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Hospital Mortality, Length of Stay, and Preventable Complications Among Critically Ill Patients Before and After Tele-ICU Reengineering of Critical Care Processes
Study Questions:
What is the association of a tele-intensive care unit (ICU) intervention with hospital mortality, length of stay, and complications that are preventable by adherence to best practices?
Methods:
This was a prospective stepped-wedge clinical practice study of 6,290 adults admitted to any of seven ICUs (three medical, three surgical, and one mixed cardiovascular) on two campuses of an 834-bed academic medical center, which was performed from April 26, 2005, through September 30, 2007. Electronically supported and monitored processes for best practice adherence, care plan creation, and clinician response times to alarms were evaluated. The main outcome measure was the case-mix and severity-adjusted hospital mortality. Other outcomes included hospital and ICU length of stay, best practice adherence, and complication rates.
Results:
The hospital mortality rate was 13.6% (95% confidence interval [CI], 11.9%-15.4%) during the preintervention period compared with 11.8% (95% CI, 10.9%-12.8%) during the tele-ICU intervention period (adjusted odds ratio [OR], 0.40; 95% CI, 0.31-0.52). The tele-ICU intervention period compared with the preintervention period was associated with higher rates of best clinical practice adherence for the prevention of deep vein thrombosis (99% vs. 85%, respectively; OR, 15.4; 95% CI, 11.3-21.1) and prevention of stress ulcers (96% vs. 83%, respectively; OR, 4.57; 95% CI, 3.91-5.77), best practice adherence for cardiovascular protection (99% vs. 80%, respectively; OR, 30.7; 95% CI, 19.3-49.2), prevention of ventilator-associated pneumonia (52% vs. 33%, respectively; OR, 2.20; 95% CI, 1.79-2.70), lower rates of preventable complications (1.6% vs. 13%, respectively, for ventilator-associated pneumonia [OR, 0.15; 95% CI, 0.09-0.23] and 0.6% vs. 1.0%, respectively, for catheter-related bloodstream infection [OR, 0.50; 95% CI, 0.27-0.93]), and shorter hospital length of stay (9.8 vs. 13.3 days, respectively; hazard ratio for discharge, 1.44; 95% CI, 1.33-1.56). The results for medical, surgical, and cardiovascular ICUs were similar.
Conclusions:
The authors concluded that implementation of a tele-ICU intervention was associated with reduced adjusted odds of mortality and reduced hospital length of stay.
Perspective:
The primary findings of this study are that a tele-ICU intervention was associated with lower hospital and ICU mortality and shorter hospital and ICU lengths of stay. The tele-ICU intervention was also associated with significantly higher rates of adherence to critical care best practices and lower rates of complications. This suggests that there may be benefits of a tele-ICU intervention beyond what is provided by daytime bedside intensivist staffing and traditional approaches to quality improvement. It should be noted that telemedicine alone may not necessarily equate to quality improvement as suggested by prior studies (JAMA 2009;302:2671-8), but is merely another tool for quality improvement. A successful telemedicine program will incorporate the basic principles of quality improvement, which include performing a detailed needs assessment, assessing barriers to practice change, prioritizing specific projects, introducing effective strategies, and measuring the results in a stepwise fashion.
Keywords: Intensive Care Units, Hospital Mortality, Telemedicine, Critical Illness, Length of Stay
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