The Maryland (USA) Critical Care Coordination Center (C4): From Pandemic to Permanence

Abstract

Introduction:The 2019 coronavirus disease (COVID-19) pandemic created overwhelming demand for critical care services within Maryland’s (USA) hospital systems. As intensive care units (ICUs) became full, critically ill patients were boarded in hospital emergency departments (EDs), a practice associated with increased mortality and costs. Allocation of critical care resources during the pandemic requires thoughtful and proactive management strategies. While various methodologies exist for addressing the issue of ED overcrowding, few systems have implemented a state-wide response using a public safety-based platform. The objective of this report is to describe the implementation of a state-wide Emergency Medical Services (EMS)-based coordination center designed to ensure timely and equitable access to critical care.Methods:The state of Maryland designed and implemented a novel, state-wide Critical Care Coordination Center (C4) staffed with intensivist physicians and paramedics purposed to ensure appropriate critical care resource management and patient transfer assistance. A narrative description of the C4 is provided. A retrospective cohort study design was used to present requests to the C4 as a case series report to describe the results of implementation.Results:Providing a centralized asset with regional situational awareness of hospital capability and bed status played an integral role for directing the triage process of critically ill patients to appropriate facilities during and after the COVID-19 pandemic. A total of 2,790 requests were received by the C4. The pairing of a paramedic with an intensivist physician resulted in the successful transfer of 67.4% of requests, while 27.8% were managed in place with medical direction. Overall, COVID-19 patients comprised 29.5% of the cohort. Data suggested increased C4 usage was predictive of state-wide ICU surges. The C4 usage volume resulted in the expansion to pediatric services to serve a broader age range. The C4 concept, which leverages the complimentary skills of EMS clinicians and intensivist physicians, is presented as a proposed public safety-based model for other regions to consider world-wide.Conclusion:The C4 has played an integral role in the State of Maryland’s pledge to its citizens to deliver the right care to the right patient at the right time and can be considered as a model for adoption by other regions world-wide.

Trends in Patient Transfers From Overall and Caseload-Strained US Hospitals During the COVID-19 Pandemic

“…Patient Transfers From Overall and Caseload-Strained US Hospitals During COVID-19 transports. 17,18 Hospitals in high-surge weeks in our study displayed a 15.4% to 19.8% increase in transfers during the third, Delta, and Omicron waves, compared with high-occupancy weeks during prepandemic times. However, the transfer patterns during high-surge weeks appeared to be conspicuously different across hospital groups stratified by bed capacity and urbanicity, with growth in transfers being predominantly limited to small urban hospitals.…”

“…However, on an aggregate basis across hospitals in our study, fewer than usual transfers occurred even during top surging weeks during the first wave. As the pandemic progressed, there was a greater comfort level with managing and transporting patients with COVID-19, and MOCCs emerged in the US for coordinating transports . Hospitals in high-surge weeks in our study displayed a 15.4% to 19.8% increase in transfers during the third, Delta, and Omicron waves, compared with high-occupancy weeks during prepandemic times.…”

“…Evidence on acute hospital transfers during the pandemic has been limited to local or narrative reports, surveys, specific patient cohorts (eg, those with stroke or ST-elevation myocardial infarction), and non-US studies . Most US states have not reported their experience with transfers to date, and among the few that have, the ability to transfer patients appeared to vary substantially across individual US state–based transfer coordination enters . Furthermore, there were media reports of US hospitals making multiple unsuccessful attempts to move patients to other hospitals .…”

“…6,[12][13][14][15][16][17] Most US states have not reported their experience with transfers to date, and among the few that have, the ability to transfer patients appeared to vary substantially across individual US state-based transfer coordination enters. 17,18 Furthermore, there were media reports of US hospitals making multiple unsuccessful attempts to move patients to other hospitals. [19][20][21][22][23] Collectively, these observations raise patient access and equity concerns and questions around the practical feasibility of load balancing as a definitive public health strategy during future pandemics.…”