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May - 2019

   

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Determinants of Intensive Care Unit Telemedicine Effectiveness An Ethnographic Study

JK Kahn, KJ Rak, CC Kuza, et al Am J Resp Crit Care Med, 2019, 199(8); 970-979

Comment

The benefits and most effective delivery of ICU telemedicine, where audiovisual technology is used to remotely monitor and care for critically ill patients from a central location, is not clear. Some studies show mortality benefit, some show little benefit or even harm.

This ethnographic evaluation of U.S. ICU telemedicine programs. This involved using a positive/negative deviance design in which hospitals were first categorised based on their change in risk-adjusted mortality after adoption of ICU telemedicine, then visited programs with a statistically significant decrease in mortality after adoption of telemedicine, increase in mortality after adoption of telemedicine, and no change in mortality. This allowed comparison of programs by outcome.

The program visit involved 3 or 4 investigators visiting both telemedicine provider and target facility, for 4-day period, observing both sides of the interaction. Ethnographic data collected  included: 

  1. direct observations of clinical care
  2. semistructured interviews with program leadership and care providers (e.g.,intensivist physicians, nonintensivist physicians, and nurses)
  3. focus groups of care providers
  4. collection of artifacts, such as written care protocols and standard operating procedures. 

The authors discovered thematic saturation occurred after 6 telemedicine facilities providing service to 10 ICUs. This involved 460 hours of directors observation, 222 interviews, 18 focus groups. They report;

ICU telemedicine care delivery takes place through four major activities;

  1. monitoring for physiologic deterioration
  2. prompting bedside providers for specific evidence-based practices
  3. serving as a resource for expert advice and guidance
  4. collecting performance data for later auditing and feedback

Telemedicine programs were most effective the they performed these activities that were appropriate, consistent, and integrated with bedside workflow. 

  1. Appropriate meant clinicians delivered needed expertise in accordance with what the bedside clinicians would have performed; and when expertise was specific to the needs of the particular ICU. 
  2. Care was considered responsive when the telemedicine facility was proactive, seeking out care deficiencies that had been missed at the bedside, yet also appropriately reactive, being available when needed and not disrupting effective care in the target ICU. 
  3. Care was considered consistent when the telemedicine facility used the same approach every time, creating a set of shared expectations about what they would do and when. 
  4. Care was considered integrated when telemedicine workflows were embedded with ICU workflows creating customary points of interaction. The two groups tended to form one care team, with each understanding their roles and responsibilities. Examples include the telemedicine unit cosigning medications, notifying organ donation services, and monitoring quality improvement data. 

They found effectiveness of telemedicine was influenced by the interaction of factors within three key domains;

  1. Leadership of both the target ICU and the facility providing the remote care
  2. Perceived value of telemedicine by front-line care providers
  3. Organizational characteristics of the telemedicine program. 

This paper provides a detailed guide to the components, structure, and interactions of an effective telemedicine system. In particular, optimising the domains of leadership, perceived values, and organisation characteristics may result in improve outcomes. 

 

Abstract

Rationale: Telemedicine is an increasingly common care delivery strategy in the ICU. However, ICU telemedicine programs vary widely in their clinical effectiveness, with some studies showing a large mortality benefit and others showing no benefit or even harm.

Objectives: To identify the organizational factors associated with ICU telemedicine effectiveness.

Methods: We performed a focused ethnographic evaluation of 10 ICU telemedicine programs using site visits, interviews, and focus groups in both facilities providing remote care and the target ICUs. Programs were selected based on their change in risk-adjusted mortality after adoption (decreased mortality, no change in mortality, and increased mortality). We used a constant comparative approach to guide data collection and analysis.

Measurements and Main Results: We conducted 460 hours of direct observation, 222 interviews, and 18 focus groups across six telemedicine facilities and 10 target ICUs. Data analysis revealed three domains that influence ICU telemedicine effectiveness: 1) leadership (i.e., the decisions related to the role of the telemedicine, conflict resolution, and relationship building), 2) perceived value (i.e., expectations of availability and impact, staff satisfaction, and understanding of operations), and 3) organizational characteristics (i.e., staffing models, allowed involvement of the telemedicine unit, and new hire orientation). In the most effective telemedicine programs these factors led to services that are viewed as appropriate, integrated, responsive, and consistent.

Conclusions: The effectiveness of ICU telemedicine programs may be influenced by several potentially modifiable factors within the domains of leadership, perceived value, and organizational structure.

May


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