Katrin Gilger

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: Sepsis is a major healthcare problem affecting millions of patients with high morbidity and mortality rates. Telemedicine, defined as the exchange of medical information via electronic communication, demonstrated to improve outcome of septic patients and to decrease mortality and length of stay on the intensive care unit (ICU). Objective: So far, it remains unknown if additional telemedicine rounds could be an effective component of performance improvement programs for sepsis, especially for underserved rural areas and hospitals without ready access to critical care physicians. We hypothesized that an additional telemedicine support may increase adherence to sepsis guidelines and improve the detection rates of sepsis and septic shock. Our objective was to evaluate the impact of additional daily telemedicine rounds on the adherence to the sepsis bundles. Methods: We conducted a retrospective, observational, multicenter study between January 2014 and July 2015 involving one Tele-ICU-Center and three ICUs in Germany. We implemented telemedicine as part of standard of care and collected the data for this study continuously during the course of the study. During daily-performed telemedicine rounds routinely screening for sepsis was conducted and the adherence to the Surviving Sepsis Campaign (SSC) 3-hour and 6-hour sepsis bundles were evaluated. Results: In total, 1,168 patients are included in this study. 196 patients were positive for severe sepsis and septic shock. We found that additional telemedicine rounds have a statistically significant effect on the adherence to the 3-hour (76.2% compared to 35%, p = 0.0095) and the 6-hour sepsis bundle (95.2% compared to 50%, p = 0.001). The results were driven by an increase of adherence to the item “Administration of fluids when hypotension” (100% compared to 80%, p = 0.049) of the 3-hour bundle, and by an increase of adherence to the item “Re-measurement of lactate” (100% compared to 65%, p = 0.003). In addition, we observed a decrease in mortality from 50% to 33.3% (quartile 1 (Q1) to Q6, p = 0.35) in patients with severe sepsis and septic shock, whereas patients demonstrated a comparable degree of severity as assessed by SAPS II and SOFA score. ICU length of stay (LOS) after diagnosis of severe sepsis and septic shock remained unchanged over the observed period. Due to a higher number of patients with sepsis in Q5 (N = 60), we observed higher effects on mortality (decrease from 50% to 23.3%, p = 0.046). Conclusions: Additional telemedicine rounds should be considered as an effective component of performance improvement programs for sepsis management.

BACKGROUND Sepsis is a major health care problem with high morbidity and mortality rates and affects millions of patients. Telemedicine, defined as the exchange of medical information via electronic communication, improves the outcome of patients with sepsis and decreases the mortality rate and length of stay in the intensive care unit (ICU). Additional telemedicine rounds could be an effective component of performance-improvement programs for sepsis, especially in underserved rural areas and hospitals without ready access to critical care physicians. OBJECTIVE Our aim was to evaluate the impact of additional daily telemedicine rounds on adherence to sepsis bundles. We hypothesized that additional telemedicine support may increase adherence to sepsis guidelines and improve the detection rates of sepsis and septic shock. METHODS We conducted a retrospective, observational, multicenter study between January 2014 and July 2015 with one tele-ICU center and three ICUs in Germany. We implemented telemedicine as part of standard care and collected data continuously during the study. During the daily telemedicine rounds, routine screening for sepsis was conducted and adherence to the Surviving Sepsis Campaign’s 3-hour and 6-hour sepsis bundles were evaluated. RESULTS In total, 1168 patients were included in this study, of which 196 were positive for severe sepsis and septic shock. We found that additional telemedicine rounds improved adherence to the 3-hour (Quarter 1, 35% vs Quarter 6, 76.2%; P=.01) and 6-hour (Quarter 1, 50% vs Quarter 6, 95.2%; P=.001) sepsis bundles. In addition, we noted an increase in adherence to the item “Administration of fluids when hypotension” (Quarter 1, 80% vs Quarter 6, 100%; P=.049) of the 3-hour bundle and the item “Remeasurement of lactate” (Quarter 1, 65% vs Quarter 6, 100%, P=.003) of the 6-hour bundle. The ICU length of stay after diagnosis of severe sepsis and septic shock remained unchanged over the observation period. Due to a higher number of patients with sepsis in Quarter 5 (N=60) than in other quarters, we observed stronger effects of the additional rounds on mortality in this quarter (Quarter 1, 50% vs Quarter 5, 23.33%, P=.046). CONCLUSIONS Additional telemedicine rounds are an effective component of and should be included in performance-improvement programs for sepsis management.