Van Gent Jan-Michael, Davis Konrad L, Henry Nichole, Zander Ashley L, Kuettel Matthew A, Edson Theodore, Nelson Thomas J, Tadlock Matthew D
Department of Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA.
Department of Pulmonary and Critical Care Medicine, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA.
Mil Med. 2018 Nov 1;183(11-12):e494-e499. doi: 10.1093/milmed/usy051.
Mortality is reduced in hospitals staffed with intensivists, however, many smaller military hospitals lack intensivist support. Naval Hospital Camp Pendleton (NHCP) is a Military Treatment Facility (MTF) that operates a 6-bed Intensive Care Unit (ICU) north of its referral center, Naval Medical Center San Diego (NMCSD). To address a gap in NHCP on-site intensivist coverage, a comprehensive Tele-Critical Care (TCC) support system was established between NHCP and NMCSD. To examine the initial impact of telemedicine on surgical ICU patients, we compare NHCP surgical ICU admissions before and after TCC implementation.
Patient care by remote intensivist was achieved utilizing video teleconferencing technology, and remote access to electronic medical records. Standardization was promoted by adopting protocols and mandatory intensivist involvement in all ICU admissions. Surgical ICU admissions prior to TCC implementation (pre-TCC) were compared to those following TCC implementation (post-TCC).
Of 828 ICU admissions, 21% were surgical. TCC provided coverage during 35% of the intervention period. Comparing pre-TCC and post-TCC periods, there was a significant increase in the percentage of surgical ICU admissions [15.3 % vs 24.6%, p = 0.01] and the average monthly APACHE II score [4.1vs 6.5, p = 0.03]. The total number of surgical admissions per month also increased [3.9 vs 6.3, p = 0.009]. No adverse outcomes were identified.
Implementation of TCC was associated with an increase in the scope and complexity of surgical admissions with no adverse outcomes. Surgeons were able to safely expand the surgical services offered requiring perioperative ICU care to patients who previously may have been transferred. Caring for these types of patients not only maintains the operational readiness of deployable caregivers but patient experience is also enhanced by minimizing transfers away from family. Further exploration of TCC on surgical case volume and complexity is warranted.
配备重症医学专家的医院死亡率较低，然而，许多规模较小的军队医院缺乏重症医学专家的支持。彭德尔顿海军医院（NHCP）是一家军事治疗机构（MTF），在其转诊中心圣地亚哥海军医疗中心（NMCSD）以北运营着一个拥有6张床位的重症监护病房（ICU）。为了解决NHCP现场重症医学专家覆盖的缺口，在NHCP和NMCSD之间建立了一个全面的远程重症监护（TCC）支持系统。为了研究远程医疗对外科ICU患者的初步影响，我们比较了TCC实施前后NHCP外科ICU的入院情况。
通过视频电话会议技术以及远程访问电子病历，由远程重症医学专家提供患者护理。通过采用协议以及要求重症医学专家强制参与所有ICU入院治疗来促进标准化。将TCC实施前（TCC前）的外科ICU入院情况与TCC实施后（TCC后）的情况进行比较。
在828例ICU入院病例中，21%为外科病例。TCC在35%的干预期间提供了覆盖。比较TCC前和TCC后时期，外科ICU入院百分比[15.3%对24.6%，p = 0.01]以及平均每月急性生理与慢性健康状况评分系统（APACHE II）评分[4.1对6.5，p = 0.03]均有显著增加。每月外科入院总数也有所增加[3.9对6.3，p = 0.009]。未发现不良后果。
TCC的实施与外科入院范围和复杂性的增加相关，且无不良后果。外科医生能够安全地扩大提供的外科服务范围，为之前可能需要转诊的患者提供围手术期ICU护理。护理这类患者不仅能保持可部署护理人员的作战准备状态，还能通过尽量减少患者与家人分离来提升患者体验。有必要进一步探索TCC对外科病例数量和复杂性的影响。
