Title: The Time Critical Diagnosis System and the Role of the Trauma Model
1The Time Critical Diagnosis System and the Role
of the Trauma Model
2The Time Critical Diagnosis System Concept
- Dr. Bill Jermyns vision for emergency medical
care in Missouri introduced some key concepts,
including - The Circle Concept
- The Emergency Medical Care Systems (EMCS)
approach - The Time Critical Diagnosis System in Missouri
3Dr. Jermyns Circle
4The Emergency Medical Care System Concept
- The EMCS Concept
- Time critical diagnoses share some fundamental
principles. - The Emergency Medical Care System is built upon
these principles, which apply whether you are
dealing with trauma, stroke, STEMI, or future
time critical diagnoses. - This is the elegance of the Circle concept.
- Bill Jermyn, DO, FACEP
5The Emergency Medical Care System Concept
- How is the EMCS different?
- Society expects emergency care to be available at
all timesEmergency Medical Treatment and Active
Labor Act (EMTALA) - Regionalization makes sense for EMCS to
appropriately allocate finite resources, decrease
costs, and improve outcomes - There are different parameters imposed by society
on the emergency medical care system than apply
to the rest of the health care system - Bill Jermyn, DO, FACEP
6The Emergency Medical Care System Concept
- Integrate public health, public safety, and the
healthcare systems into the Emergency Medical
Care System. - Make you think about the system design for the
patient, provider, and support future needs. -
- Bill Jermyn, DO, FACEP
7The Time Critical Diagnosis System Concept
- We work together towards the common goal of
improved patient care for those diagnoses that
are time dependent. We dont do it separately.
Bill Jermyn, DO, FACEP
8The Time Critical Diagnosis System ConceptThe
TCD System Umbrella
- Time Critical Diagnosis System
Stroke
STEMI Other
Trauma
9The Time Critical Diagnosis System
- Uses the well-established trauma system model but
keeps the individual system components separate
in a cooperative structure. That is, they have to
cooperate, but they do not dilute one another. - Brings a much larger public focus on the entire
system than the individual components could ever
hope to achieve. - Bill Jermyn, DO, FACEP
10The Time Critical Diagnosis System Concept
- What are the similarities?
- Three diagnoses sick trauma, stroke, STEMI
- Right patient, right place, right time, right
care - We have clear evidence that timely and
appropriate treatment of these three diagnoses
can improve patient outcomes. - Bill Jermyn, DO, FACEP
11The Time Critical Diagnosis System Concept
- What Are The Similarities?
- Circle concept of system of care
- Data collection and data collection platform
- QI process
- Public education
- Importance of early recognition and appropriate
transport and triage (Right Care, Right Place,
Right Time) -
-
12The Time Critical Diagnosis System Concept
- What Are The Similarities?
- Concepts of parallel processing and moving
care forward. - Need for common time saving measuresleave on EMS
stretcher, one call transfers - Legislative requirements
- Political mechanism
- Bill Jermyn, DO, FACEP
13The Time Critical Diagnosis System Concept
- What Are The Similarities?
- Need for well-designed inter-facility transfer
mechanisms - In-hospital programs that can contribute to the
overall effort - Patient outcome improvements require a total
system perspective---If it takes 5 hrs to get the
patient to the right place, who cares if you save
15 minutes of hospital time? -
-
14The Time Critical Diagnosis System Concept
- Why Design Only One System?
- Shared resources (data collection, QI, political,
funding, provider/public education, prevention,
staffing) - Shared resources increase the odds of successful
implementation and viability - A common system is easier for participants to
deal with (hospitals, 9-1-1, EMS, etc) - Bill Jermyn, DO, FACEP
15The Time Critical Diagnosis System
- Why Combine The Systems?
- Political strength is more effective if we band
together - QI process easier if we integrate across
disciplines and opportunity for lessons learned
is greater - National emphasis to better integrate emergency
systems - Bill Jermyn, DO, FACEP
16The Time Critical Diagnosis System Concept
- System Requirements
- Includes all the stakeholders for system design
and structure. - Viable and supports patient care
- Means to sustain itself
- Improves care over time-able to refine itself
- Consistent data collection and use to support QI
- Bill Jermyn, DO, FACEP
17The Time Critical Diagnosis System Concept
- Does System Design Matter?
- Bill Jermyn, DO, FACEP
18The Time Critical Diagnosis System Concept
- Current System Development Focus
- Pre-Hospital
- Hospital
- Quality Improvement
- Public Education
- Professional Education
- To be addressed
- 911
- Payer
19Time Critical Diagnosis System History
- 2003Identified need to improve EMCS
- 2004 Held state summit on reform- included
legislators and medical community - 2005 State Government involvement begins
- 2006 DHSS and stakeholders draft strategic plan
for 360/365 EMCS system - 2007 Governor approves DHSS draft legislation
DHSS forms Time Critical Diagnosis Task Force to
develop formal recommendations funding secured - Bill Jermyn, DO, FACEP
20Time Critical Diagnosis History
- Jan-March Bills introduced in Legislature Task
Force of over 100 professionals across state met
5 times. - May House Bill 1790 enabling reform was passed
by legislature on last day of session. It was one
of only 139 bills to pass. - July The Governor signs bill into law.
- August Task Force submitted formal
recommendations for system reform to state health
department - September Trauma Task Force convened
- September/October Stroke and STEMI
implementation groups convened - Bill Jermyn, DO, FACEP
21The Role of the Trauma Model
- Lessons Learned
- Trauma SYSTEM saved lives
- Accommodate regional and local variations
- Set standards that are agreed upon by all
- Verify compliance with those standards by some
objective means - Bill Jermyn, DO, FACEP
22The Role of the Trauma Model
- Lessons Learned, cont.
- Gather Quality Improvement (QI) data, analyze it,
and use it to adapt and refine the system - Involve the the correct stakeholders
- Design to encourage parallel processing not
sequential - Examine all aspects of the patients care
-
- Bill Jermyn, DO, FACEP
23The Role of the Trauma Model
- Lessons Learned, contd
- Self-assessment accreditation processes help
some, but independent, outside review teams and
center designation improve outcomes even more
(DiRusso S et al. Preparation and achievement of
American College of Surgeons Level 1 trauma
verification raises hospital performance and
improves patient outcomes. J Trauma 2001 Aug.
51(2)294-300.) (Mann NC et al. Systematic review
of published evidence regarding trauma system
effectiveness. J Trauma 1999 Sept47(3 Suppl)
S25-S35.) - Bill Jermyn, DO, FACEP
24Trauma Model History The Nation and Missouri
Year Nation Missouri
1981 Early 1980s 1984 Block Grants for EMS Orange Co trauma system implemented Orange Co Preventable deaths drop from 34 to 15 PHHS Block supports EMS services (current) Trauma system center designations based on self-assessment Bill Jermyn, DO, FACEP
25Trauma Model History The Nation and Missouri
Year Nation Missouri
1985 1988 1990 Injury in America Trauma Care Systems Devl Act (PL 101-590) Authorizes funding through 1995one size did not fit all Trauma CommitteeOutside reviewers start to verify standards at designated facilities Bill Jermyn, DO, FACEP
26Trauma Model History The Nation and Missouri
Year Nation Missouri
1998 2006 EMS statutes revised6 EMS regions authorized (no funding) IOM Report ?EMCS Regionalization Recommendation Bill Jermyn, DO, FACEP
27Where is Trauma in Missouri Now
28Where Are We Now
- We have center designation
- We have center accreditation
- We have pre-hospital services
- We have a State Registry
- We have protocols
29Where Are We Now
- But do we have a system or do we function in
silos?
30Where Are We Now
- Do we know the trends in state data?
- Do we have well established Regional and State QI
processes? - Do pre-hospital and hospital providers
communicate about patient care? In the field?
In transfer? - Does dispatch communicate with field personnel
and hospital personnel? - Do we coordinate resources and response?
- Do we have evidence-based plans of action
throughout the state - Do we have effective medical control and
direction?
31Where Are We Now
- Do we have a financial base that can support a
system? - Do we have comprehensive public education, injury
and violence prevention programs? - Essentially, does one aspect of the system build
on the prior and feed into the next?
32Where Are We Now
- Unintentional Injury Profile for Missouri
(www.dhss.mo.gov/ASPsUnintentional/Trend) - Deaths Motor Vehicle Traffic
- Three-Year Moving Average Rates
- The curve for Missouri is flat
- 91-93 18.4/100,000
- 04-06 18.9/100,000
- Some improvements seen in 07 and 08
33Where Are We Now
- Why is the curve flat?
- Do we have good measures?
- Do we have effective injury prevention programs?
- Do we have an effective Trauma SYSTEMS approach?
34Where Are We Now
- We did a pilot study/survey
- Some responded (N19 mainly out-of-hospital
providers) - Gave a starting point for more directed survey
35Where Are We Now
- We asked about Regional Challenges
- You replied
- Access
- Knowledge
- Resources
- QA/QI
- Protocols
- Coordination
- Helicopter Early Launch Protocols
- Diversion/Delays
- Culture/Attitudes
36Where Are We Now
- We asked about Local Challenges
- You replied
- Sense of urgency around class 2 and 3s
- Resources/Education
- Diversion/Delays
- Destination determination
- Funding
- Dispatch/EMD
- Coordination
37Where Are We Now
- Other Issues Raised
- Divergent classification schemes
- Equipment/Technology needs
- Communication
- Injury Prevention
- Medical Direction
- Self-Referral
- Role of small and rural hospitals
- Hospital Delays
38Where Are We Now
- We have a system, but its components are
sometimes - Fragmented
- In need of updating
- And not cooperating and coordinating efforts
39Where Are We Now
- The issues raised in this pilot study reinforce
the objectives for this Task Force - This process will run in parallel to the Stroke
and STEMI implementation process set forth in the
TCD Task Force Report
40Where Are We Now
- This is an opportunity to assess where we are,
state what we need, and implement plans to move
our system forward - There is intense interest in seeing the trauma
system succeed and grow - The trauma system model creates the core
infrastructure for the TCD System in Missouri
41Goals and Objectives
- Goals
- To design an integrated emergency medical system
- To broaden the trauma system approach and
perspective to improve injury prevention efforts,
patient care throughout the circle, and patient
outcomes - To set the framework for the stroke and STEMI
arms of the TCD System - To establish an efficient and effective approach
for future time critical diagnoses incorporated
into the system
42Goals and Objectives
- Objectives
- To assemble a Task Force for trauma from the
various stakeholders in Missouris trauma system
guided by a Steering Committee for this process - To have clear Roles and Responsibilities for the
Task Force and Steering Committee
43Goals and Objectives
- Objectives
- To have clear end products for the close of the
Task Force efforts - To have clear agendas for each of the meetings
- To debrief and have synthesis of regional and
state level at each stage in the process
44Goals and Objectives
- To conduct the meeting agendas using the TCD
System components and address - Response Coordination- Dispatch EMD/PAI
- Pre-Hospital Response and Transport
- Hospitals
- Quality Improvement
- Professional Education
- Public Education/Prevention
- Payer
- Administration and Infrastructure
45Goals and Objectives
- Objectives
- End Products
- Recommendations to the Department
- Review of Regional structure and function
- Updated PAI/EMD
- Augmented on- and off-line medical control
- Helicopter Early Launch Protocols
- Triage/transfer protocols updated with latest
evidence
46Goals and Objectives
- End Products Contd
- Review of potential need/role/criteria for Level
IV Centers - Augmented QI/process evaluation of system
development - Plan for QI on statewide and regional basis for
centers seeing trauma patients, designated and
non-designated - Common language state trauma classification
scheme with regional variables
47Conclusions
- We have assembled a large group of stakeholders
- Some of us will agree on some things and diverge
on others - The same stakeholders that agree on one thing may
diverge on another - We will need to compromise and find common ground
- This is a consensus building process to build the
best system we can for the patient
48Conclusions
- Nothing endures but change.
- Heraclitus
- 540BC-480BC
- Courtesy of Bill Jermyn, DO, FACEP