A multicentre stepped wedge cluster randomised
controlled trial

Telehealth in the Intensive Care Unit (ICU) has been growing to meet the increasing need for critical care expertise (1). Previous studies have reported that ICU telehealth may impact patients and health outcomes. However, little evidence exists on whether telehealth can improve adherence to process quality indicators in acute ICU care.

The Enhanced Recovery after Intensive Care (ERIC) Project investigated the effectiveness of a structured, telemedical quality improvement (QI) intervention at ICU on the adherence to German quality indicators (QIs) in a regional network of twelve ICUs in Germany (2). The authors conducted a multicentre, superiority stepped-wedge cluster randomised pragmatic controlled trial from September 2018 to March 2020.

The QI intervention consisted of (a) daily telemedical rounds guided by eight German acute ICU care QIs and (b) expert teleconsultations (24/7) for urgent medical consultations. The control group was standard of care according to local standards of the hospital site without telemedical support. In the study period, 1463 patients comprising 1554 ICU stays (433 control, 1120 intervention) were enrolled.

The intervention, as implemented, significantly increased QI performance for “sedation, analgesia and delirium” (adjusted odds ratio (99.375% confidence interval [CI]) 5.328, 3.395–8.358), “ventilation” (OR 2.248, 1.198–4.217), “weaning from ventilation” (OR 9.049, 2.707–30.247), “infection management” (OR 4.397, 1.482–13.037), “enteral nutrition” (OR 1.579, 1.032–2.416), “patient and family communication” (OR 6.787, 3.976–11.589), and “early mobilisation” (OR 3.161, 2.160–4.624). There was no evidence of a difference in adherence to “daily multi-professional and interdisciplinary clinical visits” between both conditions (OR 1.606, 0.780–3.309).

STUDY STRENGTHS & LIMITATIONS

• The main limitations were selection and recruitment bias; findings may only be fully applicable to some of Germany’s hospitals, and a possible overestimation of adherence to a standard of care.
• Nevertheless, the study reported several strengths. These included its innovative stepped-wedge design, which allowed the rigorous evaluation of implementing the study’s large-scale QI intervention. Despite its heterogeneity, the sample was representative of the German ICU population.
• The study also highlighted the usefulness of telehealth support in the ICU, given its wide acceptance from the critical care community during the COVID-19 pandemic.

TAKE-HOME MESSAGES

A telemedical QI programme improved the quality of care compared to standard care. These results need further confirmation in a broader setting of hospitals and research on investigating the effectiveness of similar QI interventions on long-term survival and post-ICU functional outcomes.

This article review was prepared and submitted by Katerina Iliopoulou and Alessandro Galazzi, on behalf of the ESICM N&AHPs Committee.