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Impact Of Weekly Case-based Tele-education

Research – Open Access

Impact of weekly case-based tele-education on quality of care in a limited resource medical intensive care unit

Pedja Kovacevic, Sasa Dragic, Tijana Kovacevic, Danica Momcicevic, Emir Festic, Rahul Kashyap, Alexander S. Niven, Yue Dong and Ognjen GajicEmail authorView ORCID ID profile
Critical Care201923:220© The Author(s). 2019
Received: 21 January 2019 Accepted: 27 May 2019Published: 14 June 2019



Limited critical care subspecialty training and experience is available in many low- and middle-income countries, creating barriers to the delivery of evidence-based critical care. We hypothesized that a structured tele-education critical care program using case-based learning and ICU management principles is an efficient method for knowledge translation and quality improvement in this setting.

Methods and interventions

Weekly 45-min case-based tele-education rounds were conducted in the recently established medical intensive care unit (MICU) in Banja Luka, Bosnia and Herzegovina. The Checklist for Early Recognition and Treatment of Acute Illness (CERTAIN) was used as a platform for structured evaluation of critically ill cases. Two practicing US intensivists fluent in the local language served as preceptors using a secure two-way video communication platform. Intensive care unit structure, processes, and outcomes were evaluated before and after the introduction of the tele-education intervention.


Patient demographics and acuity were similar before (2015) and 2 years after (2016 and 2017) the intervention. Sixteen providers (10 physicians, 4 nurses, and 2 physical therapists) evaluated changes in the ICU structure and processes after the intervention. Structural changes prompted by the intervention included standardized admission and rounding practices, incorporation of a pharmacist and physical therapist into the interprofessional ICU team, development of ICU antibiogram and hand hygiene programs, and ready access to point of care ultrasound. Process changes included daily sedation interruption, protocolized mechanical ventilation management and liberation, documentation of daily fluid balance with restrictive fluid and transfusion strategies, daily device assessment, and increased family presence and participation in care decisions. Less effective (dopamine, thiopental, aminophylline) or expensive (low molecular weight heparin, proton pump inhibitor) medications were replaced with more effective (norepinephrine, propofol) or cheaper (unfractionated heparin, H2 blocker) alternatives. The intervention was associated with reduction in ICU (43% vs 27%) and hospital (51% vs 44%) mortality, length of stay (8.3 vs 3.6 days), cost savings ($400,000 over 2 years), and a high level of staff satisfaction and engagement with the tele-education program.


Weekly, structured case-based tele-education offers an attractive option for knowledge translation and quality improvement in the emerging ICUs in low- and middle-income countries.


The World Health Organization defines telemedicine as “a health service in conditions where the distance is a critical factor, and it involves the use of information and communication technologies for the exchange of useful information about diagnosis, treatment and prevention of diseases and injuries, for research and continuous medical education of health workers, all in order to improve the health of individuals and their communities”. Telemedicine in critical care has largely gone down the advanced E-ICU pathway to provide 24/7 intensivist support in high-income countries. However, there are alternate paths within the scope of telemedicine suitable for wide array of health care settings, including “e-learning” or tele-education.

Preliminary studies from Mayo Clinic investigators recently demonstrated that video-enabled remote simulation training based on a structured platform (CERTAIN: Checklist for Early Recognition and Treatment of Acute Illness) can be a successful and efficient case-based learning method to disseminate clinical skills to critical care practitioners in diverse international settings.

In low- and middle-income countries, tele-education may offer an attractive option to accelerate knowledge translation and address infrastructure barriers and limited opportunities for intensive care subspecialty training. Video-enabled, case-based discussions were chosen as a cost-efficient method to provide face-to-face education and reinforcement of the CERTAIN platform, which provides a standardized approach and checklist of common, evidence-based best critical care practices.

Our aim was to provide a longitudinal tele-education program and evaluate the impact of spaced, case-based learning and reinforcement on clinical practice and patient outcomes in a recently established intensive care unit in Bosnia and Herzegovina.

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