Telecritical Care Versus Usual Care in ICU Patients

Since its introduction in 1977, telecritical care (TCC) has been used to combat worldwide intensivist shortages and guide bedside clinical care in multiple types of ICU settings. Despite its long history, no definitive evidence exists that the use of TCC statistically improves clinical outcomes.

Previous reviews and meta-analyses have suggested that implementation of TCC coverage led to improvements in both ICU mortality and ICU length of stay (LOS).^1,2 However, these reviews were mainly retrospective, and study outcomes were often mixed, with a lack of experimental data showing clinical superiority. To fill this research gap, the authors of the Tele-Critical Care Versus Usual Care on ICU Performance (TELESCOPE) randomized control trial wanted to determine whether the initiation of intensivist-led tele-ICU multidisciplinary rounds, monthly ICU quality meetings, and the use of this remote team to create evidence-based clinical protocols would be superior to usual care.³

The TELESCOPE study is a parallel cluster randomized control trial conducted in 30 Brazilian general ICUs in which all patients older than 18 years (excluding justice-related admissions) were enrolled from June 1, 2019, to April 7, 2021. Fifteen ICUs were randomized to receive TCC interventions and 15 were randomized to usual care or no change from the baseline of non-specialist ICU coverage. A two-month data acquisition period was used to create a restrictive randomization algorithm to ensure that ICU differences (e.g., number of ICU beds, mean ICU LOS, simplified acute physiology scores, standardized mortality ratio) were minimized between the groups.

Three waves of ICU enrollment were performed to allow for ethical approval, completion of the baseline period, and logistics. The experimental group ICUs would have TCC-led multidisciplinary rounds in the ICU on non-holiday weekdays, hold monthly discussions of care performance indicators, and distribute 19 evidence-based clinical protocols to the multidisciplinary team. The control group would continue with usual care, consisting of no specialist interventions or quality improvement projects. The primary outcome was detection of a statistical change in ICU LOS at the patient level. Secondary outcomes included unit quality performance, patient mortality, incidence of hospital-acquired infections, and ventilator-free days at 28 days.

In the intervention group, TCC visits occurred on 68% of eligible days, with a median of 8 (5-13) minutes spent per patient, leading to a daily duration of multidisciplinary rounds of 53 (35-93) minutes. During these rounds, a mean of five clinical recommendations were given per patient, with 76% (66% - 83%) accepted. ICU LOS did not differ between the groups, with a mean (SD) of 8.1 (10) days in the TCC group and 7.1 (9) days in the usual care group (P = 0.24). Hospital mortality, hospital-acquired infections, ventilator-free days, and quality matrices were also similar between the groups.

The authors proposed several explanations for the study’s neutral results. First, the local teams were not obligated to accept the tele-intensivist guidance. The authors tried to mitigate this risk by promoting empathetic communication between teams, advocating for the same tele-intensivist to be involved on a day-to-day basis and holding monthly collaborative meetings.

Second, the ICUs chosen might have been too heterogeneous and diverse to see lasting change with just one ICU intervention. This study was performed during the COVID-19 pandemic, so perhaps the addition of a tele-intensivist was not sufficient to statistically improve ICU LOS amid severely ill patients, staff shortages, and resource limitations.

Third, the lack of consistent TCC rounds on a daily basis severely limits the ability to determine whether the intervention failed to show any outcome improvement.

Finally, it appears that the appropriate use of TCC resources is still indeterminate and future research will be needed to make this determination.

References
1.    Fusaro MV, Becker C, Scurlock C. Evaluating tele-ICU implementation based on observed and predicted ICU mortality: a systematic review and meta-analysis. Crit Care Med. 2019 Apr;47(4):501-507.
2.    Kalvelage C, Rademacher S, Dohmen S, Marx G, Benstoem C. Decision-making authority during tele-ICU care reduces mortality and length of stay: a systematic review and meta-analysis. Crit Care Med. 2021 Jul 1;49(7):1169-1181.
3.    Pereira AJ, Noritomi DT, Dos Santos MC, et al. Effect of tele-ICU on clinical outcomes of critically ill patients: the TELESCOPE randomized clinical trial. JAMA. 2024 Oct 9:e2420651. Online ahead of print.