Seriously ill patients at UMass Memorial Medical Center suffered fewer complications and were less likely to die when they were monitored by doctors working in a remote "eICU," some of the first evidence that telemedicine can improve on care provided at the bedside.
Intensive care specialists who oversaw the hospital's intensive care units from a low-rise office building three miles away improved care by essentially acting as a second set of eyes for the on-site doctors and nurses, found a study published online today by the Journal of the American Medical Association.
The remote doctors enforced treatment plans for patients, ensured that caregivers followed best practices to prevent infections and pneumonia, and even at times prompted staff to respond to alarms on monitors warning a patient was in trouble.
Particularly significant is that UMass Memorial, a Worcester teaching hospital with 834 beds and seven intensive care units, already had sophisticated critical care facilities and expertise. But even at a large academic medical center, the eICU appears to have improved care. The death rate for 1,529 patients in intensive care prior to the hospital opening the eICU was 10.7 percent, compared with 8.6 percent for the 4,761 ICU patients cared for with the help from telemedicine.
"We thought we were going to have an impact, but this turned out to be a little more than what we initially counted on," said Dr. Craig Lilly, the study's lead author, who is director of the eICU program and a professor at the University of Massachusetts Medical School. "We really thought we were giving the best possible care. But it turned out, we could do better."
Dr. Jeremy Kahn, an associate professor of critical care and health policy at the University of Pittsburgh, said in an interview that while telemedicine programs have exploded in the past decade, studies of the benefits, especially in ICUs, have produced disappointing results. Policy-makers have questioned whether this expensive technology is useful at all, if it just drives up health care costs without showing a payoff of improving care.
In an editorial, also published by JAMA, Kahn wrote that the new study "is the first convincing evidence that ICU telemedicine can be an effective complement to bedside care in some settings."
However, he cautioned, the UMass Memorial program does not answer at least two key questions about the technology: Will it improve care in rural and remote community hospitals, which are considered more in need of help from highly-trained specialists but where doctors and nurses may be less tolerant of outside interference? And, would patients benefit just as much if hospitals simply hired additional specialists to oversee care on-site, which would be less expensive than building and operating a remote eICU?
The study "says telemedicine can be one way to improve the quality of care, it doesn't say it's the best way," Kahn said in the interview.
UMass Memorial Health Care was the first hospital network in Massachusetts to build an eICU, which opened in 2007; there are more than 40 nationally. The programs are intended to cope with the soaring number of ICU patients and a shortage of intensive care specialists. The idea is that doctors in a remote setting can monitor more patients in more ICUs than they could in person.
The vast majority of hospitals do not have an ICU specialist working at night or on weekends, despite studies showing that when intensive care doctors manage patients, their mortality rates drop by an average of 30 percent.
At UMass Memorial, bedside monitors feed heart rates, urine output, breaths per minute and other information about patients over a secure data line to a wall of video screens in the eICU. Doctors there also can see patients' medical records, test results, and nurses' notes, as well as use video conferencing equipment to see patients.
UMass researchers found that this added layer of care increased use of "best practices" in treating patients and prevented complications. Caregivers followed guidelines for preventing ventilator-associated pneumonia, for example, 52 percent of the time with the eICU, up from 33 percent before it was in operation. Meanwhile, rates of these infections fell from 13 percent among ICU patients before the eICU to 1.6 percent afterward.
UMass Memorial spent $7.1 million to set up the eICU. Lilly would not reveal the annual budget, saying a cost analysis would be covered in a future paper. He said the eICU cuts the cost of caring for patients by about 25 percent, partly because of declines in complications and the length of stay in the hospital.
Pittsburgh's Kahn said two other recent studies of telemedicine in intensive care did not find a benefit, probably for two reasons. UMass Memorial's eICU doctors also work in the hospital, leading to a high level of acceptance of the program. In many other hospitals, doctors can opt out of review by remote specialists.
Along with the eICU, the Worcester hospital also adopted broader quality initiatives, including setting daily goals for ICU patients and standardizing best practices. Because of this, he said, it's hard to know whether some of the positive impact could have been achieved simply by adding doctors at the bedside. In his editorial, Kahn said he found the mortality reduction attributed to the eICU "implausibly large."
Dr. Lee Schwamm, vice chair of neurology at Massachusetts General Hospital and director of Partners Healthcare's telestroke center, said it's been "very hard to tease out" the benefits of telemedicine because hospitals often adopt these programs as part of broader initiatives. "Telemedicine by itself in isolation is not the solution," but may enable best practices and other benefits to flow to the remote location, he said.
Patrick Muldoon, president of HealthAlliance Hospital, with campuses in Leominster and Fitchburg and part of the UMass Memorial system, said he is a believer. The UMass eICU began overseeing the hospital's tiny 10-bed intensive care unit in 2008, though it was not included in the study.
"Nurses and doctors can't be with every patient every minute," he said. "The eICU is constantly monitoring patients and will spot trouble in between visits. It doesn't put hands at the bedside, but it's the next best thing."
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|White Coat Notes covers the latest from the health care industry, hospitals, doctors offices, labs, insurers, and the corridors of government. Chelsea Conaboy previously covered health care for The Philadelphia Inquirer. Write her at firstname.lastname@example.org. Follow her on Twitter: @cconaboy.|
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