1. TIME CRITICAL DIAGNOSIS SYSTEM in MISSOURI
Welcome—Local person can begin—welcome group.
Introductions

2. Identify those that are from the region
Explain that the colors reflect the colors that are in each of the 6 respective regions.
Meeting Schedule
Jefferson City September 29 Central
Kirksville October 5 Central
Cape Giradeau September 30 Southeast
St. Louis October 1 East Central
Kansas City October 6 Kansas City and Northwest
Springfield October 7 Southwest

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
Stroke, STEMI and trauma are all time critical diagnoses.
Tag line reference- Right Care at the Right Place at the Right Time
Table of contents

4. Why Time Critical Diagnosis System Matters: Leading 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
The magnitude of the time critical diagnoses clearly warrant attention
The FACT SHEET in your packets also outlines some other noteworthy facts about these conditions.

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
‘ – 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
- Project has been in the works since 2003 when MFH identified need for EMS/Trauma
100s of individuals around the state have been involved through the years, including representatives from respected medical associations and facilities across the state and nation.
The late Dr. Bill Jermyn’s vision for a complete, integrated Emergency Medical System has driven this reform.
In 2008 DHSS and MFH led a Task Force which created recommendations that were approved by the state.
- May 2008 HB 1790 was unanimously passed to create a new EMS system, Governor signed the bill in July 2008.
-First of its kind state-wide reform for both Stroke and STEMI.
-Detailed TIMELINE in YOUR PACKET

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
Missouri’s 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 MVC’s 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
Why aren’t patients getting the recommended treatment in the recommended time frame?
The system isn’t designed for it.
Current protocol for ambulances is to triage to the nearest hospital - not necessarily a facility equipped to deliver best 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
That’s the problem.
What’s the solution?
Why aren’t patients getting the recommended treatment in the recommended time frame?
The system isn’t designed for it.
Current protocol for ambulances is to triage to the nearest hospital - not necessarily a facility equipped to deliver best 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

14. Creating a Time Critical Diagnosis System
The Solution:
The Right Care
at the
The Right Place
in the
The Right Time
That’s why we need to develop a system that ensures that patients reach
The appropriate facility
Within the appropriate time
For the appropriate care
Or as we like to say…

15. Creating a Time Critical Diagnosis System
The solution:
Using the Trauma System
as a Model
That’s why we need to develop a system that ensures that patients reach
The appropriate facility
Within the appropriate time
For the appropriate care
Or as we like to say…

16. Using Trauma System as a Model
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
Luckily, we have an existing model – the Trauma model saves lives by making sure that patients in need of acute trauma care get to the right facility as quickly as possible.
And it’s a proven model. The trauma system saves lives, improves patient outcomes, creates efficiencies and cost savings, and allows for 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 Definitions
RSMo Public Information & Education
RSMo Center Designation
RSMo 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
Need to update

20. Overview of Regulations
Transition to DHSS staff

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
Fall meetings are at the tail-end of the drafting process. Have had over 20 statewide meetings/conference calls and now conducting meetings to provide overview to interested health care community.
We need your feedback. Welcome your input at this stage.

22. Missouri Regulations Both 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
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
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
8 hrs/every other yr
Call Roster
ED Doctor
4 hrs/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.
ED RN
4 hrs/yr
6 hrs every other year
ICU RN
Not required
STEMI
Unit RN
8 hrs/yr (I, II) and 8 hrs/every other year (III)

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

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.
Call Roster
10 hrs/yr
ED Doctor
4 hrs/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
ED RN
4 hrs/yr
ICU RN
Not required
Stroke Unit RN
Not required (8 hrs for III’s 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 Regulations Regional Plans
Regional or community based plans for transporting trauma, STEMI or stroke patients may be submitted to DHSS RSMo but not required
These Regulations to be written

34. Missouri Regulations Next Steps Finish Community-Based Plan
Conduct legal and administrative reviews
Submit proposed stroke and STEMI regulations to Secretary of State’s 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. Professional Education
Next Steps
Professional Education
Professional education planning (Fall-2009 through Spring-2010)
Conduct professional education (Begin Summer 2010)

37. Next Steps Tracking Progress
Create evaluation mechanism to track progress and outcomes
- The designation process will identify hospital’s levels within stroke and STEMI. The requirements for designation have been developed by the TCD team and will be approved as part of the regulations.
EMS and hospital personnel will all be included in the professional education program.
A public education plan will be developed in 2010 – will likely include media outreach and speaking engagements.

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 application—filed 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
The End Goal is this:
An integrated emergency medical care system that broadens the trauma system approach and perspective to improve injury prevention efforts, patient care throughout this circle, and ultimately, to improve patient outcomes across the state of Missouri.

41. Right care. Right Place. Right Time Time Critical Diagnosis-
The End Goal:
360/365 Emergency Medical Care System
Right care. Right Place. Right Time
Time Critical Diagnosis-
Trauma
Stroke
STEMI
Better outcomes for Missourians
The End Goal is this:
An integrated emergency medical care system that broadens the trauma system approach and perspective to improve injury prevention efforts, patient care throughout this circle, and ultimately, to improve patient outcomes across the state of Missouri.