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How Maryland responded to hospitals at capacity

Clinicians have released a review of the first statewide critical care coordination center


Maryland began using prehospital emergency medical clinicians paired with critical care physicians in its Critical Care Coordination Center in November 2020. Their mission: ensure the right patient receives the right service, at the right time and in the right place. Pictured are Paramedics and Critical Care Coordinators Jason Wolf and Joshua Bosley

Photo/Courtesy of Todd Bowman

Many Americans watched on the news or from the windows of their homes the devastating effects of the COVID-19 pandemic that began in 2019. Government leaders knew that they needed to work with healthcare officials to develop a plan to ensure that every critical patient was treated.

As reported in a newly released peer reviewed article in “Critical Care Explorations,” Maryland’s Governor, Larry Hogan, recognized the need for centralized critical care and authorized funds to staff the first known statewide critical care coordination center. 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 statewide critical care coordination center in the coronavirus disease 2019 pandemic – and beyond,” depicts how public health emergencies, like COVID-19, can place unprecedented demand on critical care services.

“This was a descriptive piece, and the purpose of the paper was to describe the initial experience of a critical care coordination center, staffed 24/7 by a critical care physician and EMS clinician, can improve critical care resource use and patient flow, not only during a pandemic, but on an everyday basis,” Maryland’s Critical Care Coordination Center Medical Director Dr. Sam Galvagno, DO, PhD, professor at the University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, said. “We are fortunate to have a state government and leaders, MIEMSS Executive Medical Director Dr. Theodore Delbridge and Physician-in-Chief of the R Adams Cowley Shock Trauma Center, Dr. Thomas Scalea, who were able to make this a reality.”

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

The C4 program assists ICUs, emergency departments, freestanding medical facilities in Maryland and adjacent states to serve a population of over 6 million across an area of nearly 10,000 square miles, from the beaches of the eastern shore to the mountainous terrain of the western counties.

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

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

Another success of the program is the use of community based intensive care units that normally do not receive patients as consults, according to Galvagno. For example, hospital such as Anne Arundel, Frederick and Suburban became ICU referral centers. This work continues to this day.

C4 “provided additional ICU specialists to consult with and to triage the best location for each patient at any given time, so that hospital ED and ICU teams could focus on life-saving medical care,” Maryland Hospital Association President and CEO Bob Atlas said. “The C4 allows community hospitals to transfer patients to other community hospitals, while still ensuring patients needing specialty services or high-level acute care went to those health systems and academic hospitals.”


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How the critical care coordination center works

Hospitals, ICUs and EDs were provided a centralized number where they were first connected with a critical care coordinator, who would ask questions regarding the patient’s status and, more specifically, the need for transfer. After the information was obtained, the sending facility would be conferenced with a statewide central intensivist, who would triage the call and ask more specific questions to get the patient to the most appropriate facility, while utilizing the most appropriate resources.

The center is staffed, 24/7 by a critical care physician and an EMS clinician.

“In the past, emergency department physicians or intensive care physicians would have to call around for an intensive care unit,” Galvagno said. “With a single call, the burden of finding an ICU bed falls on the C4 staff. The C4 coordinator and physician are fully devoted to this activity and may devote their full attention to finding the right ICU for a patient.”

In some cases, the C4 team reaffirms that the patient may remain at the current facility. The benefits are enormous and represent an actual regionalized system, Galvagno explained.


Dr. Asa Margolis, DO, MPH, MS; MIEMSS central intensivist physician, triages a call on the C4 line. Margolis is an assistant professor of emergency medicine at Johns Hopkins and program director of the EMS Fellowship. He joins nearly 60 other critical care physicians who work in the Critical Care Coordinator 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 deliver specific care to a defined population of patients.

“Historical and current examples include neonatal intensive care units, trauma centers, and stroke/STEMI centers,” Galvagno said. “A major goal of regionalization is to allocate scarce healthcare 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 the rural portions of Maryland appear to be benefitting from the C4 program as ICU resources are concentrated most densely in the Baltimore and Washington D.C. regions.

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

Center adds pediatrics in 2021

“Pediatric care is very scarce ... from California, to New York, to Florida, the majority of hospitals are not able to admit [pediatric] patients to their own facilities,” Associate State Medical Director for Pediatrics for Maryland, Dr. Jennifer Anders, MD, FAAP, said. “In Maryland, the need [for a pediatric patient] to be transferred is about 16 times more likely. These statistics were long ahead of COVID.”

In Maryland, there are fewer pediatric acute care inpatient hospitals compared to adult inpatient ICU hospitals, Anders said.

“Most children who go to an emergency department with or without COVID and need to be admitted will end up requiring an interfacility transfer to another hospital,” according to Anders.

With the success of the C4 line with adults over the past year, it was a natural fit to use the resources in finding beds for pediatric patients.

C4 Pediatrics began taking calls on October 1.

The pediatric emergency medicine and pediatric critical care physicians and paramedic coordinators can be reached by calling the same central number as the adult line and selecting the pediatric prompt, 24/7.

The Central Advisor Pediatric Physician will be available for consultations in real time and facilitate the transfer of patients requiring a pediatric intensive care units or pediatric acute care unit utilizing, according to Anders.

“Patients with chronic condition, where their specialists know them ... it is important to have them transported to their home centers,” Anders said. “The C4 line is good for isolated acute illness where the patient isn’t attached to a specific hospital, COVID or not. Get the patient to an appropriate bed, to take care of their acute problem.”

The C4 serves as a model for a tiered statewide regionalized system that ensures the demand for critical care services may be met during a pandemic and beyond. We are equally fortunate to have a robust public safety model/EMS system (MIEMSS) that can be used as the backbone for something like C4. The infrastructure and leadership at MIEMSS is what allowed C4 to become 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 that paradigm for critical care,” Galvagno said.

Todd Bowman is a nationally registered and flight paramedic with more than 18 years of prehospital experience in Maryland. He attended Hagerstown Community College for his paramedic education and later obtained his bachelor’s degree in journalism from Shepherd University in Shepherdstown, West Virginia. His experience ranges from rural, metro and aviation-based EMS. He is an experienced EMS manager, public information officer and instructor. Follow him on social media at @_toddbowman.