ICU telemedicine can reduce inter-hospital ICU transfers

Last Updated: 2018-06-19

By Will Boggs MD

NEW YORK (Reuters Health) - ICU telemedicine significantly reduces inter-hospital ICU transfers between Veterans Health Administration (VHA) hospitals, researchers report.

"Low-resource ICUs often transfer their sick patients out to other high-resource acute care facilities," Dr. Spyridon Fortis from Iowa City VA Health Care System and University of Iowa Roy J. and Lucille A. Carver College of Medicine told Reuters Health by email. "ICU telemedicine can help those ICUs."

Previous studies have found small effects of telemedicine on ICU mortality, but reducing transfers from regional hospitals to larger facilities could lower the cost of care and improve patient, family, and staff satisfaction.

Between 2011 and 2014, the VA implemented ICU telemedicine in 52 ICUs in 23 acute care facilities located in 9 states.

Dr. Fortis and colleagues compare the proportion of ICU patients in hospitals with vs without an ICU telemedicine program who transferred to other acute care facilities.

The rate of inter-hospital transfers decreased from 3.46% to 1.99% after telemedicine implementation in ICU telemedicine hospitals. During the same interval, inter-hospital transfer rates decreased from 2.05% to 1.68% at non-telemedicine hospitals.

After adjustment for other factors, the overall risk of ICU transfers declined by 21% after ICU telemedicine implementation, with even greater decreases in patients with gastrointestinal diagnoses (a 45% relative decrease) and respiratory diagnoses (a 48% relative decrease), according to the June 15th Chest online report.

"The effect of telemedicine on transfers was more prominent in patients that do not require any high-resource intervention," Dr. Fortis explained. "For example, we saw that telemedicine reduced transfers in respiratory patients. Patients with status asthmaticus on mechanical ventilator are very challenging for non-critical care trained physicians although they do not require any invasive procedure (apart from the intubation). An intensivist with the help of a bedside respiratory therapist can manage these patients remotely by watching the ventilator monitors."

"On the contrary," he said, "telemedicine does not affect oncological or cardiological patients that require special interventions like coronary angiography."

Telemedicine was associated with decreases in medical patient, but not surgical patient, transfers.

ICU telemedicine did not affect 30-day adjusted or unadjusted mortality, but mortality of transferred patients from telemedicine ICUs increased from 6% to 8.7% after implementation, suggesting that patients were triaged appropriately with transfer of the sickest patients.

"ICU telemedicine reduces hospital transfers without affecting mortality," Dr. Fortis said. "ICUs are able to keep the patients locally without compromising their care."

Dr. Sean M. Caples from the Mayo Clinic in Rochester, Minnesota, who recently evaluated the impact of telemedicine monitoring of community ICUs on inter-hospital transfers, told Reuters Health by email, "There is little discussion about the fact that mortality rates of transferred patients actually increased post-telemedicine implementation. It calls into question the methods by which patients are identified for transfer."

"A reduction in inter-hospital transfers might be desirable but the associated increase in mortality should prompt a deeper dive into why," he said.

Dr. Caples also wondered, "Why would there be a reduction in the transfer rates of all patients except those in the lowest quartile illness severity? In other words, why are the least sick patients still being transferred at the same rates post-telemedicine?"

The authors did, however, note various limitations that constrained their ability to answer these and other questions, including the lack of information regarding the availability of procedures at various hospitals, the lack of matching between telemedicine and non-telemedicine ICUs, and the lack of information about whether patients were transferred directly to another hospital's ICU from the emergency department.

SOURCE: http://bit.ly/2yrKUhm Chest 2018.