Remote ICU Care Linked to Reduced Mortality in Critically Ill Patients

Martha Kerr

October 24, 2007 (Chicago) — Remotely monitored intensive care units (eICUs) with a "tele-intensivist" is associated with a reduction in both ICU and in-hospital mortality, as well as a reduction in length of stay in the hospital, and the eICU also significantly cuts costs and saves limited healthcare resources, investigators reported here at CHEST 2007, the American College of Chest Physicians 73rd Annual Scientific Assembly.
The use of tele-intensivists who remotely monitor ICUs is the subject of a number of studies that are being reported here this week.
In one, Gregory H. Howell, MD, of the Department of Internal Medicine at St. Luke's Health System in Kansas City, Missouri, and colleagues evaluated the value of 24-hour ICU monitoring by tele-intensivists over 5 quarters, beginning with the first quarter of 2006, when the eICUs were first implemented, and ending with the first quarter of 2007.
Dr. Howell described the eICU as a room with monitors, camera feeds directly from the patients' rooms, and access to laboratory results, blood oxygen levels, and other sources of information on the patients' status.
The eICU is monitored 24 hours a day by a tele-intensivist, who communicates with the on-site hospital staff, prescribing medications and other treatments for the critically ill patient, as well as ensuring that protocols and standards of care are met.
Dr. Howell's study involved 7 hospitals in the Kansas City area, with 84 ICU beds that were monitored remotely. His team compared Acute Physiology And Chronic Health Evaluation (APACHE) III severity scores and patient outcomes across the 5 quarters.
The researchers found that severity-adjusted ICU mortality dropped from 1.0 to 0.68, and in-hospital mortality dropped from 0.95 to 0.77. Length of stay dropped from 1.18 to 0.96 days in the ICU and from 1.9 to 0.84 days in the hospital between the first quarter and the fifth quarter.
"The odds ratio for ICU mortality was 0.71, and the odds ratio for hospital mortality was 0.71," Dr. Howell told Medscape Pulmonary Medicine. He acknowledged that the numbers are not large in this phase of the study, but that "there is a significant downward trend" in mortality and length of stay.
"At $2000 to $3000 a day for ICU care, saving even a quarter of a day will result in significant savings," Dr. Howell pointed out. "Next we'll look at APACHE III scores in the period before implementation of the eICU and afterward, rather than just temporal trends. We expect those numbers to be more significant."
In a second study, Edward T. Zawada, MD, FCCP, of the Avera ICU Research Group of Avera McKennan Hospital and University Health Center of the University of South Dakota in Sioux Falls, analyzed the financial benefit of a tele-intensivist program.
Dr. Zawada and colleagues compared the APACHE III severity scores in the year before with the 2 years following implementation of the tele-intensivist program, randomly selecting 200 ICU patients from a tertiary hospital (24 beds) and 3 regional hospitals (a total of 26 beds).
ICU length of stay fell from 1.13 days before to 0.60 days after implementation, for a drop of 46.8% with the tele-intensivists in the tertiary hospital and a drop of approximately 35% in the 3 regional hospitals.
Hospital length of stay ratios were –21% with the tertiary hospital and –20% in 1 regional hospital, with lower values for the other 2 rural sites.
There was an annual reduction of 4146 ICU days and 572 hospital days with the tele-intensivist program, Dr. Zawada reported.
"We provide immediate intervention when downward trends are detected to avert disaster," Dr. Zawada said in an interview with Medscape Pulmonary Medicine after his presentation.
"We estimate that there is $6.4 million saved over the 4 hospitals," Dr. Zawada said. "This program has been surprisingly well-received by hospitals and patients. The rural sites are very happy."
Dr. Zawada and Dr. Howell both say that the purpose of the eICU is twofold — to provide the best quality of care and to implement standards of care.
"Our institution is committed to the eICU program," Dr. Howell noted, but he cautioned that his data are correlational: "We can't assume cause and effect" of the eICU on reduced mortality, he said
Dr. Howell and Dr. Zawada have disclosed no relevant financial relationships.
CHEST 2007: American College of Chest Physicians 73rd Annual Scientific Assembly: Session 875. Presented October 22, 2007.