The many applications of telemedicine include the monitoring of hospital patients by physicians at another location. A new study by investigators at The University of Texas Health Science Center at Houston points to factors that may influence the effectiveness of remote patient monitoring in an intensive care unit setting. Findings appear in the Dec. 23-30 issue of JAMA, the Journal of the American Medical Association.
Remote patient monitoring in intensive care units or ICUs is on the rise in part because of a shortage of physicians specializing in the care of the critically ill. To make the most of these specialists known as intensivists, some ICU administrators have created off-site work areas where these doctors can monitor multiple ICUs with the aid of technology. The job of these virtual intensivists is mainly to support the caregivers on the units by intervening in critical situations and identifying potential problems.
The study was designed to measure the impact of remote patient monitoring in ICUs on patient outcomes. Researchers analyzed the records of 2,034 patients before the implementation of an ICU telemedicine program (tele-ICU) by a major healthcare system in the United States and the records of 2,108 patients afterward. The 2003-2006 study involved six ICUs in five hospitals.
Results varied, according to Eric Thomas, M.D., M.P.H., the study’s lead author and a professor of medicine at The University of Texas Medical School at Houston. There were no significant overall changes in death rates, the frequency of eight complications or the ability of patients to leave earlier. The study did reveal that survival rates for the extremely ill improved in all the ICUs studied.
“The mortality reduction we observed in the sickest population may be associated with the frequency of assessment triggered by unexpected changes in condition and the severity of illness,” said Bela Patel, M.D., director of the Critical Care Medicine Program at the UT Medical School at Houston.
Because results are at odds with a study published in 2004 in which deaths rates and average length of stay declined in two adults ICUs in a large tertiary care hospital following the implementation of a tele-ICU program, Thomas believes a variety a factors could impact the effectiveness of an ICU telemedicine program.
Thomas and his colleagues point to three factors in particular. They include how the tele-ICU was used by the remote intensivists to alter care in the monitored units; its acceptance by physicians in the monitored units; and integration of the information systems of the tele-ICU and the monitored units.
The tele-ICU in the latest study consisted of a remote office in the administrative offices of the healthcare system, which was staffed by intensivists, nurses and technicians. Workstations provided real-time vital signs, audiovisual connections to patients’ rooms, access to laboratory values and early warning signals for changes in patient status.
Most physicians who cared for patients in the monitored units retained control of decisions affecting their patients but did give the tele-ICU authority to intervene in life-threatening situations. Investigators found that progress notes were faxed from monitored units to the tele-ICU. Likewise, tele-ICU orders were entered into the computer workstation and then printed in the monitored units.
Thomas, who is director of the University of Texas-Memorial Hermann Center for Healthcare Quality and Safety, said addressing these factors may improve tele-ICU outcomes.
In 2009 about 4,900 adult ICU beds in the United States were supported by comprehensive or high-availability telemedicine-ICU programs, according to an article in the Journal of Intensive Care Medicine. In addition, more than 1 million patients had been monitored by these programs.
“Given the expense of tele-ICU technology, the conflicting evidence about its effectiveness, and the existence of other quality improvement interventions for ICUs, further use of this technology should proceed in the context of careful monitoring of patient outcomes and costs,” the authors concluded in their paper.
Other quality improvement interventions include the use of checklists to make sure certain practices are followed.
Three researchers formerly affiliated with the UT Health Science Center at Houston, Joseph Lucke, Ph.D., Lisa Weavind, M.D., and Laura Wueste, also contributed to the study.
The study, which is titled “Association of Telemedicine for Remote Monitoring of Intensive Care Patients With Mortality, Complications, and Length of Stay,” was supported by the Agency for Healthcare Research and Quality, the National Center for Research Resources and the Center for Clinical and Translational Sciences at the UT Health Science Center at Houston.
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