STEMI Regulations Part 2

Right Care. Right Place. Right Time.
The Role of the Rural and Critical
Access Hospital in the TCD System

The End Goal:
360/365 Emergency Medical Care System

Meeting Purpose
• TCD System Review
– Background
– Overview of Proposed Missouri Regulations
• Rural Hospital and CAH Roles in the TCD System
• Next Steps
• Questions

TCDS Background and History

Why Time Critical Diagnosis System
Matters:
Leading causes of death in Missouri
1st
Heart Disease, including ST-Elevation
Myocardial Infarction (STEMI)
3rd
Stroke
1st
/4th
/5th
Trauma-injury-accidents, motor vehicle
accidents, suicide, homicide, other;
Leading cause of YPLL

Why Time Critical Diagnosis
Matters: STEMI
• Heart disease, including STEMI, is the leading cause
death in this state.
• In 2004, Missouri’s heart disease death rate was 13.5
percent higher than the national rate.
• Missouri was in the bottom ten (45 out of 52) in
coronary heart disease death rates.
• The prevalence of heart disease was higher than the
national average
– Missouri ranked 9th among the 50 states in heart disease
prevalence in 2005.
• . Rosamond, W, Flegal K, Furie, K, et.al. Heart Disease and Stroke 2008 Update: A report from the
American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2008;
117; e25-el46; Epub 2007 December 17;
http://circahajournals.org/cgi/content/full/117/4/e25. Retrieved June 24, 2008.
• . MO BRFSS 2005

Matters: STEMI
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
Prompt treatment reduces death and disability.

Matters: Stroke
STROKE
• Stroke is the third leading cause of death in the state.
• In 2004, Missouri’s stroke death rate was 11 percent higher than
the national rate.
• Missouri ranked low (40 out of 52) in the comparison of stroke
death rate between states.
• Missouri was ranked 7th
in stroke prevalence.
• 15-30% will be disabled (leading cause of disability)
• 20% require institutionalization first 3 months post-stroke
• Only a small percent of ischemic stroke patients get definitive care
within the 3 hour window recommended.

Matters: Stroke
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

Matters: Trauma
TRAUMA
• Trauma is the first, fourth or fifth leading cause of death in
Missouri depending on group
• It is the most frequent cause of visits to the emergency
department, causing more than half a million visits in 2006
• 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

Using Trauma System as a Model
Trauma System:
• 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

Missouri’s Goals
–Reduce incidence and severity of
injury, stroke, and STEMI
–Improve access into the system
–Improve outcomes of those injured
or suffering stroke and STEMI
–Improve system evaluation and
QA/QI/PI Processes

Missouri’s Key Guiding Principles
–Patient centered care
–Evidence-based system design
–Population-based approach
–Evaluation mechanism

TCD System Goal

Developing the System:
August 2008: TCD Stroke/STEMI Task Force
compiled formal recommendations
Sept.’08-Present: TCD Trauma Task Force convened for
compiling recommendations
2008-Present: Stroke and STEMI Implementation groups
meeting regularly and compiling standards for stroke
and STEMI center designation and EMS
Implementation: Progress and Goals

Overview of Regulations

Legislative Synopsis:
2008: House Bill 1790 enabling reform passed
unanimously by the Missouri Assembly and
signed into law
RSMo 190-100 Definitions
RSMo 190.200 Public Information & Education
RSMo 190.241 Center Designation
RSMo 190.243 Transportation to Centers
Implementation: Progress and Goals

Missouri Regulations
1. Law authorizes DHSS to promulgate
regulations
2. Inclusive process for drafting
regulations
3. DHSS submits as “Proposed Rules”
– Office of the Secretary of State and
– Joint Committee on Administrative Rules
1. Public Comment Period
2. Final Rules

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

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

Both Stroke & STEMI
• Data submission for statewide registry
• Performance improvement and patient
safety requirements
• Public education to promote prevention
and signs and symptoms awareness

STEMI Center Stipulations
Level I Level II
PCI Receiving Center PCI Receiving Center

STEMI Center Stipulations
Level III Level IV
Lytic Center
some PCI capability
“Drip and Ship”

CMEs-STEMI
Level I Level II Level III Level IV
Medical
Director-
10 hrs/yr 10 hrs/yr 8 hrs/every other yr
Call
Roster
10 hrs/yr 10 hrs/yr 8 hrs/every other yr
ED
Doctor
4 hrs/yr 6 hrs/every other yr

Continuing Education-STEMI
Manager 10 hrs/yr 8 hrs/yr 8 hrs every other yr.
ED RN 4 hrs/yr 4 hrs/yr 6 hrs every other year
ICU RN 8 hrs/yr Not
required
STEMI
Unit RN
8 hrs/yr (I, II) and 8 hrs/every
other year (III)
Not
required

Stroke Center Stipulations
Level I Level II
Align with comprehensive
stroke center standards
•Align with The Joint
Commission-Primary
Stroke Centers standards

Stroke Center Stipulations
Level III Level IV
“Drip and Ship” Rapid Entry into the
System

CMEs-Stroke
Medical
Director-
12 hrs/yr 8 hrs/yr
8
hrs every other yr.
And 6 hrs every other
yr.
Call
Roster
10 hrs/yr 8 hrs/yr
ED
Doctor
4 hrs/yr 4 hrs/yr

Continuing Education-Stroke
Manager 10 hrs/yr 8 hrs/yr
8 hrs
every other yr. and 6
hrs every other yrED RN 4 hrs/yr 4 hrs/yr
ICU RN 10 hrs/yr 8 hrs/yr Not required
Stroke
Unit RN
10 hrs/yr 8 hrs/yr Not required (8 hrs for
III’s that will keep pts.
under supervised
relationship with a II or II)

Trauma
• Level IV Trauma Center regulations under
development
•Survey sent to CAH
• Update old trauma regulations
• Update pediatric trauma regulations
• Transport under discussion
• Injury Specific triage/transfer guidelines under
development
• Other

STEMI and Stroke Patient Transport
• STEMI patient classification
• STEMI patient transport
• Stroke patient classification
• Stroke Patient Transport

Regional Plans
Regional or community based
plans for transporting trauma,
STEMI or stroke patients may be
submitted to DHSS. 190.200
RSMo but not required

Rural and CAH’s in the TCD
System

Rural and CAH’s
• Stroke Regulation Review
• STEMI Regulation Review
• We will develop guidelines for
Rural and Critical Access
Hospitals and receiving
hospitals

Next Steps

1. Work group compiling plan and materials
2. Launch public education campaign
– TCD System/9-1-1
– Signs and symptoms and importance of
calling 911
Next Steps
Public Education

1. Professional education planning (Fall-2009
through Summer-2010)
2. Convene Professional Education work group
(Fall 2010)
3. Conduct professional education (Begin mid-
2011)
Next Steps
Professional Education

Next Steps
Tracking Progress
Create evaluation mechanism to track
progress and outcomes

1. Review existing data system
– CDC Info Aid
– MU Health Informatics
1. Convene quality assurance work group (late
2010)
– 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
1. Implement plan
– Update state database and reporting methodologies
– Training
– Compile reports to support PI/Quality Assurance
– Regional Processes
Next Steps
Quality Assurance

1. DHSS creates application—filed as part of
regulations
2. Once regulations effective, hospitals may submit
application (similar to trauma center application
and review process currently in place)
3. DHSS conducts review
4. DHSS approves designation for those that meet
standards
Next Steps
Center Application

The End Goal:

Contact Information
• Dr. Samar Muzaffar
– samar.muzaffar@dhss.mo.gov
• Cindy Gillam
– cindy.gillam@dhss.mo.gov
• Website
– www.dhss.mo.gov; go to Time Critical Diagnosis
System

STEMI Regulations Part 2

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