title: Intensive care unit telemedicine: alternate paradigm for providing continuous intensivist care.
abstract: OBJECTIVE
  Intensive care units (ICUs) account for an increasing percentage of hospital admissions and resource consumption. Adverse events are common in ICU patients and contribute to high mortality rates and costs. Although evidence demonstrates reduced complications and mortality when intensivists manage ICU patients, a dramatic national shortage of these specialists precludes most hospitals from implementing an around-the-clock, on-site intensivist care model. Alternate strategies are needed to bring expertise and proactive, continuous care to the critically ill. We evaluated the feasibility of using telemedicine as a means of achieving 24-hr intensivist oversight and improved clinical outcomes.
  
  
  METHODS
  Observational time series triple cohort study.
  
  
  METHODS
  A ten-bed surgical ICU in an academic-affiliated community hospital.
  
  
  METHODS
  All patients whose entire ICU stay occurred within the study periods.
  
  
  METHODS
  A 16-wk program of continuous intensivist oversight was instituted in a surgical ICU, where before the intervention, intensivist consultation was available but there were no on-site intensivists. Intensivists provided management during the intervention using remote monitoring methodologies (video conferencing and computer-based data transmission) to obtain clinical information and to communicate with on-site personnel. To assess the benefit of the remote management program, clinical and economic performance during the intervention were compared with two 16-wk periods within the year before the intervention.
  
  
  RESULTS
  ICU and hospital mortality (observed and Acute Physiology and Chronic Health Evaluation III, severity-adjusted), ICU complications, ICU and hospital length-of-stay, and ICU and hospital costs were measured during the 3 study periods. Severity-adjusted ICU mortality decreased during the intervention period by 68% and 46%, compared with baseline periods one and two, respectively. Severity-adjusted hospital mortality decreased by 33% and 30%, and the incidence of ICU complications was decreased by 44% and 50%. ICU length of stay decreased by 34% and 30%, and ICU costs decreased by 33% and 36%, respectively. The cost savings were associated with a lower incidence of complications.
  
  
  CONCLUSIONS
  Technology-enabled remote care can be used to provide continuous ICU patient management and to achieve improved clinical and economic outcomes. This intervention's success suggests that remote care programs may provide a means of improving quality of care and reducing costs when on-site intensivist coverage is not available.
authors.affiliation: Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, MD, USA. brosenfeld@visicu.com
authors.forename: B A
authors.initials: BA
authors.lastname: Rosenfeld
authors.forename: T
authors.initials: T
authors.lastname: Dorman
authors.forename: M J
authors.initials: MJ
authors.lastname: Breslow
authors.forename: P
authors.initials: P
authors.lastname: Pronovost
authors.forename: M
authors.initials: M
authors.lastname: Jenckes
authors.forename: N
authors.initials: N
authors.lastname: Zhang
authors.forename: G
authors.initials: G
authors.lastname: Anderson
authors.forename: H
authors.initials: H
authors.lastname: Rubin
mesh_terms: D018806:APACHE; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003266:Continuity of Patient Care / Q000458:organization & administration*; D003363:Cost Control; D003422:Critical Care / Q000458:organization & administration*; D005240:Feasibility Studies; D005260:Female; D017721:Hospital Costs / Q000706:statistics & numerical data; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D017146:Models, Organizational; D015397:Program Evaluation; D011446:Prospective Studies; D011787:Quality of Health Care; D012189:Retrospective Studies; D017216:Telemedicine / Q000458:organization & administration*; D017749:Total Quality Management / Q000458:organization & administration; D016896:Treatment Outcome