Tele-Critical Care Utilisation and ICU Outcomes

A new study examined the relationship between the duration of tele-critical care (TCC) implementation and clinical outcomes. The research focused on 35 hospitals with 444 ICU beds that utilised TCC between 2012 and 2020, analysing 193,367 patient stays to determine whether prolonged TCC deployment improved ICU mortality rates, length of stay, and mechanical ventilation utilisation.

The study population consisted primarily of male veterans, with 95.3% male patients and an average age of 63 years. The overall discharge status showed that 93.7% of patients survived their ICU stay, with an average unit length of stay of 2.83 days. 

The findings revealed a trend towards lower standardised ICU mortality rates with longer TCC utilisation. While the correlation between TCC deployment duration and mortality showed a modest negative association, the results became statistically significant after five years of implementation. When comparing hospitals with more than five years of TCC deployment to those with five years or less, the actual-to-predicted standardised mortality rate decreased significantly. This reduction remained consistent for thresholds of six and seven years of deployment, suggesting that sustained TCC implementation provides meaningful mortality benefits even when baseline mortality rates are already lower than predicted.

ICU length of stay demonstrated a significant relationship with prolonged TCC deployment. The standardised length of stay was initially higher than predicted during the first year of TCC utilisation but progressively declined with longer deployment duration. The analysis revealed a significant negative correlation between standardised ICU length of stay and TCC deployment duration. Hospitals with more than four years of TCC implementation showed a 92% ratio of actual to predicted length of stay, while those with more than five years demonstrated a 90% ratio, both representing statistically significant improvements. This suggests that TCC's impact on length of stay was more prominent than its effect on mortality, potentially due to greater opportunities for improvement given the initially higher-than-expected length of stay.

Regarding invasive mechanical ventilation, the study analysed 143,000 admissions and found that 17.5% of ICU patients in the VA received invasive ventilation during the study period. However, unlike mortality and length of stay, the standardised invasive mechanical ventilation rate did not demonstrate a significant relationship with TCC deployment duration. 

The researchers proposed that the gradual improvement in outcomes over time reflects the challenges of implementing new healthcare technologies. Drawing on change management science, they suggested that it can take up to 17 years for new medical innovations to be fully integrated into clinical practice. The delayed effect of TCC on mortality rates, requiring five years to achieve statistical significance, may reflect the time needed for acculturation and acceptance of TCC as an integral member of the multidisciplinary critical care team.

The study concluded that extended TCC implementation improves ICU mortality rates and reduces ICU length of stay, with clear benefits emerging after prolonged deployment. However, the authors acknowledge several limitations, including the retrospective observational design, potential confounding factors from differences in technology and clinical practices across facilities, and limited generalisability outside the VA system. They recommend further research to explore the mechanisms behind TCC's effects and the change management factors influencing successful adoption.

Source: Critical Care Medicine
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