COUNCIL OF THE DISTRICT OF COLUMBIA
COMMITTEE ON THE JUDICIARY AND PUBLIC SAFETY
DRAFT COMMITTEE REPORT
1350 Pennsylvania Avenue, NW, Washington, DC 20004
TO:
All Councilmembers
FROM:
Councilmember Tommy Wells, Chairperson
Committee on the Judiciary and Public Safety
DATE:
June 19, 2014
SUBJECT:
Report on Bill 20-327, “Stroke System of Care Act of 2014”
The Committee on the Judiciary and Public Safety, to which Bill 20-327, “Stroke System
of Care Act of 2014” was referred, reports favorably and recommends approval by the Council.
CONTENTS
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
Background And Need ...............................................................1
Legislative Chronology..............................................................4
Position Of The Executive .........................................................5
Comments Of Advisory Neighborhood Commissions ..............5
Summary Of Testimony and Statements ...................................5
Fiscal Impact ..............................................................................7
Section-By-Section Analysis .....................................................7
Committee Action ......................................................................7
Attachments ...............................................................................8
I.
BACKGROUND AND NEED
INTRODUCTION
Bill 20-327, the “Stroke System of Care Act of 2013” was introduced on June 6, 2013 by
Councilmembers Catania, Alexander, Wells, Grosso, and Chairman Mendelson. The bill was
jointly referred to the Committee on Health and the Committee on the Judiciary and Public
Safety. On October 29, 2013, the Committee on Health and the Committee on the Judiciary and
Public Safety held a joint hearing on the bill. A summary of the testimony provided at the
hearings, as well as other submitted statements, is found below in section V.
Bill 20-327 would give the Department of Health the ability to designate a hospital as a
primary stroke center ( “PSC”) or an accredited acute care hospital ( “AACH”) based on
accreditation standards set by The Joint Commission,1 or another nationally recognized
organization selected by the Department of Health. In addition, Bill 20-327 would authorize and
“The Joint Commission” is an independent, nonprofit standards-setting and accrediting organization, founded in
1951, that evaluates and accredits more than 20,000 health-care organizations and programs in the United States.
1
Committee on the Judiciary and Public Safety
DRAFT Report on Bill 20-123
June 19, 2014
Page 2 of 9
require the Department of Health to collect reported data on stroke care patients and procedures
in stroke care centers, based on nationally recognized guidelines.
The Committee made a few amendments to the introduced bill. The substantive changes
contained in the Committee Print are outlined in detail below.
BACKGROUND
Generally, a stroke or "brain attack" occurs when a blood clot blocks an artery (a blood
vessel that carries blood from the heart to the body) or a blood vessel (a tube through which the
blood moves through the body) breaks, interrupting blood flow to an area of the brain.
Strokes fall under two categories: ischemic strokes and hemorrhagic strokes. An ischemic stroke
occurs when arteries are blocked by blood clots or by the gradual build-up of plaque and other
fatty deposits. About 87% of strokes are ischemic.2 A hemorrhagic stroke occurs when a blood
vessel in the brain breaks leaking blood into the brain. Hemorrhagic strokes account for 13% of
all strokes, yet are responsible for more than 30% of all stroke deaths.3
When either of these types of strokes occurs, brain cells begin to die and brain damage
occurs. Approximately two million brain cells die every minute during a stroke; when this
happens, abilities controlled by that area of the brain are lost. These abilities may include speech,
movement and memory. How a stroke patient is affected depends on where the stroke occurs in
the brain and how much the brain is damaged. For example, someone who has a small stroke
may experience only minor problems, such as weakness of an arm or leg. People who have
larger strokes may be paralyzed on one side or lose their ability to speak. More than two-thirds of
survivors will have some type of disability.
A transient ischemic attack ( “TIA”) or “mini-stroke” is another condition that is similar
to a stroke. A TIA occurs if blood flow to a portion of the brain is blocked only for a short time.4
Thus, damage to the brain cells typically isn’t permanent. Like ischemic strokes, TIAs often are
caused by blood clots. Although TIAs are not full-blown strokes, they greatly increase the risk of
having a stroke. While a stroke can have detrimental physical effects on an individual, strokes
have shown to have a significant financial impact as well. The average lifetime cost of an
ischemic stroke in the United States is about $140,048.5 The estimated direct and indirect cost of
stroke in the United States in 2010 was $73.7 billion dollars.6
Feinleib M, Ingster L, Rosenberg H, Maurer J, Singh G, Kochanek K. “Time trends, cohort effects, and geographic
patterns in stroke mortality in the United States.” Ann Epidemiol
3
Available at: http://www.stroke.org/site/PageServer?pagename=stroke. (Accessed June 15, 2014).
4
Available at: http://www.nhlbi.nih.gov/health/health-topics/topics/stroke/. (Accessed June 15, 2014).
5
Taylor TN, Davis PH, Torner JC, Holmes J, Meyer JW, Jacobson MF. “Lifetime cost of stroke in the United
States.” Stroke. 1996; 27(9); 1459-1466
6
Available at: http://www.stroke.org/site/PageServer?pagename=stroke. (Accessed June 15, 2014).
2
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DRAFT Report on Bill 20-123
June 19, 2014
Page 3 of 9
Stroke Incidence Rate
Stroke is the fourth leading cause of death and a leading cause of disability among DC
residents.7 It affects people of all ages, gender, and race, and is the primary cause of disability in
the United States.8 However, statistics show that African Americans have almost twice the risk
of first-ever stroke compared with white Americans; approximately 55,000 more women than
men have a stroke each year.9 In 2009, 4.6% of adults living in the District had a stroke,
compared to 2.6% of adults nationally.10 DC falls within the “Stroke Belt”, a group of 10-12
southeastern states that demonstrate stroke death rates that are approximately 10% higher than
the rest of the nation.11
Implementation of a coordinated Stroke Care System in the District of Columbia
It is widely accepted in the medical community that public awareness of stroke, in
combination with rapid delivery of treatment, can save lives. Major advances have been made in
the past several decades in stroke prevention, treatment, and rehabilitation. However, despite
these successes, there are still significant obstacles that remain in translating these scientific
advances into clinical practice.
In 2011, the National Institute of Health (NIH) released a report through its Stroke
Disparities Program that evaluated stroke awareness and acute stroke care in the District, with a
focus on the African-American population.12 The report stated that although healthy volunteers
knew what to do hypothetically when experiencing stroke symptoms, these same volunteers
would not act accordingly when actually experiencing stroke symptoms, resulting in few patients
calling 9-1-1 immediately.13 This delay in getting to the hospital resulted in a delay of treatment,
which would exacerbate the damaging effects of the stroke.
Currently, the only FDA-approved treatment for acute stroke is Tissue Plasminogen
Activator (herein “tPA), which is most effective when given immediately after stroke symptoms
begin.14 Where tPA is administered within 90 minutes following the onset of stroke symptoms,
patients who receive care are three times as likely to have favorable outcomes. The 2011 NIH
report stated that in the District, blacks are one-third as likely as whites to receive tPA. The
obstacles that prevent timely care for District residents can be related to a fragmentation of
7
American Heart Association. District of Columbia Fact Sheet on Stroke (2012). Available at:
http://www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm_307159.pdf (Accessed
June 15, 2014).
8
Available at: http://www.stroke.org/site/PageServer?pagename=stroke . (Accessed June 15, 2014).
9
Available at: http://www.stroke.org/site/PageServer?pagename=stroke. (Accessed June 15, 2014).
10
, Written testimony of Jennifer Witten.
11
Wiley-Blackwell. "U.S. health: Cognitive decline incidence higher in southern Stroke Belt." ScienceDaily 26
May 2011. Available at: www.sciencedaily.com/releases/2011/05/110526102352.htm (Accessed June 15, 2014).
12
Hsia AW, Castle A, Wing KK. “Understanding Reasons for Delay in Seeking Acute Stroke Care in an
Underserved Urban Population. Stroke 2011. June 42(6): 1697-1701. (May 5, 2011)
13
Id.
14
http://www.webmd.com/stroke/tissue-plasminogen-activator-t-pa-for-stroke (Accessed June 15, 2014).
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DRAFT Report on Bill 20-123
June 19, 2014
Page 4 of 9
stroke-related care caused by inadequate integration of the various facilities, agencies, and
professionals that should be closely collaborating to provide stroke care.15
A stroke system should coordinate and promote patient access to the full range of
activities and services associated with stroke prevention, treatment, and rehabilitation.
Currently, hospitals, the American Heart Association, the American Stroke Association, and the
Fire and Emergency Medical Services (FEMS) voluntarily participate in a coordinated stroke
response effort called the DC Stroke Collaborative. This group meets on a regular basis to
discuss successful stroke programs, promote stroke education programs, and share stroke care
data, in order to advance stroke care in the District. The DC Stroke Collaborative began with
participation from three area hospitals, but has grown to include six of the District’s 10 hospitals.
The DC Stroke Collaborative has provided admirable service toward stroke prevention, but there
remains a need to implement a formal stroke care system that will coordinate care between
hospitals and agencies, create a data collection system to track effectiveness of stroke care, and
implement national standards to evaluate each hospital’s ability to provide timely and effective
stroke care.
Bill 20-327, as amended, would strengthen the role of the Department of Health to ensure
that health care systems run effectively based on national criteria of primary stroke centers and
accredited acute care hospitals established by the Joint Commission, or another nationally
accredited entity acceptable to the Department of Health.16 Additionally, the bill would allow the
Department of Health to collect aggregate data from FEMS and local hospitals in order to
evaluate aspects of clinical stroke care, coordination of care, and effects of relevant interventions
through the District in a timely manner.17 Lastly, the bill would standardize pre-hospital
protocols related to the assessment, treatment, and transport of stroke patients by licensed
emergency medical services in the District.
Building a strong stroke care system in the District is the next critical step in improving
patient outcomes in the prevention, treatment, and rehabilitation of stroke. The current
fragmented approach to stroke care in the District provides inadequate linkages and coordination
among the fundamental components of stroke care. Establishing a stroke care system that is
coordinated and on par with national standards should make significant contributions to
decreasing the burden of death and disability and improve the lives of stroke sufferers and their
families across the District.18
II.
June 06, 2013
15
LEGISLATIVE CHRONOLOGY
Bill 20-327, the “Stroke System of Care Act of 2013”, is introduced by
Councilmembers Catania, Alexander, Wells, Grosso, and Chairman
Mendelson.
See http://www.nhlbi.nih.gov/health/health-topics/topics/stroke/. (Accessed June 15, 2014).
Written testimony of Jennifer Witten .
17
Written testimony of Dr. Hsia .
18
Written testimony of Jennifer Witten.
16
Committee on the Judiciary and Public Safety
DRAFT Report on Bill 20-123
June 19, 2014
Page 5 of 9
June 18, 2013
Bill 20-327 is referred to the Committee on the Judiciary and Public
Safety.
June 14, 2013
Notice of Intent to act on Bill 20-327 is published in the District of
Columbia Register.
September 27, 2013 Notice of a Public Hearing is published in the District of Columbia
Register.
October 29, 2013
The Committee on the Judiciary and Public Safety holds a public hearing
on Bill 20-327.
June 19, 2014
The Committee on the Judiciary and Public Safety marks-up Bill 20-327.
III.
POSITION OF THE EXECUTIVE
Dr. Brian W. Amy, MD, MHA, MPH, FACPM, Senior Deputy Director, Public Safety
Division, Office of the Attorney General of the District of Columbia, testified on behalf of the
executive in support of Bill 20-409. Dr. Amy stated the bill will aid the District in the
coordination of stroke care among hospitals and emergency medical service providers. However,
Dr. Amy raised some concerns about the bill. Specifically, Dr. Amy stated that the bill as
introduced would require a patient suffering a stroke to be transported to the nearest PSC rather
than the nearest hospital, which could result in delayed treatment for the patient and remove
flexibility for the emergency service providers transporting the patient. Additionally, Dr. Amy
raised a concern about patient information remaining private under the data reporting
requirements of the bill. Dr. Amy stated the executive is supportive as long as the bill is in
compliance with patient confidentiality protections, including the Health Insurance Portability
and Accountability Act (HIPPA). Dr. Amy offered to work with the Committee and the stake
holders to ensure the bill is protective of patient information, but also effectively coordinates
stroke care in the District.
IV.
COMMENTS OF ADVISORY NEIGHBORHOOD COMMISSIONS
The Committee received no testimony or comments from Advisory Neighborhood
Commissions.
V.
SUMMARY OF TESTIMONY AND STATEMENTS
The Committee on the Judiciary and Public Safety held a joint public hearing with the
Committee on Health on Tuesday, October 29, 2013. The testimony summarized below is from
those hearings. A copy of the witness list is attached; the video recording of the hearing is
available at
http://oct.dc.gov/services/on_demand_video/on_demand_October_2013_week_5.shtm); and the
Hearing Record is on file with the Office of the Secretary.
Committee on the Judiciary and Public Safety
DRAFT Report on Bill 20-123
June 19, 2014
Page 6 of 9
Dr. Amie W. Hsia, Medical Director at Stroke Center MedStar Washington, testified that
stroke awareness and acute stroke care in the District is disconnected. She stated there is a great
need for targeted interventions in the community, and with a centralized database of patient
information, stakeholders will be able to better identify gaps in the stroke care system and
customize neighborhood interventions to these gaps. Dr. Hsia stated full support of the bill.
Jennifer Witten, Senior Government Relations Director at American Heart and Stroke
Association, testified that stroke has a debilitating effect on an individual’s life, as well as a
costly impact on the surrounding community and health care systems. Ms. Witten stated that
promoting national standards to evaluate the hospitals that provide stroke care is essential to
providing the best quality of care for the patient. She recommended the Committee move the bill
forward.
Kathleen Burger D.O., Director of Stroke Program at George Washington Hospital,
testified that George Washington Hospital was one of the founding members of the DC Stroke
Collaborative, and believes the bill will promote more specialized stroke care in the District .
Mary Cres Rodrigazo, BSN, RN, Stroke Program Coordinator, testified that any chance
to improve the coordination of emergency medical service providers, hospitals, stakeholders, and
the local communities will greatly improve the chances of stroke patients to receive timely and
effective care when needed. Additionally, Ms. Rodrigazo stated that specialized care for stroke
patients will be enhanced upon implementation of the bill.
DC Stroke Collaborative, submitted supplemental testimony that stated DOH would not
be responsive for surveying the hospitals periodically, as that task would fall to the Joint
Commission. The Collaborative further stated they do not feel that DOH would need additional
employees or funding to be able to implement the bill. Lastly, the Collaborative stated the
citywide database would be pulling information from HIPPA-compliant reports, therefore there
should be no concerns with patient privacy being violated.
Michael Augustus Lee, Public Witness, is in support of the bill and any efforts to bring
more government assistance to the community.
VI.
IMPACT ON EXISTING LAW
Bill 20-327 is a freestanding bill that would empower the Department of Health to
designate qualified hospitals as primary stroke centers or acute stroke capable centers. The bill
also includes sections on the designation of accredited acute care hospitals and primary stroke
centers by the Department of Health, revocation of the designation, the requirements for prehospital care protocol and training, as well as the continuous improvement of quality of care.
Committee on the Judiciary and Public Safety
DRAFT Report on Bill 20-123
VII.
June 19, 2014
Page 7 of 9
FISCAL IMPACT
The attached DATE Fiscal Impact Statement from the Chief Financial Officer states that
funds are sufficient to implement Bill 20-327. This legislation requires ______________
Committee on the Judiciary and Public Safety
DRAFT Report on Bill 20-123
VIII.
June 19, 2014
Page 8 of 9
SECTION-BY-SECTION ANALYSIS
Section 1
States the short title of the bill as the “Stroke System of Care Act of 2014”
Section 2
Defines accredited acute care hospitals, primary stroke care centers, and certifying
entities.
Section 3
States the requirements for applicant hospitals seeking designation from DC DOH
as an accredited acute care hospital or primary stroke care center
Section 4
States the requirements for suspension or revocation by DC DOH as an accredited
acute care hospital or primary stroke care center
Section 5
States that DC DOH must create and must publish a list of each ACCH and PSC
on its website within 180 days of implementation of the bill. FEMS must also
publish the list on its website.
Section 6
States that DC DOH and FEMS shall establish pre-hospital protocol and training
for the assessment, treatment, and transport of stroke patients by licensed
emergency medical service providers.
Section 7
States that DC DOH and FEMS shall establish a plan for achieving continuous
improvement in quality of care for stroke patients, including the creation of a
database of information and statistics of stroke patients .
Section 8
Subsection (a) states that information provided to DC DOH, FEMS, or the District
is confidential and not a public record, except for subsection (b).
Subsection (b) states that data compiled in aggregate form to establish a plan for
continuous quality of care under Section 7 is a public record, as long as it does not
reveal protected, confidential information
Section 9
States the Mayor has the power to issue rules to implement the provisions of this
act.
Section 10
States the Act shall apply upon the inclusion of its fiscal effect in an approved
budget and financial plan, as certified by the Chief Financial Officer to the Budget
Director of the Council in a certification published by the Council in the District
of Columbia register.
Section 11
Adopts the fiscal impact statement.
Section 12
Provides the effective date.
Committee on the Judiciary and Public Safety
DRAFT Report on Bill 20-123
IX.
June 19, 2014
Page 9 of 9
COMMITTEE ACTION
On June 19, 2014 the Committee met to consider Bill 20-327. The meeting was called to
order at __:__ _M, and Bill 20-327 was the _______ on the agenda. After ascertaining a quorum
(Chairperson Wells and Councilmembers ________ present), Chairperson Wells moved the
report, with leave for staff to make technical, editorial, and conforming changes. After an
opportunity for discussion, the vote to approve the report was _______ ( ). Chairperson Wells
then moved the print, with leave for staff and the General Counsel to make technical and
conforming changes.
Councilmember ______began the discussion . . .
After an opportunity for discussion, the vote to approve the print was _________
(__).The meeting adjourned at __:__ _M.
X.
ATTACHMENTS
1.
Bill 20-327 as introduced.
2.
Witness List.
3.
Fiscal impact statement.
4.
Legal sufficiency determination by the General Counsel.
5.
Committee Print for Bill 20-327.