ICU Telemedicine Program Financial Outcomes

BACKGROUND

ICU telemedicine improves access to high-quality critical care, has substantial costs, and can change financial outcomes. Detailed information about financial outcomes and their trends over time following ICU telemedicine implementation and after the addition of logistic center function has not been published to our knowledge.

METHODS

Primary data were collected for consecutive adult patients of a single academic medical center. We compared clinical and financial outcomes across three groups that differed regarding telemedicine support: a group without ICU telemedicine support (pre-ICU intervention group), a group with ICU telemedicine support (ICU telemedicine group), and an ICU telemedicine group with added logistic center functions and support for quality-care standardization (logistic center group). The primary outcome was annual direct contribution margin defined as aggregated annual case revenue minus annual case direct costs (including operating costs of ICU telemedicine and its related programs). All monetary values were adjusted to 2015 US dollars using Producer Price Index for Health-Care Facilities.

RESULTS

Annual case volume increased from 4,752 (pre-ICU telemedicine) to 5,735 (ICU telemedicine) and 6,581 (logistic center). The annual direct contribution margin improved from $7,921,584 (pre-ICU telemedicine) to $37,668,512 (ICU telemedicine) to $60,586,397 (logistic center) due to increased case volume, higher case revenue relative to direct costs, and shorter length of stay.

CONCLUSIONS

The ability of properly modified ICU telemedicine programs to increase case volume and access to high-quality critical care with improved annual direct contribution margins suggests that there is a financial argument to encourage the wider adoption of ICU telemedicine.

Tools to investigate how interprofessional education activities link to competencies

Integrating interprofessional education (IPE) activities and curricular components in health professions education has been emphasized recently by the inclusion of accreditation standards across disciplines. The Interprofessional Education Collaborative (IPEC) established IPE competencies in 2009, but evaluating how activities link to competencies has not been investigated in depth. The purpose of this project is to investigate how well two IPE activities align with IPEC competencies. To evaluate how our IPE activities met IPEC competencies, we developed a checklist and an observation instrument. A brief description of each is included as well as the outcomes. We analyzed Disaster Day, a simulation exercise that includes participants from Nursing, Medicine, and Pharmacy, and Interprofessional Healthcare Ethics (IPHCE), a course that introduced medical, nursing, and pharmacy students to ethical issues using didactic sessions and case discussions. While both activities appeared to facilitate the development of IPE competencies, Disaster Day aligned more with IPEC competencies than the IPHCE course and appears to be a more comprehensive way of addressing IPEC competencies. However, offering one IPE activity or curricular element is not sufficient. Having several IPE options available, utilizing the tools we developed to map the IPE curriculum and evaluating competency coverage is recommended.

Conceptualizing Interprofessional Teams as Multi-Team Systems-Implications for Assessment and Training

SGEA 2015 CONFERENCE ABSTRACT (EDITED). Evaluating Interprofessional Teamwork During a Large-Scale Simulation. Courtney West, Karen Landry, Anna Graham, and Lori Graham. CONSTRUCT: This study investigated the multidimensional measurement of interprofessional (IPE) teamwork as part of large-scale simulation training.

BACKGROUND

Healthcare team function has a direct impact on patient safety and quality of care. However, IPE team training has not been the norm. Recognizing the importance of developing team-based collaborative care, our College of Nursing implemented an IPE simulation activity called Disaster Day and invited other professions to participate. The exercise consists of two sessions: one in the morning and another in the afternoon. The disaster scenario is announced just prior to each session, which consists of team building, a 90-minute simulation, and debriefing. Approximately 300 Nursing, Medicine, Pharmacy, Emergency Medical Technicians, and Radiology students and over 500 standardized and volunteer patients participated in the Disaster Day event. To improve student learning outcomes, we created 3 competency-based instruments to evaluate collaborative practice in multidimensional fashion during this exercise.

APPROACH

A 20-item IPE Team Observation Instrument designed to assess interprofessional team's attainment of Interprofessional Education Collaborative (IPEC) competencies was completed by 20 faculty and staff observing the Disaster Day simulation. One hundred sixty-six standardized patients completed a 10-item Standardized Patient IPE Team Evaluation Instrument developed from the IPEC competencies and adapted items from the 2014 Henry et al. PIVOT Questionnaire. This instrument assessed the standardized or volunteer patient's perception of the team's collaborative performance. A 29-item IPE Team's Perception of Collaborative Care Questionnaire, also created from the IPEC competencies and divided into 5 categories of Values/Ethics, Roles and Responsibilities, Communication, Teamwork, and Self-Evaluation, was completed by 188 students including 99 from Nursing, 43 from Medicine, 6 from Pharmacy, and 40 participants who belonged to more than one component, were students at another institution, or did not indicate their institution. The team instrument was designed to assess each team member's perception of how well the team and him- or herself met the competencies. Five of the items on the team perceptions questionnaire mirrored items on the standardized patient evaluation: demonstrated leadership practices that led to effective teamwork, discussed care and decisions about that care with patient, described roles and responsibilities clearly, worked well together to coordinate care, and good/effective communication.

RESULTS

Internal consistency reliability of the IPE Team Observation Instrument was 0.80. In 18 of the 20 items, more than 50% of observers indicated the item was demonstrated. Of those, 6 of the items were observed by 50% to 75% of the observers, and the remaining 12 were observed by more than 80% of the observers. Internal consistency reliability of the IPE Team's Perception of Collaborative Care Instrument was 0.95. The mean response score-1 (strongly disagree) to 4 (strongly agree)-was calculated for each section of the instrument. The overall mean score was 3.57 (SD = .11). Internal consistency reliability of the Standardized Patient IPE Team Evaluation Instrument was 0.87. The overall mean score was 3.28 (SD = .17). The ratings for the 5 items shared by the standardized patient and team perception instruments were compared using independent sample t tests. Statistically significant differences (p < .05) were present in each case, with the students rating themselves higher on average than the standardized patients did (mean differences between 0.2 and 0.6 on a scale of 1-4).

CONCLUSIONS

Multidimensional, competency-based instruments appear to provide a robust view of IPE teamwork; however, challenges remain. Due to the large scale of the simulation exercise, observation-based assessment did not function as well as self- and standardized patient-based assessment. To promote greater variation in observer assessments during future Disaster Day simulations, we plan to adjust the rating scale from "not observed," "observed," and "not applicable" to a 4-point scale and reexamine interrater reliability.

Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes

CONTEXT

The association of an adult tele-intensive care unit (ICU) intervention with hospital mortality, length of stay, best practice adherence, and preventable complications for an academic medical center has not been reported.

OBJECTIVE

To quantify the association of a tele-ICU intervention with hospital mortality, length of stay, and complications that are preventable by adherence to best practices.

DESIGN, SETTING, AND PATIENTS

Prospective stepped-wedge clinical practice study of 6290 adults admitted to any of 7 ICUs (3 medical, 3 surgical, and 1 mixed cardiovascular) on 2 campuses of an 834-bed academic medical center that was performed from April 26, 2005, through September 30, 2007. Electronically supported and monitored processes for best practice adherence, care plan creation, and clinician response times to alarms were evaluated.

MAIN OUTCOME MEASURES

Case-mix and severity-adjusted hospital mortality. Other outcomes included hospital and ICU length of stay, best practice adherence, and complication rates.

RESULTS

The hospital mortality rate was 13.6% (95% confidence interval [CI], 11.9%-15.4%) during the preintervention period compared with 11.8% (95% CI, 10.9%-12.8%) during the tele-ICU intervention period (adjusted odds ratio [OR], 0.40 [95% CI, 0.31-0.52]). The tele-ICU intervention period compared with the preintervention period was associated with higher rates of best clinical practice adherence for the prevention of deep vein thrombosis (99% vs 85%, respectively; OR, 15.4 [95% CI, 11.3-21.1]) and prevention of stress ulcers (96% vs 83%, respectively; OR, 4.57 [95% CI, 3.91-5.77], best practice adherence for cardiovascular protection (99% vs 80%, respectively; OR, 30.7 [95% CI, 19.3-49.2]), prevention of ventilator-associated pneumonia (52% vs 33%, respectively; OR, 2.20 [95% CI, 1.79-2.70]), lower rates of preventable complications (1.6% vs 13%, respectively, for ventilator-associated pneumonia [OR, 0.15; 95% CI, 0.09-0.23] and 0.6% vs 1.0%, respectively, for catheter-related bloodstream infection [OR, 0.50; 95% CI, 0.27-0.93]), and shorter hospital length of stay (9.8 vs 13.3 days, respectively; hazard ratio for discharge, 1.44 [95% CI, 1.33-1.56]). The results for medical, surgical, and cardiovascular ICUs were similar.

CONCLUSION

In a single academic medical center study, implementation of a tele-ICU intervention was associated with reduced adjusted odds of mortality and reduced hospital length of stay, as well as with changes in best practice adherence and lower rates of preventable complications.

Interfacial Reaction in Aluminum/Carbon Multilayer Thin Films

The reaction at the interface between Al and amorphous C in Al/C multilayer thin films with modulation wavelengths of about 25nm and 125nm has been investigated by differential scanning calorimetry, X-ray diffraction, transmission electron microscopy/selected area electron diffraction and high resolution transmission electron microscopy. The reaction was found to take place in two steps. The first step onsets at about 300°C, and was identified as the diffusion of C into Al. The second step starts above 400°C, at a temperature strongly dependent on the modulation wavelength of the film, and is the formation of A14C3. The carbide has been observed to nucleate and grow inside the Al layers. The multilayer structure is preserved in the samples up to at least 550°C, and Al grains start to grow at or below 300°C.

Altered gene expression in cells from patients with lysosomal storage disorders suggests impairment of the ubiquitin pathway

By comparing mRNA profiles in cultured fibroblasts from patients affected with lysosomal storage diseases, we identified differentially expressed genes common to these conditions. These studies, confirmed by biochemical experiments, demonstrated that lysosomal storage is associated with downregulation of ubiquitin C-terminal hydrolase, UCH-L1 in the cells of eight different lysosomal disorders, as well as in the brain of a mouse model of Sandhoff disease. Induction of lysosomal storage by the cysteine protease inhibitor E-64 also reduced UCH-L1 mRNA, protein level and activity. All cells exhibiting lysosomal storage contained ubiquitinated protein aggregates and showed reduced levels of free ubiquitin and decreased proteasome activity. The caspase-mediated apoptosis in E-64-treated fibroblasts was reversed by transfection with a UCH-L1 plasmid, and increased after downregulation of UCH-L1 by siRNA, suggesting that UCH-L1 deficiency and impairment of the ubiquitin-dependent protein degradation pathway can contribute to the increased cell death observed in many lysosomal storage disorders.

Intracellular distribution of lysosomal sialidase is controlled by the internalization signal in its cytoplasmic tail

Sialidase (neuraminidase), encoded by the neu-1 gene in the major histocompatibility complex locus catalyzes the intralysosomal degradation of sialylated glycoconjugates. Inherited deficiency of sialidase results in sialidosis or galactosialidosis, both severe metabolic disorders associated with lysosomal storage of oligosaccharides and glycopeptides. Sialidase also plays an important role in cellular signaling and is specifically required for the production of cytokine interleukin-4 by activated T lymphocytes. In these cells, neu-1-encoded sialidase activity is increased on the cell surface, suggesting that a specific mechanism regulates sorting of this enzyme to the plasma membrane. We investigated that mechanism by first showing that sialidase contains the internalization signal found in lysosomal membrane proteins targeted to endosomes via clathrin-coated pits. The signal consists of a C-terminal tetrapeptide (412)YGTL(415), with Tyr(412) and Leu(415) essential for endocytosis of the enzyme. We further demonstrated that redistribution of sialidase from lysosomes to the cell surface of activated lymphocytes is accompanied by increased reactivity of the enzyme with anti-phosphotyrosine antibodies. We speculate that phosphorylation of Tyr(412) results in inhibition of sialidase internalization in activated lymphocytes.

Mutations in sialidosis impair sialidase binding to the lysosomal multienzyme complex

Sialidosis is an autosomal recessive disease caused by the genetic deficiency of lysosomal sialidase, which catalyzes the catabolism of sialoglycoconjugates. The disease is associated with progressive impaired vision, macular cherry-red spots, and myoclonus (sialidosis type I) or with skeletal dysplasia, Hurler-like phenotype, dysostosis multiplex, mental retardation, and hepatosplenomegaly (sialidosis type II). We analyzed the effect of the missense mutations G68V, S182G, G227R, F260Y, L270F, A298V, G328S, and L363P, which are identified in the sialidosis type I and sialidosis type II patients, on the activity, stability, and intracellular distribution of sialidase. We found that three mutations, F260Y, L270F, and A298V, which are clustered in the same region on the surface of the sialidase molecule, dramatically reduced the enzyme activity and caused a rapid intralysosomal degradation of the expressed protein. We suggested that this region might be involved in sialidase binding with lysosomal cathepsin A and/or beta-galactosidase in the multienzyme lysosomal complex required for the expression of sialidase activity. Transgenic expression of mutants followed by density gradient centrifugation of cellular extracts confirmed this hypothesis and showed that sialidase deficiency in some sialidosis patients results from disruption of the lysosomal multienzyme complex.

Ficoll-Hypaque leukocyte preparations from burned patients contain activated nonlymphoid cell populations that take up thymidine

Previously, we reported that Ficoll-Hypaque-purified leukocytes from burned patients were activated in vivo, even when the mitogen response of these cells was depressed. In these patients, the SBT (endogenous blastogenesis), but not the mitogen response predicted sepsis. The current experiments were performed to clarify why the SBT is increased even when mitogen-stimulated blastogenesis is impaired. We found that neither selective lymphocyte subpopulation (OKT3, T4, T8), nor macrophage depletion returned the increased SBT to normal and that by phenotype and flow cytometric morphology, the Ficoll-Hypaque-purified leukocyte preparations of the burned patients contained fewer lymphocytes than controls (p less than 0.001). Discontinuous Percoll gradients and sheep-RBC rosetting were used to determine the relative contribution of T cells and non-T cells to the increased SBT. These studies indicated that both T cells and non-T cells were activated; however, the non-T cells were primarily responsible for the increased SBT. Thus the peripheral blood of burned patients contains a large fraction of metabolically active non-mononuclear cells that cosediment with mature lymphocytes and could result in artifactual alterations in the assessment of lymphocyte function by in vitro tests.