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

Abstract

Purpose Supporting the provision of intensive care medicine through telehealth potentially improves process quality. This may improve patient recovery and long-term outcomes. We investigated the effectiveness of a multifaceted telemedical programme on the adherence to German quality indicators (QIs) in a regional network of intensive care units (ICUs) in Germany. Methods We conducted an investigator-initiated, large-scale, open-label, stepped-wedge cluster randomised controlled trial enrolling adult ICU patients with an expected ICU stay of ≥ 24 h. Twelve ICU clusters in Berlin and Brandenburg were randomly assigned to three sequence groups to transition from control (standard care) to the intervention condition (telemedicine). The quality improvement intervention consisted of daily telemedical rounds guided by eight German acute ICU care QIs and expert consultations. Co-primary effectiveness outcomes were patient-specific daily adherence (fulfilled yes/no) to QIs, assessed by a central end point adjudication committee. Analyses used mixed-effects logistic modelling adjusted for time. This study is completed and registered with ClinicalTrials.gov (NCT03671447). Results Between September 4, 2018, and March 31, 2020, 1463 patients (414 treated on control, 1049 on intervention condition) were enrolled at ten clusters, resulting in 14,783 evaluated days. Two randomised clusters recruited no patients (one withdrew informed consent; one dropped out). The intervention, as implemented, significantly increased QI performance for “sedation, analgesia and delirium” (adjusted odds ratio (99.375% confidence interval [CI]) 5.328, 3.395–8.358), “ventilation” (OR 2.248, 1.198–4.217), “weaning from ventilation” (OR 9.049, 2.707–30.247), “infection management” (OR 4.397, 1.482–13.037), “enteral nutrition” (OR 1.579, 1.032–2.416), “patient and family communication” (OR 6.787, 3.976–11.589), and "early mobilisation" (OR 3.161, 2.160–4.624). No evidence for a difference in adherence to “daily multi-professional and interdisciplinary clinical visits” between both conditions was found (OR 1.606, 0.780–3.309). Temporal trends related and unrelated to the intervention were detected. 149 patients died during their index ICU stay (45 treated on control, 104 on intervention condition). Conclusion A telemedical quality improvement program increased adherence to seven evidence-based German performance indicators in acute ICU care. These results need further confirmation in a broader setting of regional, non-academic community hospitals and other healthcare systems. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-022-06949-x.

Mobilisation practices during the SARS-CoV-2 pandemic: A retrospective analysis (MobiCOVID)

“…Contrary to our initial hypothesis and other published data [36] we found that COVID-19 patients in the surge ICUs displayed higher rates of EM and higher levels of IMS. In our opinion the following factors may have influenced the focus on topics like EM and the results: (1) Authors of this paper who are established researchers in the field of early mobilisation participated in the teaching and were responsible for part of the surge ICUs, (2) early reports of long-lasting deep sedation with benzodiazepines and nearly no EM stimulated discussion to provide care according to our 10 quality indicators of intensive care medicine which includes EM and (3) intensivists of our hospital provided telemedicine care consultations to all hospitals in Berlin treating critically ill COVID-19 patients based again on the 10 quality indicators [37] . These may have had more influence on the surge ICUs since the multiprofessional critical care teams had not worked together before and allowed new workflows to be established with integration of the recommendations provided.…”

Subjective Ratings of Mental and Physical Health Correlate With EQ-5D-5L Index Values in Survivors of Critical Illness: A Construct Validity Study*

“…We conducted a secondary analysis of the multicenter, stepped-wedge cluster-randomized controlled Enhanced Recovery after Intensive Care (ERIC) trial (ClinicalTrials.gov: NCT03671447) (32, 33). ERIC was approved by the Institutional Review Board of Charité—Universitätsmedizin Berlin (EA1/006/18) on January 26, 2018.…”

“…ERIC was approved by the Institutional Review Board of Charité—Universitätsmedizin Berlin (EA1/006/18) on January 26, 2018. The presented analysis is original, has not been published before, adhered to the ethical standards of the Declaration of Helsinki from 1964 and its later amendments, and adhered to the Transparent Reporting of multivariable predication model for Individual Prognosis Or Diagnosis (TRIPOD) statement ( Supplement A , http://links.lww.com/CCM/H251) (33).…”

Telemedicine in emergency responses: reflections from a critical care telemedicine programme between Uzbekistani and German clinicians during COVID-19

“…One peer-to-peer approach involving an interdisciplinary team of healthcare professionals, called the ‘hub-and-spoke model,’ facilitates live audio–video interaction at the bedside from a tertiary hospital to remote care providers to assist remote-site physicians in treating challenging cases. 3 The ‘hub-and-spoke model’ is a multiprofessional peer-to-peer approach involving an interdisciplinary team of doctors, nurses and allied healthcare professionals under the hybrid model, which combines teleconsultations with training and educational activities. It also enables the delivery of telemedical services across national borders, 4 which offers solutions to clinical questions and promotes the exchange of knowledge and experience about the novel infectious disease between healthcare professionals on a global level.…”

“…Different telemedical models exist in the context of acute care. One peer-to-peer approach involving an interdisciplinary team of healthcare professionals, called the ‘hub-and-spoke model,’ facilitates live audio–video interaction at the bedside from a tertiary hospital to remote care providers to assist remote-site physicians in treating challenging cases 3. The ‘hub-and-spoke model’ is a multiprofessional peer-to-peer approach involving an interdisciplinary team of doctors, nurses and allied healthcare professionals under the hybrid model, which combines teleconsultations with training and educational activities.…”