Fran Lowry

February 22, 2016

ORLANDO, Florida — Using telemedicine to provide remote support from critical care specialists to community hospitals reduces mortality, the number of patients needing to be transferred to tertiary care hospitals, and costs, new research shows.

"One year after we started our telecritical care program for community hospitals caring for acutely ill patients, mortality rates in the intensive care units and in the hospital were both decreased by almost 40%," said William Beninati, MD, from Intermountain Healthcare in Salt Lake City.

"There was also a small decrease in ICU costs," he said here at the Society of Critical Care Medicine's 45th Critical Care Congress.

"Our telecritical care support center is staffed 24/7 by critical care nurses and physicians. From this center, we use electronic tools to connect to, on an average day, about 160 intensive care patients in Utah and southern Idaho," Dr Beninati told Medscape Medical News.

Dr William Beninati

Intermountain Healthcare is an integrated system with seven community hospitals located west of the Rocky Mountains and east of the Sierra Nevada that have ICUs but no critical care physicians on staff.

"We also have a group of rural hospitals that do not even have ICUs. These are critical-access hospitals that can take up to six patients, and if anyone gets acutely ill, they get transferred right away," Dr Beninati explained.

Telecritical Care Uses Skype for Business

An audio-visual connection, adapted from Microsoft's Skype for Business by the Intermountain software development team, is used to provide the remote support.

"The team won a major national innovation award for applying Skype for Business to telemedicine, and it has worked very well for us," Dr Beninati said.

"We have two-way communication, and many of our patients in the ICU can communicate with us directly or, if they cannot, they can often gesture to us and we can talk to them and they can gesture back to us. We also spend a lot of time communicating with family members," he said.

The telemedicine apparatus and medical staff are housed in a warehouse in Salt Lake City.

"We have a very high bandwidth, and that is why we are in the warehouse. This is only for telemedicine purposes. So, on the days that we are providing support to community hospitals located many miles away, we will be in the warehouse," Dr Beninati said.

On the days when the physicians are not in the warehouse providing remote support, they are working in tertiary care medical centers. "There are five of them in Utah," he said.

It's not magic. It's just basic bread-and-butter critical care medicine that is done all over the country, but with a second set of eyes.

In addition to having an audio-visual link through Skype to the patient's bedside, the doctors and nurses providing the remote support have access to relevant electronic medical records and the vital signs of the patient.

"We can read notes, lab results, we can see radiographic studies, electrocardiograms, pulse oximeters, all of the various monitors, in addition to accessing the two-way audio-visual component," Dr Beninati explained.

In May 2014, when the remote support system was instituted, Dr Beninati and his group began a stepped-wedge implementation of 24-hour nursing support. In August 2014, they began daytime intensivist support. By December 2014, physician staffing had changed to 24-hour coverage.

In their study, Dr Beninati and his team compared outcomes in community hospitals before the telecritical care program was instituted and 1 year after the implementation.

The analysis involved almost 6000 patients — 2976 before implementation and 2715 after implementation.

Mortality rates in the ICU were better after implementation than before (1.55% vs 2.65%; P = .004), as were mortality rates in the hospital (1.84% vs 2.92%; P = .008) and transfers to an acute care hospital (7.92% vs 8.74%).

And per patient costs decreased from $1546 before implementation to $1395 after implementation (P = .032). "We saved a tremendous amount of money by using our own home-grown system rather than a commercial system," Dr Beninati said.

"We used a relatively simple, straightforward, home-developed system that could be replicated elsewhere. The model we use for staffing with physicians and nurses can be done anywhere. It's not magic. It's just basic bread-and-butter critical care medicine that is done all over the country, but with a second set of eyes, which we, as the remote doctors, represent," he explained.

Study Demonstrates the Utility of Telemedicine

This study shows that such an approach is useful, experts who were not part of the research told Medscape Medical News.

Dr Robert Hyzy (Source: Dr Robert Hyzy)

"The authors used an established stepped-wedge design to implement intensivist coverage by telemedicine and demonstrated improvements in mortality, as well as cost, while taking care of more patients and transferring fewer away," said Robert Hyzy, MD, from the division of pulmonary and critical care medicine at the University of Michigan in Ann Arbor, who comoderated the oral session.

"While the absolute magnitude of the differences seen in the various outcome measures was not large, they were statistically significant and consistent across the array of measures studied, demonstrating the utility of this approach," Dr Hyzy said.

Dr Maurene Harvey

"I have long been a supporter of telemedicine in critical care as one way to insure that ICU patients get the expert care they so desperately need at this most vulnerable time," added comoderator Maurene Harvey, MPH, a critical care educator and consultant from Glenbrook, Nevada.

"Intensive care has more diseases, devices, and interventions seen nowhere else in healthcare," she said.

"We do not let nurses work in the ICU without extensive specialized training, but have let physicians with no special training care for these very sick patients. Involving physicians trained in intensive care by telemedicine is an effective and rapidly spreading way to have more patients benefit from their expertise," Dr Harvey said.

Dr Beninati, Dr Hyzy, and Dr Harvey have disclosed no relevant financial relationships.

Society of Critical Care Medicine's (SCCM) 45th Critical Care Congress: Abstract 42. Presented February 21, 2016.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.