Marc T. Zubrow

Critical care telemedicine: evolution and state of the art.

Objectives: To review the growth and current penetration of ICU telemedicine programs, association with outcomes, studies of their impact on medical education, associations with medicolegal risks, identify program revenue sources and costs, regulatory aspects, and the ICU telemedicine research agenda. Data Sources: Review of the published medical literature, governmental documents, and opinions of experts from the Society of Critical Care Medicine ICU Telemedicine Committee. Data Synthesis: Formal ICU telemedicine programs now support 11% of nonfederal hospital critically ill adult patients. There is increasingly robust evidence of association with lower ICU (0.79; 95% CI, 0.65–0.96) and hospital mortality (0.83; 95% CI, 0.73–0.94) and shorter ICU (–0.62 d; 95% CI, –1.21 to –0.04 d) and hospital (–1.26 d; 95% CI, –2.49 to –0.03 d) length of stay. Physicians in training report experiences with telemedicine intensivists that are positive and increased patient safety. Early studies suggest that implementation of ICU telemedicine programs has been associated with lower numbers of malpractice claims and costs. The requirements for Medicare reimbursement and states with legislation addressing providing professional services by telemedicine are detailed. Conclusions: The inclusion of an ICU telemedicine program as a major part of their critical care delivery paradigm has been implemented for 11% of critically ill U.S. adults as a solution for the problem of access to adult critical care services. Implementation of an ICU telemedicine program is one practical way to increase access and reduce mortality as well as length of stay. ICU telemedicine research including comparative effectiveness studies is urgently needed.

The GENESIS Project (GENeralized Early Sepsis Intervention Strategies) A Multicenter Quality Improvement Collaborative

Background: Improved outcomes for severe sepsis and septic shock have been consistently observed with implementation of early best practice intervention strategies or the 6-hour resuscitation bundle (RB) in single-center studies. This multicenter study examines the in-hospital mortality effect of GENeralized Early Sepsis Intervention Strategies (GENESIS) when utilized in community and tertiary care settings. Methods: This study was comprised of 2 strategies to assess treatment. The first was a prospective before-and-after observational comparison of historical controls to patients receiving the RB after implementation of GENESIS in 4 community and 4 tertiary hospitals. The second was a concurrent examination comparing patients not achieving all components of the RB to those achieving all components of the RB in 1 community and 2 tertiary care hospitals after implementation of GENESIS. These 4 subgroups merged to comprise a control (historical controls treated before GENESIS and RB not achieved after GENESIS) group and treatment (patients treated after GENESIS and RB achieved after GENESIS) group for comparison. Results: The control group comprised 1554 patients not receiving the RB (952 before GENESIS and 602 RB not achieved after GENESIS). The treatment group comprised 4801 patients receiving the RB (4109 after GENESIS and 692 RB achieved after GENESIS). Patients receiving the RB (treatment group) experienced an in-hospital mortality reduction of 14% (42.8%-28.8%, P < .001) and a 5.1 day decrease in hospital length of stay (20.7 vs 15.6, P < .001) compared to those not receiving the RB (control group). Similar mortality reductions were seen in the before-and-after (43% vs 29%, P < .001) or concurrent RB not achieved versus achieved (42.5% vs 27.2%, P < .001) subgroup comparisons. Conclusions: Patients with severe sepsis and septic shock receiving the RB in community and tertiary hospitals experience similar and significant reductions in mortality and hospital length of stay. These findings remained consistent when examined in both before-and-after and concurrent analyses. Early sepsis intervention strategies are associated with 1 life being saved for every 7 treated.

Improving Care of the Sepsis Patient

BACKGROUND In 2004, Christiana Care Health System (Christiana Care), a 1,100-bed tertiary care facility, used the Surviving Sepsis Campaign guidelines as the foundation for an independent initiative to reduce the mortality rate by at least 25%. METHODS In 2004, an interdisciplinary sepsis team developed a process for rapidly recognizing at-risk patients; evaluating a patients clinical status; and providing appropriate, timely therapy in three major areas of sepsis care; recognition of the sepsis patient, resuscitation priorities, and intensive care management. The Sepsis Alert program, which did not require additional staffing, was developed and implemented in 10 months. The Sepsis Alert packet included a care management guideline, a treatment algorithm, an emergency department treatment order set, and multiple adjuncts to streamline patient identification and management. RESULTS Introduction of sepsis resuscitation and critical care management standards led to a 49.4% decrease in mortality rates (p < .0001), a 34.0% decrease in average length of hospital stay (p < .0002), and a 188.2% increase in the proportion of patients discharged to home (p < .0001) when the historic control group is compared with the postimplementation group from January 2005 through December 2007. DISCUSSION An integrated leadership team, using existing resources, transformed frontline clinical practice by providers from multiple disciplines to reduce mortality in the population of patients with sepsis.

Emergency Department Tachypnea Predicts Transfer to a Higher Level of Care in the First 24 hours After ED Admission

OBJECTIVES The authors hypothesized that vital sign abnormalities detected in the emergency department (ED) can be used to forecast clinical deterioration occurring within 24 hours of hospital admission. METHODS This was a retrospective case-control study performed after implementation of a hospitalwide rapid response team (RRT) system. Inclusion criteria for study patients consisted of age > or = 18 years, admission to the general floor though the ED, and RRT activation and subsequent transfer to a higher level of care in the first 24 hours. Control patients were > or =18 years, were admitted to the floor though the ED, never required RRT or transfer to a higher level of care, and were matched to cases by risk of mortality. Multilevel logistic regression was used to model the odds of an adverse outcome as a function of race and sex, respiratory rate (RR), heart rate (HR), and systolic (sBP) and diastolic blood pressure (dBP) at time of transfer from the ED. RESULTS A total of 74 cases and 246 controls were used. RR (odds ratio [OR] = 2.79 per 10-point change, 95% confidence interval [CI] = 1.41 to 5.51) and to a lesser extent dBP (OR = 0.81, 95% CI = 0.67 to 0.97) contributed significantly to the odds of intensive care unit (ICU) or intermediate care transfer within 24 hours of admission; HR (OR = 1.15, 95% CI = 0.98 to 1.37) did not. CONCLUSIONS Emergency department RR preceding floor transfer appears to have a significant relationship to the need for ICU or intermediate care transfer in the first 24 hours of hospital admission.

Resident Perceptions of a Tele-Intensive Care Unit Implementation

OBJECTIVE Remote intensive care unit (ICU) monitoring (tele-ICU) may provide a means to address the shortage of intensive care physicians. However, the consequences of implementing a tele-ICU system for house staff education and clinical experience are unknown. The purpose of this study was to determine resident perceptions of the impact of a tele-ICU implementation on patient care, education, and the overall work environment. MATERIALS AND METHODS Cross-sectional survey of residents who rotated through the medical ICU within the first year after the implementation of a tele-ICU in a large, academically affiliated, community hospital. Each question was graded on a 5-point Likert scale. RESULTS Thirty-five of 60 residents completed the survey (58% response rate). Sixty-three percent of residents reported that tele-ICU was associated with an improved ability to focus on urgent patient issues, and 46% thought that the tele-ICU helped them to feel less overwhelmed. Although most residents were neutral (51%), 37% agreed that the tele-ICU was a valuable educational experience. Seventy-seven percent reported that the tele-ICU integration was associated with improved patient safety, but many were concerned about the impact on continuity and communication. There was no perceived association with patient or family satisfaction. CONCLUSIONS Our study suggests that a tele-ICU implementation in a medical ICU does not seem to have a negative impact on the educational experience of residents and is associated with perceived improvements in patient safety and quality. Future studies should objectively measure the educational impact of implementing a tele-ICU system.

Antecedent bradycardia and in-hospital cardiopulmonary arrest mortality in telemetry-monitored patients outside the ICU ,

BACKGROUND Patients with in-hospital cardiopulmonary arrest (IHCA) precipitated by respiratory insufficiency often exhibit bradycardia before the arrest. We hypothesized that bradycardia frequently occurs in the 10 min preceding IHCA and is associated with poor outcomes when IHCA occurs outside the intensive care unit (ICU). OBJECTIVES To determine the prevalence and association of antecedent bradycardia with outcome in adult patients with IHCA occurring outside the ICU. METHODS We performed a retrospective cohort study among telemetry monitored adults with IHCA outside the ICU in a two-hospital health system between 2008 and 2010 with follow-up until their discharge or death in-hospital. We defined (1) IHCA as >1 min of chest compressions or trans-thoracic defibrillation, (2) Antecedent bradycardia as at least 2 min of continuous heart rate between 1 and 59 beats per minute in the 10min preceding IHCA, and (3) ventricular tachyarrhythmia arrests as presence of sustained ventricular tachyarrhythmia for >20 s in the 10 min preceding IHCA. RESULTS Of 98 IHCAs, 39 (39.8%) survived to hospital discharge. Of 98 IHCAs, 53 (54.1%) had antecedent bradycardia. After adjusting for potential confounders, antecedent bradycardia was associated with death prior to hospital discharge (adjusted OR=3.80, 95% CI: 1.47-9.81, p=0.006). Among patients with ventricular tachyarrhythmia arrests, antecedent bradycardia was associated with a higher risk of death (OR=13.1, 95% CI 1.92-89.5, p=0.009). CONCLUSIONS Antecedent bradycardia occurred frequently and was associated with death prior to hospital discharge in non-ICU hospitalized adults on telemetry monitoring who developed IHCA.

Ultrasound images transmitted via FaceTime are non-inferior to images on the ultrasound machine

PURPOSE Remote telementored ultrasound (RTMUS) systems can deliver ultrasound (US) expertise to regions lacking highly trained bedside ultrasonographers and US interpreters. To date, no studies have evaluated the quality and clinical utility of US images transmitted using commercially available RTMUS systems. METHODS This prospective pilot evaluated the quality of US images (right internal jugular vein, lung apices and bases, cardiac subxiphoid view, bladder) obtained using a commercially available iPad operating FaceTime software. A bedside non-physician obtained images and a tele-intensivist interpreted them. All US screen images were simultaneously saved on the US machine and captured via a FaceTime screen shot. The tele-intensivist and an independent US expert rated image quality and utility in guiding clinical decisions. RESULTS The tele-intensivist rated FaceTime images as high quality (90% [69/77]) and could comfortably make clinical decisions using these images (96% [74/77]). Image quality did not differ between FaceTime and US images (97% (75/77). Strong inter-rater reliability existed between tele-intensivist and US expert evaluations (Spearmans rho 0.43; P<.001). CONCLUSION An RTMUS system using commercially available two-way audiovisual technology can transmit US images without quality degradation. For most anatomic sites assessed, US images acquired using FaceTime are not inferior to those obtained directly with the US machine.

Remote tele-mentored ultrasound for non-physician learners using FaceTime: A feasibility study in a low-income country

Purpose Ultrasound (US) is a burgeoning diagnostic tool and is often the only available imaging modality in low‐ and middle‐income countries (LMICs). However, bedside providers often lack training to acquire or interpret US images. We conducted a study to determine if a remote tele‐intensivist could mentor geographically removed LMIC providers to obtain quality and clinically useful US images. Materials and methods Nine Haitian non‐physician health care workers received a 20‐minute training on basic US techniques. A volunteer was connected to an intensivist located in the USA via FaceTime. The intensivist remotely instructed the non‐physicians to ultrasound five anatomic sites. The tele‐intensivist evaluated the image quality and clinical utility of performing tele‐ultrasound in a LMIC. Results The intensivist agreed (defined as “agree” or “strongly agree” on a five‐point Likert scale) that 90% (57/63) of the FaceTime images were high quality. The intensivist felt comfortable making clinical decisions using FaceTime images 89% (56/63) of the time. Conclusions Non‐physicians can feasibly obtain high‐quality and clinically relevant US images using video chat software in LMICs. Commercially available software can connect providers in institutions in LMICs to geographically removed intensivists at a relatively low cost and without the need for extensive training of local providers. HighlightsUltrasound is a valuable diagnostic tool, although education in interpretation can be limited.Our prior work proves that live FaceTime images are high quality.High quality, clinically useful images can be transmitted from an LMIC to the United States.Commercially available technology can be used to increase diagnostic yield in LMICs.Telementored ultrasound partnerships between a LMIC and the United States are feasible.

Correlations between first documented cardiac rhythms and preceding telemetry in patients with code blue events

BACKGROUND Among in-hospital cardiac arrest (IHCA) patients, the first cardiac rhythm documented on resuscitation records (FDR) is often used as a surrogate for arrest etiology. Although the FDR generally represents the electrical activity at the time of cardiopulmonary resuscitation initiation, it may not be the ideal rhythm to infer the arrest etiology. We hypothesized that a rhythm present earlier-at the time of the code blue call-would frequently differ from the FDR, because the FDR might represent the later stage of a progressive cardiopulmonary process. OBJECTIVE To evaluate agreement between FDR and telemetry rhythm at the time of code blue call. DESIGN Cross-sectional study. SETTING A 750-bed adult tertiary care hospital and a 240-bed adult inner city community hospital. PATIENTS Adult general ward patients monitored on the hospitals telemetry system during the 2 minutes prior to a code blue call for IHCA. INTERVENTION None. MEASUREMENTS Agreement between FDR and telemetry rhythm. RESULTS Among 69 IHCAs, agreement between FDR and telemetry was 65% (kappa = 0.37). Among 17 events with FDRs of ventricular tachyarrhythmia (VTA), telemetry showed VTA in 12 (71%) and other organized rhythms in 5 (29%). Among 12 events with first documented rhythms of asystole, telemetry showed asystole in 3 (25%), VTA in 1 (8%), and other organized rhythms in 8 (67%). CONCLUSIONS The FDR had only fair agreement with the telemetry rhythm at the time of code blue call. The telemetry rhythm may be a useful adjunct to the FDR when investigating arrest etiology.

A Pilot Study of Ultrasonography-Naïve Operators’ Ability to Use Tele-Ultrasonography to Assess the Heart and Lung

Introduction: Remotely tele-mentored ultrasound (RTMUS) involves the real-time guidance of US-naïve providers as they perform point-of-care ultrasound (POCUS) by remotely located, US-proficient providers via telemedicine. The concordance between RTMUS and POCUS in the evaluation of critically ill patients has not been reported. This study sought to evaluate the concordance between RTMUS and POCUS for the cardiopulmonary evaluation of patients in acute respiratory insufficiency and/or shock. Methods: Ultrasound-naÏve nurses performed RTMUS on critically ill patients. Concordance between RTMUS and POCUS (performed by critical care fellows) in the evaluation of the heart and lungs was reported. The test characteristics of RTMUS were calculated using POCUS as a gold standard. Concordance between RTMUS and available transthoracic echocardiography (TTE) and computed tomography (CT) scans was also reported. Results: Twenty patients were enrolled. Concordance between RTMUS and POCUS was good (90%-100%) for left ventricle function, right ventricle (RV) dilatation/dysfunction, pericardial effusion, lung sliding, pulmonary interstitial syndrome, pleural effusion, and fair (80%) for lung consolidation. Concordance between RTMUS and TTE or CT was similar. RTMUS was highly specific (88%-100%) for all abnormalities evaluated and highly sensitive (89%-100%) for most abnormalities although sensitivity for the detection of RV dilatation/dysfunction (33%) and pulmonary interstitial syndrome (71%) was negatively impacted by false negatives. Conclusions: RTMUS may be a reasonable substitute for POCUS in the cardiopulmonary evaluation of patients with acute respiratory insufficiency and/or shock. These findings should be validated on a larger scale.