The Impact of Remote ICU Monitoring on Patient Outcomes and Processes of Care

背景：越来越多的人认识到，重症监护室（ICU）的医生配备 接受过重症监护医学（重症监护医生）培训的医生可以改善患者的治疗效果。强化人员配置 重症监护室现已得到一些知名的公共和私营伙伴关系的认可和倡导。 然而，医院采用重症监护人员配置受到一系列因素的阻碍，包括 重症监护医师短缺。招募和留住重症监护医生可能特别具有挑战性， 较小的农村医院，包括退伍军人健康管理局（VA）内的许多较小的设施。中 为了克服重症监护医生短缺的问题，越来越多的医院安装了远程ICU 监控系统。这些系统典型地将联合收割机的高速视频会议与视频会议的特征相结合。 电子病历（EMR），用于连接远程（物理）ICU的临床护理团队和患者， 重症监护医生和护士在中央监测中心;使用这项技术，它是可能的单一 重症监护医生和两三名护士监测分布在多个地点的100多名患者， 物理ICU监测中心的工作人员可以检查生命体征和实验室测试，撰写命令， 通过视频会议与物理ICU的现场临床护理团队沟通， 个别病人的情况。尽管医院迅速采用了远程ICU监控，但严格的 关于这些系统影响的经验数据极为有限。 目的：本研究的目的是利用一个独特的自然实验， 在VISN 23内的8个ICU（7家医院）中实施远程ICU监控系统 在2010年日历年度。我们的主要目标将是检查远程ICU监测对 患者结局包括死亡率、呼吸机获得性肺炎和ICU住院时间。我们的次要 目标是制定一个分类法，用于描述中央委员会提出的建议的性质。 监护中心，并评估实施ICU监护系统的成本。 方法：本研究将采用混合方法。首先，我们将使用经过验证的VA管理和 临床数据，以评估远程监测对患者死亡率、住院时间和选定的 中间患者结局，包括呼吸机获得性肺炎（VAP）和导管相关性 血液感染（CR-BSI）。对于这些分析，干预组将由连续患者组成 在VISN-23中的八个ICU中，将实施远程ICU监测系统。的 对照组将由一组患者组成，这些患者在VISN-23之外的8个对照ICU住院， 接收远程监控并通过倾向分数匹配进行选择。第二，我们会发展一个 用于描述监测中心工作人员提出的建议的性质的分类法，然后使用 分类法，以表征治疗和诊断建议的类型和相对频率。 第三，我们会研究与推行遥距 重症监护室监控程序。 对VA的影响：该评价将使VA内的临床医生和管理员了解受益 以及实施远程ICU监控计划的成本。

Background: There is growing appreciation that the staffing of intensive care units (ICUs) by physicians trained in critical care medicine (intensivists) can result in improved patient outcomes. Intensivist staffing of ICUs has now been endorsed and advocated by a number of high-profile public and private partnerships. However adoption of intensivist staffing by hospitals has been hampered by an array of factors including a shortage of intensivist physicians. Recruiting and retaining intensivists may be particularly challenging for smaller rural hospitals including many smaller facilities within the Veterans Health Administration (VA). In an effort to overcome a lack of available intensivists a growing number of hospitals have installed remote ICU monitoring systems. These systems typically combine high-speed videoconferencing with features of an electronic medical record (EMR) to connect the clinical care team and patients at the remote (physical) ICUs to intensivist physicians and nurses at a central monitoring center; using this technology it is possible for a single intensivist and two or three nurses to monitor upwards of one hundred patients distributed across multiple physical ICUs. Staff at the monitoring center can check vital signs and laboratory tests, write orders, and communicate via videoconference with the on-site clinical care teams at the physical ICUs about changes in the condition of individual patients. Despite rapid adoption of remote ICU monitoring by hospitals, rigorous empirical data about the impact of these systems are extremely limited. Objectives: The objective of this study is to take advantage of a unique natural experiment that will occur with the implementation of a remote ICU monitoring system in the eight ICUs (seven hospitals) within VISN 23 during calendar year 2010. Our primary objective will be to examine the impact of remote ICU monitoring on patient outcomes including mortality, ventilator acquired pneumonia, and ICU length of stay. Our secondary objectives are to develop a taxonomy for describing the nature of the recommendations made by the central monitoring center and to evaluate the cost of implementing the ICU monitoring system. Methods: This study will use a mixed-methods approach. First, we will use validated VA administrative and clinical data to assess the impact of remote monitoring on patient mortality, length of stay, and selected intermediate patient outcomes including ventilator acquired pneumonia (VAP) and catheter-related bloodstream infections (CR-BSI). For these analyses the intervention group will consist of consecutive patients admitted to the eight ICUs within VISN-23 where the remote ICU monitoring system will be implemented. The control group will consist of a cohort of patients admitted to eight control ICUs outside of VISN-23 that will not receive remote monitoring and are selected by propensity score matching. Second, we will develop a taxonomy for describing the nature of the recommendations made by the monitoring center staff and then use the taxonomy to characterize the types and relative frequency of therapeutic and diagnostic recommendations. Third, we will examine the start-up and maintenance costs associated with the implementation of the remote ICU monitoring program. Impact on VA: This evaluation will allow clinicians and administrators within the VA to understand the benefits and costs of implementing a remote ICU monitoring program.