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DENVER – An intensive care unit telemedicine intervention was associated with lower hospital and ICU mortality and shorter hospital and ICU lengths of stay in a prospective, unblinded study conducted at one academic medical center over a 2-year period.
The intervention also was associated with significantly higher rates of adherence to critical care best practices and lower rates of complications. More rapid responses to alerts for physiologic instability and off-hours, off-site intensivist care plan reviews were identified as critical care process elements that may have contributed to the lower mortality and shorter lengths of stay associated with the tele-ICU intervention, Dr. Craig M. Lilly reported at an international conference of the American Thoracic Society. The study was simultaneously published online in JAMA (2011;305:E1-9 [doi:10.1001/jama.2011.697]).
Tele-ICU is defined as the provision of care to critically ill patients by health care professionals located remotely. Tele-ICU clinicians use audio, video, and electronic links to assist bedside caregivers in monitoring patients, oversee best practice adherence, and help create and execute care plans, said Dr. Lilly of the University of Massachusetts, Worcester.
Unlike previous studies of the effects of tele-ICU programs, this one focused on changes in the process of care rather than the ICU structure. Prior to the study start, best practices were standardized for the prevention of venous thrombosis, cardiovascular complications, ventilator-associated pneumonia, and stress ulcers. For the primary analysis, a representative sample of preintervention cases was obtained by identifying consecutive hospital discharges from an administrative database for cases managed in each of the seven ICUs (three medical, three surgical, and one mixed cardiovascular). Admission, discharge, and laboratory information was abstracted electronically.
The off-site team included an intensivist and used tele-ICU workstations. The tele-ICU team serially reviewed the care of individual patients, performed real-time audits of best practice adherence, performed workstation-assisted care plan reviews for patients admitted at night, monitored system-generated electronic alerts, audited bedside clinician responses to in-room alarms, and intervened when the responses of bedside clinicians were delayed and patients were deemed physiologically unstable. The off-site team was able to communicate with bedside clinicians or directly manage patients by recording clinician orders for tests, treatments, consultations, and management of life-support devices, Dr. Lilly said.
A total of 6,290 qualifying adult patients were identified from 6,465 electronic admission registrations to any of the seven ICUs, with 1,529 admitted during the preintervention period and 4,761 during the tele-ICU intervention period (the periods were staggered between 2005 and 2007).
Unadjusted ICU mortality was significantly lower in the tele-ICU group, compared with the preintervention group (10.7% vs. 8.6%). When adjusted for acuity, locus of care, physiologic parameters, laboratory values, and time trend, the odds ratio was 0.37. Hospital mortality also was reduced with tele-ICU (13.6% vs. 11.8%). The unadjusted difference was not statistically significant, but hospital mortality was significantly lower with tele-ICU after adjustment for acuity, locus of care, physiological parameters, laboratory values, and time trend, with an odds ratio of 0.40.
Both ICU and hospital mean lengths of stay were significantly lower with tele-ICU. The intervention group had a mean hospital stay of 9.8 days, compared with 13.3 days in the preintervention group. After adjustment for acuity, time trends, physiologic parameters, laboratory values, and locus of care, the hazard ratio was 1.44. For ICU stay, the mean was 4.5 days in the tele-ICU group vs. 6.4 days in the preintervention group. After adjustment for all of the previously listed factors, that hazard ratio was 1.26. Results for medical, surgical, and cardiovascular ICUs were similar, Dr. Lilly said.
To understand how tele-ICU team activities affected care processes and to evaluate the degree to which the association of the intervention with changes in mortality could be attributed to these changes in process, another analysis examined adherence to best practices, incidence of common ICU complications, intensivist involvement for cases admitted during nighttime hours, responses to alerts, and ICU type.
The tele-ICU intervention was associated with significantly better adherence to deep vein thrombosis prevention best practices and cardiovascular protection best practices, as well as lower rates of catheter-related bloodstream infection and ventilator-associated pneumonia. These factors also were associated with significantly lower ICU and hospital mortality. The proportion of the tele-ICU association with lower mortality that could be attributed to adherence to these best practices and complication measures was estimated to be 25% for hospital mortality and 30% for ICU mortality.
"This suggests that there are benefits of a tele-ICU intervention beyond what is provided by daytime bedside intensivist staffing and traditional approaches to quality improvement such as the process changes presented," Dr. Lilly commented.
"These findings suggest that critical care programs that implement processes that increase adherence to best practice, lower rates of complications, shorten response times to alerts and alarms, and support early intensivist case involvement will provide better care at a lower cost. ... Our study suggests that the introduction of a tele-ICU program that collaborates with and supports bedside clinicians is one way to accomplish these aims."
All study authors reported having no conflicts of interest.
Multiple commercial applications of ICU telemedicine now exist, and telemedicine is widely touted as an all-encompassing strategy to improve ICU outcomes. Yet even after 25 years, the optimal role of telemedicine in the ICU remains uncertain. Several previous studies have not demonstrated a benefit. The difference with the telemedicine program in this study is that it was tightly linked to specific quality improvement activities. For this reason, the study by Dr. Lilly and colleagues provides the first convincing evidence that ICU telemedicine can be an effective complement to bedside care in some settings.
The seven ICUs in this study, however, are part of one relatively well-resourced academic medical center that has a strong culture of quality improvement. It is unclear if these results could be replicated in hospitals with fewer resources to devote toward ICU quality. Moreover, all of the telemedicine physicians also worked in the target ICUs, which may have served to increase buy-in among local practitioners. These results may not translate to settings in which the telemedicine unit and hospital unit do not share physicians.
In the right settings and with the right goals, telemedicine can indeed be used to help improve outcomes. Yet, just as with all applications of health information technology, good outcomes should not be assumed. The challenge is to not conclude from this study that ICU telemedicine always is associated with improved quality of care, but instead to continue to explore how telemedicine can be used in clinical settings in which other strategies for quality improvement have not worked. Only then will it be possible to improve the use and avoid the misuse of this complex and evolving technology.
Dr. Jeremy M. Kahn is with the department of critical care medicine and the department of health policy and management at the University of Pittsburgh.
Multiple commercial applications of ICU telemedicine now exist, and telemedicine is widely touted as an all-encompassing strategy to improve ICU outcomes. Yet even after 25 years, the optimal role of telemedicine in the ICU remains uncertain. Several previous studies have not demonstrated a benefit. The difference with the telemedicine program in this study is that it was tightly linked to specific quality improvement activities. For this reason, the study by Dr. Lilly and colleagues provides the first convincing evidence that ICU telemedicine can be an effective complement to bedside care in some settings.
The seven ICUs in this study, however, are part of one relatively well-resourced academic medical center that has a strong culture of quality improvement. It is unclear if these results could be replicated in hospitals with fewer resources to devote toward ICU quality. Moreover, all of the telemedicine physicians also worked in the target ICUs, which may have served to increase buy-in among local practitioners. These results may not translate to settings in which the telemedicine unit and hospital unit do not share physicians.
In the right settings and with the right goals, telemedicine can indeed be used to help improve outcomes. Yet, just as with all applications of health information technology, good outcomes should not be assumed. The challenge is to not conclude from this study that ICU telemedicine always is associated with improved quality of care, but instead to continue to explore how telemedicine can be used in clinical settings in which other strategies for quality improvement have not worked. Only then will it be possible to improve the use and avoid the misuse of this complex and evolving technology.
Dr. Jeremy M. Kahn is with the department of critical care medicine and the department of health policy and management at the University of Pittsburgh.
Multiple commercial applications of ICU telemedicine now exist, and telemedicine is widely touted as an all-encompassing strategy to improve ICU outcomes. Yet even after 25 years, the optimal role of telemedicine in the ICU remains uncertain. Several previous studies have not demonstrated a benefit. The difference with the telemedicine program in this study is that it was tightly linked to specific quality improvement activities. For this reason, the study by Dr. Lilly and colleagues provides the first convincing evidence that ICU telemedicine can be an effective complement to bedside care in some settings.
The seven ICUs in this study, however, are part of one relatively well-resourced academic medical center that has a strong culture of quality improvement. It is unclear if these results could be replicated in hospitals with fewer resources to devote toward ICU quality. Moreover, all of the telemedicine physicians also worked in the target ICUs, which may have served to increase buy-in among local practitioners. These results may not translate to settings in which the telemedicine unit and hospital unit do not share physicians.
In the right settings and with the right goals, telemedicine can indeed be used to help improve outcomes. Yet, just as with all applications of health information technology, good outcomes should not be assumed. The challenge is to not conclude from this study that ICU telemedicine always is associated with improved quality of care, but instead to continue to explore how telemedicine can be used in clinical settings in which other strategies for quality improvement have not worked. Only then will it be possible to improve the use and avoid the misuse of this complex and evolving technology.
Dr. Jeremy M. Kahn is with the department of critical care medicine and the department of health policy and management at the University of Pittsburgh.
DENVER – An intensive care unit telemedicine intervention was associated with lower hospital and ICU mortality and shorter hospital and ICU lengths of stay in a prospective, unblinded study conducted at one academic medical center over a 2-year period.
The intervention also was associated with significantly higher rates of adherence to critical care best practices and lower rates of complications. More rapid responses to alerts for physiologic instability and off-hours, off-site intensivist care plan reviews were identified as critical care process elements that may have contributed to the lower mortality and shorter lengths of stay associated with the tele-ICU intervention, Dr. Craig M. Lilly reported at an international conference of the American Thoracic Society. The study was simultaneously published online in JAMA (2011;305:E1-9 [doi:10.1001/jama.2011.697]).
Tele-ICU is defined as the provision of care to critically ill patients by health care professionals located remotely. Tele-ICU clinicians use audio, video, and electronic links to assist bedside caregivers in monitoring patients, oversee best practice adherence, and help create and execute care plans, said Dr. Lilly of the University of Massachusetts, Worcester.
Unlike previous studies of the effects of tele-ICU programs, this one focused on changes in the process of care rather than the ICU structure. Prior to the study start, best practices were standardized for the prevention of venous thrombosis, cardiovascular complications, ventilator-associated pneumonia, and stress ulcers. For the primary analysis, a representative sample of preintervention cases was obtained by identifying consecutive hospital discharges from an administrative database for cases managed in each of the seven ICUs (three medical, three surgical, and one mixed cardiovascular). Admission, discharge, and laboratory information was abstracted electronically.
The off-site team included an intensivist and used tele-ICU workstations. The tele-ICU team serially reviewed the care of individual patients, performed real-time audits of best practice adherence, performed workstation-assisted care plan reviews for patients admitted at night, monitored system-generated electronic alerts, audited bedside clinician responses to in-room alarms, and intervened when the responses of bedside clinicians were delayed and patients were deemed physiologically unstable. The off-site team was able to communicate with bedside clinicians or directly manage patients by recording clinician orders for tests, treatments, consultations, and management of life-support devices, Dr. Lilly said.
A total of 6,290 qualifying adult patients were identified from 6,465 electronic admission registrations to any of the seven ICUs, with 1,529 admitted during the preintervention period and 4,761 during the tele-ICU intervention period (the periods were staggered between 2005 and 2007).
Unadjusted ICU mortality was significantly lower in the tele-ICU group, compared with the preintervention group (10.7% vs. 8.6%). When adjusted for acuity, locus of care, physiologic parameters, laboratory values, and time trend, the odds ratio was 0.37. Hospital mortality also was reduced with tele-ICU (13.6% vs. 11.8%). The unadjusted difference was not statistically significant, but hospital mortality was significantly lower with tele-ICU after adjustment for acuity, locus of care, physiological parameters, laboratory values, and time trend, with an odds ratio of 0.40.
Both ICU and hospital mean lengths of stay were significantly lower with tele-ICU. The intervention group had a mean hospital stay of 9.8 days, compared with 13.3 days in the preintervention group. After adjustment for acuity, time trends, physiologic parameters, laboratory values, and locus of care, the hazard ratio was 1.44. For ICU stay, the mean was 4.5 days in the tele-ICU group vs. 6.4 days in the preintervention group. After adjustment for all of the previously listed factors, that hazard ratio was 1.26. Results for medical, surgical, and cardiovascular ICUs were similar, Dr. Lilly said.
To understand how tele-ICU team activities affected care processes and to evaluate the degree to which the association of the intervention with changes in mortality could be attributed to these changes in process, another analysis examined adherence to best practices, incidence of common ICU complications, intensivist involvement for cases admitted during nighttime hours, responses to alerts, and ICU type.
The tele-ICU intervention was associated with significantly better adherence to deep vein thrombosis prevention best practices and cardiovascular protection best practices, as well as lower rates of catheter-related bloodstream infection and ventilator-associated pneumonia. These factors also were associated with significantly lower ICU and hospital mortality. The proportion of the tele-ICU association with lower mortality that could be attributed to adherence to these best practices and complication measures was estimated to be 25% for hospital mortality and 30% for ICU mortality.
"This suggests that there are benefits of a tele-ICU intervention beyond what is provided by daytime bedside intensivist staffing and traditional approaches to quality improvement such as the process changes presented," Dr. Lilly commented.
"These findings suggest that critical care programs that implement processes that increase adherence to best practice, lower rates of complications, shorten response times to alerts and alarms, and support early intensivist case involvement will provide better care at a lower cost. ... Our study suggests that the introduction of a tele-ICU program that collaborates with and supports bedside clinicians is one way to accomplish these aims."
All study authors reported having no conflicts of interest.
DENVER – An intensive care unit telemedicine intervention was associated with lower hospital and ICU mortality and shorter hospital and ICU lengths of stay in a prospective, unblinded study conducted at one academic medical center over a 2-year period.
The intervention also was associated with significantly higher rates of adherence to critical care best practices and lower rates of complications. More rapid responses to alerts for physiologic instability and off-hours, off-site intensivist care plan reviews were identified as critical care process elements that may have contributed to the lower mortality and shorter lengths of stay associated with the tele-ICU intervention, Dr. Craig M. Lilly reported at an international conference of the American Thoracic Society. The study was simultaneously published online in JAMA (2011;305:E1-9 [doi:10.1001/jama.2011.697]).
Tele-ICU is defined as the provision of care to critically ill patients by health care professionals located remotely. Tele-ICU clinicians use audio, video, and electronic links to assist bedside caregivers in monitoring patients, oversee best practice adherence, and help create and execute care plans, said Dr. Lilly of the University of Massachusetts, Worcester.
Unlike previous studies of the effects of tele-ICU programs, this one focused on changes in the process of care rather than the ICU structure. Prior to the study start, best practices were standardized for the prevention of venous thrombosis, cardiovascular complications, ventilator-associated pneumonia, and stress ulcers. For the primary analysis, a representative sample of preintervention cases was obtained by identifying consecutive hospital discharges from an administrative database for cases managed in each of the seven ICUs (three medical, three surgical, and one mixed cardiovascular). Admission, discharge, and laboratory information was abstracted electronically.
The off-site team included an intensivist and used tele-ICU workstations. The tele-ICU team serially reviewed the care of individual patients, performed real-time audits of best practice adherence, performed workstation-assisted care plan reviews for patients admitted at night, monitored system-generated electronic alerts, audited bedside clinician responses to in-room alarms, and intervened when the responses of bedside clinicians were delayed and patients were deemed physiologically unstable. The off-site team was able to communicate with bedside clinicians or directly manage patients by recording clinician orders for tests, treatments, consultations, and management of life-support devices, Dr. Lilly said.
A total of 6,290 qualifying adult patients were identified from 6,465 electronic admission registrations to any of the seven ICUs, with 1,529 admitted during the preintervention period and 4,761 during the tele-ICU intervention period (the periods were staggered between 2005 and 2007).
Unadjusted ICU mortality was significantly lower in the tele-ICU group, compared with the preintervention group (10.7% vs. 8.6%). When adjusted for acuity, locus of care, physiologic parameters, laboratory values, and time trend, the odds ratio was 0.37. Hospital mortality also was reduced with tele-ICU (13.6% vs. 11.8%). The unadjusted difference was not statistically significant, but hospital mortality was significantly lower with tele-ICU after adjustment for acuity, locus of care, physiological parameters, laboratory values, and time trend, with an odds ratio of 0.40.
Both ICU and hospital mean lengths of stay were significantly lower with tele-ICU. The intervention group had a mean hospital stay of 9.8 days, compared with 13.3 days in the preintervention group. After adjustment for acuity, time trends, physiologic parameters, laboratory values, and locus of care, the hazard ratio was 1.44. For ICU stay, the mean was 4.5 days in the tele-ICU group vs. 6.4 days in the preintervention group. After adjustment for all of the previously listed factors, that hazard ratio was 1.26. Results for medical, surgical, and cardiovascular ICUs were similar, Dr. Lilly said.
To understand how tele-ICU team activities affected care processes and to evaluate the degree to which the association of the intervention with changes in mortality could be attributed to these changes in process, another analysis examined adherence to best practices, incidence of common ICU complications, intensivist involvement for cases admitted during nighttime hours, responses to alerts, and ICU type.
The tele-ICU intervention was associated with significantly better adherence to deep vein thrombosis prevention best practices and cardiovascular protection best practices, as well as lower rates of catheter-related bloodstream infection and ventilator-associated pneumonia. These factors also were associated with significantly lower ICU and hospital mortality. The proportion of the tele-ICU association with lower mortality that could be attributed to adherence to these best practices and complication measures was estimated to be 25% for hospital mortality and 30% for ICU mortality.
"This suggests that there are benefits of a tele-ICU intervention beyond what is provided by daytime bedside intensivist staffing and traditional approaches to quality improvement such as the process changes presented," Dr. Lilly commented.
"These findings suggest that critical care programs that implement processes that increase adherence to best practice, lower rates of complications, shorten response times to alerts and alarms, and support early intensivist case involvement will provide better care at a lower cost. ... Our study suggests that the introduction of a tele-ICU program that collaborates with and supports bedside clinicians is one way to accomplish these aims."
All study authors reported having no conflicts of interest.
FROM AN INTERNATIONAL CONFERENCE OF THE AMERICAN THORACIC SOCIETY
Major Finding: Unadjusted ICU mortality was significantly lower in the tele-ICU group, compared with the preintervention group (10.7% vs. 8.6%). Hospital mortality also was reduced with tele-ICU (13.6% vs. 11.8%). Both ICU and hospital mean length of stay were significantly shorter with tele-ICU (hospital stay, 9.8 days vs. 13.3 days; ICU stay, 4.5 vs. 6.4 days).
Data Source: Prospective clinical practice study of 6,290 adult patients admitted over 2 years to seven ICUs in an academic medical center.
Disclosures: All study authors reported having no conflicts of interest.