Telemedicine with clinical decision support for critical care: a systematic review

21st century critical care medicine: An overview

Critical care medicine in the 21st century has witnessed remarkable advancements that have significantly improved patient outcomes in intensive care units (ICUs). This abstract provides a concise summary of the latest developments in critical care, highlighting key areas of innovation. Recent advancements in critical care include Precision Medicine: Tailoring treatments based on individual patient characteristics, genomics, and biomarkers to enhance the effectiveness of therapies. The objective is to describe the recent advancements in Critical Care Medicine. Telemedicine: The integration of telehealth technologies for remote patient monitoring and consultation, facilitating timely interventions. Artificial intelligence (AI): AI-driven tools for early disease detection, predictive analytics, and treatment optimization, enhancing clinical decision-making. Organ Support: Advanced life support systems, such as Extracorporeal Membrane Oxygenation and Continuous Renal Replacement Therapy provide better organ support. Infection Control: Innovative infection control measures to combat emerging pathogens and reduce healthcare-associated infections. Ventilation Strategies: Precision ventilation modes and lung-protective strategies to minimize ventilator-induced lung injury. Sepsis Management: Early recognition and aggressive management of sepsis with tailored interventions. Patient-Centered Care: A shift towards patient-centered care focusing on psychological and emotional well-being in addition to medical needs. We conducted a thorough literature search on PubMed, EMBASE, and Scopus using our tailored strategy, incorporating keywords such as critical care, telemedicine, and sepsis management. A total of 125 articles meeting our criteria were included for qualitative synthesis. To ensure reliability, we focused only on articles published in the English language within the last two decades, excluding animal studies, in vitro/molecular studies, and non-original data like editorials, letters, protocols, and conference abstracts. These advancements reflect a dynamic landscape in critical care medicine, where technology, research, and patient-centered approaches converge to improve the quality of care and save lives in ICUs. The future of critical care promises even more innovative solutions to meet the evolving challenges of modern medicine.

Trauma THOMPSON: Clinical Decision Support for the Frontline Medic

INTRODUCTION

U.S. Military healthcare providers increasingly perform prolonged casualty care because of operations in settings with prolonged evacuation times. Varied training and experience mean that this care may fall to providers unfamiliar with providing critical care. Telemedicine tools with audiovisual capabilities, artificial intelligence (AI), and augmented reality (AR) can enhance inexperienced personnel's competence and confidence when providing prolonged casualty care. Furthermore, implementing offline functionality provides assistance options in communications-limited settings. The intent of the Trauma TeleHelper for Operational Medical Procedure Support and Offline Network (THOMPSON) is to develop (1) a voice-controlled mobile application with video references for procedural guidance, (2) audio narration of each video using procedure mentoring scripts, and (3) an AI-guided intervention system using AR overlay and voice command to create immersive video modeling. These capabilities will be available offline and in downloadable format.

MATERIALS AND METHODS

The Trauma THOMPSON platform is in development. Focus groups of subject matter experts will identify appropriate procedures and best practices. Procedural video recordings will be collected to develop reference materials for the Trauma THOMPSON mobile application and to train a machine learning algorithm on action recognition and anticipation. Finally, an efficacy evaluation of the application will be conducted in a simulated environment.

RESULTS

Preliminary video collection has been initiated for tube thoracostomy, needle decompression, cricothyrotomy, intraosseous access, and tourniquet application. Initial results from the machine learning algorithm show action recognition and anticipation accuracies of 20.1% and 11.4%, respectively, in unscripted datasets "in the wild," notably on a limited dataset. This system performs over 100 times better than a random prediction.

CONCLUSIONS

Developing a platform to provide real-time, offline support will deliver the benefits of synchronous expert advice within communications-limited and remote environments. Trauma THOMPSON has the potential to fill an important gap for clinical decision support tools in these settings.

The Integration of Clinical Decision Support Systems Into Telemedicine for Patients With Multimorbidity in Primary Care Settings: Scoping Review

BACKGROUND

Multimorbidity, the presence of more than one condition in a single individual, is a global health issue in primary care. Multimorbid patients tend to have a poor quality of life and suffer from a complicated care process. Clinical decision support systems (CDSSs) and telemedicine are the common information and communication technologies that have been used to reduce the complexity of patient management. However, each element of telemedicine and CDSSs is often examined separately and with great variability. Telemedicine has been used for simple patient education as well as more complex consultations and case management. For CDSSs, there is variability in data inputs, intended users, and outputs. Thus, there are several gaps in knowledge about how to integrate CDSSs into telemedicine and to what extent these integrated technological interventions can help improve patient outcomes for those with multimorbidity.

OBJECTIVE

Our aims were to (1) broadly review system designs for CDSSs that have been integrated into each function of telemedicine for multimorbid patients in primary care, (2) summarize the effectiveness of the interventions, and (3) identify gaps in the literature.

METHODS

An online search for literature was conducted up to November 2021 on PubMed, Embase, CINAHL, and Cochrane. Searching from the reference lists was done to find additional potential studies. The eligibility criterion was that the study focused on the use of CDSSs in telemedicine for patients with multimorbidity in primary care. The system design for the CDSS was extracted based on its software and hardware, source of input, input, tasks, output, and users. Each component was grouped by telemedicine functions: telemonitoring, teleconsultation, tele-case management, and tele-education.

RESULTS

Seven experimental studies were included in this review: 3 randomized controlled trials (RCTs) and 4 non-RCTs. The interventions were designed to manage patients with diabetes mellitus, hypertension, polypharmacy, and gestational diabetes mellitus. CDSSs can be used for various telemedicine functions: telemonitoring (eg, feedback), teleconsultation (eg, guideline suggestions, advisory material provisions, and responses to simple queries), tele-case management (eg, sharing information across facilities and teams), and tele-education (eg, patient self-management). However, the structure of CDSSs, such as data input, tasks, output, and intended users or decision-makers, varied. With limited studies examining varying clinical outcomes, there was inconsistent evidence of the clinical effectiveness of the interventions.

CONCLUSIONS

Telemedicine and CDSSs have a role in supporting patients with multimorbidity. CDSSs can likely be integrated into telehealth services to improve the quality and accessibility of care. However, issues surrounding such interventions need to be further explored. These issues include expanding the spectrum of medical conditions examined; examining tasks of CDSSs, particularly for screening and diagnosis of multiple conditions; and exploring the role of the patient as the direct user of the CDSS.

Teleneurocritical Care for Patients with Large Vessel Occlusive Ischemic Stroke Treated by Thrombectomy

BACKGROUND

Teleneurocritical care (TNCC) provides 24/7 virtual treatment of patients with neurological disease in the emergency department or intensive care unit. However, it is not known if TNCC is safe, effective, or associated with similar outcomes compared with in-person neurocritical care. We aim to determine the effect of daily inpatient consults from TNCC on the outcomes of patients with large vessel occlusive acute ischemic stroke treated by thrombectomy.

METHODS

A multicenter, retrospective cohort of consecutive patients ≥ 18 years old with acute ischemic stroke from a large vessel occlusion treated by thrombectomy were identified from 2018 to 2021 within a telehealth network of an integrated not-for-profit health care system in the United States. The primary end point was good functional outcome, i.e., modified Rankin Scale 0-3, at the time of hospital discharge in patients receiving in-person neurocritical care versus TNCC.

RESULTS

A total of 437 patients met inclusion criteria, 226 at the in-person hospital (median age 67, 53% women) and 211 at the two TNCC hospitals (median age 74, 49% women). The rate of successful endovascular therapy (modified Thrombolysis in Cerebral Infarction score 2b-3) was not different among hospitals. Good functional outcome at discharge was similar between in-person neurocritical care and TNCC (in-person 31.4% vs. TNCC 33.5%, odds ratio 0.88, 95% confidence interval 0.6-1.3; p = 0.64). Only National Institutes of Health stroke scale and age were multivariable predictors of outcome. There were no differences in mortality (9.3% vs. 13.2%, p = 0.19), intensive care unit length of stay (2.1 vs. 1.9 days, p = 0.39), or rate of symptomatic intracerebral hemorrhage (6.8% vs. 6.6%, p = 0.47) between in-person neurocritical care and TNCC.

CONCLUSIONS

Teleneurocritical care allows for equivalent favorable functional outcomes compared with in-person neurocritical care for patients with acute large vessel ischemic stroke receiving thrombectomy. The standardized protocols used by TNCC in this study, specifically the comprehensive 24/7 treatment of patients in the intensive care unit for the length of their stay, may be relevant for other health systems with limited in-person resources; however, additional study is required.

Automation: A revolutionary vision of artificial intelligence in theranostics

The last two decades have witnessed an extraordinary evolution of automation and artificial intelligence (AI), which has become an integral part of our daily lives. Lately, AI has also been assimilated in the field of medicine to upgrade overall healthcare system and encourage personalized treatment. Theranostics literally meaning combination of diagnosis and therapeutics, is a targeted pharmacotherapy, based on specific targeted diagnostic tests. Numerous theranostic agents/biomarkers are available which can identify the most beneficial treatment, correct dose or predict response to a medicine, thus, maximizing drug efficacy, minimizing toxicity and providing informed treatment choice. For instance, a statistics based Cluster-FLIM technology provides precise data on drug-receptor binding behavior in biological tissues using fluorescence real experimental imaging. Automated Idylla™ qPCR System is another approach in oncology to determine the EGFR mutations at initial stage as well as during the treatment and also assists the oncologist in designing the treatment protocol. Recent incorporation of automation and AI in theranostics has brought a drastic change in early detection and treatment protocols for various diseases such as cancer and diabetes. Also, it leads to quick analysis of number of diverse experimental datum with accuracy. The approach mainly uses computer algorithms to unveil relevant and significant information from clinical data, thereby assisting in making accurate, logical and pertinent decisions. This review highlights the emerging uses/role of automation and AI in theranostics, technical difficulties and focuses on its future prospects to facilitate a patient specific, reliable and efficient pharmacotherapy.

Outcomes Associated with ICU Telemedicine and Other Risk Factors in a Multi-Hospital Critical Care System: A Retrospective, Cohort Study for 30-Day In-Hospital Mortality

Introduction: Intensive care unit telemedicine (ICU-TM) is expanding due to increasing demands for critical care, but impact on outcomes remains controversial. This study evaluated the association of ICU-TM and other clinical factors with 30-day, in-hospital mortality. Methods: This retrospective, cohort study included 151,780 consecutive ICU patients admitted to nine hospitals in the Cleveland Clinic Health System from 2010 to 2020. Patients were identified from an institutional datamart and Acute Physiology and Chronic Health Evaluation IV (APACHE IV) registry. Primary outcome was 30-day in-hospital mortality. Analyses included multivariate logistic regression modeling, and survival analysis. Results: Overall, unadjusted 30-day, in-hospital mortality incidence was significantly different with (5.6%) or without ICU-TM (7.2%), and risk ratio was 0.78 (95% confidence interval [CI] 0.75-0.81) (p < 0.0001). Mortality rate for ICU-TM and no ICU-TM was 2.4/1,000 versus 3.2/1,000 patient days, respectively (p < 0.0001). Multivariate logistic regression showed that ICU-TM was associated with reduced 30-day mortality (odds ratio 0.78, 95% CI 0.72-0.83). Increased risk was seen with cardiac arrest admissions, males, acute stroke, weekend admission, emergency admission, race (non-white), sepsis, APACHE IV score, ICU length of stay (LOS), and the interaction term, emergency surgical admissions. Reduced risk was associated with hospital LOS, surgical admission, and the interaction terms (weekend admissions with ICU-TM and after-hour admissions with ICU-TM). The model c-statistic was 0.77. Median ICU and hospital lengths of stay were significantly reduced with ICU-TM, with no difference in 48-h mortality or 48-h mortality rate. Conclusion: ICU telemedicine exposure appears to be one of several operational and clinical factors associated with reduced 30-day, in-hospital mortality.

Review of Systematic Reviews in the Field of Telemedicine

Background: Although the systematic reviews regarding telemedicine have increased in recent decades, no comprehensive studies have been conducted to review these systematic reviews. The present study aimed to review the published systematic reviews regarding telemedicine applications for the report and appraisal of several aspects. Methods: The literature search was performed in the PubMed database for the systematic reviews published during January 2010-June 2020 in the field of telemedicine using "telemedicine" Mesh terms. The extracted data from the selected articles were the year of publication, telemedicine specialty, clinical outcomes, cost evaluation, and satisfaction assessment. Data analysis was performed using descriptive statistics. Results: Among 746 retrieved articles, 191 cases were selected and reviewed. Most of the studies were focused on telemedicine (n=35; 18.3%), followed by telerehabilitation (n=22; 11.5%), tele-diabetes (n=18; 9.4%), telecardiology (n=16; 8.3%), home telecare (n=13; 6.8%), telepsychiatry (n=12; 6.3%), teledermatology (n=11; 5.7%), and teleneurology (n=9; 4.7%). The selected studies were primarily focused on clinical outcomes (72.7%), followed by cost-effectiveness (32.4%) and user satisfaction (29.3%). In addition, they mostly indicated that telemedicine services yielded acceptable clinical outcomes (72.5%), cost-effectiveness (67.7%), and healthcare provider/patient satisfaction (83.9%). Conclusion: Although telerehabilitation, tele-diabetes, telecardiology, home telecare, and telepsychiatry were studied further, there are still some specific specialties such as teleradiology, telepathology, and telepediatric that should be considered more. Moreover, investigation of various outcomes could result in a more comprehensive view of this field. Therefore, further investigations in this regard would improve telemedicine applications and encourage potential telemedicine providers to initiate these applications.

Telemedicine in Intensive Care Units: Scoping Review

BACKGROUND

The role of telemedicine in intensive care has been increasing steadily. Tele-intensive care unit (ICU) interventions are varied and can be used in different levels of treatment, often with direct implications for the intensive care processes. Although a substantial body of primary and secondary literature has been published on the topic, there is a need for broadening the understanding of the organizational factors influencing the effectiveness of telemedical interventions in the ICU.

OBJECTIVE

This scoping review aims to provide a map of existing evidence on tele-ICU interventions, focusing on the analysis of the implementation context and identifying areas for further technological research.

METHODS

A research protocol outlining the method has been published in JMIR Research Protocols. This review follows the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews). A core research team was assembled to provide feedback and discuss findings.

RESULTS

A total of 3019 results were retrieved. After screening, 25 studies were included in the final analysis. We were able to characterize the context of tele-ICU studies and identify three use cases for tele-ICU interventions. The first use case is extending coverage, which describes interventions aimed at extending the availability of intensive care capabilities. The second use case is improving compliance, which includes interventions targeted at improving patient safety, intensive care best practices, and quality of care. The third use case, facilitating transfer, describes telemedicine interventions targeted toward the management of patient transfers to or from the ICU.

CONCLUSIONS

The benefits of tele-ICU interventions have been well documented for centralized systems aimed at extending critical care capabilities in a community setting and improving care compliance in tertiary hospitals. No strong evidence has been found on the reduction of patient transfers following tele-ICU intervention.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/19695.

Diagnoses and Health Care Utilization for After-Hours Telemedicine Versus Primary Care Visits

OBJECTIVE

The use of a nation-wide, pediatricians online (PO) after-hours telemedicine service has been offered in Israel for more than a decade. We sought to compare PO visits with those to the primary care pediatrician (PCP).

METHODS

This is a retrospective cross-sectional study using Israel's largest health care provider database. We included children aged 0 to 18 years using either PO or PCP between 2015 and 2018. We compared the baseline characteristics, matching by socioeconomic status, chronic illness, and diagnosis, and compared their admission rates, laboratory testing, and medication prescription.

RESULTS

During this study period there were 262,541 PO visits and a random 10% sample of PCP visits which yielded 1,813,103 visits. Users of PO were more likely to have a higher socioeconomic status (43% vs 28.9%), fever (13.3% vs 4.4%) and less likely to have acute respiratory conditions (8.8% vs 16.7%). Users of PO had higher rates of emergency department admissions (2.9% vs 0.4%), hospital admissions (0.9% vs 0.2%), and lower rates of laboratory testing (3.7% vs 7.4%) and medication prescription (42.0% vs 52.0%) within 24 hours. All differences were statistically significant (P < .005).

CONCLUSIONS

Our pediatric telemedicine service operating after-hours has been found to be feasible, and widely used, for a myriad of clinical conditions. Significant differences exist between PO and PCP visit characteristics and outcomes. However, it remained unclear whether these differences reflect the difference in the patient population or whether they are the result of the different clinical services. Further research is warranted to clarify this matter.

Nurses' Perceptions of Telemedicine Adoption in the Intensive Care Unit

BACKGROUND

With telemedicine technology, off-site expert clinicians can consult in real time with bedside nurses and providers. The success of telemedicine may depend on its acceptance by bedside nurses and providers.

OBJECTIVES

To compare nurses' perceptions of telemedicine in 2 intensive care units (ICUs) at Emory University Hospital, an academic medical center, and to determine the relation between nurses' years of ICU experience and their perceptions of telemedicine in the hospital's ICUs (Emory e-ICU Center).

METHODS

This study used a descriptive correlational design. Nurses in the 2 units completed a demographic form and a questionnaire about their perceptions of the Emory e-ICU Center.

RESULTS

A total of 60 participants completed the study (30 nurses from each unit). Among the entire sample, the perception scores ranged from 2.4 to 5.0, with a mean score of 3.8 (SD, 0.6). Perception scores were significantly higher for nurses in the acute respiratory ICU than for those in the cardiovascular ICU; nurses in the acute respiratory ICU had spent less time working in an ICU. No statistically significant correlation was found between nurses' years of experience in an ICU and their perception scores. This correlation was also not significant within each unit. Nurses' experience with telemedicine in the ICU also did not correlate significantly with perception scores.

CONCLUSIONS

Despite differences in nurses' years of experience, the perceptions of the Emory e-ICU Center did not differ significantly among nurses.

Association of Unit-Level Telecritical Care Intensity of Service and Length of Stay in the Intensive Care Unit

Background: Telecritical care (TCC) has been shown to improve outcomes in the intensive care unit (ICU). A TCC was developed and implemented a nocturnal TCC across 10 ICUs in our Health System. TCC coverage patterns and level of involvement vary among ICUs. We identified an opportunity to determine the impact of TCC involvement on the ICU length of stay (LOS). Objective: The primary objective of this study was to assess if intensity of service provided by TCC impacts ICU LOS. Methods: This retrospective review was conducted for all patients admitted to covered ICUs during a 2-year period. ICUs were stratified by the coverage model provided by the TCC and the count of orders placed by the TCC served as a surrogate for intensity of service. Confounding variables were abstracted from the Acute Physiology and Chronic Health Evaluation (APACHE) databases. Spearman's rank correlation coefficient was used to measure the strength of the relationship between ICU LOS and TCC order volume. A linear regression model was used to describe the relationship between order volume and ICU LOS, while adjusting for confounding variables. Results: There is a strong negative relationship between TCC order volume and ICU LOS, as shown by the Spearman rank correlation coefficient of -0.818. The associated p-value of 0.0038 supports the strength of this relationship. Conclusion: Our results demonstrate the impact of nocturnal TCC involvement in patient care. As TCC order volume per ICU admission increases, ICU LOS decreases. We interpret this as an indication for deeper involvement between the TCC team and any on-site providers.

[Avoiding Long-term Impairment in Critical Care Using Telemedicine: The ERIC Example]

There is a high demand for critical care, which is forecasted to further grow in the future. Increasing patient morbidity and complexity concurring with a shortage of trained intensivists imposes challenges on critical care clinicians. Weathering these challenges, telemedical programs can help utilize and allocate resources more efficiently as well as foster adherence to best practice, thereby directly impacting quality of care. Studies have predominantly shown reductions in mortality and length of stay. Successful telemedical programs employ experienced intensivists, have well-functioning equipment and high acceptance among on-site clinicians. The multicenter, pragmatic, stepped wedge cluster-randomized controlled quality improvement trial Enhanced Recovery after Intensive Care (ERIC) pilots a new form of critical care provision in Germany. With a target study sample size of n = 1431 patients, the study aims to utilize telemedicine to increase adherence to a set of evidence- and consensus-based quality indicators for acute critical care. In an intersectoral case-care management, patients are followed three and six months after discharge from the intensive care unit to be assessed for long-term impairments and post-intensive care syndrome.

Telemedicine in Intensive Care Units: Protocol for a Scoping Review

Background

Telemedicine has been deployed to address issues in intensive care delivery, as well as to improve outcome and quality of care. Implementation of this technology has been characterized by high variability. Tele-intensive care unit (ICU) interventions involve the combination of multiple technological and organizational components, as well as interconnections of key stakeholders inside the hospital organization. The extensive literature on the benefits of tele-ICUs has been characterized as heterogeneous. On one hand, positive clinical and economical outcomes have been shown in multiple studies. On the other hand, no tangible benefits could be detected in several cases. This could be due to the diverse forms of organizations and the fact that tele-ICU interventions are complex to evaluate. The implementation context of tele-ICUs has been shown to play an important role in the success of the technology. The benefits derived from tele-ICUs depend on the organization where it is deployed and how the telemedicine systems are applied. There is therefore value in analyzing the benefits of tele-ICUs in relation to the characteristics of the organization where it is deployed. To date, research on the topic has not provided a comprehensive overview of literature taking both the technology setup and implementation context into account.

Objective

We present a protocol for a scoping review of the literature on telemedicine in the ICU and its benefits in intensive care. The purpose of this review is to map out evidence about telemedicine in critical care in light of the implementation context. This review could represent a valuable contribution to support the development of tele-ICU technologies and offer perspectives on possible configurations, based on the implementation context and use case.

Methods

We have followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist and the recommendations of the Joanna Briggs Institute methodology for scoping reviews. The scoping review and subsequent systematic review will be completed by spring 2021.

Results

The preliminary search has been conducted. After removing all duplicates, we found 2530 results. The review can now be advanced to the next steps of the methodology, including literature database queries with appropriate keywords, retrieval of the results in a reference management tool, and screening of titles and abstracts.

Conclusions

The results of the search indicate that there is sufficient literature to complete the scoping review. Upon completion, the scoping review will provide a map of existing evidence on tele-ICU systems given the implementation context. Findings of this research could be used by researchers, clinicians, and implementation teams as they determine the appropriate setup of new or existing tele-ICU systems. The need for future research contributions and systematic reviews will be identified.

International Registered Report Identifier (IRRID)

DERR1-10.2196/19695

Telemedicine in the intensive care unit: A vehicle to improve quality of care?

The high demand for intensive care, which is predicted to further increase in the future, is contrasted by a shortage of trained intensivists and specialized nurses. Telemedicine has been heralded as a promising solution. Yet, there is considerable heterogeneity in tele-critical care when it comes to measurable effects. However, the focus has been on telemedical solutions substituting on-site intensivist functions, and outcome measures have primarily been mortality and length of stay. In a new model of telemedicine for the ICU, telemedicine could be used to increase adherence to best practice guidelines and indicators of process quality. Further, indicators of process quality, functional outcomes and quality of life measures should be incorporated in the evaluation of outcomes, as patients frequently value those higher than mere survival.

University of California Technology Wellness Index: A Physician-Centered Framework to Assess Technologies' Impact on Physician Well-Being

Technology is increasingly being incorporated into the everyday workflows of physicians. There are concerns that electronic medical records and other digital technologies will contribute to the growing epidemic of physician burnout. However, some technologies, such as telemedicine, have demonstrated positive effects on physician health by saving time, enhancing work-life balance, improving quality, and restoring more control and flexibility to their practices. Organizations often lack data to evaluate the impact of technologies on physician health. The University of California Technology Wellness Index is a framework that provides a fast, systematic, physician-centered method to assess the impact of technology on physician well-being.

Remote Surveillance Technologies: Realizing the Aim of Right Patient, Right Data, Right Time

The convergence of multiple recent developments in health care information technology and monitoring devices has made possible the creation of remote patient surveillance systems that increase the timeliness and quality of patient care. More convenient, less invasive monitoring devices, including patches, wearables, and biosensors, now allow for continuous physiological data to be gleaned from patients in a variety of care settings across the perioperative experience. These data can be bound into a single data repository, creating so-called data lakes. The high volume and diversity of data in these repositories must be processed into standard formats that can be queried in real time. These data can then be used by sophisticated prediction algorithms currently under development, enabling the early recognition of patterns of clinical deterioration otherwise undetectable to humans. Improved predictions can reduce alarm fatigue. In addition, data are now automatically queriable on a real-time basis such that they can be fed back to clinicians in a time frame that allows for meaningful intervention. These advancements are key components of successful remote surveillance systems. Anesthesiologists have the opportunity to be at the forefront of remote surveillance in the care they provide in the operating room, postanesthesia care unit, and intensive care unit, while also expanding their scope to include high-risk preoperative and postoperative patients on the general care wards. These systems hold the promise of enabling anesthesiologists to detect and intervene upon changes in the clinical status of the patient before adverse events have occurred. Importantly, however, significant barriers still exist to the effective deployment of these technologies and their study in impacting patient outcomes. Studies demonstrating the impact of remote surveillance on patient outcomes are limited. Critical to the impact of the technology are strategies of implementation, including who should receive and respond to alerts and how they should respond. Moreover, the lack of cost-effectiveness data and the uncertainty of whether clinical activities surrounding these technologies will be financially reimbursed remain significant challenges to future scale and sustainability. This narrative review will discuss the evolving technical components of remote surveillance systems, the clinical use cases relevant to the anesthesiologist's practice, the existing evidence for their impact on patients, the barriers that exist to their effective implementation and study, and important considerations regarding sustainability and cost-effectiveness.

Intensive Care Unit Telemedicine in the Era of Big Data, Artificial Intelligence, and Computer Clinical Decision Support Systems

This article examines the history of the telemedicine intensive care unit (tele-ICU), the current state of clinical decision support systems (CDSS) in the tele-ICU, applications of machine learning (ML) algorithms to critical care, and opportunities to integrate ML with tele-ICU CDSS. The enormous quantities of data generated by tele-ICU systems is a major driver in the development of the large, comprehensive, heterogeneous, and granular data sets necessary to develop generalizable ML CDSS algorithms, and deidentification of these data sets expands opportunities for ML CDSS research.

Quality Improvement and Telemedicine Intensive Care Unit: A Perfect Match

The health care delivery system is complex. New technologies offer new treatment options. The process of quality improvement includes system re-engineering. Telemedicine intensive care is an evolving area of delivery. Its core characteristic is the need for a merger of human and machine activity. Optimal use of quality improvement tools can lead to improved patient-centered outcomes. This article outlines how quality improvement tools can be used to facilitate the patient-centered collaboration with a focus on defining evidence-practice gaps, developing actionable metrics, analyzing the impact of proposed interventions, quantifying resources, prioritizing improvement plans, evaluating results, and diffusing best practices.

Impact of Synchronous Telemedicine Models on Clinical Outcomes in Pediatric Acute Care Settings: A Systematic Review

OBJECTIVES

To evaluate the impact of synchronous telemedicine models on the clinical outcomes in pediatric acute care settings.

DATA SOURCES

Citations from EBM Reviews, MEDLINE, EMBASE, Global Health, PubMed, and CINAHL.

STUDY SELECTION

We identified studies that evaluated the impact of synchronous telemedicine on clinical outcomes between January 2000 and April 2018. All studies involving acutely ill children in PICUs, pediatric cardiac ICUs, neonatal ICUs, and pediatric emergency departments were included. Publication inclusion criteria were study design, participants characteristics, technology type, interventions, settings, outcome measures, and languages.

DATA EXTRACTION

Two authors independently screened each article for inclusion and extracted information, including telecommunication method, intervention characteristics, sample characteristics and size, outcomes, and settings.

DATA SYNTHESIS

Out of the 789 studies initially identified, 24 were included. The six main outcomes of interest published were quality of care, hospital and standardized mortality rate, transfer rate, complications and illness severity, change in medical management, and length of stay. The use of synchronous telemedicine results improved quality of care and resulted in a decrease in the transfer rate (31-87.5%) (four studies), a shorter length of stay (8.2 vs 15.1 d) (six studies), a change or reinforcement of the medical care plan, a reduction in complications and illness severity, and a low hospital and standardized mortality rate. Overall, the quality of the included studies was weak.

CONCLUSIONS

Despite the broad recommendations found for using telemedicine in pediatric acute care settings, high-quality evidence of its impacts is still lacking. Further robust studies are needed to better determine the clinical effectiveness and the associated impacts of telemedicine in pediatric acute care settings.

Telemedicine/Virtual ICU: Where Are We and Where Are We Going?

Intensive care unit telemedicine (tele-ICU) is technology enabled care delivered from off-site locations that was developed to address the increasing complexity of patients and insufficient supply of intensivists. Although tele-ICU deployment is increasing, it continues to cover only a small proportion of ICU patients. This is primarily due to expense, with first-year costs exceeding $50,000 per bed. Meta-analyses of outcomes indicate survival benefits and quality improvements, albeit with significant heterogeneity. Depending on the context, a wide range of estimated incremental cost-effectiveness ratios reflects variable effects on cost and outcomes, such as mortality or length of stay. Tele-ICUs may fit within a hybrid model of care to complement high-intensity ICU staff coverage. However, more research is required to foster consensus and determine best practices. This review summarizes data on tele-ICU structure, operations, outcomes, and costs. Evidence was extracted from meta-analyses, with secondary data from Cleveland Clinic's tele-ICU experience.

A Systematic Review of Nurses' Perspectives Toward the Telemedicine Intensive Care Unit: A Basis for Supporting Its Future Implementation in China?

Aim: The purpose of this systematic review is to critique and summarize existing research on intensive care unit (ICU) nurses' perspectives toward the telemedicine intensive care unit (Tele-ICU). The intention of this study is to explore the evidence base to support the potential future implementation of Tele-ICU program in China. Methods: We searched for published articles pertaining to Tele-ICU system with a centralized monitoring model between January 2000 and July 2017 using Cochrane Library, Academic Search Premier, Cumulative Index to Nursing and Allied Health Literature, British Education Index, MEDLINE, MLA International Bibliography, and Web of Science. Studies were coded by methodology, participants, and findings. The textual narrative synthesis method was applied to synthesize the outcomes. Results: Findings were categorized as follows: perceptions of the Tele-ICU (including the role of Tele-ICU, benefits for nurses, patients, and management); attitudes of Tele-ICU (usefulness and challenges of Tele-ICU); level of satisfaction; factors affecting acceptance of Tele-ICU. Discussion: This review has synthesized significant factors influencing optimal usage of Tele-ICU from nurses' perspectives. Also, it might make a better case for findings to support Tele-ICU future implementation into Chinese tertiary hospitals.

Digital maturity: are we ready to use technology in the NHS?

Digital maturity assessments (DMAs) are a self-assessment mechanism for organisations. They can be effectively utilised to generate local digital roadmaps. In their simplest form, these allow organisations to understand their state of readiness to integrate digital technologies. This is achieved by assessing the capability and compatibility of their information systems to communicate or interface both within and across organisations. Through utilising and responding to the findings of DMAs, it is thought that the NHS will be better able to provide a patient-centred service to meet local needs within a national framework. It is this exchange and integration of information across health and social care systems that will drive innovation and transformation in the NHS.