A TIME CRITICAL SYSTEM APPROACH to STROKE and STEMI in MISSOURI

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A TIME CRITICAL SYSTEM APPROACH to STROKE and
STEMI in MISSOURI
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Ground Rules for Todays Meeting

• Turn cell phones and pagers to vibrate.
• Step outside to take a call
• Save Q A until the end for one-on-one
  discussion with presenters

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(No Transcript)
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Meeting Purpose

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

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Meeting Format

• Regulations statewide application
• Reflect collective contribution of enough
  volunteers to equal two full time employees.
• Regional meetings represent a significant
  milestone in this investment.

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More than 400 Missouri health care professionals
weigh in on the TCD process
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Overview Time Critical Diagnosis System
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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

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360/365 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 plan
• 2008 Authorizing Legislation
• 2008 The Time Critical Diagnosis teams

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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.

• For heart attack victims.

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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-needle (PCI) - lower
  risk of mortality
• 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.

• For stroke victims.

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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
• Note-New evidence extends this window to 270
  minutes

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

• But
• Only a small percentage of stroke victims get the
  recommended treatment within the recommended time
• Fewer than 50 of STEMI patients have
  door-to-needle time within 30 minutes, and fewer
  than 40 have door to balloon time within 90
  minutes

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Why Time Critical Diagnosis Matters

• Current protocol - ambulances triage to the
  nearest hospital - not necessarily a facility
  equipped to deliver best 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 General 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 Task Force compiled formal
  recommendations
• 2008-Present Stroke and STEMI Implementation
  groups meeting regularly and compile standards
  for stroke and STEMI center designation and EMS
  guidelines

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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 Highest level, functions as resource
  center within region
• Level II Next highest, provide care to high
  volumes of stroke and STEMI patients
• Level III Access into system in non-metropolitan
  areas, provide limited care 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 Stroke Center Stipulations
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Missouri Regulations CMEs-Stroke
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Missouri Regulations Continuing Education-Stroke
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Missouri Regulations STEMI Center Stipulations
Exception process if dont meet volume standards
(1)(F) 3.
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Missouri Regulations STEMI Center Stipulations
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Missouri Regulations CMEs-STEMI
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Missouri Regulations Continuing Education-STEMI
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Missouri Regulations Next Steps

• Tally commentsthrough 10/19/09
• Compile final draft 11/09
• Conduct legal and administrative reviews
• Submit proposed regulations to Secretary of
  States office and JCAR by early 2010
• Allow public comment period (at least 30 days)
• Compile public comment response (90 days)
• File final order of rulemaking with JCAR (30 days
  prior to filing with Secretary of State)
• File final order of rulemaking, effective 30 days
  after published

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System Components
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Out-of-Hospital Services

• Protocols and guidelines
• Dispatch protocol for TCD Patients
• Helicopter utilization guidelines
• Classification guidelines for stroke and STEMI
  patients
• Field assessment, transport and transfer
  protocols for stroke and STEMI patients

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Missouri RegulationsRegional Plans

• Regional or community based plans for
  transporting STEMI or stroke patients may be
  submitted to DHSS. 190.200 RSMo

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Next Steps Professional Education

• Complete field assessment, transport and transfer
  protocols, and guidelines
• Professional education planning (Fall-2009
  through Spring-2010)
• Conduct professional education (Begin Spring
  2010)

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Next Steps Quality Assurance

• Review existing data system
• 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
• Convene Regional Committees

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Next Steps Public Education

• Convene work group
• Compile plan
• Launch public education campaign
• TCD System
• Signs and symptoms and importance of calling 911

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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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Next Steps Staging Implementation
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Next StepsTracking Progress

• Create evaluation mechanism to track progress
  and outcomes

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The End Goal 360/365 Emergency Medical Care
System
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The End Goal
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• We want to hear from you
• Please Share Your Comments!
• www.TCDComments.com
• MO Department of Health and Senior Services
• September 2009