Where do critical care patients end up?

A new analysis catapults a young University of Pittsburgh doctor into a debate about whether high-stakes patients are ending up in the right hospital.

 

Health researcher David Wallace, 37, is a critical care physician. That means his patients have complex, time-sensitive and often expensive-to-treat health problems. Some colleagues in the field wonder if they should move toward something called regionalized care.

“By that I mean, a strategy to health care wherein patients with high-risk conditions would be treated selectively at hospitals that maintained high volumes,” Wallace said.

The research began with a hunch, and Wallace admits, an assumption: the idea that practice makes perfect. The premise is that high-volume hospitals likely have more expertise and better equipment and that those high-volume hospitals get better results.

For medical centers across Pennsylvania, Wallace mapped routes from home to hospital for more than 31,000 cases of acute respiratory failure treated in 2007. It’s a condition that critical care doctors see a lot. Patients with acute respiratory failure can’t get oxygen into their blood and often need help from a mechanical ventilator.

The investigation, which was limited to adult patients, identified where each person was treated, the closest hospital to home and the closest high-volume hospital. That travel-route analysis uncovered one group that Wallace dubbed “really needs improvement.”

“Twenty six percent of patients were brought to a treating facility that was low-volume center and it would have been a shorter trip to go to the high-volume center,” Wallace said. “That’s an opportunity, I think, for potential reorganization of where patients are sent.”

There was encouraging news too. About 16 percent of patients were treated at a high-volume hospital even though that medical center was not the closest to home.

The medical world already uses regionalized care in some situations. There are both formal and informal guidelines that send certain pediatric patients to a children’s hospital; other directives send patients with serious injury to a trauma center.

The new analysis asks if critical care patients should be triaged in a similar way.

Wallace said he doesn’t want to discount what small hospitals can do and he said his analysis has to be considered against a backdrop of a constantly changing health system.

Experts have identified many protocols and procedures that lead to excellent care for critically ill patients.

“Smaller centers are getting better,” Wallace said. “To some extend those standards which are associated with good outcomes can be exported from the large center to the small center.”

The new review adds to an ongoing debate about regionalized care but may stir up more questions than answers.

“It would be important to show that health outcomes are actually better in the high-volume hospital, that’s the next logical step for this kind of analysis,” Wallace said.