• H S Rafkin and J W Hoyt.
• Department of Critical Care Medicine, St. Francis Medical Center, Pittsburgh, PA.
• Crit Care Clin. 1994 Jan 1;10(1):157-77.

AbstractAs CCM has grown, the diversity of ICU patients, as well as that of ICU organization and structure, has grown. This growth has led to numerous questions regarding health care delivery in the ICU. These questions contributed to the development of systems that objectively evaluate the quality of health care delivery in ICUs. Severity of disease scoring systems have been developed and allow for a valid analysis of ICU performance at several levels. These systems should help intensivists determine how health care delivery can be optimized in ICUs. Despite the controversy that surrounds severity of disease scoring and prognostic systems, it is not unreasonable to suggest that, because of the feedback these systems would provide, health care delivery in the ICU would be improved through more extensive use of them at the present time. The information acquired through the use of objective scoring systems ultimately must be used to improve the efficiency of ICUs. The structure and organization of ICUs in the United States, as well as the training of those who treat ICU patients, are excessively diverse, and a more standardized approach to health care delivery in the ICU ultimately will be required. Present information suggests that decentralized ICUs with part-time ICU physicians result in poorer outcomes. The APACHE III study intends to explore these relationships in more detail. Certainly, more studies looking at these issues are needed, but we are at least beginning to answer the questions that resulted from the rapid growth of critical care in the 1980s. The SCCM data suggest two possible alternatives, not necessarily exclusive of each other: (1) A large percentage of ICUs may be obligated to undergo structural changes in the near future. (2) Regionalization of critical care, already present, may continue. Certain rural areas may find it more expedient to send the most critically ill patients to tertiary centers in nearby cities, as opposed to a wholesale upgrading of the delivery of care in their own ICUs. Ultimately, all hospitals will be obligated to provide patients access to the highest quality of critical care.

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