[ Correspondence ]
Editor’s Note: Authors are invited to respond to Correspondence that
cites their previously published work. Those responses appear after the
related letter. In cases where there is no response, the author of the
original article declined to respond or did not reply to our invitation.
Leveraging ICU Telemedicine
to Reduce Low-Value
Interhospital Transfer
To the Editor:
In a large study with rigorous methods, Fortis and
colleagues1 reported in a recent issue of CHEST (July
2018) that ICU telemedicine was associated with a
decreased rate of interhospital transfers among patients
in Veterans Affairs ICUs. Although mortality was not
the study’s primary outcome, the authors also present
the interesting result that ICU telemedicine was
associated with increased adjusted 30-day mortality
among transferred patients. The authors reasonably
suggest that this finding indicates appropriate triage of
the most severely ill patients. We would like to point out
that appropriate, or high-value, interhospital transfers
are those in which the transfer has a high likelihood of
improving the patient’s outcome; these are not
necessarily the sickest patients. The opportunity for
decreasing low-value transfers includes both keeping
patients at local ICUs by leveraging the remote expertise
of tele-intensivists and also reducing futile transfers; that
is, transfer of patients with extremely high risk of death
for whom additional intervention at the destination
hospital will not likely alter the disease trajectory. This
latter type of low-value transfer imposes a cost not only
on the health-care system but also on the patient and
family, who suffer the added hardship of experiencing
end-of-life processes far from home. To further clarify
the increased mortality found in transferred patients
with ICU telemedicine in this study, we wonder if the
authors have access to additional data such as orders for
care limitation or transition to comfort-focused care at
the destination hospital that would allow estimation of
“futile transfers” and whether these events were
associated with ICU telemedicine. We also solicit the
authors’ reflections on how ICU telemedicine can be
leveraged to reduce low-value transfers on this end of
the spectrum.
988 Correspondence
Stephanie Parks Taylor, MD
Brice Taylor, MD
Charlotte, NC
AFFILIATIONS: From the Department of Internal Medicine (Dr S. P.
Taylor); and the Department of Internal Medicine, Pulmonary and
Critical Care (Dr B. Taylor), Carolinas Medical Center.
FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.
CORRESPONDENCE TO: Stephanie Parks Taylor, MD, Internal
Medicine, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC
28203; e-mail: stephanie.p.taylor@carolinashealthcare.org
Copyright Ó 2018 American College of Chest Physicians. Published
by Elsevier Inc. All rights reserved.
DOI: https://doi.org/10.1016/j.chest.2018.07.032
Reference
1. Fortis S, Sarrazin M, Beck B, Panos R, Reisinger H. ICU telemedicine
reduces interhospital transfer in the Veterans Health Administration.
Chest. 2018;154(1):69-76.
Response
To the Editor:
We thank Drs Taylor and Taylor for their comments
on our study1 and their suggestions regarding further
investigation of the effect of telemedicine on critical
care outcomes. As they pointed out, ICU telemedicine
was associated with increased mortality in the
transferred patients. The increased mortality in the
transferred patients following telemedicine
implementation may reflect that the “less sick”
patients were not transferred (the denominator is
smaller) while the sickest patients continued to be
transferred. We agree that appropriate interhospital
transfers are only those that can change the patients’
trajectory. Very sick patients who are unlikely to
survive even if they receive care in high-resource
facilities should not be transferred for the reasons that
Drs Taylor and Taylor described. Nevertheless, family
and, often, providers may request transfer of the
sickest patients to advanced tertiary centers out of
desperation. It is possible that ICUs with fewer
resources may not be prepared for end-of-life
discussions. Although we have no additional data
regarding these futile transfers, a previous report
showed that palliative care expertise can be provided
to critically ill patients remotely via telemedicine.2
ICU telemedicine should play a key role in end-of-life
[ 154#4 CHEST OCTOBER 2018 ]