e g iona liza tion Re inve nting r R ic a rdo Ma rtine z, MD Bre nda n G. Ca rr, MD MS sity E mor y Unive r University of Pennsylvania
Disc lo sure s • Carr – Federal research funding • AHRQ, NICHD, CDC, NINDS – Foundation research funding • NRCPR/GWTG – ASPR Policy Research Fellow • IPA in process • Martinez – Former President, Schumacher Group Division East – Chairman, Medical Sports Group
What is regionalization? • the organization of a system for the delivery of health care within a region to avoid costly duplication of services and to ensure availability of essential services. – Mosby’s medical dictionary
What is regionalization? • The purpose of regionalization is to concentrate limited or expensive health care services locally within an area while dispersing primary and secondary care more broadly. • The Parkland plan
What is regionalization? • A method of providing high-quality, cost- efficient health care to the largest number of patients, by sharing information, avoiding duplication of services, improving resource allocation, and capitalizing on economies of scale.
Overview • The Trauma System • Volume & Outcome • Time & Outcome • The Emergency Care “System” • Taking it to scale • Reinventing regionalization • Where are we now?
Accidental Death & Disability • “The patient must be transported to the emergency department best prepared for his particular problem…Hospital emergency departments should be surveyed…to determine the numbers and types of emergency facilities necessary to provide optimal emergency treatment for the occupants of each region….” I OM – 1966
T ra uma Ca re – A Syste m System - A complex unit formed of many often diverse parts subject to a common plan or serving a common purpose
The Rule Book(s)
The Trauma Model – Inventory
Access to trauma care
The Trauma Model - Outcomes
Overview • The Trauma System • Volume & Outcome • Time & Outcome • The Emergency Care “System” • Taking it to scale • Reinventing regionalization • Where are we now?
Regionalization of Surgical Care •12 surg ic a l pro c e dure s CABG, AAA, T URP, e tc . •1500 ho spita ls Mortality Proc e dure s =
The Volume-Outcome Relationship
Regionalized Elective Care • CABG (public reporting) • Neonatal ICU (high risk pregnancy) • Cardiac Care Center • Cancer Centers • Vascular Surgery (Leapfrog Group) • ICU care (Leapfrog Group)
Overview • The Trauma System • Volume & Outcome • Time & Outcome • The Emergency Care “System” • Taking it to scale • Reinventing regionalization • Where are we now?
STEMI
Sepsis
ime T Volume
Overview • The Trauma System • Volume & Outcome • Time & Outcome • The Emergency Care “System” • Taking it to scale • Reinventing regionalization • Where are we now?
ACEP Report Card
Future of Emergency Care • …e sta blish a (ne w) le a d a g e nc y fo r e me rg e nc y a nd tra uma c a re • …prima ry pro g ra mmatic re spo nsibility fo r the full c o ntinuum o f e me rg e nc y me dic al se rvic e s a nd e me rg e nc y a nd tra uma c a re fo r a dults a nd c hildre n • …inc luding me dic al 9-1-1 a nd e me rg e nc y me dic al dispa tc h, pre ho spita l E MS, a nd ho spital b a se d e me rg e nc y a nd tra uma
Future of Emergency Care • …de ve lo p e vide nc e -b ase d c a te g o rizatio n syste ms fo r E MS, e me rg e nc y de pa rtme nts, a nd tra uma c e nte rs b a se d o n … c a pa b ilitie s • …e sta blish a de mo nstratio n pro g ra m … to pro mo te c o o rdinate d, re g io na lize d, a nd a c c o untab le e me rg e nc y c a re syste ms…
IOM Recommendation: Regionalize emergency care
Institute of Medicine • Regionalizing Emergency Care Systems Sept.10-11, 2009
What is an Emergency Department?
Emergency Care - Inventory
E me rg e nc y me dic ine o rg a niza tio ns sho uld “ re vise the c la ssific a tio n o f e me rg e nc y de pa rtme nts . . . to re fle c t the le ve l o f c a re a va ila b le …a nd indic a te whe the r o r no t fa c ilitie s a re a de q ua te …24 ho urs a da y.’ ’ June 1999
Emergency Care - Categorization g o e t al, A c ad EM 2007 C amar
Pennsylvania & Wisconsin Emergency Departments 249/ 301 EDs (82.7% r e spo nse r ate )
Disease based regionalization?
Disease based regionalization?
Disease based regionalization?
The Emergency care “system”?
Overview • EM in perspective • Volume & Outcome • Time & Outcome • The Emergency Care “System” • Taking it to scale? • Reinventing regionalization • Where are we now?
STEMI
STEMI 30+% of ST E MI pa tie nts g e t no re pe rfusion the ra py
3% of isc he mic stroke s tre ate d at T JC c e rtifie d c e nte rs 3-8.5% re c e ive rt-PA
Sepsis
Sepsis 5-7% of E Ds pe r for m E GDT
26% of physic ia ns ha ve use d hypothe r mia
The New Jersey STEMI “system”
Va ria b ility in OHCA o utc o me s Survival after out of hospital Vfib arrest 45 40 % survival to discharge 35 30 25 20 15 10 5 0 Iowa Toronto Vancouver Alabama Dallas Milwaukee Ottawa Portland Pittsburgh Seattle City
Ho spita l c ha ra c te ristic s & o utc o me s
Regionalizing Emergency Care Workshop Sept 10, 2009 •Broad-based stakeholders –private, fed/state/local government, Public health, academic. •Little progress since 2006 Report. •Looking for consensus and strategies to move regionalization forward •Multiple views – modern and traditional •Workshop report published in December, 2009
Where are we now? Where do we want to go? How will we get there?
When focus has its drawbacks…. When focus kills…
Model Drives Adoption • Driving force of regionalization since 1970’s: – Get the right patient to the right place at the right time
Where are we now? • Current model: – Designed for low frequency, high impact events – Changed the world! – Led to many improvements in patient care! – Frustratingly low uptake in market – Current format may not meet emerging and future needs
TERTIARY/URBAN • EM trained physicians • Specialist consultants • Interventions/equipment SUBURBAN SMALL SUBURBAN/LARGER RURAL • Non- EM physicians • Scarcity of specialist • Less resources SMALLER RURAL
Acuity at Arrival (TRIAGE) • Resuscitative 5.1% • Emergent 10.8% • Urgent 36.6% • Semi-Urgent 22.0% • Non-Urgent 12.1%
Most Frequent Chief Complaints • Abdominal Pain • Chest Pain • Fever • Headache • Injury High frequency, moderate impact
Financial “Health” • Economics of Transfers – On patient – On local facility – On local providers – On community Is this even measured??
• EM trained physicians TERTIARY/URBAN • Specialist consultants • Interventions/equipment SUBURBAN SMALL SUBURBAN/LARGER RURAL • Non- EM physicians • Scarcity of specialist • Less resources SMALLER RURAL
Attributes of Quality Health Care • Patient-centered “ Crossing the Quality Chasm” • Safe - Institute of Medicine, 2001 • Effective • Efficient • Timely • Equitable Can be measured at patient, provider, facility and systems level
Six Redesign Imperatives • Reengineered care processes • Effective Use of Information Technologies • Knowledge and skills management • Development of effective teams • Coordination of care across patient conditions, services, and sites of care over time
What is the “market” saying? Maybe the model is wrong. Change the model!
Challenges • Time, distance, geography • Restricted access to information • Workforce shortages – provider/caregivers • Maldistribution of provides and resources • Aging population • Growth in patients with chronic disease • Access to primary care limited Stibilit f dl
Opportunities • Lots of redundancies and resources – Helicopters, beds, ICUs, specialties.. • Technologies can leverage our ability to scale cognitive resources and integrate others • Move to electronic data, images and records • Growth of high-speed data and voice connections/Internet • Move toward quality and value-based payments
Resources • Equipment/technology – fixed – Move patient to • Procedural skills – fixed – Move patient to • Cognitive skills – mobile – Move to patient
Electronic Collaboration Connecting … providers patients resources “Integration and Collaboration”
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