Due to an aging population and improvement in life-sustaining treatments, there is a growing demand for critical care services and innovation. The purpose of this paper is to identify studies and evidence that explore the impact of a tele-ICU system (remote monitoring by advanced practitioners of critical care patients in ICU units using technological innovation) on ICU length of stay in medical-surgical ICUs. Recent studies from 2009 to 2014 were identified through PubMed, CINAHL, Scopus, and Medline online search databases. Three recent primary research studies were selected based on search criteria and the usage of the Philips VISICU tele-ICU system. The primary outcome of ICU length of stay was compared between studies. Secondary outcomes such as ICU mortality, hospital length of stay, and hospital mortality were also examined.
In 2004 and 2009, the Leapfrog Group set the ICU Physician Staffing (IPS) safety standard which argued that care in Intensive Care Units (ICUs) is strongly influenced by whether intensive care specialty physicians, or intensivists, are the primary providers of patient care (Leapfrog Group for Patient Safety, 2008) . A hallmark systematic review determined that high intensity staffing (ICUs where intensivists manage or co-manage all patients) is associated with a 30% reduction in hospital mortality and a 40% reduction in ICU mortality when compared to low intensity staffing (where intensivists manage or co-manage some or none of the patients) (Provonost, 2002).
Despite the evidence from studies and recommendations supporting similar conclusions, hospitals have been limited in their ability to implement intensivist-centric models due to a shortage of intensivist physicians. In addition, the shortage of critical care nurses limit the number of ideal clinicians who are most proficient at implementing evidence-based solutions to improve outcomes in the ICU (Willmitch, Golembeski, Kim, Nelson, & Gidel, 2012). A collaborative report from the U.S. Health Resources and Services Administration (2007) and the American College of Chest Physicians (ACCP) predicts a 1,500-intensivist deficit in the USA by the year 2020 (Goran & Mullen-fortino, 2012). In the United States, more than a third of individuals require ICU level care during their last year of life, accounting for 13.3% of total hospital costs and 13.4% of acute care hospital beds (Winterbottom & Campbell, 2012). One way to alleviate this inequality between supply and demand is to implement tele-ICU to provide around-the-clock access to off-site intensivists and critical care nurses through the use of audio and video links, connecting them to bedside caregivers managing critically ill patients (Khunlertkit & Carayon, 2013; Sadaka et al., 2013).
What is Tele-ICU?
Tele-ICU or Tele-Intensive Care Unit is more broadly defined as a system that utilizes remote monitoring technology to promote the efficient deployment of intensivist and critical care resources. The three studies examined in this article utilized components of Philips VISICU Inc.'s tele-ICU package which consists of the Philips VISICU eCare Manager electronic critical care system, Philips VISICU Smart Alerts, and the Philips VISICU camera system in each individual room. The eCare Manager is the central platform of the Philips VISICU system which has an electronic display of physiologic monitoring and measurements such as blood pressure, pulse oximetry, heart rate, and telemetry. In addition, it includes advanced algorithms to help pick up early warning signs. The Smart Alerts system is a decision support tool that helps detect and advise both in-house and remote clinicians of trends and changes in patients' conditions", (Philips Corporation, 2013).
The most common utilization of tele-ICU adopted today is using onsite tools to allow remote critical care experts to continuously monitor and access ICU patient data (Kumar, Merchant, & Reynolds, 2013). Two teams of providers, the ICU staff in the unit and the tele-ICU staff off-site, utilize audio and video equipment that allows both groups to interact and communicate as they continuously monitor critically ill patients. A critical feature of tele-ICU is the ability for clinicians to be involved in a patient's care from admission to discharge. Virtual rounds occur frequently: tele-ICU nurses or physicians review patient specific data including lab findings, vital signs, radiology imaging, current medications, and clinical documentation and assessments (Goran & Mullen-fortino, 2012). The system integrates real-time access to bedside and clinical patient information, an alert system that detects changes in the patient's condition, and an online clinical decision support tool, allowing for another set of experienced eyes to ensure an appropriate plan of care.
Many hospitals across the United States are now utilizing tele-ICU to bring the presence of an intensivist to hospitals that may not otherwise have the infrastructure or resources to bring critical care experts to the bedside. By doing so, medical centers are able to enhance the quality of care through improved efficiency, decreased human labour, and standardization of best practice in the ICU (Bauman & Hyzy, 2012). In 2000, Sentara Hospital was the first hospital to implement the tele-ICU approach (Kumar et al., 2013). Since then, the use of tele-ICU monitoring has spread rapidly, with 1 million patients being monitored from 2003-2013 in more than 250 hospitals (Khunlerkit & Carayon, 2013).
Primary articles and supporting evidence (including meta-analyses and systematic reviews) were compiled after a search of online databases - Pubmed, CINAHL, Scopus, and Medline. Single word and combinations of the following keywords were utilized: Tele-ICU, Telemedicine, ICU Length of Stay, Remote Monitoring, and Intensive Care. The search yielded hundreds of articles which were narrowed down to thirteen articles based on the year published, population (medical-surgical vs. other specialty ICUs), number of patients in study, and outcomes studied. There were fewer than twenty primary articles examining ICU length of stay and tele-ICU implementation in adult medical-surgical ICU patients, and fewer than ten studies written in the past five years.
During review, it became clear that tele-ICU interventions varied between different health systems and studies. To create consistency and limit confounding variables, this review narrowed the number of studies further to only those hospitals that utilized the Philips VISICU tele-ICU package.
Analysis of Sources
This paper examines three recent primary sources and the effect of VISICU tele-ICU technology on care in the ICU. The primary outcome assessed was the length of ICU stay, and secondary outcomes examined included ICU mortality, hospital mortality, and length of hospital stay. ICU length of stay reflects a more direct representation of the interventions implemented in the ICU, and therefore was chosen as the primary focus. In addition, hospital/ICU mortality and hospital length of stay are potentially misguided by confounding factors out of control of the critical care team. In additional, not all of the studies investigated these secondary outcomes, and therefore were not considered as the primary focus of this paper. All three articles were published between 2009 and 2014 and were conducted in adult medical-surgical ICUs in the United States (See Table 1).
Methods and Population
Lilly et al. (2011) conducted a study in seven adult ICUs (3 medical, 3 surgical, and 1 mixed cardiovascular) on two campuses of an academic medical center. Patients were all older than 18 years of age. A total of 6,290 qualifying cases were identified - 1,529 in the pre-tele-ICU period and 4,761 in the post implementation period. The Acute Physiology and Chronic Health Evaluation (APACHE) III system was used to calculate patient acuity, and tele-ICU intervention episode type was recorded. The study was a prospective, unblinded, stepped-wedge study of the VISICU Inc. and Cerner Healthcare Solutions tele-ICU tools. These tools included an alert system for physiological trends, abnormal lab values, and review of response, in addition to electronic detection of non-adherence, real-time auditing, nurse manager audits, and team audits. The tele-ICU team worked 24 hours a day and included an intensivist at all hours. The tele-ICU team reviewed the care of individual patients, performed real-time audits of best practice adherence, performed workstation-assisted care plan reviews for patients admitted at night, monitored system-generated electronic alerts, audited bedside clinician responses to in-room alarms, and intervened when responses of bedside clinicians were delayed and patients were unstable. It was one of the few studies that took place in an academic medical center.
Willmitch et al. (2012) retrospectively studied the implementation of a 24/7 tele-ICU program in a five-hospital, diverse, suburban, community-based healthcare system. This pre- and post- observational study collected baseline information for 1 year before tele-ICU initiation and compared it to outcomes data collected for 3 years post-implementation of the VISICU, Sovera, and Siemens information systems. A total of 6,504 patients were in the baseline group, 6,353 in 1 year post group, 6,018 in 2 years post group and 5,781 in 3 years post group for a total of 24,656 adult ICU patients, making this one of the largest and most comprehensive studies assessing the benefits of tele-ICU. Severity of illness was quantified by the All Patient Refined-Diagnosis Related Groups and higher in the post-tele-ICU groups (APACHE scores were used in the other two studies, but not used because scores were not available for the baseline pre-intervention year). The purpose of this study was to study clinical outcomes (hospital LOS, ICU LOS, hospital mortality) before and after implementation of a telemedicine program in the ICU. The type of ICU (medical-surgical vs. specialty) was not revealed in the study, but was assumed to be medical-surgical due to the inclusion of primarily community hospitals.
The study by Sadaka et al. (2013) was conducted at a large community hospital in a 17-bed medical-surgical ICU, and was the only single-hospital study out of the three primary sources selected. It was a retrospective study of pre- and post- implementation of the VISICU tele-ICU with a total of 2,823 adult patients (630 pre-intervention and 2,193 post-intervention). Baseline characteristics, Acute Physiologic Scores (APS) and APACHE IV scores were used to measure severity of illness. The ICU model of care in this large community hospital was an "open" ICU where the primary care provider admitted patients to the ICU and continued to act as the primary physician, with consult on some patients with an in-house intensivist who managed these patients during day time only. After the tele-ICU adoption, two board-certified intensivists had full order writing privileges to initiate evidence-based therapies and hospital-approved protocols, fully managing patients remotely. The main outcomes examined were ICU and hospital length of stay, and ICU and hospital mortality.
Analysis of Outcomes
The research by Lilly et al. (2011), Willmitch et al. (2012), and Sadaka et al. (2013) all showed that the adoption of tele-ICU in a heterogeneous ICU population decreased ICU length of stay (LOS). All three studies adjusted for severity of illness and still found statistically significant decreases to ICU LOS (see Figure 1). This indicated that tele-ICU cases of similar type and acuity still had better outcomes than their non-tele-ICU counterparts, and both unadjusted and adjusted data indicated decreased ICU LOS.
Figure 1: Tele-ICU Effects on ICU Length of Stay
Lilly et al. (2011) showed that ICU length of stay was reduced from 6.4 days in the pre-intervention group to 4.5 days in the post-intervention group, hazard ratio 1.26 (95% Confidence Interval [CI] 1.17-1.36; P <.001). The researchers adjusted for season of year and APACHE III acuity score and matched cases 1-to-1 between the two cohorts. The mean length of ICU stay decreased from 6.9 days pre-intervention to 4.2 days post-intervention (P<0.001). The high-powered study by Willmitch et al. (2012) reported a decrease in severity-adjusted ICU length of stay by 12.6% at the end of the three-year deployment of a tele-ICU model. Similar to Lilly et al. (2011), Willmitch et al. (2012) found a statistically significant increase of severity of illness when comparing baseline to each of the post-implementation periods (p<0.001). After adjusting for severity of illness based on the All Patient Refined-Diagnosis Related Groups score, ICU LOS was reduced from 4.35 days (95% CI 4.22-4.49) pre-intervention to 3.80 days (95% CI 3.65-3.94) 3 years post-tele-ICU intervention (p<0.001). Sadaka et al. (2013) also showed a statistically significant decrease in ICU LOS, reduced from average LOS of 2.7 days (Standard Deviation [SD], 4.1) pre-intervention compared to 2.2 days (SD, 3.4) after tele-ICU adoption (HR = 1.16, 95% CI 1.00-1.40, p = 0.01).
Additionally, there is strong evidence that secondary outcomes such as hospital LOS, ICU mortality, and hospital mortality decreased as a result of tele-ICU as well. Willmitch et al. (2012) showed a statistically significant decrease in severity-adjusted hospital LOS by 14.2% and the relative risk of hospital mortality decreased by 23% with implementation of tele-ICU. Sadaka et al. (2013) showed that tele-ICU improved ICU survival and hospital survival. However, in this study hospital length of stay actually increased, which the authors hypothesized was due to a larger number of patients surviving the ICU and staying more days in the hospital.
Examining Adherence to Best Practices
Only one of the three articles successfully examined staff adherence to best practices in the ICU in relation to tele-ICU technology. Lilly et al. (2011) revealed that tele-ICU increased compliance with critical care best practices to prevent deep vein thrombosis, stress ulcers, ventilator associated pneumonias, and catheter-related blood stream infections. Sadaka et al. (2013) reported 100% compliance with best practices after implementation of tele-ICU, but did not have pre-intervention compliance data to compare to. Lilly et al. (2011) quantified the impact of adherence to best practices in a tele-ICU setting on decreases in hospital mortality, hospital LOS, and preventable complications. The researchers also found that the fraction of patients requiring mechanical ventilation and the duration of mechanical ventilation was significantly lower in the post-intervention group compared with the pre-intervention group.
These reported outcomes suggest additional underlying benefits of tele-ICU. Not only does tele-ICU improve outcomes by increasing the presence of off-site critical care experts by the bedside, but in addition, practitioners by the bedside are more likely to adhere to best practice standards. In one analysis, Lilly et al. (2011) calculated that only about 25% to 30% of the lower mortality rates in the study were attributed to improved best practice adherence. Interestingly, this suggests that there are benefits of the tele-ICU intervention beyond the traditional approaches to improving best practice adherence by the bedside, which is a topic requiring further study.
Variables that may have impacted the observed outcomes include (1) acceptance of tele-ICU on the unit by bedside ICU staff and (2) the retrospective pre- and post- intervention design of the studies.Many additional studies have shown that widespread acceptance of and enthusiasm for the intervention by clinicians is critical not only to the increased utilization of the new technology, but also to improving patient outcomes. A study by Thomas, Lucke, Wueste, Weavind, & Patel (2009) identified that lack of cooperation between bedside physicians and the tele-ICU teams was a major reason for the limited impact of the tele-ICU on reducing mortality in their study. Sadaka et al. (2013) "attests from our own experience that bedside and Tele-ICU team collaboration is an important determinate of favorable outcomes resulting from Tele-ICU intervention" (p. 4). Although cooperation and acceptance is difficult to quantify, it is a significant factor for hospital executives to take into account before implementing a large undertaking like tele-ICU initiation.
All three of the studies discussed above were of the pre- post intervention study design. Willmitch et al. (2012) and Sadaka et al. (2013) were retrospective studies, and Lilly et al. (2011) was prospective. While pre-post intervention data does not assess for gradual temporal changes that occur over time and is generally not considered as powerful a study design as randomized control trials, it would be difficult, if not impossible, to implement a blinded, randomized control trial of a tele-ICU intervention. This is due to the fact that it would be impossible to blind clinicians about the presence of tele-ICU, and that tele-ICU cannot easily be added and removed from a hospital's protocols, and has extraordinary associated costs. The costs typically range from $2-5 million to initiate the command center and install the components of the tele-ICU systems, with an additional operational cost of $600,000-1.5 million per year (Kumar et al., 2013). Therefore, it would not be cost effective and therefore unlikely for an ICU to institute tele-ICU and then remove the intervention immediately after a study. Also, it is not feasible to perform a randomized controlled study to investigate the effectiveness of tele-ICU in a given unit because it would be challenging to have two groups - one with tele-ICU and another without in the same unit. Adopting tele-ICU is not a single isolated intervention, but rather a system alteration that influences countless parties.
A last source of potential bias is that these studies and others like it were conducted to report findings post-acceptance of tele-ICU technology, with little likelihood that the technology would be terminated. This could introduce an unintended bias for successful results.
Type of Technology
When studying the implementation of new technologies, the particular technological system is an important factor to consider. All three studies examined the execution of components of Philips VISICU Inc.'s tele-ICU package which consists of the VISICU eCare Manager electronic critical care system, VISICU Smart Alerts, and the VISICU camera system in each individual room. The medical center studied by Lilly et al. (2011) also utilizes a portion of Cerner Healthcare Solutions tele-ICU tools, but the article does not specify the exact component. The study by Willmitch et al. (2012) utilizes the aforementioned VISICU systems with the Sovera archival system for patient data and Siemens health information system. The specific components were not specified in the article, but should have been included to allow for comparison of different components of the system. It is also important to note that none of the studies were sponsored by the technology companies utilized.
Implications for ICU Practice
The widespread application of this research to hospitals in the US is two-fold. For hospitals that already have tele-ICU, practitioners should be encouraged to embrace the new technology and maximally utilize the service, as the benefits of tele-ICU systems have been shown to reduce ICU length of stay and improve other patient outcome measures. Collaboration and participation between bedside staff and tele-ICU staff is a critical part of the success of tele-ICU. For hospitals that have not yet implemented tele-ICU but are considering the technology, it is important to realize that tele-ICU has been documented to improve outcomes in numerous healthcare settings (Breslow et al., 2004; McCambridge et al., 2010; Rosenfeld et al, 2000; Zawada et al., 2009). However, the technology may not be appropriate for every hospital settling, particularly those that differ significantly from the ones studied in the cited literature.
The literature supports the fact that tele-ICU helps meet multiple evidence-based guidelines and standards that improve ICU patient outcomes, particularly in reducing ICU length of stay. However, the initiation of a tele-ICU program is not as simple or as straightforward as implementing other forms of evidence-based guidelines, which usually involve the application of a single new treatment, process, or protocol. There are many unique obstacles to this technology including cost, training, physician and nurse attitudes, changes in roles and responsibilities, and concerns regarding patient confidentiality and security (Winterbottom & Campbell, 2012). The adoption of a tele-ICU system into an ICU environment should be seen as a complex culture change that involves multiple aspects of healthcare, finance, and technology, and heavily impacts care provision and workflow, changes in traditional roles, and number of alerts in an already high-stress environment. Yoo & Dudley (2009)point out that the deployment of tele-ICU systems involves different elements in different hospital systems, and that these subtle modifications may lead to significantly dissimilar outcomes.Not every hospital system and ICU floor is able to accommodate such drastic changes.
Another important issue to address is that the cost of adoption varies depending on the setting, hardware, software, training, and compatibility issues with other systems in the hospital (Kumar et al., 2013). Breslow et al. (2004) studied the outcomes of a hospital that hired a consulting company to complete a cost-benefit analysis of tele-ICU implementation in their particular setting. They highlighted that the specific elements of tele-ICU that improve the quality of patient care are not well-understood, and that the individual benefits of tele-medicine needed to be studied in more depth (Breslow et al., 2004; Khunlertkit & Carayon, 2013). Lilly et al. (2011) and Sadaka et al.'s (2013) two studies attempted to pinpoint one of the beneficial components of the tele-ICU intervention - adherence to best practice interventions such as deep vein thrombosis and gastric ulcer prophylaxis. However, additional studies examining other specific advantages of tele-ICU are necessary. With tele-ICU being a significant cost to a hospital, determining the exact benefit that an ICU unit will receive is critical, and will vary from ICU to ICU. This decision should not be made until a careful analysis of the cost-benefits in the specific ICU is completed.
In today's health care industry, there is room for ICU practitioners to provide more efficient and effective care. As the population ages and increases in number, ICUs will be overwhelmed with older and sicker patients and will face the problematic shortage of intensivists and critical care nurses. Even in ICUs with adequate staffing, only about 50% of critical care patients receive the required elements of evidence-based best practice bundles recommended in nationally recognized specialty guidelines (Bauman & Hyzy, 2012).
Tele-ICU has the potential to alleviate these problems by utilizing the skills and experience of remote intensivists and critical care nurses in an efficient and effective manner. All three primary investigative studies by Lilly et al. (2011), Willmitch et al. (2012), and Sadaka et al. (2013) concluded that implementation of a tele-ICU program like the Philips VISICU eICU program reduces ICU length of stay in mixed medical-surgical ICUs. For hospitals with limited access to in-house intensivists, tele-ICU has been shown to be an effective alternative to physically having intensivists in ICUs (Breslow et al., 2004). The results of these three studies show that there are many benefits to tele-ICU system implementation, although more investigation is required to pinpoint the specific elements of tele-ICU that are responsible for the observed improved outcomes. Therefore, the decision to implement tele-ICU should be based more on the individual factors of each ICU, bedside staff acceptance of tele-ICU, and individual site cost-benefit analysis.
Although adoption of tele-ICU has been slower than other mandatory technologies like electronic health records, healthcare is moving towards more technological solutions to provide more efficient and higher quality care to meet heavy demand. Studies such as these, in addition to meta-analyses such as the one by Young et al. (2011), indicate that there is powerful evidence to support the use of a novel innovation such as tele-ICU to significantly improve widely recognized clinical endpoints.
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Stephanie Hwang, AG-ACNP, BA, BSN, RN
Adult-Gerontology Acute Care Nurse Practitioner Graduate, 2014
University of Pennsylvania, School of Nursing
I am a critical care ICU nurse, recently graduating in Aug 2014 with my Adult Gerontology Acute Care Nurse Practitioner Master's degree, looking forward to gaining experience at and beyond the bedside as an advanced practice nurse. I hope to apply these clinical skills to other nursing related arenas such as nursing innovation, healthcare IT, medical devices, nursing education, and international health.