What is a System of Care?
In September of 2017 the state was assessed, at our request, by a team put together by the National Highway Traffic Safety Administration (NHTSA). The State did very well in the assessment and that report has been released to the public. (If you didn’t get it, check the email address you have in the Continuum system. The state faired extremely well in most areas, and areas where recommendations were made we were aware we had some opportunities; there were no surprises. One of the areas evaluated were the systems of care, specifically our Trauma and Stroke Systems. It was recommended that we pursue legislation to create a cardiac system of care which is generally done before a stroke system in many states, but we have a good handle on it here so it’s never been addressed, yet.
The goal of a system of care is to ensure that all patients are rapidly identified, transported, or transferred in a timely fashion to a hospital that care provide the most appropriate level of care for the particular clinical situation. A system of care relies on many factors including education, transportation, evaluation, treatment, transfer — if necessary — and rehabilitation. A system of care can be local, regional, or state-wide, or may even cross state lines as we do here in South Carolina. We include many of our sister cities within our systems of care due to their proximity and often times higher levels of care available to our patients on this side of the border. If you don’t consider transportation to Savannah, Augusta, or Charlotte, you should if your patient can clinically benefit from the trip.
Systems of care, by definition have several layers to them, and should consider patient population, ability to sustain specific levels of care and a multitude of other factors. Building several higher level of care centers in a small geographic area in an attempt to capture market share should be avoided. In the end, patient loads may be distributed proportionately between them; however, no one team can become proficient without sufficient patient influx. Eventually the system will even itself out but often times at great expense to the hospital system itself and ultimately the patients. A well distributed system of multiple levels of care within the system is key to ensuring proper patient care and system efficiency. For the purpose of discussion today, we will use the South Carolina Stroke System of Care as an example, but the concepts remain basically the same for trauma and acute coronary care. I said basically; YES, there are certainly inherent differences between them, but the overall concepts are very similar.
What is the Right Formula for Building a State-Wide System of Care?
This is the easy part; said no one, ever! This is often the hardest part about building an efficient system of care. All too often the race to the top begins between hospitals and systems and rarely is consideration given on the front end as to what the entire system, regionally or state-wide, should look like. There is no magic formula as to how many Level One trauma centers or Comprehensive Stroke Centers one particular area can support. How far out should the next level center be? In what direction? Do we need one both north and south, or can we travel 20 minutes extra and make it across the county line to another care center? These are all questions we can’t answer. They MUST be considered on the front end of building any system and MUST have all the local players at the table.
Hospitals, 911 EMS agencies, Inter-facility EMS agencies, local governments, doctors, nurses, system of care specialists, and others should be brought together to help develop the system and concentrate on patient care, not market share. If you’re region is doing this, following these steps and others you may have the potential to put together a great regional system of care that will, in turn benefit the state and beyond. If you’re not, you’re probably following the same formula that a great majority of states do and it’s every person for themselves. If you’re region hasn’t yet begun planning for a stroke system of care, I encourage each of you as leaders in your particular field to get everyone around the table, buy some sandwiches and sodas, and work as a collective to benefit your populations. Only you can determine the right formula for your region.
OK, So We Have the Right Centers in the Right Areas; Now What?
Well to get to this point, you have probably knocked out a great deal of the other factors that should be considered in the development of a system of care, such as education, transportation, evaluation, treatment, transfer — if necessary — and rehabilitation. Education must take place when developing your system to identify tools that need to be used to identify patients that will benefit from your system. In the trauma system, we use the CDC Trauma Triage Guidelines, for stroke we use a triage and transport tool modeled closely after guidelines developed by the AHA Stroke Council, chaired by South Carolina’s own Dr. Ed Jauch. This triage tool is currently being used statewide and its use and score should reported on every suspected stroke patient transported to an ED. If you’re not using the Stroke Triage Tool, start tomorrow.
The transport portion of this tool will be mandatory for use one year from the effective date of the new Stroke Regulation, 61-118, or approximately July 2019. To recap, USE THE TRIAGE TOOL NOW, refer to the transport guidelines as your Medical Control Physician deems necessary, and be prepared to have the transport guidelines become “mandatory” in July 2019. The tool is an integration of a qualitative and quantitative tool. First, a quick stroke scale determines the patient may be having a stroke (Think FAST), once it has been determined the patient may be suffering from stroke related symptoms, then the quantitative tool kicks in (Think RACE) where a score is determined based on signs and symptoms. Any patient that scores greater than or equal to a 4 should be considered as highly probable for a Large Vessel Occlusion (LVO). If you haven’t been educated on these tools as of yet, ask your training officer to go over them with you ASAP. Reporting of these scores has been mandatory for some time now in South Carolina.
Once education has occurred — both at the EMS and ED levels — to recognize strokes and their severity, now we have to educate ourselves as to what hospitals offer what services, and how far away they are. (If the receiving facility has no idea what a RACE score is, the system isn’t working.)
One of the FIRST steps in a hospital obtaining certification as a stroke center at any level is to interact with local EMS. (Seriously, look it up in the Joint Commission standards.) If you can figure out a person is having a “bad” stroke, you also need to know where to take them. Here’s where I’ll save space and keep you in suspense; have you do some homework, if you will. Find the Transport Guidelines, read them closely, have a conversation about what stroke patient goes where NOW, not when they are in the back of your ambulance tomorrow. Transportation and recognition by EMS personnel is KEY in many strokes to survivability and quality of life of stroke patients. Don’t kid yourself, although you may not perform any high level treatment of a majority of stroke patients. You will save lives and brain by recognizing what is going on, declaring that emergency to the receiving ED, and rapidly transporting that patient to the correct facility.
Now the patient has been field diagnosed, transported to the appropriate level center, and turned over to the care team. Now what? Well, if your center of choice — or necessity — was a lower level of care than the patient needs — it happens, but should be the exception, not the rule — then rapid transfer out of that facility is needed. This is where our inter-facility, and in some rare cases, the 911 system needs to be ready to respond with critical care trained personnel to get this patient rapidly to a higher level of care. This could be by ground or air, but the fact remains that the rapid deployability and acceptance of these patients regardless of ability to pay needs to be the standard of care. The aforementioned NHTSA report also spoke of the need for private EMS to rapidly respond and transport these critical patients.
Now the patient is either at or has been transferred to the appropriate level of care. Treatment begins and whether that is a thrombectomy, the starting or continuing of IV thrombolytic care, or in some cases where time has become our enemy, we must simply wait and see the final damage, the patient is now in the hands of highly trained and disease specific professionals. This may be accomplished easier than you think. A patient who is exhibiting some stroke symptoms, but scores a 1 on the RACE score and is 30 or more minutes away from a designated stroke center, may be transported to your local telemedicine enabled center. Here the same professionals in Charleston, or Greenville, or Columbia can assist the ED physician via telemedicine and recommend appropriate courses of care based on patient presentation. Every patient does not need a Comprehensive center, but every patient deserves the proper level of care and evaluation by disease specific professionals.
The stroke system of care is undergoing significant evolution. There are promising data to suggest that with new technologies and approaches, primary prevention and community education will become easier and more accessible, and will allow people to have greater participation in their own outcomes. The evidence-based Acute Stroke Ready, Primary, Thrombectomy-Capable, and comprehensive stroke center concepts have been translated into robust, rapidly growing certification programs. The continued dissemination of our improved EMS routing protocols allows for better allocation of patients to stroke centers, even as we confront the challenge of further improving prehospital recognition of stroke. National quality improvement initiatives by the AHA and others help to ensure that patients directed to stroke centers receive evidence-based treatment, which has resulted in improved stroke care and better clinical outcomes. In South Carolina’s rural area, the use of telemedicine to extend the reach of neurologists has resulted in increased administration of time-sensitive thrombolytic therapy and better patient outcomes, although greater efficiency within our stroke system will likely be needed to realize the complete benefits of endovascular therapy, although early results are encouraging. Finally, further integration of rehabilitation programs into stroke centers and coordination with community-based rehabilitation services is needed to ensure the best possible outcome for our stroke patients.
Rob Wronski is the South Carolina Department of Health and Environmental Control (SC DHEC) Bureau Chief of EMS. He has served in many roles since becoming a firefighter paramedic in 1991, culminating with his selection as Chief of EMS for the state where he has served for nearly three years. He has held several executive positions including Assistant Chief of the St. Andrews Fire Department in Charleston, Medical Officer of the Mt. Pleasant Fire Department, and a Shift Commander in the Beach Park (IL) Fire Department. His experience includes working in fire-based EMS, including ALS and BLS first response as well as fire based and county based ALS transport.