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Development of the Minnesota Acute Stroke Transport and Treatment System

Development of the Minnesota Acute Stroke Transport and Treatment System. Minnesota Acute Stroke System Council Webinar March 30 and 31, 2011. 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.

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Development of the Minnesota Acute Stroke Transport and Treatment System

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  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 HealthAlbert.tsai@state.mn.us (651) 201-5413 • James Peacock, PhD, MPH Minnesota Department of HealthJames.peacock@state.mn.us (651) 201-5405 • Justin Bell, JD American Heart Associationjustin.bell@heart.org (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

  5. What is a stroke system approach? • A stroke system approach involves coordination of stroke care along the entire continuum from primary prevention through rehabilitation.

  6. Stroke Care System • Should provide both patients and providers with the tools necessary to promote effective stroke prevention, treatment, and rehabilitation • Should identify and address potential obstacles • Should be customized to each state, region or locality

  7. Overarching Systems Coordination (ideal state) A “body” exists to oversee stroke system at the state level Key stakeholders are identified Regular meetings occur Shared agenda is created, stakeholders agree on opportunities and next steps for improvement

  8. Overarching Systems Coordination (continued) Mechanism exists to monitor and evaluate system The best interest of the stroke patient is held as highest objective Geo-political boundaries, corporate affiliations and political maneuvering should be minimized

  9. Notification/Response of EMS(ideal state) Processes are in place that facilitate rapid access to EMS EMS dispatch uses the most current stroke triage recommendations EMS responders are dispatched at the highest-level emergency response All patients with signs or symptoms are transported to nearest appropriate stroke center

  10. Notification/Response of EMS(continued) ED Drs are involved with stroke experts to develop: EMS stroke education materials Assessment, treatment and transport protocols for EMS providers EMS personnel can perform assessments & screening of patient for hyper-acute interventions

  11. Acute Treatment for Stroke Strategies exist for hospitals not seeking stroke center status to ensure they have action plans to triage, treatment (or transport) stroke patients.

  12. Sub-Acute Stroke Care & Secondary Prevention(ideal state) Stroke teams, stroke units and protocols (organized approaches) are in place All patients with a history of stroke are provided secondary prevention education addressing all major modifiable risk factors

  13. Sub-Acute Stroke Care & Secondary Prevention(continued) Stroke patients & families receive education on risk factors, warning signs & how to activate EMS Smooth transition exists from inpatient to outpatient care

  14. Stroke Systems of Care (big picture) • Primary prevention • Public awareness • Emergency Medical Services • Acute treatment • Sub-acute treatment • Rehabilitation, Recovery, and Secondary Prevention

  15. Context Acute Stroke System

  16. Implementing or maintaining statewide or regional system Developing a statewide or regional system in 2011-2012 Stroke Systems of Care: A National Movement Source: State Stroke Systems Program Survey, 2010. Survey of HDSP Program Managers, Cardiovascular Health Council, National Association of Chronic Disease Directors.

  17. Models from other states • Utah • Washington • Massachusetts • Many differences…but many common themes

  18. 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

  19. 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.

  20. Deaths in Minnesota, 2009 Source: Minnesota Department of Health Center for Health Statistics, web portal (accessed 3/9/2011)

  21. Hospitalizations • Pregnancy, childbirth, and newborn infants • Pneumonia • Congestive heart failure • Coronary artery disease • Osteoarthritis • Non-specific chest pain • Mood disorders • Cardiac dysrhythmias • Septicemia • Intervertebral disc and spine problems • Acute myocardial infarction • Acute stroke • Chronic obstructive pulmonary disease Source: Healthcare Cost and Utilization Project - HCUP Facts and Figures: Statistics on Hospital-Based Care in the United States, 2007http://www.hcup-us.ahrq.gov/reports/factsandfigures/2007/pdfs/section2_1.pdf

  22. Why an acute stroke system? • Location of strokes • Long drive times to stroke centers • Potential for all hospitals to improve

  23. Minnesota Stroke Hospitalizations, 2008 Source: Minnesota Hospital Uniform Billing Claims Data, Health Economics Program, Minnesota Department of Health and Minnesota Hospital Association.

  24. 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.

  25. Why a stroke system? • Location of strokes • Long drive times to stroke centers • Potential for all hospitals to improve

  26. Goal: Stroke Onset to Treatment < 180 minutes 60 minutes 60 minutes 60 minutes On Scene to Dx: ASAP Onset to recognition + 9-1-1: ASAP Door to Image: 25 min EMS to Scene On Scene to Hospital: 60 min Door to Needle: 60 min RECOGNITION & EMS TO SCENE TRIAGE & TRANSPORT DIAGNOSIS & TREATMENT

  27. Proximity to Urban Areas for Zip Codes with High Senior Populations Grand Forks Duluth Fargo Legend US Census Bureau Urban Areas St. Cloud County Boundaries 20% or more 65 yrs + Minneapolis-St. Paul La Crosse Rochester Sioux Falls Population Data: 2007 Population estimates by Zip Code, ESRI Drive Times: WWAMI Rural Health Resource Center

  28. Why an acute stroke system? • Location of strokes • Long drive times to stroke centers • Potential for all hospitals to improve

  29. Hospital Readiness • So a lot of patients go to rural facilities…are they ready?

  30. 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

  31. 24/7 CT scan availability for • rapid diagnosis • 100% in 6 regions • Great than 80% in all regions

  32. Dedicated team for stroke • improves rapid triage and • treatment • Over 90% in Metro and Southwest • Only 60% - 67% in Central, South Central,and West Central • 50% in Northwest

  33. Protocols for ischemic stroke • improve rapid triage and • treatment • Over 90% in Metro and Southwest • 60% - 67% in Northeast and West Central • 50% in South Central

  34. 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

  35. 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

  36. 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.

  37. Summary: Why a stroke system? • 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 building • Most ischemic stroke patients are not getting the best therapy (combination of public awareness and health system issues) • 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

  38. 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

  39. 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

  40. 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

  41. How do we create a system? • Convene statewide advisory council to develop system plan • Based on current national standards • Designed to fit Minnesota’s needs • Implement the plan/system

  42. 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

  43. 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

  44. 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

  45. 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.

  46. 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.

  47. Discussion • Questions, Concerns • Meeting Format • Webinar/Teleconference: any changes? • Schedule/Timeframe • Suggestions for process • What information/data do you want or need going forward?

  48. 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

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