對ICU病患進行遙控監測並未改善結果
作者：Fran Lowry
出處：WebMD醫學新聞
December 29, 2009 — 根據發表於12月23/30日版美國醫學會期刊(Journal of the American Medical Association)的觀察研究，對加護病房(ICUs)患者進行遙控監測並不會改善他們的死亡率或減少住ICU或住院天數。
德州大學健康科學中心的Eric J. Thomas醫師等人寫道，可以讓主治醫師在非現場處同時監測多名ICU病患的遠距醫學科技已經越來越普遍，但是支持使用的證據很少，再者，並不清楚主治醫師遙控監測是否對所有ICU病患有幫助，或者只對其中一些ICU病患有幫助。
研究目標是評估ICU遙控監測對於死亡率、併發症與住院天數的影響。
研究者在美國灣岸地區一個大型非營利健康照護體系的5所醫院的6個ICU，執行遙控監測前後，分別測量前述結果。
此研究包括介入前期(2003年1月至2005年8月)的2,034名病患，以及介入後期(2004年7月至2006年7月)的2,108名病患。
其中655名病患(31.1%)被當地醫師將治療完整的授權給遠距醫療ICU(tele-ICU)，其他1,393名病患只有在威脅生命事件時才介入。
【遠距醫療ICU設計】
遠距醫療ICU系統包括一個位於該健康照護體系行政中心的遙控辦公室，與各醫院不同地點。設備包括視聽監控儀器，週一到週五的中午到隔天早上7點、以及週六日24小時，有2位主治醫師。
每個主治醫師和2個護士與1個技術員一起工作，各監測半數的ICU病床。他們坐在提供即時生命徵象與趨勢圖表的電腦工作站，與病房有視聽連線，病患異常狀態會有相關的早期警訊訊號，也可以評估影像檢查和給藥紀錄。
研究發現，觀察到的介入前期住院死亡率為12.0% (95%信心區間[CI]為10.6%-13.5%)，介入後期為9.9% (95% CI，8.6% - 11.2%)，整體死亡率降低2.1% (95% CI，0.2% - 4.1%；P = .03)。
觀察到的介入前期ICU死亡率為9.2% (95% CI，8.0% - 10.5%)，介入後期為7.8% (95% CI，6.7% - 9.0%)，減少了1.4% (95% CI，-0.3%到3.2%；P = .12)。
校正疾病嚴重度之後，遠距醫療介入對於住院或ICU死亡率沒有顯著影響，不過，遠距醫療介入和疾病嚴重度之間有顯著的交互影響(P < .001)。作者們報告指出，遠距監控與改善較重症者的存活有關，但是較輕症者沒有改善也沒有惡化。
存活出院者中，觀察到的平均出院天數在介入前期為9.8天，介入後期為10.7天。存活轉床的ICU病患中，觀察到的平均出院天數在介入前期為4.3天，介入後期為4.6天。
【對於最嚴重病患的影響未知】
作者們指出，他們沒有出院後的資料，認為遠距醫療ICU介入會使最嚴重的病患較快轉到安寧照護或其他臨終照護地點。這或許是照護上的適當改善，但是，因為沒有出院後的存活資料，無法得知最嚴重病患住院死亡率的顯著降低是否可以代表長期死亡率有同樣的減少。
作者們認為，其他可能的研究限制包括，偵測與監測偏見，執行遙控監測的醫師和護士可能會增加對於併發症的監測和紀錄。
他們結論表示，基於遠距醫療ICU科技的花費、有關其效果的證據相互矛盾、有其他可以有效改善ICU介入品質的方法，此科技的後續使用需在病患結果與花費之間仔細衡量。
加州大學舊金山分校的Erika J. Yoo醫師和R. Adams Dudley醫師在編輯評論中寫道，評估遠距醫療在ICU中的效果是個挑戰。
他們寫道，基於醫院和使用的遠距醫療ICU系統之間的異質性，不可能有單一研究可以明確表達遠距醫療對於重症者的利益，反之，文獻統合分析將是改善瞭解遠距醫療ICU方式之效果的最重要方法。
編輯們結論表示，考慮綜合這些文獻以提出後續檢驗遙控監測的假設，同時提出檢驗其他ICU照護因素的假設，將有助於確認何時與如何使用遠距醫療ICU方式。
Thomas醫師、Yoo醫師與Dudley醫師皆宣告沒有相關財務關係。
Remote Monitoring of ICU Patients Does Not Improve Outcomes
By Fran Lowry
Medscape Medical News
December 29, 2009 — Remote monitoring of patients in intensive care units (ICUs) does not appear to improve their mortality or reduce length of stay in the ICU or hospital, according to an observational study published in the December 23/30 issue of the Journal of the American Medical Association.
"Telemedicine technology, which can enable intensivists to simultaneously monitor several [ICUs] from an off-site location, is increasingly common, but there is little evidence to support its use," write Eric J. Thomas, MD, MPH, from the University of Texas Health Science Center, Houston, and colleagues. "Furthermore, it is not known whether remote monitoring by intensivists would benefit all or only a subset of ICU patients."
The aim of this study was to assess the effect of remote monitoring in the ICU on mortality, complications, and length of stay.
The researchers measured these outcomes before and after remote monitoring was implemented in 6 ICUs of 5 hospitals in a large, nonprofit healthcare system located in the Gulf Coast region of the United States.
The study included 2034 patients in the preintervention period (January 2003 - August 2005) and 2108 patients in the postintervention period (July 2004 - July 2006).
Local physicians delegated full treatment authority to the telemedicine ICU (tele-ICU) for 655 patients (31.1%) and authority to intervene only in life-threatening events for the remaining 1393 patients.
Telemedicine ICU Design
The tele-ICU system consisted of a remote office located in the administrative offices of the healthcare system, separate from all the hospitals. It was equipped with audiovisual monitoring apparatus and was staffed by 2 intensivists from noon to 7 am Monday through Friday and 24 hours a day on Saturday and Sunday.
Each intensivist worked with 2 nurses and 1 technician to monitor half of the ICU beds. They sat at computer workstations that provided real-time vital signs with graphic trends, audiovisual connections to patients' rooms, early warning signals regarding abnormalities in a patient's status, and access to imaging studies and medication administration records.
The study found that the observed hospital mortality rates were 12.0% (95% confidence interval [CI], 10.6% - 13.5%) in the preintervention period and 9.9% (95% CI, 8.6% - 11.2%) in the postintervention period, for an overall decrease in mortality rates of 2.1% (95% CI, 0.2% - 4.1%; P = .03).
Observed ICU mortality rates in the preintervention period were 9.2% (95% CI, 8.0% - 10.5%) and 7.8% (95% CI, 6.7% - 9.0%) in the postintervention period, for a preintervention to postintervention decrease of 1.4% (95% CI, ?0.3% to 3.2%; P = .12).
After adjustment for severity of illness, there were no significant differences associated with the telemedicine intervention for hospital or ICU mortality. However, there was a significant interaction between the tele-ICU intervention and severity of illness (P < .001). Remote monitoring was associated with improved survival in sicker patients, but with no improvement or worse outcomes in less sick patients, the authors report.
The observed average hospital length of stay among patients who survived to discharge was 9.8 days preintervention and 10.7 days postintervention. The observed average length of stay in the ICU for patients who survived to transfer was 4.3 days for the preintervention period vs 4.6 days for the postintervention period.
Significance of Effect on Sickest Patients Unknown
The authors point out that they have no data on survival after hospital discharge and suggest that the tele-ICU intervention may have led to the sickest patients being transferred more quickly to hospice or other sites of care where they died. This may have been an appropriate improvement in care, but without postdischarge survival data it is not possible to know whether the significant reduction in hospital mortality that was seen in the sickest patients translates to the same reduction in long-term mortality.
Another potential limitation of the study could be detection and surveillance bias, which may have led to increased surveillance and documentation of complications by the physicians and nurses doing the remote monitoring, the authors suggest.
They conclude, "Given the expense of tele-ICU technology, the conflicting evidence about its effectiveness, and the existence of other effective quality improvement interventions for ICUs, further use of this technology should proceed in the context of careful monitoring of patient outcomes and costs."
In an accompanying editorial, Erika J. Yoo, MD, and R. Adams Dudley, MD, MBA, from the University of California–San Francisco, write that evaluating the effectiveness of telemedicine in the ICU is challenging.
"Given the heterogeneity of the tele-ICU systems and the hospitals adopting them, it is unlikely that any single study can definitely address the benefits of telemedicine for the critically ill," they write. "Rather, literature syntheses will be the most important approach to improving the understanding of the effects of tele-ICU support."
The editorialists conclude, "Synthesis of this literature with an eye to sequential hypothesis testing of remote monitoring and parallel hypothesis testing for other important elements of ICU care would help to determine when and how to use tele-ICU."
Dr. Thomas, Dr. Yoo, and Dr. Dudley have disclosed no relevant financial relationships.
JAMA. 2009;302:2671-2678, 2705-2706.
