An Intraoperative Telemedicine Program to Improve Perioperative Quality Measures
Authors: King Christopher R. , Gregory Stephen , Fritz Bradley A. , Budelier Thaddeus P. , Ben Abdallah Arbi , Kronzer Alex , Helsten Daniel L. , Torres Brian , McKinnon Sherry , Goswami Shreya , Mehta Divya , Higo Omokhaye , Kerby Paul , Henrichs Bernadette , Wildes Troy S. , Politi Mary C. , Abraham Joanna , Avidan Michael S. , Kannampallil Thomas ,   ACTFAST Study Group, Abdelhack Mohamed , Aranake-Chrisinger Amrita , Archer Aaron , Arends Maureen , Armstrong Emily , Athiraman Umeshkumar , Balasubramanian Sennaraj , Bansal Anchal , Battig Kara , Benematti Danielle , Benzinger George , Bollini Mara , Borle Anuradha , Bottros Michael , Boyle Walter , Bozada Thomas , Bradley Margaret , BrandonUfert BrandonUfert , Brown Christina , Brown-Shpigel Jamie , Burton Jamila , Carmony Megan , Cass Kathryn , Cavallone Laura , Chen Yunwei , Chen Yixin , Choi Han , Coggin Marissa , Cohen Zachary , Critchlow Casey , Davies Christopher , Davis Christopher , Demler-Barth Aaron , Durk Ryan , Eddins Daniel , Eisenbath David , Ellis Meredith , Emmert Daniel , Escallier Krisztina , Exler Jane , Fingerman Mitchell , Fischbach Ellen , Frasca Elizabeth , Ge Michelle , Gillihan Jason , Goez Marie , Goodwin Natasha , Graetz Thomas , Guffey Ryan , Gupta Shelly , Gurba Katharine , Gutesa Kelsey , Guthrie Tracey , Hakim Michael , Hantler Charles , Haw Peter , Heeger Hilary , Herrera Erin , Hincker Alex , Hovis Robert , Hubbard Gary , Hueneke Rocco , Ingram Mark , Iqbal Zahid , Ironstone Susan , Jacobsen Kyle , Jain Nisha , Kadi Bassel , Kangrga Ivan , Karanikolas Menelaos , Kinealy Bridget , Kinworthy Mary , Kirkpatrick Holly , Kiveric Esad , Knibb Andrea , Knittel Justin , Kokefer Andreas , Koman Helga , Kras Joseph , Kraus Kristin , Lakshminarasimhachar Anand , Larese Joseph , Lattanand Chakrapol , Malshet Casarella Aparna , Mathew Jonathan , Maybrier Hannah , McAvity Peter , McClellan Alyssa , McDowell Jacob , McKenzie Heather , Meng Alicia , Mickle Angela , Milbrandt Melissa , Mohinder Singh Preet , Mohrmann Alexander , Monks David , Montes de Oca Arianna , Murray-Torres Teresa , Najrabi Khatera , Nowakowski Lauren , Nwokeabia Ifeanyi , Oberhaus Jordan , Owusu-Bediako Ekua , Park Daniel , Patel Aamil , Perez Sarah , Phillips Caroline , Potter David , Pulley Debra , Rangrass Govind , Rao Janavi , Rathor Rashmi , Riordan Isabella , Ritter Cameron , Roller Evan , Sabino Martha , Sanzalone Matthew , Sayfutdinova Elvira , Schadler Craig , Schappe Elizabeth , Schatz Alexandra , Sebastiani Anne , Seiber Kimberly , Sharma Anshuman , Sillery Sarah , Silver Kate , Siraco Susan , Somercik Melanie , Sontha Pratyush , Spencer James , Spencer Erika , Stevens Tracey , Swaniker Jasmin , Szabo Martha , Terkonda Raghu , Thai Carolyn , Todorovic Marko , Tolly Brian , Trammel Emma , Tripathi Sandhya , Tseng Lisa , Uding Bradley , Upadhyayula Ravi , Varaday Swarup , Varnum William , Wang Minna , Watkins Sarah , Willingham Mark , Wise William , Wolfe Rachel , Wolfson Maxim , Woodstock Hannah , Wright Randy , Yang Katie , Yee Branden , Yuan Jennifer , Zanaboni Paul , Zenga Jessica , Zhang James , Zheng Tianyang , Zimick Nicholas , Zwingelberg Joshua 
Published: September 2023

Importance

Telemedicine for clinical decision support has been adopted in many health care settings, but its utility in improving intraoperative care has not been assessed.

Objective

To pilot the implementation of a real-time intraoperative telemedicine decision support program and evaluate whether it reduces postoperative hypothermia and hyperglycemia as well as other quality of care measures.

Design, Setting, and Participants

This single-center pilot randomized clinical trial (Anesthesiology Control Tower–Feedback Alerts to Supplement Treatments [ACTFAST-3]) was conducted from April 3, 2017, to June 30, 2019, at a large academic medical center in the US. A total of 26 254 adult surgical patients were randomized to receive either usual intraoperative care (control group; n = 12 980) or usual care augmented by telemedicine decision support (intervention group; n = 13 274). Data were initially analyzed from April 22 to May 19, 2021, with updates in November 2022 and February 2023.

Intervention

Patients received either usual care (medical direction from the anesthesia care team) or intraoperative anesthesia care monitored and augmented by decision support from the Anesthesiology Control Tower (ACT), a real-time, live telemedicine intervention. The ACT incorporated remote monitoring of operating rooms by a team of anesthesia clinicians with customized analysis software. The ACT reviewed alerts and electronic health record data to inform recommendations to operating room clinicians.

Main Outcomes and Measures

The primary outcomes were avoidance of postoperative hypothermia (defined as the proportion of patients with a final recorded intraoperative core temperature &amp;gt;36 °C) and hyperglycemia (defined as the proportion of patients with diabetes who had a blood glucose level ≤180 mg/dL on arrival to the postanesthesia recovery area). Secondary outcomes included intraoperative hypotension, temperature monitoring, timely antibiotic redosing, intraoperative glucose evaluation and management, neuromuscular blockade documentation, ventilator management, and volatile anesthetic overuse.

Results

Among 26 254 participants, 13 393 (51.0%) were female and 20 169 (76.8%) were White, with a median (IQR) age of 60 (47-69) years. There was no treatment effect on avoidance of hyperglycemia (7445 of 8676 patients [85.8%] in the intervention group vs 7559 of 8815 [85.8%] in the control group; rate ratio [RR], 1.00; 95% CI, 0.99-1.01) or hypothermia (7602 of 11 447 patients [66.4%] in the intervention group vs 7783 of 11 672 [66.7.%] in the control group; RR, 1.00; 95% CI, 0.97-1.02). Intraoperative glucose measurement was more common among patients with diabetes in the intervention group (RR, 1.07; 95% CI, 1.01-1.15), but other secondary outcomes were not significantly different.

Conclusions and Relevance

In this randomized clinical trial, anesthesia care quality measures did not differ between groups, with high confidence in the findings. These results suggest that the intervention did not affect the targeted care practices. Further streamlining of clinical decision support and workflows may help the intraoperative telemedicine program achieve improvement in targeted clinical measures.

Trial Registration

ClinicalTrials.gov Identifier: NCT02830126