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Clinical Commentary |

Uncharted Paths: Hospital Networks in Critical Care

Theodore J. Iwashyna, MD, PhD; Jason D. Christie, MD, MSCE; Jeremy M. Kahn, MD, MS; David A. Asch, MD, MBA
Author and Funding Information

*From the Division of Pulmonary and Critical Care (Dr. Iwashyna), Department of Medicine, University of Michigan, Ann Arbor, MI; the Division of Pulmonary, Allergy, and Critical Care (Dr. Christie), Department of Medicine and the Leonard Davis Institute of Health Economics (Drs. Kahn and Asch), University of Pennsylvania, Philadelphia, PA.

Correspondence to: Theodore J. Iwashyna, MD, PhD, 3A23 300 NIB, SPC 5419, 300 North Ingalls, Ann Arbor, MI 48109; e-mail: tiwashyn@umich.edu


There are no conflicts of interest for any of the authors of this manuscript.

This analysis was supported in part by a Fellows Career Development Award from the American Thoracic Society, National Institutes of Health (NIH)/National Heart, Lung, and Blood Institute (NHLBI) Cardiopulmonary Epidemiology Training Grant No. 5T32HL007891 and NIH/NHLBI No. 1K08HL091249-01.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).


Chest. 2009;135(3):827-833. doi:10.1378/chest.08-1052
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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.

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