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The Time Critical Diagnosis System and the Role of the Trauma Model


THE TIME CRITICAL DIAGNOSIS SYSTEM AND THE ROLE OF THE TRAUMA MODEL Samar Muzaffar, MD MPH Where Are We Now We did a pilot study/survey Some responded (N=19; mainly ... – PowerPoint PPT presentation

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Title: The Time Critical Diagnosis System and the Role of the Trauma Model

The Time Critical Diagnosis System and the Role
of the Trauma Model
  • Samar Muzaffar, MD MPH

The Time Critical Diagnosis System Concept
  • Dr. Bill Jermyns vision for emergency medical
    care in Missouri introduced some key concepts,
  • The Circle Concept
  • The Emergency Medical Care Systems (EMCS)
  • The Time Critical Diagnosis System in Missouri

Dr. Jermyns Circle
The Emergency Medical Care System Concept
  • The EMCS Concept
  • Time critical diagnoses share some fundamental
  • 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

The 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

The 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

The 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

The Time Critical Diagnosis System Concept The
TCD System Umbrella
  • Time Critical Diagnosis System

The 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

The Time Critical Diagnosis System Concept
  • What are the similarities?
  • Three diagnoses sick trauma, stroke, STEMI
  • Right patient, right place, right time, right
  • We have clear evidence that timely and
    appropriate treatment of these three diagnoses
    can improve patient outcomes.
  • Bill Jermyn, DO, FACEP

The 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)

The 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

The Time Critical Diagnosis System Concept
  • What Are The Similarities?
  • Need for well-designed inter-facility transfer
  • 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?

The Time Critical Diagnosis System Concept
  • Why Design Only One System?
  • Shared resources (data collection, QI, political,
    funding, provider/public education, prevention,
  • 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

The Time Critical Diagnosis System
  • Why Combine The Systems?
  • Political strength is more effective if we band
  • QI process easier if we integrate across
    disciplines and opportunity for lessons learned
    is greater
  • National emphasis to better integrate emergency
  • Bill Jermyn, DO, FACEP

The 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

The Time Critical Diagnosis System Concept
  • Does System Design Matter?
  • Bill Jermyn, DO, FACEP

The Time Critical Diagnosis System Concept
  • Current System Development Focus
  • Pre-Hospital
  • Hospital
  • Quality Improvement
  • Public Education
  • Professional Education
  • To be addressed
  • 911
  • Payer

Time 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

Time 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
  • September Trauma Task Force convened
  • September/October Stroke and STEMI
    implementation groups convened
  • Bill Jermyn, DO, FACEP

The 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

The 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
  • Examine all aspects of the patients care
  • Bill Jermyn, DO, FACEP

The 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)
  • Bill Jermyn, DO, FACEP

Trauma Model History The Nation and Missouri
Trauma Model History The Nation and Missouri
Trauma Model History The Nation and Missouri
Where is Trauma in Missouri Now
  • Goals and Objectives

Where Are We Now
  • We have center designation
  • We have center accreditation
  • We have pre-hospital services
  • We have a State Registry
  • We have protocols

Where Are We Now
  • But do we have a system or do we function in

Where Are We Now
  • Do we know the trends in state data?
  • Do we have well established Regional and State QI
  • 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

Where Are We Now
  • Do we have a financial base that can support a
  • 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?

Where Are We Now
  • Unintentional Injury Profile for Missouri
  • 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

Where 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?

Where Are We Now
  • We did a pilot study/survey
  • Some responded (N19 mainly out-of-hospital
  • Gave a starting point for more directed survey

Where 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

Where 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

Where 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

Where Are We Now
  • We have a system, but its components are
  • Fragmented
  • In need of updating
  • And not cooperating and coordinating efforts

Where 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

Where 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

Goals 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
  • 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

Goals 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

Goals 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

Goals 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

Goals 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

Goals and Objectives
  • End Products Contd
  • Review of potential need/role/criteria for Level
    IV Centers
  • Augmented QI/process evaluation of system
  • Plan for QI on statewide and regional basis for
    centers seeing trauma patients, designated and
  • Common language state trauma classification
    scheme with regional variables

  • 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

  • Nothing endures but change.
  • Heraclitus
  • 540BC-480BC
  • Courtesy of Bill Jermyn, DO, FACEP