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Correspondence |

Does Size Matter in ICU Telemedicine? FREE TO VIEW

Spyridon Fortis, MD; Boulos S. Nassar, MD; Heather S. Resinger, PhD
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

aCenter for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA

bDivision of Pulmonary, Critical Care, and Occupational Medicine, Department of Internal Medicine, University of Iowa, Iowa City, IA

cDivision of General Internal Medicine, Department of Internal Medicine, University of Iowa, Iowa City, IA

CORRESPONDENCE TO: Spyridon Fortis, MD, UIHC-Internal Medicine, 200 Hawkins Dr, C33 GH, Iowa City, IA 52242


Copyright 2017, American College of Chest Physicians. All Rights Reserved.


Chest. 2017;151(4):946. doi:10.1016/j.chest.2017.01.037
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In a recent issue of CHEST (August 2016), Hawkins et al showed that direct intervention of ICU telemedicine is associated with reduced ICU and hospital lengths of stay. This is another “positive study” in a large academic center. While one would expect ICU telemedicine, known also as tele-ICU, to improve outcomes in small rural hospitals with no intensivist, urban large-volume hospitals seem to benefit the most.

Small ICUs need to be grouped with others to create a financially sustainable tele-ICU program, whereas large ICUs may already have the optimal number of ICU beds covered by one telemedicine center. This may be critical for the operation of a telemedicine program for the following reasons:

  • 1.

    Patient data collection: Tele-ICU software integrates data from the electronic medical record (EMR), laboratory and imaging results, and vital signs. If this software does not integrate all data, the telemedicine staff must collect the rest of the data from multiple resources, which reduces their efficiency. In single-center programs, there may be only one EMR (one access) for all sites. In multifacility programs, telemedicine staff may need to access several different EMRs., Similarly, are vital signs records and other data such as radiographic images incorporated into the EMR? If not, the complexity of the telemedicine process increases even further. When complexity is higher, multifacility systems are affected the most.

  • 2.

    Authority to intervene: Hawkins et al showed that allowing ICU telemedicine to intervene at any time compared with simply notifying the bedside staff was associated with reduced length of stay. In multifacility programs with several unrelated hospitals, variability in hospital policy or even administrative preference among the various ICUs may not allow that option.

  • 3.

    Collaboration between telemedicine and bedside ICUs: In multifacility telemedicine programs, tele-ICU staff is unlikely to know the on-site staff, whereas in single-center telemedicine programs, the tele-ICU personnel is small in size, which helps cultivating better relationships with bedside ICUs. Tele-ICU staff may even maintain bedside practice in those ICUs.

  • 4.

    Bedside practice evolution: As a preparation for telemedicine implementation, ICUs may adopt common practices. Although this process can be straightforward within the same institute, it may be difficult for several unrelated ICUs in multifacility tele-ICU programs.

In conclusion, the fact that large-volume hospitals can be organized around one or two hospitals, whereas small-volume hospitals need to be grouped with several others, can explain this paradoxical greater benefit from tele-ICU in large-volume urban hospitals. Further research should investigate the association of the aforementioned factors with ICU telemedicine efficacy.

References

Hawkins H.A. .Lilly C.M. .Kaster D.A. .Groves R.H. Jr..Khurana H. . ICU telemedicine comanagement methods and length of stay. Chest. 2016;150:314-319 [PubMed]journal. [CrossRef] [PubMed]
 
Kahn J.M. .Le T.Q. .Barnato A.E. .et al ICU telemedicine and critical care mortality: a national effectiveness study. Med Care. 2016;54:319-325 [PubMed]journal. [CrossRef] [PubMed]
 
Reynolds H.N. .Bander J.J. . Options for tele-intensive care unit design: centralized versus decentralized and other considerations: it is not just a “another black sedan.”. Crit Care Clin. 2015;31:335-350 [PubMed]journal. [CrossRef] [PubMed]
 
Nassar B.S. .Vaughan-Sarrazin M.S. .Jiang L. .Reisinger H.S. .Bonello R. .Cramp P. . Impact of an intensive care unit telemedicine program on patient outcomes in an integrated health care system. JAMA Intern Med. 2014;174:1160-1167 [PubMed]journal. [CrossRef] [PubMed]
 
Fortis S. .Weinert C. .Bushinski R. .Koehler A.G. .Beilman G. . A health system-based critical care program with a novel tele-ICU: implementation, cost, and structure details. J Am Coll Surg. 2014;219:676-683 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

Hawkins H.A. .Lilly C.M. .Kaster D.A. .Groves R.H. Jr..Khurana H. . ICU telemedicine comanagement methods and length of stay. Chest. 2016;150:314-319 [PubMed]journal. [CrossRef] [PubMed]
 
Kahn J.M. .Le T.Q. .Barnato A.E. .et al ICU telemedicine and critical care mortality: a national effectiveness study. Med Care. 2016;54:319-325 [PubMed]journal. [CrossRef] [PubMed]
 
Reynolds H.N. .Bander J.J. . Options for tele-intensive care unit design: centralized versus decentralized and other considerations: it is not just a “another black sedan.”. Crit Care Clin. 2015;31:335-350 [PubMed]journal. [CrossRef] [PubMed]
 
Nassar B.S. .Vaughan-Sarrazin M.S. .Jiang L. .Reisinger H.S. .Bonello R. .Cramp P. . Impact of an intensive care unit telemedicine program on patient outcomes in an integrated health care system. JAMA Intern Med. 2014;174:1160-1167 [PubMed]journal. [CrossRef] [PubMed]
 
Fortis S. .Weinert C. .Bushinski R. .Koehler A.G. .Beilman G. . A health system-based critical care program with a novel tele-ICU: implementation, cost, and structure details. J Am Coll Surg. 2014;219:676-683 [PubMed]journal. [CrossRef] [PubMed]
 
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