House Bill 1790, sponsored by Rep. Robert Wayne Cooper, creates a "Time Critical Diagnosis System" for stroke and ST-elevation myocardial infarction (STEMI), a particularly fatal type of heart attack. Missouri is the first state in the nation to enact legislation governing a STEMI and stroke statewide system of care.Well, since this is D2B time is now a tracked "Pay-for-Performance" measure, I guess it's not surprising that we're circling our wagons and spending countless hours to fufill the government's expectations. But the data upon all of this wild excitement rests is based on "hospital door" to "balloon" time, not "patient's door" to "balloon" time. Doctors still need time to assess the complexities of social situations and confounding medical issues. Should a patient with widely disseminated cancer who also has an acute heart attack recieve similar "life-saving" resources? Further, one wonders how much more administrative and bureaucratic overhead our healthcare system can handle for this one initiative. What about the patients already in the ER waiting to be seen? It goes without saying that the administrative complexities of this system are sure to be stunning. Just look at all of the bureaucratic planning:
The health department has already been preparing the state to implement a system of stroke and STEMI centers. A Time Critical Diagnosis Task Force that was formed by the department in November has been meeting to discuss how to build the new system. The task force included more than 100 members of the emergency medicine community.The first question to be answered by the Task Force should be this: when have 100 people in a committee ever fully agreed on anything?
With appropriate training and oversight there is not much reason for ED involvement in this. We spend a ridiculous amout on trauma activation by EMS (activation that often by-passes the ED) that has less than 10 percent of the trauma alerts emergently going to the OR. The whole justification for the trauma system was the "Golden Hour" from injury to surgery. A lot of places manage with level 3 trauma centers - staff not on the premises, but on-call. Similar arrangements can be made for cath lab availability. Trauma centers receive supplemental funding to offset costs.
The portion of EMS STEMI alerts being cathed is over 90 percent. Compare that to less than 10 percent of trauma alert patients in surgery emergently. Clearly, there is a lot of time to be saved in most systems. Some are already doing this and doing it well.
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