Critical care telemedicine: evolution and state of the art.

OBJECTIVES: To review the growth and current penetration of ICU telemedicine programs, association with outcomes, studies of their impact on medical education, associations with medicolegal risks, identify program revenue sources and costs, regulatory aspects, and the ICU telemedicine research agenda. DATA SOURCES: Review of the published medical literature, governmental documents, and opinions of experts from the Society of Critical Care Medicine ICU Telemedicine Committee. DATA SYNTHESIS: Formal ICU telemedicine programs now support 11% of nonfederal hospital critically ill adult patients. There is increasingly robust evidence of association with lower ICU (0.79; 95% CI, 0.65-0.96) and hospital mortality (0.83; 95% CI, 0.73-0.94) and shorter ICU (-0.62 d; 95% CI, -1.21 to -0.04 d) and hospital (-1.26 d; 95% CI, -2.49 to -0.03 d) length of stay. Physicians in training report experiences with telemedicine intensivists that are positive and increased patient safety. Early studies suggest that implementation of ICU telemedicine programs has been associated with lower numbers of malpractice claims and costs. The requirements for Medicare reimbursement and states with legislation addressing providing professional services by telemedicine are detailed. CONCLUSIONS: The inclusion of an ICU telemedicine program as a major part of their critical care delivery paradigm has been implemented for 11% of critically ill U.S. adults as a solution for the problem of access to adult critical care services. Implementation of an ICU telemedicine program is one practical way to increase access and reduce mortality as well as length of stay. ICU telemedicine research including comparative effectiveness studies is urgently needed.

Salivary and free serum cortisol evaluation.

BACKGROUND: Physiologic free serum cortisol may more accurately reflect adrenal function than total cortisol levels. Salivary cortisol estimates free serum cortisol. We researched the clinical viability of salivary cortisol in hospitalized patients. METHODS: Free serum cortisol, and salivary cortisol were measured via ELISA in hospitalized and outpatient patients. RESULTS: We obtained 37/71 satisfactory saliva samples from intensive care unit (ICU) patients. The correlation between free serum, and salivary cortisol over all collected samples was 0.914 (p < 0.001). We identified disparate interpretations for adrenal insufficiency (AI) utilizing total versus free serum cortisol. CONCLUSIONS: Salivary cortisol is an acceptable surrogate for free serum cortisol when satisfactory salivary volumes are procured. Due to inadequate sample volumes, and contamination, it should not be generally adopted in the ICU. We identified discordance between free and total cortisol in interpreting AI, suggesting reinterpretation of seminal trials investigating physiologic corticosteroid replacement on the basis of total cortisol levels. The analysis of both free serum cortisol via ultrafiltration and salivary cortisol involved two steps: sample centrifugation followed by ELISA, suggesting consideration of widespread adoption of free serum cortisol in future investigations.