EDITORIAL
TELEMEDICINE: GETTING A GOOD RECEPTION
With the ongoing advances in technology, telemedicine provides the potential ability to treat patients remotely, across vast distances. In a recent review, Nguyen et al.1 extol the likely benefits of telemedicine, but at the same time point out the present lack of demonstrated benefit. Telemedicine is, by its nature, an intervention that does not lend itself easily to investigation by randomized controlled trial. The evidence examining its efficacy reflects both this difficulty and the relative novelty of the concept.
Rosenfeld et al. published the first feasibility study of remote ICU management by 24-hour “on-call” intensivists2. They studied a single open model surgical ICU, that, for a 16-week period, was provided with 24-hour off-site monitoring and video conferencing facilities with a team of intensivists. The intensivists were responsible for day to day patient management and were provided with real-time patient monitoring data, as well as the results of laboratory and radiological investigations. Compared with the baseline periods prior to the intervention, the ICU mortality was reduced by 46-68%, and the hospital mortality by 30-33%. The ICU length of stay and associated costs also decreased during the study period. Subsequent larger studies reported similar improvements in mortality3,4.
While these initial results appeared promising, they were limited by significant variability in baseline sickness severity, relatively small sample size, and single hospital design. A more recent study from Morrison et al. attempted to address some of these concerns while using a similar underlying methodology5. They collected data from four ICUs at two hospitals following the installation of a commercial system similar to the one described by Breslow et al.3. Morrison et al. were not able to demonstrate any significant difference in ICU or hospital mortality, or hospital cost, and ICU length of stay increased. The authors hypothesized that a low baseline mortality and a variable use of the eICU facility by the hospital physicians may have contributed to their findings.
In Australia there is a separate discipline of Intensive Care with formal training and a separate College (http://www.cicm.org.au). However, outside large cities, smaller hospitals often do not have a resident intensive care specialist and care of critically ill patients usually is undertaken by anaesthetists. It was within this framework that we looked at telemedicine in a different way to the American model.
In 2009, our tertiary referral university-based hospital started a telemedicine service to an 8-bed shared intensive care and coronary care unit 500 km up the Queensland coast that had no formally trained intensive care medical staff. Regular daily ward rounds were undertaken by an intensive care specialist for 1 hour between Monday-Friday via a video conference link. In addition, this specialist was available for the remainder of the day to deal with additional queries via telephone consultation. Ward rounds used a mobile wireless web-camera as part of a computer videoconferencing system. Pathology and radiology were available as necessary, using a state-wide system already in place.
The benefits reported by the regional centre staff have included nursing support and direction for the management of the critically ill including the sharing and development of common policies and procedures. Medical staff have benefited from a practical, as well as an academic, ward round and the unit has been able to improve junior doctor recruitment and make non-intensive care specialist staff more comfortable in the day to day management of the critically ill. Local staff satisfaction has improved, as has the camaraderie and professional relationship between the regional and teriary unit. There has been a significant decrease in the need to transfer patients out of the hospital to tertiary centres. However, this significantly increased the need for local intensive care beds as more work was being done locally. We are presently more formally analyzing adjusted mortality rates (SMRs).
Almost as an aside, using very similar technology has allowed a weekly-run, state-wide, teaching session to be held where, in rotation, each of the many ICUs takes turns in presenting a topic and have input from a vast array of specialist staff. One of us (JL) has recently set up a monthly lecture and question and answer session with some Indian sites.
Telemedicine has been described as “the use of electronic information and communication technologies to provide health care when the caregiver and patient are geographically distanced”6. We would like to modify this comment and concept to “the use of electronic information and communication technologies to help with health care when the advisor and the patient are geographically distanced”.
This editorial arises from the reviewed article within this Monitor by Thomas et al.7 (p.70) that was unable to demonstrate a benefit in their way of performing telemedicine. We have great faith in, and have invested heavily in, what we believe telemedicine to be.
Rob Boots
Associate Professor, Department of Critical Care, University of Queensland, Deputy Director, Department of Intensive Care Medicine, Royal Brisbane Hospital
Jeremy Cohen
Staff Specialist, Department of Intensive Care Medicine,
Royal Brisbane Hospital
Jeffrey Lipman
Professor and Head: Discipline of Anaesthesiology and Critical Care,
The University of Queensland School of Medicine,
Director: Department of Intensive Care Medicine, Royal Brisbane Hospital, Australia.
References
1. Nguyen YL, Kahn JM, Angus DC. Reorganizing adult critical care delivery: the role of regionalization, telemedicine, and community outreach. Am J Respir Crit Care Med 2010;181:1164-1169.
2. Rosenfeld BA, Dorman T, Breslow MJ et al. Intensive care unit telemedicine: alternate paradigm for providing continuous intensivist care. Crit Care Med 2000;28:3925-3931.
3. Breslow MJ, Rosenfeld BA, Doerfler M et al. Effect of a multiple-site intensive care unit telemedicine program on clinical and economic outcomes: an alternative paradigm for intensivist staffing. Crit Care Med 2004;32:31-38.
4. McCambridge M, Jones K, Paxton H et al. Association of health information technology and teleintensivist coverage with decreased mortality and ventilator use in critically ill patients. Arch Intern Med 2010;170:648-653.
5. Morrison JL, Cai Q, Davis N et al. Clinical and economic outcomes of the electronic intensive care unit: results from two community hospitals. Crit Care Med 2010;38:2-8.
6. Yoo EJ, Dudley RA. Evaluating telemedicine in the ICU. JAMA 2009;302:2705-2706.
7. Thomas EJ, Lucke JF, Wueste L, Weavind L, Patel B. Association of telemedicine for remote monitoring of intensive care patients with mortality, Complications, and length of stay. JAMA 2009;302:2671-2678. (See this issue p.70).
