Page 96 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

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

and the impact on total census was marginal. The study concluded that disease-specific referral centers (Fig. 10-1). These different models
regionalizing care was feasible and might result in a significant mortality may suit different regions to varying degrees. Next, policy makers must
benefit for these patients. explicitly define the methods to identify regional referral centers and
Although this study provides some conceptual support for regional- the method to identify patients in need to transfer to a regional care
ization, there are a number of important limitations. The study assumed center. It is essential that these criteria be objective to avoid subjective
that patients transferred to regional referral centers would receive the and necessarily arbitrary decisions that may hurt hospital economies or
same mortality benefit as patients originally admitted to those centers, allow for gaming of the system. Potential structural criteria for referral
an untested assumption. Additionally, the study assumed a perfect tri- center certification include intensivist physician staffing and the avail-
age model whereby all eligible patients were successfully triaged to a ability of definitive surgical, coronary, and cardiac care, among others
regional referral center. In reality, triage is extremely difficult under the (Table 10-2). 11,23,34-39 Certification as a regional referral center should be
best of circumstances, even in trauma where triage criteria are relatively voluntary, yet certification should be regulated by existing governmen-
standardized and objective. In the broader world of critical care, there tal bodies in order to ensure that the number and location of regional
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are no commonly accepted strategies for triaging patients at high risk for referral centers best meet population needs. The goal is not only to
death. There are several strategies under development, although early improve access but also to make access as equitable as possible—equity
evidence suggests that none are adequate for immediate use. 31 may be harmed if some areas are overserved by regional centers and
■ BARRIERS other areas are underserved.
Practically, regionalization will require the dedicated, coordinated
Regionalization faces several key barriers to implementation efforts of clinicians and policy makers. Support from all relevant
(Table 10-1). In a 2009 survey of intensive care physicians, the most stakeholders is needed, with leadership likely coming from profes-
significant perceived barrier to regionalization was the lack of a strong sional medical societies who are in the best position to develop
centralized authority to regulate and enforce the system. In the evidence-based standards for hospital certification, and governmental
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United States, there is no central health authority to oversee such a sys- accreditation bodies who are in the best position to enforce those
tem—even trauma regionalization is a patchwork of mechanisms and standards. Regionalization will also require demonstration products
authorities that varies across regions. There is also substantial hospital supporting both feasibility and effectiveness. Given the large-scale
competition in the United States, which might preclude standardization system changes that regionalization involves, it is unlikely that we can
of critical care delivery across hospitals in a region. Some countries such proceed until initial studies demonstrate improvements in patient-
as the United Kingdom, Canada, and Australia have public health sys- centered outcomes.
tems and regional health authorities capable of regulating a regionalized ■
critical care system; however, even in these countries hospitals may resist ROLE OF INTENSIVISTS
efforts to dictate the services they can provide. Practicing intensivists should be aware of the key roles they will play in a
Another major barrier to regionalization is the personal strain on regionalized system. If critical care is regionalized, it will likely occur as
families that regionalization may cause. Under a regionalized scenario, an inclusive system, whereby all hospitals are capable of providing some
patients and families may be forced to travel long distances to receive level of critical care, but more seriously ill patients are systematically
critical care, often by unfamiliar clinicians in unfamiliar settings. The transferred to higher levels. This is in contrast to an exclusive system,
system may therefore place undue burden on families and compromise whereby only some hospitals can provide critical care and triage occurs
the patient-physician relationship, leading to adverse consequences entirely outside the hospital. The distinction is important because exclu-
such as cognitive and emotional dysfunction among family members. sive systems place the burden of triage and initial treatments both on
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Patients and families may be willing to accept a higher risk of death if it emergency medical personnel and emergency physicians and intensiv-
means receiving critical care closer to home. ists practicing in small community centers. Although these clinicians
Other barriers to regionalization include capacity constraints at large- may not need extensive experience in caring for patients with severe
volume hospitals, the difficulty in accurately identifying patients in need multiple organ dysfunction, they will still need the ability to quickly
of transfer, and providers’ (both hospitals and physicians) potential recognize emerging critical care syndromes and activate the necessary
unwillingness to sacrifice income when patients are transferred to other treatment and transfer protocols. Intensivists will also be responsible
hospitals for care. for helping to inform overall system design, including the outcomes by
■ IMPLEMENTATION STRATEGIES which accountable care systems will be evaluated and benchmarked.
Ultimately, it is essential that intensivists take an active role in the devel-
To overcome these barriers and effectively implement regionalized opment of regional critical care systems, lest regionalization proceed
care will require both intelligent system design and a coordinated without significant intensivist input.
effort among stakeholders. Several issues around the design of a
regionalized care system must be addressed by careful comparative- TELEMEDICINE
effectiveness research. First, regional systems can be designed around
either a traditional hub-and-spoke model or a model with multiple ICU telemedicine refers to the use of audiovisual technology to pro-
vide critical care from a remote location. Telemedicine itself is a broad
concept that has been in use for decades in several medical fields. In
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TABLE 10-1 Barriers to the Development of Regionalized Systems of Care general, there are three major categories of telemedicine: store-and-
forward, remote monitoring, and interactive care. Store-and-forward
Need for a strong central authority to regulate and manage the system
systems such as teleradiology and telepathology involve the remote
Lack of consensus on the criteria for a regional referral center analysis of static medical data and are common in the current health
Lack of objective patient triage criteria system. In the ICU, telemedicine most typically refers to a combination
of remote monitoring, by which the health status of patients is continu-
Potential to overwhelm capacity and resources at large referral centers
ously monitored, and interactive care, by which the technology is used
Risks of routine interhospital transport for critical ill patients to directly manage patients in real time. Applications of telemedicine-
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Physician and hospital resistance to lose autonomy and income based technology that do not involve direct patient contact, for example,
distance-based medical education and quality improvement, come
Potential to decrease overall quality at small volume hospitals
under the rubric telehealth, and, although important to the practice of
Personal strain on patients and families critical care, are not discussed here.

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