Page 95 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 10: Telemedicine and Regionalization 63

ill patients in a variety of different care settings. This chapter will out- In addition to improving mortality, regionalization could lower
line conceptual models for telemedicine and regionalization, review the costs for patients with critical illness. ICUs exhibit economies of scale,
existing evidence base in support of these two approaches, and provide meaning that additional production in terms of patient throughput is
practical guidance for clinicians who increasingly will be required to accompanied by lower per-unit costs. Most hospital costs are fixed, and
24
develop, manage, and practice in these regional systems of care. with higher volumes those fixed costs can be spread over more patients,
ultimately improving overall efficiency. For example, the cost of a single
REGIONALIZATION ECMO machine might be prohibitively expensive for a small commu-
nity hospital that might use it one or two times per year. However, if a
Regionalization is defined as the systematic transfer of high-risk criti- large center uses ECMO frequently, the costs of that machine are spread
cally ill patients to designated regional referral centers. A regionalized over many patients, reducing the per-patient costs of ECMO. In this
critical care system requires four primary components: way, concentrating high-risk, high-cost care such as critical care has the
• A method to delineate regions, by either geography or political potential to reduce overall costs for the health system.
• A method to objectively stratify hospitals by the level of critical care ■ UNINTENDED CONSEQUENCES
boundaries

they are capable of providing Regionalization carries a number of potential unintended consequences
• A strategy for triaging patients to designated high-level hospitals that could limit or even negate any potential clinical or economic ben-
efits. First, upscaling critical care capacity at some hospitals necessarily
25
• A regulatory body to manage and oversee the system means downscaling capacity at other hospitals. One effect of such a
Although there are few examples of regionalized critical care in exis- down-scaling may be to reduce the ability of these small hospitals to
tence today, regionalized health care exists for several disease syndromes care for sick patients in an emergency. For example, under a regional-
that are analogous to critical care. Regionalized trauma systems are per- ized scenario smaller hospitals will see fewer cases of sepsis. Septic
haps the best example. Most industrial nations have instituted regional- patients receiving care in these hospitals may be subject to increased
ized trauma care in some form. The concept for regionalized trauma morbidity as a result. In this way, although regionalization may ben-
emerged in 1960s out of the advances in emergency medicine and triage efit patients ultimately transferred to large regional referral centers, it
made during the Vietnam conflict, as well as the advocacy work of pro- may harm patients who receive care at smaller community hospitals.
fessional societies that recognized the potential for improved outcomes Regionalization may also harm small hospitals economically, since many
by centralizing care for seriously injured patients. Most existing trauma high-margin medical services such as oncology and cardiac surgery
10
systems are supported by specific legislation, and several studies docu- depend on high-quality critical care. Down-scaling critical care may
ment that injured patients receiving care in a trauma center are less likely force these hospitals to abandon these profitable programs.
to experience morbidity and mortality as a result of their injury than Second, regionalization may place significant capacity strain on
similar patients receiving care in a nontrauma center. 11 high-volume referral centers. Many large academic medical centers
Other clinical domains that are regionalized in some form include are already under pressure to expand critical care capacity in a setting
neonatology, stroke, and acute myocardial infarction, although for- of limited resources. A persistently high census may reduce access to
14
12
13
mal regionalization for these areas is far less prevalent than for trauma. critical care beds, potentially increasing mortality for some patients.
All of these areas, including critical care, share attributes that support Indeed, boarding critically ill patients in the emergency department
the potential benefits of centralized care. These include or in ICUs unequipped to care for specialty cases is associated with
higher mortality, 26,27 a situation that may increase under regionalization.
• The high risk for an adverse outcome Regionalization may also strain our capacity for interhospital transport.
• The time sensitive nature of the conditions Available evidence suggests that long-distance transfer of critically ill
28
• The extensive infrastructure and stand-ready costs necessary for patients is both feasible and safe. However, that reality may change if
effective 24-hour care the system is required to transfer more patients, and more sick patients,
• Demonstrated volume-outcome relationships that suggest that out- over longer distances.
Finally, regionalization may increase rather than decrease health care
comes might be improved by centralizing care at high-volume costs despite the added efficiency from the economies of scale. In addi-
centers 15 tion to existing health care costs, regionalization incurs the added costs
Due to this strong theoretical foundation, regionalization of critical of routine interhospital transport and regulation of the system. Many
care is supported by several multidisciplinary stakeholder groups. Calls trauma systems struggle with issues of costs and cost-effectiveness, and
16
for implementing regionalization of care have occurred both for critical it is likely that the critical care system, which would be of greater scale,
care in general and for specific disease states with a high likelihood of will have these same issues.
critical illness, including acute myocardial infarction, acute stroke, high-
risk surgeries, and out-of-hospital cardiac arrest. 17 ■ EVIDENCE
■ POTENTIAL BENEFITS To date there are few direct data in support of regionalized critical
care. As mentioned above, regionalization is indirectly supported by
Regionalization has several potential benefits, foremost being the the existence of volume-outcome relationships and positive evaluations
potential for increased survival for critically ill patients. Rapid triage of analogous systems such as regionalized trauma and neonatal care.
25
of critical ill patients to hospitals capable of providing definitive criti- Additional indirect support came from a 2008 study that simulated the
cal care could facilitate several time-sensitive evidence-based practices impact of regionalization for nonsurgical patients in the United States
associated with improved outcomes, including thrombolysis for stroke, receiving mechanical ventilation. In that study, which analyzed hospi-
18
29
therapeutic hypothermia for cardiac arrest, and early adequate volume tal discharge data from eight diverse states, nearly 50% of mechanically
19
resuscitation for severe sepsis. Care at a high-volume regional referral ventilated patients received care in ICUs with very low admission vol-
20
center could also facilitate evidence-based practices that although not umes. Simulating the transfer of those patients to high-volume centers
time sensitive are complex and may be better provided at experienced and assuming a mortality benefit similar to past volume-outcome stud-
regional referral centers, such as low-tidal-volume ventilation for acute ies resulted in a significant number of lives saved, with only 15.7 patients
lung injury, daily interruption of continuous sedative infusions, and needed to transfer in order to prevent one death. Transfer distances were
22
21
ECMO for severe acute respiratory failure. 23 relatively small for most patients, especially those located in urban areas,

Section01.indd 63 1/22/2015 9:37:07 AM