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Does ICU Telemedicine Improve Outcomes? Current State of the Evidence

  • Ricardo Teijeiro
  • M. Elizabeth WilcoxEmail author
Chapter

Abstract

Onsite staffing by intensivists has been associated with lower morbidity and mortality. However, there is an existing gap that is widening between intensivist workforce and patient demand. Tele-ICU has been proposed as an efficient method for intensivist care as it offers the possibility of reducing latency response times to urgent pages, providing inpatient consultation in areas where an intensivist is not immediately available, increasing adherence to best practices, and providing monitoring via a technology bundle that may not otherwise exist.

To date, existing studies of tele-ICU effectiveness have had mixed results. Although ICU mortality has been consistently reduced by tele-ICU implementation, secondary outcomes such as hospital mortality and hospital length of stay have not been consistently shown a benefit. Differing technology configuration, baseline ICU organizational characteristics, case mix of the implementation site, and the “dose” of the intervention may be responsible for these discrepancies. ICUs most likely to benefit from tele-ICU seem to have less infrastructure by way of quality audit and feedback processes. However, the existing evidence is limited by the absence of randomized or quasi-randomized trials of tele-ICU implementation and relies only on before-after observational designs.

As tele-ICU implementation carries the burden of significant cost and upkeep, a number of groups are investigating the core components responsible for reported benefit with the hopes of improving its cost-effectiveness. It seems that technology implementation is insufficient to ensure effectiveness, and as such concentrated efforts to systems reengineering and promoting a strong culture of collaboration between caregiving parties are of paramount importance.

Keywords

Tele-ICU Implementation guidelines Outcomes Systems reengineering Cost-effectiveness 

References

  1. 1.
    Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002;288(17):2151–62.PubMedCrossRefGoogle Scholar
  2. 2.
    Gershengorn HB, Harrison DA, Garland A, Wilcox ME, Rowan KM, Wunsch H. Association of intensive care unit patient-to-intensivist ratios with hospital mortality. JAMA Intern Med. 2017;177(3):388–96.PubMedCrossRefGoogle Scholar
  3. 3.
    Kerlin MP, Adhikari NK, Rose L, Wilcox ME, Bellamy CJ, Costa DK, Gershengorn HB, Halpern SD, Kahn JM, Lane-Fall MB, et al. An Official American Thoracic Society Systematic review: the effect of nighttime intensivist staffing on mortality and length of stay among intensive care unit patients. Am J Respir Crit Care Med. 2017;195(3):383–93.PubMedGoogle Scholar
  4. 4.
    Wilcox ME, Chong CA, Niven DJ, Rubenfeld GD, Rowan KM, Wunsch H, Fan E. Do intensivist staffing patterns influence hospital mortality following ICU admission? A systematic review and meta-analyses. Crit Care Med. 2013;41(10):2253–74.PubMedCrossRefGoogle Scholar
  5. 5.
    Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J Jr. Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA. 2000;284(21):2762–70.PubMedCrossRefGoogle Scholar
  6. 6.
    Halpern NA, Pastores SM, Greenstein RJ. Critical care medicine in the United States 1985–2000: an analysis of bed numbers, use, and costs. Crit Care Med. 2004;32(6):1254–9.PubMedCrossRefGoogle Scholar
  7. 7.
    Cooper RA. There’s a shortage of specialists: is anyone listening? Acad Med. 2002;77(8):761–6.PubMedCrossRefGoogle Scholar
  8. 8.
    Coustasse A, Deslich S, Bailey D, Hairston A, Paul D. A business case for tele-intensive care units. Perm J. 2014;18(4):76–84.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Venditti A, Ronk C, Kopenhaver T, Fetterman S. Tele-ICU “myth busters”. AACN Adv Crit Care. 2012;23(3):302–11.PubMedCrossRefGoogle Scholar
  10. 10.
    Davis TM, Barden C, Gavish A, Goran S, Jackson W, Goliash I, Graley A, Herr P, Marcin JP, Morris JM, et al. Policy: American Telemedicine Association guidelines for teleICU operations. Telemed e-Health. 2016;22(12):1–10.CrossRefGoogle Scholar
  11. 11.
    Wilcox ME, Adhikari NK. The effect of telemedicine in critically ill patients: systematic review and meta-analysis. Crit Care. 2012;16(4):R127.PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Thomas EJ, Lucke JF, Wueste L, Weavind L, Patel B. Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay. JAMA. 2009;302(24):2671–8.PubMedCrossRefGoogle Scholar
  13. 13.
    Morrison JL, Cai Q, Davis N, Yan Y, Berbaum ML, Ries M, Solomon G. Clinical and economic outcomes of the electronic intensive care unit: results from two community hospitals. Crit Care Med. 2010;38(1):2–8.PubMedCrossRefGoogle Scholar
  14. 14.
    Rosenfeld BA, Dorman T, Breslow MJ, Pronovost P, Jenckes M, Zhang N, Anderson G, Rubin H. Intensive care unit telemedicine: alternate paradigm for providing continuous intensivist care. Crit Care Med. 2000;28(12):3925–31.PubMedCrossRefGoogle Scholar
  15. 15.
    Breslow MJ, Rosenfeld BA, Doerfler M, Burke G, Yates G, Stone DJ, Tomaszewicz P, Hochman R, Plocher DW. Effect of a multiple-site intensive care unit telemedicine program on clinical and economic outcomes: an alternative paradigm for intensivist staffing.[Erratum appears in Crit Care Med. 2004 Jul;32(7):1632]. Crit Care Med. 2004;32(1):31–8.PubMedCrossRefGoogle Scholar
  16. 16.
    Marcin JP, Schepps DE, Page KA, Struve SN, Nagrampa E, Dimand RJ. The use of telemedicine to provide pediatric critical care consultations to pediatric trauma patients admitted to a remote trauma intensive care unit: a preliminary report. Pediatr Crit Care Med. 2004;5(3):251–6.PubMedCrossRefGoogle Scholar
  17. 17.
    Kohl BA, Gutsche JT, Kim P, Sites FD, Ochroch EA. Effect of telemedicine on mortality and length of stay in a University hospital [abstract]. Crit Care Med. 2007;35:A111.Google Scholar
  18. 18.
    Vespa PM, Miller C, Hu X, Nenov V, Buxey F, Martin NA. Intensive care unit robotic telepresence facilitates rapid physician response to unstable patients and decreased cost in neurointensive care. Surg Neurol. 2007;67(4):331–7.PubMedCrossRefGoogle Scholar
  19. 19.
    Norman V, French R, Hassan E, Kabani N, Stone D, Griebel J Jr, Tragico E. Effect of a telemedicine facilitated program on intensive care unit length of stay (LOS) and financial performance. Crit Care Med. 2009;37(12):A3.Google Scholar
  20. 20.
    Zawada ET Jr, Herr P, Larson D, Fromm R, Kapaska D, Erickson D. Impact of an intensive care unit telemedicine program on a rural health care system. Postgrad Med. 2009;121(3):160–70.PubMedCrossRefGoogle Scholar
  21. 21.
    McCambridge M, Jones K, Paxton H, Baker K, Sussman EJ, Etchason J. Association of health information technology and teleintensivist coverage with decreased mortality and ventilator use in critically ill patients. Arch Intern Med. 2010;170(7):648–53.PubMedCrossRefGoogle Scholar
  22. 22.
    Lilly CM, Cody S, Zhao H, Landry K, Baker SP, McIlwaine J, Chandler MW, Irwin RS, University of Massachusetts Memorial Critical Care Operations Group. 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(21):2175–83.PubMedCrossRefGoogle Scholar
  23. 23.
    Lilly CM, McLaughlin JM, Zhao H, Baker SP, Cody S, Irwin RS. Group UMMCCO: a multicenter study of ICU telemedicine reengineering of adult critical care. Chest. 2014;145(3):500–7.PubMedCrossRefGoogle Scholar
  24. 24.
    Willmitch B, Golembeski S, Kim SS, Nelson LD, Gidel L. Clinical outcomes after telemedicine intensive care unit implementation. Crit Care Med. 2012;40(2):450–4.PubMedCrossRefGoogle Scholar
  25. 25.
    Sadaka F, Palagiri A, Trottier S, Deibert W, Gudmestad D, Sommer SE, Veremakis C. Telemedicine intervention improves ICU outcomes. Crit Care Res Prac. 2013;2013:456389.Google Scholar
  26. 26.
    Nassar BS, Vaughan-Sarrazin MS, Jiang L, Reisinger HS, Bonello R, Cram P. Impact of an intensive care unit telemedicine program on patient outcomes in an integrated health care system. JAMA Intern Med. 2014;174(7):1160–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Fortis S, Sarrazin MV, Beck BF, Panos RJ, Reisinger HS. ICU telemedicine reduces interhospital ICU transfers in the Veterans Health Administration. Chest. 2018;154(1):69–76.PubMedCrossRefGoogle Scholar
  28. 28.
    Howell GH, Lem VM, Ball JM. Remote ICU care correlates with reduced health system mortatality and length of stay outcomes. Chest. 2007;132(4):443S.CrossRefGoogle Scholar
  29. 29.
    Rincon T, Seiver A, Farrell W, Daly MA. Increased documentation of ICD-9-CM codes and template-oriented monitoring and screening with tele-ICU. Crit Care Med. 2009;37(12):A5.Google Scholar
  30. 30.
    Institute NEH: Critical care, critical choices: the case for tele-ICUs in intensive care. 2010. https://www.nehi.net/writable/publication_files/file/teleicu_critical_care_critical_choices.pdf.
  31. 31.
    Marcin JP, Nesbitt TS, Kallas HJ, Struve SN, Traugott CA, Dimand RJ. Use of telemedicine to provide pediatric critical care inpatient consultations to underserved rural Northern California. J Pediatr. 2004;144(3):375–80.PubMedCrossRefGoogle Scholar
  32. 32.
    Davis K, Perry-Moseanko A, Tadlock MD, Henry N, Pamplin J. Successful implementation of low-cost tele-critical care solution by the U.S. Navy: initial experience and recommendations. Mil Med. 2017;182(5):e1702–7.PubMedCrossRefGoogle Scholar
  33. 33.
    Franzini L, Sail KR, Thomas EJ, Wueste L. Costs and cost-effectiveness of a telemedicine intensive care unit program in 6 intensive care units in a large health care system. J Crit Care. 2011;26(3):329.e321–6.CrossRefGoogle Scholar
  34. 34.
    Lilly CM, Motzkus C, Rincon T, Cody SE, Landry K, Irwin RS, UMass Memorial Critical Care Operations Group. ICU telemedicine program financial outcomes. Chest. 2017;151(2):286–97.PubMedCrossRefGoogle Scholar
  35. 35.
    Chen J, Sun D, Yang W, Liu M, Zhang S, Peng J, Ren C. Clinical and economic outcomes of telemedicine programs in the intensive care unit: a systematic review and meta-analysis. J Intensive Care Med. 2018;33(7):383–93.PubMedCrossRefGoogle Scholar
  36. 36.
    Young LB, Chan PS, Lu X, Nallamothu BK, Sasson C, Cram PM. Impact of telemedicine intensive care unit coverage on patient outcomes: a systematic review and meta-analysis. Arch Intern Med. 2011;171(6):498–506.PubMedCrossRefGoogle Scholar
  37. 37.
    Kowitlawakul Y. The technology acceptance model: predicting nurses’ intention to use telemedicine technology (eICU). Comput Inform Nurs. 2011;29(7):411–8.PubMedCrossRefGoogle Scholar
  38. 38.
    Kleinpell R, Barden C, Rincon T, McCarthy M, Zapatochny Rufo RJ. Assessing the impact of telemedicine on nursing care in intensive care units. Am J Crit Care. 2016;25(1):e14–20.PubMedCrossRefGoogle Scholar
  39. 39.
    Chu-Weininger MY, Wueste L, Lucke JF, Weavind L, Mazabob J, Thomas EJ. The impact of a tele-ICU on provider attitudes about teamwork and safety climate. Qual Saf Health Care. 2010;19(6):e39.PubMedGoogle Scholar
  40. 40.
    Ries M. Tele-ICU: a new paradigm in critical care. Int Anesthesiol Clin. 2009;47(1):153–70.PubMedCrossRefGoogle Scholar
  41. 41.
    Groves RH Jr, Holcomb BW Jr, Smith ML. Intensive care telemedicine: evaluating a model for proactive remote monitoring and intervention in the critical care setting. Stud Health Technol Inform. 2008;131:131–46.PubMedGoogle Scholar
  42. 42.
    Ikeda DH. The impact of using a standard protocol for the surviving sepsis 6 and 24 hr bundles in septic patients on total icu risk adjusted mortality. Crit Care Med. 2006;34(12):A108.CrossRefGoogle Scholar
  43. 43.
    Loyola S, Wilhelm J, Fornos J. An innovative approach to meeting early goal-directed therapy using telemedicine. Crit Care Nurs Q. 2011;34(3):187–99.PubMedCrossRefGoogle Scholar
  44. 44.
    Breslow MJ. Remote ICU care programs: current status. J Crit Care. 2007;22(1):66–76.PubMedCrossRefGoogle Scholar
  45. 45.
    Yoo BK, Kim M, Sasaki T, Melnikow J, Marcin JP. Economic evaluation of telemedicine for patients in ICUs. Crit Care Med. 2016;44(2):265–74.PubMedCrossRefGoogle Scholar
  46. 46.
    Franzini L, Thomas E. Costs and effectiveness of tele-ICUs in reducing morbidity and mortality in intensive care units. J Med Econ. 2008;11(1):165–9.PubMedCrossRefGoogle Scholar
  47. 47.
    Young MP, Birkmeyer JD. Potential reduction in mortality rates using an intensivist model to manage intensive care units. Eff Clin Pract. 2000;3(6):284–9.PubMedGoogle Scholar
  48. 48.
    Milstein A, Galvin RS, Delbanco SF, Salber P, Buck CR Jr. Improving the safety of health care: the leapfrog initiative. Eff Clin Pract. 2000;3(6):313–6.PubMedGoogle Scholar
  49. 49.
    Yoo BK, Kim M, Sasaki T, Hoch JS, Marcin JP. Selected use of telemedicine in intensive care units based on severity of illness improves cost-effectiveness. Telemed J E Health. 2018;24(1):21–36.PubMedCrossRefGoogle Scholar
  50. 50.
    Lilly CM, Fisher KA, Ries M, Pastores SM, Vender J, Pitts JA, Hanson CW 3rd. A national ICU telemedicine survey: validation and results. Chest. 2012;142(1):40–7.PubMedCrossRefGoogle Scholar
  51. 51.
    Kahn JM, Hill NS, Lilly CM, Angus DC, Jacobi J, Rubenfeld GD, Rothschild JM, Sales AE, Scales DC, Mathers JAL. The research agenda in ICU telemedicine: a statement from the Critical Care Societies Collaborative. Chest. 2011;140(1):230–8.PubMedPubMedCentralCrossRefGoogle Scholar
  52. 52.
    Lilly CM, Thomas EJ. Tele-ICU: experience to date. J Intensive Care Med. 2010;25(1):16–22.PubMedCrossRefGoogle Scholar
  53. 53.
    Gabler NB, Ratcliffe SJ, Wagner J, Asch DA, Rubenfeld GD, Angus DC, Halpern SD. Mortality among patients admitted to strained intensive care units. Am J Respir Crit Care Med. 2013;188(7):800–6.PubMedPubMedCentralCrossRefGoogle Scholar
  54. 54.
    Anesi GL, Liu VX, Gabler NB, Delgado MK, Kohn R, Weissman GE, Bayes B, Escobar GJ, Halpern SD. Associations of ICU capacity strain with disposition and outcomes of patients with sepsis presenting to the emergency department. Ann Am Thorac Soc. 2018;15:1328.PubMedCrossRefGoogle Scholar
  55. 55.
    Brown SE, Rey MM, Pardo D, Weinreb S, Ratcliffe SJ, Gabler NB, Halpern SD. The allocation of intensivists’ rounding time under conditions of intensive care unit capacity strain. Am J Respir Crit Care Med. 2014;190(7):831–4.PubMedPubMedCentralCrossRefGoogle Scholar
  56. 56.
    Kahn JM, Le TQ, Barnato AE, Hravnak M, Kuza CC, Pike F, Angus DC. ICU telemedicine and critical care mortality: a national effectiveness study. Med Care. 2016;54(3):319–25.PubMedPubMedCentralCrossRefGoogle Scholar
  57. 57.
    Hua M, Halpern SD, Gabler NB, Wunsch H. Effect of ICU strain on timing of limitations in life-sustaining therapy and on death. Intensive Care Med. 2016;42(6):987–94.PubMedPubMedCentralCrossRefGoogle Scholar
  58. 58.
    Wagner J, Gabler NB, Ratcliffe SJ, Brown SE, Strom BL, Halpern SD. Outcomes among patients discharged from busy intensive care units. Ann Intern Med. 2013;159(7):447–55.PubMedPubMedCentralCrossRefGoogle Scholar
  59. 59.
    Weissman GE, Gabler NB, Brown SE, Halpern SD. Intensive care unit capacity strain and adherence to prophylaxis guidelines. J Crit Care. 2015;30(6):1303–9.PubMedPubMedCentralCrossRefGoogle Scholar
  60. 60.
    Howell MD. Managing ICU throughput and understanding ICU census. Curr Opin Crit Care. 2011;17(6):626–33.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Instituto Nacional de Ciencias Medicas y Nutrición Salvador ZubiránMexico CityMexico
  2. 2.Department of Medicine (Respirology)University Health NetworkTorontoCanada
  3. 3.Interdepartmental Division of Critical Care MedicineUniversity of TorontoTorontoCanada

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