Telehealth Helps Cut Mortality Risk Among ICU Patients

Marcia Frellick

February 02, 2021

Patients who received telemedicine in an intensive care unit (ICU) were less likely to die and more likely to have a shorter hospital stay than those who received standard ICU care without a 24-hour intensivist on-site, new data suggest.

Chiedozie I. Udeh, MD, staff intensivist with the Cleveland Clinic Foundation, presented results of a retrospective study of 153,987 consecutive ICU patients at the Society for Critical Care Medicine (SCCM) 2021 Critical Care Congress.

Among the statistically significant findings were that 30-day mortality decreased by 18% (odds ratio [OR], 0.82, 95% CI, 0.77 - 0.87) and length of stay in the ICU decreased by 1.6 days in the telehealth model (95% CI, 1.5 - 1.7), compared with the traditional model. The total length of the average hospital stay was reduced by 2.1 days (95% CI, 1.9 - 2.4).

Patients in the study received ICU care at one of nine Cleveland Clinic hospitals between January 1, 2010 and December 31, 2019. Overall, 108,482 (70%) received ICU-telemedicine care during hours when an intensivist was not on-site.

Chiedozie Udeh

Udeh told Medscape Medical News that only the largest academic centers typically have an intensivist on-site 24 hours a day. In the traditional model, critical care specialists may be on-site during the day but on call after hours.

In the tele-ICU model, in contrast, a intensivist — perhaps at a command center serving several hospitals — can observe and order treatments for patients remotely. The specialist has access to the patient's medical record and test results, can monitor vital signs and visible changes, and can talk with both the patient and the nurse or other provider in the room.

Udeh said he suspects the 18% drop in mortality risk and the shorter hospital stay come from time saved. The physician doesn't have to ask the nurse to look up health information, and with constant monitoring can spot problems sooner or prevent them.

"You reduce a lot of the time from event to intervention or prevent an event by being more proactive," Udeh said.

Ben Scott

Ben Scott, MD, associate professor of anesthesiology and critical care at the University of Colorado (UC) in Aurora, told Medscape Medical News his institution uses the tele-ICU model in several of the smaller hospitals there and is not surprised that Udeh's team found such positive results. Scott was not involved in Udeh's study.

"Most of us who have been working in this area and studying the results believe that these programs can make a big difference," said Scott, who is also vice chair for the SCCM tele-critical-care committee.

The smaller UC hospitals have ICU capability but not the census numbers to warrant 24-hour intensivist coverage. Of course they do have 24-hour nursing coverage, and they typically use telemedicine when an intensivist is needed during the night, Scott said.

Hard to Pinpoint Telemedicine's Role

Scott said it's hard to determine from studies how much telemedicine is influencing outcomes, compared with potentially confounding factors. A hospital with several ICUs might choose to send a patient to a certain ICU for a particular reason, which could confound comparisons.

The statistical techniques Udeh's team used, however, helped account for confounding, Scott said. The extended years for the study and large patient sample also strengthen confidence in the results, he said.

The researchers found that several factors can increase an ICU patient's risk of dying, including the reason for admission (such as cardiac arrest or sepsis), being admitted on a weekend, and the patient's race. But they found that telemedicine might mitigate the effects of weekend admissions; the telemedicine patients admitted on a weekend in this study were no more likely to die than those admitted on a weekday.

The telemedicine model is especially important in areas without intensivists.

"If my only recourse is to send my patient out of town or out of state to another hospital, it's a win–win," Udeh said.

Regardless of the resources of individual hospitals, the national picture is clear, he said. "We just don't have enough people trained in critical care to place an intensivist in every ICU 24/7."

Just last week, Santa Cruz Valley Regional Hospital in Green Valley, Arizona temporarily shut down its ICU. The hospital CEO said the closure came because the hospital was unable to hire a pulmonologist.

Balancing Cost Issues

Cost issues with the tele-ICU have been a barrier for widespread adoption, Udeh said. He estimated that only about 15% to 20% of hospitals incorporate the model.

Hospitals must pay for hardware and the telehealth service while still needing to have someone on staff available to come in if a physician's presence is needed. And so far, those costs are not generally reimbursable by payers.

Hospitals must balance the costs with the potential for better outcomes and shorter stays, he said.

The model has benefits for the provider as well.

Udeh recounted being awakened by a call in the middle of the night and fighting off grogginess to quickly process information and make critical decisions.

But with the tele-ICU model, providers are awake for a specified shift and are periodically rounding on patients electronically with real-time access to health information.

Udeh said many of the tele-ICU platforms have decision support built in, with various degrees of complexity, so that the system might flag when a patient's blood pressure is trending down, for example.

Although this research used prepandemic data, COVID-19 has highlighted the need for solutions to stretch ICU workforces.

Scott pointed out that in the pandemic, many hospitals that don't have regular critical care services have had to take care of critically ill patients.

Having a telemedicine program can help bring that expertise to the bedside, he said.

Udeh, his coinvestigators, and Scott have disclosed no relevant financial relationships.

Society for Critical Care Medicine (SCCM) 2021 Critical Care Congress: Abstract 16. Presented January 31, 2021.

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune, Science News and Nurse.com and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick.

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