Page 94 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

62 PART 1: An Overview of the Approach to and Organization of Critical Care

KEY REFERENCES
Regionalization might improve outcomes by concentrating
• Aylwin C, König T, Brennan N, et al. Reduction in critical mortal- patients at high-quality centers of excellence and by increasing the
ity in urban mass casualty incidents: analysis of triage, surge, and efficiency of care.
resource use after the London bombings on July 7, 2005. Lancet. • Important barriers to regionalization include the need for a strong
2006-2007;368(9554):2219-2225. central authority to regulate and manage the system and potential
• Dries D, Bracco D, Razek T, Smalls-Mantey N, Amundson D. capacity strain at large-volume hospitals.
Conventional explosions and blast injuries. In: Geiling J, ed. • Telemedicine entails the use of audio, visual, and electronic links to
Fundamental Disaster Management. Mount Prospect, IL: Society provide critical care across a distance. Telemedicine might improve
of Critical Care Medicine; 2009:7-1-7-26. outcomes by leveraging intensivist expertise across greater num-
• Gomersall C, Tai D, Loo S, et al. Expanding ICU facilities in bers of patients and facilitating local quality improvement, thereby
an epidemic: recommendations based on experience from the improving access to high-quality critical care.
SARS epidemic in Hong Kong and Singapore. Int Care Med. • Important barriers to telemedicine include the high cost of the
2006;32:1004-1013. infrastructure and operation, local resistance to organizational
• Hanley ME, Bogdan GM. Mechanical ventilation in mass casu- changes, and pragmatic barriers related to interoperability with
alty scenarios. Augmenting staff: project XTREME. Respir Care. existing clinical information systems.
2008;53:176-188. • Both regionalization and telemedicine will play an important role
• Kirschenbaum L, Keene A, O’Neill P, Westfal R, Astiz ME. The in future critical care delivery. Critical care clinicians should be
experience at St. Vincent’s Hospital, Manhattan, on September 11, prepared to help shape these complementary approaches, as well
2001: Preparedness, response, and lessons learned. Crit Care Med. as work to maintain patient centeredness in the face of a rapidly
2005;33(1):S48-S52. evolving critical care system.
• Nates J. Combined external and internal hospital disaster: impact
and response in a Houston trauma center intensive care unit. Crit
Care Med. 2004;32(3):686-690. For most of its history, critical care medicine has existed as a local pur-
• Rubinson L, Branson RD, Pesik N, Talmor D. Positive-pressure suit. Nurses and physicians provided high-intensity care to seriously ill
patients within a hospital, but rarely thought beyond the hospital walls.
ventilation equipment for mass casualty respiratory failure. More recently, however, the practice of critical care has evolved into a
Biosecur Bioterror. 2006;4:183-194. regional endeavor, one in which intensivists across multiple hospitals
• Rubinson L, Hick JL, Curtis JR, et al. Definitive care for the must provide for the critical care needs of an entire populace within a
critically ill during a disaster: medical resources for surge capacity: region. Regional referral centers now routinely provide specialty critical
from a Task Force for Mass Critical Care summit meeting, January care services to the highest-risk patients, interhospital transfers of criti-
1
26-27, 2007, Chicago, IL. Chest. 2008;133:32S-50S. cally ill patients are increasingly common, and the threats of pandemics
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• Rubinson L, Hick JL, Hanfling DG, et al. Definitive care for the and natural disasters are forcing hospitals within regions to coordinate
3
critically ill during a disaster: a framework for optimizing critical their critical care services. Governmental agencies will soon require
care surge capacity: from a Task Force for Mass Critical Care summit that regional critical care services not only be coordinated but also
meeting, January 26-27, 2007, Chicago, IL. Chest. 2008;133:18S-31S. be accountable—that is, hospitals and regions will have to show that
• Writing Committee of the WHO Consultation on Clinical of they are capable of effectively providing high-quality critical care to all
patients in need.
4
Pandemic (H1N1) 2009 Influenza. Clinical Aspects of Pandemic 2009
Influenza A (H1N1) Virus Infection. NEJM. 2010;362:1708-1719. Several factors explain this paradigm shift in critical care. First, the
expansion of information technology allows hospitals to share clinical
information rapidly and securely. Second, advances in the quality of
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interfacility transport allow the safe transfer of extremely sick patients
across large distances. Third, a shortage of trained intensivist physicians
6
REFERENCES has made it difficult to match intensivist supply with the increasing
demand for critical care under the current system. Finally, and perhaps
7
Complete references available online at www.mhprofessional.com/hall
most importantly, health care stakeholders increasingly recognize that
hospitals vary widely in their capabilities and overall quality of critical
care. Not all hospitals are capable of providing 24-hour trauma care,
8
stroke diagnosis and treatment, emergent surgery, coronary interven-
CHAPTER Telemedicine and tions, or specialty medical care such as continuous renal replacement
therapy or extracorporeal membrane oxygenation (ECMO). Hospitals
10 Regionalization that provide these services are often few and far between, as it is expen-
Jeremy M. Kahn sive and inefficient to reproduce these services at all hospitals. Moreover,
hospitals that care for a large number of critically ill patients typically are
of higher quality, with lower risk-adjusted mortality compared to low-
volume hospitals. Critical care outcomes might be improved by concen-
9
KEY POINTS trating patients in these centers of excellence, or by using technology to
deliver the expertise of these hospitals to smaller, community centers.
• Intensive care unit practitioners increasingly will be required to These developments mean that innovative strategies are needed to cre-
develop, manage, and participate in regional systems of critical care. ate coordinated, accountable, regional systems of critical care. This chap-
• Regionalization and telemedicine are two strategies by which criti- ter will discuss two such strategies: regionalization, in which high-risk
cal care can be coordinated across a region. patients are systematically transferred to regional referral centers, and
• Regionalization entails the systematic triage and transfer of high-risk telemedicine, in which audiovisual technology is used to provide critical
critically ill patients to designated regional referral centers. care services across a distance. As regional care systems develop they will
likely incorporate both of these approaches to meet the needs of critically

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