title: Introduction of Tele-ICU in rural hospitals: Changing organisational culture to harness benefits.
abstract: OBJECTIVE
  This study evaluates rural hospital staff perceptions of a telemedicine ICU (Tele-ICU) before and after implementation.
  
  
  METHODS
  We conducted a longitudinal qualitative study utilising semistructured group or individual interviews with staff from three rural ICU facilities in the upper Midwest of the United States that received Tele-ICU support. Interviews occurred pre-implementation and at two time points post-implementation. Interviews were conducted with: ICU administrators (n=6), physicians (n=3), nurses (n=9), respiratory therapists (n=5) and other (n=1) from July 2011 to May 2013. Transcripts were analysed for thematic content.
  
  
  RESULTS
  Overall, rural ICU staff viewed Tele-ICU as a welcome benefit for their facility. Major themes included: (1) beneficial where recruitment and retention of staff can be challenging; (2) extra support for day shifts and evening, night and weekend shifts; (3) reduction in the number of transfers larger tertiary hospitals in the community; (4) improvement in standardisation of care; and (5) organisational culture of rural ICUs may lead to under-utilisation.
  
  
  CONCLUSIONS
  ICU staff at rural facilities view Tele-ICU as a positive, useful tool to provide extra support and assistance. However, more research is needed regarding organisational culture to maximise the potential benefits of Tele-ICU in rural hospitals.
authors.affiliation: Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, United States. Electronic address: cassie.goedken@va.gov.
authors.forename: Cassie Cunningham
authors.initials: CC
authors.lastname: Goedken
authors.affiliation: Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, United States.
authors.forename: Jane
authors.initials: J
authors.lastname: Moeckli
authors.affiliation: University Health Network and Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada.
authors.forename: Peter M
authors.initials: PM
authors.lastname: Cram
authors.affiliation: Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, United States; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, United States.
authors.forename: Heather Schacht
authors.initials: HS
authors.lastname: Reisinger
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D005260:Female; D006780:Hospitals, Rural / Q000639:trends*; D006801:Humans; D007362:Intensive Care Units / Q000639:trends*; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D015146:Midwestern United States; D009726:Nurses / Q000523:psychology*; D010465:Perception; D036301:Qualitative Research; D017216:Telemedicine / Q000379:methods / Q000592:standards* / Q000639:trends
keywords: Access to health care; Critical care; Qualitative research; Rural healthcare; Telemedicine