Missouri is the first state in the
nation to comprehensively
integrate the common
processes involved in the medical
treatment of time-critical conditions.
Legislated by Missouri House Bill 1790,
the state’s Time Critical Diagnosis
(TCD) statute is designed to ensure
the timely and appropriate emergency
medical treatment for people who
suffer trauma, stroke and the potentially
fatal form of heart attack known
as STEMI (ST-segment elevation
myocardial infarction).
In Missouri, the idea behind TCD was
initially proposed by John William
Jermyn III, DO, a Barnes-Jewish
Hospital emergency physician, the first
emergency medical services (EMS)
director for the state of Missouri and
an EMS advocate.
“It is widely known in Missouri that
Dr. Jermyn was the champion for
the TCD system,” says David Tan,
MD, medical director of Washington
University EMS. “Unfortunately, the
legislation passed one day after Bill
died, but without his work and passion
for improving emergency medicine,
this would not have come about.”
The TCD statute passed in July 2008,
but regulations that will mandate
how TCD is implemented are still
being considered. “The plan and
the hope is that they will be passed
in 2013,” says Brian Froelke, MD,
Washington University emergency
medicine physician at Barnes-Jewish
Hospital. “A huge benefit of the bill is
that it’s a living document, allowing
the regulations to be updated as the
practice of medicine changes.”
The Missouri Department of Health
and Senior Services has issued the following statement about TCD
and its impact: “The TCD system
represents the continuum of services,
beginning with public education
about prevention, recognition of signs
and symptoms, and the importance
of immediately seeking care. It then
circles through the series of system
components to emphasize evidencebased
and best practices for incident
recognition, first aid, 911 access,
response coordination, prehospital
response, transport, emergency
department care, acute medical
care and rehabilitation. Finally, it
incorporates quality-improvement
processes through the system.”
TCD’s goal is to ensure patients are
transported to a hospital that has the
equipment and infrastructure to offer
the best outcome. “It makes sense
to transport patients with emergent
conditions another four minutes so
they will have access to the specialized
care they need,” says Bill Warsing,
CCEMTP, PNCCT, lead paramedic,
specialty care transport, with Abbott
EMS/AMR. He is dual-licensed in
Missouri and Illinois and has been a
paramedic for 15 years.
Warsing explains that before TCD, the
law simply required that a patient be
taken to the closest hospital. “Many
patients thought that a hospital was a
hospital; that you would get the same
care no matter where you went.”
But as health care has become
increasingly advanced and procedures
more complex, a one-size-fits-all
attitude can be costly to the patient.
Once the new TCD system is enacted,
hospitals will be designated as trauma,
stroke and STEMI centers by the state
of Missouri and, by law, patients with
these conditions may be taken to these
recognized centers.
In fact, some area hospitals already have
been designated as trauma, stroke and
STEMI centers. Barnes-Jewish Hospital
was first nationally recognized as a
Level I trauma center by the American
College of Surgeons in 1996 and has
maintained that verification ever since.
According to Froelke, TCD also
provides a framework for transfers so
that stroke and STEMI patients don’t
have to wait the usual two-and-a-half
hours for a transfer from a hospital that
is not equipped to expedite their care.
“Having lost my father to a stroke, I
regard TCD in a very personal way,”
says Tan. “The crucial link to survival
is prehospital care–knowing the signs
for these conditions, knowing what
to do and where to take the patient.
There is a reason that the state’s slogan
for TCD is ‘Right care. Right place.
Right time.’”