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1 Development of the Minnesota Acute Stroke Transport and Treatment System Minnesota Acute Stroke System Council Webinar March 30 and 31, 2011.

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Presentation on theme: "1 Development of the Minnesota Acute Stroke Transport and Treatment System Minnesota Acute Stroke System Council Webinar March 30 and 31, 2011."— Presentation transcript:

1 1 Development of the Minnesota Acute Stroke Transport and Treatment System Minnesota Acute Stroke System Council Webinar March 30 and 31, 2011

2 2 Webinar Logistics You will be placed on mute until Q/A time To ask an immediate question, use the chat function Questions and discussion time at end

3 3 Introductions Albert Tsai, PhD, MPH Minnesota Department of Health (651) James Peacock, PhD, MPH Minnesota Department of Health (651) Justin Bell, JD American Heart Association (952)

4 4 Overview Context for stroke systems of care Data: Why stroke? Why an acute stroke system? Developing an acute stroke system Questions, Discussion

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6 What is a stroke system approach? A stroke system approach involves coordination of stroke care along the entire continuum from primary prevention through rehabilitation.A stroke system approach involves coordination of stroke care along the entire continuum from primary prevention through rehabilitation.

7 Stroke Care System Should provide both patients and providers with the tools necessary to promote effective stroke prevention, treatment, and rehabilitationShould provide both patients and providers with the tools necessary to promote effective stroke prevention, treatment, and rehabilitation Should identify and address potential obstaclesShould identify and address potential obstacles Should be customized to each state, region or localityShould be customized to each state, region or locality

8 Overarching Systems Coordination (ideal state) A body exists to oversee stroke system at the state levelA body exists to oversee stroke system at the state level Key stakeholders are identifiedKey stakeholders are identified Regular meetings occurRegular meetings occur Shared agenda is created, stakeholders agree on opportunities and next steps for improvementShared agenda is created, stakeholders agree on opportunities and next steps for improvement

9 Overarching Systems Coordination (continued) Mechanism exists to monitor and evaluate systemMechanism exists to monitor and evaluate system The best interest of the stroke patient is held as highest objectiveThe best interest of the stroke patient is held as highest objective Geo-political boundaries, corporate affiliations and political maneuvering should be minimizedGeo-political boundaries, corporate affiliations and political maneuvering should be minimized

10 Notification/Response of EMS (ideal state) Processes are in place that facilitate rapid access to EMSProcesses are in place that facilitate rapid access to EMS –EMS dispatch uses the most current stroke triage recommendations –EMS responders are dispatched at the highest-level emergency response –All patients with signs or symptoms are transported to nearest appropriate stroke center

11 Notification/Response of EMS (continued) ED Drs are involved with stroke experts to develop:ED Drs are involved with stroke experts to develop: –EMS stroke education materials –Assessment, treatment and transport protocols for EMS providers EMS personnel can perform assessments & screening of patient for hyper-acute interventionsEMS personnel can perform assessments & screening of patient for hyper-acute interventions

12 Acute Treatment for Stroke Strategies exist for hospitals not seeking stroke center status to ensure they have action plans to triage, treatment (or transport) stroke patients.Strategies exist for hospitals not seeking stroke center status to ensure they have action plans to triage, treatment (or transport) stroke patients.

13 Sub-Acute Stroke Care & Secondary Prevention (ideal state) Stroke teams, stroke units and protocols (organized approaches) are in placeStroke teams, stroke units and protocols (organized approaches) are in place All patients with a history of stroke are provided secondary prevention education addressing all major modifiable risk factorsAll patients with a history of stroke are provided secondary prevention education addressing all major modifiable risk factors

14 Sub-Acute Stroke Care & Secondary Prevention (continued) Stroke patients & families receive education on risk factors, warning signs & how to activate EMSStroke patients & families receive education on risk factors, warning signs & how to activate EMS Smooth transition exists from inpatient to outpatient careSmooth transition exists from inpatient to outpatient care

15 15 Stroke Systems of Care (big picture) Primary prevention Public awareness Emergency Medical Services Acute treatment Sub-acute treatment Rehabilitation, Recovery, and Secondary Prevention

16 16 Context Acute Stroke System

17 17 Stroke Systems of Care: A National Movement Implementing or maintaining statewide or regional system Developing a statewide or regional system in Source: State Stroke Systems Program Survey, Survey of HDSP Program Managers, Cardiovascular Health Council, National Association of Chronic Disease Directors.

18 18 Models from other states Utah Washington Massachusetts Many differences…but many common themes

19 19 History of stroke systems work in Minnesota Minnesota Stroke Partnership (2005) Core working group developed (2009) Competing priorities, lack of staff resources (2010) HDSP State Plan development (2010) Commitment by MDH and AHA to move ahead ( ) Stroke Council convened March 2011

20 20 Why stroke? Annually, 795,000 people experience a new or recurrent stroke. This translates to one stroke every 40 seconds in the US. An estimated 7 million Americans are stroke survivors, and as many as 30 percent of them are permanently disabled, requiring extensive and costly care. In 2007, the cost of stroke is estimated at $40.9 billion ($25.2 b direct costs). Mean lifetime cost estimated at $140,048. In Minnesota,** every year, stroke is the cause of: 2,000 deaths 12,000 hospitalizations $362 million inpatient costs *Source: Roger et al, Circulation 2011; 123:e000;e000. Heart disease and stroke statistics update. **Source: Minnesota Department of Health Fact Sheet: Stroke in Minnesota, June 2010.

21 21 Deaths in Minnesota, 2009 Cause of DeathNumber 1. Cancer9, Heart Disease7, Unintentional Injury2, Stroke2, Chronic Lower Respiratory Disease1, Alzheimers Disease1, Diabetes1, Nephritis Pneumonia and Influenza Suicide589 Source: Minnesota Department of Health Center for Health Statistics, web portal (accessed 3/9/2011)

22 22 Hospitalizations 1. Pregnancy, childbirth, and newborn infants 2. Pneumonia 3. Congestive heart failure 4. Coronary artery disease 5. Osteoarthritis 6. Non-specific chest pain 7. Mood disorders 8. Cardiac dysrhythmias 9. Septicemia 10. Intervertebral disc and spine problems 11. Acute myocardial infarction 12. Acute stroke 13. Chronic obstructive pulmonary disease Source: Healthcare Cost and Utilization Project - HCUP Facts and Figures: Statistics on Hospital-Based Care in the United States, 2007

23 23 Why an acute stroke system? Location of strokes Long drive times to stroke centers Potential for all hospitals to improve

24 24 Minnesota Stroke Hospitalizations, 2008 Location of hospitals No. of hospitals Stroke Discharges % of strokes Twin Cities206,80060 Outstate (Large hospitals) 64,72322 Outstate (Small/Medium- sized hospitals) 1051,97318 Total13111,276100% Source: Minnesota Hospital Uniform Billing Claims Data, Health Economics Program, Minnesota Department of Health and Minnesota Hospital Association.

25 25 Where are stroke patients going first? 2,096 are transferred to another facility From small or rural hospital: 1,545 Bottom line: Annually, at small or rural Minnesota hospitals… 1,973 strokes arrive and are kept 1,545 more are transferred out Total = ~3,500 (one in three strokes) arrive first at a small, rural hospital in Minnesota Source: Minnesota Hospital Uniform Billing Claims Data, Health Economics Program, Minnesota Department of Health and Minnesota Hospital Association.

26 26 Why a stroke system? Location of strokes Long drive times to stroke centers Potential for all hospitals to improve

27 27 60 minutes Door to Image: 25 min Door to Needle: 60 min 60 minutes On Scene to Dx: ASAP On Scene to Hospital: 60 min Onset to recognition : ASAP EMS to Scene Goal: Stroke Onset to Treatment < 180 minutes RECOGNITION & EMS TO SCENE TRIAGE & TRANSPORT DIAGNOSIS & TREATMENT

28 St. Cloud Minneapolis-St. Paul Rochester La Crosse Sioux Falls Fargo Grand Forks Duluth Proximity to Urban Areas for Zip Codes with High Senior Populations Legend US Census Bureau Urban Areas County Boundaries 20% or more 65 yrs + Population Data: 2007 Population estimates by Zip Code, ESRI Drive Times: WWAMI Rural Health Resource Center N% Minnesota Population, 20105,303,925 Outside of 30 minute window2,378,94845% Outside of 60 minute window1,593,72930%

29 29 Why an acute stroke system? Location of strokes Long drive times to stroke centers Potential for all hospitals to improve

30 30 Hospital Readiness So a lot of patients go to rural facilities…are they ready?

31 EMS Pre-notification increases rapid response in the ED Almost 100% in Metro Less than 25% in South Central and Southeast 0% in West Central

32 24/7 CT scan availability for rapid diagnosis 100% in 6 regions Great than 80% in all regions

33 Dedicated team for stroke improves rapid triage and treatment Over 90% in Metro and Southwest Only 60% - 67% in Central, South Central,and West Central 50% in Northwest

34 Protocols for ischemic stroke improve rapid triage and treatment Over 90% in Metro and Southwest 60% - 67% in Northeast and West Central 50% in South Central

35 IV-tPA is the only FDA- approved treatment for acute ischemic stroke 100% in Southeast 90% - 95% in Central, Metro, Northeast, and Southwest 80% - 83% in Northwest and West Central Only 67% in South Central

36 Participation in Stroke QI Programs improves quality of acute and sub-acute care 71% in Metro 50% in Southwest 33% and fewer in the rest of the state

37 37 Minnesota Hospital Stroke Quality Improvement Survey 2010 Pre-notification leading to activation of stroke teams is variable. Most have CT scanners. Most have stroke protocols. Most have tPA protocols, but we know that many dont often give it. Organized QI for stroke is practiced in a growing number of hospitals, but is less common outstate.

38 38 Summary: Why a stroke system? 1. Many at risk are far from a PSC, but most are near a community hospital. Some community hospitals are ready, some community hospitals are not. All hospitals can and should be ready for acute stroke treatment. Stroke system can support statewide capacity building 2. Most ischemic stroke patients are not getting the best therapy (combination of public awareness and health system issues) 3. Most eligible ischemic stroke patients are not getting the best therapy (health system issue) Stroke system should increase the likelihood of all patients getting the best therapy available – regardless of geographic location

39 39 Guiding Principles: What we want Infrastructure to increase capacity Infrastructure to appropriately allocate new or current resources Infrastructure for monitoring data Inclusive Assurance that EMS has clear guidance Something that is good for every type of hospital Something that encourages innovation and quality Something that encourages partnerships, including telemedicine

40 40 Guiding Principles: What we dont want Getting in the way of current good work Getting in the way of market competition Forcing overly burdensome data collection Duplication and bureacracy Unfunded mandates Dictating transport destinations Dictating transfer destinations

41 41 What is a stroke system? (PROPOSED FRAMEWORK) Dispatch: Streamlined, rapid dispatch EMS: Streamlined protocols Transport protocols Data collection, performance improvement Hospitals: Categorizations for capabilities Standardized protocols Data collection, performance improvement Governance, Coordination, Monitoring, Staffing

42 42 How do we create a system? Convene statewide advisory council to develop system plan Based on current national standards Designed to fit Minnesotas needs Implement the plan/system

43 43 Council Representation Hospitals, Minnesota Hospital Association Doctors, Nurses, Administrators Emergency Medicine Neuroscience Neurology Quality EMS, Minnesota Ambulance Association Stratis Health American Academy of Neurology American Heart Association Minnesota Department of Health

44

45 45 What are we looking for from you? Content expertise Input/Consensus on products System framework Protocols Expectations of EMS Expectations of Hospitals Governance and coordination See Charter

46 46 Time Line (DRAFT) PHASE 1: Planning ( ) March, April, May, June – Informational & Planning meetings June 13–Minnesota Stroke Conference (panel) June 28 – table at Rural Health Conference July, September – Planning meetings September 24– EMS Medical Directors Conference October, November – Planning meetings Solicit input and comments from stakeholders during this open comment period PHASE 2: Adoption (2012?) Final decisions Final Adoption PHASE 3: Implementation (2012?) Applications Communication Preparation Launch PHASE 4: Maintenance, Performance Improvement

47 47 Lets be honest and acknowledge: There is a desire to maintain autonomy – by EMS, hospitals. Politics will play a role in discussions. There is market competition at hand. Some physicians are reluctant to adhere to guidelines (i.e., administer tPA). The b word: Bypass.

48 48 In Sum Our overall public health goal is to reduce the burden of stroke. We know primary prevention is key; we know rehabilitation is key. This effort is focused on the middle piece – what happens when EMS is called and when patients arrive at the hospital. The goal is that every patient, regardless of location, should have the opportunity to receive the same high quality of care anywhere in the state.

49 49 Discussion Questions, Concerns Meeting Format Webinar/Teleconference: any changes? Schedule/Timeframe Suggestions for process What information/data do you want or need going forward?

50 50 Next Steps Get meetings on your calendar Visit website (www.health.state.mn.us/cvh)www.health.state.mn.us/cvh Review materials Provide comments and questions – , online, mail, phone Attend and participate in meetings


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