1. The Acute Healthcare System of Alabama
System Information/Education

2. No Conflicts of Interest
University of South Alabama Alabama Department of Public Health Office of EMS National Registry of EMTs

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

4. Interesting Data
No data showing that ALS saves more lives than BLS in EMS.
Data shows acute care hospital selection saves lives.

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
Alabama Statewide Trauma System

6. Why Develop a State-wide System?
Trauma is the number one killer between one year and forty-four years of age!
Cardiovascular is the number one cause of death.
Stroke is the fifth leading cause of death.
Ask about what the other top killers are for all ages–1. Cardiac ,2 Cancer,3. Stroke , cost to AL. for trauma costs more than the sum of 1,2,3 , illustrate an 8yo into a mailbox with spinal injuies will remain a quad for the rest of his life who pays the tremendous cost , head injury from single car crash 28 yom with wife and two children , patient remains comatose for 9 months then altered for the rst of his life , who pays for care , family support as well children’s education - tri modal distribution is one third of trauma patients die immediately at the scene, one third in the first hour and one third two weeks or so post injury last third die because of end organ failure heart attack , stroke , kidney failure , sepsis,etc these die because they can not repay the end organ debt that occurs with shock , also explain co morbid factors which effect the debt and repayment

7. Top 10 Leading Causes of Death in the United States
1. Heart disease 2. Cancer (malignant neoplasms) 3. Chronic lower respiratory disease 4. Accidents (unintentional injuries) 5. Stroke (cerebrovascular diseases) 6. Alzheimer's disease 7. Diabetes (diabetes mellitus) 8. Influenza and pneumonia 9. Kidney disease (nephritis, nephrotic syndrome, and nephrosis) 10. Suicide (intentional self-harm).

8. 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

9. 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 – under review
Stroke – Four Levels of Care – under review
STEMI – Two Levels of Care
Determined by each Hospital
Volunteer participation by Hospitals
Hospitals can change level status as needed

10. 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
Average EMTALA transfer time is 6.5 hours
Average ATS transfer time is less than 15 minutes.

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

12. Evidence of System Improvement
Alabama Department Pubic Health,
Alabama Hospital Association,
Alabama Department of Transportation
conducted a study on vehicle trauma in 2011
which demonstrated the trauma system has
reduced mortality by 34% on highways.
This use of 12% mortality decrease is based upon a peer review published article . The article compared the patients entered into the trauma system before and after the start up. The variables' of patient age, sex, and etc were factored. The second point is supported in several way’s: LOS decreased from 19 days to now 9,the seven counties ( BREMSS) currently serve are the only counties with a decreased accidental rate UNTIL THIS YEAR .

13. Alabama Trauma System

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

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

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

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

18. Level Two Trauma Center
Baptist Hospital, Pensacola

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

20. 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

21. 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.

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

23. Alabama Stroke System

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

25. Entry Criteria - Stroke
Which is the best instrument to determine entry criteria? Evidence-based criteria. Data rapidly changing. …Transport patient to nearest stroke center verses transport to highest level stroke center. Numerous pilot projects being used to determine.

26. Stroke Center Levels Level One Comprehensive Stroke Center
(Joint Commission Stoke Center Classification)

27. Comprehensive Stroke Center
University of Alabama at Birmingham

28. Stroke Center Level 1.5
Joint Commission Stroke Center Classification to recognize hospitals with neurological interventional capabilities.
Evidence-based data of better entry level criteria for initial patient transport (time-related-care).

29. Stroke Center 1.5 University of South Alabama Medical Center
Mobile Infirmary Medical Center
Sacred Heart – Pensacola
Baptist Hospital – Pensacola
Progressing to 24/7 coverage
Interventional specialist are highly sought
Interventional labs are expensive

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

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

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

33. Level Three Stroke Centers
Springhill Medical Center North Baldwin Infirmary South Baldwin Medical Center Thomas Hospital D. W. McMillan Hospital Monroe County Hospital Grove Hill Hospital Jackson Medical Center Thomas Hospital Free-Standing ER

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

35. Community Stroke Centers
Washington County Hospital Atmore Community Hospital Evergreen Medical Center

36. ADPH Data
Disclaimer: Only as accurate as what is reported and this data is under reported by the hospitals.
HOR = Hospital Outcome Reports
Data from January 1 – February 28, 2018
Data from Gary Varner, MPH, NRP – Senior Epidemiologist and State EMS Data Manager and Augustine M. Amenyah, Ed,D., MPH – Epidemiologist

37. Reported Strokes Per Region
Aero 602 East 252 BREMSS 2,010 West 28 * *Not in the state Southeast 2,352 system. Gulf 296 Total 5,540

38. Recorded CT Scans
CT – Yes 4,259 CT – No 88 CT – Unknown 37 Total 4,384

39. Stroke Diagnosis
Yes 1,944 No 2,317 Unknown 94 Total 4,355

40. Stroke Types
Ischemic 1,452 Hemorrhagic 494 No Stroke 72 Total 1,928

41. tPA Administration
Yes 370 No 1,297 Unknown 53 Total 1, % of patients recorded to have been diagnosis with an ischemic stroke recorded to have been given tPA.

42. Strokes admitted to…
Floor 2,112 SICU 1,260 Total 3,372

43. Conclusions
High number of over-triaged patients Significant number of tPA administrations Many level 3 stroke centers with only a few actually administering tPA. Majority of patients were admitted for other medical conditions.

44. Alabama STEMI System

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

46. Percutaneous Coronary Intervention (PCI) capable.
STEMI Center Levels
Percutaneous Coronary Intervention (PCI) capable.

47. STEMI Centers Thomas Hospital Mobile Infirmary Medical Center
Providence Hospital
Springhill Medical Center
USA Medical Center
Sacred Heart Hospital
Baptist Hospital
South Baldwin Regional MC

48. Non-STEMI Centers North Baldwin Infirmary D. W. McMillan Hospital
Atmore Hospital
Monroe County Hospital
Grove Hill Hospital
Evergreen Medical Center
Jackson Medical Center
Washington County Hospital

49. STEMI System
Will be implemented statewide as soon as the stroke system is completed.
ATCC currently routing patients to PCI – Centers throughout Alabama.

50. AAHCS COMPONENTS 911 Pre - notice on incident EMS Response & Care
EMS Transport ( ground or air )
ATCC patient routing with center availability linkage
QI Process (System-wide)
Follow-up on all Level ONE & TWO patients – feedback to EMSP
ATS changes only last three areas .The EMT will have the ATCC tool to help make more responsible decisions as well as a learning process through return of patient outcome .The patient outcome will be returned in some manner by the Region to the first responder as well as the transport agency.

51. AAHCS LEGAL STATUS Triage standards part of ADPH/OEMS Protocols
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
Protects the EMSP & HOSPITAL when followed
RTAC –Regional Trauma Advisory Board ,STAC –State Trauma Advisory Board Stress to not follow the ATS standards is a rule violation and can result in a sanction to the EMT and agency involved as well as increased liability

52. TRIAGE Prioritizes patient status
Currently % of all trauma patients
Currently high volume of over triage in stroke and STEMI system
Changes to stop under triage & over triage
Stress not every trauma patient , but only ones which meet entry criteria .Overtriage is based on a system patient who is discharged from the ER. Under triage is patient who must (or should have been ) cared for by the trauma team in an ATS trauma center.

53. Secondary Triage (Patient Routing )
Based upon patient vitals, entry criteria, hospital availability, transport time
ATCC and EMSP make the decision
Best chance the patient has is TX to the right hospital the first time
ATCC performs this function based upon patient condition , transport time ,and trauma center availability.goal is provide so we do not allow a patient to wait several hours to be transferred.

54. Secondary Triage (Patient Routing )
No airway – Closest ER
Hemodynamically unstable; no IV Closest ER
Uncontrollable Bleeding- Closest ER
Call the ATCC first. ATCC will notify the hospital, then arrange for transfer

55. Alabama Trauma Communication Center
Computer linkage
of all acute
healthcare centers

56. OPERATIONS- INTRA -NET
ATCC is tied to the hospitals by intran net not inter net because of reliability , harder to hack , and easier to maintain . At least one level of redundancy with phone line , wireless, VPN.

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

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

59. AAHCS CARD
Every EMS unit has an AAHCS card for trauma, stroke, and STEMI
All triage factors
All communication methods
All information needed
Show a demo cc and pass out at the end of class if available , if not available Region will make available

60. Quality Improvement QI at regional level
Patient entry by Emergency hospital
Inter - facility transfers
Improper action by ATCC
Each Region will have their own QI committee , under triage will be determined by patients placed in the system by hospitals , inter facility transfers to level one and two or community hospitals of trauma patients not in the ATS . Improper actions by the ATCC should be reported to the Region who will place it in their QI process with follow up and correction of the issue by ATCC , if needed.

61. www. alabamapublichealth. gov/ems/health-systems
Health System Website
www. alabamapublichealth. gov/ems/health-systems

62. QUESTIONS

63. Thank You! 600 Clinic Drive, Suite 400 Mobile, AL 36688-0002
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