Table 2 Barriers to regionalization of adult critical care.

Patient and Family

Financial strain

If you are asking someone to transfer a loved one four hours [away], and they choose to be with that loved one for weeks on end, there is an economic cost to that.

The cost of having to drive 40–50 miles to a tertiary center could be a barrier.

Personal strain

To get to a place only to end up getting to another place that's further away I think adds a lot of emotional stress to family.

Nobody wants their loved one a hundred miles away, particularly when they're sick.

Physician

General agreement

I think it would be very difficult to get rural pulmonologists and critical care physicians to participate.

I think it is better to cultivate some of the services locally.

Loss of income

[They] stand to lose business. They don't want to lose the patients to the bigger hospitals.

Everybody wants the payers; it's all money driven.

Loss of autonomy

[Physicians will be] concerned that if they give up their patients they will never get them back.

They like to take care of their patients no matter what.

Source hospital

Loss of income

If they took all of our sick patients it could be devastating to our facility.

Patients equals volume equals financial viability.

Loss of care capacity

If they took away all our sick patients, we would become a fairly useless institution.

It will lower the variety of care a nurse is exposed to and therefore they will have less growth potential in technology.

Destination hospital

Overwhelmed resources

We're full all the time with what we've got.

Nobody is equipped to handle that. We have trouble getting people in. Who's going to take those patients?

Large facilities already divert patients regularly.

Cost and reimbursement

Sometimes when you get the acutely ill in the ICU, they are coming with no insurance.

Hospitals...have the potential for a great deal of financial woe, inheriting all the patients that might come to them for critical care without any reimbursement.

System

Regulation

Lack of authority to do any of this.

I can't envision a central triage system that would work without controversy.

Cost and cost-effectiveness

Cost is going to be a huge barrier.

Need to find out whether the outcome justifies the expense.

Limited staffing

We basically cannot use all of our beds because of our nursing situation.

Triage and infrastructure

The infrastructure is not there to do this.

It would be hard to make the call quickly regarding where the patient should go.

There would have to be additional [ambulance] rigs put into play so we're not missing the 911 calls.