JAMA: Tele-ICUs may lower mortality, length of stay

Telemedicine has been touted as a promising strategy to increase the efficiency of ICUs. While patients’ needs and costs of adult critical care continue to rise, the benefits of a tele-ICU intervention may be associated with lower mortality and shorter length of stay, in addition to stricter adherence to best practices, according to a study published in the June 1 issue of the Journal of the American Medical Association.

In the study, Craig M. Lilly, MD, of the University of Massachusetts Memorial Medical Center, and colleagues sought to quantify the association of ICU telemedicine with hospital mortality, length of stay and complications that are preventable by adherence to best practices. The stepped-wedge clinical practice study assessed 6,290 adults admitted to seven ICUs on two campuses of an 834-bed academic medical center between April 26, 2005 and Sept. 30, 2007.

The researchers found improvement in hospital mortality from the preintervention period to the tele-ICU intervention period.

However, in an accompanying editorial in JAMA, Jeremy M. Kahn, MD, of the department of critical care at the University of Pittsburgh, wrote telemedicine should not be assumed to improve outcomes singularly, and that the “optimal role of telemedicine in the ICU remains uncertain.”

In an earlier study published in JAMA in December 2010, Eric J. Thomas, MD, MPH, University of Texas Medical School at Houston, and colleauges found that remote monitoring of ICU patients in six ICUs of five hospitals was not associated with an overall improvement in mortality or length of stay.

“These results have left clinicians, hospital administrators and policy makers wondering how to best use the technology, if at all,” Kahn wrote.

In the current study, Lilly et al focused on processes of care. They standardized best practices of care and introduced a form for ICU daily goals before the start of the study. A representative sample of preintervention cases was obtained by identifying consecutive hospital discharge cases managed in each of the seven ICUs. The tele-ICU remotely reviewed the care of patients, performed real-time audits of best practice adherence, performed workstation-assisted care plan reviews for patients admitted at night, among multiple other duties. Meanwhile, processes in the preintervention ICU unit included bedside monitor alarms, daily goal sheet and telephone case review initiated by house staff or an affiliate practitioner.

Contrary to Thomas’ earlier findings, Lilly et al recorded significant improvements in mortality, length of stay and stricter adherence to best practices. The hospital mortality rate was 13.6 percent in the preintervention period compared with 11.8 percent during the tele-ICU intervention. 

Investigators also found the tele-ICU intervention period was associated with higher rates of best clinical practice adherence for the prevention of deep vein thrombosis and prevention of stress ulcers, best practice adherence for cardiovascular protection, prevention of ventilator-associated pneumonia, lower rates of preventable complications and a shorter hospital length of stay.

They also “identified more rapid response to alerts for physiological instability, and off-hours, off-site intensivist care plan review as critical care process elements that may have contributed to lower mortality and shorter lengths of stay associated with the tele-ICU intervention.”

“The association of lower mortality and shorter length of stay at an academic medical center implies that there are benefits of the tele-ICU care beyond providing bedside intensivist expertise to ICUs,” the authors wrote. “It is unique because it attributes the association of the intervention with lower mortality to best practice adherence and decreased complication rates targeted by the intervention.”

Kahn argued that the use of telemedicine can improve outcomes, but not alone. “A successful telemedicine program will follow the basic tenets of quality improvement: performing a detailed needs assessment, assessing the barriers to practice change, prioritizing specific projects, introducing effective strategies for improvement, and measuring the results in a stepwise fashion,” he wrote.

“This view of telemedicine as just another instrument for quality improvement has a downside. It means that the question of whether ICU telemedicine is good or bad is tangential to the real issue,” Kahn wrote. “But the upside, as demonstrated by Lilly et al, is that in the right settings and with the right goals, telemedicine can indeed be used to help improve outcome.”