MD Intensive Care Coordination Lightens EMS and Hospital Burden

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Many Americans watched the news or from their home windows at the devastating effects of the COVID-19 pandemic that began in 2019. Government leaders knew they had to work with health officials to develop a plan to to ensure that every critical patient is treated. .

As noted in a peer-reviewed article recently published in “Critical Care Explorations,” Maryland Governor Larry Hogan recognized the need for centralized intensive care and authorized funds to staff the first care coordination center. intensive known statewide. The center was based at the Maryland Institute for Emergency Medical Services Systems (MIEMSS) in Baltimore. MIEMSS oversees and coordinates the statewide EMS system.

The article, “The Role of a State-Wide Critical Care Coordination Center in the 2019 Coronavirus Disease Pandemic – and Beyond,” describes how public health emergencies, such as COVID -19, can place an unprecedented demand on intensive care services.

Maryland began using prehospital emergency medical clinicians paired with intensive care physicians at its ICU coordination center in November 2020. Their mission: to ensure the right patient receives the right service, at the right time. and in the right place.  Pictured are Paramedics and Intensive Care Coordinators Jason Wolf and Joshua Bosley

Maryland began using prehospital emergency medical clinicians paired with intensive care physicians in its ICU coordination center in November 2020. Their mission: to ensure the right patient receives the right service, at the right time. and in the right place. Pictured are Paramedics and Intensive Care Coordinators Jason Wolf and Joshua Bosley (Photo / Courtesy of Todd Bowman)

“This was a descriptive article, and the purpose of the article was to describe the initial experience of an intensive care coordination center, staffed 24/7 by an intensive care physician. and an EMS clinician, can improve critical care resource utilization and patient flow, not just during a pandemic, but day-to-day, ”said the medical director of the Maryland Intensive Care Coordination Center, the Dr Sam Galvagno, DO, PhD. “We are fortunate to have a state government and leaders, the Executive Medical Director of MIEMSS, Dr Theodore Delbridge and the Chief Medical Officer of the R Adams Cowley Shock Trauma Center, Dr Thomas Scalea, who were able to make it happen. “

The published review covers a 6-month period from December 16, 2020 to July 1, 2021, according to Galvagno. The C4 program was launched in November 2020. “Over 1,700 consultations have been completed to date, with over 800 actual patient movements,” said Galvagno.

The C4 program helps intensive care units, emergency departments, free-standing medical facilities in Maryland and adjacent states serve a population of over 6 million people in an area of ​​nearly 10,000 square miles, beaches from the east coast to the mountainous terrain of the western counties.

Galvagno said an important finding from this initial descriptive work is the role of the consultation … not all patients had to be moved.

“Many (patients) could be treated in local intensive care units,” said Galvagno.

Another success of the program is the use of community intensive care units that do not normally see patients in consultation, according to Galvagno. For example, hospitals like Anne Arundel, Frederick and Suburban have become referral centers in intensive care. This work continues to this day.

C4 “provided additional critical care specialists to visit and sort out the best location for each patient at any given time, so that hospital emergency department and intensive care teams can focus on life-saving medical care.” said Bob Atlas, president and CEO of the Maryland Hospital Association. “The C4 allows community hospitals to transfer patients to other community hospitals, while ensuring that patients in need of specialized services or high-level acute care come to these health systems and teaching hospitals.”


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How the intensive care coordination center works

Hospitals, intensive care units and emergency departments were assigned a centralized number where they were first put in contact with an intensive care coordinator, who would ask questions about the patient’s condition and, more specifically , on the need for a transfer. Once the information is obtained, the sending facility would be conferenceed with a central statewide intensivist, who would sort out the call and ask more specific questions to bring the patient to the most appropriate facility, all using the most appropriate resources.

The center is staffed 24/7 with an intensive care physician and an EMS clinician.

“In the past, emergency department doctors or intensive care doctors had to call an intensive care unit,” Galvagno said. “With just one call, the onus of finding an intensive care bed falls on C4 staff. The C4 coordinator and the doctor are completely dedicated to this activity and can devote their full attention to finding the right intensive care unit for a patient.

In some cases, the C4 team reaffirms that the patient can stay in the current facility. The benefits are huge and represent a true regionalized system, explained Galvagno.

Dr Asa Margolis, DO, MPH, MS;  MIEMSS central resuscitator, sorts a call on line C4.  Margolis is Assistant Professor of Emergency Medicine at Johns Hopkins and Program Director of the EMS Fellowship.  He joins nearly 60 other intensive care physicians who work at the Intensive Care Coordination Center.

Dr Asa Margolis, DO, MPH, MS; MIEMSS central resuscitator, sorts a call on line C4. Margolis is Assistant Professor of Emergency Medicine at Johns Hopkins and Program Director of the EMS Fellowship. He joins nearly 60 other intensive care physicians who work at the Intensive Care Coordination Center. (Photo / Courtesy of Todd Bowman)

Regionalization has been defined as a systematic concentration of selected patients in a subset of centers of excellence through the establishment of a network of resources that provide specific care to a defined patient population.

“Historical and current examples include neonatal intensive care units, trauma centers, and stroke / STEMI centers,” said Galvagno. “A major objective of regionalization is to allocate scarce health resources to include protocols, definitive procedures or care pathways. This is done on the basis of geography, with the overall goal of providing higher value care. “

Galvagno added that hospitals in rural Maryland appear to benefit from the C4 program, as intensive care resources are concentrated more densely in the Baltimore and Washington DC areas.

“Minnesota, Arizona, and Seattle now have similar systems, although ours is ongoing and now goes beyond the pandemic to include day-to-day operations, including pediatric patients,” Galvagno said. “We have a separate C4 pediatric team that is now staffed 24/7 to manage pediatric intensive care and acute care resources. “

Center adds pediatrics in 2021

“Pediatric care is very rare … from California to New York to Florida, the majority of hospitals are unable to admit [pediatric] patients in their own facilities, ”said Dr. Jennifer Anders, MD, FAAP, state assistant medical director for pediatrics for Maryland. “In Maryland, the need [for a pediatric patient] to be transferred is about 16 times more likely. These statistics were well ahead of COVID. “

In Maryland, there are fewer pediatric acute care hospitals than adult intensive care hospitals, Anders said.

“Most children who go to the emergency room with or without COVID and need to be admitted will eventually require an inter-facility transfer to another hospital,” according to Anders.

With the success of the C4 line among adults over the past year, it was only natural to use resources to find beds for pediatric patients.

C4 Pediatrics began receiving calls on October 1st.

Pediatric emergency physicians and pediatric intensive care physicians and paramedical coordinators can be reached by calling the same central number as the adult line and selecting the pediatric prompt, 24/7.

The central advising pediatrician doctor will be available for real-time consultations and will facilitate the transfer of patients requiring a pediatric intensive care unit or a pediatric acute care unit, according to Anders.

“Patients with chronic illness, where their specialists know them… it is important to have them transported to their reception centers,” said Anders. “The C4 line is good for isolated acute illnesses where the patient is not attached to a specific hospital, COVID or not. Bring the patient to an appropriate bed to manage their acute problem. “

The C4 serves as a model for a state-wide, multi-tiered regionalized system that ensures that the demand for critical care services can be met during a pandemic and beyond. We’re also fortunate to have a Robust Public Safety Model / System (MIEMSS) that can be used as a backbone for something like C4. MIEMSS’s infrastructure and leadership is what made C4 a reality, according to Galvagno.

“The fundamental mission of all critical care organizations is to ensure that the right patient receives the right service at the right time and in the right place by the right clinicians. This is the same paradigm used for EMS throughout Maryland. The C4 was designed to implement this paradigm for critical care, ”said Galvagno.


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