Summer 2014 Issue

Kentucky Chapter ACEP

Summer 2014

Kentucky Chapter ACEP

Ryan Stanton, 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
Ryan Stanton, MD, FACEP

It has been a while since we have last talked. The last EPIC is lost in ACEP cyberspace somewhere and thus the great words from your board are lost to history...and maybe the NSA. The moral of my "lost topic" was that the Kentucky state legislative session was rather rough for medical providers. Neither the "Review Panel Bill" nor the "Expert Witness Bill" were successful, though we have received word that our sponsors are interested in taking up our bill next year. The key for next session is that we MUST have greater involvement by the healthcare community and our members to help educate and overcome an incredibly powerful trial lawyer community.

That actually brings me to my next topic for this publication. I have believed that we live in a state in which our greatest chance for significant positive reform for patients and providers must come on the federal level. As much as I believe in states’ rights, there are only so many piles you can step on before you realize you need to go play in another yard. We are fortunate that we have some very supportive legislative representatives in Washington DC, which has been noticed on the state and national levels of ACEP. I want to thank a stellar team that made the hill visits representing Kentucky.

Wes Brewer is your President-Elect and has been tireless in his efforts for emergency medicine for KACEP. He has always had a great feel for the pulse of Frankfort and Washington. He has a great way of communicating with legislators and has been a fixture for our L&A team for seven years.

Brandon Pace is a resident at the University of Kentucky ER and is a fellow ETSU graduate like myself. It was his first visit to Washington DC...ever!!! Not only did he take in the many sites of DC with his wife, but represented the future of Emergency medicine well. I look forward to him being part of our delegation for years to come.

Andrew Ramsey represented the University of Louisville ER as a weathered pro and not to mention provided some great pictures with our legislators. He is a resident physician and also was attending his firstLeadership and Advocacy Conference. He has spent a fair amount of time in DC and was a great resource while we were there.

I enjoyed the hill visits with these guys. We had five meetings, including three with the actual legislative member. Our legislators are overall supportive of emergency medicine and the bills that are currently in front of congress. We have one of the more positive days during hill visits secondary to a delegation that understands the value of emergency medicine and the steps we must take to support providers and access to care. If we can only convince the rest of the country, it would be smooth sailing.

Dr. Rosenau, ACEP President presenting 911 Network Member of the Year to Dr. Stanton, KY ACEP President
There were three major legislative efforts for this session with ACEP. Of course, SGR repeal is an ongoing effort, but that pitch has become a broken record. EMTALA coverage and liability reform are a popular subject and there is currently a House (HR36) and Senate (S961) Bill. Most of our legislators support this bill and Rep. Barr has his own bill that would make EMTALA care or any federally funded care eligible for federal court and a physician review panel. Rep. Barr is the 6th district representative in the House and he gave a talk to our entire conference on his legislation, and is very supportive of our profession and ACEP. His bill would be golden for a state in which we have a toxic medico legal environment. Other bills include HR1180/S577 which is a GME funding bill that would expand residency positions by 3,000 per year for five years. This could be a great breakthrough for a system that has been frozen for 17 years. I think the message of a provider shortage is finally hitting home. And finally, ACEP has grasped the national emergency that is mental health care and access. HR3717 would help address mental health and hopefully provide access to much needed mental health providers, facilities and free much needed space in the ER.

I realize that politics is a painful pill to swallow, but we must be active. If we don't help drive the bus, we will quickly find ourselves under the bus. Over the next several years, the face of healthcare will change. It will change for better and worse, but we must be there to advocate for our profession and our patients. We must push the needle towards positive change. I call on you to help me and our profession on the local, state, and federal level.

Finally, keep your ear to the rail. We are planning to have a short ER medical director conference in conjunction with our annual meeting. This will be an opportunity to bring providers of all residency sources into the KACEP tent in order to advance emergency care in our state. As always, I am grateful for everything you do and your ongoing support.

Emergency Medical Services Certification Program

Kentucky Chapter of American College of Emergency Physicians would like to congratulate Franklin W. Fannin, Timothy G. Price, and Irvin Englert Smith for their recent Emergency Medical Services (EMS) certification program, developed by the American Board of Emergency Medicine.

Notes from the ACEP Leadership and Advocacy Conference, Washington, DC, 2014
Andrew Ramsey
University of Louisville, PGI

 

The ACEP Leadership and Policy Conference is an annual event in which ACEP membership converges on Washington DC to discuss broad-themed issues in emergency medicine, learn advocacy, and meet with elected officials to advance emergency medicine’s cause. This year’s conference had the highest attendance on record. The 500+ ACEP-member strong contingent, over several days, met with elected officials from 44 states. The five-member KACEP delegation was fortunate to meet with several local congressmen, including Brett Guthrie (R-KY 2nd), John Yarmuth (D-KY 3rd), and Andy Barr (R-KY, 6th), as well as senior staff for Senators Mitch McConnell (R-KY) and Rand Paul (R-KY). Major issues presented for discussion this year included EMTALA liability reform, mental health services, and increasing GME funding for residencies.

Whether or not this year’s meetings will inspire policy change is yet to be seen. However, it’s certain that Kentucky’s emergency medicine community makes an impact in Washington, DC. At the conference, Ryan Stanton, KACEP’s current president, was honored with the ACEP 911 Member of the Year Award, given to an ACEP member who exemplifies outstanding political engagement. KACEP member Steven Stack, an EP from Lexington, KY, was recognized as the incoming president of the American Medical Association. Kentucky congressman Andy Barr (R-KY 6) championed his support for emergency medicine to the ACEP delegation as he discussed his bill, H.R. 4106, which proposes “safe harbors,” in which physicians are given special liability protection when practicing within established care guidelines. Wes Brewer, KACEP’s president-elect, effortlessly mediated a cooperative dialogue between the physician advocates and delegates. These national accolades are not to detract from countless hours of backyard-advocacy practiced around KY.

I expect that advocacy conflicts with the modus operandi of many EPs. Advocacy requires infinite patience in the face of systemic inefficiency, encourages a malleable political countenance, and has no tangible endpoint. Relationships facilitate outcomes. There is no algorithm consistently leading to success; it is a low-yield intervention. Despite these challenges, it is critical that ED physicians become involved with advocacy. Emergency department visits are increasing with the Affordable Care Act and EPs, the stewards of around-the-clock healthcare, must advocate for their departments. Without our voices, our perspective will surely be lost in the melee. As we learned from our recent conference experience, however, congressional doors are open to ACEP membership. Take a few minutes and lend your voice to the EP call.

Altered Standards
Daniel J. O’Brien, Chair, Emergency Medical Services
KACEP Committee, Government Affairs

As Emergency Medical System experts we understand the necessity of field triage and we understand that a disaster may be in the eye of the beholder. If it appears that, for even a brief
period of time, that the resources at the scene are being outstripped by the situation at hand we understand that it is necessary and appropriate to triage both the patients and the resources according to the triage model we have adopted, the resources and the need. It happens often and thankfully briefly such as when an ambulance comes on the scene of a motor vehicle crash with multiple victims. Once additional units arrive the scene frequently reverts from the triage footing to standard practice.

But what if the resource limitation wasn’t in the field? What if it was in your hospital? What if it was to last for days or even weeks? What are your obligations? What are your liabilities?

Let’s take a look at a real-life scenario. Let’s see how we might do in the same situation. In August 2005 the floodwaters of Hurricane Katrina marooned Anna Pou, MD and the remaining staff of the Memorial Medical Center in Upton New Orleans. The power was knocked out, there was no running water and temperatures soared to over 100 degrees. The backup generators survived the storm but were threatened by sewer water flooding the power switches just a few feet above the ground.

The physicians formulated an evacuation plan. It initially didn’t include fifty two patients in an adjacent long-term facility. Coast Guard and disaster services were well aware of their issues. The sense was that everyone would be evacuated in a few hours. A crew of doctors, nurses and family members carried patients to the only working elevator to roof of a parking garage and through a 3-by-3 foot hole cut in a machine room to get the patients to a helipad where the Coast Guard took over. By nightfall the patient count was reduced from 180 to 130 patients.

Evacuations stopped at nightfall. The adjacent long-term facility personnel were working to secure evacuations that would occur in the morning.

In the middle of the night the generators failed. After two days without sleep, little food and no water the volunteers attempted to get as many of the fifty-two long-term acute care patients to the helipad. Seven flights of stairs. No lights. No elevator. Ventilator patients became the first priority. Ambu bags were distributed. There wasn’t enough oxygen and manpower to save them all. Triage decisions were made.

The patients were assigned to three groups. Group ONE’s were moved to the ED to be evacuated by boat on the morning. Group TWO’s was placed in a line along the corridor leading to the hole that led to the helipad. Group THREE’s were moved to a corner of the building to wait their turn.

The next morning arrived. Coast Guard and military rescue operations began shifting to rooftop rescues and other priorities. Fewer and fewer helicopters and boats arrived. At 72 hours of
continuous work it became clear that some patients were not going to be able to be evacuated from the seventh floor and that most of the remaining patients were in critical condition. The
heat was rising. There was little food and no water. The staff was spent. Some physicians and Dr. Pou decided to sedate some of the Group THREE patients with morphine and midazolam.

After four days the hospital was evacuated. Forty-five decomposing corpses were found, several from prior to the disaster, and Dr. Pou was arrested and charged with murder in the deaths of four patients.

Are Physicians Protected in Emergencies?
The Emergency Medical Treatment and Active Labor Act (EMTALA) outlines the standard of care and, in theory, provides some liability protection in that it must be determined if a patient has an emergency condition, if so stabilized and if necessary transferred to a facility willing and able to provide care. However, EMTALA does not apply to inpatients.

What about the Volunteer Protection Act of 1997 (VPA)? It doesn’t apply if you are a staff physician.

What about Louisiana’s Good Samaritan Act? It doesn’t apply to staff physicians

The good news:
In December 2001 the Centers for Disease Control (CDC) released the Model State Emergency Powers Act (MSEHPA). Which include provisions intended to ensure the development of comprehensive plans for emergencies, facilitate early detection and grant state and local officials powers in order to handle emergencies. This includes providing immunity to physicians for causing death or injury to any person…except in the event of gross negligence or willful misconduct. Forty-four states and the District of Columbia has passed bills or resolutions related to the act.

The bad news:
Kentucky is not one of them.

Dr. Pou was charged and brought before a grand jury that refused to indict her. There are three civil suits pending. We will never know exactly what happened on those four days in August
but we would be wise to reflect on what would happen if that had been one of us.

Kentucky is exploring the creation and adoption of altered or crisis standards of care that would be authorized and implemented in a disaster. This will be a complex project. A State Disaster Medical Advisory Committee has been created with a broad mix including representatives from the governor’s office, the National Guard, Homeland Security, hospitals, clinics, ethicists, and special needs populations to name but a few. The Kentucky Chapter of ACEP was well represented at a recent working group of the committee. The creation of Altered Standards that are implemented within the framework of a declared disaster and authorized by the Governor’s Office would go a long way to protecting the citizens and healthcare providers of our commonwealth. There will be significant resistance and it will take a great effort but it is our hope that our organization will have a major role in their development.

Wes Brewer
President Elect
Chair, Governmental Affairs

The Kentucky Legislature is once again in session and not to anyone’s surprise the partisan gridlock remains astounding. Do not despair because every now and then a good bill will actually make it through and become law. Despite partisanship, much of what drives legislative activity is citizen involvement. Legislators respond to numbers. That is why your involvement is so crucial but unfortunately so lacking. Physicians generally have the notion that if we support a cause that is good and beneficial everyone will see that and our legislators will thoroughly understand each and every issue and vote accordingly. Every issue that comes before the legislature has multiple different angles and agendas. The trick is to get your points across in a convincing manner above the rest of the noise. Here is where we have to do much of the heavy lifting. If we do not speak for ourselves, not many will step forward to do so. My suspicion is that most of us neglect to make that call to our legislator to respond to an action alert or leave a message on the legislative hotline because we feel that one call or one message will not have a big impact. It is true that your legislator may not actually see your actual comments but I can assure that they do keep a close watch on response to issues. Every day they will see a stack of messages divided into yes and no piles. Opinion is indeed swayed by the size of the stack. If you are not contributing to these processes, you are by default allowing someone else to speak for you.

If you have never had the opportunity to visit the Capitol while the General Assembly is in session put it on your bucket list. The atmosphere is not unlike a crowded Middle Eastern bazaar. Each day you can barely make your way through the halls because of hordes of people there trying to influence some obscure piece of legislation. Last week Ryan Stanton and I spent an entire day in Frankfort advocating for our expert witness bill. I was immediately struck by the fact that during almost every meeting a comment was made about how rare it was for physicians to contact their elected officials much less to actually have face to face meetings. While the two of us trudged from office to office, I could not help but notice how many interest groups were there with easily a hundred or more members. Makes you wonder who really got heard that day.

ICD-10-CM
Melissa Platt, Immediate Past President
Chair, Medical Reimbursement Committee

Here are some common questions to help familiarize yourself and your practice about the upcoming ICD-10.
The answers were provided by ACEP.


FAQ. What is ICD-10-CM?
ICD-10-CM is the long awaited diagnosis code set revision to ICD-9-CM. There is another code set known as ICD-10-PCS (Procedure Coding System).

The International Classification of Diseases (ICD) is the copyrighted official publication of the World Health Organization (WHO) and is part of the WHO family of classifications (which includes International Classification of Functioning, Disability and Health, International Classification of Health Interventions and International Classification of Diseases for Oncology). The primary purpose of ICD is for epidemiological tracking of illness and injury. ICD has been used in the US since 1949 (ICD¬6). The first formal US adaption was by the US Public Health Service with ICD¬7. The current US adaptions are controlled by the “cooperating parties”: National Center for Health Statistics/CDC (NCHS), Centers for Medicare and Medicaid Services (CMS), American Hospital Association (AHA), and American Health Information Management Association (AHIMA).

Until recently, WHO revised ICD every 8-10 years. The US version of ICD-9 (ICD-9-CM [clinical modification]) has been in use since 1979. ICD-10 was approved by the World Health Assembly in 1989 and released for use in 1994. It is currently used by a majority of countries. The US has been using ICD-10 for mortality statistics since 1999.

FAQ. What is the implementation date for ICD-10?
On January 16, 2009, the Department of Health and Human Services released the HIPAA Administrative Simplification: Modifications to Medical Data Code Set Standards to Adopt ICD-10-CM and ICD-10-PCS Final Rule (CMS-0013-F). At this writing, the scheduled compliance date for implementation of the ICD-10-CM/PCS Coding System is October 1, 2014 for all covered entities.

FAQ. Why do we need ICD-10-CM?
Frankly, ICD-9-CM is running out of codes. Hundreds of new diagnosis codes are submitted by medical societies, quality monitoring organizations and others annually. ICD-10-CM will allow not only for more codes but also for greater specificity and thus better epidemiological tracking. This will allow providers to better identify certain patients with specific conditions that will benefit from tailored disease management programs, e.g. diabetes, hypertension, asthma.

FAQ. How are ICD-9 and ICD-10 different?
The ICD-10-CM codes are very different from those currently used in ICD-9-CM. All codes in ICD-10-CM are alpha-numeric. There may be up to seven alpha-numeric characters, requiring billing software program changes to accommodate the additional digits, as well as extensive coder training. ICD-10-CM will have greater specificity (i.e. granularity) along with laterality (anatomic location). Specialty societies had significant input in the development of the depth of detail they wanted to enable the tracking of certain conditions and injuries. Given the increased level of coding specificity required by ICD-10, it is anticipated the degree of documentation required by physicians will also increase.

ICD-10-CM codes will be able to provide more in depth information about the patient's condition that can be more easily captured in an electronic medical record. Physician (HCFA 1500) and hospital (UB-04) billing forms have been updated to accommodate the changes.

Examples: ICD-9-CM ICD-10-CM  
Precordial Chest Pain 786.51 R07.2  
Asthma, Acute Exacerbation 493.92 J45.901  
       
Thumb laceration      
Thumb, w/o nail damage, initial encounter 883.0 S61.011A Laceration w/o FB, right thumb, initial encounter
    S61.012A Laceration w/o FB, left thumb, initial encounter
    S61.019A

Laceration w/o FB, unspecified thumb, initial encounter

 

*Just as with ICD-9-CM, clear physician documentation will be important to aid in assigning appropriate ICD-10-CM codes.

FAQ. What are the estimated costs for adopting the new ICD-10 coding systems?
There have been many questions as to the cost of implementing ICD-10. The RAND Science and Technology Policy Institute is publishing its findings on the cost and benefits of implementing ICD-10. According to the draft executive summary, providers will incur costs for computer reprogramming, the training of coders, physicians, and code users, and for the initial and long-term loss of productivity among coders and physicians. The cost of sequential conversion (10-CM then 10-PCS) is estimated to run $425M to $1.15B in one-time costs plus somewhere between $5 and $40 million a year in lost productivity.

RAND assumes the benefits as largely coming from the additional detail that ICD-10-CM and ICD-10-PCS would offer. The benefit of more accurate payments to hospitals for new procedures ranges from $100M to $1.2B. Benefits from fewer rejected claims would be $200M to $2.5B and $100M to $1B for fewer exaggerated claims. The identification of more cost-effective services and direction of care to specific populations would result in a benefit of $100M to $1.5B. This is in addition to any benefits that would come from better total disease management and better directed preventive care.

Blue Cross and Blue Shield sponsored a study to determine costs to the health care industry in adopting ICD-10-CM and ICD-10-PCS. The study indicated a cost range of $5.5-13.5 billion for systems implementation, training, loss of productivity, re-work, and contract re-negotiations during a 2-3 year implementation period. Over half of the costs would be borne by health care providers. Long term recurring costs for loss of productivity were estimated at $150 million to $380 million. However, both hospitals and third party payers have already made extensive investments in preparation for the October 1, 2014 scheduled change over.

"Recreational" Drug Use Like Playing Russian Roulette
Feb 11, 2014

WASHINGTON, Feb. 11, 2014 /PRNewswire-USNewswire/ -- The untimely deaths of actors Philip Seymour Hoffman and Cory Monteith from drug overdoses once again highlight a serious continuing public health problem in America that emergency physicians see every day. "We see up close and personal the severe damage these poisons can do to the human body," said Dr. Alex Rosenau, president of the American College of Emergency Physicians. "Sadly, for many overdose victims, it's too late. They are not lucky enough to make it through the doors of an emergency department for a chance that we can save them."

According to the Centers for Disease Control and Prevention (CDC), drug overdose was the leading cause of injury death in 2010. Among people 25 to 64, drug overdose caused more deaths than motor vehicle crashes.

  • More than 75 percent of the 38,000 drug overdose deaths in 2010 were unintentional and 60 percent were related to prescription drugs.
  • Drug overdose deaths rose 102 percent from 1999 to 2010.
  • In 2011, drug misuse and abuse caused 2.5 million emergency room visits.
  • Illicit drug abuse contributes $11 billion to health care costs, according to the National Institute on Drug Abuse.

"Using substances like heroin, cocaine or methamphetamine is like ingesting toxic chemicals," said Dr. Rosenau. "It's a huge risk, not only of addiction, but with your life."
A recent study in Annals of Emergency Medicine found that states that decriminalized marijuana saw dramatic increases in poison center calls and emergency department admissions regarding children with unintentional marijuana exposures. The study says that high-doses of the drug in edible products, such as candies, cookies and chocolates, may have played a significant role in the increase rate of accidental reported exposure, chiefly because kids can't distinguish between products that contain marijuana and those that don't.
Emergency physicians urge you to be on the lookout for warning signs if you suspect a loved one may be involved with illicit drug use. They include:

  • Physical changes like a lasting cough or red, glazed eyes and repeated health complaints.
  • Emotional changes, like sudden mood swings, personality change, depression, poor judgment and irritability to name a few.
  • Family changes like starting arguments or withdrawing attention as well as breaking rules.
  • Social changes like new friends, problems with the law and changes to less conventional styles in dress and music.
  • If it's a student — issues may include lack of interest in school, lower grades, increased absences from class and discipline problems.

For information on how to get help, please go to our website www.EmergencyCareForYou.org.
ACEP is the national medical specialty society representing emergency medicine. ACEP is committed to advancing emergency care through continuing education, research and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies.
SOURCE American College of Emergency Physicians (ACEP)
For further information: Mike Baldyga, 202-370-9288, mbaldyga@acep.org

Submitted
Tadd Roberts
Chair, Emergency & Disaster Preparedness

Open World
Russia
Healthcare in the US May 23-31, 2014
Louisville, KY

Sponsored by the
Open World Leadership Center
About the World Affairs Council of Kentucky & Southern Indiana:

 

The World Affairs Council of Kentucky and Southern Indiana (WAC) is a community-based non-profit membership organization created for the purpose of developing cross-cultural relationships among professionals and institutions in the Louisville area and their counterparts throughout the world, and to sponsoring educational programs on international affairs for our state and community. WAC has participated in the Open World Program since its inception, and is experienced in all types of professional and cultural programming for Open World Delegations.

  • Dr. Arsen Tazhutinovich Aliyev
  • Dr. Anton Valeryevich Dragunov
  • Dr. Aleskey Yuryevich Golev
  • Dr. Konstantin Anatolyevich Kondrashov
  • Dr. Vasiliy Vladimirovich Monastyrev
  • Dr. Kamo Eduardovich Nazaryan
  • Ms. Vera Vladimirovna Paponova, Open World Facilitator
  • Mr. Sergei Vladov, Interpreter
  • Dr. Daniel J O’Brien, KACEP EMS Committee Chair
  • Dr. Melissa Platt, KACEP Past President, Medical Reimbursement Chair
  • Mrs. Ashlee M Melendez, KACEP Executive Director

Clinical News

Hypertonic Saline Indications for Bronchiolitis Lack Evidence for Clear Guidance
The therapeutic value of hypertonic saline in treating bronchiolitis in young children remains unclear, based on the findings of two randomized controlled trials with conflicting results.
Read the entire article

Statins Don't Help, May Harm in COPD, Sepsis-Associated ARDS
Two separate prospective, multicenter trials of statins stopped early when interim results showed they did not help – and potentially harmed – patients with moderate to severe chronic obstructive pulmonary disease or sepsis-associated acute respiratory distress syndrome.
Read the entire article

Telemedicine Gives Small Hospitals the Biggest Boost in rTPA Use for Stroke
A telemedicine program for patients with acute ischemic stroke increased the use of recombinant tissue plasminogen activator by as much as 13% in the year after implementation.
Read the entire article

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