No increase in 30-day mortality was observed after the cuts.
This article first appeared June 18, 2018 on Medpage Today.
By Salynn Boyles
A Veterans Affairs program using telemedicine to improve care of critically ill patients in regional VA hospitals appeared to reduce transfers to intensive care units (ICUs) at larger facilities without compromising patient survival, researchers said.
From 2011 to 2014, the VA implemented the program in 52 ICUs in 23 regional acute care hospitals in nine states, explained Spyridon Fortis, MD, of the Iowa City VA Health Care System, and colleagues writing in the journal CHEST.
Under the program, clinicians at these regional hospitals were connected with ICU staff at VA centers in Cincinnati and Minneapolis who were available around the clock to provide guidance on patient management.
Using data collected during the implementation period through 2015 on these 23 regional telemedicine hospitals, as well as 94 others not included in the program, Fortis and colleagues found the following:
- Transfers decreased from 3.46% to 1.99% in the telemedicine hospitals and from 2.03% to 1.68% in the non-telemedicine facilities between pre- and post-telemedicine implementation periods (P<0.001).
- After adjusting for demographics, illness severity, admission diagnosis and facility, ICU telemedicine was associated with overall reduced transfers with a relative risk of 0.79 (95% CI 0.71-0.87, P<0.001).
- This reduction occurred in patients with moderate (RR 0.77; 95% CI 0.61-0.98, P=0.034), moderate to high (RR 0.79; 95% CI 0.63-0.98, P=0.035) and high illness severity (RR 0.73; 95% CI 0.60-0.90, P=0.003) and in non-surgical patients (RR 0.82; 95% CI 0.73-0.92, P=0.001).
- Transfers decreased most dramatically in patients admitted with gastrointestinal (RR 0.55; 95% CI 0.41-0.74, P<0.001) and respiratory diagnoses (RR 0.52; 95% CI 0.38-0.71, P<0.001).
Moreover, the telemedicine program was not associated with an increase in 30-day mortality.
The study tracked more than half a million patient admissions overall to VA ICUs, including just over 97,000 with access to telemedicine services. Once intubation was performed, a teleintensivist, in collaboration with the bedside respiratory therapist, helped manage these patients remotely by using cameras to watch the patients and review the vital signs and mechanical ventilator settings and wave forms.
"Telemedicine has been shown in previous studies to improve mortality and reduce hospital length of stay, but our study is among the first to formally examine the effect of telemedicine on hospital transfers," Fortis told MedPage Today.
Fortis and colleagues noted that while one estimate suggested that telemedicine might reduce hospital transfers by 25% to 75%, another study involving a single tertiary center found the practice to be associated with an increase in transfers.
"That report was limited by small sample size, the close proximity of the community hospital ICUs to the reference tertiary center, and the single tertiary center to which all patients were transferred was the ICU telemedicine hub," the researchers wrote. "The effect of ICU telemedicine on inter-hospital transfers of critically ill patients still remains unclear."
"The transfer decline occurred mainly in patients with respiratory and gastrointestinal admission diagnoses," Fortis and colleagues wrote. "Although it is unclear why transfers decreased in patients with gastrointestinal admission diagnoses, transfer reduction in respiratory patients may occur due to remote availability of critical care expertise through telemedicine. Care of patients with respiratory diseases, in particular those requiring mechanical ventilation, can be challenging and transferring patients requiring mechanical ventilation is common."
Study limitations cited by the researchers included the exclusion of critically ill patients transferred prior to ICU admission and lack of information on diverted patients, bedside staffing levels at various VA facility ICUs or the level of care in the hospitals that received transferred patients.