Dear Editor,
Tele-ICU strategies can extend access to intensivist expertise and support evidence-based care where on-site resources are limited, although their effects on clinical outcomes remain inconsistent [1]. The multicenter cluster-randomized TELESCOPE trial evaluated a structured tele-ICU intervention led by board-certified intensivists and did not show a significant reduction in overall ICU length of stay in the overall critically ill population [2]. Cardiac surgical patients represent a clinically distinct population exposed to early postoperative hemodynamic instability, arrhythmias, and organ dysfunction, making this subgroup relevant for evaluating the experience with structured tele-ICU support.
We examined the experience of adults enrolled in the TELESCOPE trial (ClinicalTrials.gov NCT03920501) who were admitted to participating ICUs after cardiac surgery. The parent trial included 30 public hospital ICUs across Brazil and compared usual care with daily remote multidisciplinary rounds led by intensivists, monthly audit-and-feedback meetings, and standardized evidence-based protocols delivered through a dedicated audiovisual system. We included adults admitted to participating ICUs after cardiac surgery and examined ICU length of stay (LOS), readiness for ICU discharge, ICU mortality, and in-hospital mortality. Mixed-effects models accounted for clustering, following the statistical framework of the parent trial. Because few centers contributed cardiac surgical cases, adjusted models included admission type, mechanical ventilation at admission, and SAPS-3.
Among 444 postoperative cardiac surgery patients, 147 were managed in ICUs assigned to the tele-ICU strategy and 297 in standard-care ICUs. Mean age was approximately 62 years, while SAPS-3 and SOFA scores indicated greater illness severity in the tele-ICU group at ICU admission. After adjustment, tele-ICU exposure was associated with a 17.4% shorter ICU LOS (95% CI, 4.2%–28.8%; p = 0.012) and earlier readiness for ICU discharge (IRR 0.80, 95% CI 0.66–0.97; p = 0.024). During the intervention period, ICU mortality was 3.9% in tele-ICU clusters and 9.6% in control clusters (adjusted OR 0.19, 95% CI 0.07–0.54; p = 0.002), while in-hospital mortality was 7.8% and 13.8%, respectively (adjusted OR 0.32, 95% CI 0.14–0.70; p = 0.004) (Table 1).
Table 1.
Effect estimates on clinical outcomes between tele-critical care and standard of care groups
| Tele-Critical Care | Standard of Care | Effect estimate type | Effect estimate (95% CI)* | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Baseline (n = 19) | Intervention (n = 128) | Baseline (n = 37) | Intervention (n = 260) | Crude | Adjusted by admission type, iMV and SAPS-3 | Adjusted by admission type, iMV, Vasopressor and SAPS-3 |
Adjusted by admission type, SAPS-3 and SOFA | ||
| ICU LOS, days | |||||||||
| Mean (SD) | 4.5 (5) | 4.3 (7) | 3.1 (2) | 4.1 (4) | Percentage change |
-4.5% (-17.3 to 10.4), p = 0.536 |
-16.0% (-27.7 to -2.5), p = 0.022 |
No convergence | -17.4% (-28.8 to -4.2),p = 0.012 |
| Median [p25-p75] | 2.8 [2.0 to 4.3] | 2.2 [1.9 to 4.8] | 2.9 [1.9 to 3.9] | 2.9 [2.0 to 4.8] | |||||
| Readiness for discharge, days | |||||||||
| Mean (SD) | 3.9 (5) | 3.6 (7) | 2.6 (2) | 3.5 (4) | IRR | 1.00 (0.83 to 1.21),p = 0.971 | 0.81 (0.67 to 0.98),p = 0.012 | 0.85 (0.70 to 1.05),p = 0.128 | 0.80 (0.66 to 0.97),p = 0.024 |
| Median [p25-p75] | 2.0 [1.0 to 3.5] | 2.0 [1.0 to 4.0] | 2.0 [1.0 to 3.0] | 2.0 [2.0 to 4.0] | |||||
| ICU mortality, n (%) | 4 (21.1) | 5 (3.9) | 1 (2.7) | 25 (9.6) | OR | 0.38 (0.14, 1.02), p = 0.055 | 0.19 (0.07 to 0.55), p = 0.002 | 0.19 (0.06 to 0.58), p = 0.003 | 0.19 (0.07 to 0.54), p = 0.002 |
| Hospital mortality, n (%) | 4 (21.1) | 10 (7.8) | 5 (13.5) | 36 (13.8) | OR | 0.53 (0.25 to 1.10), p = 0.088 | 0.33 (0.15 to 0.72), p = 0.006 | 0.36 (0.16 to 0.82), = 0.014 | 0.32 (0.14 to 0.70), p = 0.004 |
*The models accounted for clustering and allowed the secular trend to randomly vary across clusters by extending the random-effects components with interactions between cluster and time period and used the Satterthwaite’s degree-of-freedom correction
Potential explanations include greater adherence to standardized postoperative care, earlier recognition of complications, and more timely adjustment of hemodynamic or ventilatory support during structured multidisciplinary rounds. These mechanisms were not directly measured and should therefore remain interpretative.
These observations contrast with the neutral overall findings of the TELESCOPE trial [2]. The difference may reflect true effect heterogeneity, but chance and residual confounding are also plausible explanations. Cardiac surgical patients often follow standardized postoperative pathways, in which timely recognition of complications or protocol deviations may be particularly relevant [3]. Remote intensivist participation may also be useful where on-site critical care coverage is limited [4].
This experience should be interpreted cautiously. The cardiac-surgery cohort was identified post hoc, few centers contributed cases, baseline severity differed between groups, and residual confounding cannot be excluded despite adjustment. The parent trial was not powered for this subgroup, so the observations should be considered hypothesis-generating [5].
Among postoperative cardiac surgery patients in the TELESCOPE trial, tele-ICU multidisciplinary rounds were associated with shorter ICU stay and lower mortality after adjustment. Given the post hoc nature of this observation and the limited number of contributing centers, prospective evaluation is warranted before inferring a subgroup-specific benefit.
Acknowledgements
The authors would like to thank the central TELESCOPE team, the local assistant teams of the 30 participating intensive care units, and the data collection team of each participating center, as well as the Hospital Israelita Albert Einstein, the technicians of the Science and Technology Secretary of the Brazilian Ministry of Health, and the Brazilian Research in Intensive Care Network (BRICNet) for their support in conducting the TELESCOPE trial.
Author contributions
AJP served as the guarantor of the integrity of the data. TADA, CHSP, OTR, and AJP contributed to the conception and design of this post hoc evaluation. AJP, DTN, and OTR secured funding. OTR performed the statistical analyses. All authors contributed to data analysis and interpretation. TADA, RCFC, and OTR drafted the manuscript. The final version of the manuscript was read, revised, and approved by all authors. TADA, DJP, and OTR supervised the work.
Funding
The parent TELESCOPE trial (ClinicalTrials.gov NCT03920501) was conducted in partnership with the Brazilian Ministry of Health through the Institutional Development Support Program of the Unified Health System (PROADI-SUS [NUP 25000.018804/2018-23]), in accordance with Ordinance 3.362 of December 8, 2017.
Data availability
The datasets used for this report are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The TELESCOPE protocol was approved by the Hospital Israelita Albert Einstein Research Ethics Committee (CAAE: 01523118.0.1001.0071), and all patients provided written informed consent. The trial was conducted in accordance with the ethical principles of the Declaration of Helsinki.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Otavio Tavares Ranzani and Adriano José Pereira contributed equally to this work.
References
- 1.Lilly CM. The Era of Evidence-Based ICU Telemedicine. Crit Care Med. 2021;49(7):1217–8. 10.1097/CCM.0000000000004996. [DOI] [PubMed] [Google Scholar]
- 2.Pereira AJ, Noritomi DT, Dos Santos MC, Corrêa TD, Ferraz LJR, Schettino GPP, et al. Effect of Tele-ICU on Clinical Outcomes of Critically Ill Patients: The TELESCOPE Randomized Clinical Trial. JAMA. 2024;332(21):1798–807. 10.1001/jama.2024.20651. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Grant MC, Crisafi C, Alvarez A, Arora RC, Brindle ME, Chatterjee S, The society of thoracic surgeons (STS). Perioperative care in cardiac surgery: a joint consensus statement by the enhanced recovery after surgery (ERAS) cardiac society, ERAS international society, and. Ann Thorac Surg. 2024;117(4):669 – 89. 10.1016/j.athoracsur.2023.12.006 [DOI] [PubMed]
- 4.Lilly CM, Cody S, Zhao H, Landry K, Baker SP, McIlwaine J, University of Massachusetts Memorial Critical Care Operations Group, et al. Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes. JAMA. 2011;305(21):2175–83. 10.1001/jama.2011.697. [DOI] [PubMed] [Google Scholar]
- 5.Wang R, Lagakos SW, Ware JH, Hunter DJ, Drazen JM. Statistics in medicine–reporting of subgroup analyses in clinical trials. N Engl J Med. 2007;357(21):2189–94. 10.1056/NEJMsr077003. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used for this report are available from the corresponding author on reasonable request.