Reorganizing adult critical care delivery: the role of regionalization, telemedicine, and community outreach.

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.