In the June 1, 2011 Journal of American Medical Association, Lilly and colleagues report a prospective, unblinded single-institution study where implementation of a tele-ICU intervention was associated with reduced adjusted odds of mortality and reduced hospital and intensive care unit (ICU) length of stay, as well as improved adherence to best practices and lower rates of preventable complications.

Authors employed a stepped-wedge design for 6,290 adult patients admitted to seven ICUs (three medical, three surgical and one mixed cardiovascular) between April 26, 2005, and September 30, 2007. The primary outcome was adjusted hospital mortality. Other outcomes included shorter hospital and ICU lengths of stay, best practice adherence and lower complication rates.

The hospital mortality rate was 13.6% (95% confidence interval [CI], 11.9%-15.4%) during the pre-intervention period compared with 11.8% (95% CI, 10.9%-12.8%) during the tele-ICU intervention period (adjusted odds ratio, 0.40 [95% CI, 0.31-0.52]). Telemedicine was associated with lower mortality rates both within ICUs over time and across ICUs during the same periods, emphasizing that the results could not be solely attributed to time trends. The tele-ICU intervention period, compared with the pre-intervention period, was associated with higher rates of best clinical practice adherence for the prevention of deep vein thrombosis, prevention of stress ulcers, cardiovascular protection and prevention of ventilator-associated pneumonia. Lower rates of ventilator-associated pneumonia, catheter-related bloodstream infections and shorter hospital lengths of stay were also reported in the tele-ICU group. Telemedicine physicians worked in conjunction with local clinicians to enforce daily goals, respond to bedside alarms and review care and adherence to evidence-based practices.

Limitations worth noting include the non-randomized, unblinded nature of the study design, as well as the fact that the study was conducted in a single academic medical center. The positive results from this study, as opposed to those of previous tele-ICU studies, may indicate a higher degree of mandatory collaboration between on-site intensivists and telemedicine physicians; participation was mandatory in all ICUs included in this study, and on-site clinical staff could not “opt out.” Additionally, all of the telemedicine physicians in the study worked in the same ICUs; hence, these results may not be replicated in settings where the telemedicine unit and hospital unit do not share ICU providers. Moreover, these results may not be replicated in hospitals that do not have existing robust quality improvement processes.

This studyby Lilly and colleagues examined a tele-ICU closely linked to specific quality improvement activities, providing the first convincing evidence that ICU telemedicine can be an effective complement to bedside care in some settings. Future large randomized multi-institutional studies will be required to confirm the external generalizability of these results.

Dragos M. Galusca, MD, a fellow at Johns Hopkins Hospital, contributed to this installment of Concise Critical Appraisal.

Concise Critical Appraisal is a regular feature in the Society of Critical Care Medicine’s eNewsletter. Authored by Samuel M. Galvagno Jr., DO. Each installment highlights journal articles most relevant to the critical care practitioner.