. 2022 Jan 6;3(1):e12631. doi: 10.1002/emp2.12631

TABLE 1.

Summation of national models of regionalization

	Problem area addressed	Leadership/criteria	Generalized structure	Differentiating factors	Outcomes/database
Trauma	24 hours in‐house surgical coverage: specialty coverage–such as orthopedic surgery, neurosurgery, anesthesiology, emergency medicine, radiology, internal medicine, plastic surgery, oral and maxillofacial, pediatric and critical care, full lab and imaging diagnostic services, and operating room/postanesthesia care unit/ICU staff.	American College of Surgeons–Committee on Trauma (ACS‐COT). Resources for Optimal Care of the Injured Patient, 2014. ²⁷ Designation–State agency, generally follow ACS‐COT standards, mandated through legislative or regulatory authority for levels of trauma care, requirements of participation, and associated penalties. Verification–voluntary, evaluation process done by ACS for level 1 and 2 centers according to adult/pediatric status, lasts for 3‐year period.	Tiered (Level I–V) according to capacity of care as by designation/verified criteria. EMS triage protocols to direct patient to most appropriate center of care–level Is for high‐acuity surgical care, through level IV and V for smaller, local facilities providing rapid evaluation, essential stabilization and transfer up the chain.	High‐level trauma care is not profitable, ²⁸ , ²⁹ leading to minimal competition for providing trauma services outside of affluent urban areas. ACS verification process is active surgeon driven, self‐imposed professional mandates leading to greater acceptance and level of participation. Proposed spinoff benefits for other time‐sensitive, surgical emergencies: ruptured aortic aneurysms, etc. ³⁰	From national data, risk‐adjusted mortality from trauma was 7.6% in designated Level 1 trauma centers versus 9.5% in undesignated centers. ³¹ Another meta‐analysis cited a 15% reduction in mortality after trauma system implementation. ³² National Trauma Data Bank ²⁷ , ³³
Burn	Specialized burn care is a low‐volume, high‐resource, high‐expertise condition to treat. Burn teams, led by burn surgeons, involve multidisciplinary efforts that could not exist without regionalization of care and the consolidation of patients in a geographic catchment area to maximize volume–outcome relationship.	American Burn Association. American Burn Association–Burn Center Verification Review Program–Verification Criteria 2018. ³⁴ Voluntary, 3‐year verification process principally evaluates survival, objective reviews of complications, emotional health and reintegration in society metrics. Additionally, the process verifies minimum guidelines for facility resources, volume, staffing, experience, continuing education, dedication to prevention, teaching and research.	Self‐designated and American Burn Association verified burn centers: Specialized unit, with dedicated ICU beds Transfer agreements for trauma care Responsive surgeon and care team ratios to fit patient acuity Rehabilitative services–occupational/physical therapy, social and psych Sufficient number of yearly admissions (100 patients)	Nurse staffing ratios and need for rehabilitation services unique to burn care–low turnover and high degree of multispecialty cooperation. Burn care given its resource‐intensive nature has low profitability to a hospital ³⁵ , ³⁶ , but given a significant catchment area can remain independently viable, even turn a profit if surrounding institutions do not "skim" insured patients. ³⁷ Spin off benefits for highly morbid conditions such as toxic epidermal necrolysis, necrotizing fasciitis and frostbite. ³⁸ , ³⁹ , ⁴⁰ , ⁴¹	Regionalization of burn care within the New York City metropolitan area was associated with care for patients in designated facilities in over 75% of the cases and a reduction in mortality by almost 50%. ⁴² National Burn Data Standard and National Burn Repository. ³⁴ , ⁴³ , ⁴⁴ , ⁴⁵
Stroke	Stroke became an acute care condition with intravenous tPA, thrombectomy, and neurosurgical intervention results demonstrating time‐sensitive benefits. System of care: IV tPA, computed tomography scanner, and stroke center–therapeutic, consultation, and interventional capabilities. Bypass to Primary Stroke Center/Comprehensive Stroke Center if < 15–20 minutes transport time, IV tPA at regional hospital if > 15–20 minutes transport time.	The Joint Commission (TJC)–Stroke Program with participation of the American Heart Association (AHA) and American Stroke Association. Specifications Manual for Joint Commission National Quality Measures. ²⁴ Voluntary verification process through a Disease‐Specific certification program.	Four‐tiered certification system: Primary Stroke Center –stroke service/unit with tPA capabilities (2003) Comprehensive Stroke Center–telestroke service and complete surgical coverage (2012) Thrombectomy Stroke Center–provide thrombectomy for large vessel occlusions (2018) Acute Stroke Ready Hospital–primarily rural, tPA available and telestroke consult agreements (2018)	Stroke patients are primarily Medicare covered, ⁴⁶ every hospital desires to treat stroke patients. ³ Telestroke is well‐received and highly effective given that stroke consult is principally cognitive based and easy to conduct via phone/imaging review. Although stroke programs are well developed and yielding successful outcomes, the EMS bypass and triage protocols are not as robust nor effective as in the trauma system–lack of state mandates.	Organized care data from Canada and Taiwan has been shown to reduce the following risks associated with stroke: death by 14%, death or institutionalized care by 18%, and death or dependency by 18% ⁸ , ⁴⁷ , ⁴⁸ American Heart Association ‐ Get Within the Guidelines Stroke (GWTG‐S) ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵² , ⁵³
STEMI PCI/Fibrinolysis	Ongoing evidence has demonstrated a decreased chance of survival if either fibrinolysis or PCI is delayed >30 minutes ⁵⁴ Push to get patients to PCI/thrombolysis capable centers as expediently as possible (door to balloon/needle times of <90 minutes and <120 minutes for inter‐hospital transfer patients).	AHA and American College of Cardiology (ACC)–Mission Lifeline: Recognition Program. TJC–STEMI/Cardiac Program (Effective July 1, 2019). American Heart Association Mission: Lifeline ‐ Hospital Recognition Criteria v3. ²⁶ Centers that meet certain time and guideline goals receive recognition on Gold, Silver, and Bronze levels respective to outcomes and compliance level. TJC program will feature 2 voluntary certifications for STEMI care.	Primary PCI centers meeting ACC/AHA guidelines: Fellowship‐trained interventional cardiologists Volume: 11 primary PCI procedures/year and 75 total PCI procedures per year) ± Cardiothoracic surgeons on staff or explicit transfer agreements for supportive care for patients with STEMI and complications–cardiac ICU Meet triage, time, and outcome goals according to established guidelines	Cardiac PCI care is profitable and most general medical service hospitals rely upon cardiovascular care for financial viability. Patients generally do not stay in hospital long (∼24–48 hours post‐op), leading to lower capitated payments System not as coordinated with significant “cooptition”–A mix between competition and cooperation, non‐optimized system Higher degree of EMS involvement with ambulance ECG and triage education for suspected STEMI. Certificate of Need laws play a significant role in establishing cardiac care facilities, minimizing procedure volume dilution.	Multiregional study in the United States indicated all process measures demonstrating coordination between EMS and hospitals had improved–first medical contact to ECG device use time of ≤90 minutes (hospital within ≤10 minutes), first medical contact to device time to catheterization laboratory activation of ≤20 minutes, and emergency department dwell time of ≤20 minutes. These improvements in treatment times corresponded with a significant reduction in mortality (in‐hospital death 4.4%–2.3%; P = 0.001) that was not apparent in hospitals not participating in the project during the same time period. ⁵⁴ American Heart Association–Coronary Artery Disease (GWTG‐CAD) databases, ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵² , ⁵³ the Cardiac Arrest Registry to Enhance Survival (CARES). ⁵⁵
Neonatal ICU/obstetrics (OB)	Limited numbers of pediatric subspecialists, pediatric ICU/intensivists, neonatal ICU/neonatologists, OB/Gyn capabilities coupled with pediatric focused trauma capabilities. Tiered structure of services needed to maximize ability to treat high‐risk and complicated perinatal and obstetric patients.	American Academy of Pediatrics. Levels of Neonatal Care–American Academy of Pediatrics Policy Statement ( ²¹ ). ²¹ ^. Recommendations for levels of perinatal care established in consortium with the March of Dimes through “Toward Improving the Outcome of Pregnancy.” These recommendations have been adopted by state perinatal programs and networks. Federal grant money available for system. Varies state to state regarding level of integration and verification.	Recommended levels of neonatal care: Level 1–Well newborn nursery: neonatal resuscitation, stabilize and provide care for infants born 35–37 weeks. Level 2–Special Care Nursery: Provide care for ≥32 weeks with neonatal specialists. Level 3–Neonatal ICU: Provide care <32 weeks with pediatric subspecialists. Level 4–Regional Neonatal ICU: all the above in addition to pediatric surgical subspecialists	Long‐standing federal and state grant support. ¹⁸ Guidelines interpreted broadly and verification generally limited. No national verifying agency. Varies state to state. Neonatal ICU care has seen increasing level of profitability, with more hospital facilities interested in providing intensivist care. ⁵⁶ , ⁵⁷ , ⁵⁸ Obstetric labor and delivery in comparison has progressively decreased in profitability, with small hospitals and facilities facing ceasing their services nationwide. ⁵⁹	One meta‐analysis demonstrated significantly worse outcomes for very low‐birth rate and very preterm infants born at level 1 and 2 centers compared to higher levels. ⁶⁰ Several studies that have looked at it from a state‐level perspective have found significant benefit for premature infants ¹⁰ , ¹¹ and have additionally identified that deregionalization trends have negatively affected care outcomes. ⁶¹ , ⁶² , ⁶³ , ⁶⁴ . Vermont‐Oxford database for neonatal ICU/OB care. ⁶⁵

Abbreviations: ABA, American Burn Association; CT, computed tomography; EMS, emergency medical services; PCI, percutaneous coronary intervention; STEMI, ST‐segment–elevation myocardial infarction; tPA, tissue plasminogen activator.