1 Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
2 Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania.
Am J Respir Crit Care Med. 2019 Apr 15;199(8):970-979. doi: 10.1164/rccm.201802-0259OC.
Telemedicine is an increasingly common care delivery strategy in the ICU. However, ICU telemedicine programs vary widely in their clinical effectiveness, with some studies showing a large mortality benefit and others showing no benefit or even harm.
To identify the organizational factors associated with ICU telemedicine effectiveness.
We performed a focused ethnographic evaluation of 10 ICU telemedicine programs using site visits, interviews, and focus groups in both facilities providing remote care and the target ICUs. Programs were selected based on their change in risk-adjusted mortality after adoption (decreased mortality, no change in mortality, and increased mortality). We used a constant comparative approach to guide data collection and analysis.
We conducted 460 hours of direct observation, 222 interviews, and 18 focus groups across six telemedicine facilities and 10 target ICUs. Data analysis revealed three domains that influence ICU telemedicine effectiveness: 1) leadership (i.e., the decisions related to the role of the telemedicine, conflict resolution, and relationship building), 2) perceived value (i.e., expectations of availability and impact, staff satisfaction, and understanding of operations), and 3) organizational characteristics (i.e., staffing models, allowed involvement of the telemedicine unit, and new hire orientation). In the most effective telemedicine programs these factors led to services that are viewed as appropriate, integrated, responsive, and consistent.
The effectiveness of ICU telemedicine programs may be influenced by several potentially modifiable factors within the domains of leadership, perceived value, and organizational structure.
远程医疗是 ICU 中越来越常见的医疗服务提供策略。然而，ICU 远程医疗项目在临床效果上差异很大，一些研究表明远程医疗具有显著降低死亡率的效果，而另一些研究则表明其没有益处，甚至有害。
确定与 ICU 远程医疗效果相关的组织因素。
我们采用现场访问、访谈和焦点小组的方式，对 10 个 ICU 远程医疗项目进行了集中的民族志评估，这些项目分布在提供远程医疗服务的设施和目标 ICU 中。项目是根据采用远程医疗后风险调整死亡率的变化（死亡率降低、死亡率不变和死亡率增加）选择的。我们使用恒比抽样方法来指导数据收集和分析。
我们在六家远程医疗设施和十家目标 ICU 进行了 460 小时的直接观察、222 次访谈和 18 次焦点小组。数据分析揭示了影响 ICU 远程医疗效果的三个领域：1）领导力（即与远程医疗角色相关的决策、冲突解决和关系建设），2）感知价值（即可用性和影响的期望、员工满意度和对运营的理解），3）组织特征（即人员配备模式、允许远程医疗部门参与的程度以及新员工的入职培训）。在最有效的远程医疗项目中，这些因素导致服务被认为是适当的、整合的、响应迅速的和一致的。
ICU 远程医疗项目的效果可能受到领导力、感知价值和组织结构等领域的几个潜在可改变因素的影响。
