CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Laboratory, Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15261, USA.
Am J Respir Crit Care Med. 2010 Jun 1;181(11):1164-9. doi: 10.1164/rccm.200909-1441CP. Epub 2010 Mar 11.
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.
医院之间重症监护服务质量的差异以及新兴的劳动力危机，需要在重症监护的组织层面进行系统变革。在这篇综述中，我们评估了三种可能扩大高质量重症监护服务可及性的替代组织模式：分层区域化、重症监护单元远程医疗以及通过区域外展进行质量改进。这些模式都有可能提高生存率并降低成本。然而，实施这些模式也存在重大障碍，包括缺乏强有力的证据基础和需要大量前期财政投资。重症监护的重组还需要所有相关利益攸关方的支持：患者及其家属、重症监护从业者、行政和公共卫生专业人员以及政策制定者。这些模式在不同程度上都需要一个中央权威机构来实施和监管系统，以及具体的立法、信息技术投资和对提供者的经济激励。现有证据并不能强烈支持特定模式的排他性使用，创建一个整合这三种互补方法的混合模式是一个可行的选择。实施的一个潜在框架包括由专业协会制定的分诊指南，这些指南可进一步制定示范项目和国家立法，以支持最佳系统。需要进一步研究这些方法的相对有效性和成本影响，以在医院、地区和国家层面上根据患者的需求和专业人员的偏好，将高质量的重症监护服务最佳匹配。
