Sepsis is a life-threatening condition that has doubled in incidence over the past decade, and timely aggressive medical intervention has been shown to save lives. Rural sepsis patients have a 38% higher mortality rate, possibly attributable to delays in early sepsis care. Rural emergency department (ED)-based provider-to-provider telemedicine has been proposed to standardize care and support local clinicians in rural hospitals. The goal of this multicenter observational comparative effectiveness study is to measure the association between tele-ED use and clinical outcomes in a cohort of rural sepsis patients.
Sepsis is a life-threatening condition that has doubled in incidence over the past decade, and timely aggressive medical intervention has been shown to save lives. Rural sepsis patients have a 38% higher mortality rate, possibly attributable to delays in early sepsis care. This effect persists even among patients who are transferred between hospitals and who bypass rural hospitals. With 17% of all hospital deaths attributable to sepsis and 19% of Americans living in rural areas, there is a critical need to identify strategies to reduce the disparities in outcomes between rural and urban sepsis care. Rural ED-based telemedicine has been proposed to standardize care and support local clinicians in rural hospitals. Telemedicine networks provide a real-time, high-definition on-demand video connection between a rural hospital and a tertiary hub 24 h daily. Based in Sioux Falls, South Dakota, Avera eCare is a tele-emergency network that serves as a hub for a 140-hospital network that spans 12 rural Midwestern states. It is the largest rural ED-based telehealth network in North America, and a network the investigators have studied previously. Our central hypothesis is that telemedicine will improve clinical outcomes through improved adherence with Surviving Sepsis Campaign (SSC) guidelines. Using comparative effectiveness methods and a patient-centered outcomes research (PCOR) approach, this study will test the hypotheses with the following specific aims: 1. To measure the association between rural ED-based telemedicine use, guideline adherence, and clinical outcomes using an observational cohort comparative effectiveness research study. Rural clinicians choose whether individual sepsis patients will be treated with telemedicine-supplemented care. Medical records will be analyzed from patients with severe sepsis who present to 25 rural hospital EDs that are part of a telemedicine network to estimate the effect of telemedicine on changing early SSC guideline adherence. Guideline adherence has been studied extensively as an outcome of sepsis implementation studies. The study will also analyze the impact of telemedicine on clinical outcomes, such as mechanical ventilation, hospital length-of-stay, and survival, using mediation analysis in a propensity-matched cohort design. Our working hypothesis is that telemedicine consultation will improve SSC guideline adherence and will reduce delays in care, leading to improved clinical outcomes. 2. To measure the effect of ED-based telemedicine on guideline adherence among patients who have telemedicine available but not used. In addition to the effect of use for individual patient care, telemedicine interactions may provide ongoing training for providers and nurses and influence care even for patients for whom telemedicine is not used. This effect may result from a learning effect in which local providers adopt practices they observe in telemedicine-consulted patients. The investigators will use hospital fixed-effects models to measure this association. The working hypothesis is that guideline adherence will increase after telemedicine adoption even in non-telemedicine patients, and adherence will be associated with the number of prior telemedicine sepsis encounters (dose-response). The rationale for this research is that dissemination and implementation of best practices through rural networks remains difficult, but telemedicine offers one potential solution. Sepsis is an ideal model to study the effect of telemedicine because it differs from other acute care conditions treated in rural hospitals (e.g., trauma, myocardial infarction) in that early treatment provided in rural hospitals may be more important than rapid transfer to tertiary centers. Focusing on telemedicine in rural sepsis care will serve as a powerful model for examining strategies for disseminating innovations across rural networks.
Use of provider-to-provider telemedicine
University of Iowa Hospitals and Clinics
Iowa City, Iowa, United States
28-day Hospital-Free Days
The total number of days in the 28 days after emergency department presentation that a patient is alive and outside the hospital.
Time frame: Within 28 days of emergency department presentation
Surviving Sepsis Campaign Guideline Adherence
Adherence with all elements of the Surviving Sepsis Campaign 3-hour and 6-hour bundles (dichotomous)
Time frame: 6 hours after emergency department arrival
Mortality
Did patient die in the hospital?
Time frame: Through hospital discharge, an average of 8 days
Mechanical Ventilation
Was mechanical ventilation required during admission?
Time frame: Through hospital discharge, an average of 8 days
Vasopressors
Was vasopressor therapy required during admission?
Time frame: Through hospital discharge, an average of 8 days
New Hemodialysis
Was dialysis required during this admission (if not on chronic dialysis)?
Time frame: Through hospital discharge, an average of 8 days
Inter-hospital Transfer
Was inter-hospital transfer required from the index hospital?
Time frame: Through hospital discharge, an average of 8 days
28-Day Ventilator-Free Days
The total number of days in the 28 days after emergency department presentation that a patient is alive and not requiring a ventilator.
This platform is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional.
Study Type
OBSERVATIONAL
Enrollment
1,191
Time frame: 28 days
28-Day Vasopressor-Free Days
The total number of days in the 28 days after emergency department presentation that a patient is alive and not requiring a vasopressor.
Time frame: 28 days
28-Day ICU-Free Days
The total number of days in the 28 days after emergency department presentation that a patient is alive and not requiring an ICU bed.
Time frame: 28 days
Emergency Department Length-of-Stay
The total duration of stay in the index emergency department.
Time frame: Index emergency department duration (1 day)
Time-to-inpatient unit arrival
The time from index emergency department registration to arrival in the inpatient unit
Time frame: 24 hours