the time critical diagnosis system and the role of the trauma model samar muzaffar, md mph
TRANSCRIPT
THE TIME CRITICAL DIAGNOSIS SYSTEM AND THE ROLE OF THE TRAUMA MODEL
Samar Muzaffar, MD MPH
The Time Critical Diagnosis System Concept Dr. Bill Jermyn’s vision for emergency
medical care in Missouri introduced some key concepts, including: The Circle Concept The Emergency Medical Care Systems
(EMCS) approach The Time Critical Diagnosis System in Missouri
Dr. Jermyn’s Circle
The Emergency Medical Care System ConceptThe EMCS Concept Time critical diagnoses share some
fundamental principles. The Emergency Medical Care System is
built upon these principles, which apply whether you are dealing with trauma, stroke, STEMI, or future time critical diagnoses.
This is the elegance of the Circle concept.
Bill Jermyn, DO, FACEP
The Emergency Medical Care System Concept How is the EMCS different?
Society expects emergency care to be available at all times—Emergency Medical Treatment and Active Labor Act (EMTALA)
Regionalization makes sense for EMCS to appropriately allocate finite resources, decrease costs, and improve outcomes
There are different parameters imposed by society on the emergency medical care system than apply to the rest of the health care system
Bill Jermyn, DO, FACEP
The Emergency Medical Care System Concept Integrate public health, public safety,
and the healthcare systems into the Emergency Medical Care System.
Make you think about the system design for the patient, provider, and support future needs.
Bill Jermyn, DO, FACEP
The Time Critical Diagnosis System Concept We work together towards the
common goal of improved patient care for those diagnoses that are time dependent. We don’t do it separately. Bill Jermyn, DO, FACEP
The Time Critical Diagnosis System Concept
The TCD System Umbrella
Time Critical Diagnosis System
Trauma Stroke STEMI Other
The Time Critical Diagnosis System Uses the well-established trauma system
model but keeps the individual system components separate in a cooperative structure. That is, they have to cooperate, but they do not dilute one another.
Brings a much larger public focus on the entire system than the individual components could ever hope to achieve.
Bill Jermyn, DO, FACEP
The Time Critical Diagnosis System Concept What are the similarities?
Three diagnoses; sick trauma, stroke, STEMI
Right patient, right place, right time, right care
We have clear evidence that timely and appropriate treatment of these three diagnoses can improve patient outcomes.
Bill Jermyn, DO, FACEP
The Time Critical Diagnosis System Concept What Are The Similarities?
“Circle concept” of system of care Data collection and data collection platform QI process Public education Importance of early recognition and
appropriate transport and triage (Right Care, Right Place, Right Time)
The Time Critical Diagnosis System Concept What Are The Similarities?
Concepts of “parallel processing” and “moving care forward”.
Need for common time saving measures—leave on EMS stretcher, one call transfers
Legislative requirements Political mechanism
Bill Jermyn, DO, FACEP
The Time Critical Diagnosis System Concept What Are The Similarities?
Need for well-designed inter-facility transfer mechanisms
In-hospital programs that can contribute to the overall effort
Patient outcome improvements require a total system perspective---If it takes 5 hrs to get the patient to the right place, who cares if you save 15 minutes of hospital time?
The Time Critical Diagnosis System Concept Why Design Only One System?
Shared resources (data collection, QI, political, funding, provider/public education, prevention, staffing)
Shared resources increase the odds of successful implementation and viability
A common system is easier for participants to deal with (hospitals, 9-1-1, EMS, etc)
Bill Jermyn, DO, FACEP
The Time Critical Diagnosis System Why Combine The Systems?
Political strength is more effective if we band together
QI process easier if we integrate across disciplines and opportunity for “lessons learned” is greater
National emphasis to better integrate emergency systems
Bill Jermyn, DO, FACEP
The Time Critical Diagnosis System Concept System Requirements
Includes all the stakeholders for system design and structure.
Viable and supports patient care Means to sustain itself Improves care over time-able to refine itself Consistent data collection and use to support
QI
Bill Jermyn, DO, FACEP
The Time Critical Diagnosis System Concept Does System Design Matter?
Bill Jermyn, DO, FACEP Sequential Process:
Parallel Process:
The Time Critical Diagnosis System Concept Current System Development Focus
Pre-Hospital Hospital Quality Improvement Public Education Professional Education
To be addressed 911 Payer
Time Critical Diagnosis System History 2003:Identified need to improve EMCS 2004: Held state summit on reform- included
legislators and medical community 2005: State Government involvement begins 2006: DHSS and stakeholders draft strategic
plan for 360/365 EMCS system 2007: Governor approves DHSS’ draft
legislation; DHSS forms Time Critical Diagnosis Task Force to develop formal recommendations; funding secured
Bill Jermyn, DO, FACEP
Time Critical Diagnosis History Jan-March: Bills introduced in Legislature; Task
Force of over 100 professionals across state met 5 times.
May: House Bill 1790 enabling reform was passed by legislature on last day of session. It was one of only 139 bills to pass.
July: The Governor signs bill into law. August: Task Force submitted formal
recommendations for system reform to state health department
September: Trauma Task Force convened September/October: Stroke and STEMI
implementation groups convened
Bill Jermyn, DO, FACEP
The Role of the Trauma Model Lessons Learned
Trauma SYSTEM saved lives Accommodate regional and local variations Set standards that are agreed upon by all Verify compliance with those standards by
some objective means
Bill Jermyn, DO, FACEP
The Role of the Trauma Model Lessons Learned, cont.
Gather Quality Improvement (QI) data, analyze it, and use it to adapt and refine the system
Involve the the correct stakeholders Design to encourage parallel processing; not
sequential Examine all aspects of the patient’s care
Bill Jermyn, DO, FACEP
The Role of the Trauma Model Lessons Learned, cont’d
Self-assessment accreditation processes help some, but independent, outside review teams and center designation improve outcomes even more (DiRusso S et al. Preparation and achievement of American College of Surgeons Level 1 trauma verification raises hospital performance and improves patient outcomes. J Trauma; 2001 Aug. 51(2):294-300.) (Mann NC et al. Systematic review of published evidence regarding trauma system effectiveness. J Trauma 1999 Sept;47(3 Suppl) S25-S35.)
Bill Jermyn, DO, FACEP
Trauma Model History: The Nation and Missouri
Year Nation Missouri1981
Early 1980’s
1984
Block Grants— for EMS •Orange Co trauma system implemented•Orange Co Preventable deaths drop from 34% to 15%
•PHHS Block supports EMS services (current)•Trauma system center designations based on self-assessment
Bill Jermyn, DO, FACEP
Trauma Model History: The Nation and Missouri
Year Nation Missouri
1985
1988
1990
Injury in America
Trauma Care Systems & Devl Act (PL 101-590)
Authorizes funding through 1995—one size did not fit all
•Trauma Committee—Outside reviewers start to verify standards at designated facilities
Bill Jermyn, DO, FACEP
Trauma Model History: The Nation and Missouri
Year Nation Missouri1998
2006
•EMS statutes revised—6 EMS regions authorized (no funding)•IOM Report EMCS Regionalization RecommendationBill Jermyn, DO, FACEP
WHERE IS TRAUMA IN MISSOURI NOWGoals and Objectives
Where Are We Now
We have center designation We have center accreditation We have pre-hospital services We have a State Registry We have protocols
Where Are We Now
But do we have a system or do we function in silos?
Where Are We Now
Do we know the trends in state data? Do we have well established Regional and
State QI processes? Do pre-hospital and hospital providers
communicate about patient care? In the field? In transfer?
Does dispatch communicate with field personnel and hospital personnel?
Do we coordinate resources and response? Do we have evidence-based plans of action
throughout the state Do we have effective medical control and
direction?
Where Are We Now
Do we have a financial base that can support a system?
Do we have comprehensive public education, injury and violence prevention programs?
Essentially, does one aspect of the system build on the prior
and feed into the next?
Where Are We Now
Unintentional Injury Profile for Missouri (www.dhss.mo.gov/ASPsUnintentional/Trend) Deaths: Motor Vehicle Traffic Three-Year Moving Average Rates
The curve for Missouri is flat ‘91-’93 18.4/100,000 ‘04-’06 18.9/100,000
Some improvements seen in ‘07 and ‘08
Where Are We Now
Why is the curve flat? Do we have good measures? Do we have effective injury prevention programs?
Do we have an effective Trauma “SYSTEMS” approach?
Where Are We Now
We did a pilot study/survey
Some responded (N=19; mainly out-of-hospital providers)
Gave a starting point for more directed survey
Where Are We Now
We asked about Regional Challenges You replied
Access Knowledge Resources QA/QI Protocols Coordination Helicopter Early Launch Protocols Diversion/Delays Culture/Attitudes
Where Are We Now
We asked about Local Challenges You replied
Sense of urgency around class 2 and 3’s Resources/Education Diversion/Delays Destination determination Funding Dispatch/EMD Coordination
Where Are We Now
Other Issues Raised Divergent classification schemes Equipment/Technology needs Communication Injury Prevention Medical Direction Self-Referral Role of small and rural hospitals Hospital Delays
Where Are We Now
We have a system, but it’s components are sometimes Fragmented In need of updating And not cooperating and coordinating efforts
Where Are We Now
The issues raised in this pilot study reinforce the objectives for this Task Force
This process will run in parallel to the Stroke and STEMI implementation process set forth in the TCD Task Force Report
Where Are We Now
This is an opportunity to assess where we are, state what we need, and implement plans to move our system forward
There is intense interest in seeing the trauma system succeed and grow
The trauma system model creates the core infrastructure for the TCD System in Missouri
Goals and Objectives
Goals: To design an integrated emergency medical
system To broaden the trauma system approach and
perspective to improve injury prevention efforts, patient care throughout the circle, and patient outcomes
To set the framework for the stroke and STEMI arms of the TCD System
To establish an efficient and effective approach for future time critical diagnoses incorporated into the system
Goals and Objectives
Objectives To assemble a Task Force for trauma from
the various stakeholders in Missouri’s trauma system guided by a Steering Committee for this process
To have clear Roles and Responsibilities for the Task Force and Steering Committee
Goals and Objectives
Objectives To have clear end products for the close of
the Task Force efforts To have clear agendas for each of the
meetings To debrief and have synthesis of regional
and state level at each stage in the process
Goals and Objectives
To conduct the meeting agendas using the TCD System components and address Response Coordination- Dispatch EMD/PAI Pre-Hospital Response and Transport Hospitals Quality Improvement Professional Education Public Education/Prevention Payer Administration and Infrastructure
Goals and Objectives
Objectives End Products
Recommendations to the Department Review of Regional structure and function Updated PAI/EMD Augmented on- and off-line medical control Helicopter Early Launch Protocols Triage/transfer protocols updated with latest
evidence
Goals and Objectives
End Products Cont’d Review of potential need/role/criteria for Level
IV Centers Augmented QI/process evaluation of system
development Plan for QI on statewide and regional basis for
centers seeing trauma patients, designated and non-designated
Common language: state trauma classification scheme with regional variables
Conclusions
We have assembled a large group of stakeholders Some of us will agree on some things and diverge
on others The same stakeholders that agree on one thing
may diverge on another We will need to compromise and find common
ground This is a consensus building process
to build the best system we can for the patient
Conclusions
“Nothing endures but change.”
Heraclitus
540BC-480BC
Courtesy of Bill Jermyn, DO, FACEP