TELEmedicine as an intervention for sepsis in emergency departments: a multicenter, comparative effectiveness study (TELEvISED Study)
Publication: Journal of Comparative Effectiveness Research
Abstract
Sepsis is a life-threatening infection that affects over 1.7 million Americans annually. Low-volume rural hospitals have worse sepsis outcomes, and emergency department (ED)-based telemedicine (tele-ED) has been one promising strategy for improving rural sepsis care. The objective of this study is to evaluate the impact of tele-ED consultation on sepsis care and outcomes in rural ED patients. The TELEvISED study is a multicenter (n = 25) retrospective propensity-matched comparative effectiveness study of tele-ED care for rural sepsis patients in a mature tele-ED network. Telemedicine-exposed patients will be matched with non telemedicine patients using a propensity score to predict tele-ED use. The primary outcome is 28-day hospital free days, and secondary outcomes include adherence with guidelines, mortality and organ failure.
ClinicalTrials.gov: NCT04441944.
Lay abstract
Sepsis is a life-threatening infection that affects over 1.7 million Americans annually. Sepsis patients in low-volume rural hospitals die more often, and emergency department-based real-time video telemedicine has been one promising strategy for improving rural sepsis care. This study evaluates the impact of telemedicine consultation on sepsis care and outcomes in rural sepsis patients. The TELEvISED study is conducted in 25 rural hospitals that participate in a mature rural telemedicine network. Patients for whom telemedicine is used will be compared with those for whom it is not used to measure the effect on mortality, hospital length-of-stay and secondary outcomes including quality of care and severity of illness.
Supplementary Material
File (supplementary material.pdf)
- Download
- 510.50 KB
References
Papers of special note have been highlighted as: • of interest; •• of considerable interest
1.
Rhee C, Dantes R, Epstein L et al. Incidence and trends of sepsis in US hospitals using clinical vs claims data, 2009–2014. JAMA 318(13), 1241–1249 (2017).
2.
Hall MJ, Williams SN, Defrances CJ, Golosinskiy A. Inpatient care for septicemia or sepsis: a challenge for patients and hospitals. NCHS Data Brief 62, 1–8 (2011).
3.
Filbin MR, Arias SA, Camargo CA Jr, Barche A, Pallin DJ. Sepsis visits and antibiotic utilization in US Emergency Departments. Crit. Care Med. 42(3), 528–535 (2014).
4.
Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit. Care Med. 29(7), 1303–1310 (2001).
5.
Rivers E, Nguyen B, Havstad S et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N. Engl. J. Med. 345(19), 1368–1377 (2001).
• First paper to show the impact of early, aggressive emergency department-based care at improving survival in critically ill patients with sepsis.
6.
Rivers EP. Point: adherence to early goal-directed therapy: does it really matter? Yes. After a decade, the scientific proof speaks for itself. Chest 138(3), 476–480; discussion 484–485 (2010).
7.
Rhodes A, Evans LE, Alhazzani W et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016. Intens. Care Med. 43(3), 304–377 (2017).
8.
Kent N, Fields W. Early recognition of sepsis in the emergency department: an evidence-based project. J. Emerg. Nurs. 38(2), 139–143 (2012).
9.
Gaieski DF, Mikkelsen ME, Band RA et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit. Care Med. 38(4), 1045–1053 (2010).
10.
Kumar A, Roberts D, Wood KE et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit. Care Med. 34(6), 1589–1596 (2006).
11.
ProCESS Investigators; Yealy DM, Kellum JA, Huang DT et al. A randomized trial of protocol-based care for early septic shock. N. Engl. J. Med. 370(18), 1683–1693 (2014).
12.
Severe Sepsis and Septic Shock, Sepsis Bundle Project (SEP-1), National Hospital Inpatient Quality Measures. In: Specifications Manual for National Hospital Inpatient Quality Measures. Center for Medicare & Medicaid Services Baltimore, MD, USA, 1–60 (2017).
• The Centers for Medicare and Medicaid Services has designed a quality measure for evaluating the appropriateness of early sepsis care that incorporates elements of the Surviving Sepsis Campaign guidelines, and our data collection is based on this national quality metric.
13.
Gaieski DF, Edwards JM, Kallan MJ, Mikkelsen ME, Goyal M, Carr BG. The relationship between hospital volume and mortality in severe sepsis. Am. J. Respir. Crit. Care Med. 190(6), 665–674 (2014).
14.
Nguyen Y-L, Wallace DJ, Yordanov Y et al. The volume-outcome relationship in critical care: a systematic review and meta-analysis. Chest 148(1), 79–92 (2015).
15.
Urban and Rural Classification and Urban Areas Criteria (2010). www.census.gov/programs-surveys/geography/guidance/geo-areas/urban-rural/2010-urban-rural.html
16.
Glickman SW, Krubert C, Koppenhaver J, Glickman LT, Schulman KA, Cairns CB. Increased rate of central venous catheterization procedures in community EDs. Am. J. Emerg. Med. 28(2), 208–212 (2010).
17.
Djogovic D, Green R, Keyes R et al. Canadian Association of Emergency Physicians Sepsis Treatment Checklist: Optimizing Sepsis Care in Canadian Emergency Departments. CJEM 14(1), 36–39 (2012).
18.
Salhi RA, Edwards JM, Gaieski DF, Band RA, Abella BS, Carr BG. Access to care for patients with time-sensitive conditions in Pennsylvania. Ann. Emerg. Med. 63(5), 572–579 (2014).
19.
Faine BA, Noack JM, Wong T et al. Interhospital transfer delays appropriate treatment for patients with severe sepsis and septic shock: a retrospective cohort study. Crit. Care Med. 43(12), 2589–2596 (2015).
20.
Burenheide K. Developing Disease State Management Guidelines for Rural Health Care (2008). www.mwcritcare.org
21.
Kaukonen K, Bailey M, Suzuki S, Pilcher D, Bellomo R. Mortality related to severe sepsis and septic shock among critically ill patients in Australia and New Zealand, 2000–2012. JAMA 311(13), 1308–1316 (2014).
22.
Arise, Anzics. The outcome of patients with sepsis and septic shock presenting to emergency departments in Australia and New Zealand. Crit. Care Resus. 9(1), 8–18 (2007).
23.
Kocher KE, Haggins AN, Sabbatini AK, Sauser K, Sharp AL. Emergency department hospitalization volume and mortality in the United States. Ann. Emerg. Med. 64(5), 446–457 (2014).
24.
Mohr NM, Wong TS, Faine B, Schlichting A, Noack J, Ahmed A. Discordance between patient and clinician experiences and priorities in rural interhospital transfer: a mixed methods study. J. Rural Health 32(1), 25–34 (2016).
25.
Groth H, House H, Overton R, Deroo E. Board-certified emergency physicians comprise a minority of the emergency department workforce in iowa. West J. Emerg. Med. 14(2), 186–190 (2013).
26.
Iwashyna TJ. The incomplete infrastructure for interhospital patient transfer. Crit. Care Med. 40(8), 2470–2478 (2012).
27.
Golestanian E, Scruggs JE, Gangnon RE, Mak RP, Wood KE. Effect of interhospital transfer on resource utilization and outcomes at a tertiary care referral center. Crit. Care Med. 35(6), 1470–1476 (2007).
28.
Mohr NM, Harland KK, Shane DM, Ahmed A, Fuller BM, Torner JC. Inter-hospital transfer is associated with increased mortality and costs in severe sepsis and septic shock: an instrumental variables approach. J. Crit. Care 36, 187–194 (2016).
29.
Mohr NM, Harland KK, Shane DM et al. Rural patients with severe sepsis or septic shock who bypass rural hospitals have increased mortality: an instrumental variables approach. Crit. Care Med. 45(1), 85–93 (2017).
30.
Van Zanten AR, Brinkman S, Arbous MS, Abu-Hanna A, Levy MM, De Keizer NF. Guideline bundles adherence and mortality in severe sepsis and septic shock. Crit. Care Med. 42(8), 1890–1898 (2014).
31.
Ward MM, Ullrich F, Mueller K. Extent of telehealth use in rural and urban hospitals. Rural Policy Brief, 1(2014 4), 1–4 (2014).
32.
Mohr N, Harland K, Chrischilles E et al. Telemedicine penetration and consultation among rural trauma patients in critical access hospital emergency departments in North Dakota. Rural Telehealth Res. Center Res. Policy Brief 2016(2), 1–4 (2016).
33.
Zachrison KS, Hayden EM, Schwamm LH et al. Characterizing New England emergency departments by telemedicine use. West J. Emerg. Med. 18(6), 1055–1060 (2017).
34.
Hollander JE, Carr BG. Virtually perfect? Telemedicine for Covid-19. N. Engl. J. Med. 382(18), 1679–1681 (2020).
35.
Potter AJ, Mueller KJ, Mackinney AC, Ward MM. Effect of tele-emergency services on recruitment and retention of US rural physicians. Rural Remote Health 14(3), 2787 (2014).
36.
Mohr NM, Vakkalanka JP, Harland KK et al. Telemedicine use decreases rural emergency department length of stay for transferred North Dakota trauma patients. Telemed. J. E. Health 24(3), 194–202 (2018).
37.
Mohr NM, Young T, Harland KK et al. Emergency department telemedicine shortens rural time-to-provider and emergency department transfer times. Telemed. J. E. Health 24(8), 582–593 (2018).
38.
Mohr NM, Hurst EK, Mackinney AC, Nash EC, Carr BG, Skow B. Telemedicine for Early Treatment of Sepsis. In: Telemedicine in the Intensive Care Unit. Koenig MA (Ed.). Springer International Publishing, NY, USA, 255–280 (2019).
39.
Rincon TA, Manos EL, Pierce JD. Telehealth intensive care unit nurse surveillance of sepsis. Comput. Inform. Nurs. 35(9), 459–464 (2017).
40.
Loyola S, Wilhelm J, Fornos J. An innovative approach to meeting early goal-directed therapy using telemedicine. Crit. Care Nurs. Q. 34(3), 187–199 (2011).
41.
Deisz R, Rademacher S, Gilger K et al. Additional telemedicine rounds as a successful performance-improvement strategy for sepsis management: observational multicenter study. J. Med. Internet Res. 21(1), e11161 (2019).
42.
Rincon TA, Bourke G, Seiver A. Standardizing sepsis screening and management via a tele-ICU program improves patient care. Telemed. J. E. Health 17(7), 560–564 (2011).
43.
Agarwal AK, Gaieski DF, Perman SM et al. Telemedicine REsuscitation and Arrest Trial (TREAT): a feasibility study of real-time provider-to-provider telemedicine for the care of critically ill patients. Heliyon 2(4), e00099 (2016).
44.
Mohr NM, Campbell KD, Swanson MB, Ullrich F, Merchant KA, Ward MM. Provider-to-provider telemedicine improves adherence to sepsis bundle care in community emergency departments. J. Telemed. Telecare (.2020) (Epub ahead of print).
•• Telemedicine in emergency departments has been shown previously to improve adherence with international sepsis care guidelines, in a cohort of multiple telemedicine networks. In the prior paper, however, patient-oriented clinical outcomes were not able to be evaluated.
45.
Machado SM, Wilson EH, Elliott JO, Jordan K. Impact of a telemedicine eICU cart on sepsis management in a community hospital emergency department. J. Telemed. Telecare 24(3), 202–208 (2018).
46.
Ilko SA, Vakkalanka JP, Ahmed A, Harland KK, Mohr NM. Central venous access capability and critical care telemedicine decreases inter-hospital transfer among severe sepsis patients: a mixed methods design. Crit. Care Med. 47(5), 659–667 (2019).
47.
Mohr N, Skow B, Wittrock A et al. Improving access to high quality sepsis care in a South Dakota emergency telemedicine network. Rural Telehealth Res. Center Res. Policy Brief 2017(8), 1–4 (2017).
•• The participating telemedicine network has implemented sepsis quality of care pathways previously, upon which the proposed evaluation is built.
48.
Campbell M, Katikireddi SV, Hoffmann T, Armstrong R, Waters E, Craig P. TIDieR-PHP: a reporting guideline for population health and policy interventions. BMJ 361, k1079 (2018).
49.
Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 370(9596), 1453–1457 (2007).
50.
Iwashyna TJ, Odden A, Rohde J et al. Identifying patients with severe sepsis using administrative claims: patient-level validation of the angus implementation of the international consensus conference definition of severe sepsis. Med. Care 52(6), e39–43 (2014).
51.
Vincent JL, Moreno R, Takala J et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the working group on sepsis-related problems of the European Society of Intensive Care Medicine. Intens. Care Med. 22(7), 707–710 (1996).
52.
Bone RC, Balk RA, Cerra FB et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest 101(6), 1644–1655 (1992).
53.
Singer M, Deutschman CS, Seymour C et al. The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA 315(8), 801–810 (2016).
54.
Zhu X, Merchant KaS, Mohr NM, Wittrock AJ, Bell AL, Ward MM. Real-time learning through telemedicine enhances professional training in rural emergency departments. Telemed. J. E. Health (2020) (Epub ahead of print).
55.
Kaji AH, Schriger D, Green S. Looking through the retrospectoscope: reducing bias in emergency medicine chart review studies. Ann. Emerg. Med. 64(3), 292–298 (2014).
56.
Campbell K, Vakkalanka P, Wittrock A et al. Telemedicine is associated with improved antibiotic appropriateness in rural emergency departments (oral presentation). Society for Education and Research in Connected Health (SEARCH) (2017).
57.
Yehya N, Harhay MO, Curley MaQ, Schoenfeld DA, Reeder RW. Reappraisal of ventilator-free days in critical care research. Am. J. Respir. Crit. Care Med. 200(7), 828–836 (2019).
58.
Surviving Sepsis Campaign: Updated Bundles in Response to New Evidence (2015). www.survivingsepsis.org/SiteCollectionDocuments/SSC_Bundle.pdf
59.
Levy MM, Evans LE, Rhodes A. The surviving sepsis campaign bundle: 2018 update. Intens. Care Med. 44(6), 925–928 (2018).
60.
Metlay JP, Waterer GW, Long AC et al. Diagnosis and treatment of adults with community-acquired pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am. J. Respir. Crit. Care Med. 200(7), e45–e67 (2019).
61.
Gupta K, Hooton TM, Naber KG et al. International Clinical Practice Guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin. Infect. Dis. 52(5), e103–e120 (2011).
62.
Stevens DL, Bisno AL, Chambers HF et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin. Infect. Dis. 59(2), e10–e52 (2014).
63.
Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit. Care Med. 13(10), 818–829 (1985).
64.
Berger T, Green J, Horeczko T et al. Shock index and early recognition of sepsis in the emergency department: pilot study. West J. Emerg. Med. 14(2), 168–174 (2013).
65.
EconomicResearch Service. Rural-urban commuting area codes (2020). www.ers.usda.gov/data-products/rural-urban-commuting-area-codes.aspx
66.
Austin PC. A comparison of 12 algorithms for matching on the propensity score. Stat. Med. 33(6), 1057–1069 (2014).
67.
Austin PC. An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivar. Behav. Res. 46(3), 399–424 (2011).
68.
Sobel M. Asymptotic confidence intervals for indirect effects in structural equation models. In: Sociological Methodology, Leinhardt S (Ed.). American Sociological Association, Washington DC, USA, 290–312 (1982).
69.
Mackinnon DP, Fairchild AJ, Fritz MS. Mediation analysis. Ann. Rev. Psychol. 58, 593 (2007).
70.
Iacobucci D. Mediation analysis and categorical variables: the final frontier. J. Consumer Psychol. 22(4), 582–594 (2012).
71.
Imai K, Keele L, Tingley D. A general approach to causal mediation analysis. Psychol. Meth. 15(4), 309–334 (2010).
72.
Valeri L, Vanderweele TJ. Mediation analysis allowing for exposure-mediator interactions and causal interpretation: theoretical assumptions and implementation with SAS and SPSS macros. Psychol. Meth. 18(2), 137–150 (2013).
73.
Linden A, Karlson KB. Using mediation analysis to identify causal mechanisms in disease management interventions. Health Serv. Outcomes Res. Meth. 13, 86–108 (2013).
74.
Williams J, Mackinnon DP. Resampling and distribution of the product methods for testing indirect effects in complex models. Struct. Equ. Modeling 15(1), 23–51 (2008).
75.
Weiss AJ, Elixhauser A. Overview of hospital stays in the United States, 2012 (Statistical Brief #180). 1–14 (2014).
76.
Rotter T, Kugler J, Koch R et al. A systematic review and meta-analysis of the effects of clinical pathways on length of stay, hospital costs and patient outcomes. BMC Health Serv. Res. 8(1), 265 (2008).
77.
Rhodes A, Phillips G, Beale R et al. The Surviving Sepsis Campaign bundles and outcome: results from the International Multicentre Prevalence Study on Sepsis (the IMPreSS study). Intens. Care Med. 41(9), 1620–1628 (2015).
78.
Levy MM, Dellinger RP, Townsend SR et al. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Intens. Care Med. 36(2), 222–231 (2010).
79.
Levy MM, Rhodes A, Phillips GS et al. Surviving Sepsis Campaign: association between performance metrics and outcomes in a 7.5-year study. Intens. Care Med. 40(11), 1623–1633 (2014).
80.
Donabedian A. The quality of care. How can it be assessed? JAMA 260(12), 1743–1748 (1988).
Information & Authors
Information
Published In
Copyright
© 2021 Future Medicine Ltd.
History
Received: 7 July 2020
Accepted: 20 November 2020
Published online: 20 January 2021
Keywords:
Topics
Authors
Metrics & Citations
Metrics
Article Usage
Article usage data only available from February 2023. Historical article usage data, showing the number of article downloads, is available upon request.
Citations
How to Cite
TELEmedicine as an intervention for sepsis in emergency departments: a multicenter, comparative effectiveness study (TELEvISED Study). (2021) Journal of Comparative Effectiveness Research. DOI: 10.2217/cer-2020-0141
Export citation
Select the citation format you wish to export for this article or chapter.
Citing Literature
- Al Anoud Abdul, Mohamed Mustaf Ahmed, Elsayed S. Moubarak, Majd Oweidat, Emma Cravo, Farah Deeba, Mohammed Alsabri, Pediatric Shock in Low-Middle-Income Countries: Evidence-Based Strategies for Recognition, Resuscitation, and System-Level Adaptations, Current Treatment Options in Pediatrics, 10.1007/s40746-026-00367-7, 12, 1, (2026).
- Joshua Cunningham, Niklas Bobrovitz, Ajaykumar Shanmugaraj, Dean Giustini, Dylan Collins, Defining emergency physicians’ consultative roles in emergency care: a scoping review, Canadian Journal of Emergency Medicine, 10.1007/s43678-025-01025-x, 28, 2, (129-137), (2025).
- Anna M. Kaldjian, Priyanka Vakkalanka, Uche Okoro, Cole Wymore, Karisa K. Harland, Kalyn Campbell, Morgan B. Swanson, Brian M. Fuller, Brett Faine, Anne Zepeski, Edith A. Parker, Luke Mack, Amanda Bell, Katie DeJong, Kelli Wallace, Keith Mueller, Elizabeth Chrischilles, Christopher R. Carpenter, Michael P. Jones, Marcia M. Ward, Nicholas M. Mohr, The Effect of Sepsis Recognition on Telemedicine Use in Rural Emergency Department Sepsis Treatment, Telemedicine and e-Health, 10.1089/tmj.2024.0281, 31, 7, (848-857), (2025).
- Nicholas M. Mohr, Kimberly A.S. Merchant, Brian M. Fuller, Brett Faine, Luke Mack, Amanda Bell, Katie DeJong, Edith A. Parker, Keith Mueller, Elizabeth Chrischilles, Christopher R. Carpenter, Michael P. Jones, Steven Q. Simpson, Marcia M. Ward, The role of telehealth in sepsis care in rural emergency departments: A qualitative study of emergency department sepsis telehealth user perspectives, PLOS One, 10.1371/journal.pone.0321299, 20, 4, (e0321299), (2025).
- Benjamin Wilkinson, Eliezer Santos León, J. Priyanka Vakkalanka, Azeemuddin Ahmed, Karisa K. Harland, Brian M. Fuller, Kalyn Campbell, Morgan B. Swanson, Brett Faine, Anne Zepeski, Luke Mack, Amanda Bell, Katie DeJong, Kelli Wallace, Edith A. Parker, Keith Mueller, Elizabeth Chrischilles, Christopher R. Carpenter, Michael P. Jones, Steven Q. Simpson, Nicholas M. Mohr, Longer Total Interhospital Transfer Times for Rural Sepsis Patients Not Associated with Increased Mortality, Prehospital Emergency Care, 10.1080/10903127.2024.2447044, 29, 8, (1111-1116), (2025).
- Andreas Edel, Kristina Fuest, George Karlis, Principles and Management of Sepsis, Best 2022 Clinical Cases in Intensive Care Medicine, 10.1007/978-3-031-36398-6_1, (3-14), (2023).
- Nicholas M. Mohr, Uche Okoro, Karisa K. Harland, Brian M. Fuller, Kalyn Campbell, Morgan B. Swanson, Cole Wymore, Brett Faine, Anne Zepeski, Edith A. Parker, Luke Mack, Amanda Bell, Katie DeJong, Keith Mueller, Elizabeth Chrischilles, Christopher R. Carpenter, Kelli Wallace, Michael P. Jones, Marcia M. Ward, Outcomes Associated With Rural Emergency Department Provider-to-Provider Telehealth for Sepsis Care: A Multicenter Cohort Study, Annals of Emergency Medicine, 10.1016/j.annemergmed.2022.07.024, 81, 1, (1-13), (2023).
- Nicholas M Mohr, Allison R Schuette, Fred Ullrich, Luke J Mack, Katie DeJong, Carlos A Camargo Jr, Kori S Zachrison, Krislyn M Boggs, Adam Skibbe, Amanda Bell, Mark Pals, Dan M Shane, Knute D Carter, Kimberly AS Merchant, Marcia M Ward, An economic and health outcome evaluation of telehealth in rural sepsis care: a comparative effectiveness study, Journal of Comparative Effectiveness Research, 10.2217/cer-2022-0019, 11, 10, (703-716), (2022).
