• 
  

  Intensive care unit practitioners increasingly will be required to develop, manage, and participate in regional systems of critical care.

  
  
• 
  

  Regionalization and telemedicine are two strategies by which critical care can be coordinated across a region.

  
  
• 
  

  Regionalization entails the systematic triage and transfer of high-risk critically ill patients to designated regional referral centers. Regionalization might improve outcomes by concentrating patients at high-quality centers of excellence and by increasing the efficiency of care.

  
  
• 
  

  Important barriers to regionalization include the need for a strong central authority to regulate and manage the system and potential capacity strain at large-volume hospitals.

  
  
• 
  

  Telemedicine entails the use of audio, visual, and electronic links to provide critical care across a distance. Telemedicine might improve outcomes by leveraging intensivist expertise across greater numbers of patients and facilitating local quality improvement, thereby improving access to high-quality critical care.

  
  
• 
  

  Important barriers to telemedicine include the high cost of the infrastructure and operation, local resistance to organizational changes, and pragmatic barriers related to interoperability with existing clinical information systems.

  
  
• 
  

  Both regionalization and telemedicine will play an important role in future critical care delivery. Critical care clinicians should be prepared to help shape these complementary approaches, as well as work to maintain patient centeredness in the face of a rapidly evolving critical care system.

For most of its history, critical care medicine has existed as a local pursuit. Nurses and physicians provided high-intensity care to seriously ill patients within a hospital, but rarely thought beyond the hospital walls. More recently, however, the practice of critical care has evolved into a regional endeavor, one in which intensivists across multiple hospitals must provide for the critical care needs of an entire populace within a region. Regional referral centers now routinely provide specialty critical care services to the highest-risk patients,¹ interhospital transfers of critically ill patients are increasingly common,² and the threats of pandemics and natural disasters are forcing hospitals within regions to coordinate their critical care services.³ Governmental agencies will soon require that regional critical care services not only be coordinated but also be accountable—that is, hospitals and regions will have to show that they are capable of effectively providing high-quality critical care to all patients in need.⁴

Several factors explain this paradigm shift in critical care. First, the expansion of information technology allows hospitals to share clinical information rapidly and securely.⁵ Second, advances in the quality of interfacility transport allow the safe transfer of extremely sick patients across large distances.⁶ Third, a shortage of trained intensivist physicians has made it difficult to match intensivist supply with the increasing demand for critical care under the current system.⁷ Finally, and perhaps most importantly, health care stakeholders increasingly recognize that hospitals vary widely in their capabilities and overall quality of critical care.⁸ Not all hospitals are capable of providing 24-hour trauma care, stroke diagnosis and treatment, emergent surgery, coronary interventions, or specialty medical care such as continuous renal replacement therapy or extracorporeal membrane oxygenation (ECMO). Hospitals that provide these services are often few and far between, as it is expensive 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.⁹ Critical care outcomes might be improved by concentrating patients in these centers of excellence, or by using technology to deliver the expertise of these hospitals to smaller, community centers.

These developments mean that innovative strategies are needed to create coordinated, accountable, regional systems of critical care. This chapter will discuss two such strategies: regionalization, in which high-risk patients are systematically transferred to regional referral centers, and telemedicine, in which audiovisual technology is used to provide critical care services across a distance. As regional care systems develop they will likely incorporate both of these approaches to meet the needs of critically ill patients in a variety of different care settings. This chapter will outline conceptual models for telemedicine and regionalization, review the existing evidence base in support of these two approaches, and provide practical guidance for clinicians who increasingly will be required to develop, manage, and practice in these regional systems of care.

Regionalization is defined as the systematic transfer of high-risk critically ill patients to designated regional referral centers. A regionalized critical care system requires four primary components:

• 
  

  A method to delineate regions, by either geography or political boundaries

  
  
• 
  

  A method to objectively stratify hospitals by the level of critical care they are capable of providing

  
  
• 
  

  A strategy for triaging patients to designated high-level hospitals

  
  
• 
  

  A regulatory body to manage and oversee the system

Although there are few examples of regionalized critical care in existence today, regionalized health care exists for several disease syndromes that are analogous to critical care. Regionalized trauma systems are perhaps the best example. Most industrial nations have instituted regionalized trauma care in some form. The concept for regionalized trauma emerged in 1960s out of the advances in emergency medicine and triage made during the Vietnam conflict, as well as the advocacy work of professional societies that recognized the potential for improved outcomes by centralizing care for seriously injured patients.¹⁰ Most existing trauma systems are supported by specific legislation, and several studies document that injured patients receiving care in a trauma center are less likely to experience morbidity and mortality as a result of their injury than similar patients receiving care in a nontrauma center.¹¹

Other clinical domains that are regionalized in some form include neonatology,¹² stroke,¹³ and acute myocardial infarction,¹⁴ although formal regionalization for these areas is far less prevalent than for trauma. All of these areas, including critical care, share attributes that support the potential benefits of centralized care. These include

• 
  

  The high risk for an adverse outcome

  
  
• 
  

  The time sensitive nature of the conditions

  
  
• 
  

  The extensive infrastructure and stand-ready costs necessary for effective 24-hour care

  
  
• 
  

  Demonstrated volume-outcome relationships that suggest that outcomes might be improved by centralizing care at high-volume centers¹⁵

Due to this strong theoretical foundation, regionalization of critical care is supported by several multidisciplinary stakeholder groups.¹⁶ Calls for implementing regionalization of care have occurred both for critical care in general and for specific disease states with a high likelihood of critical illness, including acute myocardial infarction, acute stroke, high-risk surgeries, and out-of-hospital cardiac arrest.¹⁷

POTENTIAL BENEFITS

Regionalization has several potential benefits, foremost being the potential for increased survival for critically ill patients. Rapid triage of critical ill patients to hospitals capable of providing definitive critical care could facilitate several time-sensitive evidence-based practices associated with improved outcomes, including thrombolysis for stroke,¹⁸ therapeutic hypothermia for cardiac arrest,¹⁹ and early adequate volume resuscitation for severe sepsis.²⁰ Care at a high-volume regional referral center could also facilitate evidence-based practices that although not time sensitive are complex and may be better provided at experienced regional referral centers, such as low-tidal-volume ventilation for acute lung injury,²¹ daily interruption of continuous sedative infusions,²² and ECMO for severe acute respiratory failure.²³

In addition to improving mortality, regionalization could lower costs for patients with critical illness. ICUs exhibit economies of scale, meaning that additional production in terms of patient throughput is accompanied by lower per-unit costs.²⁴ Most hospital costs are fixed, and with higher volumes those fixed costs can be spread over more patients, ultimately improving overall efficiency. For example, the cost of a single ECMO machine might be prohibitively expensive for a small community hospital that might use it one or two times per year. However, if a large center uses ECMO frequently, the costs of that machine are spread over many patients, reducing the per-patient costs of ECMO. In this way, concentrating high-risk, high-cost care such as critical care has the potential to reduce overall costs for the health system.

UNINTENDED CONSEQUENCES

Regionalization carries a number of potential unintended consequences that could limit or even negate any potential clinical or economic benefits.²⁵ First, upscaling critical care capacity at some hospitals necessarily means downscaling capacity at other hospitals. One effect of such a down-scaling may be to reduce the ability of these small hospitals to care for sick patients in an emergency. For example, under a regionalized scenario smaller hospitals will see fewer cases of sepsis. Septic patients receiving care in these hospitals may be subject to increased morbidity as a result. In this way, although regionalization may benefit patients ultimately transferred to large regional referral centers, it may harm patients who receive care at smaller community hospitals. Regionalization may also harm small hospitals economically, since many high-margin medical services such as oncology and cardiac surgery depend on high-quality critical care. Down-scaling critical care may force these hospitals to abandon these profitable programs.

Second, regionalization may place significant capacity strain on high-volume referral centers. Many large academic medical centers are already under pressure to expand critical care capacity in a setting of limited resources. A persistently high census may reduce access to critical care beds, potentially increasing mortality for some patients. Indeed, boarding critically ill patients in the emergency department or in ICUs unequipped to care for specialty cases is associated with higher mortality,^26,27 a situation that may increase under regionalization. Regionalization may also strain our capacity for interhospital transport. Available evidence suggests that long-distance transfer of critically ill patients is both feasible and safe.²⁸ However, that reality may change if the system is required to transfer more patients, and more sick patients, over longer distances.

Finally, regionalization may increase rather than decrease health care costs despite the added efficiency from the economies of scale. In addition to existing health care costs, regionalization incurs the added costs of routine interhospital transport and regulation of the system. Many trauma systems struggle with issues of costs and cost-effectiveness, and it is likely that the critical care system, which would be of greater scale, will have these same issues.

EVIDENCE

To date there are few direct data in support of regionalized critical care. As mentioned above, regionalization is indirectly supported by the existence of volume-outcome relationships and positive evaluations of analogous systems such as regionalized trauma and neonatal care.²⁵ Additional indirect support came from a 2008 study that simulated the impact of regionalization for nonsurgical patients in the United States receiving mechanical ventilation.²⁹ In that study, which analyzed hospital discharge data from eight diverse states, nearly 50% of mechanically ventilated patients received care in ICUs with very low admission volumes. Simulating the transfer of those patients to high-volume centers and assuming a mortality benefit similar to past volume-outcome studies resulted in a significant number of lives saved, with only 15.7 patients needed to transfer in order to prevent one death. Transfer distances were relatively small for most patients, especially those located in urban areas, and the impact on total census was marginal. The study concluded that regionalizing care was feasible and might result in a significant mortality benefit for these patients.

Although this study provides some conceptual support for regionalization, there are a number of important limitations. The study assumed that patients transferred to regional referral centers would receive the same mortality benefit as patients originally admitted to those centers, an untested assumption. Additionally, the study assumed a perfect triage model whereby all eligible patients were successfully triaged to a regional referral center. In reality, triage is extremely difficult under the best of circumstances, even in trauma where triage criteria are relatively standardized and objective.³⁰ In the broader world of critical care, there are no commonly accepted strategies for triaging patients at high risk for death. There are several strategies under development, although early evidence suggests that none are adequate for immediate use.³¹

BARRIERS

Regionalization faces several key barriers to implementation (Table 10-1). In a 2009 survey of intensive care physicians, the most significant perceived barrier to regionalization was the lack of a strong centralized authority to regulate and enforce the system.³² In the United States, there is no central health authority to oversee such a system—even trauma regionalization is a patchwork of mechanisms and authorities that varies across regions. There is also substantial hospital competition in the United States, which might preclude standardization of critical care delivery across hospitals in a region. Some countries such as the United Kingdom, Canada, and Australia have public health systems and regional health authorities capable of regulating a regionalized critical care system; however, even in these countries hospitals may resist efforts to dictate the services they can provide.

Another major barrier to regionalization is the personal strain on families that regionalization may cause. Under a regionalized scenario, patients and families may be forced to travel long distances to receive critical care, often by unfamiliar clinicians in unfamiliar settings. The system may therefore place undue burden on families and compromise the patient-physician relationship, leading to adverse consequences such as cognitive and emotional dysfunction among family members.³³ Patients and families may be willing to accept a higher risk of death if it means receiving critical care closer to home.

Other barriers to regionalization include capacity constraints at large-volume hospitals, the difficulty in accurately identifying patients in need of transfer, and providers’ (both hospitals and physicians) potential unwillingness to sacrifice income when patients are transferred to other hospitals for care.

IMPLEMENTATION STRATEGIES

To overcome these barriers and effectively implement regionalized care will require both intelligent system design and a coordinated effort among stakeholders. Several issues around the design of a regionalized care system must be addressed by careful comparative-effectiveness research. First, regional systems can be designed around either a traditional hub-and-spoke model or a model with multiple disease-specific referral centers (Fig. 10-1). These different models may suit different regions to varying degrees. Next, policy makers must explicitly define the methods to identify regional referral centers and the method to identify patients in need to transfer to a regional care center. It is essential that these criteria be objective to avoid subjective and necessarily arbitrary decisions that may hurt hospital economies or allow for gaming of the system. Potential structural criteria for referral center certification include intensivist physician staffing and the availability of definitive surgical, coronary, and cardiac care, among others (Table 10-2).^11,23,34-39 Certification as a regional referral center should be voluntary, yet certification should be regulated by existing governmental bodies in order to ensure that the number and location of regional referral centers best meet population needs. The goal is not only to improve access but also to make access as equitable as possible—equity may be harmed if some areas are overserved by regional centers and other areas are underserved.