Introduction of Tele-ICU in rural hospitals: Changing organisational culture to harness benefits.

OBJECTIVE: This study evaluates rural hospital staff perceptions of a telemedicine ICU (Tele-ICU) before and after implementation. METHODS: We conducted a longitudinal qualitative study utilising semistructured group or individual interviews with staff from three rural ICU facilities in the upper Midwest of the United States that received Tele-ICU support. Interviews occurred pre-implementation and at two time points post-implementation. Interviews were conducted with: ICU administrators (n=6), physicians (n=3), nurses (n=9), respiratory therapists (n=5) and other (n=1) from July 2011 to May 2013. Transcripts were analysed for thematic content. FINDINGS: Overall, rural ICU staff viewed Tele-ICU as a welcome benefit for their facility. Major themes included: (1) beneficial where recruitment and retention of staff can be challenging; (2) extra support for day shifts and evening, night and weekend shifts; (3) reduction in the number of transfers larger tertiary hospitals in the community; (4) improvement in standardisation of care; and (5) organisational culture of rural ICUs may lead to under-utilisation. CONCLUSIONS: ICU staff at rural facilities view Tele-ICU as a positive, useful tool to provide extra support and assistance. However, more research is needed regarding organisational culture to maximise the potential benefits of Tele-ICU in rural hospitals.

A multi-modal intervention for Activating Patients at Risk for Osteoporosis (APROPOS): Rationale, design, and uptake of online study intervention material.

OBJECTIVE: To develop an innovative and effective educational intervention to inform patients about the need for osteoporosis treatment and to determine factors associated with its online uptake. METHODS: Postmenopausal women with a prior fracture and not currently using osteoporosis therapy were eligible to be included in the Activating Patients at Risk for OsteoPOroSis (APROPOS). Four nominal groups with a total of 18 racially/ethnically diverse women identified osteoporosis treatment barriers. We used the Information, Motivation, Behavior Skills conceptual model to develop a direct-to-patient intervention to mitigate potentially modifiable barriers to osteoporosis therapy. The intervention included videos tailored by participants' race/ethnicity and their survey responses: ranked barriers to osteoporosis treatment, deduced barriers to treatment, readiness to behavior change, and osteoporosis treatment history. Videos consisted of "storytelling" narratives, based on osteoporosis patient experiences and portrayed by actresses of patient-identified race/ethnicity. We also delivered personalized brief phone calls followed by an interactive voice-response phone messages aimed to promote uptake of the videos. RESULTS: To address the factors associated with online intervention uptake, we focused on participants assigned to the intervention arm (n = 1342). These participants were 92.9% Caucasian, with a mean (SD) age 74.9 (8.0) years and the majority (77.7%) had some college education. Preference for natural treatments was the barrier ranked #1 by most (n = 130; 27%), while concern about osteonecrosis of the jaw was the most frequently reported barrier (at any level; n = 322; 67%). Overall, 28.1% (n = 377) of participants in the intervention group accessed the videos online. After adjusting for relevant covariates, the participants who provided an email address had 6.07 (95% CI 4.53-8.14) higher adjusted odds of accessing their online videos compared to those who did not. CONCLUSION: We developed and implemented a novel tailored multi-modal intervention to improve initiation of osteoporosis therapy. An email address provided on the survey was the most important factor independently associated with accessing the intervention online. The design and uptake of this intervention may have implications for future studies in osteoporosis or other chronic diseases.

Impact of telemedicine intensive care unit coverage on patient outcomes: a systematic review and meta-analysis.

BACKGROUND: Although remote intensive care unit (ICU) coverage is rapidly being adopted to enhance access to intensivists, its effect on patient outcomes is unclear. We conducted a meta-analysis to examine the impact of telemedicine ICU (tele-ICU) coverage on mortality and length of stay (LOS). METHODS: We conducted a systematic review of studies published from January 1, 1950, through September 30, 2010, using PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Global Health, Web of Science, the Cochrane Library, and conference abstracts. We included studies that reported data on the primary outcomes of ICU and in-hospital mortality or on the secondary outcomes of ICU and hospital LOS. RESULTS: We identified 13 eligible studies involving 35 ICUs. All the studies used a before-and-after design. The studies included 41 374 patients (15 667 pre-tele-ICU and 25 707 post-tele-ICU patients). Tele-ICU coverage was associated with a reduction in ICU mortality (pooled odds ratio, 0.80; 95% confidence interval [CI], 0.66-0.97; P = .02) but not in-hospital mortality for patients admitted to an ICU (pooled odds ratio, 0.82; 95% CI, 0.65-1.03; P = .08). Similarly, tele-ICU coverage was associated with a reduction in ICU LOS (mean difference, -1.26 days; 95% CI, -2.21 to -0.30; P = .01) but not hospital LOS (mean difference, -0.64; 95% CI, -1.52 to 0.25; P = .16). CONCLUSION: Tele-ICU coverage is associated with lower ICU mortality and LOS but not with lower in-hospital mortality or hospital LOS.

The frequency of missed test results and associated treatment delays in a highly computerized health system.

BACKGROUND: Diagnostic errors associated with the failure to follow up on abnormal diagnostic studies ("missed results") are a potential cause of treatment delay and a threat to patient safety. Few data exist concerning the frequency of missed results and associated treatment delays within the Veterans Health Administration (VA). OBJECTIVE: The primary objective of the current study was to assess the frequency of missed results and resulting treatment delays encountered by primary care providers in VA clinics. METHODS: An anonymous on-line survey of primary care providers was conducted as part of the health systems ongoing quality improvement programs. We collected information from providers concerning their clinical effort (e.g., number of clinic sessions, number of patient visits per session), number of patients with missed abnormal test results, and the number and types of treatment delays providers encountered during the two week period prior to administration of our survey. RESULTS: The survey was completed by 106 out of 198 providers (54 percent response rate). Respondents saw and average of 86 patients per 2 week period. Providers encountered 64 patients with missed results during the two week period leading up to the study and 52 patients with treatment delays. The most common missed results included imaging studies (29 percent), clinical laboratory (22 percent), anatomic pathology (9 percent), and other (40 percent). The most common diagnostic delays were cancer (34 percent), endocrine problems (26 percent), cardiac problems (16 percent), and others (24 percent). CONCLUSION: Missed results leading to clinically important treatment delays are an important and likely underappreciated source of diagnostic error.