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Abstract & Commentary
ICU Telemedicine Can Improve Patient Outcomes
By David J. Pierson, MD, Editor, Professor, Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, is Editor for Critical Care Alert.
Synopsis: In the ICUs of a well-staffed academic medical center committed to quality improvement, in which closed staffing, multidisciplinary rounds, and the daily use of checklists were already in place, implementation of a 24-hour ICU telemedicine system that was well accepted by the medical staff was associated with impressive improvements in adherence to best practice standards as well as with reductions in hospital mortality and lengths of stay.
Source: Lilly CM, et al. Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes. JAMA 2011;305:2175-2183.
Intensive care unit (ICU) telemedicine has been widely embraced in U.S. hospitals as part of the current focus on preventing medical errors and improving an array of measures related to the quality of care. This comprehensive study from the University of Massachusetts sought to document the impact of implementing ICU telemedicine on patient outcomes and the use of best practices that had already been established in the institution. A culture of enthusiasm for and widespread adoption of quality improvement measures was already in place in the authors' two component hospitals before the study began, as were the following practices:
In a staggered fashion over 10 months, continuous, 7-day, 24-hour ICU telemonitoring was introduced to the 834-bed institution's seven adult ICUs. The intensivists performing the telemonitoring were staff members who also worked in the monitored ICUs. All patients admitted to the three medical, three surgical, and one mixed cardiovascular ICUs for several months before and several months after the switch to telemedicine in the respective units were included in the study. The primary outcome measures were case-mix and severity-adjusted hospital mortality before and after introduction of ICU telemedicine in the ICU in question; others included hospital and ICU lengths of stay, adherence to best practices, and complication rates.
During the prospective, stepped-wedge clinical practice study design period, 6465 patients were admitted to the study ICUs, of whom 6290 met all entry criteria and were evaluated. Slightly more of the telemedicine-period patients had medical rather than surgical diagnoses, and their severity of illness was slightly greater; otherwise the patient population did not change. Hospital mortality declined from 13.6% (95% confidence interval [CI], 11.9-15.4%) to 11.8% (95% CI, 10.9-12.8%) after implementation of telemedicine (adjusted odds ratio, 0.40; 95% CI 0.31-0.52). Concomitantly, adherence to best practices in the ICUs increased (prevention of deep venous thrombosis, 85% vs 99%; stress ulcer prevention, 83% vs 96%; cardiovascular protection, 80% vs 99%; prevention of ventilator-associated pneumonia, 33% vs 52%). The rates of ventilator-associated pneumonia (OR, 0.15; 95% CI, 0.09-0.23) and catheter-related bloodstream infections (OR, 0.50; 95% CI, 0.27-0.93) went down after implementation of ICU telemedicine, and hospital lengths of stay decreased significantly, with no differences between the clinical services (medicine vs surgery) on which the patients were managed.
This study demonstrated statistically significant, clinically important improvements in the outcome variables examined after implementation of ICU telemedicine. However, the title of this abstract/commentary was deliberately chosen as "telemedicine CAN improve outcomes" rather than that it WILL do so. A recent systematic review1 and two thoughtful commentaries by Kahn2,3 emphasize that positive results from the implementation of an ICU telemedicine system are not automatic and cannot be expected unless several other things are also present.
The meta-analysis by Young et al1 shows that the research previously published in this area is generally weak and has mainly consisted of observational time-series, which are notoriously susceptible to bias and confounding. In addition, several previous studies have failed to show benefits from implementing ICU telemedicine. As pointed out by Kahn,2,3 these studies have had at least two important differences from the present study of Lilly et al. First, local physician buy-in of ICU telemedicine has been poor, with only a minority of them participating in the study institutions. The Lilly study took place in an institution in which a culture of quality improvement had already been firmly established. The physicians doing the telemonitoring were fully integrated into the medical staff, and buy-in on the part of the overall staff was excellent. Second, the implemented telemedicine programs in the negative studies have focused primarily on preventing medical errors — and generally only at night — rather than on improving adherence to best practices across the board. As Kahn states, "rather than using ICU telemedicine to prevent medical errors, perhaps we should use it to implement ICU best practices, such as evidence based sedation and mechanical ventilator management."3
This study shows that, in the right institutional environment and as part of a comprehensive, system-wide program to improve ICU outcomes by identifying and implementing evidence-based best practices, ICU telemedicine can further those efforts and benefit patients. However, introducing telemedicine in the absence of the other components of the program employed by Lilly et al would seem to offer much less promise of success.