The gap between evidence and critical care practice, substantial variation in critical care across hospitals, and the growing intensivist workforce crisis in the United States are unlikely to go away soon. As such, the need for studying more efficient, cheaper critical care strategies is likely to expand. Consequently, there are special challenges we must face in the reorganization of critical care.
Traditional medical education emphasizes individual patient care at the bedside, with lessons on the pathophysiology of disease tightly linked to the patient history and physical examination, a focus on communication with the patients, ethics, and professionalism in response to new challenges faced by doctors. Yet, this multidisciplinary curriculum does not prepare trainees to practice in the fully integrated health system of the future. This health system provides care across regions using a combination of technological, physical approaches, and shared resources. The Accreditation Council for Graduate Medical Education has been proactive in this regard by incorporating “systems-based practice” as a core competency critical care fellowship education. To ensure a prepared workforce we must continue to emphasize a system's view in the education of our future intensivists. This will include an understanding of when patients should or should not be treated at referral hospitals.
Balancing Stakeholder Needs
If critical care is organized into a regionalized system, competing stakeholder needs will require careful balancing. The relevant stakeholders in critical care include community physicians, academic physicians, other clinicians, hospitals, governmental agencies, EMS personnel who transport patients, and health care purchasers. All these stakeholders have different needs and incentives that do not always align. For example, regionalization may require community physicians to sacrifice autonomy, patients, and procedures in order to achieve greater health care quality. Conversely, hospitals that receive patients from smaller centers may operate with high census, straining staff, and resources. A balance of stakeholder views and appropriate “buy-in” is a major practical hurdle to future implementation studies.
Maintaining Patient Centeredness
Most importantly, the patient should be at the center of future proposals for regionalized care. Patients have shown that they will not always choose longer distances for specialized care,46 and we must not forget to consider patient and family wishes when we suggest transferring critically ill patients. In fact, many important components of multidisciplinary critical care, including pastoral services, end-of-life care, and family presence may be more challenging when far from home.
In the end, we face a growing challenge to maximize health care value, whereby the greatest benefit is achieved for the greatest number of people in the most efficient manner. Mindful of the importance of the patient, regionalization is one strategy to accomplish this goal.