An innovative telemedical network to improve infectious disease management in critically ill patients and outpatients: a stepped-wedge, cluster randomized controlled trial (TELnet@NRW)

Marx G, Greiner W, Juhra C, et al. An innovative telemedical network to improve infectious disease management in critically ill patients and outpatients: a stepped-wedge, cluster randomized controlled trial (TELnet@NRW). Journal of Medical Internet Research . 2022.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 (e.g., no shared electronic health record, no digital transfer of patient findings).; OBJECTIVE: 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 multicentre, stepped-wedge cluster randomised trial (Feb 2017 - Jan 2020) to establish a telemedicine inpatient-outpatient network among university hospitals, hospitals, and outpatient physicians in North Rhine Westphalia, Germany. Patients ≥ 18 years of age in the intensive care unit (ICU) 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 resp. once per week to enhance treatment quality. The primary outcome was adherence to the ten Choosing Wisely recommendations for infectious disease management. Guideline adherence was analysed using binary logistic regression models.; RESULTS: Overall, 159,424 patients (10,585 inpatients, 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 (OR 4.00 [95% CI 1.83, 9.20], P<.01) and in sepsis management in critically ill patients (OR 6.82 [95% CI 1.27, 56.61], P=.04). There was a statistically non-significant decrease in sepsis related mortality from 28.8% (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 taking part 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<.01) and asymptomatic bacteriuria (OR 9.31 [95% CI 3.79, 25.94], P<.01). For the other recommendations, we found no significant effects, or we had too few observations to generate models. 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.; CLINICALTRIAL: ClinicalTrials.gov, NCT03137589, https://clinicaltrials.gov/ct2/show/NCT03137589