HOUSE BILL NO. 27 "An Act relating to medical care for major emergencies." 2:21:23 PM REPRESENTATIVE GENEVIEVE MINA, SPONSOR, introduced the bill by reading from prepared remarks: Thank you for hearing HB 27, Major Medical Emergencies The goal of HB 27 is to modernize Alaska's system for Emergency Medical Services (EMS) by including strokes and heart attacks. Why bring the bill forward? I introduced this in the last legislature after convos with physicians and EMS providers who identified a gap in Alaska's EMS system. Background In the 1960s, with high rates of injuries and deaths from car accidents, public health leaders and policymakers developed America's EMS system to focus on pre-hospital care. A strong EMS system, rather than just the ER care, is important for preventing lives through the "Golden Hour," a crucial amount of time to ensure that someone after a traumatic injury could avoid death by getting to the "right person, to the right place, at the right time. As part of this movement, the state created the Alaska Office of EMS. The office developed Alaska's trauma system of care in the 90s by coordinating public and private agencies, funding agencies through pass-through grants, and developing training and protocols. What is a system of care? It is creating a network for phases of stroke care between prehospital care, transport, treatment to home, and supporting hospitals and clinics. They also designate certified trauma centers, ensuring that hospitals meet state and national standards for different levels of trauma. Modern EMS and the focus on the "golden hour" has evolved beyond trauma. Issue: We have no system of care for other time- sensitive, medical emergencies, specifically strokes and heart attacks. In 2022, 744 Alaskans died from trauma, 217 died from strokes, and 510 died from cardiovascular disease (such as a heart attack). Alaska has unique challenges in meeting "Golden Hour" due to rural Alaska and transportation issues, and standardizing best practices between clinics, hospitals, and EMS providers. There are now best practices and improved technology for STEMIs and strokes, as well as stroke centers and STEMI centers - but no one is coordinating Alaska's hospitals, provider organizations, and communities on improving their care. What does HB 27 do? HB 27 is very straightforward: it expands the Office of EMS' powers to replicate Alaska's trauma system of care, allowing the office to create a system of care for strokes and for heart attacks. Additionally, it allows EMS to replicate trauma designation process for strokes and STEMIs. At least 41 states have (or are finalizing) regional or statewide protocols that ensure patients experiencing a critical stroke such as ELVO are transported directly to Level 1 stroke centers. Impacts: The improvements in the trauma system of care reduced transfer time to meet the "Golden Hour." It improved outcomes where every single minute meant the difference between walking out of the hospital the next day or requiring 24 hour 7 day a week 24/7 care. Other improvements on outcomes focused on data collection and improving technology to transmit screenings and other technology between clinics and hospital. In addition, it will result in cost savings for the state by ensuring people receive the right care at the right time and preventing more drastic health outcomes. In Closing we cannot change when a patient arrives to a hospital. But we can improve the workflow to diagnose a case and make the decision-making process more efficient. b. HB 27 updates Alaska's EMS system and ensures that our state reflects modern EMS standards so that Alaskans experiencing a stroke or heart attack get to the "right person, to the right place, at the right time. 2:26:29 PM Co-Chair Foster wanted the committee to hear from invited testimony. BRIAN WEBB, SELF, ANCHORAGE, shared that he was a paramedic for over 47 years. He related that minutes mattered for trauma and medical emergencies and Emergency Medical Services (EMS) mut quickly respond and determine the correct facility to transport the patient. He pointed out that a statewide system was lacking for medical emergencies. There were no data registries, few facility designations, nor standardized protocols. The bill provided the structure necessary for better prevention, decisions, and outcomes. Since the passage of HB-168 [Trauma Care Centers/Fund, Chapter 98 SLA 10, 06/21/2010] in 2010, which established trauma centers and a trauma care fund, Alaska EMS had been better equipped to make critical transport decisions. The results enhanced our training and skills and enabled us to deliver trauma patients to the most appropriate facility and saved lives. The legislation addressed a critical gap in the treatment of major medical emergencies, particularly heart attacks and strokes, by offering a system of registry, standards, and voluntary facility registration. In addition, the legislation identified resource gaps, improved transport planning, and opened doors for planning partnerships improving the delivery of care by EMS. The voluntary facility designation not only benefitted hospitals it resulted in better outcomes and lowers death rates and disabilities. The bill's costs were minimal compared to the long term costs of disability and preventable deaths, which created significant saving "downstream." 2:29:32 PM LUCY HE, NEUROSURGEON, PROVIDENCE AND ALASKA REGIONAL HOSPITALS, ANCHORAGE, offered her testimony. She explained that Alaska was one of the few remaining states lacking any funding for time sensitive emergencies. The success of such programs elsewhere in the United States (US) with limitations such as that existed in Alaska had been demonstrated. The incidence of stroke in Alaska was the same as in the Southeastern US but Alaska had very limited resources. The resources for stroke recovery and prevention remained significantly underfunded and the main limitation was identifying the patients as early as possible in the field and creating a coordinated and efficient system of transfer. She continued that without guidance from the Department of Health (DOH) and the resources to track the data the state could not improve its response. She observed that the Alaska native population was prone to aneurism ruptures. However, there was no data regarding patient care remaining in or leaving the state in those instances. The state's most recent report on stroke care in Alaska was published in 2019 referencing 2016 data. She reported that DOH acknowledged that there was a significant gap in data. She continued that DOH along with the Alaska Stroke Coalition collaborated on acquiring Coverdell Grants [Paul Coverdell Forensic Science Improvement Grants Program (the Coverdell program)]. The grants were denied because the state lacked a formalized system for tracking stroke care. The state needed additional resources and funding in order to evolve a program. She emphasized the importance of rapid correct diagnosis and intervention due to insufficient recovery, outpatient, and therapy resources. She offered a statistic that by 2030 the global economic impact of strokes would reach $1 trillion. She stressed the importance of treatment, prevention, and decreasing stroke risk. She urged support for the bill. 2:33:32 PM Representative Johnson thought that the bill was a good idea. She encouraged DOH to look to vacant positions to reduce the cost of the bill versus adding a position. She noted that the fiscal note added a range 20 position. GENE WISEMAN, SECTION CHIEF, RURAL AND COMMUNITY HEALTH, DEPARTMENT OF PUBLIC HEALTH, ANCHORAGE, asked for Representative Johnson to repeat the question. Representative Johnson obliged and reiterated the question. Mr. Wiseman deferred the answer to a colleague in DOH. Representative Mina answered that it was a good question. She communicated that in discussions with the department, she discovered that there was a gap in statute concerning the state's system of care. She determined that there was a need from the state's health professionals. She wanted to help address filling the one position through a vacancy. 2:36:59 PM Representative Bynum wanted a better understanding how the bill would improve care in the state. He noted that in many communities there were limited places where emergency victims could go. In those instances where there was one regional hospital, the patient would be evaluated a flown out to another facility if necessary. He wondered how adding a position at the state level would accomplish the goal of the bill and inquired about the position's workload. Representative Mina responded that the legislation was about improving the EMS system overall and especially for rural communities that would benefit the most. She deferred further answer to Mr. Webb who had worked closely with Alaska's EMS system. She also suggested that Dr. He address the specific gaps in stroke care and how a system of care would benefit responders and providers. Representative Bynum repeated the question. He was trying to understand how creating the position would create benefits to remote communities who were trained at the local level on addressing strokes and heart attacks that he believed received a "high focus" with rural responders. In addition, was the bill focused on places with large populations in the state. 2:41:12 PM Mr. Wiseman replied that the position would replicate DOH's trauma systems. He elaborated that under Rural Community Health Systems the office of EMS and the trauma unit were paired together. The Trauma systems unit had two employees; one managed the Trauma Registry data base. The data base manager convened committees of hospital subject matter experts and from the EMS system to build the coordinated care approach. The hospitals voluntarily entered their data into the registry to create a statewide overview and track patients and outcomes better. The trauma systems unit only had two employees who were extremely busy and one additional employee to track additional data would be necessary. Additionally, coordinating the committees and site visits for certification was time consuming. The objective was to analyze the data for care coordination at a systems of care state level approach. He emphasized the amount of work necessary to produce a systemic change. Representative Galvin referenced that 41 other states had the same proposed coordinated approach. She asked how other states approached implementing the system. She wondered whether hospitals had a coordinated approach or if it was truly best accomplished through the state. Representative Mina deferred to Dr. He who had experience in setting up the coordinated approach. 2:45:32 PM Dr. He responded that Hawaii was the best example of an EMS statewide system that utilized both via a Hawaii Statewide Stroke coalition that brought together most hospital clinicians. The state tracked stroke data in coordination with the stroke coalition. She described why both was necessary. She indicated that as a clinician, she and other clinicians reviewed cases of transfers which helped to determine the outcomes and what worked best or did not work at one facility or another and decided who provided better interventions for specific issues. She relayed an example from Hawaii of coordinated state and hospital data and how it determined the best interventions to help shorten transport time to the right facility. She offered that the data helped Hawaii EMS in recognizing how long transport times were and how to shorten it. She elucidated that it was outside Alaska hospital purview to mandate they examine the efficiency of patient transport and would be unable to manifest changes unless statewide protocols were in place. She emphasized that coordination between the state and hospitals was essential. She shared that in states with successful EMS systems they had both a DOH tracking system and the clinical providers that worked together to integrate what was happening in the field and identifying the gaps. She discussed issues with sharing stroke imaging statewide and believed that state involvement could help find a better solution. The success in improving stroke care with the proposed paradigm was dependent on the state and clinicians working together to improve patient care and outcomes. 2:49:17 PM Co-Chair Josephson wanted to understand the "Golden Hour" concept better. He understood that time was of the essence for stoke victims for the administration of reverse clotting agents for a successful recovery. He wondered whether part of the bill was to try to get reverse clotting agents to people in the field in small rural areas. He asked whether the bill only entailed coordination or would there be a component for training and providing new medical treatment opportunities in smaller hospitals. Representative Mina replied that supplying clot busting drugs and medical services was different than coordination and providing training. She deferred the answer to Mr. Webb. Co-Chair Foster noted that Mr. Webb was no longer online. Representative Mina requested hearing from Mr. Wiseman. Mr. Wiseman asked for clarification on the question. Co- Chair Josephson understood elements of the bill. He asked if another element of the legislation was to get treatment modalities in rural areas for rapid response and better outcomes for the patient. Mr. Wiseman answered that the golden hour timeframes were different for stroke and heart attacks. He spoke to enhanced training for pre-hospital providers for heart attack recognition and mitigation. He elaborated that it was not the same for stroke, which needed imaging to determine the cause. The statewide coordinated training would be developed for heart attacks and strokes to ensure the right determination under protocol for where a patient should be sent for trauma care and treatment. He provided an example regarding a stroke victim in a rural community where pre-hospital providers would determine the right hospital to medivac the patient to. 2:55:56 PM Co-Chair Josephson asked if the training and coordination would be with sub-regional clinics and clinics in villages. Mr. Wiseman responded in the affirmative. The coordinating committees would set baseline protocols and there would be associated training to support austere clinics in rural settings to respond appropriately. However, he was unsure whether a stroke patient could be handled in a community like Dutch Harbor. He deferred further answer to Dr. He. Dr. He relayed that she agreed with Mr. Wiseman. She shared from personal experience that in the prior summer there were several patients that experienced massive strokes on cruise ships. She focused on one patient where the cruise ship responders identified the problem and wanted to get the patient to the closest hospital for administration of clot busting drugs. The medication must be administered within four and one half hours after the event. The EMS providers on the scene recognized that the patient might need additional intervention known as a clot retrieval, which was only done in Anchorage. The patient was transferred to a hospital in Southeast Alaska and received imaging and clot busting medication in time. However, the imaging also showed the patient was a candidate for clot intervention. The patient had to wait for yet another flight crew to be transferred, which led to a significant delay. She concluded that coordinating and improving efficient transfers and consistency of care mattered the most utilizing the most efficient process by which to triage and determine the appropriate facility. She noted that the situation was a classic example and the tracked data, if in place, could provide solutions by looking at it in a larger context and identifying patterns. She suggested that one solution could utilize "on hold" medivac services. She exemplified another case where a stroke patient needing clot intervention was transferred 3 times over 13 hours. The delay was significant because 2 million brain cells die per minute. Even cutting the time in half could produce a better outcome for the patient. She emphasized that for patients in rural areas coordination mattered much more than in urban areas. 3:00:54 PM Representative Stapp hypothesized a scenario where someone had a heart attack in Unakleet and was not transferred to Norton Sound Health Corporation in Nome but was transported directly to Anchorage. He could not understand why someone would be diverted to a rural health clinic prior to going to Anchorage regarding a major medical emergency. He shared from personal experience working with a dozen Alaska Native health corporations that major emergencies were always transferred directly to Anchorage due to the corporations lacking the necessary trauma level care. He was not opposed to the bill, but he was confused how it would achieve the outcome because it was a voluntary program. He asked how the program would be effective. Representative Mina answered that it would need to be determined which hospital to send a patient directly to Anchorage to. If there was not a standard protocol, there would be a great reliance on the provider in the rural community where the emergency happened, they and might not have the same training as a licensed EMS professional. The standard of care helped provide more direction for rural areas where there was no coordination to know which specific Anchorage hospital was appropriate. Representative Mina addressed his concerns regarding the voluntary element of the bill. She communicated that there was difference between each provider having its own internal protocols versus having the providers working with each other on where to transfer patients. She deferred to Mr. Wiseman to speak to creating a standard system of care versus none at all. 3:05:23 PM Mr. Wiseman responded that the statute was set up for the trauma system in a way the voluntary nature spoke to the hospitals themselves.He expounded that whether they wanted to participate and become certified as a Level IV to Level II trauma center was a voluntary program in the state. The department determined that carrying the same voluntary nature to a stroke or heart attack center would replicate for the EMS program as well. The vast majority of hospitals had become trauma centers over the years on a voluntary basis. The hospitals increased their in-house training and capabilities to meet the trauma center standard. Representative Stapp asked Dr. He whether regional Native Health corporations could currently treat a heart attack or stroke. Dr. He answered that it depended. She related that they had the diagnostic imaging capabilities and clot busting medicines, but for higher level intervention the patient had to be transported to Anchorage. An EKG could be tested or sent easily but stroke imaging could not be transferred quickly. She elaborated that the EMS crew determined whether the patient had to transfer directly to Anchorage, and it was not necessary for every shore patient. Even if a facility had clot busting medications, the patient needed to be at an ICU level of nursing care according to current standards and had to transfer somewhere else after they were administered the clot busting drugs. Most of the small clinics do not have the ability. She described further complications with strokes and clot busting drugs and pointed to the varied issues that arise. Representative Stapp asked who would make the decision as to where victims were transferred. He wondered who would have the standardized information to decide. He experienced that currently responders erred on the side of caution and sent the patient directly to a major hospital. Dr. He responded that the EMS first responder would be the most appropriate person to make the call. She furthered that other symptoms make it difficult to delineate a stroke in the field, like hallucinations making appear it was substance issues. Therefore, training and resources for pre-hospital staff would be very helpful. Lacking the tracking data regarding patients with strokes, gaps could be identified and more efficient decisions regarding care could be made. 3:12:24 PM Representative Stapp asked if the data would be available after the fact through the Heath Information Exchange (HIE) after the fact. DR. He responded in the negative. Mr. Wiseman reviewed the published fiscal impact note from DOH (FN 1(DOH) appropriated to Public Health for Emergency Response. He reported that the $240.6 thousand was to accomplish the objectives of the bill that would require one additional full time position in the trauma systems unit within the Division of Public Health. The position would support coordination of multiple stakeholder committees to build a process. Additionally, funding for (Information Technology) IT systems enhancements will be required to implement tracking and reporting of heart attack and stroke. Co-Chair Foster interjected that the fund sources were; Federal Receipts at $28.9 thousand and G/F match in UGF was $211.7 totaling $240.6 thousand. Representative Bynum described that in Southeast Alaska a patient requiring major medical care was automatically flown out. He voiced that there were already systems in place that accomplished getting someone to care. He asked what the reach of regulatory components would be given the fact that the healthcare institutions were already heavily regulated. He cited AS 18.08.200 (14) and noted that it currently read, "immediate medical surgical intervention or treatment to prevent death or permanent disability." He inquired how the current definition did not meet the requirement for heart attack or stroke. Representative Mina replied that there was a difference between regulations and creating guidance and protocols for the best standards of care for the state's EMS system. She voiced that the authority for DOH to create the standard of care would not exist without the inclusion of heart attack or stroke in the definition in statute. She deferred to Mr. Wiseman to speak to the current authority of the Office of EMS and haw it related to regulations for healthcare facilities and why the current statute did not include heart attack or stroke. 3:18:15 PM Mr. Wiseman answered that in the current statute AS 18.08 related to EMS and trauma care. He indicated that trauma care was added in 2010, because a system of care needed to be developed and focus on a system of care. It gave the department a higher level of authority to focus on the issue of trauma care systems. He spoke to the importance of data and how the system was built on the data viewed from a high level and the provider committee process to establish the standards. The current set of EMS standards focused on the pre-hospital level of care. He announced that DOH's authority to establish the EMS systems of care approach was currently non-existent as the original statute was not sufficient to develop a trauma system prior to its inclusion in 2010. He spoke to coordination regarding cruise ship passengers. He offered that the Coast Guard had to lift approximately 219 patients off the ships to transfer them to care and they needed to be involved as well as private providers. He voiced that currently there was no statewide approach. Representative Johnson commented that she would like to see some letters of support from stakeholders other than from paramedics, LifeMed Alaska, LLC or EMS providers who would be directly impacted. She guessed that there might be a protocol in place already. She thought it might become a mandatory system for providers. She was not sure how it would impact insurance companies. She voiced that she wanted to hear from someone in the other body who had medical experience. She hoped for more information in general. 3:23:34 PM Representative Jimmie described how medical emergencies were handled in the remote part of Alaska she lived in. Ultimately, some were evacuated through LifeMed. She was aware from experience that the LifeMed responders made the treatment decisions. Representative Tomaszewski asked how many specialty hospitals were in Alaska. Mr. Wiseman replied that there were 15 level 4 trauma centers, 1 level 3 trauma center, and 2 level 2 trauma centers in the state. He was unable to answer what level of specialty care was available in receiving centers. Representative Tomaszewski pointed to the sponsor statement and wondered whether the hospital had adopted the national criteria for EMS system of care. He read from the sponsor statement: "HB 27 will ensure that the receiving specialty hospitals meet DOH-adopted national criteria for being a voluntary stroke or heart attack center." He asked whether DOH had adopted the national criteria. Mr. Wiseman replied that the national criteria DOH had adopted was from the American College of Surgeons, which established the current system of care and provided credential for facilities. He elucidated that there were other national accrediting bodies that a hospital could participate in. Representative Tomaszewski stated that the objective of the bill was to establish criterion that all hospitals in the state follow so everyone was "on the same page." Mr. Wiseman responded in the affirmative and added that it depended on if the hospital voluntarily wanted the certification to become a stroke or heart attack center. The department would identify the national entity that would be used to establish the standards. Representative Tomaszewski inquired what the outcome of volunteering to be a specialty hospital would mean for the facility. Mr. Wiseman replied that he was unsure what the financial impact on the hospital to obtain the certification was. The certification would help the patient be directed to the right provider for care. Representative Tomaszewski asked if there were any hospitals in the state that had adopted the national criteria to be a heart attack or stroke center. Mr. Wiseman deferred the answer to Dr. He. The department did not currently track the information. 3:30:40 PM Representative Bynum noted that the current statute required trauma care. He inquired whether DOH was already doing all it wanted for stroke and heart attack and was doing all it wanted for all other traumas except for stroke and heart attack. Representative Mina replied that the state did have a robust system of trauma care but lacked a robust system of care for heart attacks and strokes. She asked Mr. Wiseman to confirm her statement. Mr. Wiseman asked for the question to be repeated. Representative Bynum complied. Mr. Wiseman responded in the affirmative. He elaborated that in the trauma system there was a statewide trauma registry that almost every hospital participated in and entered its data so outcomes could be tracked. The trauma systems review committee had published several guidelines for certain types of trauma and protocols were produced statewide. HB 27 was HEARD and HELD in committee for further consideration. Co-Chair Foster discussed future meetings.