Right Care. Right Place. Right Time. TIME CRITICAL DIAGNOSIS SYSTEM in MISSOURI

Right Care. Right Place. Right Time.

TIME CRITICAL DIAGNOSIS SYSTEM in MISSOURI



Meeting Purpose• Why Time Critical Diagnosis Matters

• STEMI, Stroke, Trauma Patient Care

• The Trauma System Model

• Implementation: Progress and Goals

• Missouri Regulations

• Next Steps


Why Time Critical Diagnosis System Matters:

Leading causes of death in Missouri

1st Heart Disease, including ST-Elevation Myocardial Infarction (STEMI)

3rd Stroke

4th Trauma-injury-accidents, motor vehicle accidents, suicide, homicide, other; Leading cause of YPLL


TCD Project History2003 – Missouri Foundation for Health (MFH) identified the

need for EMS/Trauma Reform

2005 – Dr. Bill Jermyn accepts State EMS Medical Director Position

2006 – Emergency Medical Care System planning

‘07-08+ – TCD Task Forces (Stroke/STEMI and Trauma)

2008 – Authorizing Legislation

2008+ –Time Critical Diagnosis stroke and STEMI implementation teams

2009 – ACS COT Review

2010 –NHTSA Review


TCD System Goal

Prompt treatment reduces death and disability.


Why Time Critical Diagnosis Matters

HEART DISEASE• Outcomes for heart attack victims can be improved with

an integrated care delivery system.

• STEMI, ST-Segment Elevation Myocardial Infarction, is a common form of heart attack that is time critical.




STEMI• Shorter time from door-to-balloon (PCI) - lower risk of

mortality– Moving towards first medical contact to balloon

• Symptom onset to treatment time greater than 4 hours independent predictor of one-year mortality

• Faster treatment and lower in-hospital mortality associated with hospital “specialization” and emphasis on PCI as principal mode of reperfusion




STROKE• Missouri-ranks 7th in stroke prevalence• Missouri’s stroke death rate – 11% higher than

national rate• 15-30% will be disabled (leading cause of disability)• 20% require institutionalization first 3 months post-

stroke




STROKE• t-PA Treatment within 180 minutes from symptom

onset:- Better odds of improvement at 24 hours - Improved 3-month outcome

• Patients treated after 180 minutes- Poorer outcomes- More hemorrhages




TRAUMA• Missouri death rates for unintentional injuries

increased 25% between 1991 and 2006• Missouri death rates for accidental injuries,

suicides, falls and MVC’s exceed national rates

• There are gaps, particularly in rural areas, for timely access to trauma care




• Current protocol – unlike trauma, ambulances triage to the nearest hospital for stroke or STEMI, not necessarily a facility equipped to deliver necessary level of care for stroke or STEMI

• Patients who self-transport may not have the knowledge to go to the right facility

• Rural populations face unique challenges in access to timely care



That’s the problem.

What’s the solution?


Creating a Time Critical Diagnosis System

The Solution:

The Right Careat the

The Right Placein the

The Right Time


Creating a Time Critical Diagnosis System

The solution:Using the Trauma System

as a Model


Using Trauma System as a Model

Trauma System:• Improves Patient Outcomes and Saves Lives

- 50% reduction in preventable death rate after implementation

- Decrease in cases of sub-optimal care from 32% to 3%• Improves Hospital Outcomes

- Better outcomes compared to voluntary system- Cost Savings through more efficient use of resources

• Improves Regional Outcomes - Regional system accommodates regional and local

variations


Implementation: Progress and Goals

Guidelines for the most appropriate care.


Legislative Synopsis:2008: House Bill 1790 enabling reform passed

unanimously by the Missouri Assembly and signed into law

RSMo 190-100 Definitions

RSMo 190.200 Public Information & Education

RSMo 190.241 Center Designation

RSMo 190.243 Transportation to Centers



Developing the System:August 2008: TCD Stroke/STEMITask Force compiled

formal recommendations

Sept.’08-Present: TCD Trauma Task Force convened and compiling recommendations

2008-Present: Stroke and STEMI Implementation groups meeting regularly and compiling standards for stroke and STEMI center designation and EMS



Overview of Regulations


Missouri Regulations

1. Law authorizes DHSS to promulgate regulations

2. Inclusive process for drafting regulations

3. DHSS submits as “Proposed Rules” – Office of the Secretary of State and – Joint Committee on Administrative Rules

4. Public Comment Period

5. Final Rules


Missouri RegulationsBoth Stroke & STEMI

Four Levels of Center DesignationLevel I Functions as resource center within region

Level II Provide care to high volumes of stroke and STEMI patients

Level III Access into system in non-metropolitan areas, more limited resources and generally refer to higher level center

Level IV Access in rural areas, stabilize and prepare for rapid transfer to higher level of care


Missouri Regulations Both Stroke & STEMI

• Voluntary process• Stroke/STEMI Program-24/7 (all levels)

– Medical Director– Program Manager/Coordinator

• Staff meet and maintain core requirements to provide care

• One-call activation protocol• Transfer – network agreements


Missouri Regulations Both Stroke & STEMI

• Data submission for statewide registry

• Performance improvement and patient safety requirements

• Public education to promote prevention and signs and symptoms awareness


Missouri Regulations STEMI Center Stipulations

Level I Level II

Require cardiac catheterization laboratory

At least 400 Elective PCIs/year

At least 200 Elective PCIs/year

At least 49 Primary PCIs/year

At least 36 PCIs/yr

On-site cardiac surgical services

On-site cardiac surgical services or expedited transfer agreement/ processAlternate Pathway


Missouri Regulations STEMI Center Stipulations

Level I Level II

Interventional Cardiologist

Cardiac/thoracic surgeon Cardiac/thoracic surgeon or agreement for expedited surgery

Conduct research Not required


Missouri Regulations CMEs-STEMI

Level I Level II Level III Level IV

Medical Director-

10 hrs/yr 10 hrs/yr 8 hrs/every other yr

Call Roster

10 hrs/yr 10 hrs/yr 8 hrs/every other yr

ED Doctor

4 hrs/yr 6 hrs/every other yr


Missouri Regulations Continuing Education-STEMI


Manager 10 hrs/yr 8 hrs/yr 8 hrs every other yr.

ED RN 4 hrs/yr 4 hrs/yr 6 hrs every other year

ICU RN 8 hrs/yr Not required

STEMIUnit RN

8 hrs/yr (I, II) and 8 hrs/every other year (III)

Not required


Missouri Regulations Stroke Center Stipulations

Level I Level II

Align with comprehensive stroke center standards

•Align with The Joint Commission-Primary Stroke Centers standards

•On-site neurosurgery •On-site or expedited transfer agreement to perform neurosurgery

Specialties: Neuro-interventionalist, emergency medicine

•Not required

•Conduct Research •Not required


Missouri Regulations CMEs-Stroke


Medical Director-

12 hrs/yr 8 hrs/yr

8 hrs every other yr.

And 6 hrs every other yr.

Call Roster

10 hrs/yr 8 hrs/yr

ED Doctor

4 hrs/yr 4 hrs/yr


Missouri Regulations Continuing Education-Stroke


Manager 10 hrs/yr 8 hrs/yr8 hrs

every other yr. and 6 hrs every other yr

ED RN 4 hrs/yr 4 hrs/yr

ICU RN 10 hrs/yr 8 hrs/yr Not required

Stroke Unit RN

10 hrs/yr 8 hrs/yr Not required (8 hrs for III’s that will keep pts.

under supervised relationship with a II or II)


Missouri Regulations Trauma

• Level IV Trauma Center regulations under development

•Survey sent to CAH• Update old trauma regulations• Update pediatric trauma regulations

• Triage/Transfer protocol under development• Injury Specific triage/transfer guidelines under development• Other


Missouri RegulationsRegional Plans

Regional or community based plans for transporting trauma, STEMI or stroke patients may be submitted to DHSS. 190.200 RSMo but not required


1. Finish Community-Based Plan

2. Conduct legal and administrative reviews

3. Submit proposed stroke and STEMI regulations to Secretary of State’s office in 2010; Trauma regulations to follow in 2011

4. Allow public comment period (at least 30 days)

5. Compile public comment response (90 days)

6. File with JCAR (30 days)

7. File final order of rulemaking, effective 30 days after published

Missouri RegulationsNext Steps


1. Work group compiling plan

2. Launch public education campaign– TCD System– Signs and symptoms and importance of

calling 911

Next StepsPublic Education


1. Professional education planning (Fall-2009 through Spring-2010)

2. Conduct professional education (Begin Summer 2010)

Next StepsProfessional Education


Next StepsTracking Progress

Create evaluation mechanism to track progress and outcomes


1. Review existing data system– CDC Info Aid– MU Health Informatics

2. Convene quality assurance work group – Define data points (benchmarks, PI, indicators, outcomes)

– Review existing systems for collection

– Compile plan to populate state Stroke and STEMI registry without creating burden for reporters

3. Implement plan– Update state database and reporting methodologies

– Training

– Compile reports to support PI/Quality Assurance

– Regional Processes

Next StepsQuality Assurance


1. DHSS creates application—filed as part of regulations

2. Once regulations effective, hospitals may submit application (similar to trauma center application and review process currently in place)

3. DHSS conducts review

4. DHSS approves designation for those that meet standards

Next StepsCenter Application


The End Goal: 360/365 Emergency Medical Care System


The End Goal:

Documents

Right Care. Right Place. Right Time. TIME CRITICAL DIAGNOSIS SYSTEM in MISSOURI