Evaluating Telemedicine in the ICU

TELEMEDICINE, DEFINED AS THE USE OF ELECTRONIC information and communication technologies to provide health care when the caregiver and patient are geographically distanced, is an increasing trend in inpatient medicine. One of the most common applications is in the intensive care unit (ICU), where ICU telemedicine (tele-ICU) can be used to increase access to intensivist physicians. In this care model, intensivist physicians and nurses, located in a central monitoring facility, are able to visually monitor patients across multiple ICUs in many hospitals using bedside cameras while also electronically tracking relevant clinical information, such as vital signs or laboratory data. The remote care team is then able to communicate orally with bedside caregivers to provide real-time, around-theclock patient care. Research has shown that dedicated onsite intensivist staffing is associated with reductions in hospital and ICU length of stay (LOS) and mortality. Thus, the appeal of tele-ICU is intuitive: it extends intensivist coverage to hospitals that do not have it and may increase the timeliness of intensivist input in other settings. Despite the attractiveness of tele-ICU and its increasing adoption, few trials have evaluated its effect on outcomes. Therefore, it is not yet clear in what situations, if any, the potential benefits might be realized. Early studies, each performed at a single center and comparing care before and after implementation of a tele-ICU system, documented decreases in LOS, mortality, and cost, first in an academicaffiliated community hospital and subsequently in a tertiarycare hospital. Presumably because few hospitals would submit to being randomized to implement or not implement tele-ICU, all subsequent tele-ICU studies also involve before-and-after study designs. Furthermore, they are limited by lack of specificity about what the intervention includes, by the inclusion of multiple changes to ICU care in the tele-ICU as implemented, and by the absence of a detailed description of preintervention ICU care. In this issue of JAMA, Thomas et al report the first federally funded multicenter evaluation of tele-ICU, expanding application of tele-ICU to 6 ICUs of varying case mix, size, and staffing. Using a before-and-after design, they measured the effect of tele-ICU on LOS, mortality, and complications and reported no overall benefit with the tele-ICU program. Although the investigators carefully describe their ICUs as “open” (admitting privileges open to physicians other than intensivists) or “closed” (admitting privileges restricted to intensivists), the “open” units were variable in their degree of exposure to intensivist care. Furthermore, their particular intervention, a proprietary tele-ICU system, included not only remote monitoring by intensivists aided by electronic patient data, but also nursing, technician, and alert-system services. The authors do not report whether similar services existed before tele-ICU implementation or whether such services varied among hospitals. Their findings may also be explained by the limited degree of treatment authority delegated to the tele-ICU by the majority of attending physicians. One interesting unanticipated observation was an apparent benefit among sicker patients, which highlights the need for careful evaluation of what each teleICU means, in terms of specific changes in ICU care relative to other alternative approaches and of which patients might benefit. Thus, even though the study by Thomas et al is a step forward with its range of hospitals and description of preintervention care, it nonetheless remains difficult to interpret. Some of the uncertainty about tele-ICU reflects the lack of consistent reference in the literature to a unifying conceptual framework of what ICU care is and how tele-ICU could improve it. Without such reference, it is difficult to delineate which components of care a tele-ICU intervention (or any other attempt to redesign ICU care) addresses. In terms of a conceptual framework of ICU care, structural issues such as staffing levels and availability of computerized order entry likely contribute to outcomes. Within a given structure, team interactions—not just among physicians, but also among physicians and nurses, respiratory therapists, and pharmacists—influence the eventual processes of care undertaken. These processes of care—such as using low tidal volumes in acute respiratory distress syndrome (ARDS)—determine clinical outcomes, while com-