Expanding Technology in the ICU: The Case for the Utilization of Telemedicine

Abstract

Introduction: Telemedicine has been utilized in various healthcare areas to achieve better patient outcomes, lower costs of providing services, and increase patient access to care. Tele-intensive care unit (ICU) technology has been introduced as a way to provide effective ICU services to patients with reduced access, as well as to decrease costs and improve patient care. Materials and Methods: The methodology for this qualitative study was a literature search and review of case studies. The search was limited to sources published in the last 10 years (2003–2013) in the English language. In total, 55 references were used for this research exploration inquiry. Results: Tele-ICU was found to be an effective way to use technology to decrease costs of providing intensive care, while improving patient outcomes such as mortality and length of stay. Several case studies supported the use of telemedicine in ICUs to provide intensive care to patients who lived in rural areas and lacked access to traditional ICUs. Furthermore, it was noted that, although the initial costs for tele-ICU startup were significant, as much as $100,000 per bed, the benefits of the utilization of this technology can offset those costs by reducing costs by 24% via decreased length of stay for patients. Conclusions: The findings of this study have suggested that the implementation of tele-ICU may have been more beneficial than costly, and it may have provided healthcare organizations the opportunity to increase quality of care and decrease mortality, while it might have decreased costs of delivering ICU services in both rural and urban areas.

Introduction

With advances in technology, physicians have been able to use state-of-the-art medical technology to treat patients more efficiently and effectively. Telemedicine has been an example of the positive impact of technology on healthcare, and it has been defined as the use of technology to provide medical services to patients across distances via telecommunications devices.¹ Telemedicine has been applied in several areas, including radiology, psychiatry, and diabetes management, as well as in intensive care units (ICUs).^1,2

Goran³ has defined tele-ICU as the provision of critical care by a team via a computer and audiovisual or telecommunication systems. Approximately 7.6–10% of hospitals in the United States currently use tele-ICU technology to provide intensive care.^4,5 Tele-ICU providers have not been utilized to replace traditional intensive care providers, but rather to work together to supplement effective intensive care.³

Each year, approximately 6 million individuals living in the United States are admitted to an ICU, which has accounted for 30% of total hospital costs in the country, as of 2010.⁶ ICUs in the United States have experienced a mortality rate of 10%, or 540,000 patients annually.⁷ Significant numbers of ICU patients have experienced a life-threatening medical error during their hospital stay. Medication errors account for 78% of serious medical errors in the ICU, and nearly all suffer a potentially life-threatening error at some point during their stay.⁸ This evidence has supported the substantial need for improvement in ICUs across the United States.⁹

As the U.S. population has continued to age, the need for intensive care providers has risen significantly. Unfortunately, providers such as intensivists have been decreasing in numbers, causing a shortage of care practitioners.¹⁰ According to a 2006 Health Resources and Services Administration study, the United States will need as many as 4,300 critical care physicians by 2020, and a 1,500 intensivist shortfall is predicted.^11,12

Physicians trained as intensivists who provide care via tele-ICU have been able to help fill this gap in order to deliver more effective healthcare.¹³ It has been suggested that tele-ICU implementation and utilization have the potential to be as effective as having dedicated intensivists in the ICU 24 h/day, relieving taxed staff, and providing quality care to the ever-increasing ICU patient population.¹⁰

The purpose of this study was to determine the potential impact and direction of the implementation of the tele-ICU in hospitals to assess current benefits and barriers of adoption of this technology.

Materials and Methods

The methodology for this qualitative study was a literature research and review of case studies. The approach for this research study followed the systematic search steps and a modified research framework used by Yao et al.¹⁴ The use of the framework in the current study is appropriate as the focus is on the subarea of telemedicine application to the ICU.

Figure 1 depicts the process of tele-ICU adoption in healthcare. To research how tele-ICU can help to improve healthcare practices in the ICU, it is first necessary to recognize the existing problems in the ICU and the issues that drive and impede adoption of tele-ICU by this industry. Then different applications can be identified to solve or partially unravel these challenges. As a final result of analyzing the literature, the benefits and barriers of tele-ICU utilization in healthcare can be identified (Fig. 1).

Fig. 1.

Research framework. ICU, intensive care unit.

The review was conducted in distinct stages, including (1) determining the search strategy and establishing inclusion and exclusion criteria, (2) extracting and analyzing the findings, and (3) literature categorization.

Step 1: Determining the Search Strategy and Establishing Inclusion and Exclusion Criteria

Telemedicine and its applications in healthcare can be applied to radiology, psychiatry, emergency medicine, and intensive care medicine, each potentially with its own set of benefits and barriers to implementation and rates of adoption, so it was decided early that the scope of the study should be narrowed just to the tele-ICU. When executing the search, the following terms were used: “tele-ICU” OR “eICU” AND “cost” OR “outcomes” OR “implementation” OR “barrier” OR “benefit.” A mix of databases and online sources was used to compile a set of references covering both academic peer-reviewed research and practitioner literature (gray literature). It was believed that this approach would help create the most comprehensive and up-to-date review. The following electronic databases and sources were used: PubMed, Medline, ESBCOhost, Academic Search Premier, and Google Scholar.

Step 2: Literature Analysis

The literature review yielded 55 sources that were assessed for information pertaining to this research project. Given the technology- and enterprise-oriented nature of the current study, literature was selected for review based on, but not limited to, the following key areas: technological issues, organizational issues, and organizational impacts. References were reviewed and determined to have satisfied the inclusion criteria if the material provided accurate information about tele-ICU with a particular focus on benefits and barriers to its implementation. Only articles that were written in English were included for review. In an attempting to stay current in research, all articles that were older than 12 years (starting from 2000) were eliminated from the search. The results presented were extracted from journal articles, case studies, and different online sources.

Step 3: Literature Categorization

In the third step, academic articles and practitioner health information technology sources were analyzed, and relevant categories were identified. The findings are presented in the subsequent sections using the categories of utilization of telemedicine technology in the ICU, tele-ICU providers, benefits of utilization of telemedicine in the ICU, and barriers to implementation of telemedicine in the ICU.

Results

Utilization of Telemedicine Technology in the ICU

The primary provider for tele-ICU services in the United States has been Phillips, in Baltimore, MD.¹⁵ This organization has provided necessary components for tele-ICU, such as bedside monitors that send information about the patient's status to both the ICU and the tele-ICU and visual or audio alert systems to notify the tele-ICU team of significant changes in the patient's conditions.¹⁶ Phillips has also provided computers and audiovisual communication devices (such as cameras and microphones) and an interface to allow the tele-ICU team access to lab reports, test results, X-rays, and a means of adding to the patient's medical record while ensuring data security.¹⁶

Telemedicine implementation and utilization in the ICU have served two purposes. First, it has allowed remote intensivists to assist in monitoring several ICU patients and to provide support to limited ICU staff, particularly in rural settings, via the use of data and decision support systems.¹⁷ Tele-ICU use also has been used to assist intensivists in treating patients as though the practitioners were present in the physical facility. This has allowed more than simple data transmission; it has enabled physicians to see and hear everything they may see and hear in the ICU itself.¹⁷ The tele-ICU has been implemented as a central station or hub, in a remote, or outside of the treating hospital, facility, where intensivist physicians and nurses can monitor it. The ICU staff has also communicated throughout the ICU via remote control to hear and see one another and the patients. The tele-ICU screen is used to show the providers patient information such as vital signs and laboratory results. The physicians and nurses have had notification of any problems with the patients' data such as vital signs and test results, as well as having a bedside or overhead view of the patient via a video camera.¹⁸

The technology used in the tele-ICU has evolved to include three different models. As identified by Reynolds et al.,¹⁹ these models are the centralized, decentralized, and hybrid models. The centralized model has been the most used, hub-and-spoke model wherein tele-ICU intensivists are situated in a central location in an urban hospital (the hub) that provides tele-ICU interventions to several outlying units or rural hospitals (the spokes). This model, while effective, has had implementation costs of $50,000–$100,000 per bed; thus the decentralized model was created as a way to prevent significant startup costs.²⁰ The decentralized model has allowed intensivists in several office locations to access the tele-ICU via desktop or laptop without relying on a central hub from which to practice. This has saved organizations from investing considerable capital to start a traditional tele-ICU.²¹ Finally, a third, hybrid model of the tele-ICU combines parts of both the centralized and decentralized models. In this model, a large hospital organization partners with an independent physicians organization to provide tele-ICU care to multiple hospitals. This is different from the centralized model in that the physicians are not located in one central area, but are in multiple facilities; thus it has decreased costs for the central hub, while allowing multiple facilities to utilize the tele-ICU care available.¹⁹

One hospital system in West Virginia, the Charleston Area Medical Center (CAMC), has used tele-ICU implementation to improve patient care in the organization's Women and Children's Hospital.²² The hospital has an intermediate care unit located in the gynecology/gynecological oncology unit and has utilized tele-ICU care in this unit. Two cameras have been installed in each of the two rooms in the intermediate care unit: one on the ceiling directly above the patient's bed and one near the foot of the bed. CAMC intensivists in other CAMC facilities use these cameras to monitor patients in these two beds, along with data from a cardiac monitor. Furthermore, an interactive monitor has been mounted in each room, which is used to allow verbal and visual interactions between the intensivist and any care providers or patients in the room (Linda Cobb, personal communication, 2012). The tele-ICU in this facility has been used to promote effective, efficient care for gynecological or oncological patients who have had a history of significant cardiac complications or who have exhibited arrhythmias during surgery. As these patients are monitored by an intensivist, if problems such as chest pain or changes in the electrocardiogram develop, the patients can be transferred to the CAMC's cardiac center, at CAMC Memorial Hospital (Linda Cobb, personal communication, 2012).

Tele-ICU Providers

Goran²³ identified two distinct groups of providers on the tele-ICU team: physicians and nurses. It has been recommended that physician-providers be trained intensivists, or at least have significant experience in an intensive care environment. These physicians must have been credentialed and have privileges in all hospitals where they provide tele-ICU interventions. Similarly, nurses on a tele-ICU team should have several years of experience in a traditional ICU setting.²⁴ Effective communication skills have been identified as the most important skill a tele-ICU team member must possess, as clear and effective communication is necessary to establishing rapport between ICU and tele-ICU, building a productive team, and providing appropriate and effective care to ICU patients.²⁵ The tele-ICU team has not replaced the traditional ICU team; rather, it has been used to support, supplement, and augment the traditional team.²⁶ This support has allowed for more positive patient outcomes such as decreased length of stay (LOS) and decreased mortality. Other healthcare providers that can join the tele-ICU team have been identified such as pharmacists, nurse practitioners, and administrative support staff in order to provide more comprehensive care.²⁴

Benefits of Utilization of Telemedicine in the ICU

Studies have examined the benefits of tele-ICU implementation. Lilly and Thomas²⁷ found evidence to support tele-ICU utilization.²⁸ The researchers identified adherence to best practices, early intervention, and increased education opportunities as well as additional provider resources for patient care and decreased medication errors as identifiable benefits to tele-ICU implementation (Table 1). Positive outcomes linked to tele-ICU utilization have included decreased mortality rate and LOS. Sapirstein et al.²⁹ found that tele-ICU technology increased staffing, which was related to decreased LOS. Furthermore, other studies, performed from 2004 to 2012, have found LOS decreased between 0.5 and 1 day (Table 1). Several test/retest or pre-/posttest studies after tele-ICU implementation, as well as qualitative research, have identified the most significant benefits of its implementation and utilization as decreased LOS of 1–2 days, decreased mortality rates of between 7% and 27%, improved patient outcomes, and cost control and savings of between $5,000 per bed to $8 million over 8 years (Table 1).

Table 1.

Benefits and Organizational Barriers of Tele-Intensive Care Unit Implementation and Utilization

	DETAILS (REFERENCE)
Benefits
Decreased LOS in ICU	• Decreased LOS from 4.35 days to 3.63 days after tele-ICU implementation⁴⁵
	• In a large healthcare facility, decreased LOS was significantly related to increased staffing with tele-ICU utilization.²⁹
	• Decreased LOS from 4.35 days to 3.80 days after tele-ICU implementation^46,52
	• Decreased in LOS from 2.7 to 2.2 days after tele-ICU implementation⁴⁷
	• LOS was decreased by 17% with tele-ICU utilization.¹⁸
	• LOS decreased from 1.18 additional days to 0.96 days after 1 year of tele-ICU utilization.⁴⁴
Decreased mortality in ICU	• Decreased mortality rate from 12.9% to 9.4% after tele-ICU implementation^45,52
	• Relative mortality risk decreased a total of 23% with utilization of tele-ICU.⁴⁶
	• Mortality rate decreased from 7.9% to 3.8% after tele-ICU implementation.⁴⁷
	• Mortality decreased by 27% with tele-ICU implementation and utilization.¹⁸
	• Mortality rate decreased in the ICU from 1.0 to 0.65 after 1 year of tele-ICU utilization.⁴⁴
Improved staff interaction	• Tele-ICU improved staff teamwork, and communication was found with tele-ICU utilization.^35,55
	• Staff communication, teamwork, and supervision were improved via tele-ICU.⁴⁸
Improved quality of care	• Tele-ICU implementation increased response times to critical events and decreased patient falls and extubation.³⁷
	• Decreased intervention times due to tele-ICU utilization improved patient outcomes.⁴⁹
	• Tele-ICU utilization led to a reduction in unnecessary transportation to hospitals with a large ICU, allowing patients to recover close to home and with family support nearby.²⁰
	• Improved patient safety and care were found with tele-ICU utilization.³⁵ Adherence to best practices and decrease of medication errors with tele-ICU utilization^27,51,53
Patient and provider satisfaction	• Tele-ICU technology has been shown to improve patient and provider satisfaction.^36,54
Barriers
Organizational challenges	• Tele-ICU implementation requires significant changes to the organizational culture that are challenges for implementation.²⁹
	• Resistance to change/failure to get buy-in from personnel^33,37,50
	• Physicians view tele-ICU and providers as a threat to autonomy in practice.^41,54
	• Providers report significant lack of understanding of the technology use in tele-ICU, as well as doubt about the efficacy of this technology to provide effective intensive care.⁴²

ICU, intensive care Unit; LOS, length of stay.

A 2005 test/retest study examined the implementation of tele-ICU for a 6-month period. The results showed a decrease in mortality rate of 3.5% during the time the tele-ICU was implemented.³⁰ Another study by the University of Massachusetts Memorial Hospital in 2010 indicated the use of tele-ICU decreased the mortality rate by 19.6% and the LOS by 29.7%.³¹ This study also showed that the cost per case was reduced by more than $5,000 per bed (Table 2).

Table 2.

Cost of Tele-Intensive Care Unit: Implementation and Utilization

REFERENCE (YEAR)	STUDY DESIGN	OUTCOME
Breslow et al.⁴⁵ (2004)	Multiple site pre-/posttest of tele-ICU utilization	24.6% reduction in costs per case, post-utilizations (savings of $2,556 per case)
Cummings et al.⁴³ (2007)	Literature review	Total cost, including initial and maintenance costs, were identified as a significant barrier to the implementation and utilization of tele-ICU technology.⁴³
Kohl et al.³⁴ (2007)	3-year pre-/posttest of tele-ICU implementation	10% reduction in costs, post-implementation
Groves et al.³³ (2008)	Pre-/posttest of tele-ICU implementation and utilization	$920,000 savings in one ICU, 1 year post-implementation
Zawada et al.³² (2009)	8-year pre-/posttest of tele-ICU utilization in a rural healthcare system	$8 million saved over 8 years, post-implementation
Berenson et al.⁴⁸ (2009)	Examination of the start-up costs in several rural tele-ICUs	Cost of tele-ICU hardware and software ranged from $30,000 to $50,000 per bed.
Franzini et al.⁴⁰ (2011)	Pre-/posttest of tele-ICU implementation in 6 ICUs in a large health care system	No significant savings were found, except when tele-ICU was used for the most acutely ill patients in a large ICU.
Lilly³¹ (2011), Lilly et al.⁵² (2011)	Pre-/post-examination of tele-ICU implementation at UMass Memorial Health Care	Tele-ICU implementation led to a savings of $5,000 per case.⁵⁵
Morrison et al.³⁹ (2010)	Pre-/post-examination of tele-ICU in two rural hospitals	No significant cost savings were identified with tele-ICU implementation and utilization.
Hulshoff et al.³⁸ (2011)	Literature review	Large ICUs, with 50–60 beds, requiring 8–12 satellite ICUs, have found tele-ICU utilization to be cost-effective.

ICU, intensive care unit.

In September 2004, an ICU in central Florida launched Florida's first tele-ICU program. The central tele-ICU monitored patients from four different hospitals miles away from the central location. It was found that after the implementation, the tele-ICU promoted prompt action, with fewer complications, and improved patient outcomes, generating a 27% decrease in mortality and a 17% decrease in LOS¹⁸ (Table 1).

A 2009 study examined the financial benefits of tele-ICU implementation in a rural health system that stretched across several Midwestern states.³² The tele-ICU system revealed a cost savings of $8 million to the rural system (Table 2). These savings demonstrated the ability to obtain a return on investment based on savings from LOS reductions, decrease in transportation costs, and more accurate billing.³²

Also in September 2004, a large hospital system in the northwest United States implemented a tele-ICU program. This program used telemonitoring in several types of ICUs, including medical, cardiovascular, surgical, and neurological ICUs, in different hospitals within this organization.³³ A test/retest study found several positive outcomes of tele-ICU implementation and utilization of this program in these ICUs. The mortality rate of all admitted ICU patients was reduced by 13%, and a savings of $920,000 was identified over the course of 1 year (Table 3).

Table 3.

Pre- and Post-Tele-Intensive Care Unit Implementation Outcomes

REFERENCE (YEAR)	STUDY DESIGN	OUTCOME
Breslow et al.⁴⁵ (2004)	Multiple site pre-/posttest of tele-ICU utilization	Mortality rate decreased from 12.9% to 9.4% post-tele-ICU implementation, and LOS was decreased from 4.35 days to 3.63 days post-implementation.
Leong et al.³⁰ (2005)	Single site pre-/posttest examination of tele-ICU implementation	Mortality rate decreased by 3.5%.
Howell et al.⁴⁴ (2007)	Pre-/post-examination of tele-ICU implementation in a rural ICU	Mortality rate decreased from 1.0% to 0.65% 1 year post-implementation, and LOS was decreased from 1.18 additional days to 0.96 days over non-ICU patients.
Chu-Weininger et al.³⁵ (2010)	Pre- and posttest of tele-ICU implementation using Teamwork Climate Scales and Safety Scores to examine the effect on staff	Teamwork Climate Scores increased by 12%.
Health First¹⁸ (2012)	Pre-/posttest of tele-ICU implementation and utilization in a large healthcare system in Florida	Mortality rate decreased 27% post-implementation, and LOS was decreased 17% post-tele-ICU implementation.
Willmitch et al.⁴⁶ (2012)	Pre-/posttest of tele-ICU implementation and utilization in a large healthcare setting	Relative mortality risk decreased a total of 23% 1 year post-implementation, and LOS decreased from 4.35 days to 3.80 days 1 year post-implementation.
Sadaka et al.⁴⁷ (2013)	Pre-/posttest of tele-ICU implementation and utilization in a rural hospital ICU	Mortality rate decreased from 7.9% to 3.8% 1 year after tele-ICU implementation, and LOS decreased from 2.7 days to 2.2 days post-implementation.

ICU, intensive care unit; LOS, length of stay.

The economic impact of tele-ICU in an academic surgical ICU allowing ongoing intensivist supervision has been measured, to study the overall cost benefits of the transition.³⁴ The researchers found that based on an average surgical tele-ICU cost per 24-h period of $1,500–$2,000 and a daily cost in a regular room of $500–$600, a nearly 10% reduction in ICU stay and 20% decrease in regular room stay resulted after implementation of the tele-ICU. The savings amounted to over $800,000 for the ICU and over $2,500,000 for the regular rooms (Tables 1 and 3).

Although cost containment and improved patient outcomes have been identified as the primary benefits of tele-ICU utilization, these are not the only benefits. Improved staff communication, teamwork, and improved supervision have also been recognized as advantages (Table 1). In a 2005 pre-/post-tele-ICU implementation study, Chu-Weininger et al.³⁵ measured the effects of tele-ICU utilization on teamwork and patient safety in the ICU via the Teamwork Climate Scales and the Safety Climate Score. The authors found tele-ICU utilization improved teamwork among staff members and improved patient safety in two out of the three ICUs studied, with teamwork scores increasing by 12% (Table 1).

Other benefits of tele-ICU utilization have been found, as well. Yeo et al.²⁰ found that tele-ICU prevented unnecessary transfers from rural hospitals, allowing patients to remain close to home and family support during the ICU stay (Table 1). Operation of tele-ICU technology has been shown to improve patient and provider satisfaction by increasing access to appropriate care, increasing the ability of providers to meet the needs of patients, and improving patient outcomes.³⁶

Additionally, a qualitative study in which Khunlertkit and Carayon³⁷ used semistructured interviews of ICU practitioners to explore the benefits of tele-ICU yielded the well-substantiated results of decreased mortality rate and decreased LOS. These researchers also found that in the views of the practitioners, tele-ICU utilization was connected with an increase in evidence-based medicine compliance and improved medication management, as well as increased patient safety via decreased patient falls and extubation (Table 1).

Barriers to Utilization of Telemedicine in the ICU

Although tele-ICU implementation and utilization have been shown to be beneficial in several areas, barriers to this technology have also been identified. Tele-ICUs are expensive to implement and maintain, costing up to $100,000 per bed for implementation alone. Also, lack of staff and practitioner acceptance and organizational challenges such as absence of corporate and practitioner education about tele-ICU and nonexistence of provider buy-in hinder the utilization of the technology (Table 3).

A cost analysis of pre- and post-tele-ICU implementation from 2003 to 2006 in six ICUs in Texas found that costs per day, per case, and per patient rose significantly, between 24% and 43%, after the technology was implemented. These authors did note that tele-ICU use was cost-effective with the most acutely ill patients in the ICU; thus costs for those patients did not significantly increase (Table 2).

Beyond not being cost-effective in some instances, tele-ICU has been found to have sizeable startup costs. A 2013 meta-analysis of the costs to implement tele-ICU found those costs ranged from $50,000 to $100,000 per tele-ICU bed. According to a 2009 study, the cost of tele-ICU implementation has been estimated as between $30,000 to $50,000 per bed (Table 3).

In contrast, one U.S.-based study suggested that 50–60 ICU beds have to be utilized in order to make the tele-ICU program effective, requiring the participation of 8–12 satellite ICUs in the network (Table 2). The authors suggested that tele-ICU on its own was not what led to a reduction in ICU, hospital mortality, and LOS, but it was the means for intensivists to treat not only more ICU patients, but also to offer more continuous care.³⁸ Other studies, from 2010 and 2011, also have identified no significant cost savings or decreased LOS between tele-ICU and traditional ICU care^39,40 (Table 2).

Resistance to change and to implementation of the technology has also been a major barrier to the utilization of the tele-ICU. According to Wood,⁴¹ tele-ICUs have become a perceived threat to some physicians because the care is shared. This sharing of care and responsibility requires physicians to relinquish some control. A few physicians may have difficulty doing so (Table 1).

Part of the resistance to the implementation of the tele-ICU may be due to lack of provider understanding of the technology. Shahpori et al.⁴² conducted an online survey study with intensivists in a Canadian healthcare organization to assess practitioner knowledge, education, and acceptance of tele-ICU technology. The authors found the practitioners rated their knowledge of and education about the technology as low and expressed little acceptance and significant doubt of the efficacy of tele-ICU technology (Table 1).

Discussion

The purpose of this study was to determine the potential impact of tele-ICU technology, as well as to determine the direction of the implementation of the electronic ICU in the hospitals to assess current benefits of and barriers to the adoption of this technology. In our study, tele-ICU implementation and utilization were identified as having several benefits, such as allowing ICU care to be delivered to far-reaching rural areas, and has been shown to decrease costs of providing intensive care, as well as improved quality of care by reducing errors and increasing patient safety. Furthermore, findings of this technology suggest that it has been able to improve patient outcomes such as mortality rate and decreased LOS.

The total cost of tele-ICU, as much as $100,000 per bed, has been identified as a potential barrier to implementation.⁴³ The potential for long-term benefits of the system, however, have been demonstrated to significantly outweigh the substantial financial costs.⁴¹ The biggest disadvantages found for implementing the tele-ICU were the financial burden of implementing this system and the costs of maintaining it. Nevertheless, it has become evident that the implementation of telemonitoring has had financial benefits and has produced positive patient outcomes. After the tele-ICU system has been in operation for more than a year, a significant decrease in total ICU costs, patient mortality rate (from 1.0 to 0.65), and LOS (from 1.18 additional days to 0.96 days) have been reported.⁴⁴

Study Limitations

This study was limited owing to the restrictions in the search strategy used, such as the number of databases searched. Researcher and publication bias may have limited the availability and quality of the research identified for review. Additionally, the search was limited to hospital organizations in the United States alone, thus excluding many international providers of tele-ICU care.

Implications

The implementation of tele-ICU has had long-term financial benefits and an increase of patient safety and patient satisfaction. Significant decreases in total ICU costs have occurred after the tele-ICU system has been operating for more than a year. Financial benefits have been identified, as well as benefits in patient safety and patient satisfaction; however, the mixed results of this literature review have indicated further research is necessary. Tele-ICU has the potential to be the wave of the future in intensive care medicine due to the costs savings and improvement of provided quality of care; however, in the United States, implementation costs for hospitals have been the main barrier of the use of telemedicine in the ICU.

Conclusions

The present study findings suggest that the implementation of tele-ICU has been to some extent more beneficial than costly. Hospitals may spend a significant amount of money implementing and maintaining the tele-ICU system, and long-term benefits may outweigh the costs through a decrease in LOS as well as a decrease in mortality rates. This technology could be identified as a technological and strategic advantage in critical care for the future.

Footnotes

Disclosure Statement

No competing financial interests exist.

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