Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA.
JAMA. 2011 Jun 1;305(21):2175-83. doi: 10.1001/jama.2011.697. Epub 2011 May 16.
The association of an adult tele-intensive care unit (ICU) intervention with hospital mortality, length of stay, best practice adherence, and preventable complications for an academic medical center has not been reported.
To quantify the association of a tele-ICU intervention with hospital mortality, length of stay, and complications that are preventable by adherence to best practices.
DESIGN, SETTING, AND PATIENTS: Prospective stepped-wedge clinical practice study of 6290 adults admitted to any of 7 ICUs (3 medical, 3 surgical, and 1 mixed cardiovascular) on 2 campuses of an 834-bed academic medical center that was performed from April 26, 2005, through September 30, 2007. Electronically supported and monitored processes for best practice adherence, care plan creation, and clinician response times to alarms were evaluated.
Case-mix and severity-adjusted hospital mortality. Other outcomes included hospital and ICU length of stay, best practice adherence, and complication rates.
The hospital mortality rate was 13.6% (95% confidence interval [CI], 11.9%-15.4%) during the preintervention period compared with 11.8% (95% CI, 10.9%-12.8%) during the tele-ICU intervention period (adjusted odds ratio [OR], 0.40 [95% CI, 0.31-0.52]). The tele-ICU intervention period compared with the preintervention period was associated with higher rates of best clinical practice adherence for the prevention of deep vein thrombosis (99% vs 85%, respectively; OR, 15.4 [95% CI, 11.3-21.1]) and prevention of stress ulcers (96% vs 83%, respectively; OR, 4.57 [95% CI, 3.91-5.77], best practice adherence for cardiovascular protection (99% vs 80%, respectively; OR, 30.7 [95% CI, 19.3-49.2]), prevention of ventilator-associated pneumonia (52% vs 33%, respectively; OR, 2.20 [95% CI, 1.79-2.70]), lower rates of preventable complications (1.6% vs 13%, respectively, for ventilator-associated pneumonia [OR, 0.15; 95% CI, 0.09-0.23] and 0.6% vs 1.0%, respectively, for catheter-related bloodstream infection [OR, 0.50; 95% CI, 0.27-0.93]), and shorter hospital length of stay (9.8 vs 13.3 days, respectively; hazard ratio for discharge, 1.44 [95% CI, 1.33-1.56]). The results for medical, surgical, and cardiovascular ICUs were similar.
In a single academic medical center study, implementation of a tele-ICU intervention was associated with reduced adjusted odds of mortality and reduced hospital length of stay, as well as with changes in best practice adherence and lower rates of preventable complications.
成人重症监护室（ICU）干预与医院死亡率、住院时间、最佳实践依从性以及学术医疗中心可预防并发症之间的关联尚未报道。
量化远程 ICU 干预与医院死亡率、住院时间以及可通过最佳实践依从性预防的并发症之间的关联。
设计、地点和患者：对 2005 年 4 月 26 日至 2007 年 9 月 30 日期间在一个拥有 834 张床位的 834 床学术医疗中心的 7 个 ICU（3 个内科、3 个外科和 1 个混合心血管）中的任何一个收治的 6290 名成年人进行的前瞻性阶梯式临床实践研究。评估了最佳实践依从性、护理计划创建以及临床医生对警报的响应时间的电子支持和监测过程。
病例组合和严重程度调整后的医院死亡率。其他结局包括医院和 ICU 住院时间、最佳实践依从性和并发症发生率。
在干预前期间，医院死亡率为 13.6%（95%置信区间[CI]，11.9%-15.4%），而在远程 ICU 干预期间为 11.8%（95%CI，10.9%-12.8%）（调整后优势比[OR]，0.40[95%CI，0.31-0.52]）。与干预前相比，远程 ICU 干预期间深静脉血栓形成（分别为 99%和 85%；OR，15.4[95%CI，11.3-21.1]）和应激性溃疡（分别为 96%和 83%；OR，4.57[95%CI，3.91-5.77]）预防的最佳临床实践依从率更高，心血管保护（分别为 99%和 80%；OR，30.7[95%CI，19.3-49.2]）预防率更高，呼吸机相关性肺炎（分别为 52%和 33%；OR，2.20[95%CI，1.79-2.70]）预防率更低，可预防并发症的发生率更低（呼吸机相关性肺炎分别为 1.6%和 13%；OR，0.15；95%CI，0.09-0.23]和导管相关血流感染分别为 0.6%和 1.0%；OR，0.50；95%CI，0.27-0.93），住院时间更短（分别为 9.8 天和 13.3 天；出院的风险比，1.44[95%CI，1.33-1.56]）。内科、外科和心血管科 ICU 的结果相似。
在一项单学术医疗中心研究中，实施远程 ICU 干预与死亡率降低、住院时间缩短以及最佳实践依从性改变和可预防并发症发生率降低有关。
