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Development of theMinnesota Acute Stroke Transport and Treatment System

Minnesota Acute Stroke System Council Webinar

March 30 and 31, 2011

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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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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

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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

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Stroke Systems of Care (big picture)

Primary prevention Public awareness Emergency Medical Services Acute treatment Sub-acute treatment Rehabilitation, Recovery, and Secondary

Prevention

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Context

Acute Stroke System

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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.

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Models from other states

Utah Washington Massachusetts

Many differences…but many common themes

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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

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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.

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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)

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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

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Why an acute stroke system?

Location of strokes Long drive times to stroke centers Potential for all hospitals to improve

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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.

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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.

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Why a stroke system?

Location of strokes Long drive times to stroke centers Potential for all hospitals to improve

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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%

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Why an acute stroke system?

Location of strokes Long drive times to stroke centers Potential for all hospitals to improve

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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

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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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.

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Discussion

Questions, Concerns

Meeting Format Webinar/Teleconference: any changes? Schedule/Timeframe Suggestions for process

What information/data do you want or need going forward?

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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