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The central legal problem with CCU care is the absence of well-defined standards for staffing and facilities. Critical care medicine has been defined more by the name of the place it is practiced in than by the qualifications of the persons delivering it. While there is a nationally recognized certification in critical care medicine, very few physicians practicing in CCUs have formal training in critical care medicine.

Ideally, CCUs would have 24-hour staffing by physicians with expertise in critical care medicine, which would limit CCUs to teaching hospitals and large, wealthy private facilities. Such a standard was politically unthinkable in the 1970s, when patient-days in the CCU translated into profits for hospitals. Even in an era of DRGs and other limits on reimbursement for CCU care, maintaining a CCU is critical to supporting certain highly profitable surgeries.

The data on surgical morbidity and mortality indicate that complicated surgery should be centralized for the best patient care. Small community hospitals downplay morbidity and mortality in favor of the convenience of local care. Such hospitals typically cannot meet proper standards for CCU staffing. Financial difficulties have forced many large urban hospitals to reduce CCU staffing and not to maintain CCU equipment properly. Physicians practicing in hospitals with inadequate CCU facilities must consider whether they can justify admitting patients needing critical care. While there may be no alternative for emergency admissions, many CCU patients are elective admissions. As it becomes increasingly difficult to transfer patients, physicians must ensure that patients are admitted to the facilities best able to care for them.

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