Perceived benefit of a telemedicine consultative service in
a highly staffed intensive care unit☆
Mark C. Romig MDa,⁎, Asad Latif MDa, Randeep S. Gill MDb,
Peter J. Pronovost MD, PhD, FCCMc, Adam Sapirstein MDa
aDepartments of Anesthesiology & Critical Care Medicine, Johns Hopkins, University School of Medicine,
Armstrong Institute for Patient Safety and Quality
bDepartments of Anesthesiology & Critical Care Medicine, Johns Hopkins, University School of Medicine
cDepartments of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine,
Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Nursing,
Johns Hopkins University Bloomberg School of Public Health
Attitude of health
Health care surveys;
staff satisfaction, and perceptions of quality of care in a highly staffed university critical care system.
Methods: We conducted an experiment to determine the effect of telemedicine on nursing-staff
satisfaction and perceptionsof thequalityofcare inanintensivecare unit(ICU). We surveyedICU nurses
using a modified version of a previously validated tool before deployment and after a 2-month
experimental program of tele-ICU. Nurses in another, similar ICU within the same hospital academic
medical center served as concurrent controls for the survey responses.
Results: Survey responses were measured using a 5-point Likert scale, and results were analyzed using
paired t testing. Survey responses of the nurses in the intervention ICU (n = 27) improved significantly
after implementation of the tele-ICU program in the relations and communication subscale (2.99 ± 1.13
pre vs 3.27 ±1.27 post, P b .01), the psychological working conditions and burnout subscale (3.10 ± 1.10
pre vs 3.23 ± 1.11 post, P b .02), and the education subscale (3.52 ± 0.84 pre vs 3.76± 0.78 post, P b .03).
In contrast, responses in the control ICU (n = 11) declined in the patient care and perceived effectiveness
(3.94 ± 0.80 pre vs 3.48 ± 0.86 post, P b .01) and the education (3.95 ± 0.39 pre vs 3.50 ± 0.80 post,
P b .05) subscales.
Conclusion: Telemedicine has the potential to improve staff satisfaction and communication in highly
© 2012 Elsevier Inc. All rights reserved.
☆Financial Support was provided by The Johns Hopkins Hospital and the Johns Hopkins Department of Anesthesiology and Critical Care Medicine.
⁎Corresponding author. Tel.: +1 410 502 3232.
E-mail addresses: email@example.com (M.C. Romig), firstname.lastname@example.org (A. Latif), email@example.com (R.S. Gill), firstname.lastname@example.org (P.J. Pronovost),
email@example.com (A. Sapirstein).
0883-9441/$ – see front matter © 2012 Elsevier Inc. All rights reserved.
Journal of Critical Care (2012) 27, 426.e9–426.e16
Telemedicine used in the intensive care unit (tele-ICU)
has been proposed as a bridge between the clinical needs and
availability of intensivists . Highly staffed models of
intensivist provider coverage are associated with lower ICU
and hospital mortality as well as reduced ICU and hospital
length of stay, but staffing in the United States is limited by
the number of available physicians [2,3]. Currently, only
approximately 1 quarter of intensive care units (ICUs) are
considered to be highly staffed, meaning more than 80% of
the patients are managed by a full-time or consulting
intensivist [2,4,5]. Current projections indicate that staffing
issues will be compounded by the aging population, which
will use more ICU resources and exacerbate the gap between
intensivist supply and demand [4-6].
Both on-site 24-hour intensivist staffing and telemedicine
service have been proposed to provide highly staffed ICUs
and improve provider satisfaction [7-9]. However, telemed-
icine services have the capacity to provide oversight for a far
larger number of critically ill patients than does 24-hour on-
site coverage. This is because in large part of the tele-ICU
organizational structure that permits a single physician to
serve as a consultant for over 100 patients at a time .
Most of the tele-ICU services are provided and used by
nurses in the telemedicine center and at the bedside,
respectively  . Although improving patient care through
telemedicine can potentially improve the satisfaction of
bedside staff with the overall care environment, only 1 study
has addressed perceptions of tele-ICU .
Multiple studies have evaluated the efficacy of tele-ICU,
and the results have been mixed [8,12-17]. Telemedicine is a
complex cultural and technical intervention, and some of the
variation in study results could be caused by the context in
which telemedicine was implemented, used, and supported
within the hospitals  . Tele-ICU may be perceived as a
threat to existing unit culture and care processes. Such
perceptions can affect staff “buy-in” and, thus, adoption of a
tele-ICU program . Lack of adequate adoption and
utilization may be an important factor in studies that failed to
show efficacy .
Since the first study showing outcome benefit of a
telemedicine intervention in the ICU, there has been
increasing adoption of tele-ICU nationwide and several
important studies of its effects on morbidity, mortality, and
processes of care [1,8,13-17], but the staff in 1 tele-ICU
system had variable attitudes about teamwork and safety
climates as they related to tele-ICU . We had previously
conducted site visits and discussions with ICU physicians
and nurses at active tele-ICUs and believed that perceptions
toward telemedicine in the ICU were an important factor in
success . We hypothesized that an effective tele-ICU
could improve communication with and satisfaction of the
bedside nurse providers. Because bedside staff involvement
in the tele-ICU system is critical to its success, we
performed the first controlled prospective study of the
perceptions of bedside staff regarding a consultative tele-
ICU system .
2. Materials and methods
We studied the use of a tele-ICU system over an 11-week
period from January 19, 2010, to April 3, 2010. The study
protocol was reviewed and approved by the Johns Hopkins
Institutional Review Board. No patient identifiers were
collected in this study, and requirements for informed
consent were waived by the review board. The intervention
was implemented in the Weinberg Intensive Care Unit
(WICU) at the Johns Hopkins Hospital (JHH). The WICU is
a highly staffed, 16-bed general surgical ICU in a large
academic center with an “open” admission policy and
mandatory intensivist consultation . Attending coverage
is available 24 hours a day, in 7-day shifts, with board-
eligible or board-certified intensivists on-site during the day
and the same attending physician available by call at night.
At night, the intensivists were able to communicate with the
ICU by telephone and access the patient's medical record via
home computer using Johns Hopkins Medicine Center for
Information Services EPR v5.5.7 (Johns Hopkins Medical
Institutions, Baltimore, Md) and Sunrise Eclipsys Critical
Care v1.4M03 (Allscripts, Chicago, Ill), although they did
not have access to any real-time or telemetry data. Additional
coverage is provided 24 hours a day on-site with either a
critical care fellow or moonlighter who supervises residents
and critical care nurse practitioners. Moonlighters were
residents who had completed a minimum of 3 years of
surgical training and had spent at least 10 months training
within the ICU.
The surgical intensive care unit (SICU) at JHH was used
as the control ICU. The SICU is a 13-bed general surgical
ICU at JHH with a patient population similar to the WICU.
Physician staffing in the SICU is identical to the WICU, with
the exception that there are no advanced practice staff
employed in the SICU.
Demographic information for each ICU was collected for
both the study period and a historical period 1 year prior
(Table 1). Patient and procedural characteristics were
obtained from ICU admission logs. Aggregated mortality
and length of stay data were available through ICU
administrative records. Payer mix and case mix index data
were collected from hospital billing records. The safety
attitudes questionnaire is administered on a biannual basis
independent of this study.
We built a tele-ICU system that could be rapidly deployed
in the WICU by supplementing existing technology with
426.e10M.C. Romig et al.
2-way audiovisual communications and real-time physio-
logic monitoring data. The tele-ICU team consisted of 1
physician and 1 nurse who staffed the tele-ICU from 19:00 to
07:00 hours. The system was staffed every night during the
study period with the exception of two 3-day periods in
February when services were suspended because of snow
emergencies. The tele-ICU system was limited to a
consultative service in which the tele-ICU staff had no
order writing authority. Communication was bidirectional,
and consultations could be initiated by any staff member in
the ICU or the tele-ICU system. During the intervention, we
added new technologies to the tele-ICU system in 2-week
intervals, with full functionality being available by the end of
the first month.
During the first 2 weeks of the study, only baseline data
for a separate research study were obtained. Clinical
engineering and information technology resources were
used to access the patient electronic data record. Historical
patient information was available with the Johns Hopkins
Medicine Center for Information Services EPR v5.5.7,
Sunrise Eclipsys Critical Care v1.4M03, and Eclipsys
Sunrise Clinical Manager v5.8 SP3 (Allscripts, Chicago,
Ill). Electronic nursing flow sheets were available in Eclipsys
Sunrise Critical Care v1.4M03. Physician orders could be
accessed through Sunrise Eclipsys Clinical Manager v5.8
SP3. Radiographic images were available through Emageon
Enterprise Visual Medical System Advanced Visualization
v22.214.171.124 (Emageon, Birmingham, Ala). Telephony ser-
vices were used for all communication during this time.
During the second 2 weeks, we added audiovisual
communication with the use of the RP7 robot (InTouch
Health, Santa Barbara, Calif). The RP7 is a self-propelled
device that was controlled from a remote workstation by the
tele-ICU staff. Both the RP7 and the workstation had a
camera and video monitor, which allowed bidirectional
audiovisual communications. From this point forward, the
RP7 was the primary mode for communication with the ICU
staff, although telephone communications were available.
Real-time hemodynamic monitoring was also added
during the second 2 weeks using the Bernoulli real-time
clinical data system (Cardiopulmonary Corp, Greenwich,
Conn). The Bernoulli interface allowed access to the
numerical hemodynamic parameters such as pulse,
invasive and noninvasive blood pressure, respiratory rate,
and temperature. This system provided the tele-ICU with
independent, customizable alarms and an interface that
allowed simultaneous monitoring of all patients within the
ICU. After the final rollout period, live and trended
waveform data were also available using the Bernoulli
interface. During the study period, no new technologies
or changes in care patterns were implemented in the
Comparison of ICU characteristics during study period and 1 year prior
Study ICU Control ICU
Study period Historic periodStudy period Historic period
Age (y), mean (SD)
Total patient days
Total mortality (mortality rate)
Mean daily census (patients)
Mean length of stay (d)
SAQ job satisfaction score
12.85 ± 3.03
12.86 ± 3.32
8.70 ± 1.87
8.71 ± 1.33
SAQ indicates safety attitudes questionnaire.
426.e11Telemedicine consultative service in a highly staffed ICU
2.3. Data collection and analysis
In consultation with research methods experts, we
modified a previously published, validated survey that was
used to assess provider perceptions when a 24-hour staffing
model was implemented [7,21]. The survey instrument was
obtained from and used with permission of the primary
author of the previous study. Questions were organized into
5 domains, which included perceived effectiveness, com-
munication and relations within the unit, psychological
working conditions and burnout, and job satisfaction and
intention to quit. Modifications to the questions addressed
local cultural terminology (eg, intensivist vs consultant), and
no changes were made to the content of the questions. Our
final survey instrument contained 26 questions that were
measured using a 5-point Likert scale. The written surveys
were administered simultaneously to nurses who worked in
either the WICU or the SICU before and after the tele-ICU
intervention (Fig. 1). Survey responses were confidential,
and respondents were assigned a numeric identifier to allow
pre-post survey matching. No respondent identifiers were
retained after distribution of the second survey.
Responses were collected in an Access 2007 database
(Microsoft, Redmond, Wash), and Prism v5.03 (Graphpad
Software, La Jolla, Calif) software was used for statistical
analysis. The means of preintervention and postintervention
responses were compared within each ICU. In addition, the
means of the individual differences between the preinterven-
tion and postintervention responses were calculated for each
question, and results were compared between the study and
control ICU. Responses to individual questions and question
subgroups and the calculated change in response over time
were compared using paired Student t test or Wilcoxon
signed rank test, where appropriate, and used 95%
confidence intervals. P values of less than .05 were
considered to be statistically significant.
A total of 710 patients were admitted to the ICUs during
the study period. Although there are some demographic
differences noted between the 2 ICUs, the composition of
each ICU did not change when compared with a historical
control period. Specifically, differences were noted in total
admissions, age, sex, total patient days, length of stay, and
case mix index, which likely reflect differences in admitting
surgical diagnosis. Differences in mean censuses were noted,
which represents the difference in ICU capacities. The payer
mix changed in both ICUs when compared with historical
data, but the payer mix is similar in both ICUs during each
period. The Johns Hopkins Hospital performs a safety
attitudes questionnaire (SAQ) on a biannual basis, and we
note that the scores differed between the 2 ICUs for the
survey that was performed during the year of this study .
The tele-ICU intervention took place in the WICU, which
has a dedicated nursing staff of 70, whereas the control ICU
(SICU) has a staff of 65 nurses. Details of each ICU are
presented in the “Methods” section. Before implementation
of the tele-ICU program, 32 WICU nurses and 23 SICU
nurses completed surveys. Upon completion of the tele-ICU
program, we obtained paired surveys from 27 WICU nurses
(completion rate, 39% off all and 84% of those who
completed the presurvey) and 11 SICU nurses (completion
rate, 18% of all and 48% of those who completed the
presurvey). After the study, demographic information was
collected for both ICUs during the study period and
compared with the same dates 1 year prior (Table 1). In
both ICUs, there were no differences observed in the total
admissions, total patient days, average daily census, and
average length of stay when the study period was compared
with the historical period. There was a noted increase in the
absolute WICU mortality during the study period. The
WICU had a shorter length of stay, a larger average daily
census, more admissions, and more total patient days when
compared with the control ICU (Table 1). This may indicate
some difference in the operations of the 2 ICUs.
Of the 26 questions in the nursing survey, the composite
responses from the WICU trended favorably for the tele-ICU
care model in 17 questions, unchanged in 4 questions, and
unfavorably in only 5 questions (Fig. 2). Negative responses
were only observed within the patient care and perceived
effectiveness questions and psychological conditions and
burnout questions; however, none of the negatively trended
responses reached statistical significance. Within these same
question sets, there was a preponderance of positively
Nursing enrollment and study administration timeline.
426.e12 M.C. Romig et al.
trended responses, some of which reached statistical
significance (P b .05). Responses within the relations and
communications subgroup were overwhelmingly positive
with statistical significance reached in 2 of the 3 questions
(P b .05). When questions within the subgroups were
aggregated and analyzed, all subgroups were either
unchanged or showed improvement, with the improvement
in the relations and communications subgroup (P = .01)
and education subgroup (P = .02) showing statistical
significance (Data not shown).
In the control ICU, only 6 questions had favorable trends,
whereas 20 were unfavorable during the study period. Of
interest, the only question that reached a negative statistical
significance (P = .01) was “The intensivists are readily
available and participate in the care of patients.” Questions
relating to patient care and perceived effectiveness, job
satisfaction and intention to quit, and education all trended
negatively. When the questions were aggregated and
analyzed as subgroups, all showed a decline over the study
period with statistical significance achieved in the patient
care and perceived effectiveness (P = .01) and education
subgroups (P = .04) (Data not shown).
As expected, the baseline (preintervention) responses
varied between the 2 ICUs. We reasoned that a comparison
of the change in survey scores between the control and
intervention ICUs would likely represent the effects of the
tele-ICU system. We calculated the differences between
values for each response before and after implementation of
the tele-ICU and compared this value for the intervention
ICU (WICU) to the control ICU (SICU). Study ICU
responses trended better than those in the control ICU in all
but 5 questions and demonstrated statistically significant
improvement for 5 of the 26 questions (Fig. 3). When
questions within the subgroups were aggregated and
analyzed, all subgroups favored the study ICU, and
statistical significance was reached in the job satisfaction
subgroup (P b .05) and the relations and communications
subgroup (P = .04) (data not shown).
Although several studies have looked at the association of
tele-ICU to various patient outcome measures, few studies
have actively addressed staff perceptions. Staff perceptions
of tele-ICU may be an underappreciated variable of program
success, as perceptions and culture are tightly tied to
successful adoption [15,19]. To date, ours is the only study
Summary of nurse responses within the study ICU.
426.e13Telemedicine consultative service in a highly staffed ICU
that measures bedside staff perceptions with simultaneous
comparison with a control ICU. These results demonstrate
that nursing staff perceived benefit from a tele-ICU in a
highly staffed ICU.
A previous study by Gajic et al  gauged the perceptions
of staff working within an ICU with 24-hour on-site
intensivist availability. Given the similarities of their on-
site model and our telemedicine model, we used a modified
version of their original survey tool in our study.
Modifications were necessary to account for variations in
local hospital culture (eg, consultant vs intensivist); however,
the meaning of the questions was unchanged. Decisions
regarding ICU staffing may require a choice between on-site
physician coverage and telemedicine coverage. By using this
survey, we are able to compare the nursing responses
between these models.
In previous studies of ICU telemedicine, the tele-ICU was
deployed as part of a greater information technology and
ICU management change program. For example, McCam-
bridge et al  characterized the tele-ICU as one component
of a coordinated health care information technology bundle.
The governance structure of ICU care within the University
of Massachusetts–Memorial health care system was restruc-
tured and centralized before a tele-ICU implementation .
In our work, we limited changes within the ICU to 2-way
audiovisual communication and tele-ICU staffing. During
the study period, there were no other quality or cultural
improvement interventions implemented in either the study
or control ICU. Thus, we conclude that benefit suggested by
our results is caused directly by the enhanced tele-ICU
services and not implementation of other technologies (eg,
electronic health record, data management, etc).
Telemedicine is a complex sociotechnical intervention,
and the context regarding how it is implemented and
supported and the type of organizations in which it is used
may influence its impact Young et al . We chose to use a
consultative care model so that it could be uniformly
applied to all patients in the test ICU. Previous studies in
tele-ICU have suffered from an inability to standardize
practice to all patients in the covered ICUs [12,15]. In
contrast, in centers where tele-ICU interventions were
mandatory and uniform, a mortality benefit was demon-
strated [8,17]. We found that, by limiting the tele-ICU team
to consultative care, bedside providers were more accepting
and that the primary surgical teams allowed all of their
patients to participate.
Although each of the ICUs is a general surgical ICU, there
were some demographic differences noted, which is likely a
function of preferentially triaging certain admitting diagno-
ses to one or the other ICU. Patient age and sex were
different between the 2 ICUs, and this is likely a result of the
number of trauma patients in the control ICU, a population
Comparison of the change in Likert score from the preintervention period to the postintervention period: intervention vs control ICU.
426.e14 M.C. Romig et al.
that tended to be younger and male. Complex vascular and
transplant cases were also primarily triaged to the control
ICU, which may be reflected in the increased case mix index
and length of stay. The baseline ICU mortality in the WICU
is extremely low (1.5% of admissions during the historical
period), and the increase during the study period (3.5 %)
likely represents random variation in this low level. Analysis
of mortality using χ2testing showed that this change was not
statistically significant. Based on this low mortality, the short
study period, and the effect size of tele-ICU in other studies,
we predicted that the current study was not powered to
investigate changes in mortality or other patient outcomes.
The SAQ was used by the hospital to measure job
satisfaction in both ICUs during the year of, but was
independent of, our study. Job satisfaction was notably
higher in the study ICU, which is consistent with our survey
findings, and may be a function of the cultural impact of
telemedicine. However, the SAQ did not explicitly study the
impact of our telemedicine intervention, so conclusions
about this measurement are limited.
Our study showed a perceived benefit of telemedicine by
nursing staff even within a highly staffed ICU. Despite
numerous studies of staff satisfaction, none have shown
a direct correlation between nursing perceptions of care
and patient outcomes. However, perceptions of improved
job satisfaction and communication among nurses have
been identified in ICUs that produce results in improving
Our result is similar to the findings of Chu-Weininger et al
, in which nurses in a tele-ICU showed improvement in
perceptions of safety and teamwork climate. In addition, our
study showed that the perception of care in the control unit
actually worsened during the time of study. Work load
factors can negatively impact staff perceptions of safety and
communication culture. The survey results in the control unit
may suggest that such stressors were present in the hospital
system during the implementation period. The fact that
WICU perceptions of safety and communications improved
during a period of perceived stress suggests that the
telemedicine intervention had a significant effect in this
area. We expect that this effect would be enhanced in a lesser
staffed ICU or by implementing a more intensive interven-
tion (eg, order writing).
We recognize that our study has limitations. First, we did
not have sufficient power to measure patient outcomes.
Based on our extremely low mortality, we recognized that
achieving adequate power to measure mortality outcomes
was beyond the scope of this study and would require a
permanent telemedicine installation. However, communica-
tion problems are a common source of errors and preventable
harm, and we believe that our results demonstrate that
enhanced communication and oversight have the potential to
improve patient outcomes. Second, this study was conducted
over a relatively short period, and we cannot know if the
improvements would persist. However, if the study had been
carried out for a longer period, other factors could have
influenced staff perceptions and potentially biased our
results. Third, we did not formally validate our survey
instrument. We used a previously published and validated
survey instrument and modified some questions to fit our
culture and nomenclature. The modifications made to the
survey were minor and not likely to significantly bias the
results. In addition, the intensivists and many of the nurses
staffing the tele-ICU routinely work in the study ICU. Staffs
in both ICUs were able to freely communicate, and staff in
the control ICU was aware of project progress within the
study ICU. It is reasonable to infer that positive perceptions
of the project were communicated to the control ICU. This
may have inadvertently influenced responses within the
control ICU resulting in a greater depression of attitudes and
perceptions than would have been seen if no project was
underway. Along these lines, postsurvey completion rates in
the study ICU appear to be much higher than the control
ICU. This may be a function of the enthusiasm for the project
in study ICU, which was not experienced in the control ICU.
Finally, both the test and control ICUs are part of a large
academic teaching hospital in which participation in process
improvement projects is an expectation. As a result our
results may not be generalizable.
Telemedicine has traditionally been thought of as a means
to bring intensivist resources to understaffed ICUs, typically
in rural or community hospitals, or to provide nocturnal
coverage in ICUs that only have a daytime intensivist. Our
study showed that the introduction of tele-ICU services in a
highly staffed academic ICU was associated with an
improvement in nursing perceptions of working conditions
and communications. We believe that this study demon-
strates the ability of telemedicine to improve the nursing
perceptions of care and processes in the ICU.
The authors would like to thank Dr John Ulatowski, the
Johns Hopkins Department of Anesthesiology and Critical
Care Medicine, Alex Nason, Johns Hopkins International,
Steve Mandel, Johns Hopkins Information Services,
Samantha Young, Judy Schroeder, Gail Biba, Christina
Lundquist, Stephanie Swanson, and Marie Diener-West for
their help and support of this project.
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