Reorganizing adult critical care delivery: the role of regionalization, telemedicine, and community outreach.
ABSTRACT Variation in the quality of critical care services across hospitals coupled with an emerging workforce crisis necessitates system-level change in the organization of intensive care. In this review, we evaluate three alternative organizational models that may expand access to high-quality critical care: tiered regionalization, intensive care unit telemedicine, and quality improvement through regional outreach. These models share a potential to increase survival and reduce costs. Yet there are also major barriers to implementation, including the lack of a strong evidence base and the need for significant upfront financial investment. Reorganization of intensive care will also require the support of all involved stakeholders: patients and their families, critical care practitioners, administrative and public health professionals, and policy makers. To varying degrees these models require a central authority to implement and regulate the system, as well as specific legislation, investment in information technology, and financial incentives for providers. The existing evidence does not strongly support exclusive use of a particular model, and creation of a hybrid model that integrates the three complementary approaches is a practical option. A potential framework for implementation involves triage guidelines developed by professional societies leading to demonstration projects and national legislation in support of optimal systems. Additional research is needed to determine the comparative effectiveness and cost implications of these approaches, with a goal of best matching high-quality critical care to patients' needs and professional preferences at the hospital, regional, and national level.
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ABSTRACT: Intensivist physician staffing is associated with lower mortality in the intensive care unit (ICU), yet many ICUs are not staffed by trained intensivists. This gap has led to a number of proposals intended to increase the intensivist supply in the United States. In this article we argue that such efforts would be both ineffective and ill-advised. Since many ICU patients are not critically ill, workforce models which base demand projections on ICU admission rather than true critical illness substantially overstate the workforce gap. Even in the presence of a workforce gap, training new intensivists would not place them in hospitals where they are needed most, would not mitigate the shortage of non-physician critical care providers, and would require a unrealistic increase in spending on physician training. Additionally, efforts to train more intensivists require us to prioritize intensive care over other specialties that are also in short supply, without clear justification for why intensivists are more important. Rather than continuing an unwarranted push to increase the intensivist supply, we suggest alternative workforce policies that emphasize novel interprofessional care models (to improve ICU quality in the absence of intensivists) combined with limitations on the future growth of ICU beds (to reduce demand through implicit rationing of care). These policies offer opportunities to reduce the mismatch between critical care supply and demand without an unnecessary expansion of the intensivist supply.American Journal of Respiratory and Critical Care Medicine 12/2014; 191(2). DOI:10.1164/rccm.201408-1477CP · 11.99 Impact Factor
Article: The Tele-ICU.
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ABSTRACT: Detection of patient deterioration and triage (prioritization of care) are two critical tasks in the high risk environment and interdisciplinary care model of patients in an intensive care unit. To make decisions and plan treatments, clinicians need to observe, integrate, communicate, and understand a wide range of information from various devices located at the bedsides of multiple patients. However, several technological and physical limitations prevent them from optimally performing these tasks, which negatively impact the capabilities of healthcare teams. The Monitoring Messenger concept was developed to overcome some of these challenges by integrating information on a mobile device and supporting team decision-making and information exchange. Results from the initial phases of this project: requirements definition using Cognitive Work Analysis and rapid device prototyping are presented in this paper.2013 IEEE International Conference on Systems, Man, and Cybernetics (SMC 2013); 10/2013