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Abstract
Objective To clarify the reasons for consultation, advice sought by frontline physicians and relationship between the patient’s pathology and the type of advice provided to guide the future development of telecritical care services.
Design Secondary analysis of transcripts of telephone calls originally recorded for quality control purposes was conducted using a thematic content analysis. The calls were conducted between December 2019 and April 2021 (total cases: 70; total time: ~15 hour).
Settings Intensivists provided consultation services to frontline physicians at secondary care institutions in the Kansai and Chubu regions.
Participants Non-intensive care frontline physicians working in five secondary care institutions in the Kansai and Chubu regions and intensivists providing a consultation service (n=26).
Interventions Not applicable.
Primary and secondary outcome measures The main outcome was the themes emerging from the language used during telephone and video consultations, indicating the gap filled by the telecritical care service.
Findings We analysed 70 cases and approximately 15 hours of anonymised audio data. We identified the following reasons for consultation: ‘lack of competence in treatment and diagnostic testing’ and ‘lack of access to consultation in their own hospital’. Frontline physicians most often sought advice related to ‘treatment’, followed by ‘patient triage and transfer’, ‘diagnosis’ and ‘diagnostic testing and evaluation’. Regarding the relationship between the patient’s pathology and type of advice provided, the most commonly sought advice by frontline physicians varied based on the patient’s pathology.
Conclusion This study explored the characteristics of 70 telecritical sessions and identified the reasons for and nature of the consultations. These findings can be used to guide the future provision and scale up of telecritical services.
- telemedicine
- qualitative research
- intensive & critical care
Data availability statement
Data are available upon reasonable request.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
This study analysed the reasons for seeking consultation and type of advice sought by frontline physicians to clarify the telecritical care needs in Japan.
The need for telecritical care was explored by performing a thematic content analysis.
No proactive, scheduled or continuous care models were analysed.
The perspective of the bedside nurses, patients or other stakeholders was not included.
Introduction
Telecritical care (the updated term of tele-intensive care unit (ICU)) is a critical care service delivered from one location to another through communications technologies.1 In the USA, telecritical care has been increasingly applied since its introduction in 2000.2 Currently, ~28% hospitals in the USA have introduced telecritical care, making it the largest telecritical care market in the world.3 Previous studies, including a systematic review, have reported the multiple benefits of telecritical care, such as reduced mortality and hospital stay, enhanced quality of care and patient safety and improved adherence to guidelines.4–6 In addition, reportedly, frontline medical staff are willing to implement telecritical care despite their fears and apprehensions regarding this technology.7 8
The utility of telecritical care was recognised many years ago worldwide, although its adoption was gradual because of barriers such as the cost of introduction. However, the necessity for telemedicine has drastically increased owing to the COVID-19 pandemic, resulting in its rapid adoption in numerous countries over the past few years, which may have had several positive impacts such as reduced mortality and increased confidence in the medical staff.9
Compared with the USA, Japan has fewer intensive care beds and intensivists. For example, the USA has 34.7 ICU beds and ~9 intensivists per 100 000 people, whereas Japan has 13.5 ICU beds and only ~1.6 intensivists per 100 000 people.10–12 Furthermore, the uneven regional distribution of intensivists is prominent in Japan, with 40% intensivists concentrated in the top five prefectures, accounting for the largest number of intensivists; consequently, ~70% hospitals in Japan cannot secure intensivists.2 13 Therefore, telecritical care may be important in Japan for providing intensive care in hospitals without intensivists. However, only few hospitals have adopted telecritical care in Japan, even after its first introduction in 2017.2
Thus, for the widespread use of telecritical care in Japan, the needs for telecritical care from the perspective of frontline physicians should be analysed. However, to the best of our knowledge, this analysis is yet to be conducted, and the direction for developing and spreading telecritical care suited to the medical situation in Japan remains undetermined. Therefore, this study aimed to clarify the telecritical care needs according to the characteristics of telecritical care sessions such as the frequency, context, physician’s specialty and perceptions of frontline physicians in Japan by analysing the reasons for consultation and the advice sought by frontline physicians using qualitative research methods.
Materials and methods
Data collection
Among the three models of telecritical care (continuous, scheduled and reactive care models), reactive care model has been the basis for the services provided by T-ICU Co.14 In this model, the frontline staff working in the hospital and treating patients contacted the remote intensivists providing consultation only when they faced problems. T-ICU is a private company located in Kobe city. T-ICU service is a consultative service that provides second opinions to frontline physicians. It hires intensivists providing consultation living in various regions and provides them with specific telephones and computers that connect them to the contracted hospitals through a highly secure system. Furthermore, intensivists providing consultation at T-ICU are available throughout the day, waiting to receive a consultation from the contracted hospitals. T-ICU also collaborates with hospitals where frontline physicians work, provides these hospitals with computers equipped with highly secure applications that connect the intensivists providing consultation to the system when necessary any time during the day and explains and demonstrates the method to use the system to frontline physicians at the time of installation. T-ICU does not have direct access to patient medical records or video visualisation of the patient. Interaction with bedside nurses is possible; however, it is not used in most cases as bedside nurses contact nurse practitioners working in another service offered by T-ICU. In T-ICU telecritical care services, all consultations are addressed regardless of the setting, including outpatient and emergency departments, grade of the frontline physician and type of request. Consultations from other specialties are also considered because the facility to consult with knowledgeable intensivists at any time can significantly relieve frontline physicians working in secondary care hospitals, which sometimes have limited medical resources.
Here, the data recorded for the quality control of the consultation service were used secondarily for research purposes. Specifically, audio data of telephone and video consultations (recorded from December 2019 to April 2021, with 70 cases and a total time of ~15 hour) between non-intensive care frontline physicians from five secondary care institutions without intensivists in the Kansai and Chubu regions (n=26) and intensivists providing consultation were transcribed verbatim and anonymised for secondary data analysis. The characteristics of telecritical care sessions, such as frequency and context, were also obtained from the transcript. This study conforms to the standards for reporting qualitative research.15
Data analyses
The needs based on the field perspective of telecritical care were explored by performing a thematic content analysis.16 17 After reading the transcript several times, MM and NN deductively coded the text by listing the frequently mentioned specific sentences that corresponded to the reasons for the consultation (ie, why frontline physicians needed to consult) and advice sought by frontline physicians. During the coding process, MM created the first draft of the codebook, which was finalised during discussions in a research meeting after receiving inputs from all coauthors. MM led the coding process based on the codebook, and MM and NN held online meetings every week to address any issues that arose while applying the code.18 We analysed all 70 records to ensure that no important themes were overlooked, even if they may have appeared infrequently, to identify the need for telecritical care in Japan.
After identifying all themes that overlapped in some cases, we tallied the number of cases included in each theme. During consultations, the conversations were in Japanese; therefore, the analysis was also conducted in Japanese to understand the subtle nuances of conversations. While writing reports, the authors, native Japanese speakers who are also fluent in English (MM and NN), translated the themes and codes into English. To ensure accuracy, native English speakers checked the accuracy of the English transcript and made necessary changes without altering the original meaning. MM and NN checked the changes, and all authors gave final approval of the content.
Researcher characteristics and reflexivity
Reflexivity was considered throughout the analyses. The first author, MM, is a medical student who studied clinical medicine before doing clinical practice. All coauthors are board-certified physicians and none of them are intensivists. However, in the Japanese medical system, doctors may move between university hospitals and city hospitals. In university hospitals, they work in the area of their specialty; however, in city hospitals, they have opportunities to independently treat critically ill patients with different diseases, as some hospitals have no intensivists. Therefore, the physicians in our team could interpret the findings of their respective specialties and identify the needs in the consultations provided by frontline physicians. In addition, NN received formal training in qualitative research and has already published multiple qualitative studies.18
While coding transcripts of recorded telecritical care conversations between frontline physicians and intensivists, the authors could have interpreted the results according to their own medical knowledge when the meaning was ambiguous due to omitted words. To avoid this, the authors tried to make interpretations according to the data as much as possible. Any doubt or dispute was resolved by discussing the doubt.
Patient and public involvement
None.
Results
As shown in table 1, ~60% of the analysed consultations were conducted at daytime. As for context, inpatient settings were the most common followed by the emergency room (ER) settings. The most common specialties of the frontline physicians were internal medicine and rehabilitation medicine, and the most common patient condition was circulatory system disease followed by infectious diseases.
Characteristics of telecritical care sessions in this study (n=70)
Table 2 shows the reasons for consultation. These reasons were divided into two categories: ‘lack of competence in treatment and diagnostic testing’ and ‘lack of access to consultation in their own hospital’. Regarding the ‘lack of competence in treatment and diagnostic testing’, many frontline physicians explained that they have to treat patients outside their specialty when they are on duty (‘I am on duty. The patient has a digestive disease whose treatment is not under the area of my expertise’ (frontline physician 1 or FP1)). They added that the patient’s situation made the response and treatment plan more complicated than the frontline physician could handle (‘I found it difficult to cope with the patient because he stated that he would not want to prolong his life and I should never use intubation or a respirator to save him’ (FP2)).
Reasons for consultation
As for the ‘lack of access to consultation in their own hospital’, there were many instances where no one else in the hospital was available for consultation when the frontline physicians were confused about the difficult situation (‘We do not have a cardiologist in this hospital. Therefore, I was wondering if I should urgently refer the patient to a nearby hospital with a cardiologist’. (FP3)). In addition, the frontline physicians could not consult the suitable physician despite being on the spot (‘My colleague, a cardiologist, rebuked me a little saying that even if I consulted with cardiologists, there is nothing (for cardiologists) to do’ (FP4)).
As a result of the teleconsultation, the frontline physicians seemed to feel relieved to be able to consult an intensivist at any time (‘Thank you so much for responding to my consultation so late in the day…that was very helpful, Doctor’ (FP5)).
Table 3 lists the advice sought by frontline physicians. The most common advice they requested from the intensivists providing consultation was related to specific knowledge and skills for treatment, and the content ranged from general advice (‘I am currently treating a patient with asthma…but her respiratory condition has not improved much…it has already been 3 or 4 hours since she was admitted and treated, but…there is no significant improvement…How can I proceed with the treatment?’(FP6)) to electrolyte correction (‘He is starting to get tetany now…calcium and magnesium levels are both decreasing…I was wondering if you could give me some advice regarding whether it is okay to do just magnesium correction at the moment and not apply calcium correction’ (FP7)) and medication (‘I would like to discuss the dosage of Predonine…a patient was admitted to the hospital yesterday. She was rushed to the emergency room with a cold body as well as urinary and fecal incontinence…with accidental hypothermia and urinary tract infection, I think she is in a slight pre-shock…she was taking 10 mg of Predonine per day and Methotrexate for rheumatoid arthritis.…in considering adrenal insufficiency…’ (FP8)). Furthermore, there was only one question related to treatment skills (‘A person who choked on a rice cake is coming to the hospital, so what should we do to remove the rice cake?’ (FP9)).
Advice sought by frontline physicians
Moreover, some frontline physicians asked for advice for patient triage and transfer, including the necessity of transport or consultation (‘I wanted to ask if I should refer the patient to a higher medical institution or ICU in this condition’ (FP10), and ‘I am not sure whether I should consult a neurosurgeon and request a surgery to remove the hematoma or I should just observe the patient without consulting a neurosurgeon’ (FP11)) and whether to respond in an inpatient or outpatient setting (‘I want to admit the patient to the hospital for observation until his symptoms subside. However, is it possible to treat the patient as an outpatient or should I just admit him to the hospital?’ (FP12)). Frontline physicians also asked for advice to make a diagnosis (‘I do not know how to respond (diagnose) because the patient’s pathology is unclear’ (FP13)), and consultations related to image reading were included (‘Could you please have a look at the MRI images?’ (FP14)).
Table 4 shows the relationship between the patient’s pathology and the type of advice provided. For patients with abnormalities in the circulatory system, central nervous system and respiratory diseases, the most common advice sought by frontline physicians were related to specific knowledge and skills for treatment (‘In the case of hemorrhagic infarction, should I lower the blood pressure a little bit for cerebral hemorrhage or not too much for cerebral infarction?’ (FP15), and ‘I would like you to tell me if there are any good settings for respiratory management, because I am not very good at that’ (FP16)). However, for patients with infectious and digestive diseases, the most common advice was related to diagnosis. For patients with infectious diseases, some frontline physicians needed advice for causative organism or virus identification, which is necessary for accurate treatment (‘I was wondering if you could advice whether I should treat it as ordinary pneumonia or I should consider tuberculosis or something similar’ (FP17)). As for those with digestive diseases, some frontline physicians needed advice for image reading skills, which are required for diagnosis (‘I have a case that looks like appendicitis. Therefore, I’d like you to take a look at the images’ (FP18)). Characteristically, for patients with trauma, the most common advice was related to patient triage and transfer (ie, the need for transport or consultation). Some frontline physicians had difficulties in obtaining an accurate medical history when a patient arrived at the hospital and did not know how to best respond (‘The patient was brought to the ER with trauma…. although his level of consciousness was clear, he was drunk (so I could not obtain a reliable medical history from him) …. I was wondering if the patient should be treated by a specialist or should I observe this patient in this hospital’ (FP19)). Deciding whether or not to transport the patient with trauma was also challenging for the frontline physicians (‘I have been told that it is a little difficult for the nearby hospitals to accept this patient. So, I was wondering if I have to transfer the patient to a hospital, going to which will take approximately two and a half hours by car…will it be better to transfer the patient now’ (FP19)). Difficulties in deciding whether to consult with the professional were also noted when managing patients with trauma (The abovementioned consultation by FP11).
Relationship between the patient’s pathology and the type of advice provided
A codebook is presented in online supplemental tables 1 and 2.
Supplemental material
Discussion
This study analysed the characteristics of telecritical care sessions, the reasons for consultation, the advice sought by frontline physicians and the relationship between the patient’s pathology and the type of advice provided.
Regarding characteristics, telecritical care sessions tended to take place during daytime, probably because more manpower is available onsite at daytime. Regarding patient’s pathology, the circulatory system was the most common, followed by infectious diseases, possibly because abnormalities in the circulatory system is a life-threatening condition,19 and physicians can feel threatened and anxious. A previous US-based study also reported high demand for consultations on the circulatory system,20 consistent with the findings of the present study.
For patients with infectious diseases, extensive knowledge of systemic management in addition to the selection of antibacterial drugs is required.21–23 However, in a previous US-based study, the demand for consultations on infectious diseases was not high.20 The high demand for consultation on infectious diseases in this Japanese survey may be related to the shortage of infectious disease specialists. The environment for pregraduate and postgraduate clinical infectious disease education in Japan has only sufficiently developed recently.24–26
As for consultation reasons, physicians utilised telecritical care services when the situations were difficult to handle because of circumstances such as the need to examine a patient outside his or her specialty, complexity of the patient’s condition or unavailability of other physicians whom he or she could consult. This may reflect the situation in Japan, where the number of ICU beds and intensivists relative to population is insufficient compared with that in the USA, and the regional distribution of intensivists is uneven.10–12
Interestingly, the role of the remote ICU is both to support specific treatment and also to provide psychological support to physicians working in an environment with few people to rely on and who are anxious, which indicates that telecritical care is accepted to some extent by frontline physicians. This result is consistent with that of previous studies reporting high levels of staff acceptance of telecritical care.7 8 However, to achieve further acceptance from all frontline medical staff, it is crucial that individuals providing teleconsultation have good communication skills and a system that guarantees and trains frontline medical staff about the technology before implementation.27
The most common advice was related to treatment, and the content ranged from general advice to advice on medication and electrolyte correction methods, which require detailed adjustments. Furthermore, there was only one question about treatment ‘techniques’, probably because teleconsultations were conducted by video or telephone call, making it difficult for onsite physicians to immediately perform the procedures with which they have no experience, despite receiving instructions. However, recently, online easy-to-understand video materials, such as the New England Journal of Medicine Videos in Clinical Medicine28 and procedure consult,29 have been available, and they can be the alternative sources of guidance on clinical care in real time. Thus, using these educational materials is a beneficial approach to provide technical support if the level of invasiveness or urgency is not too high.
The second most common advice was on patient triage and transfer. Many consultations on whether to transport the patient to a higher order medical institution were found. In the US-based setting, while many previous studies have demonstrated that telemedicine is expected to decrease the number of transfers by providing support that enables secondary hospitals to care for patients with highly complicated but non-surgical conditions such as those requiring mechanical ventilation,30 some studies have demonstrated that telemedicine has increased transfers from secondary hospitals with less-resourced ICUs to higher medical institutes.6 31 This is because telemedicine has removed barriers to patient transfer, such as the risk of deterioration of the patient, and prompted appropriate triage.6 31 Therefore, telemedicine is expected to support appropriate triage at secondary hospitals and facilitate transfer to higher order medical institutions.
For advice related to diagnosis, there were consultations on image reading, indicating the intensivists providing consultation should have skills in image reading; they should also acquire knowledge to deal with various diseases. Finally, according to the analysis of the relationship between the patient’s pathology and the type of advice, most advice in specific knowledge and techniques related to treatment for circulatory, central nervous system and respiratory diseases were requested by frontline physicians. This result may be explained by the fact that the treatment of the abovementioned conditions requires complex adjustments of fluids and medications and respiratory settings. Furthermore, the percentage of questions regarding diagnosis was higher for infectious and gastrointestinal diseases than for other conditions. The reason could be that in infectious diseases, diagnosis should include the identification of the causative bacteria and viruses to provide accurate treatment,22 23 and in gastrointestinal diseases, image reading skills are often required for the diagnosis.32 33 Characteristically, for trauma, the largest percentage of advice was related to patient triage and transfer. Obtaining an accurate medical history from a patient with trauma is often difficult on arrival at the hospital, and sometimes, deciding whether to transport the patient to a higher level hospital or admit the patient as an outpatient is difficult. Therefore, advice on how to deal with the situation would increase in trauma cases. These results clarify both the types of specialties that need to be addressed by the telecritical care services and also the types of information that is needed even within a certain specialty. The results of this study provide useful information that should be considered by each telecritical care service when it becomes widely used in Japan in the future.
Previous studies on telecritical care have examined the effectiveness of telecritical care outside of Japan, the issues involved and the acceptance and image of telecritical care among the onsite medical staff. In the USA, for example, telecritical care contributes to lower mortality rates, improved patient satisfaction by shortening hospital stay, improved work environment and increased hospital revenue by improving cost efficiency.4 5 7 However, research on the specific needs of telecritical care, such as this study, is still lacking in Japan and overseas. Therefore, this study is novel, and it provides important information for the future diffusion of telecritical care.
This study has limitations. First, this study targeted only five secondary care hospitals in the Kansai and Chubu regions; therefore, the reasons for consultation and the content of advice may have been influenced by the size, occupancy rate and location of the hospitals, indicating that the results may not apply to other physicians in Japan. Second, this study only considered reactive models of telecritical care and did not analyse proactive, scheduled or continuous care models. Therefore, we have not fully explored the need of proactive, scheduled or continuous care in telecritical care. Third, the perspectives of bedside nurses, patients and other stakeholders were also not considered; thus, we may have missed some important needs in the field. Fourth, there were no intensivists among the authors, indicating that the interpretation of the findings may not have reflected the perspective of intensivists in this study. To address these limitations, in future studies, the research team, including the intensivists, should conduct research at many hospitals in various regions for various telecritical care models and from various perspectives to understand the telecritical care needs more widely and specifically. Fifth, ‘the reasons for consultation’ of frontline physicians were not always explicitly stated within the consultation session, as the data collected by the T-ICU for quality control were used for conducting secondary research. Future studies that explicitly ask frontline physicians regarding their reasons for consultation are warranted. Finally, we have not investigated the impact of the T-ICU service on patient safety, specific utilisations of the service and demographics of the frontline physicians, such as their years of experience. The lack of this information limits our understanding of the effectiveness of telecritical care and identification of who needs support from telecritical care the most. Therefore, the benefits of telecritical care and demographics of frontline physicians should be explored to determine the effectiveness of telecritical care in a future study.
As for the study implications, this study was able to clarify the characteristics of telecritical care sessions, the reasons for consultation, the advice sought by frontline physicians and the relationship between the patient’s pathology and the type of advice provided. Hence, the results provide essential information for the future spread of telecritical care services. These results also suggest that support for procedures in telecritical care may be a niche that still remains inadequately addressed. Recently, easy-to-understand online video materials have been increasingly used.28 29 In the future, providing information from these materials, especially for non-invasive or non-urgent procedures, must be considered while also utilising new innovations to develop remote consultation methods for procedures. Finally, the reasons for consultation by frontline physicians and the advice they seek, as revealed in this study, can also be considered to indicate the points where frontline physicians have problems in their clinical practice. Therefore, if support cannot be provided in telecritical care sessions but can be provided by hospitals through other means, physicians’ satisfaction level might increase and their anxiety in clinical work at hospitals might be mitigated.
In conclusion, this study analysed the characteristics of telecritical care sessions, reasons for consultation, advice sought by frontline physicians and relationship between the patient’s pathology and the type of advice provided. These findings can be used to guide future provision and scale up of telecritical services.
Data availability statement
Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
In this study, audio and video data of consultation sessions that were recorded or videotaped by T-ICU for work quality control (the consulting physicians were aware that the content was recorded during the sessions) were anonymised and used for secondary research purposes. This study was approved by the Research Ethics Committee of Tokyo Medical and Dental University (approval no.: M2021-354), and the need to obtain written informed consent was waived.
Acknowledgments
We would like to thank Dr Nakanishi, Dr Konoike and all the staff at T-ICU Co. for their cooperation in conducting this study.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors Conceptualisation, MM and NN; methodology, MM and NN; validation, NN, EO, YI, AK, KY, YA and MY; formal analysis, MM, NN, EO, YI, AK, YA and MY; resources, MM and KY; data curation, MM; writing—original draft preparation, MM and NN; writing—review and editing, NN, EO, YI, AK, KY, YA and MY; visualisation, MM; supervision, NN and MY. All authors have read and agreed to the published version of the manuscript. NN and MY are guarantors.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests In this study, data recorded for the purpose of quality control of the consultation service of T-ICU Co. were used for secondary use for research purposes. For this purpose, anonymised data were provided free of charge by T-ICU Co.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.