Pereira Adriano J, Noritomi Danilo T, Dos Santos Maura Cristina, Corrêa Thiago D, Ferraz Leonardo J R, Schettino Guilherme P P, Cordioli Eduardo, Morbeck Renata A, Morais Lúbia C, Salluh Jorge I F, Azevedo Luciano C P, Biondi Rodrigo S, Rosa Regis G, Cavalcanti Alexandre B, Berwanger Otavio, Serpa Neto Ary, Ranzani Otavio T
Hospital Israelita Albert Einstein, São Paulo, Brazil.
Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil.
JAMA. 2024 Dec 3;332(21):1798-1807. doi: 10.1001/jama.2024.20651.
Despite its implementation in several countries, there has not been a randomized clinical trial to assess whether telemedicine in intensive care units (ICUs) could improve clinical outcomes of critically ill patients.
To determine whether an intervention comprising daily multidisciplinary rounds and monthly audit and feedback meetings performed by a remote board-certified intensivist reduces ICU length of stay (LOS) compared with usual care.
DESIGN, SETTING, AND PARTICIPANTS: A parallel cluster randomized clinical trial with a baseline period in 30 general ICUs in Brazil in which daily multidisciplinary rounds performed by board-certified intensivists were not routinely available. All consecutive adult patients (aged ≥18 years) admitted to the participating ICUs, excluding those admitted due to justice-related issues, were enrolled between June 1, 2019, and April 7, 2021, with last follow-up on July 6, 2021.
Remote daily multidisciplinary rounds led by a board-certified intensivist through telemedicine, monthly audit and feedback meetings for discussion of ICU performance indicators, and provision of evidence-based clinical protocols.
The primary outcome was ICU LOS at the patient level. Secondary outcomes included ICU efficiency, in-hospital mortality, incidence of central line-associated bloodstream infections, ventilator-associated events, catheter-associated urinary tract infections, ventilator-free days at 28 days, patient-days receiving oral or enteral feeding, patient-days under light sedation, and rate of patients with oxygen saturation values under that of normoxemia, assessed using generalized linear mixed models.
Among 17 024 patients (1794 in the baseline period and 15 230 in the intervention period), the mean (SD) age was 61 (18) years, 44.7% were female, the median (IQR) Sequential Organ Failure Assessment score was 6 (2-9), and 45.5% were invasively mechanically ventilated at admission. The median (IQR) time under intervention was 20 (16-21) months. Mean (SD) ICU LOS, adjusted for baseline assessment, did not differ significantly between the tele-critical care and usual care groups (8.1 [10.0] and 7.1 [9.0] days; percentage change, 8.2% [95% CI, -5.4% to 23.8%]; P = .24). Results were similar in sensitivity analyses and prespecified subgroups. There were no statistically significant differences in any other secondary or exploratory outcomes.
Daily multidisciplinary rounds conducted by a board-certified intensivist through telemedicine did not reduce ICU LOS in critically ill adult patients.
ClinicalTrials.gov Identifier: NCT03920501.
尽管远程医疗已在多个国家实施，但尚无随机临床试验来评估重症监护病房（ICU）中的远程医疗能否改善危重症患者的临床结局。
确定与常规护理相比，由远程的具备委员会认证资质的重症医学专家进行的每日多学科查房以及每月的审核与反馈会议组成的干预措施是否能缩短ICU住院时长（LOS）。
设计、设置与参与者：一项平行整群随机临床试验，在巴西30个综合ICU进行了基线期研究，在此期间，具备委员会认证资质的重症医学专家进行的每日多学科查房并非常规开展。2019年6月1日至2021年4月7日期间，纳入了所有入住参与研究ICU的连续成年患者（年龄≥18岁），排除因司法相关问题入院的患者，并于2021年7月6日进行末次随访。
由具备委员会认证资质的重症医学专家通过远程医疗进行每日多学科查房，每月召开审核与反馈会议以讨论ICU绩效指标，并提供循证临床方案。
主要结局是患者层面的ICU住院时长。次要结局包括ICU效率、院内死亡率、中心静脉导管相关血流感染发生率、呼吸机相关事件、导尿管相关尿路感染、28天无呼吸机天数、接受口服或肠内喂养的患者天数、轻度镇静下的患者天数以及氧饱和度值低于正常血氧饱和度的患者比例，使用广义线性混合模型进行评估。
在17024例患者中（基线期1794例，干预期15230例），平均（标准差）年龄为61（18）岁，44.7%为女性，序贯器官衰竭评估评分中位数（四分位间距）为6（2 - 9），45.5%在入院时接受有创机械通气。干预的中位（四分位间距）时间为20（16 - 21）个月。经基线评估调整后，远程重症监护与常规护理组的平均（标准差）ICU住院时长无显著差异（分别为8.1[10.0]天和7.1[9.0]天；百分比变化为8.2%[95%置信区间， - 5.4%至23.8%]；P = 0.24）。敏感性分析和预设亚组的结果相似。在任何其他次要或探索性结局方面均无统计学显著差异。
具备委员会认证资质的重症医学专家通过远程医疗进行的每日多学科查房并未缩短危重症成年患者的ICU住院时长。
ClinicalTrials.gov标识符：NCT03920501。
