Embed Size (px)
Citation preview
1
Development of theMinnesota Acute Stroke Transport and Treatment System
Minnesota Acute Stroke System Council Webinar
March 30 and 31, 2011
2
Webinar Logistics
You will be placed on mute until Q/A time To ask an immediate question, use the
chat function Questions and discussion time at end
3
Introductions
Albert Tsai, PhD, MPH Minnesota Department of [email protected] (651) 201-5413
James Peacock, PhD, MPH Minnesota Department of [email protected] (651) 201-5405
Justin Bell, JD American Heart [email protected] (952) 278-7921
4
Overview
Context for “stroke systems of care” Data:
Why stroke? Why an acute stroke system?
Developing an acute stroke system Questions, Discussion
What is a stroke system approach?What is a stroke system approach?
• A stroke system approach involves A stroke system approach involves coordination of stroke care along coordination of stroke care along the entire continuum from primary the entire continuum from primary prevention through rehabilitation.prevention through rehabilitation.
Stroke Care SystemStroke Care System• Should provide both patients and Should provide both patients and
providers with the tools necessary to providers with the tools necessary to promote effective stroke prevention, promote effective stroke prevention, treatment, and rehabilitationtreatment, and rehabilitation
• Should identify and address potential Should identify and address potential obstaclesobstacles
• Should be customized to each state, Should be customized to each state, region or localityregion or locality
Overarching Systems Overarching Systems Coordination (ideal state)Coordination (ideal state)• A “body” exists to oversee stroke A “body” exists to oversee stroke
system at the state levelsystem at the state level• Key stakeholders are identifiedKey stakeholders are identified• Regular meetings occur Regular meetings occur • Shared agenda is created, Shared agenda is created,
stakeholders agree on stakeholders agree on opportunities and next steps for opportunities and next steps for improvementimprovement
Overarching Systems Overarching Systems Coordination (continued)Coordination (continued)
• Mechanism exists to monitor and Mechanism exists to monitor and evaluate systemevaluate system
• The best interest of the stroke patient is The best interest of the stroke patient is held as highest objectiveheld as highest objective
• Geo-political boundaries, corporate Geo-political boundaries, corporate affiliations and political maneuvering affiliations and political maneuvering should be minimizedshould be minimized
Notification/Response of EMSNotification/Response of EMS(ideal state)(ideal state) • Processes are in place that Processes are in place that
facilitate rapid access to EMS facilitate rapid access to EMS – EMS dispatch uses the most current EMS dispatch uses the most current
stroke triage recommendations stroke triage recommendations – EMS responders are dispatched at the EMS responders are dispatched at the
highest-level emergency responsehighest-level emergency response– All patients with signs or symptoms All patients with signs or symptoms
are transported to nearest appropriate are transported to nearest appropriate stroke center stroke center
Notification/Response of EMSNotification/Response of EMS(continued)(continued)• ED Drs are involved with stroke ED Drs are involved with stroke
experts to develop:experts to develop:– EMS stroke education materialsEMS stroke education materials– Assessment, treatment and transport Assessment, treatment and transport
protocols for EMS providersprotocols for EMS providers
• EMS personnel can perform EMS personnel can perform assessments & screening of patient assessments & screening of patient for hyper-acute interventionsfor hyper-acute interventions
Acute Treatment for StrokeAcute Treatment for Stroke
• Strategies exist for hospitals not Strategies exist for hospitals not seeking stroke center status to seeking stroke center status to ensure they have action plans to ensure they have action plans to triage, treatment (or transport) triage, treatment (or transport) stroke patients.stroke patients.
Sub-Acute Stroke Care & Sub-Acute Stroke Care & Secondary PreventionSecondary Prevention(ideal state)(ideal state)• Stroke teams, stroke units and Stroke teams, stroke units and
protocols (organized approaches) protocols (organized approaches) are in placeare in place
• All patients with a history of stroke All patients with a history of stroke are provided secondary prevention are provided secondary prevention education addressing all major education addressing all major modifiable risk factors modifiable risk factors
Sub-Acute Stroke Care & Sub-Acute Stroke Care & Secondary PreventionSecondary Prevention(continued)(continued)• Stroke patients & families receive Stroke patients & families receive
education on risk factors, warning education on risk factors, warning signs & how to activate EMS signs & how to activate EMS
• Smooth transition exists from Smooth transition exists from inpatient to outpatient care inpatient to outpatient care
15
Stroke Systems of Care (big picture)
Primary prevention Public awareness Emergency Medical Services Acute treatment Sub-acute treatment Rehabilitation, Recovery, and Secondary
Prevention
16
Context
Acute Stroke System
17
Stroke Systems of Care: A National Movement
Implementing or maintaining statewide or regional system
Developing a statewide or regional system in 2011-2012
Source: State Stroke Systems Program Survey, 2010. Survey of HDSP Program Managers, Cardiovascular Health Council, National Association of Chronic Disease Directors.
18
Models from other states
Utah Washington Massachusetts
Many differences…but many common themes
19
History of stroke systems work in Minnesota
Minnesota Stroke Partnership (2005) Core working group developed (2009) Competing priorities, lack of staff
resources (2010) HDSP State Plan development (2010) Commitment by MDH and AHA to move
ahead (2010-2011) Stroke Council convened March 2011
20
Why stroke? Annually, 795,000 people experience a new or recurrent stroke.
This translates to one stroke every 40 seconds in the US.
An estimated 7 million Americans are stroke survivors, and as many as 30 percent of them are permanently disabled, requiring extensive and costly care.
In 2007, the cost of stroke is estimated at $40.9 billion ($25.2 b direct costs).
Mean lifetime cost estimated at $140,048.
In Minnesota,** every year, stroke is the cause of: 2,000 deaths 12,000 hospitalizations $362 million inpatient costs
*Source: Roger et al, Circulation 2011; 123:e000;e000. Heart disease and stroke statistics - 2011 update.**Source: Minnesota Department of Health Fact Sheet: Stroke in Minnesota, June 2010.
21
Deaths in Minnesota, 2009
Cause of Death Number
1. Cancer 9,575
2. Heart Disease 7,233
3. Unintentional Injury 2,031
4. Stroke 2,023
5. Chronic Lower Respiratory Disease 1,961
6. Alzheimer’s Disease 1,374
7. Diabetes 1,022
8. Nephritis 801
9. Pneumonia and Influenza 591
10. Suicide 589
Source: Minnesota Department of Health Center for Health Statistics, web portal (accessed 3/9/2011)
22
Hospitalizations
1. Pregnancy, childbirth, and newborn infants2. Pneumonia3. Congestive heart failure4. Coronary artery disease5. Osteoarthritis6. Non-specific chest pain7. Mood disorders8. Cardiac dysrhythmias9. Septicemia10. Intervertebral disc and spine problems11. Acute myocardial infarction12. Acute stroke13. Chronic obstructive pulmonary disease
Source: Healthcare Cost and Utilization Project - HCUP Facts and Figures: Statistics on Hospital-Based Care in the United
States, 2007 http://www.hcup-us.ahrq.gov/reports/factsandfigures/2007/pdfs/section2_1.pdf
23
Why an acute stroke system?
Location of strokes Long drive times to stroke centers Potential for all hospitals to improve
24
Minnesota Stroke Hospitalizations, 2008
Location of hospitals
No. of hospitals
Stroke Discharges
% of strokes
Twin Cities 20 6,800 60
Outstate
(Large hospitals)
6 4,723 22
Outstate
(Small/Medium-sized hospitals)
105 1,973 18
Total 131 11,276 100%
Source: Minnesota Hospital Uniform Billing Claims Data, Health Economics Program, Minnesota Department of Health and Minnesota Hospital Association.
25
Where are stroke patients going first?
2,096 are transferred to another facility From small or rural hospital: 1,545
Bottom line: Annually, at small or rural Minnesota hospitals… 1,973 strokes arrive and are kept 1,545 more are transferred out Total = ~3,500 (one in three strokes) arrive first at a
small, rural hospital in Minnesota
Source: Minnesota Hospital Uniform Billing Claims Data, Health Economics Program, Minnesota Department of Health and Minnesota Hospital Association.
26
Why a stroke system?
Location of strokes Long drive times to stroke centers Potential for all hospitals to improve
27
60 minutes
Door to Image: 25 min
Door to Needle: 60 min
60 minutes 60 minutes
On Scene to Dx: ASAP
On Scene to Hospital: 60 min
Onset to recognition + 9-1-1: ASAP
EMS to Scene
Goal: Stroke Onset to Treatment < 180 minutes
RECOGNITION & EMS TO SCENE
TRIAGE & TRANSPORT
DIAGNOSIS & TREATMENT
St. Cloud
Minneapolis-St. Paul
RochesterLa Crosse
Sioux Falls
Fargo
GrandForks
Duluth
Proximity to Urban Areas forZip Codes with
High Senior Populations
LegendUS Census Bureau Urban Areas
County Boundaries
20% or more 65 yrs +
Population Data: 2007 Population estimates by Zip Code, ESRIDrive Times: WWAMI Rural Health Resource Center
N %
Minnesota Population, 2010 5,303,925
Outside of 30 minute window 2,378,948 45%
Outside of 60 minute window 1,593,729 30%
29
Why an acute stroke system?
Location of strokes Long drive times to stroke centers Potential for all hospitals to improve
30
Hospital Readiness
So a lot of patients go to rural facilities…are they ready?
EMS Pre-notification increases rapid response in the ED
• Almost 100% in Metro
• Less than 25% in South Central and Southeast
• 0% in West Central
24/7 CT scan availability forrapid diagnosis
• 100% in 6 regions
• Great than 80% in all regions
Dedicated team for strokeimproves rapid triage andtreatment
• Over 90% in Metro and Southwest
• Only 60% - 67% in Central, South Central,and West Central
• 50% in Northwest
Protocols for ischemic strokeimprove rapid triage andtreatment
• Over 90% in Metro and Southwest
• 60% - 67% in Northeast and West Central
• 50% in South Central
IV-tPA is the only FDA-approved treatment for acute ischemic stroke
• 100% in Southeast
• 90% - 95% in Central, Metro, Northeast, and Southwest
• 80% - 83% in Northwest and West Central
• Only 67% in South Central
Participation in Stroke QI Programs improves quality of acute and sub-acute care
• 71% in Metro
• 50% in Southwest
• 33% and fewer in the rest of the state
37
Minnesota Hospital Stroke Quality Improvement Survey 2010
Pre-notification leading to activation of stroke teams is variable.
Most have CT scanners. Most have stroke protocols. Most have tPA protocols, but we know
that many don’t often give it. Organized QI for stroke is practiced in a
growing number of hospitals, but is less common outstate.
38
Summary: Why a stroke system?
1. Many at risk are far from a PSC, but most are near a community hospital.
Some community hospitals are ready, some community hospitals are not.
All hospitals can and should be ready for acute stroke treatment.
Stroke system can support statewide capacity building2. Most ischemic stroke patients are not getting the best
therapy (combination of public awareness and health system issues)
3. Most eligible ischemic stroke patients are not getting the best therapy (health system issue)
Stroke system should increase the likelihood of all patients getting the best therapy available – regardless of geographic location
39
Guiding Principles: What we want
Infrastructure to increase capacity Infrastructure to appropriately allocate new or current
resources Infrastructure for monitoring data Inclusive Assurance that EMS has clear guidance Something that is good for every type of hospital Something that encourages innovation and quality Something that encourages partnerships, including
telemedicine
40
Guiding Principles: What we don’t want
Getting in the way of current good work Getting in the way of market competition Forcing overly burdensome data collection Duplication and bureacracy Unfunded mandates Dictating transport destinations Dictating transfer destinations
41
What is a stroke system? (PROPOSED FRAMEWORK)
Dispatch: Streamlined, rapid dispatch
EMS: Streamlined protocols Transport protocols Data collection, performance improvement
Hospitals: Categorizations for capabilities Standardized protocols Data collection, performance improvement
Governance, Coordination, Monitoring, Staffing
42
How do we create a system?
Convene statewide advisory council to develop system planBased on current national standardsDesigned to fit Minnesota’s needs
Implement the plan/system
43
Council Representation Hospitals, Minnesota Hospital Association Doctors, Nurses, Administrators
Emergency Medicine Neuroscience Neurology Quality
EMS, Minnesota Ambulance Association Stratis Health American Academy of Neurology American Heart Association Minnesota Department of Health
45
What are we looking for from you?
Content expertise Input/Consensus on “products”
System framework Protocols Expectations of EMS Expectations of Hospitals Governance and coordination
See Charter
46
Time Line (DRAFT)
PHASE 1: Planning (2011-2012) March, April, May, June – Informational & Planning meetings
June 13–Minnesota Stroke Conference (panel) June 28 – table at Rural Health Conference
July, September – Planning meetings September 24– EMS Medical Directors Conference
October, November – Planning meetings Solicit input and comments from stakeholders during this “open comment” period
PHASE 2: Adoption (2012?) Final decisions Final “Adoption”
PHASE 3: Implementation (2012?) Applications Communication Preparation Launch
PHASE 4: Maintenance, Performance Improvement
47
Let’s be honest and acknowledge:
There is a desire to maintain autonomy – by EMS, hospitals.
Politics will play a role in discussions. There is market competition at hand.
Some physicians are reluctant to adhere to guidelines (i.e., administer tPA).
The “b” word: Bypass.
48
In Sum
Our overall public health goal is to reduce the burden of stroke.
We know primary prevention is key; we know rehabilitation is key.
This effort is focused on the middle piece – what happens when EMS is called and when patients arrive at the hospital.
The goal is that every patient, regardless of location, should have the opportunity to receive the same high quality of care anywhere in the state.
49
Discussion
Questions, Concerns
Meeting Format Webinar/Teleconference: any changes? Schedule/Timeframe Suggestions for process
What information/data do you want or need going forward?
50
Next Steps
Get meetings on your calendar
Visit website (www.health.state.mn.us/cvh)
Review materials
Provide comments and questions – email, online, mail, phone
Attend and participate in meetings
