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KEY POINTS

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KEY POINTS

  • Regionalization refers to the systematic transfer of high-risk critically ill patients to regional referral centers where intensivists provide high-intensity care.

  • Regionalization has several unrealized benefits including the potential to increase survival for critically ill patients through greater use of evidence-based practices and clinical experience with performing of advanced interventions, and shorter time to definitive therapy. Concentrating high-risk, high-cost care for the critically ill also has the potential to reduce overall costs for the health system.

  • Potential unintended consequences include the downscaling of critical care capacity at smaller hospitals resulting in reduced ability to provide advanced care in emergencies due to an erosion of clinical skills, inadequate equipment, or familiarity of clinicians with best practice.

  • Regionalization may increase intensive care unit (ICU) occupancy or census beyond the capabilities of high-volume referral centers and may also strain the capacity for interhospital transport.

  • Barriers to implementation of regionalization include the lack of a strong centralized authority to regulate and enforce the regionalized system; strain on families due to the longer distances to travel for care at referral hospitals, lack of familiarity with physicians/care team at new hospitals, and risks of interfacility transport to new hospital; capacity constraints at large-volume hospitals; and both hospitals' and physicians' potential unwillingness to sacrifice income when patients are transferred to other hospitals for care.

  • Special challenges include the need to educate new clinicians in understanding when patients should or should not be treated at referral hospitals, balancing stakeholder needs, and maintaining patient centeredness.

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Critical care is usually perceived as a local activity within one hospital—nurses and physicians providing high-intensity care to seriously ill patients within a defined geographic space, without considering the larger health care system outside the hospital. More recently, however, critical care has evolved into a regional activity, one in which intensivists across many hospitals collaborate to provide high-intensity care to all individuals in an entire geographic area. Large hospitals functioning as “regional referral centers” now routinely provide specialty critical care to the sickest patients,1 often after long distance interhospital transfers,2 while the threats of pandemics and natural disasters are forcing hospitals to align within regions in a state of critical care preparedness.3 Moreover, 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 Such is the mandate of the United States Patient Protection and Affordable Care Act—which seeks to link payment to quality, coordinated care, and more efficient health care delivery at the level of the system, not just the individual provider.

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Many factors might explain the shifting paradigm in the delivery of critical care. First, critical care is expanding and now accounts for more than $80 billion per year in US health care costs, almost 1% of the gross domestic product (GDP)....

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