Introducing the remote monitoring that characterizes "telemedicine" into intensive care units made no significant difference, either positive or negative, in death rates or lengths of stay, researchers said.
In the first large, multicenter evaluation of tele-ICU technology, hospital and ICU mortality rates (after adjusting for illness severity) both declined slightly after remote monitoring by intensivists was introduced, but the differences did not achieve statistical significance, reported Eric J. Thomas, MD, MPH, of the University of Texas Medical School at Houston, and colleagues.
Mean length of stay, inhospital as well as in ICUs, increased slightly after the remote monitoring began, the researchers also reported in the Dec. 23/30 issue of the Journal of the American Medical Association.
Many in the medical community have looked to telemedicine as a way to stretch the limited number of intensivists.
Thomas and colleagues noted that onsite staffing of ICUs with certified intensivists is associated with improved outcomes, but there are not enough of these professionals to provide full-time coverage of all ICUs.
This situation "has led to the use of telemedicine technology to allow intensivists to remotely and simultaneously care for patients in several ICUs," Thomas and colleagues wrote.
But whether outcomes are improved by having ICU patients monitored by intensivists at remote locations, compared with hospitalists or other physicians working directly in the ICU, hadn't been studied rigorously before.
So Thomas and colleagues analyzed data from six ICUs in five hospitals in the Gulf Coast region, including 2,034 patients treated before a tele-ICU system was introduced and 2,108 patients treated afterward.
The centralized system serving all the participating hospitals was implemented at different times for each of the six ICUs, from March 2004 to September 2005.
It included audiovisual monitors and was staffed by two intensivists on weekdays from noon until 7:00 a.m. the following day and round-the-clock on weekends. Four registered nurses and two administrative technicians were also stationed in the tele-ICU center for the full 168 hours every week.
Each intensivist worked with two nurses and one technician to cover half the ICU beds.
The participating ICUs included one "closed" (admitting privileges open only to intensivists), 16-bed medical unit; one closed 11-bed trauma and surgical unit; and four open medical-surgical units totaling 60 beds. Two of the latter were in small community hospitals and the others were in large urban institutions.
Staffing protocols varied among these ICUs both before and after the intervention. For example, one of the open units had onsite intensivist coverage for about half of patients, while only about 10% were seen by intensivists in another.
Moreover, after the intervention was begun, individual physicians determined how much authority the remote unit had in caring for their patients. Admitting physicians could allow tele-ICU staff to intervene only in life-threatening situations, or they could let the remote team give routine orders and change treatment plans freely.
In the end, the researchers found, "almost two-thirds of the patients in our study had physicians who chose minimal delegation to the tele-ICU," which may have contributed to the lack of significant outcomes improvement in the study.
The specific summary findings before and after the tele-ICU was introduced were:
- Hospital mortality: 12.0% before (95% CI 10.6% to 13.5%), 9.9% after (95% CI 8.6% to 11.2%)
- ICU mortality: 9.2% before (95% CI 8.0% to 10.5%), 7.8% after (95% CI 6.7% to 9.0%)
- Mean hospital length of stay: 9.8 days before (95% CI 9.4 to 10.2), 10.7 days after (95% CI 10.2 to 11.1)
- Mean ICU length of stay: 4.3 days before (95% CI 4.0 to 4.5), 4.6 days after (95% CI 4.3 to 4.9)
Patients with more severe illness at admission did, however, appear to derive significant benefit from the tele-ICU system.
Post-hoc analysis showed that patients with Simplified Acute Physiology Score II (SAPS II) values of 39 or more had significantly lower hospital mortality rates after the intervention, whereas those with lower scores had higher mortality, the researchers reported.
They also found that the longer hospital length of stay failed to reach significance after results were adjusted for SAPS II scores.
Complication rates were also similar before and after the intervention, and there were no differences in results for closed versus open ICUs.
Besides the lack of delegation to the tele-ICU remote teams, Thomas and colleagues speculated that another reason for the lack of major outcomes improvement could have been lack of full coordination between onsite and remote staff.
"The tele-ICU and the monitored units did not share clinical notes or computerized physician order entry within a common electronic record. These notes were instead faxed to the tele-ICU daily," the researchers wrote. "Greater integration of clinical information might have resulted in a larger effect on mortality."
In an accompanying editorial, two other health-policy researchers called the study "a step forward" in understanding whether telemedicine is useful, but they said the variability in how it was implemented in the study hospitals made the findings hard to interpret.
Erika Yoo, MD, and R. Dudley Adams, MD, MBA, both of the University of California San Francisco, noted that the open ICUs, which comprised most of the beds included in the study, "were variable in their degree of exposure to intensivist care."
They also wrote that ICU procedures and staffing protocols are vital in determining outcomes, but these are far from uniform.
"Given the heterogeneity of tele-ICU systems and the hospitals adopting them, it is unlikely that any single study can definitely address the benefits of telemedicine for the critically ill," Yoo and Adams wrote.
They argued that future research needs to define and collect data on individual components of tele-ICU systems so that their contributions to outcome improvements, or lack thereof, can be evaluated.
"Tele-ICU is a potentially valuable change in ICU care, but its complexity means that 'tele-ICU improves care' is not a testable hypothesis," they argued.
Reposted from: http://www.medpagetoday.com/CriticalCare/Intensivists/17723
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