Intensive care units (ICUs) that implemented a telemedicine intervention with electronic monitoring of critically ill patients by health care professionals located remotely had lower hospital and ICU mortality, lower rates of preventable complications and shorter hospital and ICU lengths of stay, according to a study conducted by clinical researchers at UMass Medical School. The study, which will appear in the online edition of the June 1 issue of the Journal of the American Medical Association, is being published early to coincide with its presentation at a meeting of the American Thoracic Society.
“Patient needs and societal costs of adult critical care have increased and more efficient methods of delivery of care are needed,” wrote Craig M. Lilly, MD, professor of medicine, anesthesiology and surgery at UMass Medical School, director of the eICU Program at UMass Memorial Medical Center and principal investigator of the study. “A tele-intensive care unit is a promising technological approach designed to systematically alter processes of care that effect outcomes.”
Tele-ICU clinicians located remotely use audio, video and electronic links to assist bedside caregivers in monitoring patients, to oversee best practice adherence and to help create and execute care plans. Tele-ICU programs have the potential to target processes that are associated with better outcomes, including shorter response times to alarms and abnormal laboratory values, more rapid initiation of life-saving therapies, and higher rates of adherence to critical care best practices, according to the article.
To examine which tele-ICU-related process changes are associated with better outcomes, Lilly and colleagues at UMass Medical School evaluated the association of a tele-ICU intervention with the risk of dying in the hospital and length of stay, and the relationship of best practice adherence and preventable complications to these outcomes. The study, performed from April 2005 through September 2007, included 6,290 adults admitted to any of seven ICUs (three medical, three surgical and one mixed cardiovascular) on two UMass Memorial Medical Center campuses.
The off-site tele-ICU team included an intensivist and tele-ICU workstations. Among the responsibilities of the team were reviewing the care of individual patients; performing real-time audits of best practice adherence; monitoring system-generated electronic alerts; auditing bedside clinician responses to in-room alarms; and intervening when the responses of bedside clinicians were delayed and patients were deemed physiologically unstable. The off-site team had the ability to communicate with bedside clinicians or directly manage patients by recording clinician orders for tests, treatments, consultations and management of life-support devices.
After an analysis of the data from the study period, the researchers found that the hospital mortality rate was 13.6 percent during the pre-intervention period compared with 11.8 percent during the tele-ICU intervention. The ICU mortality rate was 10.7 percent for the pre-intervention group and 8.6 percent for the tele-ICU group. The length of hospital stay was 13.3 days in the pre-intervention group and 9.8 days in the tele-ICU group. The length of ICU stay was 6.4 days in the pre-intervention group and 4.5 days in the tele-ICU group.
Tele-ICU was also associated with notable improvements in the prevention of common complications seen in ICUs, such as deep vein thrombosis, stress ulcers and ventilation-assisted pneumonia.
“Even in an adult ICU at an academic medical center that had been previously well staffed with a dedicated intensivist model and had robust best practice programs in place before the intervention, tele-ICU intervention was associated with lower mortality and shorter lengths of stay,” wrote the authors. “Only part of these associations could be attributed to following best practice guidelines and lower rates of preventable complications. 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.”