Table 1.

—Design of Studies Evaluating Staff Acceptance of TICU Coverage

Study/Year	Publication Status	Study Method	Participants	Evaluation Point	Summary of Findings
Berenson et al5/2009	Published	Interview	Administrators (n = 453 pre and 58+ post)	Pre/Post	• Pre: Perception that substantial costs are not justified by potential benefit, that current staffing was adequate, and that onsite was preferable to off-site staff.
					• Post: Broad perception that TICU improves quality and safety, but no objective data support those beliefs. Frustration with IT interface problems.
Coletti et al30/2008	Published	Quantitative survey	Medical ICU residents (n = 35)	Post	• 77% reported improved patient safety.
					• 63% reported improved ability to focus on urgent patient issues.
					• 51% reported increase in uninterrupted periods of rest.
					• 37% reported that TICU held educational value.
Crawley31/2008	Meeting abstract	Case study	Staff (n = NR)	Post	• Reports of enhanced training of physician staff, high system reliability, and enhanced Army-Navy cooperation.
					• Perceived workload increase, big-brother concerns, lack of need, failure to recognize when help is needed, and IT interface/security challenges.
DiMartino et al29/2009	Meeting abstract	Quantitative survey	Nurses (n = 91)	Post	• 72% believed that TICU increases patient survival.
					• 47% believed that TICU prevents errors.
					• 42% believed that TICU improves family satisfaction.
					• 13% felt “spied upon.”
					• 11% believed that TICU was intrusive.
					• 9% believed that TICU interrupted workflow.
					• 79% believed that knowing the telephysician was important, and 61% were more likely to contact the consultant if they knew the physician on call.
Faiz et al32/2006	Meeting abstract	Quantitative survey	Telephysicians (n = 16)	Post	• Of 16 fellows rotating through the eICU remote site, 14 of 16 would want to work in a place with TICU, and 13 of 16 believed that it protected against liability.
					• All believed that TICU improved patient care.
Grundy et al28/1977	Published	Quantitative and qualitative survey	Physicians and nurses (n = NR)	Post	• 88% of nurses believed that TICU benefited patients, and 70% believed that it enhanced education.
					• Nurses reported positive attitudes toward TICU on 40 occasions and negative attitudes on 21.
					• Over time, resistance was replaced by enthusiasm.
					• Physicians reported positive attitudes toward TICU on 17 occasions and negative attitudes on 4.
					• Although acceptance increased over time, physicians implemented only 46% of consultant suggestions in the last 84 d of the program. Some physicians resented the consultant.
Heath et al33/2009	Published	Quantitative survey	Physicians (n = 41consultations), Teleintensivists (n = 63 consultations)	Post	• Unit of analysis was the consultation.
					• In 88% of pediatric consultations to rural EDs, the physician agreed that consultation improved care.
					• In 89% of consultations, the consulting intensivist agreed that the consultation improved care.
Kowitlawakul34/2008	Published	Quantitative and qualitative survey	Nurses (n = 117 quantitative and n = 34 qualitative)	Pre	• On a five-point Likert scale, the item mean was 3.3 on the 21-item Nurse Attitudes Toward eICU survey.
					• The item mean was 3.2 on the six-item Intention to Use scale.
					• Nurses believed that TICU would benefit units without adequate physician coverage and might benefit new nurses.
					• Nurses believed that it was unnecessary in some units, that conflicts between on- and off-site staff could undermine patient outcomes, and that it could lead to extra work and staff cuts.
Marcin et al35/2004	Published	Quantitative survey	Physicians (n = 53), nurses, respiratory therapists (n = 17)	Post	• On a five-point Likert scale, overall satisfaction averaged 4.56 for referring physicians and 4.53 for nurses and respiratory therapists.
					• Among aspects of TICU consultations, the physicians scored audiovisual quality lowest (mean, 4.31), and the nurses and respiratory therapists scored ease of equipment use lowest (mean, 3.59).
Marttos et al27/2008	Meeting abstract	Quantitative survey	Clinicians (physicians and nurses, n = 71 combined), both bedside and telepresence	Post	• Results were very positive on the basis of means of a five-point Likert scale: overall experience, 4.29; user satisfaction, 4.22; technical issues, 4.31; and clinical application, 4.17.
					• No significant variation over time suggested positive attitudes toward TICU from first use.
Mathews et al36/2007	Published	Case study	Nurses (n = NR)	Pre/Post	• Prior to implementation, nurses were apprehensive and resistant, fearing repercussions from constant monitoring, increased workload, and increased nurse to patient ratios.
					• A work team was able to decrease apprehension and increase acceptance of TICU staff.
McNelis et al26/2008	Meeting abstract	Quantitative survey	Physicians (n = NR)	Post	• Staff intensivists communicated with surgical ICU staff during off hours through robot or telephone.
					• Satisfaction with the robot (mean, 6.5) was significantly greater than satisfaction with the telephone (mean, 4.5).
Mora et al37/2007	Meeting abstract	Quantitative survey	Residents (n = 96)	Post	• Of the residents with TICU experience, 82.3% believed that it improves patient care, and 73.8% believed that it improves the care they deliver to patients; 66.7% desired telemonitoring postresidency.
					• Of events potentially benefiting from telemonitoring, ventilator management was mentioned by the most (70%), and supervision of online placement was mentioned the least (42%).
Poropatich et al25,45,46/2008	Meeting abstract	Quantitative survey	Physicians (n = 8), residents (n = 22), nurses (n = 45)	Post	• On a 10-point scale, overall satisfaction averaged 8.5 for physicians, 8.1 for residents, and 8.3 for nurses.
					• A majority of physicians and residents believed that the robot saved time.
					• Measured collectively, no clinicians believed that the telephone was better than the robot or that the video or audio quality was poor.
					• 95% believed that remote telepresence improves care. There was high satisfaction with no difference in support between types of providers.
Roberts and Dewoody38/2008	Published	Quantitative survey	Nurses (n = NR)	Pre/Post	• The development of an orientation program for eICU care staff was associated with increased staff satisfaction with eICU and increased number of assistance calls and interactions with teleclinicians.
Rogove et al39/2009	Meeting abstract	Quantitative survey	Physicians (n = NR)	Post	• Physician satisfaction by survey was excellent.
Siek et al24/2008	Meeting abstract	Case study	Physicians, nurses (n = NR)	Post	• Pulmonary and critical care physicians appreciated consultations with colleagues, but the cardiovascular surgeon would not use the eICU resource.
					• Nurses believed that the system was great and provided resources for the night shift, but they noted manipulation of physicians.
Stafford et al40/2008	Published	Interview	Telephysicians (n = 26), telenurses (n = 44)	Post	• Physical stress and boredom were challenges, but the telecenter fosters teamwork with a focus on improved patient care.
					• Telestaff can become frustrated by the inability to directly intervene and by the resistance encountered from ICU staff.
					• Calls from ICU nurses increase when (they learn) consulting physicians are on duty.
Sucher et al23/2009	Meeting abstract	Quantitative survey	Physicians, nurses (n = NR)	Pre	• 67% agreed that the robot would facilitate patient care between intensivists and bedside clinicians, and 72% agreed that the robot would assist bedside clinicians in managing emergencies.
Thomas et al41/2007	Published	Quantitative survey	Physicians (n = NR)	Pre/Post	• The Safety Attitudes Questionnaire revealed that a significant increase in the mean teamwork score (from 69.7 to 78.8) and safety climate score (from 66.4 to 73.4) after TICU was implemented.
					• Item scores also revealed a decrease in perceived interruptions, an increase in confidence that patients are adequately covered, and an increase in belief that a physician can be accessed in an emergency.
Westbrook et al22,47‐49/2008	Published	Interviews, quantitative survey	Physicians (n = 6), nurses (n = 12),telephysicians (n = 13)	Post	• Following implementation of a virtual critical care unit in Australia, all consulting physicians reported that they were able to increase decision support to ED clinicians, and this had improved patient management.
					• Many also noted increased workload and responsibility; 71% were satisfied with TICU design.
					• ED physicians perceived greater support, and nurses reported increased autonomy and less stress.
					• 65% of ED clinicians were satisfied with TICU design.
					• The majority of all respondents reported improved interhospital relationships.
Youn42/2006	Published	Quantitative survey	Nurses (n = NR)	Post	• Nursing satisfaction averaged 4.7 to 5.0 (on a five-point scale) for improved communication and collaboration and better patient outcomes.
Zawada et al21,43,50/2009	Published	Quantitative survey	Physicians, nurse, telephysicians (n = NR)	Post	• Ten of 11 community hospitals responded.
					• Using a five-point scale, 90% of hospital administrators and lead clinical staff agreed that tele-ICU improved patient care, was easy to use, and should be available to every small or critical access hospital.
					• More than 90% of telephysicians indicated that the TICU improved critical care in tertiary and community ICUs.
					• All of them agreed better, safer care can be delivered by a telecritical care team.

eICU = electronic ICU; IT = information technology; NR = not reported; TICU = tele-ICU.