The system of care approach to public health provides a functional framework for making use of resources to optimize the care of patients. The intent is to address conditions which have a significant impact on mortality and morbidity. This functional framework generally includes hospitals designated based on resources for the care of particular types of patients, destination guidelines for the transport of patients to the appropriate hospital via Emergency Medical Service (EMS), criteria for activation and/or the utilization of hospital resources, data collection and data use for improving system performance. In terms of patient care, the system of care framework promotes best practices for caring for patients.
Mississippi Systems of Care
Mississippi’s first system of care was developed to address morbidity and mortality from traumatic injuries. The public health community often refers to trauma as a surgical disease. Indeed, patients who sustain traumatic injury require specialized care, including resuscitation and surgery. The probability for a successful outcome associated with trauma is increased when the patient receives initial resuscitation and surgery in a timely manner. Based on national standards, this is facilitated by the designation of appropriate trauma centers, the use of EMS field destination guidelines and the use of hospital trauma team activation criteria. Trauma center designation ensures hospitals have the resources to provide definitive care for specific types of traumatic injuries. EMS field destination guidelines provide a mechanism for triaging patients for transport to the most appropriate trauma center. Trauma activation criteria categorize patients according to neurological and hemodynamic status, anatomical injury and mechanism of injury and guide the decision-making process for activating the hospital trauma team based on injury severity. The trauma system of care began as a voluntary system of care that evolved into a mandatory system of care requiring hospitals to participate commensurate with their resources.
Based on successes of the trauma system of care to get the right patient to the right hospital at the right time, cardiologists, EMS, hospitals, and the Mississippi Healthcare Alliance created a STEMI (ST-elevation myocardial infarction) system of care plan first approved by the Mississippi State Board of Health in 2011 to reduce death and disability resulting from STEMI events in Mississippi. Over the last 20 years, advances in the treatment of STEMI have resulted in dramatic reductions in death attributed to STEMI. The STEMI system of care plan focuses resources on rapid reperfusion of the STEMI patient, utilizing either fibrinolytic therapy, or primary Percutaneous Coronary Interventions (PCI), to reduce mortality from STEMI heart attacks. In the STEMI system of care, field recognition by pre-hospital providers utilizing 12-lead ECG, coupled with pre-hospital notifications of the receiving facilities and designated PCI resources, can further reduce time to reperfusion, resulting in improved outcomes.
Improved patient outcomes from the STEMI system of care led a collaborative effort of the Mississippi State Department of Health (MSDH), neurologists, Mississippi Healthcare Alliance, Mississippi Hospital Association and American Heart Association to design a voluntary stroke system of care to get the patient suffering from a stroke to an appropriate hospital so that patients who are candidates for thrombolytic and interventional therapies may receive appropriate care in a timely manner. The stroke system of care focuses on early recognition of stroke, promoting populations to call 911 when signs and symptoms of stroke occurs, minimizing door to CT times and ensuring early administration of thrombolytics. In 2013, the Mississippi State Board of Health approved the stroke system of care making Mississippi the first state to have three functioning acute care systems including a mandatory trauma system.
This process of matching patients with resources offers the best possible opportunities for best outcomes, and over the course of their development the State Board of Health has adopted rules and regulations for the systems of care to ensure participant hospitals meet minimum prescribed standards. In the case of the Trauma Care System, statute mandates hospital participation in the system, and the rules and regulations apply to each licensed hospital. In the case of the STEMI and Stroke care systems, hospitals voluntarily apply to become designated centers, but designated centers must comply with the rules and regulations recommended by their respective advisory committees and must be approved by the State Board of Health. As the preceding established systems of care matured, each recognized the need for minimum standards for participant hospitals.
Mississippi COVID-19 System of Care Overview
A task force appointed by Governor Reeves recommended the development and implementation of a statewide system of care to ensure the most efficient use of all Mississippi hospitals’ inpatient hospital resources for COVID-19 patients who require admission during the COVID-19 pandemic. Accordingly, the COVID-19 system of care was designed to provide a framework for efficient use of resources to optimize the care of COVID-19 patients. This is facilitated by the voluntary designation of hospitals based on their ability to care for COVID-19 patients, the use of EMS guidelines for the care and transport of patients, guidelines for the immediate transfer of patients to a higher level of care when indicated, guidelines for the transfer of less acute patients to a lower level of care when a higher-level facility is not indicated (to decompress higher level facilities) and telemedicine consultation services. Telemedicine services in the COVID-19 system of care plan require higher-level facilities to provide consultation services between physicians and/or mid-level providers, when immediate transfer is not indicated as per the guidelines for immediate transfer, but consultation may otherwise offer a benefit in the management of the patient or in decisions to transfer patients to a lower level of care.
To facilitate implementation of the COVID-19 system of care plan the University of Mississippi Medical Center (UMMC), an Emergency Support Function – 8 (ESF-8) primary agency in the Governor’s Comprehensive Emergency Management Plan (CEMP), to support MSDH by coordinating acute medical services within Mississippi, activated Mississippi MED-COM. In accordance with the CEMP, Mississippi MED-COM, a service of UMMC, coordinates, and in some cases facilitates, the movement of every COVID-19 patient, including those transferred for higher level care, those transferred to a lower- level facility, those transferred to inpatient hospice, those transferred to licensed nursing home facilities, and those transferred for convalescence. Transfers to a higher level of care are normally destined to the closest appropriate facility based on bed and resource availability. The plan also allows for transfers to a lower-level facility within reasonable proximity so as not to unduly stress EMS operations. Further, the plan recognizes that UMMC offers clinical trials specifically associated with COVID-19 and makes provision for patients to be transferred to UMMC for advanced therapeutics.
System Design
The COVID-19 system of care is comprised of numerous components designed to utilize Mississippi inpatient hospital beds and other resources more efficiently for COVID-19 patients including pre-hospital COVID-19 EMS response and treatment guidelines to assist EMS providers in the decision- making process regarding hospital destination selection and clinical decision-making, criteria for self-designation of levels of participation for hospitals and other healthcare facility resources; provisions for skilled nursing facilities and in-patient hospice facilities to participate; communications on the overall status of pre-hospital activities, hospital and other healthcare resource availability and evaluating and improving system performance and safety considerations. The plan calls for automatic acceptance of acute COVID-19 patients when immediate transfer to a higher-level facility is indicated. While the COVID-19 system of care plan is a voluntary system of care, the plan makes provisions to allow for mandatory participation of resources when capacity issues may necessitate and make mandatory for every hospital to report to the Statewide Acute Care Capacity Status System (SACCSS) to support the communications and performance and safety components of the plan. Due to the fact that this system of care was newly developed, MSDH and UMMC collaborated closely throughout the system’s activation to monitor effectiveness.
Levels of Participation
MSDH and UMMC developed a self-assessment survey that was completed by healthcare facilities agreeing to participate at the assessed capability. Healthcare facilities are classified under the plan based on their capabilities to provide clinical management of COVID-19 patients. MSDH designated participating hospitals at one of four levels and the plan provides for a fifth level for convalescing facilities and a sixth level for long-term acute care (LTAC) hospitals and skilled nursing facilities. Hospitals designating as Level I-IV are found in Figure 1.
Level I COVID-19 Centers act as tertiary/quaternary care facilities at the hub of the COVID-19 system of care and must have adequate depth and availability of both resources and personnel. These centers also have the responsibility of providing leadership in education, COVID-19 research and system planning. These centers may provide telemedicine services for consultation with physicians and advanced practice providers at lower-level facilities for the management of COVID-19 patients and when clinically appropriate, these centers may transfer COVID-19 patients to lower levels of care, inpatient hospice facilities, nursing home facilities, or convalescing centers. Level I Centers are required to have dedicated COVID-19 negative pressure hospital beds, intensive care unit (ICU), pulmonologist, intensivist, infectious disease services, emergency medicine, anesthesia, continuous renal replacement therapy, hospital-based critical care transport teams for COVID-19 patient transfers, telemedicine consultation for COVID-19, rapid turn-around-time COVID-19 testing, and active inpatient COVID-19 clinical trials. UMMC is the only Level I designated center.
Level II COVID-19 Centers are acute care facilities with the commitment, resources, and specialty training necessary to provide sophisticated COVID-19 care that should transfer COVID-19 patients to Level I Centers for advanced therapeutics and/or participation in clinical trials. During periods of limited resources these centers may transfer appropriate COVID-19 patients to other Level II COVID-19 centers and when clinically appropriate, these centers may transfer appropriate COVID-19 patients to lower levels of care, inpatient hospice facilities, nursing home facilities, or convalescing centers. Level II centers are required to have negative pressure hospital beds, ICU, board certified or eligible critical care physician, pulmonologist or intensivist, infectious disease service or telemedicine, emergency medicine, anesthesia, full inpatient renal dialysis treatment to include continuous renal replacement therapy, and a preference that the center provide telemedicine consultation for COVID-19. Eleven Mississippi hospitals are currently designated as Level II centers.
Level III COVID-19 Centers are acute care facilities with the commitment, medical staff, personnel, and specialty training necessary to provide initial care of the COVID-19 patient are expected to provide isolation and stabilization of the COVID-19 patient and will transfer COVID-19 patients to the appropriate higher level based on clinical needs. The decision to transfer a patient to a higher level of care rests with the physician attending the COVID-19 patient. Level III COVID-19 centers work collaboratively with other COVID-19 facilities under the Mississippi COVID-19 System of Care to receive patients from Level I and II centers when clinically appropriate and must have an ICU capable of ventilator management. Twenty-three hospitals are currently designated as Level III centers.
Level IV COVID-19 Centers are facilities with a commitment to the care of the COVID-19 patient. These facilities are typically staffed by a physician, or an advanced practice provider and their principal role is to provide isolation and stabilization of COVID-19 patients and transfer these patients to the appropriate higher level of care based on the clinical presentation of the patient. These centers may receive patients from Level I, II and III centers when clinically appropriate. Twenty-eight hospitals self-designate as Level IV centers.
Level V COVID-19 Centers are MSDH contracted rural hospitals for receiving convalescing COVID-19 patients from higher level centers. This level plays an important role in the pandemic for decompressing higher levels of care centers when COVID-19 patients complete their inpatient stay but are unable to safely return to a nursing home, or home with high-risk family members while still under isolation for COVID-19.
Level VI COVID-19 Centers are LTAC facilities with a commitment to the rehabilitation of COVID-19 patients. These facilities are required to have negative pressure care rooms and ventilator management.
System Operations
The COVID-19 system of care plan provides a process for bidirectional patient movement to the most appropriate level of care for the individual patient while adjudicating available hospital capacity and capability. Clinical criteria for this bidirectional patient movement were developed by UMMC and were approved by MSDH for incorporation to the system of care. This includes moving patients to higher-level centers for required services to effectively manage COVID-19 is utilized when lower-level centers lack both capacity and specialists to appropriately care for the COVID-19 patient. Higher-level centers are required to have consultant specialists available (e.g., pulmonology, nephrology, hematology) available within 30 minutes of request. The plan also requires discussion between facilities when seeking to transfer patients in cardiac arrest or post-cardiac arrest.
Patient de-escalation processes are available through the plan for moving patients from higher-level centers to lower-level centers to maximize available COVID-19 capacity and resources for the acutely ill. De-escalation under the plan can be considered for ventilated patients with only respiratory failure to move to lower-level ICU; patients with blood oxygen saturation ≥ 88% on ≤ 6 liters of oxygen with stable respiratory status to move to lower-level medical surgical bed; convalescing patients that are unable to perform activities of daily living (ADL’s) who would need medical surgical bed and resources, (e.g., occupational therapy, physical therapy, social work); qualifying convalescing patients that are able to perform ADL’s that are eligible to be discharged to MSDH contracted convalescent centers; long term care patients, nursing home placement patients, and hospice patients.
The COVID-19 system of care plan also provides that if, or when, hospitals and health systems of Mississippi reach a point where they can no longer accommodate patient demands, Mississippi ESF-8 will enact a COVID-19 rotation managed by Mississippi MED-COM and will direct patients to destinations on a rotating basis based on patient request, geography, and resource availability. During times when there are little to no critical care availability statewide, what became known as the “plus one” process was activated. This process rotates patients needing critical care services to the hospital with services to care for the patient even if the facility lacks inpatient or critical care bed space. Thus, hospitals with critical care services must have plans to take an additional patient “plus one” when they are next in rotation even if their ICUs are full. To maintain visibility on bed space and resource availability during times of patient rotation all Mississippi licensed hospitals are required to report COVID-19 patient transfers (from emergency departments or inpatient) to Mississippi MED-COM and through the Statewide Acute Care Capacity Status System (SACCSS) at a frequency provided by the department. The plan also makes provisions that for an interfacility transfer of a suspected or known COVID-19 patient to a higher or lower level of care may be coordinated through Mississippi MED-COM as part of the Mississippi COVID-19 System of Care.
With the continued shortage of staffing in hospitals limiting the number of staffed beds for care of COVID-19 patients, the system of care plan was modified to provide for a focused ICU rotation process for certain critical care patients. This section of the COVID-19 System of Care Plan may be activated by Health Office Order when, due to a wave of COVID-19, there is limited availability of ICU beds in the state of Mississippi. This focused ICU section allows the most critically ill patients to be transferred for definitive care, while not overwhelming any one hospital. Request for transfer to an ICU bed would be made through Mississippi MED-COM where appropriate patients for transfer are triaged and those meeting criteria are transferred on a rotational basis. Key points of this section of the plan emphasize that only a specific and limited list of critical medical conditions (Figure 2) to define what is appropriate for transfer in this Focused ICU section and includes a provision for patients that do not match the triage criteria exactly to be reviewed by a physician. Rotation of patients is maintained by Mississippi MED-COM and allowed hospitals to choose to transfer within their own network or directly however, if the accepting facility wanted “credit” for that transfer they are required to notify MED-COM of the acceptance. They would then be moved appropriately in the rotation list. Transfers are triaged based on available resources and the focused system of care can utilize bidirectional patient flow allowing high-level centers to transfer to lower-level centers to create additional capacity for critical care patients. The plan requires that hospitals requesting use of the system of care for transfers must accept the patient back once the critical conditions were resolved or stabilized.
Periods of Mandatory Rotation
Acknowledging that Mississippi reached a point where hospitals could no longer accommodate acute clinical demands due to the impacts of COVID-19, the first State Health Officer’s Order requiring mandatory participation in the Mississippi COVID-19 system of care was issued and became effective on December 13, 2020, to ensure the proper assignment of patients to the appropriate hospital. Mississippi MED-COM was tasked with monitoring hospital capacity and capability related to providing care to patients with COVID-19 and directing patients to available critical care beds and when no beds are available, to hospital destinations on a rotating basis based on geography and resource availability. To expedite acceptance of patients entering the system of care, the State Health Officer’s Order required that all patients accepted by higher level facilities be accepted by the Emergency Department physician. Mississippi MED-COM reported on January 14, 2021, that 1,027 patients entered the system of care rotation during this period of mandatory rotation with 19% being COVID escalations of care, 74% non-COVID related, and 7% with other emergency diagnosis with COVID as part of the diagnosis. A table (Figure 3) indicating the types of patients entering the COVID-19 system of care rotation shows that the most frequent use of rotation was for general ICU, general ICU COVID, and neurological patients.
The COVID-19 system of care mandatory rotation system activated again by State Health Officer’s Order on July 29, 2021, in response to hospital capacity issues related to the Delta variant surge. This variant’s impact also resulted in additional resources coming to Mississippi to augment inpatient capacity. Two United States Health and Human Services Disaster Medical Assistance Teams were deployed to Mississippi hospitals. Additionally, the Samaritan’s Purse, a 501(c) 3 tax-exempt charity, operated a sizable emergency field hospital in the parking garage at UMMC. During this activation 3,199 patients entered the system of care. Similar to the previous activation 23% were COVID and 77% were non-COVID patients entering the rotation system. The nature of transfers and their COVID status (Figure 4) indicates that the majority of COVID or persons under investigation (PUI) for COVID were transferred for pulmonary reasons.
Due in part to worsening staffing shortages in hospitals throughout Mississippi, the most recent activation of the COVID-19 system of care plan rotation was limited to the focused ICU rotation component of the plan. The focused ICU rotation began on January 11, 2022, in response to critical care shortages related to the Omicron variant surge. A total of 574 patients requested to enter the system of care. Of those 348 patients representing the sickest of the sick needing transfer entered the system during the period of January 11, 2022, through February 9, 2022. Again, similar to previous periods of mandatory rotation, 21% were COVID or PUI patients and 77% non-COVID with 2% reported with a pending status for determining COVID versus non-COVID. The nature of the transfers (Figure 5) shows the numbers of patients entering the focused ICU rotation.
Conclusions
Mississippi’s healthcare system performed, and continues to perform, with extraordinary levels of service and self-sacrifice to care for patients in Mississippi during periods of significant COVID-19 transmission and in many cases in communities with extraordinarily limited staffing. Strong partnerships, public health leadership, and effective communications are key to successful implementation of systems of care designed to maximize available healthcare resources. The COVID-19 system of care plan allowed for the standardized implementation of best practices while simultaneously adjudicating the limited resources available during the various waves of COVID-19. This system continues to be an effective tool and protective measure to help reduce morbidity and mortality from COVID-19 in Mississippi.