• Prevention & Screening

• Prevention & Screening
• Cardiology

A large integrated network of physicians and other health care providers in the Caribbean, South Florida, and Central America has grown to 1200 providers and at the same time is reducing costs of care, according to a presentation by Kester Nedd, DO, Jackson Health System International Program, Miami, Florida, USA. The network was founded to improve barriers associated with 1) triage of patients; 2) scarcity of certain specialists; 3) case management; and 4) insurance issues that affect delivery of effective care in the region.

The network began at the Jackson Memorial Hospital System and the affiliated University of Miami Miller School of Medicine Health System. Following a successful 1.5-year pilot program, it has grown to include providers in the Bahamas, Barbados, and Panama. The program is driven by physicians, who use algorithms to identify patients at risk for catastrophic events, and communicate with other physicians of the same specialty to triage patients to centers of excellence (COE) in the region, according to Dr. Nedd. The network will be incorporating telemedicine to aid in this effort.

Rapid triage can be critical. For example, in acute vascular cases with potential neurological impact (eg, carotid artery dissection), care at a COE early has the potential to prevent a cascade of events leading to further complications (eg, intracerebral hemorrhage). While triage issues in catastrophic cases can be difficult even in the United States, the existence of protocols developed under the context of accreditation and certification programs and in consideration of medical-legal risk mitigation facilitates more effect decision-making [Bullock MR et al. J Neurotrauma 1996].

When seeking to transfer a patient with a complex or potentially catastrophic case, physicians should be familiar with the accepting institution and its staff. Building familiarity with neighboring COEs has proven challenging, yet is necessary to be able to direct patients with complex conditions at centers with the highest levels of expertise. This has ancillary economic benefits, for countries like Panama for example by increasing medical tourism. Difficulty in the Caribbean region results in some cases because the payments associated with these transfers, are limited by the lack of health insurance in the region. In those with insurance, difficulties may also arise especially with insurance companies, not only due to inaccessibility during off-hours but also potentially by poorly trained personnel who must make decisions influencing the care of critically ill patients.

Specialists are better able to share information when they speak with other practioners of the same speciality, according to Dr. Nedd. He added that new reimbursement mechanisms should greatly facilitate the creation of regional COEs by physicians and healthcare systems secondary to more predictable payment sources.

While new systems for triage may be especially important in the context of cerebrovascular complications, other brain injury, and trauma, the concepts used may be readily transferred to other areas of emergency medicine. While COEs in the Caribbean have provided new patient treatment opportunities, rapid planning is the essential underpinning of a successful transfer.

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