An Innovative Telemedical Network to Improve Infectious Disease Management in Critically Ill Patients and Outpatients (TELnet@NRW): Stepped-Wedge Cluster Randomized Controlled Trial

Gernot Marx, Wolfgang Greiner, Christian Juhra, Svenja Elkenkamp, Daniel Gensorowsky, Sebastian Lemmen, Jan Englbrecht, Sandra Dohmen, Antje Gottschalk, Miriam Haverkamp, Annette Hempen, Christian Flügel-Bleienheuft, Daniela Bause, Henna Schulze-Steinen, Susanne Rademacher, Jennifer Kistermann, Stefan Hoch, Hans-Juergen Beckmann, Christian Lanckohr, Volker Lowitsch, Arne Peine, Fabian Juzek-Kuepper, Carina Benstoem, Kathrin Sperling, Robert Deisz, Gernot Marx, Wolfgang Greiner, Christian Juhra, Svenja Elkenkamp, Daniel Gensorowsky, Sebastian Lemmen, Jan Englbrecht, Sandra Dohmen, Antje Gottschalk, Miriam Haverkamp, Annette Hempen, Christian Flügel-Bleienheuft, Daniela Bause, Henna Schulze-Steinen, Susanne Rademacher, Jennifer Kistermann, Stefan Hoch, Hans-Juergen Beckmann, Christian Lanckohr, Volker Lowitsch, Arne Peine, Fabian Juzek-Kuepper, Carina Benstoem, Kathrin Sperling, Robert Deisz

Abstract

Background: Evidence-based infectious disease and intensive care management is more relevant than ever. Medical expertise in the two disciplines is often geographically limited to university institutions. In addition, the interconnection between inpatient and outpatient care is often insufficient (eg, no shared electronic health record and no digital transfer of patient findings).

Objective: This study aims to establish and evaluate a telemedical inpatient-outpatient network based on expert teleconsultations to increase treatment quality in intensive care medicine and infectious diseases.

Methods: We performed a multicenter, stepped-wedge cluster randomized trial (February 2017 to January 2020) to establish a telemedicine inpatient-outpatient network among university hospitals, hospitals, and outpatient physicians in North Rhine-Westphalia, Germany. Patients aged ≥18 years in the intensive care unit or consulting with a physician in the outpatient setting were eligible. We provided expert knowledge from intensivists and infectious disease specialists through advanced training courses and expert teleconsultations with 24/7/365 availability on demand respectively once per week to enhance treatment quality. The primary outcome was adherence to the 10 Choosing Wisely recommendations for infectious disease management. Guideline adherence was analyzed using binary logistic regression models.

Results: Overall, 159,424 patients (10,585 inpatients and 148,839 outpatients) from 17 hospitals and 103 outpatient physicians were included. There was a significant increase in guideline adherence in the management of Staphylococcus aureus infections (odds ratio [OR] 4.00, 95% CI 1.83-9.20; P<.001) and in sepsis management in critically ill patients (OR 6.82, 95% CI 1.27-56.61; P=.04). There was a statistically nonsignificant decrease in sepsis-related mortality from 29% (19/66) in the control group to 23.8% (50/210) in the intervention group. Furthermore, the extension of treatment with prophylactic antibiotics after surgery was significantly less likely (OR 9.37, 95% CI 1.52-111.47; P=.04). Patients treated by outpatient physicians, who were regularly participating in expert teleconsultations, were also more likely to be treated according to guideline recommendations regarding antibiotic therapy for uncomplicated upper respiratory tract infections (OR 1.34, 95% CI 1.16-1.56; P<.001) and asymptomatic bacteriuria (OR 9.31, 95% CI 3.79-25.94; P<.001). For the other recommendations, we found no significant effects, or we had too few observations to generate models. The key limitations of our study include selection effects due to the applied on-site triage of patients as well as the limited possibilities to control for secular effects.

Conclusions: Telemedicine facilitates a direct round-the-clock interaction over broad distances between intensivists or infectious disease experts and physicians who care for patients in hospitals without ready access to these experts. Expert teleconsultations increase guideline adherence and treatment quality in infectious disease and intensive care management, creating added value for critically ill patients.

Trial registration: ClinicalTrials.gov NCT03137589; https://ichgcp.net/clinical-trials-registry/NCT03137589.

Keywords: eHealth; evidence-based medicine; infectious disease medicine; sepsis; telemedicine.

Conflict of interest statement

Conflicts of Interest: GM is the coordinator of the S1 Guideline Telemedicine in Intensive Care Medicine and chairman of the German Society for Telemedicine (DGTelemed). In the past, he has given lectures for Philips. GM is cofounder of Clinomic GmbH. WG, SE, and DG report grants from the Federal Joint Committee (Gemeinsamer Bundesausschuss), during the conduct of the study. AP is a cofounder of Clinomic GmbH. The authors declare no other competing interests.

©Gernot Marx, Wolfgang Greiner, Christian Juhra, Svenja Elkenkamp, Daniel Gensorowsky, Sebastian Lemmen, Jan Englbrecht, Sandra Dohmen, Antje Gottschalk, Miriam Haverkamp, Annette Hempen, Christian Flügel-Bleienheuft, Daniela Bause, Henna Schulze-Steinen, Susanne Rademacher, Jennifer Kistermann, Stefan Hoch, Hans-Juergen Beckmann, Christian Lanckohr, Volker Lowitsch, Arne Peine, Fabian Juzek-Kuepper, Carina Benstoem, Kathrin Sperling, Robert Deisz. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 02.03.2022.

Figures

Figure 1
Figure 1
Study flow diagram.
Figure 2
Figure 2
Sepsis bundle compliance over time.

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