Intensive Care Unit Telemedicine Program
Statistical analysis: Nassar, Vaughan-Sarrazin, Jiang, Cram. Obtained funding: Cram. Administrative, technical, or material support: Nassar, Reisinger, Bonello, Cram. Study supervision: Nassar, Vaughan-Sarrazin, Cram. Conflict of Interest Disclosures: Dr Bonello is the medical director of the VISN 23 Tele-ICU program. No other disclosures are reported. Funding/Support: This work is supported by a K24 award from the National Institute of Arthritis and Musculoskeletal and Skin Disease (grant AR062133 to Dr Cram) and by the US Department of Veterans Affairs (grant IRR 09-336 to all authors). Role of the Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the views of the US Department of Veterans Affairs. REFERENCES 1. Rosenfeld BA, Dorman T, Breslow MJ, et al. Intensive care unit telemedicine: alternate paradigm for providing continuous intensivist care. Crit Care Med. 2000;28(12):3925-3931. 2. Zawada ET Jr, Kapaska D, Herr P, et al; Avera eICU Research Group. Prognostic outcomes after the initiation of an electronic telemedicine intensive care unit (eICU) in a rural health system. S D Med. 2006;59(9):391-393. 3. 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):375-380. 4. Kahn JM, Hill NS, Lilly CM, et al. The research agenda in ICU telemedicine: a statement from the Critical Care Societies Collaborative. Chest. 2011;140 (1):230-238.
Original Investigation Research
proactive remote monitoring and intervention in the critical care setting. Stud Health Technol Inform. 2008;131:131-146.
15. Clinical Classifications Software for ICD-9-CM. http://www.hcup-us.ahrq.gov/toolssoftware/ccs /ccs.jsp. Accessed August 19, 2013.
6. Breslow MJ, Rosenfeld BA, Doerfler M, et al. Effect of a multiple-site intensive care unit telemedicine program on clinical and economic outcomes: an alternative paradigm for intensivist staffing. Crit Care Med. 2004;32(1):31-38.
16. Render ML, Welsh DE, Kollef M, et al; SISVistA Investigators. Automated computerized intensive care unit severity of illness measure in the Department of Veterans Affairs: preliminary results. Crit Care Med. 2000;28(10):3540-3546.
7. 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.
17. Chaudhry SI, Mattera JA, Curtis JP, et al. Telemonitoring in patients with heart failure. N Engl J Med. 2010;363(24):2301-2309.
8. 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):2671-2678. 9. Lilly CM, Cody S, Zhao H, et al; 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):2175-2183. 10. Moeckli J, Cram P, Cunningham C, Reisinger HS. Staff acceptance of a telemedicine intensive care unit program: a qualitative study. J Crit Care. 2013; 28(6):890-901. 11. Render ML, Deddens J, Freyberg R, et al. Veterans Affairs intensive care unit risk adjustment model: validation, updating, recalibration. Crit Care Med. 2008;36(4):1031-1042. 12. Render ML, Kim HM, Welsh DE, et al; VA ICU Project (VIP) Investigators. Automated intensive care unit risk adjustment: results from a National Veterans Affairs study. Crit Care Med. 2003;31(6): 1638-1646. 13. Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36(1):8-27. 14. Quan H, Sundararajan V, Halfon P, et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care. 2005;43 (11):1130-1139.
18. Wilson SR, Cram P. Another sobering result for home telehealth—and where we might go next. Arch Intern Med. 2012;172(10):779-780. 19. Takahashi PY, Pecina JL, Upatising B, et al. A randomized controlled trial of telemonitoring in older adults with multiple health issues to prevent hospitalizations and emergency department visits. Arch Intern Med. 2012;172(10):773-779. 20. Celi LA, Hassan E, Marquardt C, Breslow M, Rosenfeld B. The eICU: it’s not just telemedicine. Crit Care Med. 2001;29(8)(suppl):N183-N189. 21. Morrison JL, Cai Q, Davis N, et al. Clinical and economic outcomes of the electronic intensive care unit: results from two community hospitals. Crit Care Med. 2010;38(1):2-8. 22. Wallace DJ, Angus DC, Barnato AE, Kramer AA, Kahn JM. Nighttime intensivist staffing and mortality among critically ill patients. N Engl J Med. 2012;366(22):2093-2101. 23. Gabler NB, Ratcliffe SJ, Wagner J, et al. Mortality among patients admitted to strained intensive care units. Am J Respir Crit Care Med. 2013;188(7):800-806. 24. Almenoff P, Sales A, Rounds S, et al. Intensive care services in the Veterans Health Administration. Chest. 2007;132(5):1455-1462. 25. 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;143(1):19-29.
5. Groves RH Jr, Holcomb BW Jr, Smith ML. Intensive care telemedicine: evaluating a model for
Invited Commentary
Telemedicine in the Intensive Care Unit Effect of a Remote Intensivist on Outcomes M. Elizabeth Wilcox, MD, MPH; Jeanine P. Wiener-Kronish, MD
Access to intensivists affects patient outcomes; highintensity staffing (transfer of care to an intensivist or a mandatory consultation with an intensivist) is associated with reduced intensive care unit (ICU) and hospital mortality Related article page 1160 rates. 1 The addition of inhospital nighttime intensivists seems to reduce mortality rates in ICUs with low-intensity staffing but not those with highintensity staffing.2 So how can our community address this
variation in intensivist staffing, which seems to dramatically alter outcomes? For example, is it possible for ICUs with low-intensity staffing or no intensivist staffing to achieve the same beneficial outcomes of high-intensity staffing by using technology? Telemedicine (TM) has been touted as a technological advance that may help when there is a paucity of intensivists, allowing more patients access to specialty care without the risk of being transferred. Telemedicine, broadly defined as the exchange of medical infor-
jamainternalmedicine.com
JAMA Internal Medicine July 2014 Volume 174, Number 7
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Fudan University User on 05/16/2015
1167
Research Original Investigation
Intensive Care Unit Telemedicine Program
mation via electronic communication, allows for real-time exchange of clinical data and direct interaction among care providers across distances and provides decision support to underserviced rural areas, small hospitals without intensivists, and large hospitals with low-intensity physician staffing models or nocturnal physician shortages. Results from previous studies on ICU TM have been mixed. A recent systematic review and meta-analysis of mostly uncontrolled, before-after observational studies3 found that ICU TM reduced ICU and hospital mortality rates and lengths of stay in critically ill patients. Some studies evaluated a complete overhaul of ICU care delivery using a complex TM “bundle” for which some individual components, such as computerized physician order entry, were shown to reduce adverse drug events and increase workflow efficiency. The entire package, continuous patient data monitoring, and computer-generated alerts together reduced ICU mortality rates compared with remote intensivist consultation alone.3 There are potential confounders in these analyses. If patients are not critically ill, having an intensivist to participate in their care may not be beneficial. If the remote intensivist’s recommendations were not followed, the consultation would probably have no impact on outcomes. If the nursing staff or respiratory therapists lack sufficient training or do not adhere to evidence-based care protocols, that may also reduce the impact of the recommendations. In this issue, Nassar and colleagues 4 report the effects of implementing an ICU TM program in an integrated regional network of 7 hospitals (8 ICUs) in the US Department of Veterans Affairs (VA). These ICUs already share an electronic health record; the intervention included support by a remote intensivist along with 2 critical care nurses (21 h/d) using an audio-video connection and an electronic algorithmic event system to monitor laboratory values, vital signs, intravenous infusion rates, and mechanical ventilator settings. In a methodologic ally rigorous approach, ICUs with TM were matched to control ICUs. However, no statistically significant differences in ICU, acute hospital, o r 3 0 - d ay m o r t a l i t y r a t e s w e r e s e e n w i t h I C U T M implementation. 4 How are we to interpret these results, especially in light of the growing interest in and use of ICU TM? The absence of benefit of ICU TM in this VA study may have been inevitable given the low mortality rates observed in the controls, reflecting an already high standard of care and/or simply low illness severity (eg,
Statistical analysis: Nassar, Vaughan-Sarrazin, Jiang, Cram. Obtained funding: Cram. Administrative, technical, or material support: Nassar, Reisinger, Bonello, Cram. Study supervision: Nassar, Vaughan-Sarrazin, Cram. Conflict of Interest Disclosures: Dr Bonello is the medical director of the VISN 23 Tele-ICU program. No other disclosures are reported. Funding/Support: This work is supported by a K24 award from the National Institute of Arthritis and Musculoskeletal and Skin Disease (grant AR062133 to Dr Cram) and by the US Department of Veterans Affairs (grant IRR 09-336 to all authors). Role of the Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the views of the US Department of Veterans Affairs. REFERENCES 1. Rosenfeld BA, Dorman T, Breslow MJ, et al. Intensive care unit telemedicine: alternate paradigm for providing continuous intensivist care. Crit Care Med. 2000;28(12):3925-3931. 2. Zawada ET Jr, Kapaska D, Herr P, et al; Avera eICU Research Group. Prognostic outcomes after the initiation of an electronic telemedicine intensive care unit (eICU) in a rural health system. S D Med. 2006;59(9):391-393. 3. 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):375-380. 4. Kahn JM, Hill NS, Lilly CM, et al. The research agenda in ICU telemedicine: a statement from the Critical Care Societies Collaborative. Chest. 2011;140 (1):230-238.
Original Investigation Research
proactive remote monitoring and intervention in the critical care setting. Stud Health Technol Inform. 2008;131:131-146.
15. Clinical Classifications Software for ICD-9-CM. http://www.hcup-us.ahrq.gov/toolssoftware/ccs /ccs.jsp. Accessed August 19, 2013.
6. Breslow MJ, Rosenfeld BA, Doerfler M, et al. Effect of a multiple-site intensive care unit telemedicine program on clinical and economic outcomes: an alternative paradigm for intensivist staffing. Crit Care Med. 2004;32(1):31-38.
16. Render ML, Welsh DE, Kollef M, et al; SISVistA Investigators. Automated computerized intensive care unit severity of illness measure in the Department of Veterans Affairs: preliminary results. Crit Care Med. 2000;28(10):3540-3546.
7. 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.
17. Chaudhry SI, Mattera JA, Curtis JP, et al. Telemonitoring in patients with heart failure. N Engl J Med. 2010;363(24):2301-2309.
8. 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):2671-2678. 9. Lilly CM, Cody S, Zhao H, et al; 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):2175-2183. 10. Moeckli J, Cram P, Cunningham C, Reisinger HS. Staff acceptance of a telemedicine intensive care unit program: a qualitative study. J Crit Care. 2013; 28(6):890-901. 11. Render ML, Deddens J, Freyberg R, et al. Veterans Affairs intensive care unit risk adjustment model: validation, updating, recalibration. Crit Care Med. 2008;36(4):1031-1042. 12. Render ML, Kim HM, Welsh DE, et al; VA ICU Project (VIP) Investigators. Automated intensive care unit risk adjustment: results from a National Veterans Affairs study. Crit Care Med. 2003;31(6): 1638-1646. 13. Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36(1):8-27. 14. Quan H, Sundararajan V, Halfon P, et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care. 2005;43 (11):1130-1139.
18. Wilson SR, Cram P. Another sobering result for home telehealth—and where we might go next. Arch Intern Med. 2012;172(10):779-780. 19. Takahashi PY, Pecina JL, Upatising B, et al. A randomized controlled trial of telemonitoring in older adults with multiple health issues to prevent hospitalizations and emergency department visits. Arch Intern Med. 2012;172(10):773-779. 20. Celi LA, Hassan E, Marquardt C, Breslow M, Rosenfeld B. The eICU: it’s not just telemedicine. Crit Care Med. 2001;29(8)(suppl):N183-N189. 21. Morrison JL, Cai Q, Davis N, et al. Clinical and economic outcomes of the electronic intensive care unit: results from two community hospitals. Crit Care Med. 2010;38(1):2-8. 22. Wallace DJ, Angus DC, Barnato AE, Kramer AA, Kahn JM. Nighttime intensivist staffing and mortality among critically ill patients. N Engl J Med. 2012;366(22):2093-2101. 23. Gabler NB, Ratcliffe SJ, Wagner J, et al. Mortality among patients admitted to strained intensive care units. Am J Respir Crit Care Med. 2013;188(7):800-806. 24. Almenoff P, Sales A, Rounds S, et al. Intensive care services in the Veterans Health Administration. Chest. 2007;132(5):1455-1462. 25. 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;143(1):19-29.
5. Groves RH Jr, Holcomb BW Jr, Smith ML. Intensive care telemedicine: evaluating a model for
Invited Commentary
Telemedicine in the Intensive Care Unit Effect of a Remote Intensivist on Outcomes M. Elizabeth Wilcox, MD, MPH; Jeanine P. Wiener-Kronish, MD
Access to intensivists affects patient outcomes; highintensity staffing (transfer of care to an intensivist or a mandatory consultation with an intensivist) is associated with reduced intensive care unit (ICU) and hospital mortality Related article page 1160 rates. 1 The addition of inhospital nighttime intensivists seems to reduce mortality rates in ICUs with low-intensity staffing but not those with highintensity staffing.2 So how can our community address this
variation in intensivist staffing, which seems to dramatically alter outcomes? For example, is it possible for ICUs with low-intensity staffing or no intensivist staffing to achieve the same beneficial outcomes of high-intensity staffing by using technology? Telemedicine (TM) has been touted as a technological advance that may help when there is a paucity of intensivists, allowing more patients access to specialty care without the risk of being transferred. Telemedicine, broadly defined as the exchange of medical infor-
jamainternalmedicine.com
JAMA Internal Medicine July 2014 Volume 174, Number 7
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Fudan University User on 05/16/2015
1167
Research Original Investigation
Intensive Care Unit Telemedicine Program
mation via electronic communication, allows for real-time exchange of clinical data and direct interaction among care providers across distances and provides decision support to underserviced rural areas, small hospitals without intensivists, and large hospitals with low-intensity physician staffing models or nocturnal physician shortages. Results from previous studies on ICU TM have been mixed. A recent systematic review and meta-analysis of mostly uncontrolled, before-after observational studies3 found that ICU TM reduced ICU and hospital mortality rates and lengths of stay in critically ill patients. Some studies evaluated a complete overhaul of ICU care delivery using a complex TM “bundle” for which some individual components, such as computerized physician order entry, were shown to reduce adverse drug events and increase workflow efficiency. The entire package, continuous patient data monitoring, and computer-generated alerts together reduced ICU mortality rates compared with remote intensivist consultation alone.3 There are potential confounders in these analyses. If patients are not critically ill, having an intensivist to participate in their care may not be beneficial. If the remote intensivist’s recommendations were not followed, the consultation would probably have no impact on outcomes. If the nursing staff or respiratory therapists lack sufficient training or do not adhere to evidence-based care protocols, that may also reduce the impact of the recommendations. In this issue, Nassar and colleagues 4 report the effects of implementing an ICU TM program in an integrated regional network of 7 hospitals (8 ICUs) in the US Department of Veterans Affairs (VA). These ICUs already share an electronic health record; the intervention included support by a remote intensivist along with 2 critical care nurses (21 h/d) using an audio-video connection and an electronic algorithmic event system to monitor laboratory values, vital signs, intravenous infusion rates, and mechanical ventilator settings. In a methodologic ally rigorous approach, ICUs with TM were matched to control ICUs. However, no statistically significant differences in ICU, acute hospital, o r 3 0 - d ay m o r t a l i t y r a t e s w e r e s e e n w i t h I C U T M implementation. 4 How are we to interpret these results, especially in light of the growing interest in and use of ICU TM? The absence of benefit of ICU TM in this VA study may have been inevitable given the low mortality rates observed in the controls, reflecting an already high standard of care and/or simply low illness severity (eg,
