Critical Care Perspective
Reorganizing Adult Critical Care Delivery
The Role of Regionalization, Telemedicine, and Community Outreach
Ye ˆn-Lan Nguyen1, Jeremy M. Kahn2,3, and Derek C. Angus1,4
1The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Laboratory, Department of Critical Care Medicine, and
4Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania;2Division of
Pulmonary, Allergy and Critical Care, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia,
Pennsylvania; and3Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
Variation in the quality of critical care services across hospitals
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
care will also require the support of all involved stakeholders:
patientsand 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 par-
ticular model, and creation of a hybrid model that integrates the
three complementary approaches is a practical option. A potential
by professional societies leading to demonstration projects and
national legislation in support of optimal systems. Additional re-
search 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 prefer-
ences at the hospital, regional, and national level.
Keywords: delivery of health care; regional health planning; intensive
Critical illness represents an enormous clinical and economic
burden on the health care system. In the United States, between
4 and 6 million patients are admitted to an intensive care unit
(ICU) each year (1). These patients face extremely high
morbidity and mortality, with costs that approach 1% of the
gross domestic product (2). Critical care delivery is also
extremely heterogeneous, in part due to varying organizational
structures within ICUs, hospitals, and health systems. This
heterogeneity may be responsible for more than 100,000 pre-
ventable annual deaths (3). These issues are important not only
in the United States but also in other industrialized countries,
all of which struggle with increasing demand for critical care in
the setting of constrained resources (4).
Critical care delivery as a proportion of total health care is
likely to grow in the coming years. Unfortunately, there is no
coordinated effort to oversee this growth, leading to increasing
spending with no concomitant improvement in quality (5–8).
Given current economic realities, continued unregulated growth
is not a viable option. Instead we must consider alternative care
models that address the variation in critical care delivery across
hospitals, expand access to high-quality critical care, and ensure
efficient matching of supply to demand.
The focus of this review is to evaluate alternative organiza-
tional models for intensive care. We consider three key
approaches: tiered regionalization, ICU telemedicine, and qual-
ity improvement through regional outreach (Table 1). We
weigh the evidence for each of these options, review how each
might be practically implemented, and discuss how all three
could be used in concert. In addition, we outline a program of
comparative effectiveness research that will provide critical
evidential support for future large-scale changes in the organi-
zation of critical care services.
Regionalization of adult critical care would entail categorizing
hospitals according to the level of critical care they can provide,
and then systematically transferring high-risk patients to
a higher level of care. A successful regionalized system requires
three components: objective identification of referral centers
within regions, either by location, resources, or performance;
a process to reliably identify high-risk patients and transfer
them to referral centers in a timely fashion; and a method to
oversee and regulate the system. Regionalization of critical care
could occur within broad categories of critically ill patients or
within diseases silos, such as acute myocardial infarction,
cardiac arrest, or sepsis.
Professional societies and academic leaders have long advo-
cated for establishment of a regionalized system of critical care
in the United States (6–8), yet to date there are very few data in
support of formal regionalization. Regionalization is indirectly
supported by the existence of a strong volume–outcome re-
lationship in critical care. Several studies show that a subset of
diverse critically ill patients is more likely to survive when
treated at institutions with high case loads (9–12). Regionaliza-
tion of critical care is also supported by successful regionaliza-
tion efforts in trauma and neonatal care (13–15). These
conditions are in many but not all ways analogous to adult
critical illness (16).
Regionalization could improve survival by concentrating
severely ill patients at hospitals with concentrated resources
and expertise to deliver high-quality care (9). A study simulat-
ing the implementation of a regionalized system for mechan-
(Received in original form September 24, 2009; accepted in final form February 22, 2010)
Correspondence and requests for reprints should be addressed to Ye ˆn-Lan
Nguyen, M.D., M.P.H., Room 605 Scaife Hall, CRISMA Laboratory, Department
of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, Pitts-
burgh, PA 15261. E-mail: YenlanFr@aol.com
Am J Respir Crit Care Med
Originally Published in Press as DOI: 10.1164/rccm.200909-1441CP on March 11, 2010
Internet address: www.atsjournals.org
Vol 181. pp 1164–1169, 2010
ically ventilated patients estimated a significant survival advan-
tage if a majority of nonsurgical mechanically ventilated
patients underwent transfer to referral centers defined by case
volume (17). Regionalization might also result in significant cost
savings. Under regionalization only a few centers would require
the expensive infrastructure necessary to care for a broad range
of critically ill patients, resulting in a more efficient use of
personnel and resources. Regionalization could also increase
efficiency by taking advantage of the economies of scale, as
higher case volume is associated with lower per-patient costs
Regionalization also has potential to worsen clinical out-
comes. Regionalization would involve the large-scale transport
of critical ill patients. Although routine transfer of critically ill
patients is safe, expanding the scale of transport may harm
patients (19). Regionalization could also overwhelm resources
at destination hospitals. Despite data that ICU census is not
strongly associated with outcomes, many large academic hospi-
tals already operate at peak capacity and could not easily
accommodate major increases in annual admissions (20). Inter-
hospital transfer could also lead to discontinuity of care, which
may negatively impact long-term outcomes. Regionalized sys-
tems would need to account for postacute care, including
appropriate access to step-down units and ward beds for
recovery, as well as a mechanism for patients to return to their
hospitals of origin. Regionalization within disease silos could
lead to loss of skills and experience in other diagnoses, limiting
Key barriers to regionalization include stakeholder resis-
tance and the lack of centralized authority to regulate and
enforce the system (21). Additionally, patients and families
could be opposed to interhospital transfer as it might place them
far away from home and familiar physicians (22). Physicians
could be unwilling to relinquish the income, autonomy, and
continuity of care they enjoy under the current system. Trans-
ferred patients consume more resources than patients admitted
from other locations, and hospital directors might therefore be
reluctant to participate in the system without reimbursement
reforms that increase compensation for referral centers (23).
The lack of cost-effectiveness data of existing regionalized
systems could be a barrier for public health professionals and
policy makers. Indeed, financing trauma systems has not been
without significant challenges, as trauma centers have non-
compressible investments to ensure readiness to provide care
(24). These costs, in major part due to physicians’ stipends, are
borne even in the absence of throughput and cannot be billed at
an individual level. An important but less-recognized barrier is
that implementing a regionalized system by itself does not
guarantee effective regionalization. Despite overt regionaliza-
tion, many high-risk neonates, as well as pediatric and adult
trauma patients with clear indications for transfer to a Level I
trauma center, are often not transferred (25–27). These findings
could be due to triage errors, inefficiencies in the transfer
system, or high severity of illness precluding transfer. All of
these issues may affect regionalization of adult critical care.
Given the complexities surrounding triage and transport,
tiered regionalization is most likely to succeed in urban areas,
areas with well-developed emergency medical transport, and
areas with short travel distances between hospitals. Existing
data suggest that the current transfer system, although disorga-
nized, still tends to move patients to higher-capability hospitals
(28). Consequently, areas with strong existing transfer systems
might be most ready to accept formal regionalization. Region-
alization will also succeed in regions with strong governmental
agencies able to induce physician and hospital participation in
the system. Despite calls to avoid disease silos when creating
regionalized systems, regionalization may be most effective for
specific identifiable critical illness syndromes with strong volume–
outcome relationships, such as sepsis, mechanical ventilation,
cancer, and high-risk surgeries (9–11, 29).
Telemedicine is the exchange of medical information via
electronic communication. Applied to the ICU, telemedicine
allows for real-time exchange of clinical data and direct in-
teraction between critical care providers across large distances.
ICU telemedicine programs typically consist of critical care
specialists in a central location providing critical care services
across multiple remotely located ICUs (30). Telemedicine staff
monitors patients via two-way audio, video, and an electronic
medical record. Some telemedicine applications also contain
decision-support tools to facilitate best practice and alarms to
alert providers to sudden changes in patient status.
ICU telemedicine is a unique approach to expanding access
to high-quality critical care. Under a telemedicine model critical
care expertise is available 24 hours per day, even in remote
areas, potentially improving survival (31). Indeed, limited data
TABLE 1. ALTERNATIVE ORGANIZATIONAL MODELS FOR ADULT CRITICAL CARE
Model Potential BenefitsPotential RisksKey Barriers Areas Where Most Effective
Tiered regionalizationIncreased survival
More efficient use of
resources and personnel
Adverse events during transport
Overwhelming resources at
Discontinuity of care
Lack of centralized
Strong existing emergency medical
Strong government regulatory
ICU telemedicineIncreased survival
Continuous critical care
Increase adherence to
Technology between the patient
and the physician
Depersonalization of the patient–
Malfunctions and downtimes
Large distances between hospitals
Small hospitals without intensivist
Integrated delivery systems
Regional outreachIncreased survival
Increase adherence to
Difficulties in evaluating the
Lack of sustained improvement
Lack of central authority
Lack of local champions
Lack of facilities and
Small regions with effective
communication between hospitals
Integrated delivery systems
Critical Care Perspective1165
indicate that telemedicine programs are associated with im-
proved outcomes in some settings, although existing studies are
not conclusive and many studies have shown no effect (31–36).
At the provider level, easy communication with experts can aid
decision making and facilitate implementation of complex
therapies, such as ventilation management in acute respiratory
distress syndrome. Telemedicine could also improve adherence
to evidence-based practice, such as lung-protective ventilation
or early goal-directed therapy (37). Of note, telemedicine is
essentially immune to geographic barriers and can be provided
from almost any location. Thus, nighttime coverage, a strain for
any workforce, might be provided from a remote time zone
where the physicians could staff the service during their daytime
The limitation of ICU telemedicine is that it creates a layer
of technology between the patient and the physician. Tele-
medicine does not allow for a physical examination or physi-
cian-led procedures, such as endotracheal intubation or central
venous line placement. All the data in support of intensivist-
staffed ICUs come from studies of a physician at the bedside,
and separating patients and clinicians in space may not work for
critical care. Additionally, patients, physicians, and other care-
givers could appropriately fear a depersonalization of the
patient–physician relationship. Because ICU telemedicine still
relies on intensivist staffing, it might simply shift resources
rather than improve access to them, and could even overextend
the capabilities of single intensivist, who might need to care for
an excessive number of remote patients. There are also
operational concerns, as ICU telemedicine could compromise
medical confidentiality if network security is insufficient, and
technological malfunctions could create dangerous downtimes.
At the health-care provider level, ICU telemedicine requires
a strong partnership and mutual trust between remote clinicians
and clinicians at the bedside
The major barrier to implementation of ICU telemedicine is
acceptance of this new technology by administrators and health-
care workers (38). Two recent studies demonstrate reluctance of
physicians to delegate full responsibility to the telemedicine
team, which may partly explain their negative results (35, 36).
Another important barrier is cost, especially in the setting of
a lack of demonstrated efficacy and in ICUs that already have
trained intensivists (38). Commercial telemedicine systems
represent a large initial capital investment for equipment and
information technology infrastructure, coupled with the ongo-
ing costs of staffing and maintenance (30). In the United States,
physician services via ICU telemedicine are not reimbursed by
major insurers, meaning that none of these costs are recouped
through billing. Given the cost issues, hospital administrators
could be reluctant to invest in telemedicine without more com-
pelling quality data. Telemedicine also carries several complex
medicolegal barriers, including torts arising from failure to
make critical diagnoses due to the lack of direct interaction,
licensing across hospitals and states, and shared decision making
The unique power of ICU telemedicine is its ability to
facilitate critical care provision over large distances. Conse-
quently, telemedicine may be the best solution in rural areas in
which distances between hospitals is large. Telemedicine may
also be most successful in small hospitals without access to
trained intensivists. If emergency medicine physicians or hospi-
talists are available for procedures and emergencies like cardiac
arrest, the telemedicine physician can provide intensive care
expertise and advice from afar. Finally, telemedicine may best
succeed in integrated delivery systems, which can overcome
credentialing barriers and do not rely on third-party billing for
QUALITY IMPROVEMENT THROUGH
Quality improvement through regional outreach is a strategy
whereby all hospitals within a region work together to bench-
mark outcomes and improve quality. Rather than systematically
transfer patients to high-quality hospitals or bring physician
expertise to patients via telemedicine, regional outreach involves
cooperation by all hospitals, both large and small, to increase the
quality of care. Under this strategy, local quality improvement
directors within hospitals work with central coordinating centers
to create clinical registries that facilitate benchmarking across
sites, providing hospitals with data demonstrating comparatively
poor outcomes or adherence to evidence-based processes. These
data can then be used to target quality-improvement efforts using
shared resources within the region.
There are several examples of how quality improvement
through regional outreach can work. Many California hospitals
routinely benchmark their clinical outcomes and care processes
through the California Intensive Care Outcomes project (39).
Hospitals in Ontario, Canada implemented their Critical Care
Strategy to measure and improve critical care performance
through several mechanisms, including a critical care informa-
tion system, critical care response teams, system-level training
initiatives, and a performance improvement collaborative (40).
In Spain, active, large-scale dissemination of the Surviving
Sepsis Campaign guidelines improved adherence to recommen-
ded care and survival among patients with sepsis (41). And in
Michigan, systematic implementation of bundled measures to
reduce catheter-related bloodstream infections appeared to
reduce the incidence of that complication (42).
Regional quality improvement has several advantages. A
culture of quality improvement within a region would lead to
a wider access to high quality of care and potential survival
benefit. The Spanish Surviving Sepsis campaign showed that
a national educational program for severe sepsis improved
patient-centered outcomes, even when the intervention was
simple and not customized to local care patterns (41). Regional
quality improvement can occur at relatively little cost. Com-
pared with regionalization and telemedicine, the infrastructure
investment, although certainly not negligible, is small. For the
Michigan Keystone Initiative, costs were limited to those of
routine data collection, as the checklist-based intervention itself
carried little if any direct costs (42).
Regional quality improvement also has limitations. Improve-
ments in survival may not accompany the process improvements
targeted under an education campaign (43). Similarly, the
design of a regional quality improvement program requires
prioritizing projects, which could be challenging in the presence
of potentially conflicting interests and agendas. For some
strategies to prevent ICU-acquired infections, such as ventila-
tor-associated pneumonia and catheter-associated bloodstream
infections, the number of options is large, with little compara-
tive effectiveness research to help prioritize interventions.
Additionally, evaluating the success of quality improvement
programs is difficult. Intermediate outcomes, such as complica-
tion rates and care processes, are probably insufficient, because
these are frequently not strongly linked to outcomes, and using
mortality to compare quality of care can be misleading (44, 45).
Finally, improvement is difficult to sustain, and initial quality
gains achieved under an outreach strategy may wane over time.
The major barrier to regional outreach through quality
improvement is the lack of a central authority to facilitate local
education and data collection. The California Intensive Care
Outcomes and Michigan Keystone projects were initiated by
academic medical centers and state hospital associations, which
1166AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 1812010
are inconsistently willing or able to oversee these programs.
Professional societies are another potential source for broad-
scale quality improvement activities. Cardiology societies have
had success in creating disease registries for hospitalized
patients that led to improvements in evidence-based practice
(46). However, professional societies are limited by budgetary
and political constraints. Other major barriers to this strategy
include incomplete infrastructure to perform data collection
and frequent lack of a local champion to effect change (47).
Local champions themselves are ineffective without requisite
leadership skills to drive change and an organizational culture
accepting of innovation (48).
Due to heightened need for communication across hospitals,
quality improvement through regional outreach may best
succeed in integrated delivery systems with common informa-
tion technology platforms across hospitals. Such electronic
medical records will facilitate data collection and data sharing
for benchmarking purposes. An outreach strategy will also be
most effective in smaller regions with strong region-wide pro-
fessional organizations. These organizations can strengthen
communication across hospitals, such as in the case of the
Rhode Island ICU collaborative, a statewide effort to reduce
ICU-acquired infections among a small group of hospitals (49).
A FRAMEWORK FOR IMPLEMENTATION
Although tiered regionalization of adult critical care, ICU
telemedicine, and regional outreach are separate and distinct
organizational models, they are not necessarily independent.
All three have a role to play, and all three could work in
concert. It is easy to conceive a model in which telemedicine is
used to provide routine care for critically ill patients in small
hospitals, while timely systematic transport to a regional re-
ferral hospital is reserved for the sickest patients. At the same
time, the telemedicine platform can be a tool to implement
broad-scale regional quality improvement initiatives.
In order to prompt debate, we propose a specific action plan
for implementation based on a framework that integrates all
three models (Figure 1). We acknowledge this plan’s limitations
but hope that it can service as a beginning point for policy
changes directed at improving regional critical care delivery.
Step One: Guideline Development
The first step will entail professional societies generating
specific guidelines for critical care organization at the hospital
and regional level. At a minimum these guidelines should define
definitive critical care (i.e., the staff, technology, and expertise
that should be available at high-level designated critical care
centers), create triage criteria that define the type of patients
who should receive high-level critical care, and identify a set of
patient-centered outcomes to measure the quality of the system.
The guidelines should follow the framework set forth in the
Prioritizing the Organization and Management of Intensive
Care Services conference, which called for hospital accredita-
tion centered around the ICU team’s presence, knowledge,
collaboration, and management (8). The guidelines should be
flexible to future developments, and like all guidelines should
be revisited as evidence evolves.
At the same time, accreditation organizations should en-
dorse graduate medical education in community critical care.
Holistic education throughout the acute care spectrum will
encourage cooperation and communication between providers
within a region and lay the groundwork for future reform.
Additionally, hospitals should begin the process of expanding
electronic medical records and developing comprehensive,
region-wide ICU clinical registries. Registries are an essential
component of large-scale benchmarking and quality improve-
ment initiatives and will facilitate all three organizational
Step Two: Demonstration Projects
The second step will entail formal demonstration projects
designed to improve access to definitive critical care services
for eligible patients, as defined in the professional society
guidelines. The demonstration projects should be funded by
national agencies, such as the U.S. Department of Health and
Human Services or the National Health Service in the United
Kingdom. States and other regional coalitions will compete for
demonstration project money, with the top four to five projects
securing funding. The best proposals will directly improve
access to critical care services, uncover the mechanisms un-
derlying quality gains, measure patient-centered outcomes,
generalize to other regions of the country, and establish
academic–community partnerships with shared expectations
and goals (50). No single model will be sufficient, so the most
competitive projects will likely include elements of regionaliza-
tion, telemedicine, and outreach.
Step Three: Effecting Widespread Change
The third step will entail specific policy changes designed to
support organizational reform based on the successful demon-
stration projects from step two. For the most part this means
legislation at the state, provincial, or national level. The
legislation will require region-level cooperation and infrastruc-
ture investment among hospitals, including the establishment of
Figure 1. Schematic for system-level organizational reform of critical care services.
Critical Care Perspective1167
regional planning boards. Existing accreditation organizations
can certify both hospitals and systems, ensuring high-level
critical care centers adhere to professional society guidelines.
Health-care purchasers can support the process by enacting
payment reforms that encourage optimal system design. Re-
imbursement reforms, such as pay-for-performance and bun-
dled payments for care episodes, can encourage adoption of
evidence-based organizational practices and effective commu-
nication between providers.
Step Four: Evaluating the System
The fourth stem will entail ongoing, critical evaluation of the
organizational reforms. Electronic medical records and clinical
registries will facilitate continuous outcome evaluation, includ-
ing long-term outcomes that extend beyond the ICU. Pro-
fessional societies will revisit and update the guidelines, based
on emerging evidence from not only ongoing health service
research but also the published experiences of regions that
effected successful and unsuccessful change. The most success-
ful programs will be adapted and expanded to increasing
numbers of health-care markets.
A RESEARCH AGENDA
Additional research is needed to better understand the relation-
ship between critical care organization and health-care quality
and define organizational models that best meet patient needs
and provider expectations. Key knowledge gaps include the
mechanisms underlying the volume–outcome relationship in
critical care, standardized criteria for the use of ICU services,
evaluation of regionalization and ICU-telemedicine costs-effec-
tiveness, optimal geographic scale for regional systems, perfor-
mance measures for ICU benchmarking, and mechanisms to
increase the effectiveness and sustainability of quality improve-
ment interventions. Comparative effectiveness research is
needed to examine competing strategies to improve critical
care in small hospitals and rural areas (i.e., regionalization vs.
telemedicine approaches), the organizational-level factors that
might modify success of these various approaches, and the
effectiveness of different strategies for large-scale sustainable
quality improvement. Perhaps most important are pilot studies
of each of the regional strategies. Health systems and regions
that are able to effect change must document and publish their
results. Once published, pilot studies attract the interest of
legislators and motivate change.
Recently the U.S. government emphasized comparative
effectiveness research as a key strategy to improve health-care
quality. Yet the Institute of Medicine’s Initial National Prior-
ities for Comparative Effectiveness Research contains only one
topic related to critical care (51). And although the Institute of
Medicine’s definition of comparative effectiveness research
includes evaluating the comparative effectiveness of health-care
delivery systems, no priority topics directly address delivery
systems for acute care. Despite these recommendations, com-
parative effectiveness research is essential to inform the system-
level change we describe. Knowledge gained from this research
will aid policy makers in making key decisions about the future
of critical care organization and delivery.
A unified national health policy on critical illness is urgently
needed. None of the three organizational models previously
described is perfect, but all share specific patterns associated
with theoretical survival benefits and costs savings. The creation
of a hybrid model that includes a tiered regionalization, tele-
medicine, and quality improvement through regional outreach
seems like a practical and feasible option. The terms and times
of implementation should be determined by payers, govern-
ments, and providers, and customized to local conditions. It is
no longer enough to agree that the current disorganized system
is leading to preventable morbidity and mortality. We must now
agree on how to fix it.
Conflict of Interest Statement: None of the authors has a financial relationship
with a commercial entity that has an interest in the subject of this manuscript.
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