Time critical diagnosis
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Time Critical Diagnosis. Rural-Urban Workgroup Samar Muzaffar, MD MPH . 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

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Time Critical Diagnosis

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Time critical diagnosis

Time Critical Diagnosis

Rural-Urban Workgroup

Samar Muzaffar, MD MPH


The public health model as a foundation

  • 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

The Public Health Model as a Foundation


The public health model as a foundation1

  • Missouri’s Key Guiding Principles

    • Patient centered care

    • Evidence-based system design

    • Population-based approach

    • Evaluation mechanism

The Public Health Model as a Foundation


The circle

The Circle


Epidemiology in missouri

Epidemiology in Missouri

Leading causes of death:

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


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.

  • Injuries account for the second highest total for inpatient hospital charges – $2 billion in 2006.

  • Compared to the entire United States, Missouri has

    • lower rates of emergency department visits for all three major categories of injuries – accidental, assault and self-inflicted

    • death rates from injuries that exceed the national rates for accidental injuries, suicides, falls, and motor vehicle injuries.

  • Missouri’s death rates for unintentional injuries have increased 25 percent between 1991 and 2006

  • There are gaps, particularly in rural areas of Missouri, for timely access to a trauma center.

TRAUMA


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.

Only a small percent of ischemic stroke patients get definitive care within the 3 hour window recommended.

STROKE


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.

STEMI


The trauma system as a model for time critical events

The Trauma System as a Model for Time Critical Events

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


  • Stroke1

    STROKE

    Prompt treatment reduces death and disability.

    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


    Stemi1

    STEMI

    Prompt treatment reduces death and disability.

    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


    Time critical diagnosis

    Implementation: Progress and Goals

    Developing the System:

    August 2008: TCD Stroke/STEMI Task Force compiled formal recommendations

    Sept.’08-May ‘11: TCD Trauma Task Force convened and compiled recommendations

    2008-Present: Stroke and STEMI Implementation groups met regularly and compiled standards for stroke and STEMI center designation and EMS


    Time critical diagnosis

    Rural and Urban System Work Group

    • Work Group:

      • Rural and Critical Access partners

      • Urban Partners

      • Pre-hospital and hospital

    • Discuss:

      • Shared Processes

      • Rural/Urban Coordination

    • Develop Shared Guidance


    Workgroup goals

    Workgroup Goals

    • Develop Rural/Urban understanding, collaboration, and coordination

    • Develop guidance for Trauma, Stroke and STEMI process in rural areas

      • Pre-hospital

      • Hospital

  • Develop guidance for coordination of interaction between rural and urban hospitals

  • Develop guidance for coordination of interaction between rural/urban pre-hospital


  • The end goal

    The End Goal:


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