Non-Urban Emergency Medicine

Quality Indicators: CMS Reporting

2007-11-09T16:05:00.000-06:00

From the Iowa Hospital Association Friday mailing:

PPS hospitals must begin submitting data on seven indicators (reduced from 10) to an as yet undisclosed contractor beginning with outpatient services provided on or after April 1, 2008 in order to receive the full payment update for 2009. Like the inpatient PPS quality reporting program, non-compliant hospitals will receive an update factor reduced by 2 percentage points for the duration of 2009.

The seven measures CMS is requiring for the initial implementation of the the Hospital Outpatient Quality Data Reporting Program have been endorsed by the National Quality Forum and include (emphasis added):

• Emergency department (ED) transfer acute myocardial infarction (AMI) 1: Aspirin at
arrival
• ED-AMI-2: Median time to fibrinolysis
• ED-AMI-3: Fibrinolytic therapy received within 30 minutes of arrival
• ED-AMI-4: Median time to electrocardiogram
• ED-AMI-5: Median time to transfer for primary PCI
• Physician Quality Reporting Initiative (PQRI) #20 (Perioperative Care): Timing of antibiotic prophylaxis
• PQRI #21 Perioperative Care: Selection of prophylactic antibiotic

No liability for doctor who revived newborn

2007-11-09T14:47:00.000-06:00

From the Seattle Times

A doctor can't be held liable for resuscitating a baby who was born without a heartbeat and survived with severe disabilities, the state Supreme Court says.

The baby's parents filed a malpractice lawsuit after the baby's 2004 birth. They claimed doctors in Vancouver, Wash., were negligent when they continued to resuscitate the baby for almost half an hour, after he was born without a heartbeat.

The parents also said the medical team should have gotten their consent before continuing to revive the baby.

But the Supreme Court justices say the doctor can't be held liable for failing to stop resuscitation efforts on a baby.

New High or Hoax?

2007-11-09T08:49:00.000-06:00

From ABC News:

Police in Naples, Fla., are on the lookout for users of "jenkem," a homemade drug created by allowing human urine and feces to ferment in a bottle with a balloon covering the opening. Users inhale the released methane gas from the balloon to get a "euphoric high similar to ingesting cocaine, but with strong hallucinations of times past," according to a Collier County Sheriff's Office bulletin.

The downside: "Subjects who used the jenkem disliked the taste of sewage in their mouth and the fact that the taste continued for several days."

Immunization Frequency

2007-11-09T08:41:00.000-06:00

From the Wall Street Journal Health Blog:

We may be getting far more immunizations than necessary, according to findings from a study in the current issue of the New England Journal of Medicine.

Antibodies from some vaccines stay around in the blood stream for much longer than previously thought, which means that the current schedules for some vaccinations may be overkill, the WSJ reports.

Tetanus shots, for instance, could be given every 30 years instead of every 10. And we seem to be protected from measles, mumps, and rubella for life, the researchers at Oregon Health and Science University find.

ED's: "Wrong place for mental-health care"

2007-11-09T08:32:00.000-06:00

From the Boston Globe:

Hospital emergency departments are among the least appropriate and most expensive places in Massachusetts for patients in psychiatric crisis. Yet these departments are where police, families, group homes, nursing homes, and others routinely take people who are agitated, panicked, or threatening to hurt themselves. Emergency departments are also where people go at the end of the month when their medications run out, when their primary physicians can't see them for two weeks, when they are frightened or desperate and have nowhere to turn after 5 p.m. and their therapist's answering machine tells them to go to the emergency room.

Medicaid and Self Pay

2007-11-09T08:26:00.000-06:00

From Reuters:

The government's Medicaid program for the poor may put more financial burden on overcrowded hospital emergency rooms than the nation's 47 million uninsured, according to a study published on Thursday.

Researchers at the University of California San Francisco and Stanford University found that the uninsured patients paid 35 percent of their overall emergency room bills in 2004, versus 33 percent for Medicaid.

"What surprised us was that uninsured patients actually pay a higher proportion of their emergency department charges than Medicaid does," said Renee Hsia, an emergency room doctor and researcher at UCSF who led the study.

"This runs counter to the widespread impression that the uninsured are universally poor payers," said Hsia, who noted that the ranks of uninsured include healthy young people who are employed full-time.

MRSA Isolation

2007-11-09T08:20:00.000-06:00

From the Houston Chronicle

SYRACUSE, N.Y. — A Syracuse hospital is taking an unusual approach to stopping the spread of antibiotic resistant staph infections by putting all patients with the superbug on the same floor.

Since 2000, Crouse Hospital has operated a unit on the seventh floor of its Memorial unit that cares exclusively for patients with MRSA, or Methicillin-resistant Staphylococcus aureus.

Hospital officials say the dedicated 17-bed unit — the only one of its kind in the United States — has slowed the spread of MRSA in the hospital, improved patient care and saved the hospital about $1 million.

Just Say No?

2007-11-07T17:04:00.000-06:00

From MedPage Today. Tales from the ER.

I thought I had heard it all, but I got a new threat recently. The context was one in which I felt a little bad about having to say no. The patient was a grandmotherly sort of lady in her middle years. She presented a sad and pathetic figure as she told me her tale of ongoing diffuse body pain which was poorly controlled even on high doses of methadone. Alas, she was out of her meds and wanted a refill (actually, her initial request was to be admitted to the hospital). She was unable to explain how she had come to be out of her pain medications.

She escalated; I explained my thought process. She yelled, she wept, and she begged. I held firm, and she was discharged. On her way out she stopped by the charting station and said, with a vicious spite in her voice, "I hate you. You are a terrible, terrible person, and I hope you suffer, and I hope your children suffer. In fact, I am going to make sure of it. I am going to go home and make a voodoo doll of you and all of your children and I am going to stick pins in all of them!"

Amazing Story

2007-11-07T17:01:00.000-06:00

From CNN.com

On July 2, Powers, a squad leader in the 118th Military Police Company out of Fort Bragg, and his unit were called to investigate a report of a late afternoon explosion in a Baghdad neighborhood. For the unit, it wasn't anything they hadn't seen before. They were on their second tour of duty in Iraq to train Iraqi police officers.

The explosion was minor and Powers walked away from the area to deal with the crowd that had gathered.

It was then that Powers felt something hit his head.

"I wondered briefly if I had been shot," he says.

In reality, Powers had been stabbed in the head. And the nine-inch knife was still stuck into the right side of his cranium.

Energy Drinks and EtOH Don't Mix

2007-11-04T15:48:00.000-06:00

From the WSJ Health Blog

Researchers there found that college students who down cocktails of booze and energy drinks, such as Red Bull, run a significantly higher risk of injury compared with students who stick to uncaffeinated alcoholic beverages. The students sucking down Speed Balls, Bullgaritas and Bull Breezes were much more likely to be hurt or injured, to ride with an intoxicated driver or to take advantage of someone else sexually.

The results follow several studies that found mixing alcohol, a depressant, and caffeine, a stimulant, can make people feel less drunk than they really are.

Some mental health patients to be diverted to ERs

2007-11-02T09:58:00.001-05:00

From the Austin Statesman

More people with mental illnesses could soon be sent to local emergency rooms instead of Austin State Hospital, and hospital officials say that could clog waiting rooms and cause longer waits for medical care throughout the Austin area.

On Nov. 8, the Austin Travis County Mental Health Mental Retardation Center will start reducing the number of people it sends to the state hospital by 43 percent — an estimated 600 to 900 people each year. Those people will be taken to emergency rooms, including ones at Brackenridge Hospital, Dell Children's Medical Center of Central Texas, Heart Hospital of Austin and St. David's Medical Center, said Jim Van Norman, MHMR's medical director.

Hospitals face fight for tax-exempt status

2007-11-02T08:46:00.000-05:00

From the ContraCosta Times

A U.S. senator has warned that if some nonprofit hospitals continue to oppose greater transparency in the community benefits they provide, he may seek stricter requirements on such institutions.
"While everyone talks about the need for sunshine, there are a few tax-exempt hospitals in the shadows that are bent on pulling the blinds and closing the drapes," said Sen. Chuck Grassley, R-Iowa.

The comments from the ranking member of the Senate finance committee came during a Tuesday roundtable discussion in Washington on whether nonprofit hospitals provide enough charity care to justify their hefty tax breaks.

Grassley noted that the Internal Revenue Service has proposed changes in its Schedule H and Form 990 that would require nonprofit hospitals to provide greater details on their charity care and other community benefits.

He called the proposed change in reporting requirements "a dramatic improvement over business as usual" and criticized hospitals that are opposing it.

"It is disgraceful that they are misleading Congress" in trying to water down and delay the Schedule H changes, he said.

"If these hospitals continue to press for keeping the public in the dark about how they justify $50 billion in tax breaks a year, that will greatly color my views about the need for legislation."

EM Physicians Dominate Romance Novels

2007-10-26T08:41:00.000-05:00

From Yahoo News

If romantic fiction is any guide, any doctor looking for love would be advised to be an emergency room surgeon or deliver babies rather than practise colon resection or remove in-grown toenails.

Hospital novels are one of the fastest-growing areas of romantic fiction which, according to the Romance Writers of America, generates 1.2 billion dollars in annual sales and accounts for 39.3 percent of all fiction sold in the United States.

In an offbeat letter published in Saturday's Lancet, Kelly describes the typical plot structure and characterisation in 20 randomly-selected medical romance novels.

Of the male protagonists, six worked in emergency medicine, five in surgery and three in obstetrics, neonatology and paediatrics, he found.

"There was a marked preponderance of brilliant, tall, muscular, male doctors with chiselled features, working in emergency medicine," says Kelly, a University College Dublin psychiatrist.

Pain Scale Absurdity

2007-10-26T08:37:00.000-05:00

From Scalpel or Sword:

Two patients came into the ER by ambulance complaining of pain.

One was a young woman with another migraine, who "usually gets" Dilaudid 4-6 mg IV in addition to IV Reglan and Ativan. She was allergic to many other medications, but she had a full bottle of dilaudid 8 mg pills and some Actiq lollipops in her purse from two different pain specialists. Her usual medications also included Ambien 20 mg at bedtime and Xanax 2 mg every 6 hours. Although she complained of vomiting constantly for 3 days, her vital signs, physical exam, bloodwork, urinalysis, and imaging tests were all negative, and she never vomited in the ER. She spoke calmly and was in no apparent distress.

The other patient was an elderly lady who had fallen at home, fracturing her hip. She was taking a blood thinner, so her grotesquely angulated and deformed thigh was also markedly swollen. The fact that she had crawled down the stairs after her injury in order to call the ambulance probably contributed to the swelling and deformity somewhat. She trembled a bit as she asked for something to relieve her pain.

Guess whose pain was a 5/10 and whose was a 10/10?

Visble Body Website

2007-10-24T20:35:00.000-05:00

The Argosy Visible Body, which promises to be a free virtual anatomy website, is looking like a rather impressive product already. Videos of the development, provided by the company, show a simple interface and an easy method to get to individual anatomic parts of the body. Here are the features the website will provide:

Search for and locate anatomical structures by name.
Hide, rotate, see through, and explore parts of human anatomy.
Move the model in three-dimensional space.
Zoom in and out.
Click on systems or structures to make them transparent or hide them.
Click on anatomical structures to reveal names.

In beta / demo now, "Coming in mid-November"

"25 Skills Every Doctor Should Possess"

2007-10-24T20:20:00.000-05:00

From the Cheerful Oncologist, excerpted below:

Skills all doctors should possess:

1. Recognize when a patient needs to be transferred to the ICU.

2. Deliver bad news compassionately, yet honestly.

3. Identify a pneumothorax on a chest radiograph.

4. Diagnose iron deficiency anemia.

5. Help a patient stop smoking cigarettes.

6. Diagnose thrombotic thrombocytopenic purpura, which has a mortality rate of 90% if not treated and 10-20% if treated.

ACEP on CA-MRSA

2007-10-23T08:48:00.000-05:00

From the American College of Emergency Physicians

Washington, D.C. — The spread of a potentially life-threatening antibiotic-resistant staph germ that is responsible for more deaths in the United States each year than the AIDS virus has prompted the American College of Emergency Physicians (ACEP) to launch an education initiative aimed at protecting the public against the further spread of infection.

"This emerging 'super bug,' as it's known, is causing ACEP to mobilize for two reasons," said Linda Lawrence, MD, FACEP, president of the American College of Emergency Physicians (ACEP). "First, we are concerned about the possible spread of this potentially dangerous bacterium – especially in schools, nursing homes and health-care settings – so we are asking people to practice good hygiene, such as frequent hand-washing, to help prevent public outbreaks. Second, ACEP is cautioning against the continued widespread overuse of antibiotics, a practice that has in part caused drug-resistant germ strains like this one to emerge."

At the same time, emergency physicians across the country are on the lookout for cases of antibiotic-resistant infections so these patients can be isolated and treated with the few types of antibiotics that remain effective, before developing potentially life-threatening complications or spreading their infection to others.

Air Medical Controversy in Texas

2007-10-23T08:46:00.000-05:00

From JEMS

EMS Units Bypassed Nearest Helicopters: Physician Says Ties to a Firm Don't Influence Agencies' Decisions

What happened to Bridges that night was part of a pattern repeated more than two dozen times in the last two years in the area: EMS crews did not call the closest helicopter ambulance service.

In each incident, the EMS unit on the ground and PHI shared the same medical director, Roy Yamada.

Yamada, a Fort Worth physician, works as director of emergency medicine for Midlothian and in a similar role for nine other area EMS departments, most in Tarrant County. He is also PHI’s North Texas medical director, a position for which he has apparently been paid almost $200,000 in 2 1/2 years.

Such ties are becoming increasingly common in the competitive air ambulance industry, in which people who oversee local EMS agencies also work for air medical providers.

But these alliances, critics say, can lead to delays in hospital care for critically injured patients as well as unnecessary helicopter flights that can cost patients as much as $10,000 when ground transport would be sufficient.

Defensive Medicine (ED Example) on CBS

2007-10-23T08:36:00.000-05:00

From CBS.com

CBS) It started as a simple stomach ache, but Alexandra Varipapa, a sophomore at the University of Richmond, decided to go to the emergency room.

There, doctors ordered a full CT scan, a radiation imaging test, which found a harmless ovarian cyst. She never questioned the CT scan, CBS News correspondent Wyatt Andrews reports.

But her father did - when he got the $8,500 bill, $6,500 of which was that CT scan.

“I was pretty flabbergasted,” said Robert Varipapa, himself a physician.

Varipapa says his daughter's pain could have been diagnosed far more easily and cheaply with a $1,400 ultrasound.

“A history, a pelvic examination and probably an ultrasound,” he said. And he would have started with the ultrasound.

But the hospital defends the CT scan, saying an ultrasound might have missed something more serious.

CMS Sets Requirement for Hospitals Without 24/7 Physician Coverage

2007-10-12T17:02:00.000-05:00

From the Iowa Hospital Association

IHA has received several questions from hospitals regarding a new Centers for Medicare & Medicaid Services (CMS) requirement aimed at patient safety and emergency services. The requirement, effective October 1, mandates that all hospitals, including inpatient acute (whether Prospective Payment System or exempt), Critical Access Hospitals, long-term care, psychiatric, rehabilitation, children’s and cancer hospitals, that do not have physicians available on the premises 24 hours per day, seven days per week (24/7) inform patients of that limitation prior to patients receiving an inpatient or outpatient service.

CMS does not plan to prescribe specific language for the notice, but its discussion of the requirement indicates the notice must specifically state the hospital does not have physicians on the premises 24/7. The notice also must describe how the hospital will meet any emergency service needs when a doctor is not on the premises. The disclosure would be required at the point of registration or preadmission testing.

CMS does not intend to provide standard language for the new disclosure notice, but the notice still requires federal Office of Management and Budget (OMB) review and clearance under the Paperwork Reduction Act. Hospitals subject to the requirement (those that do not have 24/7 physician coverage on site) will need to create a disclosure notice and a plan for distributing the notice at all inpatient admissions and outpatient encounters.

Available information suggests hospitals simply need to provide the notice to each patient, without obtaining patient signatures documenting individual receipt. Hospital policies and procedures must be documented. However, the American Hospital Association cautions against finalizing the notice and procedures until CMS receives OMB clearance and issues provider manual instructions.

CMS has already completed the first part of the clearance process by soliciting public comment on the proposed disclosure requirement. CMS has yet to publish another notice with a 30- day comment period directly to OMB. It is expected that instructions will not be circulated to hospitals until the instructions receive OMB clearance, which is still pending.

California ED data

2007-10-12T13:50:00.000-05:00

This week's San Diego Union Tribune features a story of one doctor's attempt to encourage hospitals to come clean with ED wait-time figures as a step toward improving traffic flow. Dr. Roneet Lev, an emergency physician at Scripps Mercy in Hillcrest, leads the Emergency Medicine Oversight Commission of the San Diego County Medical Society. She recently persuaded 19 hospitals to share emergency room procedures and statistics.

Also in California, the site of the Office of Statewide Health Planning and Development posts numbers from hospitals on the annual number of patients who enter the ED without being seen. It also asks facilities to disclose the number of hours per month they were on diversion. All you have to do is type in the city or name of the hospital you're researching.

Firefighters, police push for city's help treating drug-resistant infection.

2007-10-12T13:44:00.000-05:00

From the Fresno Bee

The Fresno City Council agreed Tuesday that a drug-resistant staph infection afflicting some city firefighters should be considered a work-related injury for firefighters and police officers.

Some firefighters are upset they're forced to pay health insurance co-payments and use their sick time to recover from the infections they believe they contracted at work.

If treated as work-related illness, the city's workers' compensation insurance would cover those bills and pay the firefighters for lost work time.

The council voted 6-1 to direct city staff to write a policy making all cases of methicillin-resistant Staphylococcus aureaus a work-related illness for firefighters and police officers. The council must approve the policy in a separate vote.

CPAP for CHF instead of ETT?

2007-10-12T08:47:00.000-05:00

From USA Today

For more than 30 years, paramedics have been saving the lives of these patients by inserting, through the vocal cords, a breathing tube about the width of a small garden hose and then pushing air into the lungs with an inflatable bag. Called intubating, it's the street version of a hospital's mechanical ventilator.

But the aggressive treatment is very uncomfortable for those on the receiving end, and it carries the risk of dangerous infection. So a device more commonly found in the hospital is making its way into the nation's ambulances, including Harper's rig in Houston.

Harper asks firefighters to bring him the breathing device known as CPAP, for continuous positive airway pressure. The football-size device with long plastic tubing and a plastic mask is being used now by emergency crews in seven other big cities, including Miami and Boston. Another 16, including Atlanta and Philadelphia, plan to put the device in ambulances soon, this month's Journal of Emergency Medical Services (JEMS) reports.

Negligent Credentialing?

2007-10-11T09:45:00.000-05:00

From the American Medical Association

Hospital can be sued for credentialing doctor with questionable qualifications, Minnesota high court rules

Physicians fear that a recent Minnesota Supreme Court decision could compromise statutory peer review protections and taint physicians in medical liability cases that are tied to negligent credentialing claims.

For the first time, the high court recognized that patients can sue hospitals for allegedly granting privileges to doctors with questionable credentials. The unanimous decision adds Minnesota to a list of at least 25 other states that recognize negligent credentialing claims.

House Bill Aims to Modernize 911 Systems

2007-10-11T09:36:00.000-05:00

From Washington Technology:

Proposed legislation in Congress that would promote implementation of IP-based 911 services is picking up support from public safety groups and disability organizations.

The 911 Modernization and Public Safety Act of 2007 (H.R. 3403), sponsored by Rep. Barton Gordon (D-Tenn.), seeks to facilitate rapid deployment of IP-enabled 911 services and IP-enabled enhanced wireless 911. It would extend enhanced 911 services to IP-based telephone services. The goal is to migrate today’s 911 systems to new technologies.