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  • Intensive care unit practitioners will be increasingly called upon 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 central authority to regulate and manage the system and potential capacity strain at high-volume hospitals.

  • Telemedicine entails the use of audio-visual technology to provide critical care across a distance. It 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 infrastructure and operation, local resistance or 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 providing high-intensity care to seriously ill patients within a hospital, but rarely thinking beyond the hospital walls. In recent decades, 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 hospitals now routinely provide specialty critical care services to the highest-risk patients across a range of diagnoses,1 interhospital transfers of critically ill patients are increasingly common,2 and the threats of pandemics and natural disasters are forcing hospitals to coordinate their critical care services across regions.3 Responses to the pandemic caused by the novel coronavirus disease 2019 (COVID-19) reflect these changes, which included the rapid development and deployment of programs to coordinate regional critical care delivery.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 relative 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, hospitals continue to vary in their critical care capability and outcomes, despite overall improvements in critical care over time.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 ...

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