Editorial
Regional ICU Care: The Future is Now
Journal of Intensive Care Medicine 25(3) 179-181 ª 2010 SAGE Publications Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0885066610362634 http://jicm.sagepub.com
Steven Y. Chang, MD, PhD,1 Sara L. Merwin, MPH,2,3 Jeffrey Fein, BA,4 and Alan M Fein, MD4
Critical care is an important consideration in the current health care debate and with good reason. Many citizens question the enormous expenditures incurred in the intensive care unit (ICU), along with the rationale for prolonged and expensive treatment for patients for whom survival is a remote possibility. An estimated 1% of our entire gross domestic product (GDP) is spent in our ICUs, and about 40% of Medicare dollars are spent on the last year of a patient’s life.1 The ICU also is where we care for a higher proportion of older patients as well as under- or noninsured patients. Consequently, debates about ‘‘death panels’’ and end-of-life care are often centered in ICUs, where stark choices are presented to dying patients, their families, and medical staff. Many of us who work in critical care often feel that we are delivering costly care to patients who are unlikely to recover.2 This is an inevitable dilemma but perhaps not an unsolvable one. For more than a decade, the concept of ‘‘regionalization’’ has been proposed as a way to make ICUs more efficient and more cost-effective.3 Although some variant of critical care is available in almost every part of the country, accessibility, quality, and resources are far from evenly distributed. Most people prefer the convenience of receiving care locally—from physicians they are familiar with and have confidence in. Changes in the delivery of critical care services have been made at a relatively rapid pace such that only the most experienced of centers are able to effectively care for the most critically ill patients. Given this, consideration should be given to regionalizing most critical care services such as practiced in trauma and pediatric critical care. The Regional ICU concept posits that, since resources and personnel are more concentrated in more densely populated areas, we should concurrently concentrate them in larger facilities, which may be less convenient but are also almost certainly better equipped to handle the most complex medical problems. Such regional ICUs would:
have greater numbers and types of intensivists and critical care nurses; be more likely to have 24/7 coverage and meet best practices standards as delineated by the Leapfrog Group4; be organized into teams that are better able to incorporate and implement best evidence protocols; have a greater familiarity with complex illnesses based on sheer volume. (There is much data to support the
relationship between volume and outcomes across the medical spectrum.)5 Despite many obstacles, regionalization has recently become more prominent in US medicine. Indeed, ICUs themselves, a relatively recent development, represent intrahospital regionalization by sequestering the sickest patients into areas where resources and attention may be concentrated. As technological developments and equipment exceed the budgets and resource allocation of many hospitals, only some facilities can be expected to maintain highly specialized ICUs. For example, the H1N1 crisis of 2009 saw increased the use of Extra Corporeal Membrane Oxygenation (ECMO)6 to care for the severe—and usually time-limited—respiratory failure associated with the influenza viral infection. This labor- and resource-intensive technology is possible only in highly specialized regional centers, with the highest levels of personnel expertise and equipment.7) Safe transfer of trauma patients from outlying facilities to level I trauma centers is often the most effective way to care for such patients.8 It has also been reported that patients requiring mechanical ventilation are likely to benefit from transfer to larger and better-equipped ICUs.9,10 This pattern of care is quietly unfolding, as operational and logistical demands trump strategic planning, throughout many parts of the world. The barriers to regional ICU care include the viability of transfers as well as physician and patient attitudes. Of course, larger centers can sometimes have difficulty absorbing a high volume of transferred patients and meeting their needs accordingly.11 There are also concerns about the safety of 1 Pulmonary and Critical Care Medicine, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, NJ, USA 2 Hofstra University School of Medicine in partnership with NSLIJ Health, Hempstead, NY 3 North Shore University Hospital, Manhasset, NY, USA 4 ProHEALTHcare Associates, NYU School of Medicine, Lake Success, NY, USA
Corresponding Author: Alan Fein, NYU School of Medicine, ProHEALTHcare Associates, 2800 Marcus Avenue, Suite 202, Lake Success, NY 11042, USA. Email:
[email protected]
179
180 inter-hospital transfer itself. Some patients, such as those who might benefit from ECMO, are ill equipped to tolerate the physiologic stresses that often occur during a transfer, especially when great distances and high levels of care are involved. Physician attitudes toward ICU regionalization present another obstacle. Several surveys have examined the attitudes of physicians and the families of patients.12 When care is highly concentrated, stress levels are higher for all involved, especially when patients are very young or very old. Additionally, the ‘‘fee for service’’ model of care currently practiced in the United States presents both real and perceived concerns about the economic impact of patient ‘‘leak.’’ Physicians who were likely to receive extra patients were, predictably, more enthusiastic about the concept of regional care and resource concentration than doctors transferring their patients. And because trauma care is less well reimbursed than, say, cardiac and neurosurgical care, different specialties face different incentives regarding transfer to regional centers.13 The paper, ‘‘Structure, Process and Outcome of All Intensive Care Units Within the Province of British Columbia, Canada,’’ by Dodek et al,14 examined the regional state of critical care using a retrospectively collected database of ICU patients admitted between 1998 and 1999. Surprisingly, and counter to other recently collected data, the authors report little correlation between the sizes of ICUs and positive outcomes. British Columbia has diverse geography and population density, with cities and suburbs, rural areas, and even remote wilderness. This study showed that ICU beds and mortality were inversely related to population, despite apparently better intensivist staffing and stricter adherence to clinical practice guidelines in urban ICUs. Additionally, population growth in some areas was not accompanied by concomitant growth in ICU services. All this despite larger ICUs providing a greater depth of services—including clinical pharmacists, respiratory therapy, and dialysis services—over a greater portion of the day. These findings suggest that there is a floor of critical care services required even in remote communities and a ceiling to the success of urban intensive care. The Dodek paper provides a cautionary tale of regionalization. Dodek and colleagues remind us that, even in a country with more centralized planning and government involvement than that seen in the United States, intensive care does not always follow logical patterns. However, there is 1 glaring problem with the Dodek study: it examines intensive care as it existed over a decade ago! The evolution of intensive care over the past 10 years includes significant change in not only technology, but training, staffing, and even the population of patients treated in this setting. The same technological innovations and digital revolution that have transformed our society and globalized many businesses and academic activities has come to many aspects of our health care delivery system. Given recent leaps in technology, regionalization makes sense. In the new paradigm, ICUs are linked electronically to ‘‘regional’’ sites so that information and expertise can be shared, and mutual decisions can then be implemented by the care team on site. This potential use of ‘‘telemedicine’’ to deliver high180
Journal of Intensive Care Medicine 25(3) level expertise to remote outposts as well as the inner city exists as a promising, but as yet fully proven modality. Emerging technologies are also likely to have significant impact on health care in the resource scarce environment of the developing world.15 The case for ‘‘telemedicine’’ as a solution to resource maldistribution remains to be proven in clinical trials. A recent study of the effectiveness of telemedicine16) failed to demonstrate improved outcomes or length of stay. Nevertheless, intuitively and for pragmatic reasons, it makes sense to concentrate our sickest and most demanding patients where the resources and experience are greatest. This process may be accomplished through physical movement of resources, personnel and resources or through the virtual movement of patient centered information. The debate about regional ICU care has been taking place for decades without clear-cut resolution. However, as we look around at the practice patterns evolving, we already have a new ‘‘virtual’’ reality. Digital regionalization is, in many ways, already here. References 1. Fein A, Chang S, Ost D, et al. Defining and measuring patient safety in the critical care unit. In: Irwin RS, Rippe JM, eds. Textbook of Intensive Care Medicine. 6th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2007. 2. Prendergast TJ, Claessens MT, Luce JM. A national survey of end-of-life care for critically ill patients. Am J Resp Crit Care Med. 1998;158(4):1163-1167. 3. Vail S, Putnam T, Slonim AD. Critical care services: is regionalization the answer? Crit Care Med. 2008;36(11):3114-3115. 4. Angus DA, Shorr AF, White A, et al. Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations. Crit Care Med. 2006;34(4): 1016-1024. 5. Stockwell DC, Slonim AD. Volume-outcome relationships: is it the individual or the team? Crit Care Med. 2006;34(9): 2495-2497. 6. Schuerer DJ, Kolovos NS, Boyd KV, et al. Extracorporeal membrane oxygenation. Chest. 2008;134(1):179-184. 7. 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 multicenter randomized controlled trial. Lancet. 2009;374(9698):1351-1363. 8. Kahn JM, Branas CC, Schwab CW, Asch DA. Regionalization of medical critical care: what can we learn from the trauma experience? Crit Care Med. 2008;36(11):3085-3088. 9. Lin H-C, Xirasagar S, Chen C-H, Hwang YT. Physician’s case volume of intensive care unit pneumonia admissions and in-hospital mortality. Am J Respir Crit Care Med. 2008;177(9):989-994. 10. Kahn JM, Linde-Zwirble WT, Wunsch H, et al. Potential value of regionalized intensive care for mechanically ventilated medical patients. Am J Respir Crit Care Med. 2008;177(3):285-291. 11. Zimmerman JE. Intensive care unit occupancy: making room for more patients. Crit Care Med. 2009;37(5): 1794-1795.
Chang et al 12. Kahn JM, Asch RJ, Iwashyna TJ, et al. Physician attitudes toward regionalization of adult critical care: a national survey. Crit Care Med. 2009;37(7):2149-2154. 13. Kelley MA, Angus DA, Chalfin DB, et al. The critical care crisis in the United States. A report from the profession. Chest. 2004; 125(4):1514-1517. 14. Dodek PM, Keenan SP, Norena M, Martin C, Wong H. Structure, process and outcome of all intensive care units within the
181 province of British Columbia, Canada. J Intensive Care Med. 2010:25.[Epub ahead of print]. 15. Bukachi F, Pakenham-Walsh N. Information technology for health in developing countries. Chest. 2007;132(5):1624-1630. 16. Thomas EJ, Lucke JF, Wueste L, et al. Association of telemedicine for remote monitoring of intensive care patients with monitoring, complications, and length of stay. JAMA. 2009;302(24): 2671-2678.
181
