High-Tech Monitoring Associated With Better Outcomes in Critically Ill Patients
By Norra MacReady
Medscape Medical News
April 13, 2010 — Round-the-clock observation using a combination of information technology and remote physician monitoring is associated with lower-than-predicted mortality, investigators reported in a study published online April 12 in the Archives of Internal Medicine.
As described in the study conclusion, these findings may be the first to demonstrate the advantages of a comprehensive and integrated health information technology application combined with remote intensivist coverage (RIC) over a standard, intensive-care unit (ICU) model that does not provide 24/7 intensivist coverage.
For 10 months, the researchers studied patients admitted consecutively to 3 ICUs with a total of 36 monitored beds in a single academic community hospital. A coordinated health information technology bundle (HITB)-RIC system was installed in each unit, consisting of electronic medical records, order entry, and medication administration systems, as well as audiovisual equipment that permitted monitoring by off-site intensivists.
"From 7 PM to 7 AM, the telemedicine team admitted new patients, responded to telephone calls from ICU nurses about their patients, and responded to computer-generated events, as identified by the electronic medical record's algorithmic event system," write lead author Matthew McCambridge, MD, from the Division of Critical Care Medicine, Pennsylvania State College of Medicine, Hershey, and colleagues. Among other critical changes, the RIC team responded to variations in patients'
blood pressure,
heart rate,
laboratory values,
mechanical ventilator parameters, and
central venous and pulmonary artery catheter values.
Comparison data were obtained from patients admitted consecutively to the same 3 ICUs during the 16 months preceding the implementation of the HITB-RIC, explain the authors.
They collected information on 959 patients in the HITB-RIC group and 954 patients in the control group. In addition to comparing crude mortality rates, the investigators compared predicted mortality based on each patient's score on the Acute Physiology and Chronic Health Evaluation (APACHE)-IV and APACHE Acute Physiology Score (APACHE-APS). They also looked at need for mechanical ventilation and hospital length of stay.
Observed hospital mortality was 14.7% in the HITB-RIC group and 21.4% in the control group (P < .001). Compared with predicted mortality, the rate among patients in the HITB-RIC group was 75.8% of that predicted by APACHE-IV (P < .001) and more than 100% of the predicted APACHE-IV mortality rate for the control group. When the patients were divided into diagnostic categories, the standardized mortality ratio, obtained by dividing the actual observed hospital mortality by that predicted by APACHE-IV, was reduced by at least 19% among patients with neurologic, cardiovascular, gastrointestinal, and respiratory illnesses. HITB-RIC patients with neurologic and gastrointestinal illnesses had significantly lower observed mortality rates compared with the control group (P = .002 and P = .04, respectively).
Similarly, 31.5% of the patients in the HITB-RIC group required ventilators compared with 36.1% of those in the control group (P = .001). There were no significant differences between the groups in ICU length of stay or overall hospital length of stay.
Limitations of the study include that it was observational and conducted at a single hospital; therefore, the findings may not be generalizable. In addition, the findings may have been affected by differences in data collection, which was paper-based for the control group and electronic for the HITB-RIC group. Nevertheless, the authors write, the data suggest that the HITB-RIC model "represents a significant advancement in the quality of critical care medicine" and could improve patient access to good critical care despite a growing shortage of qualified intensivists.
The authors have disclosed no relevant financial relationships.
