B&B ImFoRmikriom ImAj3E M^N^=L-MENT 300 @eftoc U=Itucon sou mm Ulmoscm M,&IRLUO$tcg MA $40 Z077Z 0 UMA6 & taol) 24@l 10 I G03 RM 00032-01 SITE VISIT REPORT WICHE MOUNTAIN STATES REGIONAL MEDICAL PROGRAM February 12, 1968 SITE VISITORS Dr. Edward Kowalewski, Chairman, Committee of Enviro=ental Medicine of the Academy of General Practice, Akron, Pennsylvania Dr. Lloyd H. Ramsey, Associate Professor of Medicine, Vanderbilt University, Nashville, Tennessee Mr. Storm Whaley, Vice President for Health Scienies, University of Arkansas, Little Rock, Arkansas DIVISION OF REGIONAL MEDICAL PROGRAM STAFF Dr. Richard P. Manegold, Associate Director for Program Development and Research, DRMP, National Ins.titutesof Health, Bethesda, Maryland- Mrs. Jessie F. Salazar, Public Health Advisor-, Grants Review Branch, DRMP, National Institutes of Health, Bethesda, Maryland WICHE STAFF AND OTHERS FROM WICHE REGION Anderson, Dr. C. LeRoy, Missoula, Montana Braun, Harold A., M.D., Missoula, Montana Brewer, Leonard W., M.D., Missoula, Montana Buker, Richard S., Jr., M.D., Cheater, Montana Grizzle, Claude O., M.D., Cheyenne, Wyoming Honkala, Fred, Missoula, Montana Humphrey, Dr. George D., Laramie, Wyoming Johnson, Zach A., M.D., Salmon, Idaho La Croix, Mrs. Lillian, R.N., Missoula, Montana McKean, Robert S., M.D., Boise, Idaho McPhail, Frank L.,M.D., Great Falls, Montana Popma, Alfred M., M.D., Boise, Idaho Nicholas, Thomas A., M.D., Buffalo, Wyoming Roberts, David L., M.D., Reno, Nevada Smith, George T., M.D., Reno, Nevada Stanchfield, Robert F., M.D., Shelby, Montana Weber, Richard D., M.D., Missoula, Montana Bunnell, Dr. Kevin P., Boulder, Colorado Elliott, Jo Eleanor, R.N., Boulder, Colorado Feldman, Raymond, M.D., Boulder, Colorado Malone, Mrs. Julia, Boulder, Colorado UNIVERSITY OF-WASHINGTON CONSULTANTS Tjelta, Tomine, R.N. Ph.D., Seattle, Washington Yarnall, Steven R., M.D., Seattle, Washington D.RAFT SITE VISIT REPORT 1 G03 RM 00032-01- WICHE MOUNTAIN STATES REGIONAL MEDICAL PR,,OGRAM February 12, 1968 GENERAL Dr. Edward Kowalewski called the meeting to order and described the purpose of the visit. Dr. Alfred M. Popma, Regional Director, introduced Dr. Kevin P. Bunnell, WICHE Associate Director, who presented the historical background of WICRE. Dr. Frank L. McPhail, Montana State Director for Regional Medical. Programs, described the background of the proposal. The site visit team was pleased to learn firsthand of the enthusiasm for the program throughout the region. Representatives from each of the states describe their expectations of the program, as well as the particular problems their isolation imposes. The team was especially impressed by the people representing different sub- regions, and by the variety of disciplines and institutions. At considerable sacrifice in terms of time and often arduous travel, many willingly participated in the meeting so that-the site visit team could perceive the extent of the involvement. Most of the major universities' were represented; nursing leaders identified the support of that profession; two representatives of the University of Washington Medical School reported the backing and interest of that school for the program. The site visit team was,impressed with the insight into the program provided by all its representatives,,,and was also satisfied that the region is obviously poised and ready to move into its operational phase. The program is growing despite the problem with staffing common to all regions. There was a feeling that the involvement of practicing physicians is at best probably only lukewarm. This was not believed to be a weakness per se, but perhaps attributable to great distances a-ad less than adequate communication. The site visit team was in agreement that it had been exposed to all facets of the WICHE Mountain States Program. The few concerns needing clarification were satisfactorily explained. These included: the rationale for the structure of the Regional Advisory Group with such a large proportion of its membership located outside the region. The opinion was that although the organizational framework is somewhat unwieldy, it does fulfill the region's needs; the seemingly cumbersome advisory group structure (both state and regional); the same feeling concerning the organization of the region as a whole. However, the visitors were satisfied that there is ample representation at all levels. A PROGRAM TO PROVIDE INTENSIVE COR@Y CARE IN SMALL HOSPITALS The Montana RMP representatives have visited all of the county medical ;societies; they have talked to all hospital representatives and to the majority of practicing physicians. Two-thirds of the hospital beds are located in nine out of the 56 counties--eight.of which have no hospit4. Much interest has evolved from the general practitioners' desire to provide better training and equipment for coronary patients. DRAFT -2- 1 G03 RM 00032-01 The proposal i6 for separate courses of training for nurses and M.D.'s based at St. Patrick Hospital. Initially forty-one hospitals are interested and committed to this program with a solid four-year training schedule. Eventually all four states--Montana, Wyoming, Nevada and Idaho will round out a total regional involvement, but this application encompasses only three of the four states. Dr. Harold A. Braun, Director of this project, stated that training for nurses in coronary care will subsequently be offered at one of four or five other larger hospitals. Some matriculants will come from hospitals without coronar'y care units and will pose special problems in evaluation. To facilitate such evaluation, continuing contact is anticipated. The nurses working in remote areas will have direct telephone access to St. Patrick personnel when their doctors are unavailable. The doctors' program will consist of two or three meetings at the university in the form of a symposium. The standard clinical problems @f coronary care will be presented as well as experience in the techniques of defibrillation and the use and maintenance of pacing equipment. The University of Washington cardiology staff will also participate in this workshop, and has assisted in developing the curriculum and a telephone-case- conference plan. Telephone consultation is now a well established pattern of practice in the region. In considering the wisdom of establishing CCUs in a smaller thau normal hospital, the site visitors were aware of factors which would ordinarily motivate against their utlization. In view of the critical two hour period following the initial onslaught of a myocardial infarction, and the long distance required to reach adequate facilities, there was consensus that the units here requested really amount to intensive care rather than coronary care units. These concerns were mitigated by the fact that some of the smaller hospitals are ready to proceed, and indeed in some instances, are prepared to supply the necessary equipment. The architectural phases of this application were interesting to the visitors, and it was noted that a consultant architect will be used and the visitors.fel.t that such an approach would simplify as well as accelerate the accommodations requiredby the small hospitals to provide adequate facilities, especially the adaptation of existing space for such units. it was noted that not enough strength exists in the hospital administrators' participation in this project, and the opinion was that the architectural consultant concept could be made more effective by a broader participation on their part. CONCLUSIONS The application under consideration was found to offer the mea@ and mechanism for an ongoing program, and further, will build on existing programs. It was the opinion of the-visitors that this region will probably always require a unique approach to regionalization because of the distances and sparceness oi population, transportation, etc. -3- 1 G03 RM 00032-01 Although very different problems confront each of the Mountain States, these states have a long history of cooperative arrangements, and this fact was attested to repeatedly throughout the visit. The visitors recomend supp ort of this coronary care training project in time and amount requested, despite some reservations on the part of some of the team, as to the feasibility of the architectural-consultant scheme. There was concurrence that the method deserves testing and should perhaps be carefully evaluated before implementation in all the participating hospitals. There was a unanimous feeling among the site visitors that the WICHE Mountain States Region is obviously ready and eager to move into the operational phase of the program. Continuing support for planning is under consideration, as well as other operational proposals.