Telemedicine Critical Care-Mediated Mortality Reductions in Lower-Performing Patient Diagnosis Groups: A Prospective, Before and After Study

Figures

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  Figure 1.. Telemedicine critical care (TCC) implementation study timeline.

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  Figure 2.. Telemedicine critical care nurse-driven workflow. The workflow incorporates codified use of the real-time automated acuity (AA) score to determine scheduled video reassessments in lower-preforming group patients. Starting from time of admission, designated lower-performing patients were reassessed every 2 hr for the initial 6 hr, followed by reassessments every 6 hr. Low acuity or improving patients were de-escalated after 24 hr to routine mandatory reassessments every 12 hr. Patients with high or worsening AA scores were returned to being reassessed every 2 hr. The AA score is derived from a proprietary algorithm embedded in the eCareManager application (Philips Healthcare). Data from six clinical domains (cardiovascular, respiratory, infectious disease, CNS, renal, and hematology) are used to determine the AA score, which has been validated by correlation with mortality (Philips Healthcare, personal communication). Each component value is calculated upon admission and updated as new data becomes available.

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  Figure 3.. Plots of observed vs expected (Acute Physiology and Chronic Health Evaluation [APACHE]-predicted) Hospital Mortality in APACHE Diagnosis Categories across the Study ICUs during the pre-telemedicine critical care (pre-TCC) implementation (A) and post-TCC implementation periods (B). Each circle represents an APACHE diagnosis category in the three study ICUs. The circle size is proportional to the number of patients in that diagnosis category. The diagonal line represents the line of unity where observed = expected (i.e., standardized mortality ratio = 1).

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  Figure 4.. The standardized mortality ratio (SMR) change (“Delta”) from the pre-telemedicine critical care (pre-TCC) to the post-TCC period is plotted against pre-TCC SMR in the same Acute Physiology and Chronic Health Evaluation diagnosis category. Each circle represents a category. The relative sizes of the circles are proportional to the sample size of that diagnosis group. The three “fitted” lines illustrate the strengths of relationships between the Delta SMR and pre-TCC SMR across all diagnosis categories (Pearson correlation coefficient, ρ = –0.92 [shown]; slope = –0.91) and for the lower-performing (pre-TCC SMR > 1.5) diagnosis category group (ρ = –0.90; slope = –1.15) and the higher-performing (pre-TCC SMR < 1.5) diagnosis category group (ρ = –0.75; slope = –0.85).