title: Uncharted paths: hospital networks in critical care.
abstract: Wide variation between hospitals in the quality of critical care lead to many potentially avoidable deaths. Regionalization of critical care is a possible solution; regionalization has been implemented for trauma and neonatal intensive care, and it is under active discussion for medical and cardiac critical care. However, regionalization is only one possible approach to reorganizing critical care services. This commentary introduces the technique of network analysis as a framework for the following: (1) understanding how critically ill patients move between hospitals, (2) defining the roles hospitals play in regional care delivery, and (3) suggesting systematic improvements that may benefit population health. We examined transfers of critically ill Medicare patients in Connecticut in 2005 as a model system. We found that patients are systematically transferred to more capable hospitals. However, we find the standard distinction of hospitals into either "secondary hospitals" or "tertiary hospitals" poorly explains observed transfer patterns; instead, hospitals show a continuum of roles. We further examine the implications of the network pattern in a simulation of quarantine of a hospital to incoming transfers, as occurred during the severe acute respiratory syndrome epidemic. Network perspectives offer new ways to study systems to care for critically ill patients and provide additional tools for addressing pragmatic problems in triage and bed management, regionalization, quality improvement, and disaster preparedness.
authors.affiliation: Division of Pulmonary and Critical Care, Department of Medicine, University of Michigan, Ann Arbor, MI. Electronic address: tiwashyn@umich.edu.
authors.forename: Theodore J
authors.initials: TJ
authors.lastname: Iwashyna
authors.affiliation: Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Philadelphia, PA.
authors.forename: Jason D
authors.initials: JD
authors.lastname: Christie
authors.affiliation: Department of Medicine and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
authors.forename: Jeremy M
authors.initials: JM
authors.lastname: Kahn
authors.affiliation: Department of Medicine and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
authors.forename: David A
authors.initials: DA
authors.lastname: Asch
mesh_terms: D003422:Critical Care / Q000458:organization & administration*; D016638:Critical Illness / Q000628:therapy; D006271:Health Facility Closure; D017052:Hospital Mortality; D006761:Hospitals / Q000145:classification*; D006801:Humans; D007362:Intensive Care Units / Q000592:standards; D010360:Patient Transfer; D011787:Quality of Health Care; D012041:Regional Medical Programs