The population of northern and rural Ontario face many challenges from a healthcare perspective. Not only do they face higher mortality rates from diabetes, cardiovascular and respiratory disease (Canadian Population Health Initiative 2006) but also because of the vast geography, it can be difficult to access timely care (MOHLTC 2011). Telemedicine is one possible solution to providing advanced care for critically ill patients in rural northern Ontario. Previous studies have shown variable results in terms of improved mortality for patients managed via telemedicine (Kahn 2016, Nassar 2014).
In Northern Ontario, there are two tertiary care centres, the Thunder Bay Regional Health Sciences Centre (TBRHSC) in the northwest and Health Sciences North (HSN) in Sudbury, in the northeast. The Intensive Care Units (ICU) in each respective centre provides telemedicine support to rural and remote emergency departments, Level 3/4 ICUs and First Nations Nursing Stations via videoconferencing. These programs have been in existence for 5-6 years. The TBRHSC program receives 1100 consultations annually while HSN receives approximately 400 consultations annually. The intensivists and ICU nurses provide support to their rural colleagues during the telemedicine consultations. The physicians also assist with determining who needs transfer and to where (e.g., hospital ward, ICU, or burn units). Some patients remain in their home community with further consultations from the intensivist for ongoing management, while in certain situations the patient’s resuscitation status is revised from full resuscitation to a palliative status based on discussion amongst the physicians, patient and families. One benefit of the TBRHSC program, it has prevented approximately $10,000,000 in patient transfers over the past 5 years.
This study will investigate the effect of rural physicians using ICU telemedicine in Thunder Bay and Sudbury for managing critically ill patients. The primary outcomes for the first part of the study will be 30-day patient mortality with secondary outcomes including: hospital length of stay, rate of ICU admission and length of stay, rate of transfer to regional centres including the distance travelled. The second part of the study will be a mixed methods analysis to evaluate the effect of using telemedicine on rural healthcare providers (i.e., physicians and nurses). Specifically, we are interested in their perspective on clinical competency, physician retention, and their perspective on the overall quality of care in rural centres.
This study will examine the use of telemedicine from both the patient and healthcare provider perspective. The investigation has been divided into two parts 1) a quantitative analysis of patient outcomes and 2) a mixed methods analysis of the health care providers (i.e., nurse and physician) using the system.
2.1 Patient analysis
Patient names and health card numbers for those patients assessed by the Thunder Bay and Sudbury telemedicine ICU programs will be uploaded to the Institute for Clinical Evaluative Sciences (ICES). Using a retrospective interrupted time series design, a control time series for patient visits 3 years prior to the initiation of the telemedicine programs will be compared to those patients assessed by the telemedicine program. The primary outcome will be the 30 day patient mortality rate before and after the initiation of the program. Secondary outcomes related to rate of transfer to regional referral centres, distance of transfers, hospital admission rate, length of stay, ICU admission rate and ICU length of stay will also be examined. The telemedicine program in Sudbury was initiated approximately 12 months prior to Thunder Bay. This differential in start times will allow us to examine the effect of the programs and control for the effect of improvements in critical care medicine that will have occurred.
One confounding factor in the analysis that will affect both transfer and mortality rates is that some patients were made palliative after consultation with the intensivist. These patients may have survived longer if they had been transferred to the tertiary care centre. Fortunately, these patients are identified within the database.
2.2 Healthcare provider analysis
The analysis of the health care providers using the telemedicine system will be comprised of two parts: 1) pre- and post-implementation surveys completed by Critical Care Services Ontario for both Thunder and Sudbury, and 2) structured interviews with the nurses and physicians using the system in the various communities across Northern Ontario. The surveys were completed prior to the initiation of the program and were repeated after 5 years at both sites. Neither set of surveys have been analyzed.
The number of communities sampled and the number of health care providers interviewed will be based on the number of consultations originating from within the communities. We also want to ensure that the sample represents different ED sizes, given that the available resources may be quite variable. The structured interviews will be transcribed and thematic analysis will be completed.
Our goal is to assess the telemedicine ICU program system used in northern Ontario. We will assess this system from both the patient and health care provider perspective.
Canadian Population Health Initiative 2006, Summary Report, How Healthy are Rural Canadians? Retrieved from https://secure.cihi.ca/free_products/rural_canadians_2006_report_e.pdf.
Ministry of Health and Long Term Care. 2011. Rural and northern health care framework. Retrieved from http://health.gov.on.ca/en/public/programs/ruralnorthern/docs/report_rural_northern_EN.pdf.
Kahn JM, Le TQ, Barnato AE, et al. ICU telemedicine and critical care mortality: a national effectiveness study. Med Care. 2016; 54(3): 319–325.
Nassar BS, Vaughan-Sarrazin MS, Jiang L, et al. Impact of an Intensive Care Unit Telemedicine Program on Patient Outcomes in an Integrated Health Care System. JAMA Intern Med. 2014;174(7):1160-1167