ABSTRACT
Das Auftreten der unbekannten Krankheit Covid-19 und die steigenden Covid-19-Fallzahlen stellten das Gesundheitswesen vor Herausforderungen. Die Häuser der Allgemeinversorgung waren bis dato größtenteils nicht mit der Behandlung eines schweren Lungenversagens vertraut und so musste dieses Wissen aus den Expertenzentren in die Häuser der Allgemeinversorgung transferiert werden. Dazu wurden im Rahmen der Vorstufe des Virtuellen Krankenhauses Nordrhein-Westfalen (VKh.NRW) Telekonsile genutzt. Sie finden zwischen zwei Ärzten der Intensivmedizin statt, stellen ortsunabhängig Expertenwissen bereit und erhöhen so die Behandlungsqualität sowie -effizienz. In der Evaluation dieser Telekonsile zeigen sich unterschiedliche Nutzungsszenarien. Während zu Beginn größtenteils allgemeine Diagnose- und Therapiewege von Interesse waren, kamen später detailliertere Fragen auf, für die unter anderem ein Pharmakologe notwendig war. Dieser Anwendungsfall bedarf mehr explizites Wissen, Patienteninformationen und damit erhöhte Technologieanforderungen. Im Rahmen der technischen Infrastruktur zeigen sich allerdings Barrieren. Daher wird evaluiert, welches Wissen in den unterschiedlichen Anwendungsfällen der Telekonsile ausgetauscht wird und welche technologischen Voraussetzungen erfüllt sein müssen, damit Telekonsile stärker zur Verwendung kommen und das Gesundheitswesen gleichermaßen entlasten und verbessern.
ABSTRACT
The Corona pandemic is a clear demonstration of the need for an alternative to face-to-face medicine. This demand makes telemedicine the tool of choice. In the preliminary stage of the Virtual Hospital North Rhine-Westphalia (VKh), tele-intensive care consultation services have contributed to both a benefit in terms of care and a benefit for individual patients. The task now is to roll out and use digitally-supported intensive-care networks across the board, including throughout Europe. The goal of telemedicine is to ensure comprehensive patient care - also across sector boundaries of the healthcare system - and to improve quality. Tele-intensive care is already an evidence-based added value and addresses current and future challenges such as resource shortage and citizen-centered care. The Virtual Hospital NRW is a telemedical network structure that is unique in Germany. It provides telemedical services from expert centers in a quality-assured and comprehensive manner for general hospitals as well as for outpatient players. Telemedical services help to overcome rigid sector boundaries and to optimize treatment processes. As a result, service-differentiated care networks are goal-oriented. The medium-term perspective could be cross-border network structures. Medical expertise and also intensive care data, both from care and research, could thus be used throughout Europe. In October 2021, the Aachen Expert Center reported on its first 112 telemedically co-managed COVID-19 patients as part of the preliminary stage of the virtual hospital. With a lethality rate of 34.2% in the group of ventilated severely ill COVID-19 patients and a transfer rate of 8%, high-quality care close to the patient's home was achieved through tele-intensive medical consultation services.
Subject(s)
COVID-19 , Telemedicine , COVID-19/epidemiology , COVID-19/therapy , Critical Care , Forecasting , Germany/epidemiology , HumansABSTRACT
OBJECTIVES: Although the current coronavirus disease 2019 pandemic demonstrates the urgent need for the integration of tele-ICUs, there is still a lack of uniform regulations regarding the level of authority. We conducted a systematic review and meta-analysis to evaluate the impact of the level of authority in tele-ICU care on patient outcomes. DATA SOURCES: We searched MEDLINE, EMBASE, CENTRAL, and Web of Science from inception until August 30, 2020. STUDY SELECTION: We searched for randomized controlled trials and observational studies comparing standard care plus tele-ICU care with standard care alone in critically ill patients. DATA EXTRACTION: Two authors performed data extraction and risk of bias assessment. Mean differences and risk ratios were calculated using a random-effects model. DATA SYNTHESIS: A total of 20 studies with 477,637 patients (ntele-ICU care = 292,319, ncontrol = 185,318) were included. Although "decision-making authority" as the level of authority was associated with a significant reduction in ICU mortality (pooled risk ratio, 0.82; 95% CI, 0.71-0.94; p = 0.006), we found no advantage of tele-ICU care in studies with "expert tele-consultation" as the level of authority. With regard to length of stay, "decision-making authority" resulted in an advantage of tele-ICU care (ICU length of stay: pooled mean difference, -0.78; 95% CI, -1.46 to -0.10; p = 0.14; hospital length of stay: pooled mean difference, -1.54; 95% CI, -3.13 to 0.05; p = 0.06), whereas "expert tele-consultation" resulted in an advantage of standard care (ICU length of stay: pooled mean difference, 0.31; 95% CI, 0.10-0.53; p = 0.005; hospital length of stay: pooled mean difference, 0.58; 95% CI, -0.04 to 1.21; p = 0.07). CONCLUSIONS: In contrast to expert tele-consultations, decision-making authority during tele-ICU care reduces mortality and length of stay in the ICU. This work confirms the urgent need for evidence-based ICU telemedicine guidelines and reveals potential benefits of uniform regulations regarding the level of authority when providing tele-ICU care.
Subject(s)
Clinical Decision-Making , Critical Care/methods , Intensive Care Units , Telemedicine , Critical Illness/mortality , Hospital Mortality , Humans , Length of Stay , Outcome Assessment, Health CareABSTRACT
BACKGROUND: In an effort to contain the effects of the coronavirus disease (COVID-19) pandemic, health care systems worldwide implemented telemedical solutions to overcome staffing, technical, and infrastructural limitations. In Germany, a multitude of telemedical systems are already being used, while new approaches are rapidly being developed in response to the crisis. However, the extent of the current implementation within different health care settings, the user's acceptance and perception, as well as the hindering technical and regulatory obstacles remain unclear. OBJECTIVE: The aim of this paper is to assess the current status quo of the availability and routine use of telemedical solutions, user acceptance, and the subjectively perceived burdens on telemedical approaches. Furthermore, we seek to assess the perception of public information quality among professional groups and their preferred communication channels. METHODS: A national online survey was conducted on 14 consecutive days in March and April 2020, and distributed to doctors, nurses, and other medical professionals in the German language. RESULTS: A total of 2827 medical professionals participated in the study. Doctors accounted for 65.6% (n=1855) of the professionals, 29.5% (n=833) were nursing staff, and 4.9% (n=139) were identified as others such as therapeutic staff. A majority of participants rated the significance of telemedicine within the crisis as high (1065/2730, 39%) or neutral (n=720, 26.4%); however, there were significant differences between doctors and nurses (P=.01) as well as between the stationary sector compared to the ambulatory sector (P<.001). Telemedicine was already in routine use for 19.6% (532/2711) of German health care providers and in partial use for 40.2% (n=1090). Participants working in private practices (239/594, 40.2%) or private clinics (23/59, 39.0%) experienced less regulatory or technical obstacles compared to university hospitals (586/1190, 49.2%). A majority of doctors rated the public information quality on COVID-19 as good (942/1855, 50.8%) or very good (213/1855, 11.5%); nurses rated the quality of public information significantly lower (P<.001). Participant's age negatively correlated with the perception of telemedicine's significance (ρ=-0.23; P<.001). CONCLUSIONS: Telemedicine has a broad acceptance among German medical professionals. However, to establish telemedical structures within routine care, technical and regulatory burdens must be overcome.