Telemedicine with clinical decision support for critical care: a systematic review

Critical care telemedicine serves a recognised need within North America, given the number of underserviced rural hospitals, lack of intensivist cover at night, and shortage of availability of intensivists. Outside the USA, providers and commissioners are showing increasing interest in telemedicine as a means of using technology effectively to re-think the way care is delivered across health economies [42]. Critical care telemedicine has important safety and quality implications as it can enable critically ill patients to stay in remote settings rather than travel to specialist centres. A networked hub and spoke structure may offer potential to level out variance in outcomes and ensure 24/7 access to specialist expertise which has implications for future workforce planning. In addition to potentially providing an additional safety net to ward-based teams, critical care telemedicine could provide a mechanism for near real-time feedback to improve situational awareness and accountability for individual actions. However, the lack of robust studies can hinder effective commissioning and can make justification of costs difficult.

Our review highlights the need for further methodologically robust evaluations of critical care telemedicine. The studies that were included were not independent of each other, which highlights the importance of opening up the field to include independent evaluations of different vendors, teams, health systems, and health economies. The impact of implementation of system transformation may take some years to achieve as it necessitates cultural change [43]. Adequately powered cluster randomised trials or randomised stepped-wedge or well-designed interrupted time series studies with 12–24-month follow-up would offer a pragmatic trade-off between study design and feasibility. Researchers should consider potential modifying variables such as healthcare skill-mix ratios (both unit and off-site cover) and jurisdictional, organisational, and regulatory influences. A logic model, a diagrammatic representation of the theory of the intervention, can help document causal assumptions [44]. In order to enable understanding of telemedicine as a complex intervention, precise definitions of interventions and consideration of contextual factors and interaction effects need to be provided [39]. Detailed descriptions need to include not only the technical set-up but also how it interacts with care organisation, clinical decision-making, and professional practice to open up the black box of implementation. Future studies require accompanying process evaluations to generate theory and guide replicability and enable measurement of different end points across the causal chain and fidelity of uptake of the components of the intervention [45]. Future research also needs to incorporate an economic analysis [18]. Data needs to be collected about escalation of concerns and the timeliness or efficacy of clinical action that occurs (or does not) as a result of critical care telemedicine. Electronic surveillance systems can generate a number of false alarms with adverse consequences for patient safety [46]. Future research needs to increase understanding about the technology’s diagnostic accuracy and the utility of the decision aids. Outcome measures should be expanded to include patient- or staff-derived outcomes (e.g. quality of life, patient satisfaction, staff burnout, acceptability of telemedicine applications to providers and patients) [13]. Longer term follow-up of the impact of telemedicine on patients may help us understand its impact on patients who survive serious illness experience but experience ‘chronic critical illness’ that continues well beyond ICU discharge and often culminates in long-term morbidity and mortality [47].