• Christina Kalvelage, Susanne Rademacher, Sandra Dohmen, Gernot Marx, and Carina Benstoem.
• All authors: Department of Intensive Care Medicine and Intermediate Care, Medical Faculty, RWTH Aachen University, Aachen, Germany.
• Crit. Care Med. 2021 Jul 1; 49 (7): 116911811169-1181.

ObjectivesAlthough the current coronavirus disease 2019 pandemic demonstrates the urgent need for the integration of tele-ICUs, there is still a lack of uniform regulations regarding the level of authority. We conducted a systematic review and meta-analysis to evaluate the impact of the level of authority in tele-ICU care on patient outcomes.Data SourcesWe searched MEDLINE, EMBASE, CENTRAL, and Web of Science from inception until August 30, 2020.Study SelectionWe searched for randomized controlled trials and observational studies comparing standard care plus tele-ICU care with standard care alone in critically ill patients.Data ExtractionTwo authors performed data extraction and risk of bias assessment. Mean differences and risk ratios were calculated using a random-effects model.Data SynthesisA total of 20 studies with 477,637 patients (ntele-ICU care = 292,319, ncontrol = 185,318) were included. Although "decision-making authority" as the level of authority was associated with a significant reduction in ICU mortality (pooled risk ratio, 0.82; 95% CI, 0.71-0.94; p = 0.006), we found no advantage of tele-ICU care in studies with "expert tele-consultation" as the level of authority. With regard to length of stay, "decision-making authority" resulted in an advantage of tele-ICU care (ICU length of stay: pooled mean difference, -0.78; 95% CI, -1.46 to -0.10; p = 0.14; hospital length of stay: pooled mean difference, -1.54; 95% CI, -3.13 to 0.05; p = 0.06), whereas "expert tele-consultation" resulted in an advantage of standard care (ICU length of stay: pooled mean difference, 0.31; 95% CI, 0.10-0.53; p = 0.005; hospital length of stay: pooled mean difference, 0.58; 95% CI, -0.04 to 1.21; p = 0.07).ConclusionsIn contrast to expert tele-consultations, decision-making authority during tele-ICU care reduces mortality and length of stay in the ICU. This work confirms the urgent need for evidence-based ICU telemedicine guidelines and reveals potential benefits of uniform regulations regarding the level of authority when providing tele-ICU care.Copyright © 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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