| Finding 1: Hospital staff’s personal experience, and anecdotes from colleagues, supported their belief that CCT has positive effects on patient care. Specifically, these effects were in terms of patient safety and quality of care, support at the bedside by critical care experts, and standardisation of practice. |
| Assessment for each GRADE‐CERQual component |
| Methodological limitations |
6 studies contributed data to this finding. None of the studies discussed researcher reflexivity. 2 studies were assessed as having methodological limitations related to data analysis and collection, of which 1 study was assessed as having methodological limitations related to research design and the other was assessed as having methodological limitations related to recruitment. A third study was also assessed as having methodological limitations related to recruitment. The body of evidence contributing to this review finding was assessed as having minor concerns about methodological limitations |
| Coherence |
No or very minor concerns about coherence |
| Relevance |
Moderate concerns about relevance, because while the studies covered different ICU settings from different countries these were all North American; and the value staff placed on their experiences and anecdotes is likely to differ across world regions |
| Adequacy |
Minor concerns about adequacy, because the 6 studies together offer only moderately rich data |
| Overall GRADE‐CERQual assessment and explanation |
| Moderate confidence |
Downgraded to moderate confidence because we had minor concerns about methodological limitations, coherence, and adequacy; and moderate concerns about relevance |
| Contributing studies |
|
Khunlertkit 2013; Moeckli 2013; Shahpori 2011a; Stafford 2008a; Ward 2015; Wilkes 2016
|
| Finding 2: Hospital staff and family members described several advantages of CCT. Bedside and hub staff strongly believed that the main advantage of CCT was having access to experts when bedside doctors were not available. Families also valued having access to experts. In addition, hospital staff described how CCT could support clinical decision making and mentoring of junior staff
|
| Assessment for each GRADE‐CERQual component |
| Methodological limitations |
7 studies contributed data to this finding. 2 studies discussed researcher reflexivity. 2 studies were assessed as having methodological limitations related to data analysis, research design and data collection. 1 study was assessed as having methodological limitations related to recruitment. The body of evidence contributing to this review finding was assessed as having minor concerns about methodological limitations |
| Coherence |
No or very minor concerns about coherence |
| Relevance |
Minor concerns about relevance, because the studies covered different ICU settings from different countries, and even though these were all North American the focus of the finding is on standard features of CCT technology that are unlikely to differ across world regions |
| Adequacy |
No or very minor concerns about adequacy |
| Overall GRADE‐CERQual assessment and explanation |
| High confidence |
Graded as high confidence because we had minor concerns about methodological limitations, relevance, coherence, and adequacy |
| Contributing studies |
|
Jahrsdoerfer 2013; Kahn 2019; Khunlertkit 2013; Moeckli 2013; Shahpori 2011a; Stafford 2008a; Thomas 2017
|
| Finding 3: Bedside staff valued the potential adaptability of CCT to speak to local needs and practices. However, this was not always evident, with reported examples being mainly around developing camera usage etiquette and integration with local protocols. |
| Assessment for each GRADE‐CERQual component |
| Methodological limitations |
3 studies contributed data to this finding. 1 study discussed researcher reflexivity. 1 study was assessed as having methodological limitations related to recruitment. The body of evidence contributing to this review finding was assessed as having no or very minor concerns about methodological limitations |
| Coherence |
Minor concerns about coherence, because the data contributing to the review finding were only reasonably consistent within studies |
| Relevance |
Moderate concerns about relevance, because while the finding is focused on a technological feature of CCT the studies only covered a small range of settings from only 1 country; and local practices are likely to differ across settings and countries |
| Adequacy |
Serious concerns about adequacy due to only 3 studies offering only thin data |
| Overall GRADE‐CERQual assessment and explanation |
| Low confidence |
Downgraded to low confidence because we had no or very minor concerns about methodological limitations, minor concerns about coherence, moderate concerns about relevance and serious concerns about adequacy |
| Contributing studies |
|
Moeckli 2013; Stafford 2008a; Thomas 2017
|
| Finding 4: Both bedside and hub clinicians reported difficulties with the implementation of CCT. Key barriers related to implementation were perceptions of additional workload, need for more coordination work, and concern around the use of cameras |
| Assessment for each GRADE‐CERQual component |
| Methodological limitations |
5 studies contributed data to this finding. None of the studies discussed researcher reflexivity. 3 studies were assessed as having methodological limitations related to data analysis and collection, of which 2 were also assessed as having methodological limitations related to research design; and 1 of the 3 was assessed as having methodological limitations related to recruitment. The body of evidence contributing to this review finding was assessed as having moderate concerns about methodological limitations |
| Coherence |
No or very minor concerns about coherence |
| Relevance |
Minor concerns about relevance, because the studies covered different ICU settings from different countries and even though these were all North American the focus of the finding is on standard features of CCT technology that are unlikely to differ significantly across world regions |
| Adequacy |
Moderate concerns about adequacy, because the 5 contributing studies together offer only moderately thin data. |
| Overall GRADE‐CERQual assessment and explanation |
| Moderate confidence |
Downgraded as moderate confidence because we had no or very minor concerns about relevance, minor concerns about coherence, and moderate concerns about methodological limitations and adequacy |
| Contributing studies |
|
Moeckli 2013; Mullen‐Fortino 2012; Shahpori 2011a; Stafford 2008a; Ward 2015
|
| Finding 5: Cost considerations featured as an influencing factor in a limited way, with only a few examples noting the high cost of implementing CCT especially compared to the cost of recruiting additional ICU staff |
| Assessment for each GRADE‐CERQual component
|
| Methodological limitations |
2 studies contributed to this finding. Neither study discussed researcher reflexivity. 1 study was assessed as having methodological limitations related to data analysis, research design, and data collection. The body of evidence contributing to this review finding was assessed as having moderate concerns about methodological limitations |
| Coherence |
No or very minor concerns about coherence. |
| Relevance |
Serious concerns about relevance, because the studies only covered a small range of settings from only 1 region; these were conducted several years ago and it is likely the health resource allocation model used then is no longer current |
| Adequacy |
Serious concerns about adequacy, because the 2 contributing studies together only offer seriously thin data. |
| Overall GRADE‐CERQual assessment and explanation |
| Low confidence |
Downgraded to low confIdence because we had no or very minor concerns about coherence, moderate concerns about methodological limitations, and serious concerns about relevance, and adequacy |
| Contributing studies |
|
Shahpori 2011a; Stafford 2008a
|
| Finding 6: Hospital staff as well as family members perceived CCT to be providing a community benefit, specifically relating to patients' and families' desire to stay close to their local community without requiring transfer to specialist centres to access critical care expertise |
| Assessment for each GRADE‐CERQual component |
| Methodological limitations |
5 studies contributed data to this finding. None of the studies discussed researcher reflexivity. 2 studies were assessed as having methodological limitations related to data collection and analysis, of which 1 study was assessed as having methodological limitations related to research design; and the other was assessed as having methodological limitations related to recruitment. A third study was also assessed as having methodological limitations related to recruitment. The body of evidence contributing to this review finding was assessed as having moderate concerns about methodological limitations |
| Coherence |
No or very minor concerns about coherence |
| Relevance |
Serious concerns about relevance, because while the studies covered different ICU settings from different countries, these were all from North America where decentralisation of health care is a strong feature. The review finding refers to factors highly influenced by social norms (values and perceptions of patients about community benefit in health care), which are highly likely to differ across world regions |
| Adequacy |
Minor concerns about adequacy, because the 5 studies together offer only moderately rich data |
| Overall GRADE‐CERQual assessment and explanation
|
| Moderate confidence |
Downgraded to moderate confidence because we had no or very minor concerns about coherence, minor concerns about adequacy, moderate concerns about methodological limitations, and serious concerns about relevance |
| Contributing studies |
|
Goedken 2017; Moeckli 2013; Shahpori 2011a; Ward 2015; Wilkes 2016
|
| Finding 7: Hospital staff greatly valued the nature and quality of social networks between the bedside and CCT hub teams. Key issues for them were trust, acceptance, teamness, familiarity and effective communication between the 2 teams |
| Assessment for each GRADE‐CERQual component |
| Methodological limitations |
8 studies contributed data to this finding. Only 1 study discussed researcher reflexivity. 1 study was assessed as having methodological limitations related to research design, data analysis and collection. 3 studies were assessed as having methodological limitations related to recruitment strategy, of which 1 was also assessed as having methodological limitations related to research design. The body of evidence contributing to this review finding was assessed as having minor concerns about methodological limitations |
| Coherence |
No or very minor concerns about coherence |
| Relevance |
Minor concerns about relevance, because the studies covered different ICU settings and even though these were all North American the focus of the finding is on standard features of health professional practice that are unlikely to differ significantly across world regions |
| Adequacy |
No or very minor concerns about adequacy |
| Overall GRADE‐CERQual assessment and explanation |
| High confidence |
Graded as high confidence because we had no or very minor concerns about coherence, and adequacy; and minor concerns about methodological limitations, and relevance |
| Contributing studies |
|
Hoonakker 2018; Jahrsdoerfer 2013; Kahn 2019; Khunlertkit 2013; Moeckli 2013; Mullen‐Fortino 2012; Stafford 2008a; Wilkes 2016
|
| Finding 8: Hospital bedside staff were concerned over the hub team not being aware of local unit norms, values, and culture. This led local bedside teams to feel that CCT intruded on their practice |
| Assessment for each GRADE‐CERQual component |
| Methodological limitations |
6 studies contributed data to this finding. Only 1 study discussed researcher reflexivity. 2 studies were assessed as having methodological limitations related to data analysis and collection, of which 1 study was also assessed as having methodological limitations related to research design, and the other study was assessed as having methodological limitations related to recruitment. The body of evidence contributing to this review finding was assessed as having moderate concerns about methodological limitations |
| Coherence |
No or very minor concerns about coherence |
| Relevance |
Moderate concerns about relevance, because while the studies covered different settings these were only from 1 country; and local unit norms, values and culture are likely to differ across countries |
| Adequacy |
Moderate concerns about adequacy, because the 6 studies together only offer moderately thin data |
| Overall GRADE‐CERQual assessment and explanation |
| Moderate confidence |
Downgraded to moderate confidence because we had no or very minor concerns about coherence, and moderate concerns about methodological limitations, relevance, and adequacy |
| Contributing studies |
|
Kahn 2019; Moeckli 2013; Mullen‐Fortino 2012; Stafford 2008a; Ward 2015; Wilkes 2016
|
| Finding 9: Bedside clinicians were reluctant to use CCT because they lacked clarity about its purpose, were concerned that their decision‐making skills would be weakened through remote supervision, and did not consider hub clinicians an equal counterpart in patient management. Hub clinicians were disengaged due to lack of role clarity and limited integration with patient care |
| Assessment for each GRADE‐CERQual component |
| Methodological limitations |
4 studies contributed data to this finding. 1 study discussed researcher reflexivity. 1 study was assessed as having methodological limitations related to data analysis, research design and data collection. 1 study was assessed as having methodological limitations related to recruitment. The body of evidence contributing to this review finding was assessed as having minor concerns about methodological limitations |
| Coherence |
No or very minor concerns about coherence |
| Relevance |
Moderate concerns about relevance, because the studies only covered a small range of settings and aspects of professional autonomy may be influenced by cultural factors and professional norms that are likely to differ across world regions |
| Adequacy |
Minor concerns about adequacy, because the 4 studies together offer only moderately rich data |
| Overall GRADE‐CERQual assessment and explanation |
| Moderate confidence |
Downgraded to moderate confidence because we had no or very minor concerns about coherence, minor concerns about methodological limitations, and adequacy, and moderate concerns about relevance |
| Contributing studies |
|
Kahn 2019; Moeckli 2013; Shahpori 2011a; Stafford 2008a
|
| Finding 10: Hospital locale shaped prioritisation of CCT, with staff in rural centres noting that CCT was of greater benefit to them considering their staff shortage and lack of critical care resources
|
| Assessment for each GRADE‐CERQual component |
| Methodological limitations |
4 studies contributed data to this finding. 1 study discussed researcher reflexivity. 2 studies were assessed as having methodological limitations related to data analysis and data collection, of which 1 study was also assessed as having methodological limitations related to research design; and the other was assessed as having methodological limitations related to recruitment strategy. The body of evidence contributing to this review finding was assessed as having moderate concerns about methodological limitations |
| Coherence |
Minor concerns about coherence, because the data were only reasonably consistent within studies |
| Relevance |
Moderate concerns about relevance, because while the studies were from different settings and countries these were all North American; and perceptions about prioritisation and availability of critical care resources are likely to differ across world regions |
| Adequacy |
Serious concerns about adequacy, because the 4 contributing studies together offered only thin data |
| Overall GRADE‐CERQual assessment and explanation |
| Low confidence |
Downgraded to low confidence because we had moderate concerns about methodological limitations, relevance, and coherence; and serious concerns about adequacy |
| Contributing studies |
|
Kahn 2019; Shahpori 2011a; Ward 2015; Wilkes 2016
|
