The Time Critical Diagnosis System and the Role of the Trauma Model

1. The Time Critical Diagnosis System and the Role of the Trauma Model Samar Muzaffar, MD MPH

2. 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

3. Dr. Jermyn’s Circle

4. The Emergency Medical Care System Concept The 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

5. 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

6. 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

7. 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

8. The Time Critical Diagnosis System ConceptThe TCD System Umbrella Time Critical Diagnosis System Stroke STEMI Other Trauma

9. 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

10. 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

11. 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)

12. 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

13. 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?

14. 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

15. 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

16. 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

17. The Time Critical Diagnosis System Concept • Does System Design Matter? Bill Jermyn, DO, FACEP

18. The Time Critical Diagnosis System Concept • Current System Development Focus • Pre-Hospital • Hospital • Quality Improvement • Public Education • Professional Education • To be addressed • 911 • Payer

19. 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

20. 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

21. 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

22. 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

23. 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

24. Trauma Model History: The Nation and Missouri

25. Trauma Model History: The Nation and Missouri

26. Trauma Model History: The Nation and Missouri

27. Where is Trauma in Missouri Now Goals and Objectives

28. 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

29. Where Are We Now But do we have a system or do we function in silos?

30. 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?

31. 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?

32. 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

33. 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?

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. Conclusions “Nothing endures but change.” Heraclitus 540BC-480BC Courtesy of Bill Jermyn, DO, FACEP