Chest
Volume 132, Issue 5, November 2007, Pages 1455-1462
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Original Research
CRITICAL CARE MEDICINE
Intensive Care Services in the Veterans Health Administration

https://doi.org/10.1378/chest.06-3083Get rights and content

Objective

We describe the national organization and distribution of intensive care services within the Veterans Health Administration (VHA), the largest single integrated health-care system in the United States.

Data Sources

Data come primarily from the 2004 Survey of Intensive Care Units in VHA, an electronically distributed survey of all ICUs in the VHA. Medical directors and nurse managers from all 213 ICUs in the VHA responded to the survey. In addition, we extracted data on the number of ICU admissions and unique veterans served from national VHA databases.

Results

The VHA has a geographically dispersed, multilevel system of care with variation in geographic access for eligible veterans (varying from 3.1 to 3.5 ICU beds per 1,000 patient discharges) and variation in service provision (from 10 to 19 level 1 ICUs across four regions). Level 1 ICUs are the highest tertiary-level ICUs, with the full range of subspecialty care. The proportion of beds associated with VHA-developed ICU levels of care ranges from 55% level 1 beds in the Northeast to 73% in the South, while level 4 beds represent 4% of all ICU beds in the South and 10% in the Midwest.

Conclusions

Overall, the VHA system has a fair amount of regional variation, but level 1 ICUs are available in all geographic regions, and there are regional clusters of all levels. Adopting a four-level system for rating ICUs may assist in monitoring and assessing the quality of care provided in the smallest, most rural facilities.

Section snippets

Survey Administration and Content

The 2004 ICU survey was conducted under the auspices of the VHA National Program Office for Pulmonary and Critical Care. It was distributed via electronic mail through regional offices to each of 126 Veterans Affairs (VA) medical centers providing acute inpatient care. Regional divisions of VHA are called Veterans Integrated Service Networks (VISNs). There are 21 VISNs within the VHA, responsible for budgeting and developing clinical policy and decision making, such as referral patterns. We

Description of VHA ICUs

A total of 213 ICUs were reported at 126 separate locations (Table 3). Seventy hospitals had one ICU, with a range from one to four ICUs. The South had the largest number of ICUs (n = 90). The mix of ICU types varies by region of the country, with single-specialty ICUs dominating in the South, and mixed ICUs dominating in the other three regions. Half the ICUs were single specialty, mostly surgical.

There was regional variation in the number of beds in each region (Fig 1, Table 3), and in the

Discussion

This study updates information from the 1990 survey of VHA ICUs2 and provides the first assessment of regional variation in levels of ICU care in the largest integrated health-care system in the United States. In the two articles34 reporting on ICU organization in the United States from the early 1990s, results were aggregated to the entire United States. The 1991 survey reported in these studies preceded development of ICU levels,17 so results were not presented by level of care. Subsequent

Conclusions

This study was unique in describing intensive care services by ICU level and by region. We describe variation across the VHA in key aspects, including availability of the highest ICU level, and in key factors described in the literature as associated with outcomes. Overall, the picture of the VHA system shows a fair amount of regional variation, but level 1 ICUs are available in all geographic regions, and there are regional clusters of all levels. This suggests that while the VHA should

ACKNOWLEDGMENT

Special thanks is given to the 2004 Survey of Intensive Care Units in VHA Technical Advisory Group for their guidance and support of this project: Peter Almenoff, MD, FCCP, National Program Director Pulmonary and Critical Care Medicine, Network Director VISN 15, Kansas City, MO; Thomas Craig, MD, Medical Services Officer, VAHQ, Washington, DC; Ralph G. Depalma, MD, National Director of Surgery, VAHQ, Washington, DC; Rhonda Eisenzimmer, RN, MSN Clinical Manager, VAMC, Fresno, CA; Robert Jesse,

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    The views expressed in this article are those of the authors and do not reflect the views of the Department of Veterans Affairs.

    The authors have no conflicts of interest to disclose.

    Members of the 2004 Survey of Intensive Care Units in VHA Technical Advisory Group are listed in the Appendix

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