When a middle-aged man with covid-19 arrived at a Western Maryland emergency room last week, the hospital had all the expertise and none of the space to treat him.
In most places, a medical staffer would have called hospital system after hospital system looking for an empty bed. But this man got sick during the same week that Maryland launched a novel and centralized method to shuffle patients among increasingly swamped hospitals. After a single phone call, he was taken 125 miles from Cumberland to Suburban Hospital in Bethesda, a transfer between hospitals that normally don’t coordinate.
“Instead of them randomly calling 40 different hospitals trying to find the one with the space, they just call us,” said Theodore R. Delbridge, who leads the state agency administering the new program.
For 50 years, the state’s hospital systems have coordinated to quickly funnel trauma patients with gunshots, strokes, internal injuries or other time-sensitive maladies to doctors and hospitals with the expertise to fix them. Maryland was the first state in the country to create such a system of coordinated trauma care; today, it is overseen by the agency Delbridge leads, the Maryland Institute for Emergency Medical Services Systems, known as MIEMSS.
As hospitals begin to reach capacity amid the unrelenting coronavirus surge, the state is adapting its system to solve a more complex puzzle: finding available beds not only for covid-19 patients, but also for other sick people who would otherwise languish in emergency rooms.
“We’re hoping to be a matchmaker,” said Delbridge, who noted that Utah and Arizona have also launched centralized coordination efforts.
Maryland’s coronavirus hospitalizations have been climbing since early November, and as of Sunday stood at 1,576, just 135 shy of the hospitalization record set in late April. Record-setting daily coronavirus case counts over the past two weeks are expected to send even more patients into hospitals in the coming days.
The patient-matching task is complicated not only because of the high volume of cases and limited number of beds. Different coronavirus patients require different types of medical care, and a hospital’s ability to treat them varies greatly day-to-day — in part because doctors and nurses can get sidelined by needing to quarantine. A shortage of nurses and critical-care doctors has amplified the challenge.
Statewide, more than 85 percent of staffed acute and intensive care unit beds are filled, according to a Maryland Health Department analysis last week. Delbridge said roughly 15 percent of ICU beds — about 250 of them — lack the medical personnel to staff them. About 1,000 acute care beds, roughly 12 percent, also lack staff.
Maryland has taken several steps to stay ahead of the hospital surge: It reactivated two shuttered hospitals in Laurel and Takoma Park; built a field hospital inside the Baltimore Convention Center; and recently required each hospital to make 10 percent more beds available when hospitalizations cross certain thresholds.
Nursing and medical students and retired doctors can get special credentials to work alongside other medical staff, helping ease the staffing crunch.
“There will always be places to take care of people, I’m not worried about that,” Delbridge said. But without the new system to make transfers far more efficient, he added, some patients may not get the care doctors want to deliver.
The system relies on sophisticated technology and experienced internal medicine doctors staffing the coordination center on a rotating basis.
Each day, hospital systems update a centralized database with information about available beds, staffing levels and the influx of critical and acute patients overnight. When an overwhelmed hospital needs to transfer a patient, a medical staffer makes a single call to the coordinator to explain the patient’s case and determine what level of care the patient might need. The coordinator does a computer search to yield the optimal location and then follows up with the receiving hospital to confirm a staffed bed is still available.
The initiative is not limited to covid-19 patients. As hospitals fill up, a cardiac or stroke patient who needs critical care could be sent to a regional facility that isn’t overflowing with intubated covid patients, Delbridge said. Patients who need serious but not critical care could be moved to keep beds available for a growing coronavirus outbreak.
In the past, and earlier in the pandemic, such transfers were done among hospitals owned and managed by the same system. Patients overcrowding intensive care units in hard-hit Prince George’s County, for example, were shuffled up to Baltimore in the spring, from one University of Maryland Medical System facility to another. Hospitals, Delbridge said, “were consuming a lot of time and energy and resources making that happen.”
In other states, where the fall surge hit earlier, medical professionals are frantically calling around to other hospitals for beds. In Lubbock, Tex., one hospital administrator told a news organization that he had to send coronavirus patients two states west to Arizona, which was the closest hospital he could find with space available. In St. Louis, it took 25 hours and calls to every Missouri hospital — plus some in Tennessee, Arkansas, Oklahoma, Nebraska and Iowa — to find someone to treat a patient with a quickly growing mass on his brain, according to the St. Louis Post-Dispatch.
Public health experts in Maryland said the state is also benefiting from its unique 40-year policy of regulating price controls for hospital services.
“We want to do right by people, and to do right by people, you need to cooperate,” said Thomas M. Scalea, director and physician in chief at the R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center in Baltimore.
Because trauma and now covid-19 patients are distributed by an independent agency, “it’s completely agnostic to individual hospital system politics,” Scalea said. “It’s about the patient.”
The pricing pact reduced competition among hospitals for lucrative patients or procedures, creating an atmosphere that makes it easier to collaborate, said Bob Atlas, president of the Maryland Hospital Association.
A bypass surgery or bandage costs the same at one hospital as another, regardless of whether the bill is paid by private commercial insurance, Medicaid or Medicare. (The state has a special waiver from the federal government to implement the law.)
“That leads to more collaboration among the hospitals,” Atlas said. “Everyone is going to comfortably serve every kind of patient, even if they have no insurance. . . . [It] reduces the incentive to choose the best paying customer.”
Effectively managing the available beds helps all hospitals, but Atlas cautioned that the system could be overwhelmed if the pace of infection doesn’t slow.
“Hospitals can do tremendous things, but if people don’t stop getting sick out in the community, we are going to spill over the banks here,” he said.
