Staffing of intensive care units (ICUs) by physicians trained in critical care medicine (intensivists) can result in improved patient outcomes. This staffing model has been endorsed by a number of high-profile public and private partnerships. However, adoption of intensivist staffing by hospitals has been hampered by a shortage of intensivist physicians. Recruiting and retaining intensivists may be particularly challenging for rural hospitals, including many smaller facilities within VA. In an effort to overcome a lack of available intensivists, a growing number of hospitals have installed ICU telemedicine systems. These systems typically combine high-speed videoconferencing with electronic medical records to connect the clinical care team and patients at the physical ICUs to intensivist physicians and nurses at a support center. Staff at the support center can check vital signs and laboratory tests, write orders, and communicate via videoconference with the on-site clinical care teams at the physical ICUs about changes in the condition of individual patients. Despite rapid adoption of ICU telemedicine by hospitals, rigorous empirical data about the impact of these systems are extremely limited.
This study takes advantage of a unique natural experiment: the implementation of an ICU telemedicine system in the eight ICUs (seven hospitals) within VISN 23. Our primary objective was to examine the impact of ICU telemedicine on patient outcomes including mortality and ICU length of stay. Our secondary objectives were to develop a taxonomy for describing ICU telemedicine utilization and to evaluate the cost of implementing the ICU telemedicine system.
First, we used validated VA administrative and clinical data to assess the impact of ICU telemedicine on patient mortality and length of stay. For these analyses the intervention group consisted of consecutive patients admitted to the eight ICUs within VISN-23 where the ICU telemedicine system was implemented. The control group will consist of a cohort of patients admitted to eight control ICUs outside of VISN-23 that had not received ICU telemedicine support and were matched to the intervention ICUs. Second, we developed a taxonomy for describing physical ICU utilization of ICU telemedicine through thematic content analysis of semi-structured interviews with physical ICU staff and a teleintensivist physician note template embedded in CPRS. Third, we examined the start-up and maintenance costs associated with the implementation of the ICU telemedicine program.
To evaluate the impact of ICU telemedicine programs on patient outcomes, we have conducted several analyses and continue to do so. We published a systematic review related to ICU telemedicine. In the review of ICU telemedicine patient outcomes, we found ICU telemedicine coverage was associated with a reduction in ICU mortality (pooled odds ratio, 0.80; 95% confidence interval [CI], 0.66-0.97; P=.02) but not in-hospital mortality for patients admitted to an ICU (pooled odds ratio, 0.82; 95% CI, 0.65-1.03; P=.08). Similarly, ICU telemedicine coverage was associated with a reduction in ICU LOS (mean difference, 1.26 days; 95% CI, 2.21 to 0.30; P=.01) but not hospital LOS (mean difference, 0.64; 95% CI, 1.52 to 0.25; P=.16). In an early analysis of VISN 23, we found implementation of ICU telemedicine was not associated with a significant decline in ICU, in-hospital, or 30-day mortality rates or LOS in unadjusted or adjusted analyses at 6 months. We are now conducting an analysis of data expanding the timeframe to 24 months post-implementation. With supplemental funding from Office of Rural Health, we are incorporating data from the VISN 10 Tele-ICU Program.
We continue to work with the ICU telemedicine programs to develop the best taxonomy for characterizing ICU telemedicine utilization. Through VA Office of Rural Health supplemental funding, we conducted site visits and qualitative interviews at the bedside ICUs at pre-implementation (1 month prior) and early (6-12 weeks) and late (1 year) post-implementation. This data allowed us to analyze bedside staff perspective of ICU telemedicine utilization. We found three major categories of utilization: 1) General ICU Patient Care, 2) ICU Clinical Decision Making, Advice, and Consultation, and 3) Urgent ICU Patient Care. Importantly, the day-to-day assistance of Tele-ICU staff related to general patient care may have less impact on patient outcomes such as mortality and LOS; however, they may contribute to staff and patient satisfaction. A manuscript of this analysis is currently under review. In addition, the ICU telemedicine programs incorporated a physician note template into CPRS in January 2012. We recently received access to this data and are analyzing it. In a preliminary analysis of the data, we found utilization has continued to increase over time, particularly in the category of communication between physical ICU and the support centers. We have a descriptive paper under development and have plans to incorporate utilization as a modifying variable into our final patient outcome manuscript.
We completed an evaluation of the costs of ICU telemedicine program implementation. We found that ICU telemedicine programs cost between $60,000-$120,000 per-bed per-year to implement and operate.
We have disseminated our findings to VISN 23's Tele-ICU Program, the National VA Tele-ICU Workgroup, and the VA Office of Rural Health. Our study findings, particularly on the barriers and facilitators to staff acceptance and perceptions of rural ICU staff, have informed changes to both VISN 23's and VISN 10's ICU Telemedicine Programs. In FY2014 and 2015, ICU telemedicine expanded into VISN 7 and VISN 15. Our work was instrumental in improving implementation strategies for both programs. As an example, our paper (Moeckli et al 2013) was distributed to ICU staff at the expansion sites.
- O'Shea AMJ, Fortis S, Vaughan Sarrazin M, Moeckli J, Yarbrough WC, Schacht Reisinger H. Outcomes comparison in patients admitted to low complexity rural and urban intensive care units in the Veterans Health Administration. Journal of Critical Care. 2019 Feb 1; 49:64-69.
- O'Shea AMJ, Vaughan Sarrazin M, Nassar B, Cram P, Johnson L, Bonello R, Panos RJ, Reisinger HS. Using electronic medical record notes to measure ICU telemedicine utilization. Journal of the American Medical Informatics Association : JAMIA. 2017 Sep 1; 24(5):969-974.
- Goedken CC, Moeckli J, Cram PM, Reisinger HS. Introduction of Tele-ICU in rural hospitals: Changing organisational culture to harness benefits. Intensive & critical care nursing : the official journal of the British Association of Critical Care Nurses. 2017 Jun 1; 40:51-56.
- Thomas JT, Moeckli J, Mengeling MA, Goedken CC, Bunch J, Cram P, Reisinger HS. Bedside Critical Care Staff Use of Intensive Care Unit Telemedicine: Comparisons by Intensive Care Unit Complexity. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2017 Sep 1; 23(9):718-725.
- 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 internal medicine. 2014 Jul 1; 174(7):1160-7.
- Moeckli J, Cram P, Cunningham C, Reisinger HS. Staff acceptance of a telemedicine intensive care unit program: a qualitative study. Journal of Critical Care. 2013 Dec 1; 28(6):890-901.
- Kumar G, Falk DM, Bonello RS, Kahn JM, Perencevich E, Cram P. The costs of critical care telemedicine programs: a systematic review and analysis. Chest. 2013 Jan 1; 143(1):19-29.
- Wilson SR, Cram P. Another sobering result for home telehealth—and where we might go next. Archives of internal medicine. 2012 May 28; 172(10):779-80.
- Kumar G, Cram P. Response to Dr Gorman. Chest. 2013 Apr 1; 143(4):1184-5.
- O'Shea AM, Vaughan-Sarrazin MS. Data Decisions and Quantitative Analysis in a Study Investigating the Impact of Remote ICU Monitoring in VA Hospitals. VIReC Good Data Practices [Cyberseminar]. HSR&D Cyberseminars. 2017 Feb 21.
- Moeckli J, Mengeling M, Goedken CL, Reisinger HS. Unit Staff Perceptions and Attitudes about Readiness to Implement and Impacts of ICU Telemedicine. Poster session presented at: VA Rural Health State of the Science Conference; 2016 Sep 13; Washington, DC.
- Fortis S, Vaughan-Sarrazin MS, Reisinger HS. The effect of ICU telemedicine on inter-hospital transfers in VA health system. Poster session presented at: VA Rural Health State of the Science Conference; 2016 Sep 12; Washington, DC.
- O'Shea AM, Vaughan-Sarrazin MS, Reisinger HS. Comparing Intensive Care Unit (ICU) Telemedicine in the Veterans Health Administration. Paper presented at: Joint Statistical Annual Meeting; 2016 Aug 2; Chicago, IL.
- Moeckli J, Reisinger HS. Tele-ICU Research and Evaluation. Paper presented at: VA VISN 10 Tele-ICU User Conference; 2016 Apr 27; Cincinnati, OH.
- O AM, Johnson L, Vaughan-Sarrazin MS, Cram PM, Reisinger HS. Quantifying Telemedicine Intensive Care in the Veterans Health Administration (VHA). Paper presented at: Joint Statistical Annual Meeting; 2015 Aug 8; Seattle, WA.
- Moeckli J, Goedken CL, Thomas JT, Cram PM, Reisinger HS. Teamwork and ICU Telemedicine. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA.
- Thomas JT, Moeckli J, Goedken CL, Bunch J, Cram PM, Reisinger HS. The ICU Telemedicine Black Box: Qualitative Analysis of Telemedicine Utilization in VA Intensive Care Units. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA.
- Moeckli J, Thomas JT, Goedken CL, Cram PM, Reisinger HS. "We’ll call you if we need you": Regulating teamwork in virtual ICUs. Paper presented at: Society for Applied Anthropology Annual Meeting; 2015 Mar 26; Pittsburgh, PA.
- Reisinger HS. You Want to measure What? Working in an Interdisciplinary Team to Develop Quality Indicators for Telemedicine Intensive Care Units. Paper presented at: American Anthropological Association Annual Meeting; 2014 Dec 5; Washington, DC.
- Reisinger HS, Moeckli J, Cunningham CL, Cram PM. "Doc in a Box": Challenges of Integrating a Virtual Team into Patient Care in Intensive Care Units (ICUs). Poster session presented at: American Anthropological Association Annual Meeting; 2013 Nov 21; Chicago, IL.
- Nassar B, Jiang L, Reisinger HS, Conello R, Cram PM. Early Impact Of Tele-ICU Implementation On Patient Mortality And Length-Of-Stay: An Analysis From The VA Healthcare System. Poster session presented at: American Thoracic Society Annual International Conference; 2013 May 20; Philadelphia, PA.
- Reisinger HS, Moeckli J, Cunningham CL, Cram PM. Technology to Improve Access: How Telemedicine Links Intensivists to Intensive Care Units in the Veterans Health Administration. Paper presented at: Society for Applied Anthropology Annual Meeting; 2013 Mar 20; Denver, CO.
- Moeckli J, Cram PM, Cunningham CL, Reisinger HS. Staff Acceptance of Tele-ICU Monitoring. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 19; National Harbor, MD.
- Young LB, Chen P, Lu X, Nallamothu B, Sasson C, Cram PM. Impact of Tele-ICU Coverage on Patient Outcomes: A Systematic Review and Meta-Analysis. Paper presented at: VA HSR&D National Meeting; 2011 Feb 17; National Harbor, MD.
Technology Development and Assessment