TIME CRITICAL DIAGNOSIS SYSTEM in MISSOURI

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TIME CRITICAL DIAGNOSIS SYSTEM in MISSOURI
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(No Transcript)
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Meeting Purpose

• Why Time Critical Diagnosis Matters
• STEMI, Stroke, Trauma Patient Care
• The Trauma System Model
• Implementation Progress and Goals
• Missouri Regulations
• Next Steps

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Why Time Critical Diagnosis System
MattersLeading 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

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TCD Project History

• 2003 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

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TCD System Goal

• Improve health outcomes for Missourians
• who suffer acute trauma, stroke or STEMI
• by establishing
• a Time Critical Diagnosis (TCD) System.

Prompt treatment reduces death and disability.
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Why Time Critical Diagnosis Matters
Prompt treatment reduces death and disability.

• 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.

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Why Time Critical Diagnosis Matters
Prompt treatment reduces death and disability.

• 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

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Why Time Critical Diagnosis Matters
Prompt treatment reduces death and disability.

• STROKE
• Missouri-ranks 7th in stroke prevalence
• Missouris 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

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Why Time Critical Diagnosis Matters
Prompt treatment reduces death and disability.

• 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

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Why Time Critical Diagnosis Matters
Prompt treatment reduces death and disability.

• TRAUMA
• Missouri death rates for unintentional injuries
  increased 25 between 1991 and 2006
• Missouri death rates for accidental injuries,
  suicides, falls and MVCs exceed national rates
• There are gaps, particularly in rural areas, for
  timely access to trauma care

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Why Time Critical Diagnosis Matters

• 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

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Why Time Critical Diagnosis Matters

• Thats the problem.
• Whats the solution?

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Creating a Time Critical Diagnosis System

• The Solution
• The Right Care
• at the
• The Right Place
• in the
• The Right Time

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Creating a Time Critical Diagnosis System

• The solution
• Using the Trauma System
• as a Model

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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

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Implementation Progress and Goals

• Guidelines for the
• most appropriate care.

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Implementation Progress and Goals

• 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

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Implementation Progress and Goals

• 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

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Overview of Regulations
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Missouri Regulations

• Law authorizes DHSS to promulgate regulations
• Inclusive process for drafting regulations
• DHSS submits as Proposed Rules
• Office of the Secretary of State and
• Joint Committee on Administrative Rules
• Public Comment Period
• Final Rules

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Missouri RegulationsBoth Stroke STEMI

• Four Levels of Center Designation
• Level 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

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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

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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

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Missouri Regulations STEMI Center Stipulations
Level I Level II
Require cardiac catheterization laboratory 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/ process Alternate Pathway
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Missouri Regulations STEMI Center Stipulations
Level I Level II
Interventional Cardiologist Interventional Cardiologist
Cardiac/thoracic surgeon Cardiac/thoracic surgeon or agreement for expedited surgery
Conduct research Not required
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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 8 hrs/every other yr
Call Roster 10 hrs/yr 10 hrs/yr 8 hrs/every other yr 8 hrs/every other yr
ED Doctor 4 hrs/yr 4 hrs/yr 6 hrs/every other yr 6 hrs/every other yr
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Missouri Regulations Continuing Education-STEMI
Level I Level II Level III Level IV
Manager 10 hrs/yr 8 hrs/yr 8 hrs every other yr. 8 hrs every other yr.
ED RN 4 hrs/yr 4 hrs/yr 6 hrs every other year 6 hrs every other year
ICU RN 8 hrs/yr 8 hrs/yr 8 hrs/yr Not required
STEMI Unit RN 8 hrs/yr (I, II) and 8 hrs/every other year (III) 8 hrs/yr (I, II) and 8 hrs/every other year (III) 8 hrs/yr (I, II) and 8 hrs/every other year (III) Not required
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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
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Missouri Regulations CMEs-Stroke
Level I Level II Level III Level IV
Medical Director- 12 hrs/yr 8 hrs/yr 8 hrs every other yr. And 6 hrs every other yr. 8 hrs every other yr. And 6 hrs every other yr.
Call Roster 10 hrs/yr 8 hrs/yr 8 hrs every other yr. And 6 hrs every other yr. 8 hrs every other yr. And 6 hrs every other yr.
ED Doctor 4 hrs/yr 4 hrs/yr 8 hrs every other yr. And 6 hrs every other yr. 8 hrs every other yr. And 6 hrs every other yr.
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Missouri Regulations Continuing Education-Stroke
Level I Level II Level III Level IV
Manager 10 hrs/yr 8 hrs/yr 8 hrs every other yr. and 6 hrs every other yr 8 hrs every other yr. and 6 hrs every other yr
ED RN 4 hrs/yr 4 hrs/yr 8 hrs every other yr. and 6 hrs every other yr 8 hrs every other yr. and 6 hrs every other yr
ICU RN 10 hrs/yr 8 hrs/yr Not required Not required
Stroke Unit RN 10 hrs/yr 8 hrs/yr Not required (8 hrs for IIIs that will keep pts. under supervised relationship with a II or II) Not required (8 hrs for IIIs that will keep pts. under supervised relationship with a II or II)
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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
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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

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Missouri Regulations Next Steps

• Finish Community-Based Plan
• Conduct legal and administrative reviews
• Submit proposed stroke and STEMI regulations to
  Secretary of States office in 2010 Trauma
  regulations to follow in 2011
• Allow public comment period (at least 30 days)
• Compile public comment response (90 days)
• File with JCAR (30 days)
• File final order of rulemaking, effective 30 days
  after published

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Next Steps Public Education

• Work group compiling plan
• Launch public education campaign
• TCD System
• Signs and symptoms and importance of calling 911

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Next Steps Professional Education

• Professional education planning (Fall-2009
  through Spring-2010)
• Conduct professional education (Begin Summer
  2010)

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Next StepsTracking Progress

• Create evaluation mechanism to track progress
  and outcomes

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Next Steps Quality Assurance

• Review existing data system
• CDC Info Aid
• MU Health Informatics
• 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
• Implement plan
• Update state database and reporting methodologies
• Training
• Compile reports to support PI/Quality Assurance
• Regional Processes

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Next Steps Center Application

• DHSS creates applicationfiled as part of
  regulations
• Once regulations effective, hospitals may submit
  application (similar to trauma center application
  and review process currently in place)
• DHSS conducts review
• DHSS approves designation for those that meet
  standards

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The End Goal 360/365 Emergency Medical Care
System
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The End Goal