Fall 2011 Issue

Kentucky Chapter ACEP

Fall 2011

Kentucky Chapter ACEP

Melissa Platt, MD, FACEP
President

Ashlee Melendez, RN, MSPH
Executive Director

Contact us:
ky.chapter@acep.org

Phone: 502-852-7874 begin_of_the_skype_highlighting 502-852-7874 FREE  end_of_the_skype_highlighting
Fax: 502-852-0066

From the President
Melissa Platt, MD, FACEP

Hello everyone! For a quick Board update, as I alluded to in the last EPIC article, the Board is working on advancing medical liability reform in our fine Commonwealth. We have met with the Kentucky Medical Association lobbyists, Kentucky Emergency Nurses Association, and we will have a short presentation at our next board meeting by a representative from the Kentucky Academy of Family Physicians. There seems to be a lot of positive interest in this subject and we hope to capitalize on its momentum.

 

There are a host of other significant, strong events that KACEP has been a part of including the statewide trauma symposium (our very own Dr. Daniel O’Brien will be a speaker), an ultrasound course, and continued involvement with the trauma network. It seems most of our KACEP members have been active with heavy material like the repeal of the SGR, Medicaid reimbursements, EMTALA etc. so I think we need a little levity injected into our worlds. It came to me when I was discussing medical school academic curriculum (yawn) with a bright eyed, energetic 2nd year student who actually used the phrase Krebs cycle in a sentence like it was normal dialect. The concrete, the factual, the linear is what she knew about medicine. I then turned around and went to complete a moonlighting shift in the “real world”. I thought of some new ideas about the medical school courses and it went something like this:

 

Anatomy 101

  • Surgical scar recognition (it seems patients forget to tell you about their surgeries until you point out the 15 inch scar across their abdomen)
  • Metal: the new bone/joint

 

Physiology 101-

  • The proportions of a person’s blood sugar to the amount of Mountain Dew left on the hospital bedside table

 

Pharmacology 101-
  • Polypharmacy- how too fit all your meds onto a tethered worn index card
  • Opana- need I say more

 

Advanced pharmacology 201-
  • Noncompliance—attendance optional

 

Microbiology 101

  • The elusive MRSA biting spider
  • Bed bugs

 

Neurophysiology 101

  • Seizure meds are not PRN

 

I actually thought of several more but you get the jest. I want to hear from you. You name your newest medical school course. Just remember…“Don’t take yourself too seriously. And don’t be too serious about not taking yourself too seriously." – Howard Ogden

So Why Do I Need To Worry About The SGR?
Wes Brewer, MD, FACEP
Governmental Affairs

The repeal of the Medicare Sustainable Growth Rate (SGR) formula has been the focus of advocacy efforts for way too long. Passed in the mid-nineties as a way to control Medicare spending, this complicated formula ties spending to the gross domestic product. Effectively this links reimbursement to outside factors that are not even remotely tied to the cost of providing medical care to seniors. Shortly after its passage almost everyone involved realized the formula was deeply flawed nothing was done.

 


During the first several years the formula even triggered some payment increases, but then the economy tanked and the formula started demanding decreases in Medicare payments. The cuts were small at first and for the most part never went into effect. The usual scenario was that shortly before the scheduled cuts were implemented there would be a whimper from the medical community and a roar from the senior lobby and Congress would typically halt the cut going from happening and perhaps even give a small raise and everyone (almost) was happy until the next cut rolled around. But the formula continued to call for even bigger cuts. Republicans promised to repeal the formula, Democrats promised to repeal the formula, fringe lunatics promised to repeal the formula, but nothing happened. The dirty little secret was that none of these were ever paid for!

 

Each time a cut was averted or a small raise was enacted Congress never included that cost in the budget, it is called kicking the can down the road (recall that most of the cost of the Iraq war and senior drug coverage were “off budget” and never paid for). We were “running up a tab” and now they want their money back. During 2010 Congress delayed cuts six times acting bravely to avert a crisis but the underlying formula was still not addressed, while pretending to do us a favor, they were just running up our tab. In order to come up with a new formula, our government insists that all the money spent to avert cuts should be paid back. The cost to fix the formula in 2005 was 45 billion, it has now risen to 300 billion and we are faced with a 29.5 percent cut in Medicare reimbursement as of January 1, 2012.


It is difficult for me to rationalize how a young physician starting practice today should have to work for less because my scheduled pay cut was averted 10 years ago. There are many who have turned to the deficit reduction committee hoping for a solution, but it is difficult to imagine that a committee looking to save 1.5 trillion dollars will somehow find an extra 300 billion floating around to keep us happy while at the same time cutting defense spending and farm subsidies.


Recently there was an Action Alert requesting members to contact their Congressperson regarding this issue-- thank you if you responded. My suspicion is that this was greeted with a long slow yawn, both sides of the issue are really tired of hearing about SGR. I would really love never writing about it again, BUT we can only afford doing nothing if we can afford to lose one third of the reimbursement from the group that represents generally 25% or more of our patients. Please contact your Congressman to press for a solution to this lingering problem, “The paycheck you save may be your own!!!”

A Seat at the Table
Ryan A. Stanton MD
Vice-President/Public Relations

I had the privilege of experiencing my first ACEP Council meeting at Scientific Assembly this year. It was very interesting to see the inner workings of the college and get a better understanding of the hot topics that will be driving our specialty in the near future. The one thing that stood out in my mind and is probably no mystery to anyone is health care reform and budget battles. We are knee deep in the most significant healthcare reforms while at the same time facing some of the worst budget issues in our country's history. We are facing a huge influx of new patients and regulations with the overhanging reality that we will have less money to successfully accomplish these goals. As this process has gotten into full swing, it has become clear that the house of medicine is a house divided, quickly pointing fingers as to who is to blame for the cost of health care and fighting for the scraps that are the remains of the government dollars. Probably to no surprise if you have worked in an ER for more than 10 minutes, everyone is very quick to point fingers and place blame on emergency medicine. Whether it's the argument that there are too many nonemergent cases, the burden of charity care, or that our workups are too expensive, we have become an easy target for inpatient and clinical brethren. So here are the facts...

  1. Emergency medicine physicians make up 4% of the physician work force in this country.
  2. Only 2 cents of every healthcare dollar goes to emergency medicine. That's right, 4% of the doctors do their job for 2% of the money.
  3. A CDC study found that only 12% of total ER visits could be classified as "nonurgent".
  4. Timely access to primary and follow-up care continues to become more difficult.
  5. We are the safety net of medicine, providing the only 24/7 access to medicine with no difference or bias in ability to pay. We are always there.

So, what can we do as emergency medicine specialists to ensure our message and role in this system is understood?

  1. Contribute to NEMPAC and EMAF. These are the political arms of our college and it's unfortunately a reality in our country, that money talks. We must have the funds available to ensure we have a seat at the table. We cannot expect other specialties and interests to speak on our behalf or even understand the value we provide to the health care system and our citizens. I had never contributed until this year, but I am now a proud "Give A Shift" member. We are currently the 4th largest PAC in medicine, so every bit gets us closer to the head of the table. If there is any question what money and action can accomplish, look no further than our friends in ophthalmology that were blindsided when the optometrists drove through laser surgery legislation.
  2. Spread the message. Emergency medicine makes up a very small piece of the overall health care budget, yet we provide a critical service to our citizens. We are the front line, life saving, safety net of medicine. As others point fingers, we have the opportunity to emerge as the knights in shining armor. We have always been there to take anyone, no matter their financial situation, 24 hours a day, 7 days a week, 365 days a year. Whether it is emergent, urgent, or nothing at all, we have been there with doors open, ready to provide the best care this country has to offer. This is our chance to get that message out. We have been there for our patients and want to be there in the future. Anyone that doesn't understand the integral role of emergency medicine doesn't truly know medicine, so we must get the message out. ACEP has many resources available on their site, under the "News Media" tab.

The face of health care is changing. We must take action to ensure changes will be in the best interest of our patients and the services we provide. So, take a moment to give of your time and wallet to get the message out to the public and our law makers, that emergency medicine isn't the problem, but an integral part of the solution for providing cost effective access to health care for everyone in this country.

Cardiology Literature That May Change Your Practice
Devin Faragasso, MD, FACEP
Education Chair

You are working the weekend overnight shift at a small community hospital. You agreed to cover the shift as a favor to a colleague. During the wee hours, two unrelated, previously healthy young patients present one hour apart with the complaint of palpitations. In both cases this was of acute onset, only a few hours ago. The first patient has a heart rate of 190 bpm, and the second 160 bpm. For each patient, the electrocardiogram reveals atrial fibrillation, with a rapid ventricular response. You see no ECG indication of ischemia, and neither patient is having chest pain. They do not have any history of atrial fibrillation.

 

This particular hospital has cardiology coverage and a hospitalist program. After giving each patient an intravenous bolus of diltiazem, their heart rate slows to below 100 bpm, and they are much more comfortable. They are, however, both still in atrial fibrillation. What you really want to do is go back to your call room and get a nap, but you are faced with a treatment decision.

 

You now have to choose between conservative or aggressive treatment for these patients. Conservative treatment typically consisting of rate control, anticoagulation, and a hospital admit for possible delayed cardioversion by cardiology.

 

Or, do you try to get these patient discharged home after cardioversion in your department? You could be preventing an unnecessary hospital admission, end an uncomfortable rhythm, and avoid the prolonged use of rate control and anticoagulation drugs. If this is your approach, do you choose chemical or electrical cardioversion? If you use electrical cardioversion, what setting of joules do choose?

 

Atrial fibrillation is the most common acute arrhythmia presenting to the emergency department (ED).1 There is no consensus at to the optimal management of recent-onset atrial fibrillation or flutter, and a great deal of controversy surrounds the issue. There is, however, a small but growing body of literature to support an aggressive approach in the emergency department. Additionally, it appears that when patients are left in atrial fibrillation for long durations, eventual cardioversion attempts will be less successful.2 In 2008, Ian Stiell, et al., presented a consecutive cohort study totaling 660 patients who presented to the University of Ottawa ED with an atrial arrhythmia of less than 48 hour duration.3 They applied their aggressive cardioversion protocol to these patients, with the result that 96.8% of these patient were discharged home, 93.3% of whom were in sinus rhythm. They had no cases of torsades de pointes, stroke, or death. The protocol called for the administration of procainamide at one gram over one hour. This resulted in a 58.3% conversion rate. For those patients who failed to convert with procainamide, they underwent subsequent electrical cardioversion with a 91.7% success rate. The median length of stay in the ED was 4.9 hours overall, with 3.9 hours for those undergoing conversion with procainamide, and 6.5 hours for those requiring electrical cardioversion.

 

The Ottawa physicain’s choice of procainamide seems to have been the result of their personal experience and comfort with this drug.4 They had previously published a consecutive cohort study of 341 patients with new atrial arrhythmia, using the same procainamide protocol.4 In that study, the largest of it kind up to that point involving procainamide, they reported a conversion rate of 52.2% for atrial fibrillation, and 28% for atrial flutter. Adverse events occurred in 10% of cases: hypotension 8.5%; bradycardia; 0.6%; atrioventricular block, 0.6%; ventricular tachycardia 0.3%. They had no cases of stroke, torsades, or death. They concluded that conversion with IV procainamide is both safe and effective.


Regarding the choice of agent for pharmacologic cardioversion, The American College of Cardiology, American Heart Association, and European Society of Cardiology, have published practice guidelines. They include class I – proven efficacy (dofetilide, IV flecanide, ibutilide, propafenone); class IIa – usefulness (amiodarone, oral flecainide); class IIb – less effective (procainamide, quinidine); and class III – should not be used (digoxin, sotalol).5 Most of the studies involving the use of these drugs for acute-onset cardioversion are small. For example, in 2000, Martinez-Marcos, et al., did a prospective, head-to-head, comparison of flecainide, propafenone, and amiodarone.6 He enrolled 150 consecutive patients, and after one hour the conversion rates were flecanide (58%), propafenone (60%), amiodarone (14%). No ventricular arrhythmia occurred in this study.

 

For the conversion of atrial arrhythmia, meta-analysis suggests that amiodarone may be no more effective than placebo after the first hour of infusion.7,8 Ibutilide, the only FDA-approved drug for this purpose, has shown a conversion rate of about 61%, but an incidence of torsades de pontes of 4.3%, with 1.7% of these cases being sustained.9,10 It is recommended that potassium, magnesium, and the QT interval be checked prior to using this drug.

 

Regarding the choice of shock energy for the conversion of atrial fibrillation, the older recommendations of starting with a low energy setting (i.e. 50 J, monophasic), with sequential small increases may be more dangerous and less effective than starting with a higher energy setting (> 200 J). In 2008, Gallagher et al., published a study evaluating the relationship shock energy to arrhythmic complications.11 They hypothesized that most cases of shock-induced ventricular fibrillation occurred from a lack of proper synchronization, with the shock occurring during ventricular repolarisation. They theorized that higher energy shocks (> 200J) would exceed the upper limit of vulnerability for ventricular fibrillation. They found, in 2522 attempts of electrical cardioversion, with 6398 shocks delivered, that ventricular fibrillation was significantly more common after shocks of < 200 J (5 of 2959 shocks vs. 0 or 3439). Conversion of atrial flutter or atrial tachycardia to atrial fibrillation was also more common at < 200 J (20 or 930 shocks vs. 1 or 313). It has been proposed that starting with lower energy may decreases the risk of shock-induced myocardial damage. Gallager, however, found that the initial use of higher energy reduces the total number of shocks required, and as a result, a lower amount of total energy delivered. At > 200 J, a far higher number of patients were converted with a single shock. They advise that in electrical cardioversion, monophasic shocks < 200 J, or biphasic shock < 100 J should be avoided. With the exceptional safety of higher energy electrical cardioversion, the primary adverse events with this strategy should be related primarily to the use of procedural sedation.

 

In patients with symptoms greater than 48 hours, or of unclear duration, aggressive protocols must be avoided unless the patient is already therapeutically anticougulated for greater than 3-4 weeks. The only possible exception is if a negative transesophageal echocardiogram is preformed immediately prior to cardioversion.12 But, even with a negative transesophageal echocardiogram, many of these patients will still require anticoagulation prior to, and after, cardioversion. Unless the patient is truly unstable, cardiology should be involved in cases of ischemia, hypotension, or acute congestive heart failure. In these days of ED overcrowding, and limited hospital bed availability, aggressive treatment of new-onset atrial arrhythmia with rapid discharge home now appears to be a viable therapeutic option.

 

Case Conclusions
You decide to try the aggressive protocol for your two patients. As mentioned before, they are healthy with a clear onset of less than 48 hours. They also have both been NPO for greater than 6 hours. You do not anticoagulate either patient. The first patient converts to sinus rhythm after 45 minutes on his procainamide drip. The second does not convert with procainamide. After obtaining informed consent, that patient is sedated with a single dose each of IV fentanyl and propofol, and successfully cardioverted with one shock of 150 J biphasic, synchronized. He awakes without complication. Both patients are discharged home from your ED on no medications, with the recommendation of outpatient cardiology follow up.

 

References
1. Connors S, Dorian P. Management of supraventricular tachycardia in the emergency department. Can J Cardiol. 1997; 13(Suppl A):19A-24A.
2. Decker V, Smars P, Vaidyanathan L, et al. A prospective, randomized trail of emergency department observation unit for acute onset of atrial fibrillation. Ann Emerg Med 2008; 52:322-8
3. Stiell I, Clement C Perry J. et al. Association of the Ottowa aggressive protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter. CJEM. 2010; 12(3):181-191
4. Stiell I, Clement C, Symington C, et al. Emergency department use of intravenous procainamie for patients with acute atrial fibrillation or flutter. Acad Emerg Med 2007; 14:1158-64
5. Fuster V, Ryden LE, Cannom D, et al. 2011 ACCF/AHA/HRS Focused update incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation. Circulation 2011; 123:269-367
6. Martinez-Marcos F, Garcia-GarmendiaK, Ortega-Carpio A, et al. Comparison of intravenous flecinide, propafenone and amiodarone for conversion of acute atrial fibrillation to sinus rhythm. Am J Cardiol 2000; 87:960-3
7. Hileman D, Spinler S. Conversion of recent-onset atrial fibrillation with intravenous amiodarone: a meta-analysis of randomized controlled trials. Pharmacotherapy 2002; 22:66-74
8. Chevalier P, Durand-Dubief A, Burri H, et al. Amiodarone versus placebo and classic drugs for cardioversion of recent-onset atrial fibrillation: a meta-analysis. J AM Coll Cardiol 2003; 41:255-62
9. Domanovits H, SchillingerM. Thoennissen J, et a;. Termination of recent-onset atrial fibrillation/flutter in the emergency department: a sequential approach with intravenous ibutilide and external electrical cardioversion. Resuscitation 2000; 45:181-7
10.  Kowey P, VanderLugt J, Luderer J. Safety and risk/benefit analysis of ibutilide for acute conversion of atrial fibrillation/flutter. Am J Cardiol 1996; 78(suppl 8A):46-52
11. Gallagher M, Yap Y, Padula M, et al. Arrhythmic complications of electrical cardioversion: Relationship to shock energy. Intern J of Cardiol 2008; 123;307-12
12. Manning W. Strategies for cardioversion of atrial fibrillaion- time for a change? (Editorial}. N Engl J Med 2001; 344:1468-70Kentucky has made trauma system. Through the efforts 69:1030-1036 
www.acep.org/workarea/downloadasset.aspx?id=9104 

Medical Reimbursement
L. Barrett Bernard, MD, FACEP
Committee Chair, Medical Reimbursement
Disaster Preparedness                                                                                                    

Medical reimbursement has never been more complicated and emergency room physicians will be under unprecedented pressure to contribute to the solution. Pertinent facts may be divided into the positive and negatives.

 

Negative

  • U.S. Healthcare costs total more than the GDP of all but five of every country in the world
  • The costs are unsustainable
  • The SGR (sustainable growth rate) is again an issue to be decided at the last minute and could represent a 29.5% decline of Medicare reimbursement.
  • The Healthcare Reform Act is certain to be considered by the Supreme Court in 2012 and the Individual Mandate portion will be threatened and this adds to the uncertainty.
  • Many of the models to manage healthcare costs( i.e. Episodes of Care or Bundling, Medical Home, Pay for Performance) involve the emergency room physician and the pressures of cost containment.
  • E.R. physicians will have unprecedented pressure to be the safety net with policies such as end-of-life decisions.

Positive

  • Emergency physicians make the most expensive routine decision in healthcare.
  • We will always be at the interface of inpatient and outpatient care.
  • We will have more patients than the current 124 million and an unprecedented chance to demonstrate our value in the healthcare system.
  • As systems experts, we have power that can be used to help in the redesign of the healthcare system.
  • In politics a good anecdote usually trumps good data and we must use our stories to guide political decisions. 

The emergency physician’s perspective is indispensible so become engaged in this process. Only then will proper care of our patients and practical reimbursement be assured.

Disaster Preparedness
L. Barrett Bernard, MD, FACEP                                                                   

Seasonal influenza surveillance figures thru Oct. 15 reveal less than 0.5% positives in 1282 test samples. If your employer mandates the influenza immunization, there is good data to support this action. The CDC studies show employee absentism drops, there is reduction of transmission of influenza to HCP, their families, and their patients and a reduction of illness.


The web site has an ingenious skit about emergency preparedness using Zombies. At the end of the skit there is a list of components of an emergency kit which every family should have.  

Emergency Preparedness Update
for October 24, 2011

 

Gun Injuries in Kids Up Sharply

BOSTON -- Firearm-related injuries to patients younger than 19 accounted for an estimated 186,000 emergency department (ED) visits over the period from 1999 to 2007, investigators reported here.


As a proportion of total ED visits for that age group, firearm injuries accounted for 30% more visits than documented in earlier studies.

 

The findings could reflect differences in the data and methods used to calculate firearm-injury rates, but might also reflect a true increase, Saranya Srinivasan, MD, said at the American Academy of Pediatrics meeting.

 

"Pediatric firearm injuries remain a significant cause of morbidity and mortality," said Srinivasan, of Children's Hospital Boston. "We reported 24 nonfatal injuries per 100,000 children, which compares with 16 per 100,000 in previous reports. That represents a 30% increase in the rate of pediatric firearm-related injuries as compared with earlier studies."


The findings came from an analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS), a database of clinical information related to ED and ambulatory care visits at 600 participating hospitals. During the period reviewed, about 279 million visits involved patients ages 0 to 19. Click here to view full story.

 

 

 

 

 

Re: KACEP 2011 Annual Meeting

Dear KACEP Member:

The Kentucky Chapter of the American College of Emergency Physicians (KACEP) is having our Annual Meeting on Thursday, November 17, 2011 in the Stakes Room at Churchill Downs in Louisville, Kentucky. 

 

Admission to the Stakes Room, lunch, parking and racing forms are provided. The meeting will proceed as follows:

 

11:30 a.m. Doors Open/ Exhibit Setup
12:00 p.m. Meeting
12:40 p.m. Lunch/Post Time  

 

Admission tickets can be picked up at the Will Call window at Gate 10 and bring a picture ID. Parking is free in the Longfield lot or $5.00 valet. If you have questions about directions you can call 1-800-28-DERBY begin_of_the_skype_highlighting 1-800-28-DERBY FREE  end_of_the_skype_highlighting. If you have any questions about the meeting, please contact Ashlee Melendez by e-mail or phone at (502) 852-7874 begin_of_the_skype_highlighting (502) 852-7874 FREE  end_of_the_skype_highlighting to RSVP. Dress Code, no jeans allowed.

 

Tickets are FREE as long as you use them!!

 



Open Board of Director Positions
If you are interested in participating or would like to nominate someone for the KACEP Board of Directors, please send e-mail to
Ashlee Melendez.  

Clinical News

COPD Exacerbations Twice as Common in Winter
Exacerbations and deaths among patients with chronic obstructive pulmonary disease follow a pronounced pattern of seasonal variation, according to an analysis of data from a randomized, controlled trial.
Read the entire article online.

 


Bacteria Ride Along on Many Hospital Uniforms
Some people wear their hearts on their sleeves. Doctors and nurses wear a lot more there, it seems. Sixty percent of doctors' hospital uniforms and 65% of nurses' uniforms tested contained potentially pathogenic bacteria in at least one place, according to research published in the American Journal of Infection Control.
Read the entire article online.

 


Focus On: The Cyanotic Neonate
“Focus On” is an ongoing series of articles that examine common complaints that present to the emergency department or highlight new literature or treatment options.

 

Learning Objectives for this article include the ability to recognize and treat uncommon presentations of common pathology and common presentations of rare pathology, discuss the presentation, evaluation, differential diagnosis and treatment of the cyanotic neonate.The physician will be able to discuss the pathophysiology of the transition from fetal to newborn circulation,explain the significance of the hyperoxia test and discuss the management of a neonate with methemoglobinemia.

 

After reading the article, take the CME quiz online.

Welcome New Members

Seth Allen Brown, MD
Timothy R. Howes, MD
Jakob Kissel, MD
David Ritchie
Katherine A. Schulman
Mary Wardrop, MD

Advertisements