Regionalisation of critical care: can we sustain an intensive care unit in every hospital?

Abstract

Critical care is a complex and resource-intensive discipline, that underpins many hospital services but is itself dependent on diagnostic and interventional support from other specialities. In the UK, the traditional assumption is that a hospital of any size offering acute or complex care will require, and support, an adult intensive care unit (ICU). However, this is increasingly challenged by a number of healthcare trends, including the need to sustain a specialist workforce 1 while meeting evolving critical care standards 2, 3, and the impact of reconfiguration in the many specialities that refer patients to, and support, intensive care. It may be timely to examine the drivers, potential impact and public acceptability of regionalised (‘hub and spoke’) models in adult critical care. At its simplest, regionalisation is already well established in the case of highly-specialised referral settings such as neurosciences and cardiothoracic surgery, and the specialist critical care that supports them. With such specialised services, the need for specialist rotas, and the logistical impracticality of delivering such care at every local hospital, are historically established and intuitive for both professionals and public. In a study of patients' family attitudes in one such setting, published in this issue of Anaesthesia, Chieregato and colleagues describe an attitude survey of the next of kin of 213 consecutive patients admitted to a networked neurosurgical ‘hub’ ICU in Italy 4. The service covers approximately one million inhabitants, receiving referrals from six ‘spoke’ hospitals, and transfers patients back to their originating ICU once specialist treatment is complete. This is similar to the operational function and catchment area of many UK specialist tertiary referral units. Of the next of kin of those patients returned to ‘spoke’ hospital ICUs, surveyed one year after admission, 67.4% would have preferred their family member to have remained at the specialist centre until ICU discharge, most commonly citing continuity and quality of care. The results may have been confounded in this case by the availability of certain pastoral care elements preferentially at the hub site, such as a liberal visiting policy and an emphasis on daily communication. The study does not compare next of kin characteristics, which may influence responses (for example, geographic proximity, demographics and socio-economic status). Another possible limitation is that the named next of kin may not be the most representative family member or carer. The applicability of the findings to a British setting may be subject to societal differences, with historically very high levels of expectation and loyalty toward local district general hospital care among the UK public. The authors comment that regular interaction between sites, and assurance of shared quality and continuity across a region, may help public acceptance of care pathways spanning multiple sites, pointing to clinical networks as a strategy for achieving shared standards. They also usefully highlight the often-overlooked element of post-critical care rehabilitation, now recognised as an essential element of the critical care pathway 5, which requires integration with healthcare systems close to the patient's home – a potential benefit of early repatriation. Chieregato et al.'s study examines just one aspect of the hub-spoke organisation of critical care, in the context of the highly specialised, relatively low-volume clinical setting of neurosciences, where the concentration of critical care to a few sites is driven by regionalisation of the referral speciality, and where the rationale is easily understood. More broadly, international academic discussion has focused on the case for, or against, regionalisation of critical care (the creation of hub and spoke ICUs) as a primary goal in itself, independent of referral speciality 6, 7. The evidence for clinical volume-outcome benefits in critical car