Effect of Telemedicine Support for Intraoperative Anaesthesia Care on Postoperative Outcomes: The TECTONICS Randomised Clinical Trial

Background Novel applications of telemedicine can improve care quality and patient outcomes. Telemedicine for intraoperative decision support has not been rigorously studied. Methods This single centre randomised clinical trial (RCT, clinicaltrials.gov NCT03923699 ) of unselected adult surgical patients was conducted between 2019-07-01 and 2023-01-31. Patients received usual-care or decision support from a telemedicine service, the Anesthesiology Control Tower (ACT). The ACT provided real-time recommendations to intraoperative anaesthesia clinicians based on case reviews and physiologic alerts. ORs were randomised 1:1. Co-primary outcomes of 30-day all-cause mortality, respiratory failure, acute kidney injury (AKI), and delirium in the Intensive Care Unit (ICU) were analysed as intention-to-treat. Results The trial completed with 71927 surgeries (35302 ACT; 36625 usual care). The ACT performed 11812 case reviews and communicated alerts regarding 2044 intervention-group patients. There was no significant effect of the ACT vs. usual care on 30-day mortality [630/35302 (1.8%) vs 649/36625 (1.8%), RR 1.01 (95% CI 0.87 to 1.16), p=0.98], respiratory failure [1071/33996 (3.2%) vs 1130/35236 (3.2%), RR 0.98 (95% CI 0.88 to 1.09), p=0.98], AKI [2316/33251 (7.0%) vs 2432/34441 (7.1%), RR 0.99 (95% CI 0.92 to 1.06), p=0.98] or delirium [1264/3873 (32.6%) vs 1298/4044 (32.1%), RR 1.02 (95% CI 0.94 to 1.10), p=0.98]. There were no significant differences in secondary outcomes or sensitivity analyses. Conclusions In this large RCT of intraoperative telemedicine decision support using real-time alerts and case reviews, we found no significant differences in postoperative outcomes. Large-scale intraoperative telemedicine is feasible, and we suggest avenues where it may be more impactful.