1. Emergency Medical Care-A Systems Approach
Bill Jermyn, DO, FACEP
11/10/2018
Bill Jermyn, DO, FACEP

2. A Little History
11/10/2018
Bill Jermyn, DO, FACEP

3. 1966
“Local political authorities have neglected their responsibility to provide optimal emergency services.”
“Adequate ambulance services are as much a municipal responsibility as firefighting and police services.”
“Emergency departments of hospitals are overcrowded, some are archaic….”
“…research in shock and trauma is inadequately supported.”
11/10/2018
Bill Jermyn, DO, FACEP

4. 1966
“Under medical leadership, national forums should be conducted at the highest levels on all subjects important to total emergency care from the time of receipt of an injury through rehabilitation.”
“The general public is insensitive to the magnitude of the problem of accidental death and injury.”
11/10/2018
Bill Jermyn, DO, FACEP

5. 1985
“The committee believes that injury is a public health problem whose toll is unacceptable. The time has come for the nation to address this problem—a problem that affects all Americans and one which an investment in research could yield an unprecedented public health return.”
11/10/2018
Bill Jermyn, DO, FACEP

6. 2001 “…emergency departments are overwhelmed ….”
“The problem is that the supply of care has been choked back.”
“…another could be to recognize emergency medical care as an essential public service, one that should be provided to every community….”
11/10/2018
Bill Jermyn, DO, FACEP

7. 2003
“Emergency Department crowding is not an issue that can be solved in the ED alone.Rather, it is a complex issue that reflects the broader health care market. It is clear that, as a key part of the health care safety net, ED’s in many of the nation’s largest cities are under strain.”
GAO
March 2003 HOSPITAL
EMERGENCY
DEPARTMENTS
Crowded Conditions
Vary among Hospitals
and Communities
GAO
11/10/2018
Bill Jermyn, DO, FACEP

8. January 2006
“Local emergency departments are at the front line of this national crisis.”
“…they must wait in emergency department hallways for hours and sometimes days.”
“…emergency medicine systems in many states are under extreme stress.”
‘Policymakers, physicians, and the general public should take note and take steps to address the shortcomings….”
The National Report Card on the State of Emergency Medicine
American College of Emergency Physicians
11/10/2018
Bill Jermyn, DO, FACEP

9. 14 June 2006
“…the nation’s emergency medical system is overburdened, underfunded, and highly fragmented….”
“This crisis is multifaceted and impacts every aspect of emergency care—from prehospital EMS to hospital-based and trauma care. The American public places its faith in the ability of the emergency care system to respond appropriately whenever and wherever a serious illness or injury occurs. But while the public is largely unaware of the crisis, it is real and growing.”
11/10/2018
Bill Jermyn, DO, FACEP

10. 1966-2006 40 years and nothing has changed!
This “crisis” affects 35% of our citizens every year
I’m tired of saying the same old thing. To get a different outcome, we have to change our approach
What do we need to do differently?
11/10/2018
Bill Jermyn, DO, FACEP

11.
We must develop the political will to fundamentally change the system.
That change requires that we all have the same concept of an Emergency Medical Care System (EMCS).
You cannot develop political will if you don’t know what you’re selling.
11/10/2018
Bill Jermyn, DO, FACEP

12. 11/10/2018
Bill Jermyn, DO, FACEP

13. Silos and “Silo Mentality”
What Do We Have Now?
Silos and “Silo Mentality”
11/10/2018
Bill Jermyn, DO, FACEP

14. 11/10/2018
Bill Jermyn, DO, FACEP

15. Our current system evolved from individual, disparate components
Our current system evolved from individual, disparate components. Therefore, it isn’t surprising that they operate and think separately—in their own silo. The only entity that examines all of the care provided is the hapless patient.
11/10/2018
Bill Jermyn, DO, FACEP

16. A Little Perspective
11/10/2018
Bill Jermyn, DO, FACEP

17. 11/10/2018
Bill Jermyn, DO, FACEP

18. Missouri 2004 1.75 Million ED visits (35% of population)
500,000 ambulance transports (10% of population)
Unknown number of “non-transport” ambulance calls– Depending on the service, this varies from 5-40% additional volume
11/10/2018
Bill Jermyn, DO, FACEP

19. FY 2006-A Tale of Two (MO) Cities
FY 2006-A Tale of Two (MO) Cities *-Does not include grants or special taxes
$22.4 Million
Police Department*
$16.3 Million
$15.1 Million
Fire Department*
$11.5 Million
$3.7 Million
Communications Center*
$2.4 Million
$41.2 Million
Total
$30.2 Million $0
Emergency Medical Care Services
11/10/2018
Bill Jermyn, DO, FACEP

20. Trauma System Funding-2007
Missouri
(0.4 FTE) $20,000
Kansas
$600,000
Iowa ?
Minnesota
$352,000
Nebraska
$3-400,000
Illinois
$14,000,000
Arkansas
Proposed bill would provide: $20-30,000,000
Oklahoma
$24,000,000
Texas
$67,000,000
11/10/2018
Bill Jermyn, DO, FACEP

21. Efficiency Model
Since the 1970’s, we have expected the medical care system to be efficient and have little excess capacity
The problem is that the emergency medical care system was lumped into the model
“Piece work” reimbursement
Unintended consequence is little ability to increase capacity/surge
11/10/2018
Bill Jermyn, DO, FACEP

22. What Happened?
Since 1986, move to outpatient therapy and earlier discharges from the hospital (HMO’s, PPO’s, etc)
Result was fewer hospital beds
Community Hospitals:
1975: 424 beds/100,000 population
2003: 280 beds/100,000 population
11/10/2018
Bill Jermyn, DO, FACEP

23. What Happened?
: Hospitals lost 103,000 inpatient medical/surgical beds and 7,800 ICU beds nationally.
: ED visits increased by 26% (90 to 114 million/year) while the number of ED’s dropped by 14%.
This has significantly increased the patient load of the remaining facilities.
11/10/2018
Bill Jermyn, DO, FACEP

24. What Do We Have Now?
Day to day capacity is strained-crowding and ambulance diversion (every minute of every day)
Boarding of admitted patients in the ED, ED crowding, and ambulance diversion
Rehab and Long Term care constraints restrict hospital discharges
National problem
11/10/2018
Bill Jermyn, DO, FACEP

25. What Do We Have Now?
2003 ACEP survey: 80% respondents said their ED’s lacked surge capacity because of crowding, boarding, and a lack of on-call specialists
The shift to outpatient therapy has severely taxed our ability to respond when the system fails
11/10/2018
Bill Jermyn, DO, FACEP

26. Why? Healthcare is not funded for surge capacity.
Encouraged to be 100% efficient.
We need to develop a way to assist the emergency portion with their ability to surge properly.
11/10/2018
Bill Jermyn, DO, FACEP

27. Take Home Medical system at capacity daily
There is little integration or coordination of the overall system
There is even less funding for the system
There is no overall plan for what we want
11/10/2018
Bill Jermyn, DO, FACEP

28. What Are The Potential Savings? Hard to Quantify
11/10/2018
Bill Jermyn, DO, FACEP

29. 11/10/2018
Bill Jermyn, DO, FACEP

30. 11/10/2018
Bill Jermyn, DO, FACEP

31. Traffic Related Deaths
Year
Setting
Number
Total
2004
(2000 Census Pop)
Rural
(1,714,078)
816
Urban
(3,881,133)
214
1,030
2005
901
208
1,109 (est.)
11/10/2018
Bill Jermyn, DO, FACEP

32. Traffic Related Deaths
Year
Setting
Number
Total
2004
(2000 Census Pop)
Rural
(1,714,078)
816
Urban
(3,881,133)
214
1,030
2005
901
208
1,109 (est.)
11/10/2018
Bill Jermyn, DO, FACEP

33. 1. Why is the rural MVC death rate increased by a factor of 10. (5
1. Why is the rural MVC death rate increased by a factor of 10? (5.4/100K vs. 52.6/100K) 2. Should we be proactive about Automatic Crash Notification? 3. Should we work on inappropriate care? 4. Can MO CALS affect this?
11/10/2018
Bill Jermyn, DO, FACEP

34. 2003 MICA (MO Information for Community Assessment) Data
Diagnosis
ED Visits
Hospital Discharge
Inpatient Days
Total Hospital Charges (millions of dollars)
Deaths
Acute Myocardial Infarction
2,054
16,386
87,572
587.8
5,098
Coronary Atherosclerosis, et al
3,725
25,784
89,906
777.6
6,060
Nonspecific Chest Pain
43,459
18,312
33,432
168.4
Cardiac Dysrhythmia
12,508
14,245
49,360
254.4
Cardiac Arrest and VF
3,107
369
2,040
16.3
Acute Cerebrovascular Disease
1,758
12,345
78,385
275.6
3,556
Transient Cerebral Ischemia
2,790
4,228
12,278
48.9
All Injuries (total n= 613,167)
571,816
41,351
850.1
1,210
MVC (total n=89,673)
81,017
8,656
51,223
273.6
980
11/10/2018
Bill Jermyn, DO, FACEP

35. In 2003: For Ischemic Heart/Brain Disease, and Trauma; 8 Diagnoses: Total charges are $3 Billion!
11/10/2018
Bill Jermyn, DO, FACEP

36. If we can improve care and decrease charges only by 0
If we can improve care and decrease charges only by 0.5% (1/200), it is a savings of $15 million per year. And this is just acute care hospitalization charges! What about long term care savings?
11/10/2018
Bill Jermyn, DO, FACEP

37. 2003 Missouri Deaths MVC 980 All other accidents/adverse effects 1,441
Stroke/TIA
3,556
Heart Disease
16,310
Total above/all deaths
22,287 / 55,195
11/10/2018
Bill Jermyn, DO, FACEP

38. 2003 Missouri Deaths 1% of these four diagnoses is 223 lives saved.
A high performance system should be able to improve more than 1%!
MO CALS
tPA for stroke
Primary PCI or lytics for STEMI
Timely Trauma Triage
11/10/2018
Bill Jermyn, DO, FACEP

39. Time Critical Diagnosis System
Three diagnoses; sick trauma, stroke, STEMI- The “Big Three”
Right patient, right place, right time, right care
Expand the current trauma system to include strokes and STEMI’s.
Not TIA’s, all strokes, NSTEMI’s, UA or chest pain, minor traumas
11/10/2018
Bill Jermyn, DO, FACEP

40. Time Critical Diagnosis System
We have clear evidence that timely and appropriate treatment of these three diagnoses can improve patient outcomes. (20:80 rule)
Small numbers of patients--patients who would be transferred to a regional center anyway so it doesn’t threaten the CAH’s.
A focus on symptom onset to definitive care
11/10/2018
Bill Jermyn, DO, FACEP

41. Case Example-2 It Can Work
Location: Rural county- 22 miles out
1050 hrs: Middle aged male develops chest pain
PMH: HTN
1051: Call received
1054: Alert dispatcher activates ground and air by the criteria we have all agreed upon through SAC
11/10/2018
Bill Jermyn, DO, FACEP

42. Case Example-2 1121: Air crew arrives at patient side
1130: Depart scene-12 lead shows inferior ST-Elevation Myocardial Infarction (STEMI)
Enroute, standard care administered, and hospital notified
1158: Arrive hospital
Cardiologist meets patient in ED, brief exam, and transfer to cath lab
11/10/2018
Bill Jermyn, DO, FACEP

43. Case Example-2 Cath team has cleared a table prospectively
1225 Needle time
1235 Lesion time
1237 Balloon time
LOS -2 days!
Post cath EF >50%
11/10/2018
Bill Jermyn, DO, FACEP

44. Case Example-2 Savings Acute: 1-2 days on LOS, $5-15,000
Long Term: Who knows how many hundreds of thousands of dollars? We saved the function of a patient who is back at work as a productive member of society instead of on disability. Estimated total health care expenditures on disability for 30 years is $345,000.00
11/10/2018
Bill Jermyn, DO, FACEP

45. Think About These Points
This case demonstrates what can happen when we all work together.
A patient had a symptom onset to balloon time of 107 minutes—from rural Missouri!
Outstanding!
11/10/2018
Bill Jermyn, DO, FACEP