TIME CRITICAL DIAGNOSIS SYSTEM in MISSOURI - PowerPoint PPT Presentation

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TIME CRITICAL DIAGNOSIS SYSTEM in MISSOURI

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TIME CRITICAL DIAGNOSIS SYSTEM in MISSOURI These Regulations to be written * * * * - The designation process will identify hospital s levels within stroke and STEMI. – PowerPoint PPT presentation

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Title: TIME CRITICAL DIAGNOSIS SYSTEM in MISSOURI


1
TIME CRITICAL DIAGNOSIS SYSTEM in MISSOURI
2
(No Transcript)
3
Meeting Purpose
  • Why Time Critical Diagnosis Matters
  • STEMI, Stroke, Trauma Patient Care
  • The Trauma System Model
  • Implementation Progress and Goals
  • Missouri Regulations
  • Next Steps

4
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

5
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

6
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.
7
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.

8
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

9
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

10
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

11
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

12
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

13
Why Time Critical Diagnosis Matters
  • Thats the problem.
  • Whats the solution?

14
Creating a Time Critical Diagnosis System
  • The Solution
  • The Right Care
  • at the
  • The Right Place
  • in the
  • The Right Time

15
Creating a Time Critical Diagnosis System
  • The solution
  • Using the Trauma System
  • as a Model

16
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

17
Implementation Progress and Goals
  • Guidelines for the
  • most appropriate care.

18
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

19
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

20
Overview of Regulations
21
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

22
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

23
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

24
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

25
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
26
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
27
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
28
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
29
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
30
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.
31
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)
32
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
33
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

34
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

35
Next Steps Public Education
  • Work group compiling plan
  • Launch public education campaign
  • TCD System
  • Signs and symptoms and importance of calling 911

36
Next Steps Professional Education
  • Professional education planning (Fall-2009
    through Spring-2010)
  • Conduct professional education (Begin Summer
    2010)

37
Next StepsTracking Progress
  • Create evaluation mechanism to track progress
    and outcomes

38
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

39
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

40
The End Goal 360/365 Emergency Medical Care
System
41
The End Goal
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