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The Impact of Remote ICU Monitoring on Patient Outcomes and Processes of Care
Heather S Reisinger, PhD
Iowa City VA Health Care System, Iowa City, IA
Iowa City, IA
Funding Period: July 2010 - December 2014
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.
External Links for this Project
NIH ReporterGrant Number: I01HX000261-01
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DRA: Health Systems
DRE: Technology Development and Assessment
MeSH Terms: none