to bring the patients into the system and then move them through the system.
Interviewer: Can you talk a little bit about the center that you run through the ICU?
Luann Tirelli: The eICU has always been in the corporate facility, which is where we are. Traditionally, command centers and eICUs are not within the walls of a hospital system. They are remote. And we support 102 ICU beds from the eICU. And when we started our program in 2004, we are now in our 15th year of the eICU, third in the nation to attain 15 year status. We had a pretty high length of stay in our ICUs. And working collaboratively over the years with the bedside teams with doing that patient population management that we do that links us to the command center into the TeleTracking app, we've dropped our length of stay from what used to be 4.8 days to 2.2 days at our ICUs. Which in turn has also decreased our hospital length of stays for the patients. And when you think of the length of stay, you want the people in and out of the hospital as rapidly as you can.
The heart of me, the nurse, wants these moms and dads to go home, the aunts and uncles, that get to go back to their families. And then the bean counter side, when we look at it from have we avoided costs? When we did our numbers in 2018, we were at $110 million in cost avoidance from length of stay. And using various applications such as the eICU product that we use called eCareManager and the TeleTracking app. Each day we can come in and we pull up TeleTrack and we can see, okay, our PCU beds might be a little full, but I need to also move ICU out. So we start our initiative to start downgrading PCU patients by looking at them using the clinical aspects that our team does and seeing the TeleTracking app each time we can see the movement. We can see where we can place patients. Linda and I, our teams coordinate on care. Sometimes it's not an appropriate bed assignment. Or if we have what we call a rapid response, which is a patient deteriorating on the floors. And we send out the mobile device and we see the patient visually. They may be saying that patient needs an ICU but we collaborate and we say, "No, not so much." And we find the right placement for the patient, which is what really facilitates patient flow and throughput.
Interviewer: Have you seen any changes in your patient satisfaction scores?
Luann Tirelli: Patient satisfaction scores have gone up considerably for various reasons. When we first started our EIC, we did not have a two-way communication with them. It was us seeing the patient and the family, but them not seeing us. Now we are two-way where we see each other. We collaborate with the patient on their care, which was a huge benefit to HCAHPS scores for our organization. And I think patients, they don't want to be there. No one wants to be in the hospital. We're renowned for horrible hospital food. Nobody wants to eat it. No one wants to stop their routines. They want to go home. So having that command center with the ability to move patients through the system at a quicker pace that's appropriate. And that's the key, appropriate. It has to be. That's where the benefit is.
Linda Castelli: [inaudible 00:09:05] Decreased wait times have also increased patient satisfaction in our ERs tremendously. Getting those beds assigned quicker. The patients in the ER waiting rooms feel they're being seen and taken back into an ER room quicker and not sitting in the waiting room as long. So I think a lot of those patient satisfaction increases may be all throughout the system, not even realizing that it is tumbling down from those decreased wait times and increase in services and getting those services to the patients quicker.
Interviewer: This actually kind of ties into my next question. You have had such sustained success. How did you decide which initial metrics that you wanted to tackle and then what improvements along the way did you make to achieve those goals?
Linda Castelli: Ready to move is a big a clinical indicator that we are still working through because everybody has a different understanding of ready to move. So initially we wanted to get those wait times down but now as we've been having discussions, this one says ready to move is when the doctor puts an order while this one says it's a different time. So now we're working on really getting those ready to move times more accurate and standardized across the system. So that when one ER says the patient's ready to move, it means the same as another ER's getting ready to move. So we have a lot of initial successes in decreasing the wait times. Now we're really going to drill down and get those wait times decreased even more and see exactly who's waiting for what all throughout the spectrum of the whole system. Because we were using it for pretty much everything now.
Interviewer: You talked about some metrics that you were really proud of when you presented at the command center summit on your side. Can you share some of those?
Luann Tirelli: The big three we look at usually from the eICU perspective is ICU length of stay and mortality and ventilator utilization. And we didn't really go into that at the command center summit because it really was not applicable to it because these are just, that was getting patients off of ventilator. But length of stay was a big one, which we had talked about, in addition to mortality. Right now, my 2019 fiscal year data that I closed out showed that appropriately placing patients, appropriately giving them the care they need and then moving through the system, we have 3000 lives that were saved over the course of our program. Now these were patients using the Phillips analytic tools that were predicted to pass away in our ICUs, not even in the hospital, just in the ICU. So these 3000 patients, because our team came together from every aspect of the care from the start to when we sent them home. Came together, we collaborated, they made it home where they shouldn't have.
So, I mean, that to me, it always chokes me up when say that because the heart of a nurse never change. I could be as high as I need to be in administration, but these are still our family. It's our community that you get to send home. And you see them in your day to day life. You'll see them in the grocery store. You'll see them in a shopping mall. And it's like, I remember when we took care of you. And even now when we come up on our 15 year anniversary, we had a technician on site. One of our plant ops development folk who wound up in the hospital. Did not expect to find himself in an ICU. Wound up having some emergency cardiac surgery. The camera came on and it was an eICU nurse there and he felt so comfortable because he had seen it from the inside. And he was so happy that the team was watching him.
And he knew what we do because anyone that you know comes into the CPL eICU area, we love to talk about what we do. And we love to give tours and they see it. But to be on the other side of the camera and to save that life, it's amazing. And we've been doing it for so long that our executive team sees the benefit of having us co-located and of how we do the throughput process for everyone. So much so that going back, probably about five years ago, our CEO came to me. And I was very flattered and he says, "You guys did such a great job with length of stay in the ICU." So I'm patting myself on the back and he says, "But you clogged up all our PCU or downgrade beds. Now what are you going to do?"
Linda Castelli: That's true.
Luann Tirelli: So it challenged us and the challenge was we've made this difference for our ICU population. What can we do for other populations? So then we started working on PCU length of stay and we've significantly cut that in half. And we can see that through the reporting that we get. I get TeleTracking reports sent to me. I can see times. I can see length of stay. We're proud of that and it. And it's spun off into so many different directions.
In this day and age, we all talk about 30 day readmissions. Very important. And they said, "Okay, well, you're now doing telemedicine visits with PCU populations or patients on the floor that aren't doing well. What can you do in the community?" So we looked at our nursing facilities. So we partnered with 12 of those. And we have an initiative where if you have a patient that's in a skilled nursing facility that has left one of our Health First hospitals and they're not doing well, you can call the eICU and get a telemedicine consult. So we have a head's up of what's going on with the patient and sometimes we can treat that patient on-site. We've been successful 67% of the time, but sometimes they have to come back. So then again, being co-located, we know where the beds are in the system. So the numbers are great. But at the end of the day, it's still that human factor that you have a dedicated team treating patients compassionately. And that's what makes me come to work every single day.
Interviewer: This ties in to some of what you just said, Luann. I understand that there's 200 plus reports that are sent out to key people on your team. How do you collaborate? How do you work together to set future patient flow goals? Or to make adjustments to anything that when you're looking at those reports, it's like if we need to fix that?
Luann Tirelli: I think an important aspect is benchmarking. And while Linda is definitely more TeleTracking heavy than I am, we're looking at more from a patient movement perspective and then looking, like we said, at times and things like that. So using the reports from that feature helps us. But I think being able to say what are you doing as an organization compared to a like organization or someone else around the nation that you're not a competitor of, but you're... Really, we're all on the same game of caring for people, making their lives matter and making it as easy for them. And I think having the ability to see the quality reports and to see dashboards and different formats, it unifies the playing field so that we're all on the same page.
Interviewer: I have this crazy cough I'm like trying not to cough.
Linda Castelli: I know I was trying not to cough so much. I think for us, we also use those reports in terms of how our nursing staff, we see that we need some education in the nursing staff. They don't realize the power of the tool that they have. And those reports can really show out trends of which nursing units get it and help us determine which charge nurses might have valuable information to share with our other charge nurses to get better use out of those nursing portals. Because the information that comes out of them is based on what's put in them. And if we have an ER who is so busy and they're not able to always put the isolation in, then we have to rely on those floor nurses and the floor clinical staff to get the information to us so that we're consistently using the most current information. If a patient's on isolation, we need to know it. If they're taken off, we need to know that as well and it needs to be real time. We try to turn on as many interfaces as possible, but we still need that clinician's eye looking at it to make sure that the information that they're sending us in the bed control department is accurate across the board.
Interviewer: So you've had so much success. What's next?
Linda Castelli: Well, honestly the disaster. We were just speaking about the disaster portal. We've had the recent hurricane. We've had a cruise ship incident recently with a whole bunch of sick patients or they weren't... Did they hit a wave or something? And a lot of people got hurt.
Luann Tirelli: Yes.
Linda Castelli: And they all came in-
Interviewer: I actually saw that on The Weather Channel.
Linda Castelli: Made the national news. Those two things have for me, anyway, when I get back from this conference, one of the first things I'm going to be doing is documenting all of the work we did on the disaster portal. So that the next time there's a disaster, anybody, not just me and my staff that I've trained, anybody that has access can go in and get the ball rolling if we had a disaster.
Interviewer: What are some of the key features or capabilities that really make that end useful during a disaster?
Linda Castelli: Well, we had a homegrown disaster application that no one used until there was a disaster. So the amount of time it took to train and retrain because of turnover, the disaster was over before we had enough people who knew how to use it working in the command centers. The TeleTracking module sits right on top of all the modules we already have. It looks just like everything else they're used to doing. The charge nurse clicks on it. She's like, "Oh, this looks like what I do every day." And she just went down her list and said, "This patient needed ALS. This patient needed to BLS. This patient... " And just gave us a brief clinical report.
The command center at Cape Canaveral was able to determine with the physician that was at the command center there which hospital was going to take the patients. We had accounts set up. I mean, it was so seamless because it was what they were used to looking at. It was nothing new that we had to bring out once a year, retrain everybody. It's what they do every day. It was no different. They looked at it like, oh, this is nothing. In fact, they were like, "This was the best evacuation we've ever had and we have to do it every single year, multiple times."
Interviewer: How do you report that information up to your different, state, federal?
Linda Castelli: We're part of the, I can't even remember the name of it, but Florida has mandated that we all reply to the database requests when they, updating all of our access, I mean, all of our systems. Make sure that we have our helicopter available. How many beds we have available, how many ICU beds. How many pediatric beds. All the different levels of care. Our security, one of the security folks who's responsible for maintaining that communication with the state of Florida, solely utilizes TeleTracking to get the answers for the questions that are in their database. So all of the census information, it just flows right over. We've created of spreadsheet. They just go in, plug in the numbers, get sent to him on a timely, so he can report it to the state. I can foresee at some point we will have an actual interface between TeleTracking and the state. And we will just hit a button and we won't have to do any calculating. So that's what I see for the future.
Luann Tirelli: I hope so, too.
Linda Castelli: Me, too.
Interviewer: I hope so, too.
Luann Tirelli: And I think our organization sees for the future that we need to remain partners in patient population management so much so that when we do have a hurricane, Linda's team and my team, we have to relocate to an area that's safe. When we first started this going back, I think it was about 2013, 14, they said to my department, "Oh, we're just going to close the eICU." And I think you guys went to a skeleton crew, just one or two people here and there.
Linda Castelli: At Holmes, at our big tertiary facility, which was a nightmare.
Luann Tirelli: And within, I think, it wasn't even 24 hours, we were just coming out of the disaster period. They said, "How quickly can you get your teams back and running?" So it was nice to see the value in that they missed us for that time and they understand that now. So looking into the future, they are looking to relocate us to an area where we don't have to pick up and move for hurricanes. But we've, I hate to say, have gotten quite expert at it now. But our system is trying to figure that out. Where the next role is and where we need to be as a command center in a space that we can grow into instead of grow out of.
Linda Castelli: Right.
Luann Tirelli: Because we're now growing out of what we have so far. So we're not sure where we're going, but in the future we're going somewhere.
Interviewer: Any final thoughts? Anything you'd like to add?
Linda Castelli: That's a loaded question now. I've been a TeleTracking and throughput promoter from literally day one because like I said, we had pieces of paper everywhere. But TeleTracking to me has met every single challenge. Every time we asked them for something, they not only have responded, they have come up with even more for us to move together in the future. So partnering with TeleTracking, I think, has been the key to our success in the last 15 years of decreasing those wait times. Improving the communication. When we first went live, the nurses on the floor wanted nothing to do with it. We had a downtime a few years ago. They didn't know how to act without their TeleTracking.
Speaker 1: It's just ingrained in the culture now.
Linda Castelli: 180 degrees opposite from that. "I don't want anything to do with it" to "Oh, my God. I can't live without it." So that is a testament to the work that you guys continue to do, improving throughput for and really improving patient care.
Luann Tirelli: And I think conferences like this are very beneficial because it allows you the ability to network. To see what's up and coming. And I go home inspired with lots of ideas-
Linda Castelli: Me, too.
Luann Tirelli: ... of how can we make it better for our organization, for our patients, for our staff. So I think there's great benefit in coming to conferences like this.