Department of Intensive Care Medicine and Intermediate Care, Medical Faculty RWTH Aachen, Aachen, Germany.
School of Public Health, Department of Health Economics and Health Care Management, Bielefeld University, Bielefeld, Germany.
J Med Internet Res. 2022 Mar 2;24(3):e34098. doi: 10.2196/34098.
Evidence-based infectious disease and intensive care management is more relevant than ever. Medical expertise in the two disciplines is often geographically limited to university institutions. In addition, the interconnection between inpatient and outpatient care is often insufficient (eg, no shared electronic health record and no digital transfer of patient findings).
This study aims to establish and evaluate a telemedical inpatient-outpatient network based on expert teleconsultations to increase treatment quality in intensive care medicine and infectious diseases.
We performed a multicenter, stepped-wedge cluster randomized trial (February 2017 to January 2020) to establish a telemedicine inpatient-outpatient network among university hospitals, hospitals, and outpatient physicians in North Rhine-Westphalia, Germany. Patients aged ≥18 years in the intensive care unit or consulting with a physician in the outpatient setting were eligible. We provided expert knowledge from intensivists and infectious disease specialists through advanced training courses and expert teleconsultations with 24/7/365 availability on demand respectively once per week to enhance treatment quality. The primary outcome was adherence to the 10 Choosing Wisely recommendations for infectious disease management. Guideline adherence was analyzed using binary logistic regression models.
Overall, 159,424 patients (10,585 inpatients and 148,839 outpatients) from 17 hospitals and 103 outpatient physicians were included. There was a significant increase in guideline adherence in the management of Staphylococcus aureus infections (odds ratio [OR] 4.00, 95% CI 1.83-9.20; P<.001) and in sepsis management in critically ill patients (OR 6.82, 95% CI 1.27-56.61; P=.04). There was a statistically nonsignificant decrease in sepsis-related mortality from 29% (19/66) in the control group to 23.8% (50/210) in the intervention group. Furthermore, the extension of treatment with prophylactic antibiotics after surgery was significantly less likely (OR 9.37, 95% CI 1.52-111.47; P=.04). Patients treated by outpatient physicians, who were regularly participating in expert teleconsultations, were also more likely to be treated according to guideline recommendations regarding antibiotic therapy for uncomplicated upper respiratory tract infections (OR 1.34, 95% CI 1.16-1.56; P<.001) and asymptomatic bacteriuria (OR 9.31, 95% CI 3.79-25.94; P<.001). For the other recommendations, we found no significant effects, or we had too few observations to generate models. The key limitations of our study include selection effects due to the applied on-site triage of patients as well as the limited possibilities to control for secular effects.
Telemedicine facilitates a direct round-the-clock interaction over broad distances between intensivists or infectious disease experts and physicians who care for patients in hospitals without ready access to these experts. Expert teleconsultations increase guideline adherence and treatment quality in infectious disease and intensive care management, creating added value for critically ill patients.
ClinicalTrials.gov NCT03137589; https://clinicaltrials.gov/ct2/show/NCT03137589.
基于循证的传染病和重症监护管理比以往任何时候都更加重要。这两个学科的医学专业知识通常在地理上仅限于大学机构。此外，住院和门诊护理之间的互联通常不足（例如，没有共享的电子健康记录，也没有患者检查结果的数字传输）。
本研究旨在建立和评估基于专家远程咨询的远程医疗住院-门诊网络，以提高重症监护医学和传染病的治疗质量。
我们进行了一项多中心、阶梯式楔形集群随机试验（2017 年 2 月至 2020 年 1 月），在德国北莱茵-威斯特法伦州的大学医院、医院和门诊医生之间建立远程医疗住院-门诊网络。年龄≥18 岁的重症监护病房患者或在门诊就诊的患者符合条件。我们通过高级培训课程和专家远程咨询提供来自重症监护医生和传染病专家的专业知识，每周按需提供一次 24/7/365 服务，以提高治疗质量。主要结局是遵循 10 项传染病管理明智选择建议的情况。使用二元逻辑回归模型分析指南的依从性。
共有来自 17 家医院和 103 名门诊医生的 159424 名患者（10585 名住院患者和 148839 名门诊患者）被纳入研究。金黄色葡萄球菌感染管理（优势比[OR]4.00，95%置信区间 1.83-9.20；P<.001）和重症患者脓毒症管理（OR 6.82，95%置信区间 1.27-56.61；P=.04）的指南依从性显著提高。对照组脓毒症相关死亡率为 29%（19/66），干预组为 23.8%（50/210），统计学上无显著差异。此外，手术后预防性抗生素治疗的延长显著减少（OR 9.37，95%置信区间 1.52-111.47；P=.04）。定期参加专家远程咨询的门诊医生治疗的患者，也更有可能根据抗生素治疗上呼吸道感染（OR 1.34，95%置信区间 1.16-1.56；P<.001）和无症状菌尿（OR 9.31，95%置信区间 3.79-25.94；P<.001）的指南建议进行治疗。对于其他建议，我们没有发现显著效果，或者我们的观察太少，无法生成模型。我们研究的主要局限性包括由于现场分诊导致的选择效应，以及控制时间趋势影响的可能性有限。
远程医疗为重症监护或传染病专家与无法获得这些专家的医院内患者护理医生之间提供了直接的、全天候的远程交互。专家远程咨询可提高传染病和重症监护管理的指南依从性和治疗质量，为重症患者创造附加值。
ClinicalTrials.gov NCT03137589; https://clinicaltrials.gov/ct2/show/NCT03137589.
