Summer 2012 Issue

Kentucky Chapter ACEP

Summer 2012

Kentucky Chapter ACEP

Melissa Platt, MD, FACEP, President

Ashlee Melendez, RN, MSPH
Executive Director

Contact us: 
ky.chapter@acep.org

Phone: 502-852-7874
Fax: 502-852-0066

From the President
Melissa Platt, MD, FACEP

I now believe that KASPER is no longer a doctor friendly ghost but more like Freddy Krueger there to mutilate your medical practice if you fall asleep. OK so I exaggerate slightly but the implementation of HB 1 has really been a nightmare. I will give you KACEP’s survival guide to the HB1 horror movie.

  • When it seems like you’ve killed the monster, never go back to see if it’s really dead. 
    During the last legislative session, the original bill was placed before legislature. It was worked, massaged, revised to be a compromise between what the politicians, law enforcement, and medical professionals could tolerate. KACEP, the organization, was very vocal in this process and made an impact upon revisions of the bill. Your individual phone calls to your legislators were heard and several legislators even commented on them. They heard your voice. The bill was ready to be passed but in the 11th hour the legislative session abruptly ended without the revised bill being brought to a full vote.
  • Never read a book of demon summoning aloud, even as a joke. 
    A special session was called with the “pill mill” legislation being 1 of 2 agenda items. Well what I can tell you is that the original bill was reintroduced and read aloud with most previous compromises and changes erased. The bill passed. It became law whether the medical community agreed or not. While KACEP continued to voice concern, it seemed that Frankfort was possessed to pass this bill.
  • People arriving to rescue you generally get ambushed by the monster; so don’t rely on them as your only means of escape. In fact, expect to be surprised and delayed by encountering their flayed corpse at some point. 
    The Kentucky Board of Medical Licensure (KBML) is now tasked with creating regulations and physician professional standards about the use of controlled substances. The KBML has been receptive to concerns expressed by KACEP regarding regulations. However in the end, the Board will pen new regulations. KACEP hopes that the KBML does not stop listening nor get ambushed.
  • Never be present immediately before during, or any time after a successful demon/devil/monster summoning. 
    We are coming to the point in this story where you are pinching yourself to wake up from the nightmare but you realize that this is really happening. You will need to start the mandatory KASPER queries July 20th if you write for a controlled substance class 2 or a class 3 containing hydrocodone. There is certain documentation that needs to be completed within your medical record. KACEP has placed on its website the actual bill for your reading pleasure as well as frequently asked questions. KACEP realizes this is at best an awkward implementation of a well- intended law gone terribly wrong. We will continue to scream like in the horror movies.
  • If you try to run away, always take the bus. If you take a car, the monster will be in it. Cabbies are always demonically possessed. Monsters will destroy any plane/boat you try to take. And you have to go through dark, underground situations to get on the subway.
    Unless you are planning to flee Kentucky, you need to register for a KASPER account. You cannot hide. The process is electronic now which should help.
  • If you are wounded by flesh–eating zombies, abandon all hope, because sooner or later no matter how many antibiotics you take, you are going to become one of them.
    There are several rumors floating around that emergency physicians can somehow be insulated from this bill. It is simply not true and will affect your practice on a daily basis. You will need to become educated about the bill and how to best implement it in your department. KACEP would like to hear about how other departments are doing this so that we can learn from each other and have the best practice implementation possible.
  • Always listen to the crazy man warning you something bad is going to happen because he’s probably right! 
    Ok instead I’m the crazy woman but I believe that we have not even begun to see the ramifications of HB1 within the medical community. As always I will try to keep abreast of the situation, scream when I have to scream, listen when I have to listen and I will not announce openly that I am not afraid, that I don’t believe, or that I’m fully prepared. That’s just asking for trouble in this horror story.

Melissa Platt, MD, FACEP
President

**Adapted from A horror Movie Character’s survival guide

Advocacy 101
Wes Brewer, MD
Government Affairs

What is advocacy and why would you want to be involved?? The answer in a nutshell -- “a man can sit for a long time with his mouth open waiting for a roast duck to fly in.” Either we wait for good things to happen to us or we can actively work to bring about needed change to benefit our patients and our profession. Advocacy is speaking out for a cause; isn’t this the very heart of emergency medicine? This is and should be a core competency for everyone who works in the trenches on the front lines of medicine.

The activity once called lobbying attracted many unsavory characters and generated more than a few scandals, so now to separate legitimate activity the preferred term is advocacy. Whatever we choose to call it, there is a significant need for our involvement in the political process. Please do not write this off as “just politics”. Undeniably, we need paid folks knocking on doors in the capital everyday laying the groundwork as our day to day presence but we simply cannot sit back and delegate all the work. You have spent years developing an expertise; please use it to your benefit. We tend to think of legislators as being well versed on a myriad of issues on which they must make decisions but in reality they can have little knowledge of what we face daily unless we take the time to educate them. The job is complicated by the fact that our elected representatives are deluged with requests from multiple groups, many with interests directly in conflict with our interests. Effective advocacy is the way to make our message stand out above the rest.

Being an advocate demands that we have defined what it is that we want and have a thorough knowledge of the given issue. Simply griping about an issue after the fact will get you nowhere. Research your issue and be prepared to explain exactly why X, Y, or Z is not the correct strategy and what should be done instead.

Work on getting to know your legislator and their office staff. Remember that a conversation with a legislative aide is just as effective as meeting the legislator in person. Their staff serves as their eyes and ears. Remember also that offending the office staff is the best way to assure that nothing you say is heard. Complaining after the fact is unproductive, express your concerns and educate your target early in the process. Familiarize yourself with the process of guiding an idea through the legislative process.

Politicians live or die by their ability to interact with the public. Show up at a town hall meeting or even a campaign event and you will be surprised by how well you will be received. If they can connect your name and face with a particular issue suddenly your opinion becomes much more visible.

Finally, a few dollars well placed are a necessary evil. Remember Senator McConnell’s assertion that money is free speech. Citizen campaign contributions and investing in your political action committee is a legitimate and necessary expense to help assure that the needs of your patients and your profession are addressed. Remember that the average trial lawyer invests 10 times more money for political advocacy than the average physician and then we wonder how they always get what they want!

Governor Beshear Signs Senate Bill 58

Dr. Wes Brewer represented KACEP at St. Elizabeth Hospital Florence as Governor Beshear signed Senate Bill 58. Also participating in the ceremony were representatives of the Emergency Nurses Association, the KY Hospital Association, Administration and Emergency Department staff at St. Elizabeth and members of both the Kentucky House and Senate. KACEP leadership collaborated with several organizations in support of the passage of this bill designed to protect both emergency department personnel and patients from violence in the ED. The bill which takes effect July 2012 allows police to arrest perpetrators of violence against staff or patients in an emergency department without actually witnessing the act.

Beat the Summer Heat!!!
Ryan A Stanton, MD

I just spent 4 days working the infield care center at the Kentucky Motor Speedway, so if there is something I have gotten plenty of practice treating, its heat related illness. If this Spring and onset of Summer continue on their current path, we will all have plenty of opportunities to deal with this common, but 100% preventable emergency.

The most important thing for you as an emergency physician to do is quickly recognize the symptoms associated with heat exhaustion, heat stroke, and know what to do in order to prevent further damage and/or permanent disability. Another important role as emergency physicians is to teach. I have had the honor to do many interviews on this subject and though I repeat the same message over and over, there is never a shortage of people who need to hear it. There are plenty of resources on the CDC and ACEP website geared towards patient education that can be important tools when patients and the media come knocking. It is key that we position ourselves as leaders in public health and safety.

The key take home teaching points...

  1. Stay well hydrated and replace electrolytes. Alcohol and caffeinated beverages don't count. Hydrate before and though out activities.
  2. Take frequent breaks in the shade or in the A/C (even better)
  3. Avoid the hottest times of the day...work early and/or late.
  4. Wear light weight, light colored, loose fitting clothing.
  5. Be mindful of the elderly and young children, they are at increased risk.
  6. Never leave a child or pet in a vehicle unattended.
  7. Wear plenty of sunscreen on exposed skin and reapply often.
  8. If you start to have symptoms of heat related illness or recognize it in others, get help quickly.

It's hot out there, so find ways to beat the heat and help others to do the same.

Ryan Stanton, MD Receives Award

David Seaberg presents Spokesperson of the Year Award to Ryan Stanton at Leadership and Advocacy Conference

Defensive Medicine A Factor in Cardiac Admissions
ACEP News
December 2011

Fewer Heart Patients Sent Home
Defensive • from page 1

COMMENTARY Cover Your ... Malpractice Risk 

"Can I be sued for that?" is one of my least favorite questions asked by medical students and residents. "Unfortunately, yes, you can be sued for almost anything" is the regrettable reply.

Fear of litigation drives medical care in increasingly significant ways, as physicians order more tests, admit more patients, and prescribe more medications in attempts to reduce malpractice risk. Physicians are very aware of defensive medicine and its impact. Now we have increasing data to support this anecdotal knowledge.

Two important studies presented at the ACEP Research Forum in October in San Francisco looked at the issue of defensive medicine in the ED. The study by Dr. Newman and colleagues showed that physicians' practices in admitting cardiac patients are often driven by fear of litigation risk, rather than actual risk (Ann. Emerg. Med. 2011;58:S210). The study by Dr. Lenehan and colleagues demonstrated a dramatic increase in admissions for CHF over a recent 14-year period; the authors concluded that this was likely due to increasing concerns about medical malpractice litigation (Ann. Emerg. Med. 2011;58:S237). Both studies increase our understanding of the disturbing trend of defensive medicine.

Previous studies have attempted to estimate the costs of defensive medicine. Experts have estimated that defensive medicine wastes up to $210 billion annually (Kavilanz, P.B. "Health Care's Big Money Wasters." 2009 Aug. 10 [http://money.cnn.com/2009/08/10/news/economy/healthcare_money_wasters/index.htm]).

Not only does defensive medicine add to health care's bottom line, but additional tests, medications, and hospital admissions also may adversely affect patient care by increasing radiation exposure, adverse medication reactions, and nosocomial infections.

The obvious absence of liability reform in the recently enacted Affordable Care Act is extremely disappointing to emergency physicians who witness the effects of defensive medicine daily. Continued movement toward liability reform at both the state and federal levels is essential to controlling health care costs and to providing the optimal medical care to our patients. Write your congressman today! I did. (It's easy - go to acep.org and click on "Advocacy.")

DR. CATHERINE A. MARCO is a professor and program director, emergency medicine residency, and director of the medical ethics curriculum at the University of Toledo (Ohio). 

Actual risk often not discussed.

Elsevier Global Medical News 
ALICIA AULT

SAN FRANCISCO - Liability concerns may drive emergency physicians' decisions regarding patients with possible cardiac conditions, based on the results of two studies presented at the Research Forum of the American College of Emergency Physicians.

Many emergency physicians weighed legal concerns more heavily than actual risk when considering whether to admit a patient for acute coronary syndrome, concluded Dr. David H. Newman and his colleagues.

The conclusion was based on an observational, matched-pairs survey conducted at the emergency departments of St. Luke's Hospital and Roosevelt Hospital in New York. Patients who were admitted "primarily for acute coronary syndrome" were surveyed after they had discussed their admission with the physician. The admitting doctor also completed a survey after communicating with the patient.

Both were asked whether risk and prognosis were discussed, as well as about the perceived potential benefits of admission and perceived primary purpose of admission.

When asked to place themselves in the same position as the patient they had just evaluated, physicians often said that they would not have chosen admission for themselves but had admitted the patient, said Dr. Newman, director of clinical research in the department of emergency medicine at Mount Sinai School of Medicine in New York.

During the 18 months of the study, 849 surveys were completed. All patients had primary or secondary complaints of chest pain. Just over half were men. One-third were black, 24% were Hispanic, 23% were white, and 19% were "other" or did not report a race. The largest proportion had attended some high school or graduated (39%), 25% had attended college, 14% had a bachelor's degree, and 15% had a graduate or professional degree (Ann. Emerg. Med. 2011;58:S210).

Dr. Newman said in an interview that he and his colleagues were surprised to see that education level was not strongly correlated with risk communication or with agreement between the physician and the patient about true risk.

In a post hoc analysis, the authors calculated a mean risk of less than 5% for death, myocardial infarction, or revascularization within 30 days.

The physicians, however, estimated a mean risk for these outcomes of 15%, and patients estimated their risk at 33%.

One-third of patients and 48% of physicians said that coronary risk (the main reason for admission) had not been part of their discussion about admitting the patient. When coronary risk was discussed, agreement between the physician and the patient about the patient's level of risk was 0.38 (about 40% more likely to agree, compared with random chance).

In 11% of cases, physicians said that concern about liability was one of the reasons for admission. That concern likely represents millions of dollars in health care spending, Dr. Newman said.

In 27% of the cases, the doctor reported that if they were a patient with the same risk, they would not stay overnight. The results hint that "something is affecting patients' decision to stay even when someone with a theoretically much more complete understanding of the risks - the doctor - would not stay," Dr. Newman said.

"It is possible that physicians do not recognize the degree to which legal concerns affect these conversations, or perhaps other system pressures [such as] financial incentives, crowding, resource utilization, [or] time are affecting this conversation," he said. "What we can say with confidence is this: Doctors and patients in the emergency department are communicating poorly about the risks of death and heart attack, and this is something we need to fix."

In another study, Dr. Patrick J. Lenehan of Morristown (N.J.) Hospital and colleagues found that a decreasing number of congestive heart failure (CHF) patients were discharged from the emergency department in 1996-2010.

The authors retrospectively reviewed emergency department visits to 27 suburban, urban, and rural New York and New Jersey hospitals. The facilities had 18,000-72,000 annual visits. Using ICD9 codes, the researchers identified patients who had likely CHF. This group included those who had CHF, heart failure, or pulmonary edema as a primary diagnosis, or as a secondary diagnosis if the primary was shortness of breath or dyspnea (Ann. Emerg. Med. 2011;58:S237).

Of 6.6 million emergency department visits, 82,230 (1%) were for CHF. Half of the patients were women, and their mean age was 72 years. The authors found that there was a 63% decrease in the number of patients discharged from 1996 to 2010. In 1996, 24% were discharged. By 2010, only 9% were discharged.

The pattern was the same for male and female patients. Given that there has been no increase in the mean patient age, the difference in discharges is not likely the result of an aging population, the authors said. The "trend is mainly due to increasing concerns about medical malpractice litigation," they suggested.

The two studies indicate an ongoing crisis and the need to enact liability reform, said Dr. David Seaberg, ACEP president. "The rapidly rising tide of patients coupled with increasing hospital admissions from the emergency department will create pressure on the health system that is not sustainable," Dr. Seaberg said in a statement. "Liability reform could relieve some of that pressure and bring down costs."

No conflicts of interest were reported by the researchers.

Quality Measures for Crowding May Unfairly Punish Urban Hospitals

For Immediate Release: Contact: Julie Lloyd, 202-728-0610 x3010
May 30, 2012, www.annemergmed.com / twiter.com/emergencydocs

Throughput quality measures approved by the National Quality Forum (NQF) to measure emergency department wait times could unfairly punish certain types of hospitals, such as larger urban hospitals with certain types of illness and injury patterns, where crowding and waits result from factors largely out of their control, according to a study published online last week in Annals of Emergency Medicine(“Exogenous Predictors of National Performance Measures for Emergency Department Crowding”).

"Bigger hospitals with more visits tend to have worse flow and longer wait times, either because of the complexity of their patient loads, or because managing flow in larger urban hospitals is more of a challenge,” said lead study author Jesse M. Pines, MD, MBA, FACEP of the Departments of Emergency Medicine and Health Policy at George Washington University in Washington D.C. “The emergency department throughput measures are intended to compare hospitals of all sizes against each other. To a patient, waiting for 30 minutes is the same regardless of where you go. But what we found is that this one-size-fits-all measurement system can make it look like certain hospitals are performing badly, while in fact they may be performing well for their peer group of other large urban hospitals.”

Researchers compared lengths of stay (LOS), waiting times and left without being seen (LWBS) rates at hospitals of varying sizes with varying patient volumes for 2008 and 2009. Median wait time was 34 minutes, median LOS for treated and discharged patients was 132 minutes, median LOS for admitted patients was 244 minutes and the LWBS rate was 1.3 percent. Outside factors had a greater effect on wait times than on length of stay or LWBS rates.

For emergency departments with more than 60,000 annual visits, wait times were 25 minutes longer than for emergency departments with 20,000 or fewer annual visits. Other outside factors that contributed to longer wait times were hospital teaching status, patient age profiles and injury profiles. For example, emergency departments with 10 percent or less of visits due to injury had median wait times of 64 minutes, while those with more than 20 percent of visits due to injury had median wait times of only 26 minutes.

“The large number of significant variables outside of hospitals’ control made it impossible for us to construct a simple system for comparing these performance measures for crowding,” said Dr. Pines. “For example, we had initially thought that annual patient volume was going to be the major factor in predicting performance, but it ended up being more complicated because so many factors were important.”

As for what this means for patients, Dr. Pines added: “Looking at the raw times, a patient might choose a smaller, rural hospital with shorter waits without considering that certain hospitals might not be the best for their particular emergency. What ultimately may be needed is either a way for patients to compare waiting times in similar hospitals or an explanation of why waiting times or LOS just tends to be longer in certain hospitals. This will give people a more accurate picture of which hospitals are doing well and why.

ER Visits Will Increase Regardless of Today's Supreme Court Ruling

For Immediate Release: Media Contact: Laura Gore
June 28, 2012, 202-728-0610 x3008, www.acep.org

Emergency Physicians Pledge to Be There for Patients
WASHINGTON — In response to the United States Supreme Court’s decision to uphold the individual mandate of the Patient Protection and Affordable Care Act, Dr. David Seaberg, president of the American College of Emergency Physicians (ACEP), today issued the following statement:

“The nation’s emergency physicians fully support the emergency care provisions in the law, such as inclusion of emergency services as an essential part of any health benefits package and the prudent layperson standard, which guarantees that health plans base coverage on the patient’s symptoms, not the final diagnosis. And regardless of the Supreme Court’s decision, it does not change the mission of emergency physicians. We pledge to be there for our patients. 

“However, while there are provisions in the law to benefit emergency patients, it is clear that emergency visits will increase, as we have already seen nationwide. There are physician shortages and there are also drug shortages and serious mismatches between patient needs and available resources. 

“The need to shore up our nation’s emergency departments is as urgent as ever. People come to the ER because they are sick, because they need help, because they feel – according to a recent CDC report – that ‘only a hospital could help.’ A recent study in Annals of Emergency Medicine shows that crowding in emergency departments is growing twice as fast as the rate of ER visits, principally because emergency patients are showing up sicker and with more complicated health problems.

“As the nation moves forward with implementing the health care reform law, we urge the Senate to follow the lead of the House in repealing the Independent Payment Advisory Board, which was included in the law. The IPAB panel does not have any accountability to Congress, health care providers or the public and will harm Medicare patients’ access to medical care.

“Medicaid is intended as one of the means of expanding coverage. Increasing the number of patients on Medicaid without an equivalent increase in the number of physicians willing to take that insurance will surely increase the flood of patients into our nation’s ERs. Coverage does not equal access and critical problems facing emergency patients are not going away. 

“ACEP has worked with — and will continue to work with — members of Congress to find solutions to improve the safety and efficiency of emergency care for all Americans. ERs are a critical, life-or-death part of our health care system and ERs need help now. This crisis in emergency care is everyone’s problem, because every person is only one step away from a medical emergency.”

Dr. Seaberg adds that this law also includes medical liability dispute resolution alternatives, but that the scope is extremely limited, which limits its potential effectiveness. America’s medical liability system is broken and without true medical liability reform, patients’ access to lifesaving care will continue to suffer.

Clinical News

Analysis Supports FAST Exam in Pediatric Blunt Trauma
The bedside focused assessment with sonography for trauma exam is used infrequently in children with blunt abdominal trauma.

When the FAST exam was used in children with a low to moderate risk of intra-abdominal injury (IAI), however, there was a substantial reduction in subsequent abdominal CT use, a planned subanalysis of a large prospective, observational trial showed.
Read the entire article online

Dipstick Proteinuria Predicts Acute Kidney Injury in Septic Patients
De novo dipstick proteinuria accurately predicted acute kidney injury among 328 critically ill septic patients, a retrospective chart study has shown. 

With sepsis, inflammation results in increased capillary permeability to plasma proteins, manifesting in an increased excretion of albumin into the urine. Because the production of creatinine from the muscle is reduced in septic patients, relying on changes in serum creatinine could delay the diagnosis of this acute kidney injury (AKI), according to Dr. Javier Neyra.
Read the entire article online

FDA Warns of Seizure Risk with Cefepime
The Food and Drug Administration has reported cases of a specific type of seizure called nonconvulsive status epilepticus that is associated with the use of the antibacterial drug cefepime in patients with renal impairment.

The seizures have been seen primarily in patients with renal impairment who did not receive appropriate dosage adjustments of cefepime, although in several cases patients received “dosage adjustment appropriate for their degree of renal impairment,” according to the agency. The FDA is working to revise the “Warnings and Precautions” and “Adverse Reactions” sections of the cefepime label to highlight this risk.
Read the entire article online

Scientific Assembly - Denver, Colorado

If you have never attended the ACEP Scientific Assembly, you’re missing the world’s largest and most prestigious emergency medicine educational conference. Register today and find out why more than 6,000 emergency care professional will travel to Denver this year to be part of this unique ACEP experience!

Critical Decisions in Emergency Medicine

Did you know that ACEP has an official CME publication? Critical Decisions in Emergency Medicine, is highly rated by subscribers for its leading-edge clinical information. Not only is it the best source for timely and practical emergency medicine information, it was developed for your practice needs.

With a 1-year subscription, you’ll have the opportunity to earn up to 60 AMA PRA Category 1 Creditsâ„¢. In addition to the CME opportunities and relevant take-home points, you'll get TWO clinical lessons with topics chosen from the “EM Model.” Lessons are written by your peers under the direction of leaders in emergency medicine education, and guide you through the “critical decisions” you must make – When are imaging studies warranted? Which laboratory studies will guide you toward the right diagnosis? Which patients should be admitted?

Every issue of Critical Decisions also includes four Bonus features to help you with all the other areas of your practice. "The LLSA Literature Review" brings you synopses of the articles from ABEM's yearly LLSA reading lists. Each summary features bulleted highlights of the articles to help you focus your continuous learning efforts. "The Critical ECG", provides an ECG illustrating a challenging condition, along with a discussion of the subtleties of its interpretation. "The Critical Image" provides an image (CT, radiograph, etc.) along with a discussion of the visual clues leading to the correct diagnosis. "The Drug Box" is a concise review of indications, dosage, and contraindication for commonly used medications. 

Preview a sample issue to see why ACEP's official CME publication should be YOUR CME publication. 

Subscribe Now

Plus, back issues of Critical Decisions in Emergency Medicine for iPad® are now available. 
(Does not include CME)


App Store is a service mark of Apple Inc.

The American College of Emergency Physicians is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. 

The American College of Emergency Physicians designates this enduring material for a maximum of 5 AMA PRA Category 1 Creditsâ„¢ per issue. Physicians should claim only the credit commensurate with the extent of their participation in the activity. 

AAPA (American Academy of Physician Assistants) accepts AMA PRA Category 1 Creditâ„¢ for organizations accredited by ACCME. Approved by the American College of Emergency Physicians for 5 ACEP Category I credits per issue. Approved by the AOA for 5 Category 2-B credits. A minimum score of 70% is required.

Welcome New Members

Jennifer A. Cotton
Kean O. Feyzeau
John M. Mayo
Ravi J. Patel
Justen W. Pettigrew

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Kentucky Chapter ACEP
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Louisville, KY 40201

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