Telemedicine intervention may improve outcomes in the intensive care unit, according to a study that will appear in the June 1 issue of the Journal of the American Medical Association.
This technology is designed to provide remote access, monitoring and a safety net to ICUs that do not have around-the-clock intensivists. The system implements a remote facility with a clinical team of nurses and intensivists who have immediate access to vital signs, electronic medical records (including labs and radiology studies), as well as communication equipment within the patients room. This allows for visualization and communication with nursing and other staff in the ICU. The leader in eICU technology has been VISICU, a Baltimore-based company that is now subsidiary of Philips. The company was founded by two ICU doctors at John Hopkins Hospital in Baltimore, Dr. Brian Rosenfeld and Dr. Michael Breslow, after they initially developed the technology in 1998. For more information on eICU technology, refer to the Philips Website.
The goal of the study, conducted over two years from 2005 to 2007, was to quantify the telemedicine intervention in the ICU with in-hospital death, duration of hospitalization and complications. The investigators in the study utilized the remote monitoring features of the system and concurrently supported and monitored for adherence to best practices, care plan creation, and clinician response times to alarms.
The main study endpoints were hospital mortality adjusted for case-mix and severity. Other endpoints were length of hospitalization and ICU stay, best practice adherence, and complication rates. The study found that the hospital mortality rate decreased from 13.6% to 11.8% when telemedicine intervention was used.
As might be expected, there was increased adherence to clinical practice guidelines designed to prevent ICU complications. For example, the use of medications in the prevention of deep vein thrombosis increased from 85% to 99% and the use of appropriate stress ulcer prophylaxis medication increased from 83% to 96%. In addition, there were decreases in preventable complications of ventilator-associated pneumonia from 13% to 1.6% and catheter-related bloodstream infection from 1.0% to 0.6%.
These are impressive results. However, from a technical standpoint, there are numerous limitations of this study, including the inability to generalize the improvements to other centers as well as the lack of randomization and blinding.
What are the real benefits?
Jeremy M. Kahn, MD, MS, from the University of Pittsburgh in Pittsburgh, Pennsylvania, wrote in his editorial accompanying the study that telemedicine is “merely a tool for quality improvement.” Having seen the eICU functioning, I would agree with Dr.Kahn. The real benefit of this technology is to allow an alarm system to be built into ICUs. This brings expert attention in a timely fashion to any changes in vital signs or critical lab values, for example, or new findings on radiology studies.
I believe the other aspects of the reported better outcomes are due simply to adherence to best practices via a Hawthorne effect—a form of reactivity whereby subjects improve or modify an aspect of their behavior being experimentally measured simply in response to the fact that they are being studied. Dr. Kahn summarizes the best use of this technology: “to define specific quality deficiencies in the target ICUs, and then design the telemedicine intervention specifically to address those deficiencies, akin to other types of quality improvement.”
In the end, the technology itself is not the solution, but rather a tool to change practice that will achieve target outcomes.