Decision-Making Authority During Tele-ICU Care Reduces Mortality and Length of Stay—A Systematic Review and Meta-Analysis*

Abstract

OBJECTIVES: Although the current coronavirus disease 2019 pandemic demonstrates the urgent need for the integration of tele-ICUs, there is still a lack of uniform regulations regarding the level of authority. We conducted a systematic review and meta-analysis to evaluate the impact of the level of authority in tele-ICU care on patient outcomes. DATA SOURCES: We searched MEDLINE, EMBASE, CENTRAL, and Web of Science from inception until August 30, 2020. STUDY SELECTION: We searched for randomized controlled trials and observational studies comparing standard care plus tele-ICU care with standard care alone in critically ill patients. DATA EXTRACTION: Two authors performed data extraction and risk of bias assessment. Mean differences and risk ratios were calculated using a random-effects model. DATA SYNTHESIS: A total of 20 studies with 477,637 patients (n tele-ICU care = 292,319, n control = 185,318) were included. Although “decision-making authority” as the level of authority was associated with a significant reduction in ICU mortality (pooled risk ratio, 0.82; 95% CI, 0.71–0.94; p = 0.006), we found no advantage of tele-ICU care in studies with “expert tele-consultation” as the level of authority. With regard to length of stay, “decision-making authority” resulted in an advantage of tele-ICU care (ICU length of stay: pooled mean difference, –0.78; 95% CI, –1.46 to –0.10; p = 0.14; hospital length of stay: pooled mean difference, –1.54; 95% CI, –3.13 to 0.05; p = 0.06), whereas “expert tele-consultation” resulted in an advantage of standard care (ICU length of stay: pooled mean difference, 0.31; 95% CI, 0.10–0.53; p = 0.005; hospital length of stay: pooled mean difference, 0.58; 95% CI, –0.04 to 1.21; p = 0.07). CONCLUSIONS: In contrast to expert tele-consultations, decision-making authority during tele-ICU care reduces mortality and length of stay in the ICU. This work confirms the urgent need for evidence-based ICU telemedicine guidelines and reveals potential benefits of uniform regulations regarding the level of authority when providing tele-ICU care.

Regionalization of Critical Care in the United States: Current State and Proposed Framework From the Academic Leaders in Critical Care Medicine Task Force of the Society of Critical Care Medicine*

“…The characteristics of ICU telemedicine programs to improve efficiency as measured by ICU length of stay is becoming clearer. Telemedicine programs that provide expert mentoring and direct management services are more effective (70, 71) than programs that provide consultative advice alone (72, 73). The interventional approach has enabled earlier recognition and provided management support for patients with time-sensitive high-risk conditions including stroke (74) and sepsis (75).…”

Effectiveness of an intensive care telehealth programme to improve process quality (ERIC): a multicentre stepped wedge cluster randomised controlled trial

“…Though several studies from the United States (US) have shown that telemedical treatment support might reduce ICU and hospital mortality and length of stay (LOS) [ 5 – 7 ], two studies (one single-centre and one multicentre trial) revealed that telemedicine improved adherence to best-practice measures like deep vein thrombosis prevention and infectious disease management [ 8 , 9 ].…”

Telemedicine Intensive Care Unit (Tele-ICU) Implementation During COVID-19: A Scoping Review

“…Remote monitoring and care have allowed for increased vigilance for patient deterioration while expanding the capacity of smaller units and decreasing staff burnout [ 5 ]. When decision-making resides with remote critical care specialists, mortality and length of stay are reduced [ 6 ].…”