Invasive mechanical ventilation (IMV) for acute respiratory failure is one of the most common and high-risk interventions among adults admitted to the intensive care unit (ICU). In 2009, an estimated 723,310 non-surgical patients in the United States (U.S.) received IMV, with an in-hospital mortality of 32%. [1] Management of IMV involves continuous processes of care coordinated between physicians, nurses, and respiratory therapists. Many hospitals, especially smaller and rural, lack in-person access to physicians with board-certification in critical care, whose involvement in the care of the critically ill, including mechanically ventilated patients, has been shown to improve outcomes. [2,3] Best practices in IMV, such as the use of low tidal volume ventilation (LTVV) and protocolized interruption of sedation (SAT) paired with spontaneous breathing trials (SBT), improve survival among mechanically ventilated patients. [[4], [5], [6]] However, these practices are not optimally implemented in clinical practice. For example, Knighton et al. reported that the rate of adherence to LTVV was only 42% in a large, major health system. [7] Similarly, in a large multi-center observational study, Balas et al. reported a 35% adherence rate to SAT and 37% adherence rate to SBT. [8] Poor adherence to these practices occurs for a multitude of patient- and clinician-related factors, including lack of awareness of best practice recommendations by clinicians. [9,10] Many of these factors are potentially improved by telemedicine oversight.

Telemedicine critical care (TCC) integrates audiovisual technologies with electronic medical records access to facilitate the remote delivery of critical care. [11] TCC improves access to physicians with critical care training [12] and offers a novel mechanism by which systematic improvements in patient care can be made by way of assisting bedside caregivers in detecting clinical instability, executing care plans, and adhering to critical care best practices. Previous work by Lilly et al. showed that TCC implementation is associated with reduced odds of mortality in ICU patients, both in a single center study and in a separate large, multicenter study. [15,16] Improved outcomes were specifically associated with intensivist review within one hour of admission, review of performance data, improved adherence to critical care best practices, and faster response times to patient deterioration. [16] Spies et al. found that implementation of TCC oversight was associated with improved quality metrics, including those pertaining to invasive mechanical ventilation management and weaning from ventilation. [17] Forni et al. showed that implementation of pharmacist TCC rounds resulted in a significant increase in patients receiving spontaneous awakening trials. [13] Kalb et al. observed in a multi-center study that implementation of TCC ventilator rounds resulted in longitudinal improvements in use of low tidal volume ventilation as well as ventilator duration and mortality. [14] TCC has been shown to improve outcomes at the ICU-level, less is understood about the impact of TCC availability at the larger, population level.

TCC program models and utilization trends vary by program and institution, ranging from continuous care models with constant patient oversight, to episodic care models with periodic review of patient data, to responsive models where TCC interaction is triggered on demand by alarm or by request from onsite providers. [11] Implementation of TCC and subsequent maintenance of availability carries a substantial cost to hospitals and health-systems, ranging $50,000–100,000 per ICU bed in the first year. [18] Considering the cost and substantial inter-program variability, the impact that TCC availability has at the hospital and system-level needs to be evaluated. Thus, this study aimed to investigate whether hospital-level availability of TCC was associated with improved in-hospital mortality among mechanically ventilated patients admitted to an ICU, and specifically among a subgroup of patients with the acute respiratory distress syndrome (ARDS).