Tele-intensive care unit: The horse out of the barn*

Despite the decline in total hospital beds, the intensive care unit (ICU) beds increased from 1985 to 2000 in the United States (1). Because of the patients’ life-threatening conditions, the complexity of their presentations, and the decision-making process, the most knowledgeable and skilled physicians should provide care for patients admitted to the ICUs. Although a recent study has raised some questions (2), most of the available data suggest that intensivist staffing of ICU improve patient outcome (3). However, the demand for intensivists far exceeds the supply, and intensivists provide care only to a minority of ICU patients (4). Balancing between the reality of intensivist shortage and best patient care, the Leapfrog Group put forth ICU physician staffing requirements, including Fundamental of Critical Care Support-certified non-intensivists to provide care in the ICU when intensivists are not available (5). Only a minority of ICU meets the Leapfrog standards for ICU staffing (6). The Leapfrog standard allows utilization of telemedicine by the intensivist (5). Compared to the Leapfrog standards, the American College of Critical Care Medicine stresses the need for uniform 24-hr 7-day per week intensivist staffing for level I and II critical care centers (7). The shortage of intensivists and the need to provide the best care to the critically ill have led to alternative potential solutions, including telemedicine. Telemedicine in the ICU (tele-ICU) is an electronic means linking ICU to another location that assists in medical decisionmaking. Given the shortage of intensivists, tele-ICU provides an alternative mechanism for intensivists to manage a larger number of critical care patients at different sites. It may also improve compliance with the standards of care via decision support tools and allow earlier recognition of events (8). Although teleICU has a promising future, there are several issues that need to be addressed before its widespread utilization. Does it really improve patient outcome? How should tele-ICU be organized? What are its financial implications? In this issue of Critical Care Medicine, Morrison et al (9) report that tele-ICU does not improve mortality or ICU length of stay, and has no impact on hospital cost. The study is an important contribution to critical care medicine and has several strengths. A relatively larger number of patients and both teaching and nonteaching medical centers were included in the study. Although located “remotely,” the electronic-ICU was staffed by health care providers familiar with the system of the study ICU. Because some of the authors of previous publications addressing tele-ICU (10, 11) were the founders of the company selling the technology, bias attributable to potentials for conflict of interest existed. No conflict of interest is apparent in the study by Morrison et al. Almost three decades have passed since the application of tele-ICU was first reported (12). Based on its potential benefits and facilitated by the technological advances of the past few decades, tele-ICU is now on the market. Despite the scarcity of data and the lack of well-designed clinical trials, it has been incorporated into daily clinical practice by some medical centers (8, 13). Rosenfeld et al (11) evaluated the role of tele-ICU in a 10-bed surgical ICU of an academic-affiliated community hospital. Using “before and after” comparisons, they showed that tele-ICU was associated with decrease in severity-adjusted hospital mortality, incidence of ICU complications, ICU length of stay, and ICU costs. Using a similar “before and after” design, Breslow et al evaluated the impact of tele-ICU in 2140 patients from two adult ICU of a tertiary care hospital (10). They reported that tele-ICU was associated with lower hospital mortality rate, shorter ICU length of stay, lower costs, and higher hospital revenues. Vespa et al (14) performed a prospective study using a before-and-after, cohort-control design to test the effectiveness of tele-ICU using a robotic system to make rounds in response to nursing paging in a neurologic ICU. The robotic telepresence enabled rapid faceto-face attending physician response to ICU patients and resulted in decreased ICU cost and length of stay. The study by Morrison et al differs from the other peerreviewed publications by showing no association between patient/cost outcomes and tele-ICU. All of these studies have some limitations. Their non-robust “before and after” design prevents the incorporation of their findings into evidencebased clinical practice. Compliance with the standards of care is likely to improve patient outcome. However, Morrison et al did not provide any information on the process of care (9). More over, 80% and 50% of the physicians opted to participate at a low level of electronic-ICU during the first and second waves, respectively, minimizing the potential impact of electronic-ICU. Inter-hospital transfer influences patient outcome. The exclusion of patients transferred to other hospitals in the study by Morrison et al weakens the strength of the results. All the reported studies suffer from inadequate sample size. In the study by Morrison et al, the overall mortality of the baseline patient population was 9.9%. If we use a realistic estimate of reducing the mortality rate to 8.9%, inclusion of 13,000 patients is needed in each arm. The authors have appropriately acknowledged these limitations. Despite the scarcity of data, the Leapfrog Group and the University HealthSystem Consortium have made recommendations about the role of tele-ICU in current and future ICU staffing (5, 15). Encouraged by such recommendations and pushed by the marketing pressure to look good, hundreds of ICU have already jumped on the tele-ICU wagon in this country (8). Evidence-based practice calls *See also p. 2.