Skip to main content
SpringerLink
Log in

Regionalization of Critical Care

  • Chapter
  • First Online:
The Organization of Critical Care

Part of the book series: Respiratory Medicine ((RM,volume 18))

Abstract

Recent efforts to improve the outcomes of intensive care emphasize not only quality improvement at the local level but also better organization and management of health care systems at the regional and national level. Central to this notion is the concept of regionalization, whereby selected critically ill patients are systematically triaged and transported to regional centers of excellence. Regionalization might improve quality and efficiency by improving access to scarce resources, increasing clinical experience in the care of complex patients, and creating economies of scale. At the same time, there are number of potential risks, including adverse events in the transport of critically ill patients, worsening of crowding at already overburdened referral ICUs, reducing clinical skill at referring hospitals, and creating a non-patient-centered system that values regional care at the expense of receiving care close to the patients’ homes. Future research and demonstration should provide insight into these tensions and lay the groundwork for regionalized critical care systems that are both effective and patient-centered.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 84.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 119.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 109.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Shortell SM, Casalino LP. Health care reform requires accountable care systems. JAMA. 2008;300(1):95–7.

    Article  CAS  PubMed  Google Scholar 

  2. Iwashyna TJ, Christie JD, Kahn JM, Asch DA. Uncharted paths: hospital networks in critical care. Chest. 2009;135(3):827–33.

    Article  PubMed Central  PubMed  Google Scholar 

  3. Davies A, Jones D, Bailey M, Beca J. Extracorporeal membrane oxygenation for 2009 influenza A (H1N1) acute respiratory distress syndrome. JAMA. 2009;302:1888–95.

    Article  CAS  PubMed  Google Scholar 

  4. Kumar A, Zarychanski R, Pinto R, et al. Critically ill patients with 2009 influenza A (H1N1) infection in Canada. JAMA. 2009;302(17):1872–9.

    Article  CAS  PubMed  Google Scholar 

  5. Iwashyna TJ, Courey AJ. Guided transfer of critically ill patients: where patients are transferred can be an informed choice. Curr Opin Crit Care. 2011;17(6):641–7.

    Article  PubMed  Google Scholar 

  6. Nathens AB, Jurkovich GJ, Cummings P. The effect of organized systems of trauma care on motor vehicle crash mortality. JAMA. 2000;283:1990–4.

    Article  CAS  PubMed  Google Scholar 

  7. Nguyen Y-L, Kahn JM, Angus DC. Reorganizing adult critical care delivery: the role of regionalization, telemedicine, and community outreach. Am J Respir Crit Care Med. 2010;181(11):1164–9.

    Article  PubMed  Google Scholar 

  8. Angus DC, Shorr AF, White A, Dremsizov TT. Critical care delivery in the United States: Distribution of services and compliance with Leapfrog recommendations. Crit Care Med. 2006;34:1016–24.

    Article  PubMed  Google Scholar 

  9. Vassar MJ, Holcroft JJ, Knudson MM, Kizer KW. Fractures in access to and assessment of trauma systems. J Am Coll Surg. 2003;197(5):717–25.

    Article  PubMed  Google Scholar 

  10. Glickman SW, Kit Delgado M, Hirshon JM, et al. Defining and measuring successful emergency care networks: a research agenda. Acad Emerg Med. 2010;17(12):1297–305.

    Article  PubMed  Google Scholar 

  11. Iwashyna TJ, Christie JD, Moody J, Kahn JM, Asch DA. The structure of critical care transfer networks. Med Care. 2009;47(7):787–93.

    Article  PubMed Central  PubMed  Google Scholar 

  12. Iwashyna TJ, Kahn JM, Hayward RA, Nallamothu BK. Interhospital transfers among Medicare beneficiaries admitted for acute myocardial infarction at nonrevascularization hospitals. Circ Cardiovasc Qual Outcomes. 2010;3(5):468–75.

    Article  PubMed Central  PubMed  Google Scholar 

  13. Veinot TC, Bosk EA, Unnikrishnan KP, Iwashyna TJ. Revenue, relationships and routines: the social organization of acute myocardial infarction patient transfers in the United States. Soc Sci Med. 2012;75(10):1800–10.

    Article  PubMed Central  PubMed  Google Scholar 

  14. MacKenzie EJ, Rivara FP, Jurkovich GJ. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354:366–78.

    Article  CAS  PubMed  Google Scholar 

  15. Durham R, Pracht E, Orban B, Lottenburg L, Tepas J, Flint L. Evaluation of a mature trauma system. Ann Surg. 2006;243(6):775–83, discussion 783–5.

    Google Scholar 

  16. Kahn JM. Volume, outcome, and the organization of intensive care. Crit Care. 2007;11(3):129.

    Article  PubMed Central  PubMed  Google Scholar 

  17. Kahn JM, Rubenfeld GD, Rohrbach J, Fuchs BD. Cost savings attributable to reductions in intensive care unit length of stay for mechanically ventilated patients. Med Care. 2008;46(12):1226–33.

    Article  PubMed  Google Scholar 

  18. Jacobs P, Rapoport J, Edbrooke D. Economies of scale in British intensive care units and combined intensive care/high dependency units. Intensive Care Med. 2004;30:660–4.

    Article  PubMed  Google Scholar 

  19. Dunning D, Johnson K, Ehrlinger J. Why people fail to recognize their own incompetence. Curr Dir Psychol Sci. 2003;12:83–7.

    Article  Google Scholar 

  20. Dawson NV, Connors AF, Speroff T, Kemka A, Shaw P, Arkes HR. Hemodynamic assessment in managing the critically ill: is physician confidence warranted? Med Decis Making. 1993;13(3):258–66.

    Article  CAS  PubMed  Google Scholar 

  21. Iberti TJ, Fischer EP, Leibowitz AB, Panacek EA, Silverstein JH, Albertson TE. A multicenter study of physicians’ knowledge of the pulmonary artery catheter. Pulmonary Artery Catheter Study Group. JAMA. 1990;264(22):2928–32.

    Article  CAS  PubMed  Google Scholar 

  22. Warren J, Fromm Jr RE, Orr RA, Rotello LC. Guidelines for the inter-and intrahospital transport of critically ill patients. Crit Care Med. 2004;32:256–62.

    Article  PubMed  Google Scholar 

  23. Fan E, MacDonald RD, Adhikari N, Scales DC. Outcomes of interfacility critical care adult patient transport: a systematic review. Crit Care. 2005;10:R6.

    Article  PubMed Central  Google Scholar 

  24. Ligtenberg JJ, Arnold LG, Stienstra Y. Quality of interhospital transport of critically ill patients: a prospective audit. Crit Care. 2005;9:R446–51.

    Article  PubMed Central  PubMed  Google Scholar 

  25. Seymour CW, Kahn JM, Schwab CW, Fuchs BD. Adverse events during rotary-wing transport of mechanically ventilated patients: a retrospective cohort study. Crit Care. 2008;12:R71.

    Article  PubMed Central  PubMed  Google Scholar 

  26. Gebremichael M, Borg U, Habashi NM, Cottingham C, Cunsolo L, McCunn M, Reynolds HN. Interhospital transport of the extremely ill patient: the mobile intensive care unit. Crit Care Med. 2000;28(1):79–85.

    Article  CAS  PubMed  Google Scholar 

  27. Chalfin DB, Trzeciak S, Likourezos A. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care. 2007;35:1477–83.

    Article  Google Scholar 

  28. McConnell KJ, Pines JM. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med. 2009;16:1–10.

    Article  Google Scholar 

  29. Goldfrad C, Rowan K. Consequences of discharges from intensive care at night. Lancet. 2000;355(9210):1138–42.

    Article  CAS  PubMed  Google Scholar 

  30. Iwashyna TJ, Kramer AA, Kahn JM. Intensive care unit occupancy and patient outcomes. Crit Care Med. 2009;37(5):1545–57.

    Article  PubMed Central  PubMed  Google Scholar 

  31. Gabler NB, Ratcliffe SJ, Strom BL, Angus DC, Rubenfeld GD, Halpern SD. ICU capacity strain on the day of admission increases the risk of in-hospital death. Am J Respir Crit Care Med. 2012;185:A5073.

    Google Scholar 

  32. Terwiesch C, Diwas KC, Kahn JM. Working with capacity limitations: operations management in critical care. Crit Care. 2011;15(4):308.

    Article  PubMed Central  PubMed  Google Scholar 

  33. Chen LM, Render M, Sales A, Kennedy EH, Wiitala W, Hofer TP. Intensive care unit admitting patterns in the veterans affairs health care system. Arch Intern Med. 2012;172(16):1220–6.

    Article  PubMed  Google Scholar 

  34. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet. 2003;361(9351):13–20.

    Article  PubMed  Google Scholar 

  35. Bonnefoy E, Steg PG, Boutitie F, et al. Comparison of primary angioplasty and pre-hospital fibrinolysis in acute myocardial infarction (CAPTIM) trial: a 5-year follow-up. Eur Heart J. 2009;30(13):1598–606.

    Article  PubMed  Google Scholar 

  36. Azoulay E, Pochard F, Kentish-Barnes N, et al. Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med. 2005;171(9):987–94.

    Article  PubMed  Google Scholar 

  37. Liu JH, Zingmond DS, McGory ML, SooHoo NF, Ettner SL, Brook RH, Ko CY. Disparities in the utilization of high-volume hospitals for complex surgery. JAMA. 2006;296(16):1973–80.

    Article  CAS  PubMed  Google Scholar 

  38. Hofer TP, Hayward RA. Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis. Ann Intern Med. 2002;137(5 Part 1):327–33.

    Google Scholar 

  39. Seymour CW, Kahn JM, Cooke CR. Prediction of critical illness during out-of-hospital emergency care. JAMA. 2010;304:747–54.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  40. Wiener RS, Welch HG. Trends in the use of the pulmonary artery catheter in the United States, 1993–2004. JAMA. 2007;298(4):423–9.

    Article  CAS  PubMed  Google Scholar 

  41. Bosk EA, Veinot T, Iwashyna TJ. Which patients and where: a qualitative study of patient transfers from community hospitals. Med Care. 2011;49(6):592–8.

    Article  PubMed Central  PubMed  Google Scholar 

  42. Boyd DR. Trauma systems origins in the United States. J Trauma Nurs. 2010;17(3):126–34, quiz 135–6.

    Google Scholar 

  43. Lasswell SM, Barfield WD, Rochat RW, Blackmon L. Perinatal regionalization for very low-birth-weight and very preterm infants: a meta-analysis. JAMA. 2010;304(9):992–1000.

    Article  PubMed  Google Scholar 

  44. Kahn JM, Branas CC, Schwab CW. Regionalization of medical critical care: what can we learn from the trauma experience? Crit Care Med. 2008;36:3085–8.

    Article  PubMed  Google Scholar 

  45. Peek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet. 2009;374(9698):1351–63.

    Article  PubMed  Google Scholar 

  46. Iwashyna TJ. The incomplete infrastructure for interhospital patient transfer. Crit Care Med. 2012;40(8):2470–8.

    Article  PubMed  Google Scholar 

  47. Branas CC, MacKenzie EJ, ReVelle CS. A trauma resource allocation model for ambulances and hospitals. Health Serv Res. 2000;35(2):489–507.

    CAS  PubMed Central  PubMed  Google Scholar 

  48. Glance LG, Osler TM, Mukamel DB, Dick AW. Estimating the potential impact of regionalizing health care delivery based on volume standards versus risk-adjusted mortality rate. Int J Qual Health Care. 2007;19:195–202.

    Article  PubMed  Google Scholar 

  49. Rubenfeld GD. Epidemiology of acute lung injury. Crit Care Med. 2003;31:S276–84.

    Article  PubMed  Google Scholar 

  50. Escobar GJ, LaGuardia JC, Turk BJ, Ragins A, Kipnis P, Draper D. Early detection of impending physiologic deterioration among patients who are not in intensive care: development of predictive models using data from an automated electronic medical record. J Hosp Med. 2012;7(5):388–95.

    Article  PubMed  Google Scholar 

  51. Estévez-Loureiro R, Calviño-Santos R, Vázquez JM, et al. Safety and feasibility of returning patients early to their originating centers after transfer for primary percutaneous coronary intervention. Rev Esp Cardiol. 2009;62(12):1356–64.

    Article  Google Scholar 

  52. Lomi A, Pallotti F. Relational collaboration among spatial multipoint competitors. Soc Netw. 2012;34:101–11.

    Article  Google Scholar 

  53. Institute of Medicine (U.S.). Committee on the future of emergency care in the United States health system. Hospital-Based Emergency Care. New York: National Academy Press; 2007.

    Google Scholar 

  54. Breslow MJ. Remote ICU care programs: current status. J Crit Care. 2007;22(1):66–76.

    Article  PubMed  Google Scholar 

  55. Kahn JM. The use and misuse of ICU telemedicine. JAMA. 2011;305(21):2227–8.

    Article  CAS  PubMed  Google Scholar 

  56. Young LB, Chan PS, Lu X, Nallamothu BK, Sasson C, Cram PM. Impact of telemedicine intensive care unit coverage on patient outcomes: a systematic review and meta-analysis. Arch Intern Med. 2011;171(6):498–506.

    Article  PubMed  Google Scholar 

  57. Lilly CM, Cody S, Zhao H, Landry K, Baker SP, McIlwaine J, Chandler MW, Irwin RS, University of Massachusetts Memorial Critical Care Operations Group. Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes. JAMA. 2011;305(21):2175–83.

    Article  CAS  PubMed  Google Scholar 

  58. Mullen-Fortino M, DiMartino J, Entrikin L, Mulliner S, Hanson CW, Kahn JM. Bedside nurses’ perceptions of intensive care unit telemedicine. Am J Crit Care. 2012;21(1):24–31, quiz 32.

    Google Scholar 

  59. Rokos IC, Sanddal ND, Pancioli AM. Inter‐hospital communications and transport: turning one‐way funnels into two‐way networks. Acad Emerg Med. 2010;17:1279–85.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, 2800 Plymouth Road, NCRC, Building 16, Room 332W, Ann Arbor, MI, 48109, USA

    Theodore J. Iwashyna

  2. Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA

    Theodore J. Iwashyna

  3. Department of Critical Care, University of Pittsburgh School of Medicine, Scaife Hall, Room 602-B, 3550 Terrace Street, Pittsburgh, PA, 15221, USA

    Jeremy M. Kahn

  4. Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA

    Jeremy M. Kahn

Authors
  1. Theodore J. Iwashyna
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jeremy M. Kahn
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jeremy M. Kahn .

Editor information

Editors and Affiliations

  1. Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada

    Damon C. Scales

  2. Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada

    Gordon D. Rubenfeld

Rights and permissions

Reprints and permissions

Copyright information

© 2014 Springer Science+Business Media New York

About this chapter

Cite this chapter

Iwashyna, T.J., Kahn, J.M. (2014). Regionalization of Critical Care. In: Scales, D., Rubenfeld, G. (eds) The Organization of Critical Care. Respiratory Medicine, vol 18. Humana Press, New York, NY. https://doi.org/10.1007/978-1-4939-0811-0_14

Download citation

  • DOI: https://doi.org/10.1007/978-1-4939-0811-0_14

  • Published:

  • Publisher Name: Humana Press, New York, NY

  • Print ISBN: 978-1-4939-0810-3

  • Online ISBN: 978-1-4939-0811-0

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation