Effect of Tele-ICU on Clinical Outcomes of Critically Ill Patients: The TELESCOPE Randomized Clinical Trial

Abstract

Importance: Despite its implementation in several countries, there has not been a randomized clinical trial to assess whether telemedicine in intensive care units (ICUs) could improve clinical outcomes of critically ill patients.

Objective: To determine whether an intervention comprising daily multidisciplinary rounds and monthly audit and feedback meetings performed by a remote board-certified intensivist reduces ICU length of stay (LOS) compared with usual care.

Design, setting, and participants: A parallel cluster randomized clinical trial with a baseline period in 30 general ICUs in Brazil in which daily multidisciplinary rounds performed by board-certified intensivists were not routinely available. All consecutive adult patients (aged ≥18 years) admitted to the participating ICUs, excluding those admitted due to justice-related issues, were enrolled between June 1, 2019, and April 7, 2021, with last follow-up on July 6, 2021.

Intervention: Remote daily multidisciplinary rounds led by a board-certified intensivist through telemedicine, monthly audit and feedback meetings for discussion of ICU performance indicators, and provision of evidence-based clinical protocols.

Main outcomes and measures: The primary outcome was ICU LOS at the patient level. Secondary outcomes included ICU efficiency, in-hospital mortality, incidence of central line-associated bloodstream infections, ventilator-associated events, catheter-associated urinary tract infections, ventilator-free days at 28 days, patient-days receiving oral or enteral feeding, patient-days under light sedation, and rate of patients with oxygen saturation values under that of normoxemia, assessed using generalized linear mixed models.

Results: Among 17 024 patients (1794 in the baseline period and 15 230 in the intervention period), the mean (SD) age was 61 (18) years, 44.7% were female, the median (IQR) Sequential Organ Failure Assessment score was 6 (2-9), and 45.5% were invasively mechanically ventilated at admission. The median (IQR) time under intervention was 20 (16-21) months. Mean (SD) ICU LOS, adjusted for baseline assessment, did not differ significantly between the tele-critical care and usual care groups (8.1 [10.0] and 7.1 [9.0] days; percentage change, 8.2% [95% CI, -5.4% to 23.8%]; P = .24). Results were similar in sensitivity analyses and prespecified subgroups. There were no statistically significant differences in any other secondary or exploratory outcomes.

Conclusions and relevance: Daily multidisciplinary rounds conducted by a board-certified intensivist through telemedicine did not reduce ICU LOS in critically ill adult patients.

Trial registration: ClinicalTrials.gov Identifier: NCT03920501.

Figure 1.. Study Flowchart

^aMore information on the study design is included in eFigure 1 in Supplement 3. The randomization used a restricted algorithm designed to minimize imbalances between groups. ICU indicates intensive care unit.

Figure 2.. Time to Intensive Care Unit (ICU) Discharge

The median (IQR) follow-up was 5.3 (2.5-11.2) days. The cause-specific hazard ratio to ICU discharge was 0.97 (95% CI, 0.82-1.14; P = .68). The model was adjusted by SAPS-3, type of ICU admission, invasive mechanical ventilation at ICU admission, number of ICU beds, region where the ICU was located, baseline category of ICU performance from the SMR and SRU matrix, batch of randomization, the mean ICU LOS in the baseline period, and accounted for clustering at the ICU level with a shared frailty model. A complete description of the competing risk framework is available in eTable 5 in Supplement 3. The analysis of the time to ICU discharge and ICU LOS accounted only for the index admission; ICU readmissions were not considered. LOS indicates length of stay; SAPS, Simplified Acute Physiology Score; SMR, standardized mortality ratio; SRU, standardized resource use.