1. Alabama Acute Health Care System Alabama Acute Health Care System System Information/Education

2. Speaker’s Disclaimer No Representation is made that the quality of the presentation services to be performed today is greater that the quality of presentation services performed by other speakers. I do not have any conflicts of interest nor am I receiving compensation from Mobile Infirmary Medical Center or any company affiliated with the conference. I am employed by the University of South Alabama with a contract with the Alabama Department of Public Health.

3. Speaker’s Disclaimer No Representation is made that the quality of the presentation services to be performed today is greater that the quality of presentation services performed by other speakers. I do not have any conflicts of interest nor am I receiving compensation from Mobile Infirmary Medical Center or any company affiliated with this conference. I am employed by the University of South Alabama with a contract with the Alabama Department of Public Health.

4. OBJECTIVES Understand the need for an Alabama Acute Health Care System (AAHCS) Understand the need for an Alabama Acute Health Care System (AAHCS) Be Aware of the AAHCS Components Be Aware of the AAHCS Components Understand the Functions of the AAHCS Components Understand the Functions of the AAHCS Components Understand the Legal Status of the AAHCS Understand the Legal Status of the AAHCS Be Able to Apply the Primary Triage Criteria Be Able to Apply the Primary Triage Criteria Be Aware of the Secondary Triage Process Be Aware of the Secondary Triage Process Be Aware of the Problems/Pitfalls of ATCC Be Aware of the Problems/Pitfalls of ATCC Be Aware of the QI Process Be Aware of the QI Process

5. Trauma Law / Rules Alabama Legislative Act 299 – 2007 Alabama Code 22-11D-1 (Amended in 2012 to include acute health care) Alabama State Board of Health Chapter 420-2-2 Alabama Statewide Trauma System

6. Why Develop a State-wide System? Why Develop a State-wide System? Trauma is the number one killer between one year and forty-four years of age! Trauma is the number one killer between one year and forty-four years of age! Cardiovascular is the number one cause of death. Cardiovascular is the number one cause of death. Stroke is the third leading cause of death. Stroke is the third leading cause of death.

7. How the Acute Health Care System saves lives How the Acute Health Care System saves lives Correctly identifies the patients who need care Anticipates the resources needed to treat the patients Locates the available needed resources

8. How the Acute Health Care System saves lives How the Acute Health Care System saves lives Routes the patient “right” the first time to reduce time to appropriate care Trauma – Four Levels of Care Trauma – Four Levels of Care Stroke – Four Levels of Care Stroke – Four Levels of Care STEMI – Four Levels of Care STEMI – Four Levels of Care Determined by each Hospital Determined by each Hospital Volunteer participation by Hospitals Volunteer participation by Hospitals Hospitals can change level status as needed Hospitals can change level status as needed

9. How the Acute Health Care System saves lives How the Acute Health Care System saves lives How Acute Health Care Systems save lives : Arranges inter-facility transfers if needed to reduce time to appropriate care Arranges inter-facility transfers if needed to reduce time to appropriate care Average EMTALA transfer time is 6.5 hours Average EMTALA transfer time is 6.5 hours Average ATS transfer time is less than 15 minutes. Average ATS transfer time is less than 15 minutes.

10. Volunteer Participation for Hospitals Volunteer Participation for Hospitals Hospital chooses to not participate in the system. Hospital chooses to not participate in the system. ATCC will not route patient to this hospital. ATCC will not route patient to this hospital. EMTALA applies! EMTALA applies!

11. Alabama Trauma System

12. Trauma Center Levels Trauma Center Levels Level One All trauma care specialty services are available “in-house”.

13. Level One Trauma Centers University of South Alabama Medical Center Sacred Heart Hospital, Pensacola

14. Trauma Center Levels Trauma Center Levels Level Two All trauma care available except neurosurgery. Physicians may be called in as needed.

15. Level Two Trauma Center Baptist Hospital, Pensacola

16. Trauma Center Levels Trauma Center Levels Level Three General surgery available for emergent trauma care. Majority of care provided by the emergency physician.

17. Level Three Trauma Centers Providence Hospital Mobile Infirmary Medical Center Springhill Medical Center North Baldwin Infirmary South Baldwin Medical Center Thomas Hospital D. W. McMillan Hospital Atmore Hospital Monroe County Hospital Grove Hill Hospital

18. Trauma Center Levels Trauma Center Levels Level Four No surgeon available. ATCC will not route patient to this hospital. Hospital should be part of the system for emergent transfers.

19. Community Trauma Centers Evergreen Medical Center Washington County Hospital Jackson Hospital

20. Alabama Stroke System

21. Stroke Center Levels Stroke Center Levels Level One Comprehensive Stroke Center (Joint Commission Stoke Center Classification) or equivalent.

22. Stroke Center Levels Stroke Center Levels Level Two Primary Stroke Center (Joint Commission Stoke Center Classification) or equivalent.

23. Primary Stroke Centers Mobile Infirmary Medical Center University of South Alabama Medical Center Providence Hospital

24. Stroke Center Levels Stroke Center Levels Level Three Acute Stroke Center Majority of care provided by the emergency physician. Must be willing to administer tPa.

25. Stroke Center Levels Stroke Center Levels Level Four Community Stroke Center Care provided by emergency physician without tPa administration.

26. Alabama STEMI System

27. STEMI Center Levels STEMI Center Levels Level One Percutaneous Coronary Intervention (PCI) capable. In-house cardiac surgery availability.

28. STEMI Center Levels STEMI Center Levels Level Two Percutaneous Coronary Intervention (PCI) capable.

29. STEMI Center Levels STEMI Center Levels Level Three Cardiac stabilization in emergency department by emergency medicine physician. Must be willing to administer fibrinolytic.

30. STEMI Center Levels STEMI Center Levels Level Four: Community Care provided by emergency physician without fibrinolytic administration.

31. AGEMSS Hospitals - Trauma University of South Alabama Medical Center Sacred Heart Hospital, Pensacola, FL Baptist Hospital, Pensacola, FL Providence Hospital Mobile Infirmary Medical Center Springhill Medical Center North Baldwin Infirmary South Baldwin Medical Center Thomas Hospital D. W. McMillan Hospital Atmore Hospital Monroe County Hospital Grove Hill Hospital Evergreen Medical Center Washington County Hospital Jackson Hospital

32. AGEMSS Hospitals - Stroke

33. AGEMSS Hospitals - STEMI

34. Evidence of System Improvement Alabama Department Pubic Health, Alabama Hospital Association, Alabama Hospital Association, Alabama Department of Transportation Alabama Department of Transportation conducted a study on vehicle trauma in 2011 conducted a study on vehicle trauma in 2011 which demonstrated the trauma system has which demonstrated the trauma system has reduced mortality by 34% on highways. reduced mortality by 34% on highways.

35. AAHCS COMPONENTS 911 Pre - notice on incident 911 Pre - notice on incident EMS Response & Care EMS Response & Care EMS Transport ( ground or air ) EMS Transport ( ground or air ) ATCC patient routing with center availability linkage ATCC patient routing with center availability linkage QI Process (System-wide) QI Process (System-wide) Follow-up on all Level ONE & TWO patients – feedback to EMSP Follow-up on all Level ONE & TWO patients – feedback to EMSP

36. AAHCS LEGAL STATUS Triage standards part of ADPH/OEMS Protocols Triage standards part of ADPH/OEMS Protocols Plan adopted by Regional Advisory Council /State Trauma & Health Systems Advisory Council / Alabama Committee of Public Health Plan adopted by Regional Advisory Council /State Trauma & Health Systems Advisory Council / Alabama Committee of Public Health EMSP SHALL follow as the standard of care and EMS rules EMSP SHALL follow as the standard of care and EMS rules Protects the EMSP & HOSPITAL when followed Protects the EMSP & HOSPITAL when followed

37. TRIAGE Prioritizes patient status Prioritizes patient status Currently 12-14 % of all trauma patients Currently 12-14 % of all trauma patients Currently high volume of over triage in stroke and STEMI system Currently high volume of over triage in stroke and STEMI system Changes to stop under triage & over triage Changes to stop under triage & over triage

38. Entry Criteria - Trauma 1. Physiological 2. Anatomical 3. Mechanism of Injury 4. EMS Personnel Discretion

39. Entry Criteria - Stroke Any positive finding on the FAST exam.

40. Entry Criteria - STEMI Positive indications on assessment and ECG.

41. Secondary Triage (Patient Routing ) Based upon patient vitals, entry criteria, hospital availability, transport time Based upon patient vitals, entry criteria, hospital availability, transport time ATCC and EMSP make the decision ATCC and EMSP make the decision Best chance the patient has is TX to the right hospital the first time Best chance the patient has is TX to the right hospital the first time

42. Secondary Triage (Patient Routing ) No airway – Closest ER No airway – Closest ER Hemodynamically unstable; no IV Closest ER Hemodynamically unstable; no IV Closest ER Uncontrollable Bleeding- Closest ER Uncontrollable Bleeding- Closest ER

43. Alabama Trauma Communication Center Computer linkage of all trauma centers

44. OPERATIONS- INTRA -NET

45. Patient’s Rights Patient information is used to determine patient routing decision Patient information is used to determine patient routing decision Decisions made with patients rights always considered Decisions made with patients rights always considered

46. ATCC Call the Alabama Trauma Communication Center Cellular Phone Cellular Phone Southern Linc Southern Linc Nextel Nextel Dispatch Dispatch

47. ATS CARD Every EMS unit has an ATS card for trauma, stroke, and STEMI Every EMS unit has an ATS card for trauma, stroke, and STEMI All triage factors All triage factors All communication methods All communication methods All information needed All information needed

48. Quality Improvement QI at regional level QI at regional level Patient entry by Emergency Medicine @ hospital Patient entry by Emergency Medicine @ hospital Inter - facility transfers Inter - facility transfers Improper action by ATCC Improper action by ATCC

49. ATS Website www.adph.org/ems

50. Stroke System in AGEMSS Region Target Date: September 1, 2015 Currently hospitals are completing applications Site Visits Approval process

51. QUESTIONS

52. Thank You! 600 Clinic Drive, Suite 400 Mobile, AL 36688-0002 Office: 461-1832 Cell: 472-7810 dgarmon@southalabama.edu dgarmon@southalabama.edu