Special Feature: Telemedicine in the ICU: Views of Adopters and Non-adopters
Special Feature
Telemedicine in the ICU: Views of Adopters and Non-adopters
By Leslie A. Hoffman, PhD, RN, Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh, is Associate Editor for Critical Care Alert.
The introduction of telemedicine in the ICU dates to the 1980s when Grundy and colleagues reported results of an 18-month trial using interactive television to provide consultation between university-based critical care physicians and a small (7-bed) inner city ICU with no intensivist of its own.1 The project was evaluated as successful in extending specialist expertise despite some organizational and technical difficulties. Today, ICU telemedicine is advocated as a potential means of solving the same problem that prompted this early study — insufficient intensivists to meet the needs of critically ill patients, especially in small and more remote facilities. The web site of the dominant ICU telemedicine vendor, VISICU®, relates that 200 hospitals in 40 health systems in 28 states now use this technology, which equates to approximately 300,000 monitored patients. While these data support widespread adoption, a recent report concluded that there were limited objective data to judge the effectiveness of this technology.2 This essay presents a summary of this report and other studies examining the use of telemedicine within the ICU.
System Implementation
In the telemedicine model, physicians and nurses located in a central monitoring station observe the care of patients in multiple ICUs. They use a combination of visual and electronic monitoring and data from system software to identify early indicators of a change in patient status and communicate suggestions regarding patient management to the bedside staff. The software also provides the potential to sort patients by acuity, diagnosis, or treatment, monitor patient outcomes, and identify gaps in standards of care.2,3
There is evidence that such monitoring can be beneficial. A study that examined events preceding medical emergency team (MET) calls on 5 medical and 5 surgical wards in a university hospital reported that almost half (44%) of the 108 calls were delayed, i.e., defined as events with documented evidence that pre-established criteria for the MET call were present for more than 30 minutes before the team was notified.4 In a second study involving > 18,000 hours of continuous monitoring in a step-down ICU, practitioners were blind to use of an electronic monitoring system (BioSyn®). The BioSyn system detected MET events an average of 6.3 hours before the team was called.5 Neither study occurred in a high-acuity ICU, where patient instability might have been detected earlier. However, there are notable benefits from a "second set of eyes," such as would be provided by these advanced monitoring systems.
Telemedicine Goals
The goals of ICU telemedicine are to provide access to critical care specialists without regard to time of day or local availability, to improve clinical decision-making, and to provide the ability to consistently implement processes of care designed to improve patient outcomes.6 While conducting a study of 12 nationally representative communities that included interviews with 453 health care leaders, Berenson and colleagues encountered 5 hospitals in different systems that had adopted ICU telemedicine (adopters), whereas the remainder located in similarly sized communities (non-adopters) had not.2 This observation prompted additional interviews with clinicians in adopter and non-adopter institutions to explore reasons for these differences. Adopters cited common reasons for their decision, including a desire to improve the quality of care, enhance hospital reputation for quality and innovation, and leverage intensivist staffing to cover more patients and improve patient outcomes. Some adopters viewed this approach as a means to promote a regional care delivery system.2 In contrast, non-adopters viewed their current care delivery system as adequate or nearly so and felt that bedside ICU staff could provide superior care. They also cited the need for the hospital to provide on-site intensivists to perform procedures, communicate with families, and supervise housestaff irrespective of the use of telemedicine.2
Impact on Patient Care
Several studies support the benefits of ICU telemedicine.7-9 Rosenfeld and colleagues compared outcomes in a surgical ICU before implementation of telemedicine when intensivist consultation was available but not on-site with outcomes following use of remote monitoring.7 Severity-adjusted ICU mortality decreased during the intervention by 68% and 46% compared with two 16-week periods before the intervention. Comparison of the outcomes during ICU telemedicine with the two 16-week periods also resulted in a reduction in hospital mortality (33% and 30%, respectively), ICU complications (44% and 50%, respectively), and ICU length of stay (34% and 30%, respectively). Although it is possible to speculate that the improved patient outcomes were due to the addition of ICU telemedicine, such improvement could be due to a number of factors. Similar results might have been achieved by changing to an on-site intensivist model of care and/or making the computer-based monitoring tools used with ICU telemedicine available to the unit. Other studies that report benefits of telemedicine also used a retrospective design and therefore are subject to the same limitations.8,9 No randomized trials have tested benefits of this care delivery system. While acknowledging inability to objectively isolate benefits, hospital chief medical officers and ICU directors in adopter systems remained strong advocates of this approach.2
Impact on Staffing
Some believe that telemedicine allows clinicians more time to interact with families or accomplish activities related to quality improvement (QI) initiatives, while relying on the intensivists and nurses involved in electronic surveillance to provide alerts if problems develop.2 However, Tang and colleagues reported that workflow was frequently interrupted and redirected during ICU telemedicine.10 Overall, physicians had an average of 2.2 ± 1.1 interruptions per hour and nurses had 7.5 ± 2.2 interruptions per hour, an outcome they found concerning. They observed that the interrupted task often was not resumed because the clinician did not recall what was being done before the interruption.
Synchronization
In all but 1 of the 5 adopter hospitals, barriers were identified, e.g., vital signs and laboratory data could be imported into the electronic monitoring system but other data such as intravenous fluid volume, ventilator settings, and medications could not when using the VISICU system. This resulted in time spent moving data from one system to another.2 However, those using an alternate system, Metavision®, report full ability to interface with bedside monitors, data from mechanical ventilators, etc., so that there was no longer a need to physically record patient data.3 As a consequence, time spent recording data could be transferred to time spent intervening.3
Costs
Several hospital systems have used ICU telemonitoring to promote use of QI initiatives such as "ventilator bundle." One reported > 95% compliance in 6 weeks, with a concomitant drop in the ventilator-associated pneumonia rate that was sustained for > 30 weeks.6 Others reported that improvements in quality of care and cost reductions were difficult to isolate.2 Cost savings were not cited as a reason for adoption of telemedicine, given lack of reimbursement for this care modality. Costs were estimated at $3-$5 million to equip 100 ICU beds, $300,000 yearly for operating costs, and $1-2 million per year per 100 beds for staffing.
Summary
There are a number of reported benefits of ICU telemedicine (see Table), including substantial reductions in mortality, ICU and hospital length of stay, and complications. However, design limitations make it difficult to isolate the impact of ICU telemedicine from ongoing QI activities and/or changes in patient acuity or unit staffing. Consequently, there is little objective information by which to judge the merits of this innovation, despite strong views supporting benefits (or lack thereof). Given the substantial costs of ICU care and benefits that might derive from identifying best practices in work design and implementation, a comparative effectiveness study would seem highly desirable to evaluate benefits. Such studies are rare, compared to studies of drugs and devices, but might yield substantial benefit.
References
- Grundy BL, et al. Telemedicine in critical care: Problems in design, implementation, and assessment. Crit Care Med 1982;10:471-475.
- Berenson RA, et al. Does telemonitoring of patients — the eICU — improve intensive care? Health Aff (Millwood) 2009 Aug 20; Epub ahead of print.
- Rabert AS, Sebastian MC. The future is now: Implementation of a tele-intensivist program. J Nurs Adm 2006;36:49-54.
- Schmid-Mazzoccoli A, et al. The use of medical emergency teams in medical and surgical patients: Impact of patient, nurse and organisational characteristics. Qual Saf Health Care 2008;17:377-381.
- Hravnak M, et al. Defining the incidence of cardiorespiratory instability in patients in step-down units using an electronic integrated monitoring system. Arch Intern Med 2008;168:1300-1308.
- Breslow MJ. Remote ICU care programs: Current status. J Crit Care 2007;22:66-76.
- Rosenfeld BA, et al. Intensive care unit telemedicine: Alternate paradigm for providing continuous intensivist care. Crit Care Med 2000;28:3925-3931.
- Breslow MJ, et al. Effect of a multiple-site intensive care unit telemedicine program on clinical and economic outcomes: An alternate paradigm for intensivist staffing. Crit Care Med 2004;32:31-38.
- Zawada ET, et al. Prognostic outcomes after the initiation of an electronic telemedicine intensive care unit (eICU) in a rural heath system. S D Med 2006;59:391-393.
- Tang Z, et al. Workflow in intensive care unit remote monitoring: A time-and-motion study. Crit Care Med 2007;35:2057-2063.
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