title: Telemedicine with clinical decision support for critical care: a systematic review.
abstract: Telemedicine applications aim to address variance in clinical outcomes and increase access to specialist expertise. Despite widespread implementation, there is little robust evidence about cost-effectiveness, clinical benefits, and impact on quality and safety of critical care telemedicine. The primary objective was to determine the impact of critical care telemedicine (with clinical decision support available 24/7) on intensive care unit (ICU) and hospital mortality and length of stay in adults and children. The secondary objectives included staff and patient experience, costs, protocol adherence, and adverse events.
  
  
  
  Data sources included MEDLINE, EMBASE, CINAHL, Cochrane Library databases, Health Technology Assessment Database, Web of Science, OpenGrey, OpenDOAR, and the HMIC through to December 2015. Randomised controlled trials and quasi-experimental studies were eligible for inclusion. Eligible studies reported on differences between groups using the telemedicine intervention and standard care. Two review authors screened abstracts and assessed potentially eligible studies using Cochrane guidance.
  
  
  
  Two controlled before-after studies met the inclusion criteria. Both were assessed as high risk of bias. Meta-analysis was not possible as we were unable to disaggregate data between the two studies. One study used a non-randomised stepped-wedge design in seven ICUs. Hospital mortality was the primary outcome which showed a reduction from 13.6 % (CI, 11.9-15.4 %) to 11.8 % (CI, 10.9-12.8 %) during the intervention period with an adjusted odds ratio (OR) of 0.40 (95 % CI, 0.31-0.52; p = .005). The second study used a non-randomised, unblinded, pre-/post-assessment of telemedicine interventions in 56 adult ICUs. Hospital mortality (primary outcome) reduced from 11 to 10 % (adjusted hazard ratio (HR) = 0.84; CI, 0.78-0.89; p = <.001).
  
  
  
  This review highlights the poor methodological quality of most studies investigating critical care telemedicine. The results of the two included studies showed a reduction in hospital mortality in patients receiving the intervention. Further multi-site randomised controlled trials or quasi-experimental studies with accompanying process evaluations are urgently needed to determine effectiveness, implementation, and associated costs.
  
  
  
  PROSPERO CRD42014007406.
authors.affiliation: Division of Women's Health, Faculty of Life Sciences and Medicine, Women's Health Academic Centre, King's Health Partners, King's College London, 10th Floor North Wing, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK. nicola.mackintosh@kcl.ac.uk.
authors.forename: Nicola
authors.identifier: 0000-0003-0137-6432
authors.initials: N
authors.lastname: Mackintosh
authors.affiliation: Guy's and St Thomas NHS Foundation Trust, London, UK.|Division of Health and Social Care Research, King's College London, London, UK.
authors.forename: Marius
authors.initials: M
authors.lastname: Terblanche
authors.affiliation: King's College Hospital NHS Foundation Trust, London, UK.
authors.forename: Ritesh
authors.initials: R
authors.lastname: Maharaj
authors.affiliation: Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK.
authors.forename: Andreas
authors.initials: A
authors.lastname: Xyrichis
authors.affiliation: Guy's and St Thomas NHS Foundation Trust, London, UK.
authors.forename: Karen
authors.initials: K
authors.lastname: Franklin
authors.affiliation: Guy's and St Thomas NHS Foundation Trust, London, UK.
authors.forename: Jamie
authors.initials: J
authors.lastname: Keddie
authors.affiliation: Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK.
authors.forename: Emily
authors.initials: E
authors.lastname: Larkins
authors.affiliation: Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK.
authors.forename: Anna
authors.initials: A
authors.lastname: Maslen
authors.affiliation: Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK.
authors.forename: James
authors.initials: J
authors.lastname: Skinner
authors.affiliation: Guy's and St Thomas NHS Foundation Trust, London, UK.
authors.forename: Samuel
authors.initials: S
authors.lastname: Newman
authors.affiliation: Division of Women's Health, Faculty of Life Sciences and Medicine, Women's Health Academic Centre, King's Health Partners, King's College London, 10th Floor North Wing, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.
authors.forename: Joana Hiew
authors.initials: JH
authors.lastname: De Sousa Magalhaes
authors.affiliation: Division of Women's Health, Faculty of Life Sciences and Medicine, Women's Health Academic Centre, King's Health Partners, King's College London, 10th Floor North Wing, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.
authors.forename: Jane
authors.initials: J
authors.lastname: Sandall
mesh_terms: D065187:Controlled Before-After Studies; D003422:Critical Care; D020000:Decision Support Systems, Clinical; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay; D017216:Telemedicine
keywords: Clinical decision support; Critical care; Patient safety; Systematic review; Telemedicine