Boyle Walter A, Palmer Christopher M, Konzen Lisa, Fritz Bradley A, White Jason, Simkins Michelle, Dieffenderfer Brian, Iqbal Ayesha, Bertrand Jill, Meyer Shelley, Kerby Paul, Buckman Sara, Despotovic Vladimir, Kozlowski Jim, Crimmins Reda Patricia, Zwir Igor, Gu C Charles, Ofoma Uchenna R
Division of Critical Care Medicine, Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO.
Barnes Jewish Hospital, St. Louis, MO.
Crit Care Explor. 2023 Sep 22;5(10):e0979. doi: 10.1097/CCE.0000000000000979. eCollection 2023 Oct.
Studies evaluating telemedicine critical care (TCC) have shown mixed results. We prospectively evaluated the impact of TCC implementation on risk-adjusted mortality among patients stratified by pre-TCC performance.
Prospective, observational, before and after study.
Three adult ICUs at an academic medical center.
A total of 2,429 patients in the pre-TCC (January to June 2016) and 12,479 patients in the post-TCC (January 2017 to June 2019) periods.
TCC implementation which included an acuity-driven workflow targeting an identified "lower-performing" patient group, defined by ICU admission in an Acute Physiology and Chronic Health Evaluation diagnoses category with a pre-TCC standardized mortality ratio (SMR) of greater than 1.5.
The primary outcome was risk-adjusted hospital mortality. Risk-adjusted hospital length of stay (HLOS) was also studied. The SMR for the overall ICU population was 0.83 pre-TCC and 0.75 post-TCC, with risk-adjusted mortalities of 10.7% and 9.5% ( = 0.09). In the identified lower-performing patient group, which accounted for 12.6% ( = 307) of pre-TCC and 13.3% ( = 1671) of post-TCC ICU patients, SMR decreased from 1.61 (95% CI, 1.21-2.01) pre-TCC to 1.03 (95% CI, 0.91-1.15) post-TCC, and risk-adjusted mortality decreased from 26.4% to 16.9% ( < 0.001). In the remaining ("higher-performing") patient group, there was no change in pre- versus post-TCC SMR (0.70 [0.59-0.81] vs 0.69 [0.64-0.73]) or risk-adjusted mortality (8.5% vs 8.4%, = 0.86). There were no pre- to post-TCC differences in standardized HLOS ratio or risk-adjusted HLOS in the overall cohort or either performance group.
In well-staffed and overall higher-performing ICUs in an academic medical center, Acute Physiology and Chronic Health Evaluation granularity allowed identification of a historically lower-performing patient group that experienced a striking TCC-associated reduction in SMR and risk-adjusted mortality. This study provides additional evidence for the relationship between pre-TCC performance and post-TCC improvement.
评估远程医疗重症监护（TCC）的研究结果不一。我们前瞻性地评估了TCC实施对按TCC实施前表现分层的患者风险调整后死亡率的影响。
前瞻性观察性前后对照研究。
一所学术医疗中心的三个成人重症监护病房。
TCC实施前（2016年1月至6月）共有2429例患者，TCC实施后（2017年1月至2019年6月）共有12479例患者。
实施TCC，包括针对特定“表现较差”患者群体的急性病驱动工作流程，该群体由急性生理与慢性健康状况评估诊断类别中的重症监护病房入院定义，TCC实施前标准化死亡率（SMR）大于1.5。
主要结局是风险调整后的医院死亡率。还研究了风险调整后的住院时间（HLOS）。整个重症监护病房人群的SMR在TCC实施前为0.83，实施后为0.75，风险调整后的死亡率分别为10.7%和9.5%（P = 0.09）。在确定的表现较差患者群体中，占TCC实施前重症监护病房患者的12.6%（n = 307）和实施后患者的13.3%（n = 1671），SMR从TCC实施前的1.61（95%CI，1.21 - 2.01）降至实施后的1.03（95%CI，0.91 - 1.15），风险调整后的死亡率从26.4%降至16.9%（P < 0.001）。在其余（“表现较好”）患者群体中，TCC实施前后的SMR没有变化（0.70[0.59 - 0.81]对0.69[0.64 - 0.73]）或风险调整后的死亡率（8.5%对8.4%，P = 0.86）。在整个队列或任何一个表现组中，标准化HLOS比率或风险调整后的HLOS在TCC实施前后没有差异。
在一所学术医疗中心人员配备充足且总体表现较好的重症监护病房中，急性生理与慢性健康状况评估的细致程度使得能够识别出一个历史上表现较差的患者群体，该群体经历了与TCC相关的SMR和风险调整后死亡率的显著降低。本研究为TCC实施前表现与实施后改善之间的关系提供了更多证据。
