04/20/2015
Time Critical Diagnoses
How We Got Here
Marc Borenstein, MD, FACEP, FACP
Professor, Chair, and Program Director
Department of Emergency Medicine
U of Missouri School of Medicine
Learning Objectives
Participants will have an awareness of the
history of TCD
Participants will have an understanding of the
importance of TDC in Missouri
Participants will have an appreciation for the
importance of communication and teamwork in
TCD
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
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Facts: MO Trauma
Death rates unintentional injuries ↑25% from
1991 to 2006
Death rates unintentional fall injuries ↑73%
during this time frame
Rural areas make timely access to trauma
centers challenging
Facts: MO Heart/STEMI
Heart disease leading cause of death
Heart/circulation disease cause of the highest
total in-patient charges, 4.2 billion in 2006
Heart disease death rate 13.5% higher than
national rate
Facts: MO Heart/STEMI
In bottom 10 states in coronary heart disease
death rates
9th of 50 states in heart disease prevalence
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Facts: MO Stroke
Death rates 11% higher than national rate
Tied at 5th of 50 states in stroke prevalence
In the bottom 10 of 50 in stroke death rates
Rural areas make timely access to stroke care
challenging
Historical Perspectives: MI/STEMI
1768 Heberden coins the term angina
1912 Herrick advised bed rest “several days”
became 2 – 3 weeks with 4 – 6 weeks
hospitalization
1928 Morphine prescribed for pain
1933 Streptokinase discovered
Historical Perspectives: MI/STEMI
1950s Oxygen, IVF, NTG, A/C Rx
1961 CCU introduced
1970s Mortality hospitalized patients decreased
from 30% to 15%
1975 – 79 1st use of intracoronary streptokinase
1984 – 86 GISSI trial over 11,000 patients
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Historical Perspectives: MI/STEMI
1974 Gruentzig coronary balloon angioplasty
1985 Palmaz – Schatz stent invented, FDA
approved 1994
1990s t-PA, ASA, anti-platelet agents
Mortality hospitalized patients decreased from
15% to 7.5%
Historical Perspectives: Stroke
1658 Johann Wepfer: Apoplexia
1664 Thomas Willis: Cerebri Anatome
1951 Wylie aortoiliac thromboendarterectomy
1951 Carrea, Molins, Murphy carotid end-to-end
anastamosis
1954 Eastcott, Pickering, Robb carotid end-toend anastamosis with induced hypothermia
Historical Perspectives: Stroke
1950s DeBakey carotid endarterectomy
1960s HTN identified as a risk factor for stroke
1970s CT scanning, ASA
1980s MRI, interventional neuro-radiology,
smoking identified as a risk factor for stroke
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Historical Perspectives: Stroke
1990s NINDS rt-PA study FDA appoval of t-PA
for stroke, microcoiling developed
2000s Thrombus removal
Historical Perspectives: Stroke
1972 Hounsfield’s CT scanner
Data collection 3-4 hrs, Reconstruction 2-3 days
Historical Perspectives: Trauma
1966 1st US civilian trauma unit Cook County
1967 Pantridge and Geddes Mobile ICU
1971 Designation of trauma centers by law
1976 ACS COT: Optimal Resources For the Care
of the Seriously Injured
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Historical Perspectives: Trauma
1976 Dr. Jim Styner air flight accident
1978 1st ATLS Course
1985 Injury in America A Continuing Public
Health Problem
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
2007-8 TCD Task Forces Stroke/STEMI, Trauma
TCD Project History
2008 Authorizing Legislation
2008-9 Time Critical Diagnosis stroke and
STEMI implementation teams
2009 ACS COT Review
2010 NHTSA Review
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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.
Why Time Critical Diagnosis Matters
Unlike trauma, ambulances often 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
Creating a Time Critical Diagnosis
System
The Solution:
The Right Care
at the
The Right Place
in the
The Right Time
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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 Regulations
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
Missouri Regulations
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
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Missouri Regulations
Stroke & STEMI
Data submission for statewide registry
Performance improvement and patient
safety requirements
Public education to promote prevention
and signs and symptoms awareness
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
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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
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
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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
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