Regionalization of care

Introduction Emergency medicine has dramatically evolved over the last half-century in response to the public's expectation of high-quality, accessible, and timely acute care. Outcomes for patients experiencing severe trauma, cardiac arrest, myocardial infarction, stroke, and burns have improved significantly. Much of this progress has been a result of substantial scientific and clinical discovery, but improvement of the delivery system has also played an important role. The goal of high-quality emergency care is to get the right resources to the right patient in the right place at the right time. Classically, regionalization efforts focused on getting the sickest patients from smaller facilities with fewer resources to larger specialty care centers with more experienced staff and specialized resources. This model of care runs the risk of over- or under-triaging, where patients may be either transported or transferred to facilities with greater resources than they require or not transferred to specialty centers that might provide life- or limb-saving intervention during their time of need. In the past decade, the Institute of Medicine (IOM) has recognized the positive impact of regional care delivery models for specific conditions, but there remains a significant challenge in the ability to appropriately match patients with high-quality care system-wide. Contributing factors include a lack of specialists, delays in care, hospital crowding, poor regional coordination resulting in fragmentation, and variation of care among providers and hospitals. The IOM recommended the development of coordinated, regionalized, and accountable emergency care systems in the United States. The challenge moving forward will be to discover novel ways to capitalize on the free flow of information, the ready access to technology, and the increasing role of patient preferences in the delivery of care. Although the concept of high-value care has permeated much of the house of medicine, there is no clear sense of how value will be defined in emergency care. The development of shared ownership of outcomes within a region across healthcare stakeholders could serve to align incentives and allow for innovation in the delivery of more patient-centered care not only for specific acute conditions, but for all patients presenting to emergency departments (EDs).