Welcome. EMS Medicine Live. March 2016

Transcription

1

2 Welcome EMS Medicine Live March 2016

3 EMS Medicine Live Course Directors Christian Knutsen, MD, MPH Derek Cooney, MD Brian Clemency, DO

4 EMS Medicine Live Vision Community & Academic EMS Physician Education Information Sharing Board Preparation Group involvement Meet and see our peers Involve your unique experiences and skills

5 EMS Medicine Live Zoom During presentation Everyone will be muted Chat questions to EMS Medicine Live to be answered either during or at the end of the presentation Raise hand virtually in chat window

6 EMS Medicine Live Zoom Recording Previous Presentations Just google EMS Medicine Live First link is our web page Second link is Facebook page

7 EMS Medicine Live Zoom Questions Questions at the end Unmute yourself to ask a question or Message Knutsen if you have a question and I ll ask for questions in order.

8 Today s Presenter: Christian Martin-Gill, MD University of Pittsburgh Assistant Professor of Emergency Medicine Associate Director of EMS Fellowship Associate Medical Director, UPMC Prehospital Care Associate Medical Director, STAT MedEvac

9 Regionalization in Emergency Care: Past, Present, and Future Christian Martin-Gill, MD, MPH Assistant Professor of Emergency Medicine University of Pittsburgh Associate Medical Director STAT MedEvac & UPMC Prehospital Care

10 Disclosures No conflicts of interest

11 Outline What is regionalization? Benefits and Challenges with regionalization Key areas of regionalization Past: Trauma Present: STEMI, Cardiac arrest, Stroke Future: Sepsis and other critical care

12 Regionalization The creation of regional systems of care to manage medical conditions that: 1. Require resources not available at all facilities 2. Have improved outcomes at specialized centers 3. Are associated with costs that are better managed at a regional level

13 Why Regionalize? Higher level of care Specialty services not available at other sites Improved care at higher volume sites Improved outcomes

14 Why Regionalize? On-Call Shortage Cost Economies of scale Unreimbursed care

15 Regionalization in Other Industries Coca-Cola Distribution Center Paducahky, KY Walmart Distribution Center Temple, TX Amazon.com Distribution Center Swansea, UK

16 Regionalization in Disaster Management Carolinas MED-1 Deployable hospital Cost: $4 million 2 OR beds, 4 ICUs, 8 exam rooms 130 beds when fully deployed

17 Poison Centers

18 Pediatric Hospitals Children s Hospital of Pittsburgh of UPMC Children s Hospital of Philadelphia

19 Regionalization Models Trauma STEMI Cardiac arrest Stroke Others?

20 The Past ( or established) TRAUMA

21 Development of Trauma Systems Have been under development for the past 45 years Vietnam war highlighted need for standardized trauma care in the U.S. Accidental Death and Disability: The Neglected Disease of Modern Society (1966) White paper from the National Academy of Sciences, Committee on Trauma and Committee on Shock Highlighted need for standardized care in trauma and EMS

22 The Government and Others Act Federal Highway Safety Act of 1966 Promoted uniform guidelines for EMS management of highway crashes Led to the establishment of organizations aimed at enhancing trauma care Early Care of the Injured Patient (American College of Surgeons, 1972) Established the initial approach for trauma patient management Emergency Medical Services Systems Act of 1973 Funded the development of EMS and trauma systems in the U.S. Advanced Trauma Life Support Course established (1980) Provided a priority-based framework that organized initial trauma resuscitation and injury management

23 The Trauma Centers of Today

24 Do trauma centers improve care? Systematic reviews & meta-analyses: Celso, J Trauma 2006 Overall quality-weighted OR was 0.85 lower mortality following trauma system implementation 15% reduction in mortality in favor of the presence of a trauma system (Lansink, Curr Opin Crit Care 2007) Mortality was reduced by 15-25% when severely injured patients were treated at a trauma center

25 Is it better to transport directly? Direct transport within an organized state trauma system reduces mortality in patients with severe traumatic brain injury (Hartl, J Trauma 2006) Evaluated 1,123 patients with severe TBI (GCS<9) treated at 22 trauma centers in New York State. Direct transport was associated with 50% lower mortality than indirect transport. Transport mode, time to admission, and prehospital intubation were not found to be related to 2-week mortality.

26 Trauma Systems Summary The evidence suggests: Improved outcomes for severely injured trauma patients treated at Level I & II Trauma Centers Higher likelihood of independent functioning if treated at Level I & II Trauma Centers for most trauma classes Reduced mortality for TBI patients treated at Level I & II Trauma Centers Better to transport directly

27 Regionalization The Present ACUTE MYOCARDIAL INFARCTION (STEMI)

28 Management of Acute Coronary Syndrome (Kereiakes, Am Heart Hosp J 2008) 7-fold higher number of deaths from ACS than from all-cause trauma in the U.S. PCI has demonstrated significant reduction in death and disability compared to thrombolytics for STEMI The benefits of PCI for STEMI are time-dependent and risk of dying increases significantly with every 30-minute increment from chest pain onset until the artery is opened American College of Cardiology recommends door-toballoon times of <90 minutes, but only 30-40% of STEMI patients receive treatment within this time period.

29 Specialized Centers for STEMI For patients admitted to community hospitals without PCI availability who require transport for PCI (Nallamothu, Circulation 2005) Average total DTB time is ~3 hours Only 4.2% of patients are treated within 90 minutes 80% of the U.S. adult population lives within 60 min. ground transport from an existing PCI center (Nallamothu, Circulation 2006) Implementation strategies that increase the number of patients with timely access to PCI could save ~4000 lives annually (Jacobs, Circulation 2006)

30 Onsite Cardiac Surgery and PCI C-PORT Trial (Aversano, JAMA 2002) 11 community hospitals with PCI and no CT surgery Treatment with PCI versus Thrombolytics At 6 months, ppci group had: Reduction in composite end point (12.4%v vs 19.9%, p = 0.03) Reduced median length of stay (4.5 vs 6.0 days, p = 0.02) C-PORT-E Trial (Aversano, NEJM 2012) PCI at hospitals with or without CT surgery was non-inferior Wennberg (JAMA 2004) Patients with PCI at hospitals without onsite cardiac surgery: More likely to die (6.0% vs 3.3%, OR 1.29, 95%CI ) Increased mortality primarily confined to hospitals performing 50 PCIs per year

31 STEMI Center: More than PCI? A systems approach with integration of prehospital 12-lead capabilities and early activation of the cath lab significantly decreases DTB times (by minutes) Increased PCI volume at facilities has been associated with improved outcomes (Snider, Cardiol Clin 2006)

32 Proposed Criteria for Level 1 Heart Attack Center (Kereiakes, Am Heart Hosp J 2008) 24-hour cardiac catheterization lab availability 24-hour cardiothoracic surgery availability >200 PCI patients/year (>36 STEMI) >75 PCI patients/year per interventional cardiologist EMS integration with prehospital 12-lead transmission Standardized protocols for referral and receiving hospitals Quality assurance program

33 Economic Considerations Local hospitals have potential to lose revenue PCI procedures significantly impacts a hospital s operating margin Loss of PCI or cardiac surgical volumes could lower a hospital s case mix index, which could lower overall Medicare reimbursement Must have financial incentives within a regional hospital network for success

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36 STEMI Summary STEMI Centers must incorporate more than just PCI Need an integrated EMS system Volume-based criteria? Like trauma and stroke, need: Standardized protocols Quality improvement program

37 POST-CARDIAC ARREST CARE

38 Variability in cardiac arrest survival Nichol, JAMA fold regional variation in the outcome of OHCA patients within ROC Survival ranged from 3.0% to 16.3%, with a median of 8.4% Herlitz, Resuscitation 2006 Compared survival rates of OHCA patients admitted to Swedish hospitals Survival 1 month after cardiac arrest varied from 14% to 42% Carr, Resuscitation 2009 Multicenter clinical registry of ICU post-cardiac arrest patients After adjusting for age and severity of illness, institutional mortality ranged from 46% to 68% Liu, Prehosp Emerg Care 2008 Hospital survival rates ranged from 29% to 42% among 8 hospitals

39 Post-Cardiac Arrest Management Percutaneous Coronary Intervention (PCI) Spaulding, NJEM 1997 Early cardiac cath provided to all cardiac arrest survivors 71.4% had significant coronary artery disease 47.6% had coronary occlusions Successful angioplasty was an independent predictor of survival in post-cardiac arrest patients (OR 5.2) Reynolds, J Intensive Care Med 2009 Association between cath and good outcome (OR 2.16)

40 Post-Cardiac Arrest Management Standardized Protocols Sunde, Resuscitation 2007 Use of protocol associated with improvement in survival to discharge from 26% to 56% (OR 3.61) Neurological outcome and 1-year survival also improved Rittenberger, Resuscitation 2008 Before and after study of the implementation of protocoldriven plans for cardiac arrest, including use of therapeutic hypothermia TH use increased each year OHCA group: from 6% to 65% to 76% (p<0.001) IHCA group: from 0% to 36% to 53% (p=.02). Patients with OHCA and ventricular dysrhythmia were more likely to have a good outcome with TH treatment than without it (good outcome in 57% vs. 8%; p=.005).

41 Cardiac Arrest Care: Other Hospital Factors Associated With Outcomes Carr, Intensive Care Med 2009 Mortality was lower at: Large hospitals (OR 0.55, P<0.001) Urban hospitals (OR 0.63, P=0.004) Teaching hospitals (OR 0.58, P=0.001) Carr, Resuscitation 2009 Hospitals that treated more than 50 cardiac arrest patients per year had a significantly lower mortality than hospitals that treated fewer than 20 patients per year (OR 0.62, 95% CI ).

42 Post-Cardiac Arrest Care Today Local and regional health systems have specialized centers for cardiac arrest care Arizona Statewide Cardiac Arrest Reporting and Educational (SCHARE) Network New York City, NY (FDNY) Boston, MA Wake County, NC Requires involvement of local, regional, or state health departments

43 Next-Gen Cardiac Arrest Care Extracorporeal Life Support Resuscitation

44 Post-Cardiac Arrest Summary We can t stop at ROSC Hospital capabilities and practices are important More than just PCI and hypothermia Need further evidence to determine what criteria should define cardiac arrest centers We are getting better!

45 ACUTE STROKE

46 History of Stroke Care 1995 Tissue Plasminogen Activator (tpa) shown to improve outcomes for stroke patients when given within 3 hours of symptom onset 30% more likely to have minimal or no disability at 3 months 6% risk of intracranial hemorrhage Leads to the development and proliferation of Primary Stroke Centers

47 Establishment of Primary Stroke Centers Recommendations for the establishment of primary stroke centers. Brain Attack Coalition. (Alberts, JAMA 2000) Review of literature from (600+ articles) Identified key elements of primary stroke centers: Acute stroke teams Stroke units Written care protocols Integrated emergency response system Radiology and lab support Social services Administrative support Continuing education

48 Establishment of Primary Stroke Centers Expected benefits of primary stroke centers (Alberts, JAMA 2000) Improved efficiency of patient care Fewer peri-stroke complications Increased use of acute stroke therapies Reduced morbidity and mortality Improved long-term outcomes Reduced costs to health care system Increased patient satisfaction

49 Quality improvement in acute stroke: the New York State Stroke Center Designation Project (Gropen, Neurology 2006) Compared outcomes of stroke patients at 32 NYC hospitals In 4 stroke centers vs 11 nondesignated hospitals: Door to physician time: 10 vs 25 minutes (p < 0.001) Time to CT for potential t-pa candidates: 31 vs 40 minutes (p = NS) Time to t-pa administration: 95 vs 115 minutes (p < 0.05) Admission to stroke units: 55.9 vs 10.9% (p < 0.001)

50 History of Stroke Care 1999 ProACT II Study Intra-arterial tpa shown beneficial for stroke patients when given within 6 hours of symptom onset Early 2000 s SYNTHESIS, MR RESCUE, IMS III Multiple trials fail to show a benefit of intra-arterial tpa or 1 st generation clot retrievers For patients that can get IV tpa, endovascular procedure was not better than IV thrombolytics alone Interventional procedures continue to be performed, with development of new devices and new research trials 2012 First Comprehensive Stroke Center is certified MERCI Retriever device Penumbra Device

51 Comprehensive Stroke Centers In addition to requirements for PSC: Dedicated Neuro ICU beds 24/7 Advanced imaging capabilities 25 administration of IV tpa 20 subarachnoid hemorrhage patients per year 15 endovascular coiling or surgical clipping procedures for aneurysm Coordinate post hospital care for patients Peer review process for stroke and SAH patients Participate in stroke research

52 Primary vs. Comprehensive Stroke Centers

53 Specialized Stroke Services Specialized Stroke Services: A Meta-Analysis Comparing Three Models of Care (Foley, Cerebrovasc Dis 2007) Compared: 1. Acute stroke unit care 2. Units combining acute and rehabilitative care 3. Rehabilitation units All 3 models were associated with significant reductions in the odds of combined death and dependency compared to usual care Postacute stroke units were associated with greatest reduction in the odds of mortality (OR 0.60, 95% CI )

54 New Studies in Advanced Stroke Care 5 randomized controlled trials published since January 2015 All provide strong evidence of benefit of intra-arterial therapy for select stroke patients with large vessel occlusions Therapy largely guided by imaging All patients were eligible for thrombolytics if within window prior to intra-arterial therapy Studies: MR CLEAN ESCAPE* EXTEND-IA* REVASCAT* SWIFT PRIME* *ESCAPE, EXTEND-IA, REVASCAT, and SWIFT PRIME all stopped early due to substantial treatment effect

55 Manual Aspiration Suction with a 20 cc syringe

56 Second Generation Devices SOLITAIRE Revascularization Device 2012 approved by FDA SWIFT Trial demonstrated better 90 outcomes compared to the Merci Retriever

57 Every 30 minute delay in opening the blood vessel causes a 10% reduction in probability of a good outcome

58 2015 AHA/ASA Focused Update on Stroke Treatment

59 2015 AHA/ASA Focused Update on Stroke Treatment Recommendations on Endovascular Interventions: Patients eligible for IV r-tpa should receive it even if endovascular treatments are being considered Select patients should receive endovascular therapy with a stent retriever, based on certain criteria including: Time of symptom onset Degree of deficit Location of occlusion (internal carotid or proximal MCA) The sooner endovascular procedures are performed, the better the outcomes

60 Current recommendations for Regionalization of EMS patients with suspected stroke (SW Pennsylvania) If patient can arrive at a PSC within 3 hours of symptom onset, transport to closest PSC (consistent with state protocol) Can decide from there if IA eligible after tpa treatment, based on telestroke consult with tertiary center Neurologist If a suspected stroke patient cannot be transported to a PSC within 3 hours of symptoms onset, EMS should call medical command to discuss the most appropriate destination Medical command should direct patient to an interventional stroke center if: Pt can arrive at the ISC within 12 hours of symptoms onset Pt has a suspected large vessel occlusion (LVO)

61 Large Vessel Occlusion

62 Designed based on elements of the NIHSS Thought to be simpler to assess by field providers than a full NIHSS Not currently utilized by EMS providers in Pennsylvania, but elements of the RACE score could be used in consultation to assist the medical command physician in knowing if patient is likely to have large vessel occlusion

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64 RACE Score Score 5 Sens: 85% Spec: 65% for LVO

65 Regionalization of Stroke Center Summary Primary Stroke Centers improve: Door to physician times Utilization of t-pa Time to t-pa administration Admissions to stroke units Postacute stroke units associated with decreased mortality Interventional procedures beneficial for patients with large-vessel occlusion Transport to Comprehensive Stroke Center

66 Regionalization THE FUTURE?

67 REGIONALIZATION OF SEPSIS & CRITICAL CARE

68 Sepsis and Other Critical Care Time intensive Resource intensive Can benefit from protocols

69 Regionalization of Critical Care: Reasons for doing it (Kahn, Crit Care Med 2008) In-house intensivists improve survival in the ICU, yet only 10% of ICUs currently staff them There are not enough trained intensivists and few ICUs are fully staffed with physicians and staff trained in critical care Mortality for critically ill patients varies among hospitals Regionalization could lower costs and increase efficiency by creating economies of scale As with trauma and STEMI care, hospitals with high volumes of critical care patients have better outcomes

70 Barriers to Regionalization of Critical Care (Kahn, BMC Health Serv Res 2008) Critical care is less well defined than trauma, stroke, etc. Loss of revenue for referring physicians and hospitals Potential to worsen outcomes at small hospitals by limiting services Potential to overwhelm large hospitals Personal and economic strain on families

71 Solutions to Barriers to Regionalization of Critical Care (Kahn, BMC Health Serv Res 2008) Improving communication between destination and source hospitals Provider education Instituting voluntary objective criteria to become a designated referral center Mechanisms to feed back patients and revenue to source hospitals

72 WHAT ABOUT SEPSIS?

73 How common is sepsis in the ambulance? Severe sepsis N=480,000 EMS encounters, 10 yrs Linked to hospital data AMI & Stroke For every 4 patients admitted with AMI, EMS transports 10 admitted with severe sepsis Seymour et al., 2012, AJRCCM

74 Importance of time delays Controversial Recent meta-analysis in Crit Care Med 3% increase in odds of death for each hour delay in antibiotic administration after first medical contact by EMS Particularly among those with prehospital distress

75 How do we improve treatment delays?

76 How could we recognize patients? Combination of fever, low blood pressure, high RR, subjective appearance of being ill Challenges: Temperature measurement Paramedic knowledge and awareness Ease of use

77 How can we recognize septic patients? Prospective cohort study of prehospital biomarkers N=432 patients , 2 hospitals, Pittsburgh City EMS Cytokines, lactate, procalcitonin, troponin

78 What can we do for patients? Direct treatment (prehospital IVF, antibiotics?) Triage and choice of destination Advance notification to hospitals

79 Future Tools in Regionalization Lactate Tissue oximetry Carbon monoxide meters Hemoglobin level meters App for triage and destination selection

80 ThinkSepsis App

81 Sepsis Alerts Are Coming

82 Summary of Regionalized Care All acute care conditions may benefit from regionalized care Many challenges to implementation Keys are: Identifying the right patients Integrated EMS-Hospital systems Appropriate alerts and hospital response Substantial regionalization work continues

83 Questions?

84 EMS Medicine Live Questions?

85 EMS Medicine Live January March April May 2016 EML Schedule Christian Knutsen, SUNY Upstate, Less Lethal Weapons Christian Martin-Gill, UPMC, Regionalization of EMS Care Dan O Donnell, IU, Pediatric Mass Casualty Case Darren Braude, U New Mexico, Extraglottic Airway or Medication assistant airway management June July August September November December Mary Mercer, UCSF-SFHG, Mass Gathering Medicine Open Craig Cooley, UT San Antonio, Board Review Topic Chad Nesbit, Penn State, Mechanical CPR Devices Jeff Lubin, Penn State, Prehospital Hemostasis Open Last Tuesday of the month at 1 PM Eastern with flexibility for presenter