ICU telemedicine intervention decreased mortality, hospital length of stay

Lilly CM. JAMA. 2011;doi:10.1001/jama.2011.697.

Implementing a telemedicine intervention resulted in lower hospital and intensive care unit mortality, lower rates of preventable complications and shorter hospital and intensive care unit lengths of stay, according to data from a clinical practice study.

“Several studies have highlighted low levels of acceptance of the tele-ICU intervention, but few studies have identified the care processes or ICU structural elements that were part of the intervention; these issues have limited the ability to compare studies and identify processes associated with improved outcomes,” the researchers wrote.

Craig M. Lilly, MD, and colleagues at the University of Massachusetts Memorial Medical Center conducted a prospective, unblinded, stepped-wedge study from April 2005 to September 2007 to determine whether a tele-ICU intervention was associated with a risk for hospital death or length of stay, and the relationship of best practice adherences and preventable complications. The study included 6,290 adults admitted to one of seven ICUs, including three medical, three surgical and one mixed cardiovascular on two campuses of an 834-bed academic medical center.

The researchers evaluated the care of individual patients, performed real-time audits of best practice adherence, 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 considered physiologically unstable. The offsite and bedside teams were able to communicate or offsite clinicians managed patients directly by recording clinician orders for tests, treatments, consultations and management of life-support devices, according to a press release.

During the pre-intervention period, the hospital mortality rate was 13.6% (95% CI, 11.9-15.4) compared with 11.8% (95% CI, 10.9-12.8) during the tele-ICU intervention period (OR=0.40; 95% CI, 0.31-0.52). Compared with the pre-intervention period, the intervention period was associated with increases in best practice adherence for preventing deep vein thrombosis (85% vs. 99%; OR=15.4; 95% CI, 11.3-21.1), preventing stress ulcers (83% vs. 96%; OR=4.57; 95% CI, 3.91-5.77) and best practice adherence for cardiovascular protection (80% vs. 99%; OR=30.7; 95% CI, 19.3-49.2).

The intervention period compared with the pre-intervention period was also associated with increases in prevention of ventilator-associated pneumonia (52% vs. 33%; OR=2.20; 95% CI, 1.79-2.70), lower rates of preventable complications (1.6% vs. 13% for ventilated-associated pneumonia; [OR=0.15; 95% CI, 0.09-0.23] and 0.6% vs. 1% for catheter-related bloodstream infections; [OR=0.50; 95% CI, 0.27-0.93]), and shorter hospital length of stay (9.8 vs. 13.3 days; HR for discharge=1.44; 95% CI, 1.33-1.56).

According to the researchers, results were similar for all three types of ICUs evaluated.

The intervention group was also associated with a decrease in the number of patients requiring mechanical ventilation and a decrease in the duration of mechanical ventilation. Patients in the intervention group were 8% more likely to go home, 6% less likely to go to rehabilitation or to a long-term care facility and 2% more likely to go to a skilled nursing facility than patients in the pre-intervention group, according to the release.

“An adult tele-ICU intervention 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 was associated with lower mortality and shorter lengths of stay,” the researchers wrote. “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.”

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