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October 5, 2011

Evaluating Tele-ICU Reengineering of Critical Care Processes

Author Affiliations

Letters Section Editor: Jody W. Zylke, MD, Senior Editor.

Author Affiliations: Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, the Netherlands (Drs Metske and Schultz) (; and Department of Intensive Care Medicine, Gelre Hospital, Apeldoorn, the Netherlands (Dr Spronk).

JAMA. 2011;306(13):1441-1442. doi:10.1001/jama.2011.1400

To the Editor: Dr Lilly and colleagues, in a prospective clinical practice study of more than 6000 adult intensive care unit (ICU) patients in an academic medical center, reported on the association of a tele-ICU intervention with improved hospital mortality, shorter length of stay in hospital, higher rates of best-practice adherence, and lower rates of preventable complications.1 The results raise some questions. It was reported that tele-intensivists initiated 77 times more interventions for physiological instability than did bedside clinicians (37 573 vs 483 interventions; Table 4 in the article). This suggests that bedside clinicians initiated hardly any interventions. Bedside interventions may be underreported in comparison with digitized decision making. Alternatively, interventions by tele-intensivists may have been initiated during off hours, when the number of attending clinicians was low, making the high ratio of tele-intensivist–initiated interventions to bedside clinician–initiated interventions more understandable. This explanation could also account for the improvement in outcome, since hospital mortality can increase outside office hours and over weekends, even when corrected for severity of illness at admission.2