Tele-ICU Monitoring and Patient Outcomes

The presence of intensivists—physicians specially trained to care for critically ill patients—in intensive care units (ICUs) has been shown to improve survival, and there are estimates that staffing ICUs with intensivists 24 hours a day would save up to 50,000 lives and $4.3 billion in the United States each year. However, many hospitals do not have either the patient volume or financial resources to hire intensivists; in addition, there is a shortage of trained intensivists at this time. In the face of those limitations, hospitals are using telemedicine ICU (tele-ICU) to compensate for the lack of 24-hour on-site intensivist coverage. Noting that the effect of using tele-ICU to enhance coverage on patient outcomes is unclear, researchers recently conducted a systematic review of studies published from January 1, 1950, to September 30, 2010. Review results were reported in Archives of Internal Medicine [2011;171(6):498-506]. The studies were collected from PubMed, the Cumulative Index to Nursing and Allied Health Literature, Global Health, Web of Science, the Cochrane Library, and abstracts of conference presentations. Studies that reported data on the primary outcomes of ICU and in-hospital mortality or on the secondary outcomes of ICU and hospital length of stay (LOS) were included in the review. The typical design of tele-ICU coverage is a combination of videoconferencing technology, telemetry, and an electronic medical record. The coverage allows off-site intensivists and/or critical care nurses to assist in the treatment of ICU patients who are critically ill. Despite clear evidence on the benefits of tele-ICU coverage, >1 million patients have received care in hospitals equipped with a tele-ICU system, the researchers noted. The initial literature search revealed 3133 unique studies of potential relevance. Of those, 2957 were eliminated because they did not pertain to tele-ICU coverage as defined for purposes of the review or did not report original research. The remaining 176 studies, of which 59 were articles and 117 were abstracts, were reviewed in full. Of those, 163 had insufficient or duplicate mortality data. Of the 13 remaining studies with complete data, 12 were included in the ICU mortality meta-analysis, 10 were included in the in-hospital mortality metaanalysis, 7 were included in the ICU LOS metaanalysis, and 6 were included in the hospital LOS meta-analysis. The 13 studies encompassed 35 ICUs from 27 hospitals and included a total of 41,374 ICU patients (15,667 preintervention and 25,707 postintervention); 7 of the studies had been published, the remaining 6 were conference abstracts. There were differences in the settings of the 13 studies and in how the remote monitoring was implemented. Of the 35 ICUs, 9 were in or affiliated with academic medical centers and 18 were in community hospitals (the others did not report the absence or presence of academic affiliation). Thirteen of the ICUs received monitoring around-the-clock, 11 were monitored primarily during evenings and on weekends, and 1 used remote monitoring on an as-needed basis (the others did not report the hours the tele-ICU monitoring was utilized). Of the 13 studies, 12 reported ICU mortality among 40,541 patients (15,311 pre–tele-ICU monitoring and 25,230 post–tele-ICU monitoring). Collectively, implementation of tele-ICU coverage was associated with a significant reduction in ICU mortality (pooled odds ratio [OR], 0.80; 95% confidence interval [CI], 0.66-0.97; P=.02). Pooled analysis of the 10 studies reporting data on in-hospital mortality did not show an association between tele-ICU coverage and a significant reduction in in-hospital mortality for patients admitted to an ICU (pooled OR, 0.82; 95% CI, 0.65-1.03; P=.08). ICU LOS was reported in 7 of the 13 studies (18 ICUs), representing 14,395 patients; hospital LOS was reported in 6 studies (17 ICUs), representing 14,232 patients. Tele-ICU coverage was associated with a significant reduction in ICU LOS (mean reduction of 1.26 days; 95% CI, −2.21 to −0.30 days; P=.01). There was no significant reduction in hospital LOS associated with use of tele-ICU coverage (mean reduction of 0.64 days; 95% CI, −1.52 to 0.25 days; P=.16). In their comments, the researchers noted that they were able to identify “several factors that are likely to mitigate the effectiveness of tele-ICU coverage but few definitive data as to which patients, ICUs, and hospitals are most likely to benefit from this technology. Given the significant resources required for tele-ICU implementation, further evaluation is clearly needed.”