Winter 2011 Issue

Winter 2011 Issue
Kentucky Chapter ACEP

Winter 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

National ACEP News: Three-Quarters of Emergency Department Directors Responding to Survey Report Inadequate Surgical Coverage

The majority of emergency department directors responding to a survey report inadequate on-call trauma coverage, and nearly one-quarter report a loss or downgrade of their hospitals’ trauma center designations. The survey results are reported in Academic Emergency Medicine (“The Shortage of On-Call Surgical Specialist Coverage: A National Survey of Emergency Department Directors”). “Twenty-one percent of emergency department deaths and permanent injury can be linked to shortages in specialty physician care. Transferring patients significant distances to an available specialist is sometimes the only option, but it can create a dangerous delay in care” said lead study author Mitesh Rao, MD, MHS, of the department of emergency medicine at Yale University.

Sixty percent of respondents reported losing the ability to provide round-the-clock coverage for at least one medical specialty in the last four years. More than three-quarters of respondents reported that their emergency departments have inadequate coverage for plastic surgery, hand surgery and neurosurgery. Almost one-quarter of survey respondents reported an increase in patients leaving before being seen by a medically needed specialist, which is known to lead to worse outcomes and increased need for hospitalization. “More than 70 percent of respondents noted difficulties with their neurosurgical coverage, and 80 percent reported inadequate hand surgery coverage,” said Dr. Rao. Teaching hospitals fare better than non-teaching hospitals, with inadequate coverage reported at 68 percent of the former and 78 percent of the latter. However, that may increase the burden on what the Institute of Medicine considers “core safety net providers” if non-teaching hospitals increasingly transfer patients who need surgical care to teaching hospitals.

State/Local News
Neither a wise man nor a brave man lies down on the tracks of history to wait for the train of the future to run over him.  ~Dwight D. Eisenhower

Here is an update on Kentucky’s Trauma Care System provided by information from Richard Bartlett who sits on the Trauma Advisory Committee (KyTAC). In 2008, House Bill 371 established a framework for an unfunded statewide trauma system.  It also established the KyTAC. Since the Trauma Care System has been in place, the number of verified trauma centers has increased, and Marcum and Wallace Hospital in Irvine (Estill County) was the first to be verified in September 2010, using Kentucky’s new Level-IV criteria. Multiple Rural Trauma Team Development Courses have been conducted in locations throughout the state to help interested rural facilities with preparations for future verification and educational offerings have been provided to aid in staff development and training. Administrative regulations for the system’s operation have been crafted, and are being reviewed within the Kentucky Cabinet for Health and Family Services for publication in the Kentucky Administrative Register. Continued funding continues to be a challenge. Thanks to those who have put so much time and effort into this cause. 

Of note, Dr. Daniel O’Brien will take the reins from Dr. Christopher Pund as the KACEP representative on the advisory committee. 

Personal
This past November, I had the opportunity to attend the weeklong session of the Emergency Department Directors Academy Phase 1. This ACEP course is divided into 4 phases spread over 2 years with the goal that at a medical director’s level, the act of healing and the science of medicine become one with the business of delivering care (their words not mine). Nonetheless, phase 1 was informative, engaging and well worth it to find 5 days off to travel to Dallas, Texas. The topics discussed were germane to the majority of medical directors. Topics included risk management, finance, contracting, information systems and management skills to name just a few. With receptions nearly every night and a diverse participant population representing the majority of practice-types; it was a great place to network and learn.

EMS Committee Chair
Daniel J. O’Brien, MD

Kentucky has made significant strides in the development of its statewide trauma system. Through the efforts of many dedicated individuals and institutions Kentucky has progressed from only two trauma centers a few years ago to three verified Level ONE centers, two verified Level THREE centers along with an additional Level ONE center, one LEVEL TWO, three LEVEL THREE and four LEVEL FOUR centers performing as non-verified, functional centers.1 However, even as the Kentucky Trauma Advisory Committee and the many other individuals and agencies continue to strive to improve the trauma management infrastructure, it is clear that without significant resources and additional brick and mortar, providing access to quality trauma care to over 4.3 million Kentuckians spread over almost 40,000 square miles will continue to require a comprehensive, high quality prehospital and interhospital transport system.2 In this milieu air medical transport systems have proliferated from three in the nineties to over twenty six aircraft based in Kentucky and over thirty-five overall providing services to the commonwealth. Accounting for only helicopters based within the state, Kentucky has the fifth highest number of aircraft-per-capita in the United States.3 This is not necessarily a problem if the mission is to deliver the opportunities and benefits of the “Golden Hour” to the majority of our citizens. But it is not without risk. Imagine if there were a medical procedure that on frequency of one in 37,000 would go awry and kill the patient, the physician and medical technician?4 There would be an outcry. Yet those are the 2009 crash statistics in the United States for helicopter EMS systems. The American College of Emergency Physicians (ACEP) issued a statement in February 2009 encouraging the respective parties to work on making the industry safer as well as calling for more physician oversight of these systems and reaffirmed that medical decisions and protocols be in the patients best interest.5 Helicopter safety has been approached in fits and starts since the inception of civilian systems. However from 2003-2008 there were 85 accidents and 77 fatalities. Helicopter EMS (HEMS) dedicated crews had the highest fatality rate (113 per 100,000 employees) of any occupation. Over two times that of structural iron and steel workers, four times that of electrical powerline installers or coal miners and six times that of police officers.6 The National Transportation Safety Board (NTSB) and Federal Aviation Administration (FAA), with input from the industry have developed a comprehensive list of recommendations to improve the safety record of the industry.7  Notably to require pilots to have Instrument Flight Rule (IFR) certification, require Helicopter Terrain Awareness and Warning Systems, radio altimeters and additional pilot training to recover from unusual attitudes to name a few. Interestingly the NTSB gave their recommendations to the Centers for Medicare and Medicaid to evaluate the reimbursement structure to see if the rate should differ according to the level of transport safety offered. The Association of Air Medical Services (AAMS) by-and-large has agreed with the proposals.8

As a physician what can you do to promote patient safety? There has been and there will likely continue to be significant controversy about the efficacy and overutilization of these systems. In the largest study to date of 41,987 subjects transported by helicopter it was shown that despite being more severely injured than ground transported patients, despite requiring more resources and having longer transport times, they were more likely to survive and be discharged home than those transported by ground.9 In 2009 ACEP published a policy statement entitled: Appropriate Utilization of Air Medical Transport on the Out-of-Hospital Setting.

Appropriate Utilization of Air Medical Transport in the Out-of-Hospital Setting

The American College of Emergency Physicians (ACEP) recognizes that helicopter air medical care is a crucial component in a tiered response (including all levels of EMS providers, BLS and ALS ground services, rescue, etc) for the expeditious initial care and delivery of the patient to an appropriate health care facility. An air medical helicopter should be an appropriately equipped and licensed ambulance that is staffed with adequate personnel to provide rapid and stabilizing care under various conditions. The air ambulance personnel should provide this care with the supervision of a qualified emergency physician cognizant of the unique features of air evacuation and use approved protocols for direct on-line as well as off-line medical control. Dispatch of the air ambulance should be under the direction of the appropriate emergency medical response entities.

Appropriate reasons to use an air medical helicopter in the out-of-hospital setting include:
1. Patient has a significant potential to require high-level life support available from an air
    medical helicopter, which is not available by ground transport.
2. Patient has a significant potential to require a time-critical intervention and an air medical
    helicopter will deliver the patient to an appropriate facility faster than ground transport.
3. Patient is located in a geographically isolated area, which would make ground transport
    impossible or greatly delayed.
4. Local EMS resources are exceeded.

The air ambulance should be recognized as a regional resource that is available to every person needing care, at any time (weather permitting), regardless of the ability to pay. The patient should have initial stabilization and preparation for flight, and then be expeditiously transported to the closest appropriate facility. (Approved 1999; Revised 2008)10 There is an excellent clinical decision tree available for download at (http://www.epmonthly.com/images/stories/Jan10/helo_figures.pdf).

Physician medical directors of critical care transport systems are aware of these issues and have been meeting regularly in the state to provide guidance and standards on medical and aircraft safety to the industry. All medical directors of critical care transport systems have been invited to participate in this Critical Care Transport Group.

In summary, as our trauma system evolves air medical systems will continue to play a critical role. The literature affirms that these systems can save lives and reduce morbidity. However, as with any invasive medical intervention there are risks. Physicians should approach air medical transport as they would any potentially hazardous medical procedure. There must be informed consent, the benefits should clearly outweigh the risks and the significant costs should be considered in the equation. We must be an advocate for our patients and our fellow healthcare providers.

1. http://www.kyha.com/wp-content/uploads/2009/12/traumasystemmaps.pdf
2. http://quickfacts.census.gov/qfd/states/21000.html
3. http://www.washingtonpost.com/wp-srv/special/nation/medical-helicopters/state-by-state.html
4. http://www.ntsb.gov/speeches/sumwalt/acep-10052009.pdf
5. http://www.acep.org/content.aspx?id=44232
6. http://www.ntsb.gov/speeches/sumwalt/AAMS-update-March-2010.pdf
7. http://www.federalregister.gov/articles/2010/10/12/2010-24862/air-ambulance-and-commercial-helicopter-operations-part-91-helicopter-operations-and-part-135
8. http://www.aams.org/AAMS/MemberServices/PublicPolicyPublicAffairs/AAMS_NPRM_Comments_-_Final.aspx
9. Brown J, Stassen N, Bankey P, et al. Helicopters and the civilian trauma system: National utilization patterns demonstrate improved outcomes after traumatic injury. J Trauma. 2010;69:1030-1036
10. www.acep.org/workarea/downloadasset.aspx?id=9104

Governmental Affairs
Wes Brewer ,MD

 I fully intended to use this space for an update about healthcare reform then I realized everything will probably have changed by the time you are reading this article. After over two years we are still unsure whether reform efforts will buy us a seat on the bus or whether the bus tires are about to roll over our heads, so for this column I will discuss a developing topic that demands our attention.

We can all agree that our primary care system is fragile and needs to be enhanced, but do they have to attack emergency medicine to accomplish their objectives? Since the beginning of the healthcare reform debate, the primary care folks have been aggressively promoting their agenda. Advancing the Medical Home model is the new buzzword - that is all well and good; however, I can't count the number of times in the past months I've heard primary care leaders in meetings or hearings state that a medical home would get the 20 to 25 percent of "inappropriate patients" out of the emergency room. I personally heard the Dean of one of our medical schools testify before a legislative commission that by "enhancing primary care" (I suspect that entails more money?) the inappropriate patients would be out of the ED and would lead to a significant reduction in the need for Emergency Medicine residency training. He did not indicate in which century this would likely happen!

We need not be confrontational, but we must challenge assertions that we know have no factual basis. The 20% number is either old data or rank speculation. Closer to the truth is the CDC data reporting that 8% of ED visits nationwide are triaged as non urgent. In addition, a significant portion of those visits occur at times when primary care is not available or are from patients who have been instructed to come to the ED or sent from nursing homes.

I will challenge each of you to use these conversations to educate your colleagues and your hospital administration as to the value of Emergency Medicine. We need to repeat and repeat again that we are not expensive care but rather are cost effective and efficient, especially for those patients who need their evaluation  and treatment begun in a time sensitive manner. Gently explain that overcrowding and long wait times are generally the result resource deficiencies and not as a result of hordes of non-urgent patients clogging the system. Feel free to point out the fact that access to insurance does not equal access to care. Remember the experience in Massachusetts that demonstrates that more people having insurance translated into much higher ED volumes. Finally, it is OK to remind our colleagues and our administrators about our role as the social safety net for those folks who sadly for a variety of reasons will never be invited into a comfy "medical home." Now tell me again about reducing those residency slots!

End of Rant

Emergency Preparedness and Disaster Planning                     �
Committee Chair
L. Barrett Bernard, MD

Influenza Update
The occurrence of influenza is taking the predicted pattern in numbers and type. 20% of tests are currently positive and the viruses identified include 66% influenza A and 34% influenza B with 7% of the influenza cases positive for the 2009 H1N1 type. Kentucky one is of eight states that has shown the most widespread geographic activity. The recommendations for antiviral agents and diagnostic tests are the same as in 2010. For these guidelines refer to the website www.cdc.gov/flu/professionals/antivirals/index.htm or www.cdc.gov/flu/professionals/diagnosis/.

MRSA
MRSA is a common diagnosis in the ER and below is the first comprehensive guideline of treatment for this disease by the IDSA. This article has been endorsed by ACEP. Included below are the tables of recommendations for the more commonly occurring SSTI but treatment of other systemic MRSA sites of infection are described in detail in the article. The entire article,  Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of MRSA infections in Adults and Children (published in Clinical Infectious Diseases Jan. 4, 2011), can be reviewed through the ACEP website.

Seat Belt Use
A recent CDC study reveals that seat belts reduce serious injuries and deaths by 50%. There are 19 states or 24% of the population that still do not have a primary enforcement law that allows law enforcement officers to pull over drivers for not using seat belts. The ER is a great opportunity to promote safety by encouraging proper seat belt use.

Disaster Preparedness
In view of the recent Tucson disaster it is an appropriate time to review the hospital policy regarding disaster preparedness. Excellent resources for guidelines to compliance can be found under Clinical Practice Management on the ACEP website and on the KMA website.   

Table 2.

Conditions in which Antimicrobial Therapy is Recommended after Incision and Drainage of an Abscess due to Community-Associated Methicillin-Resistant Staphylococcus aureus

Severe or extensive disease (eg, involving multiple sites of infection) or rapid progression in presence of associated cellulitis

Signs and symptoms of systemic illness

Associated comorbidities or immunosuppression (diabetes mellitus, human immunodeficiency virus infection/AIDS, neoplasm)

Extremes of age

Abscess in area difficult to drain completely (eg, face, hand, and genitalia)

Associated septic phlebitis

Lack of response to incision and drainage alone


Table 3.  
Recommendations for the Treatment of Methicillin-Resistant Staphylococcus aureus (MRSA) 

 

Manifestation

Treatment

Adult dose

Pediatric dose

Classa

Comment

Skin and soft-tissue infection (SSTI)

         

Abscess, furuncles, carbuncles

Incision and drainage

   

AII

For simple abscesses or boils, incision and drainage is likely adequate. Please refer to Table 2 for conditions in which antimicrobial therapy is recommended after incision and drainage of an abscess due to CA-MRSA.

Purulent cellulitis (defined as cellulitis associated with purulent drainage or exudate in the absence of a drainable abscess)

Clindamycin

300–450 mg PO TID

10–13 mg/kg/dose PO every 6–8 h, not to exceed 40 mg/kg/day

AII

Clostridium difficile–associated disease may occur more frequently, compared with other oral agents.

 

TMP-SMX

1–2 DS tab PO BID

Trimethoprim 4–6 mg/kg/dose, sulfamethoxazole 20–30 mg/kg/dose PO every 12 h

AII

TMP-SMX is pregnancy category C/D and not recommended for women in the third trimester of pregnancy and for children <2 months of age.

 

Doxycycline

100 mg PO BID

≤45kg: 2 mg/kg/dose PO every 12 h >45kg: adult dose

AII

Tetracyclines are not recommended for children under 8 years of age and are pregnancy category D.

 

Minocycline

200 mg × 1, then 100 mg PO BID

4 mg/kg PO × 1, then 2 mg/kg/dose PO every 12 h

AII

 
 

Linezolid

600 mg PO BID

10 mg/kg/dose PO every 8 h, not to exceed 600 mg/dose

AII

More expensive compared with other alternatives

Nonpurulent cellulitis (defined as cellulitis with no purulent drainage or exudate and no associated abscess)

β-lactam (eg, cephalexin and dicloxacillin)

500 mg PO QID

Please refer to Red Book

AII

Empirical therapy for β-hemolytic streptococci is recommended (AII). Empirical coverage for CA-MRSA is recommended in patients who do not respond to β-lactam therapy and may be considered in those with systemic toxicity.

 

Clindamycin

300–450 mg PO TID

10–13 mg/kg/dose PO every 6–8 h, not to exceed 40 mg/kg/day

AII

Provide coverage for both β-hemolytic streptococci and CA-MRSA

 

β-lactam (eg, amoxicillin) and/or TMP-SMX or a tetracycline

Amoxicillin: 500 PO mg TID See above for TMP-SMX and tetracycline dosing

Please refer to Red Book See above for TMP-SMX and tetracycline dosing

AII

Provide coverage for both β-hemolytic streptococci and CA-MRSA

 

Linezolid

600 mg PO BID

10 mg/kg/dose PO every 8 h, not to exceed 600 mg/dose

AII

Provide coverage for both B-hemolytic streptococci and CA-MRSA

Complicated SSTI

Vancomycin

15–20 mg/kg/dose IV every 8–12 h

15 mg/kg/dose IV every 6 h

AI/AII

 
 

Linezolid

600 mg PO/IV BID

10 mg/kg/dose PO/IV every 8 h, not to exceed 600 mg/dose

AI/AII

For children ≥12 years of age, 600 mg PO/IV BID. Pregnancy category C

 

Daptomycin

4 mg/kg/dose IV QD

Ongoing study

AI/ND

The doses under study in children are 5 mg/kg (ages 12–17 years), 7 mg/kg (ages 7–11 years), 9 mg/kg (ages 2–6 years) (Clinicaltrials.gov NCT 00711802). Pregnancy category B.

 

Telavancin

10 mg/kg/dose IV QD

ND

AI/ND

Pregnancy category C

 

Clindamycin

600 mg PO/IV TID

10–13 mg/kg/dose PO/IV every 6–8 h, not to exceed 40 mg/kg/day

AIII/AII

Pregnancy category B

 

Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant StaphylococcusAureus Infections in Adults and Children 

MEET THE NEW KACEP BOARD MEMBERS for 2011

President, Melissa Platt, MD

Past President, Barbara Reynolds, MD

Vice President, Ryan Stanton, MD

Secretary/Treasurer, Robert Pringle, MD

Education Committee Chair, Devin Feragasso, MD

Governmental Affairs Committee Chair, Wes Brewer, MD

Membership Committee Chair, Eric Richardson, MD

Public Relations Committee Chair, Ryan Stanton, MD

Emergency Medical Services Committee Chair, Daniel O’Brien, MD

Medical Reimbursement Committee Chair, Walt Green, MD

Emergency & Disaster Preparedness Committee Chair, L. Barrett Bernard, MD

Young Physician’s Committee Chair, Sonya Melville, MD

Councillors   Alternate Councillors
Ryan Stanton   Steve Stack
Melissa Platt   Salvator Vicario
Royce Coleman   Daniel Danzl
Chris Pund   Jeff Violette

 

 








 

Clinical News

CMS Tweaks Hospital Sedation Policy, Again
The Centers for Medicare and Medicaid Services has revised its recently updated anesthesia guidelines, following complaints the policy was unworkable.

Hospitals are now directed to develop their own internal policies concerning what is anesthesia versus analgesia, which leaves open the option of using different guidelines in different clinical departments. The revisions also provide greater flexibility regarding pre- and postanesthesia evaluations, while particularly problematic references to propofol and labor epidural anesthesia were dropped entirely.
Read the entire article online

Food Allergy Guidelines Encourage Earlier Use of IM Epinephrine
New federal guidelines on food allergy recommend “prompt and rapid” treatment of food-induced anaphylaxis with intramuscular epinephrine as first-line therapy.

And in cases of a suboptimal response to epinephrine – or if symptoms progress – “repeat epinephrine dosing remains first-line therapy over adjunctive treatments,” the guidelines say.

The “consistency and strength” of the recommendation for prompt treatment with IM epinephrine may come as a surprise to some emergency physicians who “reserve treatment with epinephrine until patients are in shock, which is an extreme and late manifestation” of anaphylaxis, said Dr. Carlos A. Camargo Jr., an emergency physician who served on the multidisciplinary expert panel that developed the guidelines for the National Institute of Allergy and Infectious Diseases.

“Earlier diagnosis of anaphylaxis and earlier treatment with epinephrine would benefit patients,” said Dr. Camargo of Massachusetts General Hospital and Harvard Medical School, both in Boston. “The guidelines strongly encourage earlier use of IM epinephrine for food-induced anaphylaxis.”
Read the entire article online

Focus On: Best Practices for Seizure Management in the Emergency Department
“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. The January 2011 article reviews the current evaluation, management, and disposition of patients presenting to the emergency department with seizures.

Learning objectives for this article include the ability to discuss the presentation of seizure in the emergency department and common mimics of seizure; discuss the management of first-time and recurrent seizures in the emergency department; outline an aggressive treatment regimen for status epilepticus, including the emerging role of levetiracetam in the treatment algorithm; and list several practices that will improve the ED care of seizure patients.
After reading the article, take the CME quiz online.

Emergency Medicine Foundation Call for Proposals

EMF is pleased to announce a call for proposals due April 1, 2011:

Ultrasound Grant proudly underwritten by Siemens
The goal of this $20,000, one-year grant is to gain a better understanding of the comparative effectiveness of emergency ultrasound as performed by emergency physicians.

EMF/EMPSF Patient Safety Grant
The goal of this $10,000, one year grant is to identify ways and means to improve patient safety in emergency medicine.

EMF/Baxter Grant on Rehydration
The goal of this $50,000, one year grant is to study subcutaneous rehydration for pediatric and/or adult patients in the emergency department.

EMF/ENA Foundation Team Grant
The goal of this $50,000, one year grant is to have physician and nurse researchers combine their expertise to develop, plan, and implement clinical research in emergency care.

All grants will be funded July 1, 2011-June 30, 2012.

Welcome New Members

 William R. Sanchez, MD

Advertisements