Objective: Intensive care units (ICUs) account for an increasing percentage of hospital admissions and resource consumption. Adverse events are common in ICU patients and contribute to high mortality rates and costs. Although evidence demonstrates reduced complications and mortality when intensivists manage ICU patients, a dramatic national shortage of these specialists precludes most hospitals from implementing an around-the-clock, on-site intensivist care model. Alternate strategies are needed to bring expertise and proactive, continuous care to the critically ill. We evaluated the feasibility of using telemedicine as a means of achieving 24-hr intensivist oversight and improved clinical outcomes.
Design: Observational time series triple cohort study.
Setting: A ten-bed surgical ICU in an academic-affiliated community hospital.
Patients: All patients whose entire ICU stay occurred within the study periods.
Interventions: A 16-wk program of continuous intensivist oversight was instituted in a surgical ICU, where before the intervention, intensivist consultation was available but there were no on-site intensivists. Intensivists provided management during the intervention using remote monitoring methodologies (video conferencing and computer-based data transmission) to obtain clinical information and to communicate with on-site personnel. To assess the benefit of the remote management program, clinical and economic performance during the intervention were compared with two 16-wk periods within the year before the intervention.
Measurements and Main Results: ICU and hospital mortality (observed and Acute Physiology and Chronic Health Evaluation III, severity-adjusted), ICU complications, ICU and hospital length-of-stay, and ICU and hospital costs were measured during the 3 study periods. Severity-adjusted ICU mortality decreased during the intervention period by 68% and 46%, compared with baseline periods one and two, respectively. Severity-adjusted hospital mortality decreased by 33% and 30%, and the incidence of ICU complications was decreased by 44% and 50%. ICU length of stay decreased by 34% and 30%, and ICU costs decreased by 33% and 36%, respectively. The cost savings were associated with a lower incidence of complications.
Conclusions: Technology-enabled remote care can be used to provide continuous ICU patient management and to achieve improved clinical and economic outcomes. This intervention’s success suggests that remote care programs may provide a means of improving quality of care and reducing costs when on-site intensivist coverage is not available.
From the Departments of Anesthesiology/Critical Care Medicine (Drs. Rosenfeld, Dorman, Breslow, and Pronovost), Medicine (Drs. Rosenfeld, Dorman, Breslow, and Rubin and Ms. Jenckes), Surgery (Drs. Rosenfeld, Dorman, Breslow, and Pronovost), and Health Policy & Management (Drs. Pronovost, Zhang, Anderson, and Rubin), The Johns Hopkins University School of Medicine, The Johns Hopkins University School of Hygiene and Public Health; and the Quality of Care Research (Dr. Rubin), Johns Hopkins University, Baltimore, MD.
Address requests for reprints to: Brian A. Rosenfeld, MD, FCCP, FCCM, VISICU, 2400 Boston Street, Suite 302, Baltimore, MD 21224. E-mail: firstname.lastname@example.org
The current affiliation of Dr. Rosenfeld and Dr. Breslow is VISICU, Baltimore, MD.