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FOCUS ON PULMONARY
DISORDERS Devra K. Dang, Section
Advisor
Telemedicine may improve care in ICU
Key point: According to results from an
observational study, implementation of a multifaceted health information
technology bundle with remote intensivist coverage reduces mortality and
use of mechanical ventilation in adult patients in the intensive care
unit (ICU) compared with a historical control.
Finer points: An observational study was conducted
in three ICUs at an academic community hospital to assess the effects of
a health information technology bundle with remote intensivist coverage
compared with a control group without such enhancements on outcomes such
as hospital mortality, mechanical ventilator and vasopressor use, and
ICU and hospital lengths of stay. The bundle consisted of interventions
such as an electronic medical record with an electronic algorithmic
event system, computer-assisted physician order entry, an electronic
medication administration record, bar code medication administration, a
radiographic picture archiving and communication system, and a two-way
audio and one-way video remote monitoring system used by the
telemedicine team of health providers to interact with patients and
caregivers from 7:00 pm to 7:00 am. The team—an intensivist and a
critical care nurse—also performed rounds every 2 hours to assess
the clinical status of all monitored patients, and interventions were
performed as needed.
The control group (n = 954) received care at the same institution for
16 months before implementation of the bundle, and the intervention
group (n = 959) received care for 10 months after implementation.
Baseline demographics were similar between the groups: mean age was 65
years, more than 86% were white, mean APACHE (Acute Physiology and
Chronic Health Evaluation) acute physiology scores were approximately
57, and APACHE-predicted hospital mortality rates were approximately 19.
The only significant difference between the two groups was diagnostic
category—a greater percentage of patients in the control group had
a cardiology diagnosis (31.0% vs. 19.8%), while a greater percentage of
patients in the intervention group had a neurology diagnosis (32.3% vs.
19.1%). The investigators reported that mortality rates were
significantly lower for the intervention versus control group (14.7% vs.
21.4%, P < 0.001) and that predicted mortality in the
intervention group was significantly lower than that predicted by APACHE
IV (29.5%, P < 0.001). In addition, ventilator use was
significantly lower in the intervention versus control group (P
= 0.001). No differences were seen for vasopressor use or ICU or
hospital lengths of stay.
What you need to know: Not every study has shown a
benefit with the use of telemedicine on outcomes in patients in the ICU.
In December 2009, Eric Thomas, MD, MPH, and colleagues published results
of their observational study of six ICUs in five large U.S. hospitals in
JAMA. These investigators found that remote monitoring of ICU
patients was not associated with an overall improvement in mortality or
length of stay. A main difference between the current analysis and the
Thomas study is that almost two-thirds of patients in the Thomas study
had minimal exposure to tele-ICU intervention, and the teleintensivists
did not have access to a computerized physician order entry system or
electronic medical records in the ICUs. Additional trials are needed to
fully understand the benefits of telemedicine in the ICU population.
What your patients need to know: Educate patients
and their family about telemedicine and the goals of therapy if these
interventions are being used.
Sources:
Posted by Alex Egervary (aegervary@aphanet.org)
June 9, 2010, 4:45 pm
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