We thank the authors of “Does Size Matter in ICU Telemedicine?” for the pertinent points made regarding how facility size and heterogeneity of practices may affect ICU telemedicine processes. We are also interested in the factors associated with better outcomes, and leveraged variation of size among our community hospitals in the analyses by Hawkins et al.
Patient data collection: The harmonized approach to data collection from the eight ICUs of the study by Hawkins et al allowed us to identify comanagement methods as a significant differentiating factor. Hospital size was not predictive. Generally speaking, current electronic systems and integration expertise allow the transfer of data through electronic interfaces and routinely simplify access to many forms of clinical information. Investment in these technologies and the proper training of critical care professionals may have prevented differences of electronic data transfer from being a detectable distinguishing factor for length of stay (LOS) outcomes in the study.
Authority to intervene: One of the important findings of the study by Hawkins et al is that it provides new information about how alternative approaches under the administrative control of the sponsoring or subscribing institutions affect outcomes and how costs compare in terms of LOS outcomes.
Collaboration between telemedicine and bedside ICUs: We strongly agree with the authors regarding the importance of collaborative relationships among ICU providers. We also agree that having staff work on both sides of the camera helps to promote these relationships. The use of two-way telemedicine systems that provide frequent communications, and which include patients who have the capacity to participate, is another effective way to form and develop these relationships. We respectfully point out that large comparative studies that included acuity-adjusted outcomes have not identified the size of the ICU telemedicine program or number of supported ICUs as associated with meaningful differences of outcomes. Some studies have noted cost benefits to rural hospitals from reduced transfers and keeping patients closer to their homes.
Standardized practice evolution: We agree that the benefits associated with standardizing care can be difficult to achieve. The sharing and benchmarking of data and the reporting solutions that are part of larger programs have provided powerful tools for encouraging the adoption of standard best practices and measuring the impact of these changes on critical care outcomes.