ICU Telemedicine Reduces Interhospital ICU Transfers in the Veterans Health Administration

Palliative Care Utilization and Hospital Transfers in Veterans Treated in Telecritical Care-Supported Intensive Care Units Versus Non-Telecritical Care Intensive Care Units

Background: Although telecritical care (TCC) implementation is associated with reduced mortality and interhospital transfer rates, its impact on goal-concordant care delivery in critical illness is unknown. We hypothesized that implementation of TCC across the Veterans' Health Administration system resulted in increased palliative care consultation and goals of care evaluation, yielding reduced transfer rates. Methods: We included veterans admitted to intensive care units between 2008 and 2022. We compared palliative care consultation and transfer rates before and after TCC implementation with rates in facilities that never implemented TCC. We used generalized linear mixed multivariable models to assess the associations between TCC initiation, palliative care consultation, and transfer and subsequently used mediation analysis to evaluate potential causality in this relationship. Results: Overall, 1,020,901 veterans met inclusion criteria. Demographic characteristics of patients were largely comparable across groups, although TCC facilities served more rural veterans. Palliative care consultation rates increased substantially in both ever-TCC and never-TCC hospitals during the study period (2.3%-4.3%, and 1.6%-4.7%, p < 0.01). Admissions post-TCC implementation were associated with an increased likelihood of palliative care consultation (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.01-1.15). TCC implementation was also associated with a reduction in transfer rates (OR 0.90, 95% CI 0.84-0.95). Mediation analysis did not demonstrate a causal relationship between TCC implementation, palliative care consultation, and reductions in interhospital transfer rate. Conclusions: TCC is associated with increased palliative care engagement, while TCC and palliative care engagement are both independently related to reduced transfers.

Innovations in Tele-Critical Care Nursing During the COVID-19 Pandemic

For decades, tele-critical care (TCC) programs have provided expert population surveillance with standardized clinical interventions for critically ill patients. The COVID-19 pandemic created massive strains on critical care resources. For this report, standard questions were used to solicit COVID-19 pandemic workflow and service modifications from a network of TCC leaders to describe the rapid expansion of TCC-supported services during the pandemic. In this article, leaders from 7 TCC programs report on the effective use of services to support changing hospital needs during the pandemic in areas such as clinical education, personal protective equipment stewardship, expansion of virtual care, and creative staffing models, among others.

Elucidation of the needs for telecritical care services in Japan: a qualitative study

OBJECTIVE

To clarify the reasons for consultation, advice sought by frontline physicians and relationship between the patient's pathology and the type of advice provided to guide the future development of telecritical care services.

DESIGN

Secondary analysis of transcripts of telephone calls originally recorded for quality control purposes was conducted using a thematic content analysis. The calls were conducted between December 2019 and April 2021 (total cases: 70; total time: ~15 hour).

SETTINGS

Intensivists provided consultation services to frontline physicians at secondary care institutions in the Kansai and Chubu regions.

PARTICIPANTS

Non-intensive care frontline physicians working in five secondary care institutions in the Kansai and Chubu regions and intensivists providing a consultation service (n=26).

INTERVENTIONS

Not applicable.

PRIMARY AND SECONDARY OUTCOME MEASURES

The main outcome was the themes emerging from the language used during telephone and video consultations, indicating the gap filled by the telecritical care service.

FINDINGS

We analysed 70 cases and approximately 15 hours of anonymised audio data. We identified the following reasons for consultation: 'lack of competence in treatment and diagnostic testing' and 'lack of access to consultation in their own hospital'. Frontline physicians most often sought advice related to 'treatment', followed by 'patient triage and transfer', 'diagnosis' and 'diagnostic testing and evaluation'. Regarding the relationship between the patient's pathology and type of advice provided, the most commonly sought advice by frontline physicians varied based on the patient's pathology.

CONCLUSION

This study explored the characteristics of 70 telecritical sessions and identified the reasons for and nature of the consultations. These findings can be used to guide the future provision and scale up of telecritical services.

Addressing the challenges of AI-based telemedicine: Best practices and lessons learned

Telemedicine is the use of technology to provide healthcare services and information remotely, without requiring physical proximity between patients and healthcare providers. The coronavirus disease 2019 (COVID-19) pandemic has accelerated the rapid growth of telemedicine worldwide. Integrating artificial intelligence (AI) into telemedicine has the potential to enhance and expand its capabilities in addressing various healthcare needs, such as patient monitoring, healthcare information technology (IT), intelligent diagnosis, and assistance. Despite the potential benefits, implementing AI in telemedicine presents challenges that can be overcome with physician-guided implementation. AI can assist physicians in decision-making, improve healthcare delivery, and automate administrative tasks. To ensure optimal effectiveness, AI-powered telemedicine should comply with existing clinical practices and adhere to a framework adaptable to various technologies. It should also consider technical and scientific factors, including trustworthiness, reproducibility, usability, availability, and cost. Education and training are crucial for the appropriate use of new healthcare technologies such as AI-enabled telemedicine. This article examines the benefits and limitations of AI-based telemedicine in various medical domains and underscores the importance of physician-guided implementation, compliance with existing clinical practices, and appropriate education and training for healthcare providers.

ICU stays that are judged to be non-beneficial: A qualitative study of the perception of nursing staff

INTRODUCTION

Non-beneficial stays in the intensive care unit (ICU) may have repercussions for patients and their families, but can also cause suffering among the nursing staff. We aimed explore the perceptions of nursing staff in the ICU about patient stays that are deemed to be "non-beneficial" for the patient, to identify areas amenable to intervention, with a view to improving how the nursing staff perceive the patient pathway before, during and after intensive care.

METHODS

Multicentre, qualitative study using individual, semi-structured interviews. All qualified nurses and nurses' aides who were full-time employees in the ICU of three participating centres were invited to participate. Interviews were recorded, transcribed and analyzed using textual content analysis.

RESULTS

A total of 21 interviews were performed from February 2020 to October 2021, at which point saturation was reached in the data. Average age of participants was 38.5±7.5 years, and they had an average of 10.7±7.4 years of experience working in the ICU. Four major themes emerged from the interviews, namely: (1) the work is oriented towards life-threatening emergencies, technical procedures and burdensome care; (2) a range of specific criteria and circumstances influence the decisions to admit patients to ICU; (3) there are significant organisational, physical and psychological repercussions associated with a non-beneficial stay in the ICU; (4) respondents made some proposals for improvements to the patient care pathway.

CONCLUSION

Nursing staff have a similar perception to physicians regarding admission decisions and non-beneficial ICU stays. The possibility of future ICU admission needs to be anticipated, discussed systematically with patients and integrated into healthcare goals that are consistent with the patient's wishes and preferences, in multi-professional collaboration including nursing and medical staff.

Digitally-enabled remote critical care: the challenges of geography and history?

The COVID-19 pandemic has rejuvenated interest in the possibility of using telemedicine as an approach to providing critical care services to patients in remote areas. Conceptual and governance considerations remain unaddressed. We summarise the first steps in a recent collaborative effort between key organisations in Australia, India, New Zealand, and the UK, and call for an international consensus on standards with due considerations to governance and regulation of this emerging clinical practice.

The impact of telehealth in sepsis care: A systematic review

OBJECTIVES

Sepsis is associated with significant mortality. Telehealth may improve the quality of early sepsis care, but the use and impact of telehealth applications for sepsis remain unclear. We aim to describe the telehealth interventions that have been used to facilitate sepsis care, and to summarize the reported effect of telehealth on sepsis outcomes.

DATA SOURCES

We identified articles reporting telehealth use for sepsis using an English-language search of PubMed, CINAHL Plus (EBSCO), Academic Search Ultimate (EBSCO), APA PsycINFO (EBSCO), Public Health (ProQuest), and Web of Science databases with no restrictions on publication date.

STUDY SELECTION

Included studies described the use of telehealth as an intervention for treating sepsis. Only comparative effectiveness analyses were included.

DATA EXTRACTION AND SYNTHESIS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guidelines, two investigators independently selected articles for inclusion and abstracted data. A random-effects subgroup analysis was conducted on patient survival treated with and without telehealth.

RESULTS

A total of 15 studies were included, involving 188,418 patients with sepsis. Thirteen studies used observational study designs, and the most common telehealth applications were provider-to-provider telehealth consultation and intensive care unit telehealth. Clinical and methodological heterogeneity was significantly high. Telehealth use was associated with higher survival, especially in settings with low control group survival. The effect of telehealth on other care processes and outcomes were more varied and likely dependent on hospital-level factors.

CONCLUSIONS

Telehealth has been used in diverse applications for sepsis care, and it may improve patient outcomes in certain contexts. Additional interventional trials and cost-based analyses would clarify the causal role of telehealth in improving sepsis outcomes.

Interfacility Transport of Critically Ill Patients

OBJECTIVES

To assess recent advances in interfacility critical care transport.

DATA SOURCES

PubMed English language publications plus chapters and professional organization publications.

STUDY SELECTION

Manuscripts including practice manuals and standard (1990-2021) focused on interfacility transport of critically ill patients.

DATA EXTRACTION

Review of society guidelines, legislative requirements, objective measures of outcomes, and transport practice standards occurred in work groups assessing definitions and foundations of interfacility transport, transport team composition, and transport specific considerations. Qualitative analysis was performed to characterize current science regarding interfacility transport.

DATA SYNTHESIS

The Task Force conducted an integrative review of 496 manuscripts combined with 120 from the authors' collections including nonpeer reviewed publications. After title and abstract screening, 40 underwent full-text review, of which 21 remained for qualitative synthesis.

CONCLUSIONS

Since 2004, there have been numerous advances in critical care interfacility transport. Clinical deterioration may be mitigated by appropriate patient selection, pretransport optimization, and transport by a well-resourced team and vehicle. There remains a dearth of high-quality controlled studies, but notable advances in monitoring, en route management, transport modality (air vs ground), as well as team composition and training serve as foundations for future inquiry. Guidance from professional organizations remains uncoupled from enforceable regulations, impeding standardization of transport program quality assessment and verification.

Association of interactions between Tele-critical care and bedside with length of stay and mortality

INTRODUCTION

Substantial variation exists in telemedicine critical care (Tele-CC) effectiveness, which may be explained by heterogeneity in Tele-CC implementation and utilization.

METHODS

We studied inpatient intensive care unit (ICU) admissions within the Veterans Health Administration from January 2005 to September 2018. Tele-CC affiliation was based on a facility's Tele-CC go-live date. Tele-CC interaction was quantified as the monthly number of video activations, recorded in the eCaremanager® (Phillips) system, per patient days. Tele-CC affiliated facilities were propensity-score matched to facilities without Tele-CC by hospital volume and average modified APACHE scores. We examined the effect of Tele-CC affiliation and the quantity of video interactions between Tele-CC and bedside on hospital outcomes.

RESULTS

Comparing Tele-CC affiliated and control facilities, affiliated patients were, on average, younger (66.8 years vs 67.8 years; p < 0.001) and more likely to be rural residents (11.3% vs 6.5%; p < 0.001). Stratifying the Tele-CC affiliated facilities, facilities with frequent interactions care for more rural and sicker patients relative to facilities with infrequent interactions. Adjusting for patient demographics, facilities in the top tertile of interactions and propensity score matched control facilities were assessed; patients in ICU's with Tele-CC access experienced shorter ICU-specific lengths of stay (RR = 0.39; 95% CI = [0.23, 0.65]). However, when facilities in the bottom tertile and propensity score matched control facilities were assessed, no significant differences were noted in ICU length of stay.

DISCUSSION

Tele-CC interactions may occur more frequently for higher acuity patients. Increased Tele-CC interactions may improve health outcomes for the most acute and complex ICU cases.

Hospital Variation in Non-Invasive Ventilation Use for Acute Respiratory Failure Due to COPD Exacerbation

Background

Non-invasive mechanical ventilation (NIV) use in patients admitted with acute respiratory failure due to COPD exacerbations (AECOPDs) varies significantly between hospitals. However, previous literature did not account for patients’ illness severity. Our objective was to examine the variation in risk-standardized NIV use after adjusting for illness severity.

Methods

We retrospectively analyzed AECOPD hospitalizations from 2011 to 2017 at 106 acute-care Veterans Health Administration (VA) hospitals in the USA. We stratified hospitals based on the percentage of NIV use among patients who received ventilation support within the first 24 hours of admission into quartiles, and compared patient characteristics. We calculated the risk-standardized NIV % using hierarchical models adjusting for comorbidities and severity of illness. We then stratified the hospitals by risk-standardized NIV % into quartiles and compared hospital characteristics between quartiles. We also compared the risk-standardized NIV % between rural and urban hospitals.

Results

In 42,048 admissions for AECOPD over 6 years, the median risk-standardized initial NIV % was 57.3% (interquartile interval [IQI]=41.9–64.4%). Hospitals in the highest risk-standardized NIV % quartiles cared for more rural patients, used invasive ventilators less frequently, and had longer length of hospital stay, but had no difference in mortality relative to the hospitals in the lowest quartiles. The risk-standardized NIV % was 65.3% (IQI=34.2–84.2%) in rural and 55.1% (IQI=10.8–86.6%) in urban hospitals (p=0.047), but hospital mortality did not differ between the two groups.

Conclusion

NIV use varied significantly across hospitals, with rural hospitals having higher risk-standardized NIV % rates than urban hospitals. Further research should investigate the exact mechanism of variation in NIV use between rural and urban hospitals.

Regionalization of Critical Care in the United States: Current State and Proposed Framework From the Academic Leaders in Critical Care Medicine Task Force of the Society of the Critical Care Medicine

OBJECTIVES

The Society of Critical Care Medicine convened its Academic Leaders in Critical Care Medicine taskforce on February 22, 2016, during the 45th Critical Care Congress to develop a series of consensus papers with toolkits for advancing critical care organizations in North America. The goal of this article is to propose a framework based on the expert opinions of critical care organization leaders and their responses to a survey, for current and future critical care organizations, and their leadership in the health system to design and implement successful regionalization for critical care in their regions.

DATA SOURCES AND STUDY SELECTION

Members of the workgroup convened monthly via teleconference with the following objectives: to 1) develop and analyze a regionalization survey tool for 23 identified critical care organizations in the United States, 2) assemble relevant medical literature accessed using Medline search, 3) use a consensus of expert opinions to propose the framework, and 4) create groups to write the subsections and assemble the final product.

DATA EXTRACTION AND SYNTHESIS

The most prevalent challenges for regionalization in critical care organizations remain a lack of a strong central authority to regulate and manage the system as well as a lack of necessary infrastructure, as described more than a decade ago. We provide a framework and outline a nontechnical approach that the health system and their critical care medicine leadership can adopt after considering their own structure, complexity, business operations, culture, and the relationships among their individual hospitals. Transforming the current state of regionalization into a coordinated, accountable system requires a critical assessment of administrative and clinical challenges and barriers. Systems thinking, business planning and control, and essential infrastructure development are critical for assisting critical care organizations.

CONCLUSIONS

Under the value-based paradigm, the goals are operational efficiency and patient outcomes. Health systems that can align strategy and operations to assist the referral hospitals with implementing regionalization will be better positioned to regionalize critical care effectively.

The STS case study: an analysis method for longitudinal qualitative research for implementation science

BACKGROUND

Ethnographic approaches offer a method and a way of thinking about implementation. This manuscript applies a specific case study method to describe the impact of the longitudinal interplay between implementation stakeholders. Growing out of science and technology studies (STS) and drawing on the latent archaeological sensibilities implied by ethnographic methods, the STS case-study is a tool for implementors to use when a piece of material culture is an essential component of an innovation.

METHODS

We conducted an ethnographic process evaluation of the clinical implementation of tele-critical care (Tele-CC) services in the Department of Veterans Affairs. We collected fieldnotes and conducted participant observation at virtual and in-person education and planning events (n = 101 h). At Go-Live and 6-months post-implementation, we conducted site visits to the Tele-CC hub and 3 partnered ICUs. We led semi-structured interviews with ICU staff at Go-Live (43 interviews with 65 participants) and with ICU and Tele-CC staff 6-months post-implementation (44 interviews with 67 participants). We used verification strategies, including methodological coherence, appropriate sampling, collecting and analyzing data concurrently, and thinking theoretically, to ensure the reliability and validity of our data collection and analysis process.

RESULTS

The STS case-study helped us realize that we must think differently about how a Tele-CC clinician could be noticed moving from communal to intimate space. To understand how perceptions of surveillance impacted staff acceptance, we mapped the materials through which surveillance came to matter in the stories staff told about cameras, buttons, chimes, motors, curtains, and doorbells.

CONCLUSIONS

STS case-studies contribute to the literature on longitudinal qualitive research (LQR) in implementation science, including pen portraits and periodic reflections. Anchored by the material, the heterogeneity of an STS case-study generates questions and encourages exploring differences. Begun early enough, the STS case-study method, like periodic reflections, can serve to iteratively inform data collection for researchers and implementors. The next step is to determine systematically how material culture can reveal implementation barriers and direct attention to potential solutions that address tacit, deeply rooted challenges to innovations in practice and technology.

Telemedicine in the ICU: Innovation in the Critical Care Process

Tele-ICU is a technology-based model designed to deliver effective critical care in the intensive care unit (ICU). The tele-ICU system has been developed to address the increasing demand for intensive care services and the shortage of intensivists. A finite number of intensivists from remote locations provide real-time services to multiple ICUs and assist in the treatment of critically ill patients. Risk prediction algorithms, smart alarm systems, and machine learning tools augment conventional coverage and can potentially improve the quality of care. Tele-ICU is associated with substantial improvements in mortality, reduced hospital and ICU length of stay, and decreased health care costs. Although multiple studies show improved outcomes following the implementation of tele-ICU, results are not consistent. Several factors, including the heterogeneity of tele-ICU infrastructure deployed in different facilities and the reluctance of health care workers to accept tele-ICU, could be associated with these varied results. Considerably high installation and ongoing operational costs might also be limiting the widespread utilization of this innovative service. While we believe that the implementation of tele-ICU offers potential advantages and makes critical care delivery more efficient, further research on the impact of this technology in critical care settings is warranted.

ICU Telemedicine Implementation and Risk-Adjusted Mortality Differences Between Daytime and Nighttime Coverage

BACKGROUND

ICU telemedicine augmentation has been associated with improvements in clinical and financial outcomes in many cases, but not all. Understanding this discrepancy is of interest given the clinical impact and intervention cost. A recent meta-analysis noted an association with mortality reduction and standardized mortality ratio (SMR) before ICU telemedicine implementation of > 1.

RESEARCH QUESTION

Does ICU telemedicine implementation affect adjusted mortality outcomes? If so, in what context?

STUDY DESIGN AND METHODS

We performed a retrospective pre-post analysis comparing before vs after ICU telemedicine implementation on the outcome of risk-adjusted ICU mortality during am vs pm admissions as well as other objective measures of ICU telemedicine involvement.

RESULTS

One thousand five hundred eighty-one patient-stays and 14,584 patient-stays were available for analysis in the implementation period before vs after ICU telemedicine implementation, respectively. The average Acute Physiology and Chronic Health Evaluation (APACHE) IVa score was 46.6 vs 54.8 (P < .01) in the am group before ICU telemedicine implementation vs the am group after ICU telemedicine implementation, respectively. The average APACHE IVa score was 47.2 vs 56.3 (P < .01) in the pm group before ICU telemedicine implementation vs the pm group after ICU telemedicine implementation, respectively. Overall, the risk-adjusted ICU mortality was 8.7% before ICU telemedicine implementation vs 6.5% (P < .01) after implementation. When stratified by am and pm admission groups, no significant difference in risk-adjusted ICU mortality was seen in the am stratum. In the pm stratum, risk-adjusted mortality was 10.8% before ICU telemedicine implementation vs 7.0% (P < .01) after ICU telemedicine implementation. The preimplementation SMR in the am admission stratum was 0.95 vs 1.30 in the pm stratum.

INTERPRETATION

We found a reduction in risk-adjusted ICU mortality with implementation of ICU telemedicine driven predominantly within the pm admission group. The pm admission SMR was 1.30, which may suggest an association with SMR of > 1 before ICU telemedicine implementation and mortality reduction. Future studies should seek to confirm this finding and should explore other important ICU telemedicine outcomes in the context of observed-to-expected ratios.

A simplified critical illness severity scoring system (CISSS): Development and internal validation

PURPOSE

To create a simplified critical illness severity scoring system with high prediction accuracy for 30-day mortality using only commonly available variables.

MATERIALS AND METHODS

This is a retrospective cohort study of ICU admissions 2010-2015 in 306 ICUs in 117 Veterans Affairs (VA) hospitals. We randomly divided our cohort into a training dataset (75%) and a validation dataset (25%). We created a critical illness severity scoring system (CISSS) using age, comorbidities, heart rate, mean arterial blood pressure, temperature, respiratory rate, hematocrit, white blood cell count, creatinine, sodium, glucose, albumin, bilirubin, bicarbonate, use of invasive mechanical ventilation, and whether the admission was surgical or not. We validated the performance of CISSS to predict 30-day mortality internally.

RESULTS

After excluding 31,743 re-admissions, we divided our sample (n = 534,001) into a training (n = 400,613) and a validation dataset (n = 133,388). In the training dataset, the area under the curve (AUC) of CISSS was 0.847(95%CI = 0.845-0.850). In the validation dataset, the AUC was 0.848 (95%CI = 0.844-0.852), the standardized mortality ratio (SMR) was 1.00 (95%CI = 0.98-1.02), and Brier's score for 30-day mortality was 0.058 (95%CI = 0.057-0.059). CISSS calibration was acceptable.

CONCLUSIONS

CISSS has very good performance and requires only commonly used variables that can be easily extracted by electronic health records.

Tele-Critical Care: An Update From the Society of Critical Care Medicine Tele-ICU Committee

OBJECTIVES

In 2014, the Tele-ICU Committee of the Society of Critical Care Medicine published an article regarding the state of ICU telemedicine, one better defined today as tele-critical care. Given the rapid evolution in the field, the authors now provide an updated review.

DATA SOURCES AND STUDY SELECTION

We searched PubMed and OVID for peer-reviewed literature published between 2010 and 2018 related to significant developments in tele-critical care, including its prevalence, function, activity, and technologies. Search terms included electronic ICU, tele-ICU, critical care telemedicine, and ICU telemedicine with appropriate descriptors relevant to each sub-section. Additionally, information from surveys done by the Society of Critical Care Medicine was included given the relevance to the discussion and was referenced accordingly.

DATA EXTRACTION AND DATA SYNTHESIS

Tele-critical care continues to evolve in multiple domains, including organizational structure, technologies, expanded-use case scenarios, and novel applications. Insights have been gained in economic impact and human and organizational factors affecting tele-critical care delivery. Legislation and credentialing continue to significantly influence the pace of tele-critical care growth and adoption.

CONCLUSIONS

Tele-critical care is an established mechanism to leverage critical care expertise to ICUs and beyond, but systematic research comparing different models, approaches, and technologies is still needed.

Central Venous Access Capability and Critical Care Telemedicine Decreases Inter-Hospital Transfer Among Severe Sepsis Patients: A Mixed Methods Design

OBJECTIVES

Severe sepsis is a complex, resource intensive, and potentially lethal condition and rural patients have worse outcomes than urban patients. Early identification and treatment are important to improving outcomes. The objective of this study was to identify hospital-specific factors associated with inter-hospital transfer.

DESIGN

Mixed method study integrating data from a telephone survey and retrospective cohort study of state administrative claims.

SETTING AND SUBJECTS

Survey of Iowa emergency department administrators between May 2017 and June 2017 and cohort of adults seen in Iowa emergency departments for severe sepsis and septic shock between January 2005 and December 2013.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Multivariable logistic regression was used to identify independent predictors of inter-hospital transfer. We included 114 institutions that provided data (response rate = 99%), and responses were linked to a total of 150,845 visits for severe sepsis/septic shock. In our adjusted model, having the capability to place central venous catheters or having a subscription to a tele-ICU service was independently associated with lower odds of inter-hospital transfer (adjusted odds ratio, 0.69; 95% CI, 0.54-0.86 and adjusted odds ratio, 0.69; 95% CI, 0.54-0.88, respectively). A facility's participation in a sepsis-specific quality improvement initiative was associated with 62% higher odds of transfer (adjusted odds ratio, 1.62; 95% CI, 1.10-2.39).

CONCLUSIONS

The insertion of central venous catheters and access to a critical care physician during sepsis treatment are important capabilities in hospitals that transfer fewer sepsis patients. In the future, hospital-specific capabilities may be used to identify institutions as regional sepsis centers.

Evaluating Tele-ICU Implementation Based on Observed and Predicted ICU Mortality: A Systematic Review and Meta-Analysis

OBJECTIVES

Past studies have examined numerous components of tele-ICU care to decipher which elements increase patient and institutional benefit. These factors include review of the patient chart within 1 hour, frequent collaborative data reviews, mechanisms for rapid laboratory/alert review, and interdisciplinary rounds. Previous meta-analyses have found an overall ICU mortality benefit implementing tele-ICU, however, subgroup analyses found few differences. The purpose of this systematic review and meta-analysis was to explore the effect of tele-ICU implementation with regard to ICU mortality and explore subgroup differences via observed and predicted mortality.

DATA SOURCES

We searched PubMed, Cochrane Library, Embase, and European Society of Intensive Care Medicine for articles related to tele-ICU from inception to September 18, 2018.

STUDY SELECTION

We included all trials meeting inclusion criteria which looked at the effect of tele-ICU implementation on ICU mortality.

DATA EXTRACTION

We abstracted study characteristics, patient characteristics, severity of illness scores, and ICU mortality rates.

DATA SYNTHESIS

We included 13 studies from 2,766 abstracts identified from our search strategy. The before-after tele-ICU implementation pooled odds ratio for overall ICU mortality was 0.75 (95% CI, 0.65-0.88; p < 0.001). In subgroup analysis, the pooled odds ratio for ICU mortality between the greater than 1 versus less than 1 observed to predicted mortality ratios was 0.64 (95% CI, 0.52-0.77; p < 0.001) and 0.98 (95% CI, 0.81-1.18; p = 0.81), respectively. Test for interaction was significant (p = 0.002).

CONCLUSIONS

After evaluating all included studies, tele-ICU implementation was associated with an overall reduction in ICU mortality. Subgroup analysis suggests that publications exhibiting observed to predicted ICU mortality ratios of greater than 1 before tele-ICU implementation was associated with a reduction in ICU mortality after tele-ICU implementation. No significant ICU mortality reduction was noted in the subgroup of observed to predicted ICU mortality ratio less than 1 before tele-ICU implementation. Future studies should confirm this finding using patient-level data.

Pilot study of telemedicine for the initial evaluation of general surgery patients in the clinic and hospitalized settings

Background

Telemedicine has had limited implementation for general surgery. The purpose of this study was to evaluate telemedicine for the initial evaluation of patients in the clinic and hospital settings.

Methods

Synchronous telemedicine consults were conducted by a single surgeon to a rural hospital and clinic. Reasons for consult, adequacy of consult, days saved by telemedicine consult compared to standard practice, correlation of telemedicine and in-person physical exam, and number of patients who required procedures were evaluated.

Results

On average, patients were evaluated 7.4 days more rapidly than if the consult had been done by our standard practice. Telemedicine was adequate for all patients in this study.

Conclusions

This is the first study using telemedicine for the initial consult of general surgery patients in the hospitalized and clinic setting in North America. The physical exam remains an important component of the general surgery evaluation, and special attention must be considered when structuring the telemedicine program. Telemedicine is an effective and expedient way to provide consultation for general surgery patients. Further study is needed to determine which general surgery issues are not amendable to telemedicine consultation, and to determine other surgical specialties that could utilize telemedicine in their practice.

•

This is the first study using telemedicine for general surgery in the United States.

•

Telemedicine has potential for use in general surgery in both the clinic and hospitalized settings.

•

Regulatory restraints on telemedicine are decreasing nationally.

•

The physical exam requires special attention for the implementation of telemedicine for general surgery.

•

Further study is required to determine which general surgery issues are amendable to telemedicine consults.

Telemedicine in the ICU: clinical outcomes, economic aspects, and trainee education

PURPOSE OF REVIEW

The evidence base for telemedicine in the ICU (tele-ICU) is rapidly expanding. The last 2 years have seen important additions to our understanding of when, where, and how telemedicine in the ICU adds value.

RECENT FINDINGS

Recent publications and a recent meta-analysis confirm that tele-ICU improves core clinical outcomes for ICU patients. Recent evidence further demonstrates that comprehensive tele-ICU programs have the potential to quickly recuperate their implementation and operational costs and significantly increase case volumes and direct contribution margins particularly if additional logistics and care standardization functions are embedded to optimize ICU bed utilization and reduce complications. Even though the adoption of tele-ICU is increasing and the vast majority of today's medical graduates will regularly use some form of telemedicine and/or tele-ICU, telemedicine modules have not consistently found their way into educational curricula yet. Tele-ICU can be used very effectively to standardize supervision of medical trainees in bedside procedures or point-of-care ultrasound exams, especially during off-hours. Lastly, tele-ICUs routinely generate rich operational data, as well as risk-adjusted acuity and outcome data across the spectrum of critically ill patients, which can be utilized to support important clinical research and quality improvement projects.

SUMMARY

The value of tele-ICU to improve patient outcomes, optimize ICU bed utilization, increase financial performance and enhance educational opportunities for the next generation of providers has become more evident and differentiated in the last 2 years.

Impact of Intensive Care Unit Telemedicine on Outcomes

Intensive care unit (ICU) telemedicine lowers mortality, shortens length of stay and improves best practice compliance when implemented effectively. As a review of the literature shows, program success is not guaranteed. The model of ICU telemedicine with published results is the one designed to leverage an intensivist-led remote critical care team, assisted by technology, data streaming, and analytics. The value of ICU telemedicine lies in how well the model is applied, leveraged, and integrated into the existing staff, structure, and processes at the bedside. Key domains to master to achieve this integration are discussed.

Quality Improvement and Telemedicine Intensive Care Unit: A Perfect Match

The health care delivery system is complex. New technologies offer new treatment options. The process of quality improvement includes system re-engineering. Telemedicine intensive care is an evolving area of delivery. Its core characteristic is the need for a merger of human and machine activity. Optimal use of quality improvement tools can lead to improved patient-centered outcomes. This article outlines how quality improvement tools can be used to facilitate the patient-centered collaboration with a focus on defining evidence-practice gaps, developing actionable metrics, analyzing the impact of proposed interventions, quantifying resources, prioritizing improvement plans, evaluating results, and diffusing best practices.

Intensive Care Unit Telemedicine Care Models

This review outlines various care models used in tele-intensive care unit (tele-ICU) programs. They may be differentiated by personnel and approach to care. Low-intensity models, such as nocturnal coverage, may be adequate for some ICU practices. Others might benefit from a high-intensity model, especially those practices that desire a proactive approach to care. Also discussed is the incorporation of the education of trainees into tele-ICU models.

Outcomes comparison in patients admitted to low complexity rural and urban intensive care units in the Veterans Health Administration

PURPOSE

To evaluate mortality, length of stay, and inter-hospital transfer in the Veteran Health Administration (VHA) among low complexity Intensive Care Unit (ICU) patients.

MATERIALS AND METHOD

Retrospective study of adult ICU admissions identified in VHA Medical SAS®; 2010-2015 at Veterans Affairs (VA) Medical Centers. Facilities classified by the Rural Urban Commuting Area code algorithm as large rural (referred to as rural) (N = 6) or urban (N = 33).

RESULTS

In rural hospitals, patients (N = 9665) were less likely to have a respiratory (12.9% v. 18.9%; p < .001) diagnosis, more likely diagnosed with sepsis (17.6% v. 4.9%), and had a higher illness severity score (42.0 vs. 41.4; p = .01) compared to urban (N = 65,846) counterparts. Mortality within ICU did not vary across facility rurality. In unadjusted analyses, facility rurality (rural vs. urban) was associated with reduced inter-hospital transfers (OR = 0.74; 95% CI = [0.69, 0.80]; p < .001) and a shorter ICU length of stay (RR = 0.82; 95% CI = [0.74, 0.91]; p < .001). This did not hold when the hierarchical data was accounted for.

CONCLUSIONS

Despite challenges, low complexity ICUs in rural VA facilities fare similarly to urban counterparts. Being part of a national healthcare system may have benefits to explore in sustaining critical care access in rural areas outside the VA healthcare system.