Risk adjusted critical care patient outcomes: a comparative analysis of critical care staffing, tele-ICU adoption, and ICU performance in relation to bedside staffing and engagement with tele-ICU
Date
2014
Authors
Hawkins, Helen Allison, author
Strathe, Marlene, advisor
Chermack, Tom, committee member
Gloeckner, Gene, committee member
Maynard, Travis, committee member
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Abstract
Telemedicine in a hospital intensive care unit, or tele-ICU, allows board-certified, critical care intensivist physicians and nurse practitioners to monitor multiple ICU patients twenty four hours a day, seven days a week (24/7) via a remote command center equipped with a network of audio-visual equipment and computer systems that provide real time access to patient data (Goran, 2012). Hospitals implement tele-ICU to address the increasing scarcity of trained intensivist resources (Jarrah & Van der Kloot, 2010), to provide improved safety through redundancy, and to enhance outcomes through standardization (Goran, 2010; Rufo, 2011). Whether at the bedside or via tele-ICU, staffing an ICU with board certified intensivist physicians is a best practice recommendation that has been shown to improve patient outcomes such as mortality and length of stay (Young, Chan, Lu et al., 2011). The purpose of this study was to evaluate multiple ICUs from a single U.S. hospital system in 2012 to determine if there were significant differences in the levels of adoption of tele-ICU and if so, assess the impact of varying levels of adoption on patient outcomes, specifically risk adjusted length of stay and observed versus expected mortality. Tele-ICU adoption was defined as the decision of ICU staff to make full use of tele-ICU resources to proactively co-manage patient care and ensure best practice adherence. Other ICU organizational factors such as bedside intensivist staffing pattern, ICU leadership effectiveness, and ICU employee engagement were also evaluated. Study results indicated significant differences in the level of adoption across the eight ICUs in the study. ICUs with low tele-ICU adoption had less than one order per patient stay compared to nearly 10-12 orders per patient stay for the ICUs with the highest levels of adoption. Significant differences were also found in both ICU and hospital observed versus expected patient lengths of stay based on level of tele-ICU adoption. A calculation was proposed and used to assess the observed versus expected mortality at the patient level across the groups based on level of adoption. Although the results mirrored the trend found in the length of stay results, differences were not significant. The study also found that ICUs with the lowest level of tele-ICU adoption and the longest lengths of stay were the ICUs staffed with intensivists at the bedside 24/7. Findings from this study suggested that the level of adoption of tele-ICU should be taken into account in future studies that evaluate patient outcomes. Future research should also evaluate the root causes of lack of tele-ICU adoption, and attempt to validate the findings in this study that patient outcomes are better when tele-ICU is fully adopted. Future studies should also attempt to measure and validate the costs and benefits of tele-ICU in conjunction with ICU staffing patterns, best practice adherence, and other organizational performance constructs that impact both the bedside and tele-ICU staff such as teamwork, culture, climate, communications, and collaboration. Studies that evaluate the optimal mix of ICU intensivist staffing should take into account the existence of tele-ICU, along with the level of adoption by bedside staff, as a component of the overall ICU staffing model.
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Subject
adoption
performance
staffing
Tele-ICU
ICU
intensivist