Winter 2014 Issue

Winter 2014

Kentucky Chapter ACEP

Ryan Stanton, MD, FACEP, President

Ashlee Melendez Executive Director

Contact us:

Phone: 502.852.7874
Fax: 502.852.0066

From the President
Ryan Stanton, MD, FACEP

I want to thank everyone who attended the KACEP Annual Meeting on November 20th at Churchill Downs. Even though racing was cancelled due to a frozen track, we still had the highest attendance in the history of our event. We also hosted the 1st Annual ER Medical Director Meeting with 15 participants learning from some of the best minds in Kentucky emergency medicine. Participants were very complimentary of the event and are already looking forward to next year. We will build on what we have learned this year and grow this conference as a way to bring emergency leaders together regardless of board certification in emergency medicine. If you did not join us this year, please plan to attend next November. For those that did attend, I promise we will have a bigger screen and brighter projector for the lectures next year.

The main theme this year was change. I think we have all realized the ground shift of healthcare legislation, but we are seeing changes in patient populations, payment, quality measures, and the overall role of emergency medicine in our medical system. The medical director conference discussed the role of ultrasound in EVERY emergency department, developing and building your personal resume, and, finally, the horizon of healthcare legislation in Kentucky. In the full KACEP meeting, we heard about the impact of the ACA, the growing role of emergency medicine, ACEP/KACEP driven legislation, and some of the challenges facing our ER and EMS providers. To summarize all of these discussions is that emergency medicine will continue to be on the front line, and we (KACEP/ACEP) will continue to fight for our profession and providers.

This is my last update as President of KACEP, and I want to thank you again for your time and support. As we move forward, Dr. Wes Brewer will lead us into the next 2 years of change. His expertise in the politics of medicine and long time commitment to our specialty will be an asset to our organization. I ask that you support him and give as you can with your time, expertise, and finances to help us move emergency medicine forward, making our profession better for us, our patients, and our future. I will continue on in my role in public relations with KACEP and ACEP.

As we move into 2015, emergency medicine must take its place at the head of the table as we continue conversations and actions to improve healthcare and wade through the litany of changes on the horizon. We must solidify the reality of emergency medicine as the hub of the medical system, empowering our providers to advocate for our patients, helping them get the care they need, when and where they need it. I think we all have a fair amount of anxiety about the trends and movements in medicine, but we must push forward with patient and provider centered solutions that will promote the best care our system can offer.

From Government Affairs

The yearly session of the Kentucky General Assembly will begin in a few weeks. This session will be the biennial: short session” lasting only 30 legislative days. The curmudgeons among us will point out that this simply means less opportunity for mischief, but the downside is that traditionally very little that is innovative or productive gets through the legislative process during the short session. Much of organized medicine in Kentucky spent the fall deferring plans for the legislative agenda assuming that Republicans would gain control of the State House of Representatives. Of course that did not happen; thus, we are left with the same divided government that we have had for years. There is, however, still talk of advocating again the concept of medical review panels that failed in the last legislature. There is even discussion of real tort reform and forming new coalitions to support modernizing our liability laws. We also expect reintroduction of bills regarding end of life care and naloxone availability for laypersons. Both of these would seem to be no brainers, but they faced opposition or lack of support in the last session. We will continue to advocate for Expert witness legislation that has been discussed for the last two General Assembly sessions. I am pleased to announce that our chapter has been given preliminary approval for an ACEP public policy grant to fund educational and legal expenses related to the expert witness proposal.

On the national scene we again face the now annual kick the can down the road event that is the “doc fix” for the Medicare SGR formula. Most physicians are numbed to the fact that we face a potential 21% reduction in Medicare reimbursements in March of 2015. We all assume that at the last minute Congress will once again pass a short term extension to prevent the imminent cut without addressing the underlying structural defect in the formula that determines Medicare payments. Expect many action alerts over the next few months until the temporary fix is enacted.

In Search of a 'Safe Harbor'  
Practice Management
Mark Plaster, MD
Published: November 29, 2014

Mark Plaster, MD has been an emergency physician for more than 30 years and is the founder and executive editor of Emergency Physicians Monthly, where a version of this article originally appeared.

At the dead center of the healthcare reform debate is the tension between saving lives and saving money. The reformers say that American healthcare costs too much and one of the ways to cut costs is to pay providers less. Providers warn that such cuts incentivize them to see more patients in a shorter amount of time, relying more and more on lab testing. Thus, these kinds of cuts could actually end up costing the system more in the long run. Providers are also incentivized to overtest because doing otherwise can expose them to potentially devastating litigation.

We all feel this push to practice defensive medicine, and in the moment it can feel like a win-win. More tests mean more lives saved and less exposure to litigation -- let someone else worry about the tab. Well, more and more, the government is being left holding this massive bill caused by defensive medicine, and politicians are taking notice. Some are even beginning to think outside the box.

In the last session of Congress, an unlikely duo emerged with their sights set on addressing defensive medicine. Congressman Ami Bera, MD, a liberal Democratic physician from California, linked up with Congressman Andy Barr, JD, a conservative Republican lawyer from Kentucky. This seemingly odd couple co-authored a tort reform bill called the Saving Lives, Saving Costs Act.

"[Bera and I] come at this issue from somewhat different ideological positions in terms of healthcare reform," said Congressman Barr in a recent interview. "We shared a view that -- whether you're for or against the Affordable Care Act -- one thing is clear: the ACA simply did not deal with the skyrocketing costs of healthcare."

According to Barr, actuaries at the Department of Health and Human Services projected healthcare spending to grow by 6% per year on average through the decade, reaching a projected 19.3% of GDP by 2023.

The crux of the law, which will likely be re-introduced in the next session of Congress, takes a slightly new approach to tort reform. Instead of putting caps on malpractice damages, the bill protects physicians from frivolous lawsuits when they are practicing within known standards of care, or "safe harbors."

"We wanted a new approach to medical malpractice reform," Barr said. "Efforts to reform our medical malpractice system have been attempted in the past without success. Critics of malpractice reform, particularly the plaintiffs, have traditionally opposed reform efforts because they oppose arbitrary limits or caps on damages and proposals that they view as limiting patients' access to justice. Other critics, typically more conservative-minded members of Congress or other conservatives, have traditionally opposed malpractice reform legislation at the federal level on the grounds that it infringes on states' rights."

Under the proposed law, medical malpractice cases involving a federal payer or federally mandated care (i.e., the Emergency Medical Treatment and Active Labor Act) could be moved to a federal court.

In such cases, a board of medical experts would examine the case for adherence to recognized clinical guidelines or best practices. If the care is deemed to have met the standard, the burden of proof would shift to the plaintiff who would be required to prove by clear and convincing evidence that the panel acted arbitrarily. This would allow the defendant to move for summary judgment before expending the time and money on discovery.

The plaintiff could still take the defendant to trial, but if he failed to show by a preponderance of the evidence that the defendant was liable, the plaintiff would be responsible for the defendant's legal costs from that point.

Critics have howled that the proposed law -- which would impact virtually all cases of alleged negligence in emergency medicine -- is intentionally biased in favor of physicians. But Barr pointed out that physicians have historically been more than willing to criticize their peers. "There are experts who testify on behalf of plaintiffs and offer testimony in depositions and in trials all the time asserting that a colleague physician has practiced substandard care."

To address this potential bias, the law calls for a three member panel of experts – one chosen by the plaintiff, one by the defense, and one that was agreeable to both sides. In the event the sides couldn't decide, a judge would appoint the third member.

One of the benefits of the law is that it encourages specialty societies to establish best practices and other clinical guidelines in an objective manner. But the bill allows the panel to look beyond clinical guidelines and develop guidelines of their own or draw on precedence in previous cases.

Moreover, the rules of evidence would be set by the panel more in keeping with an alternative dispute resolution model. The result, if all goes as planned, would be a set of known best practices that could create more safe harbors, allowing physicians to practice in a less defensive, more cost-effective manner.

According to Barr, the most criticized feature of the law is the "loser pay" feature.

"If the defendant prevails at the review panel stage," explained Barr, "and the plaintiff makes the decision to proceed but the defendant ultimately prevails either at summary judgment or at trial, the defendant then can recover his or her costs for the litigation from that point forward. The purpose of this is to deter the prosecution of frivolous claims."

Since this legislation was presented at the last session of Congress, it will have to be re-introduced in the next session. The bill received a number of endorsements from medical specialty societies, including the American College of Emergency Physicians.

Before the end of the session, the bill had been introduced in the house judiciary committee, the energy and commerce committee, and the health subcommittee. Furthermore, the bill had 15 co-sponsors from both sides of the aisle. In the next session, Barr will be on the lookout for a Senate companion bill, so that the two houses can work together to get a bill on the president's desk.

Despite the positive steps taken in the last session, Barr admitted that this fight is far from over.

"This is early in the process," Barr warned. "We just filed the bill in this term of Congress. But we feel like the bipartisan nature of the bill, the fact that we have all of the endorsements and the fact that we've received so many co-sponsors this quickly; the fact that we're getting responses from a lot of outside organizations ... that gives us a lot of hope to move it forward."

The question remains as to whether this bill would actually save costs. According to Barr, the numbers play out in their favor. "A report from the [Congressional Budget Office] indicated that direct federal spending would be reduced by roughly $50 billion over about 10 years, due to savings from Medicaid, Medicare, the Children's Health Insurance Program, and the Federal Employees Health Benefits program, if we implemented medical liability reform such as the one we have proposed."

In terms of the bill's chance of success, Barr is pinning much of his hope on its bipartisan appeal. "The concept of medical liability reform like the one that we have introduced has been endorsed by the National Commission on Fiscal Responsibility and Reform, which is a bipartisan group, and the Bipartisan Policy Center's Debt Reduction Task Force. So budget experts from both parties have endorsed it. We maintain hope that this doesn't have to be a partisan or ideological issue," he said.

Tadd Roberts, MD
Chair, Disaster and Preparedness Committee

Now that the Ebola fears have diminished, I think it is time to critically evaluate our response. I am certain that every hospital in the country reacted in the same manner. Every ED director and hospital administrator was mandated to attend hours of CDC conference calls, planning meetings, and staff training. Thousands of dollars were spent on supplies to include suits, masks, disinfectants and the like. Overall, the response was overwhelming and, some would argue, ineffective. 

Now we are in a place of stagnation. The likelihood of another Ebola scare is small. Safeguards have been put in place at critical international airports in order to screen the incoming, and travel restrictions largely protect us. But what happens to all of the equipment and momentum gathered in the past months?

I feel it is time to redirect the public’s attention. We battle C. Diff, VRE, MRSA and other alphabet monsters daily. We all know that each of these pathogens have a greater chance of killing your everyday American than Ebola; yet, where is the response? Why are we not seeing a massive uprising against these ICU killers? In comparison to the Ebola war, the VRE battle seems like little more than a street fight. 

Let’s all encourage our hospitals to mount the same response to MDROs as they did for Ebola. Look towards new technology such as robots that disinfect hospital rooms with UV sterilization, copper infused anti-microbial coatings, and old fashioned infection control. The battle against these pathogens hasn’t been lost. It’s just largely been ignored.

Golden Cross Award Winner

Dr. Danzl received the Golden Cross Award from the KY Chapter of the American College of Emergency Physicians

Purpose: To recognize a person or organization who makes an outstanding contribution to the care of acutely sick or injured persons in Kentucky.

University of Louisville
Louisville, Kentucky   40292
Assistant Professor of EM (07/01/79 to 07/01/83)
Associate Professor of EM (early promotion) (07/01/83 to 7/01/89)
Tenure; granted 07/01/86
Professor of EM (07/01/89 to date)
Professor and Chair, Department of EM (April 1, 1991 to date)
Associate, Department of Surgery (07/01/91 to date)

Oral Examiner for American Academy of EM since 1982. He has had the most oral exams of any examiner in history.

He has over 180 publications and presentations

Founding member of American Academy of EM and Association of Academic Chairs of EM

Sits on numerous editorial boards

Past President for KY Chapter of ACEP in 1985-86

Dr. Danzl has made a profound difference to the future of EM.

Clinical News

ED Visits Hit Record High, With More Cases Requiring Urgent Treatment
The nation’s emergency departments saw more than 136 million patient visits in 2011, the highest number ever recorded, compared with 129.8 million in 2010, according to new data released by the Centers for Disease Control and Prevention (CDC). The percentage of patients with nonurgent medical conditions dropped by half—an overwhelming 96 percent were triaged as needing medical treatment within two hours, up from 92 percent in 2010.
Read the Entire Article

How to Perform Positive Pressure Technique for Nasal Foreign Body Removal
The Case

A 3-year-old female presents to the emergency department after placing a small bead into her left nostril. The bead became lodged, and the child is unable to move any air out of the left naris. All efforts to remove the foreign body prior to arrival have failed. The child is currently cooperative but apprehensive. Is there a minimally invasive way to safely, quickly, and easily remove or dislodge the foreign body?
Read the Entire Article

How to Approach End-of-Life Care Discussions, Determine Treatment Goals for Patients Near Death in the Emergency Department
Case: A 79-year-old woman with metastatic lung cancer presents to the ED with severe dyspnea. Assisted ventilation appears necessary. The family is in attendance and under the impression that she will benefit from chemotherapy and/or radiation. According to the family, no one has discussed her prognosis or an advance directive with either the patient or them. Should this patient be immediately intubated?
Read the Entire Article

Join Emergency Medicine's Premier Grassroots Advocacy Network
Jeanne Slade, NEMPAC and Grassroots Advocacy Director

Nearly 70 new Members of Congress will be sworn in as part of the 114th Congress – which will consider many critical issues that affect all emergency physicians and patients. To hit the ground running in this new Congress, ACEP is recruiting new members for the 911 Legislative Network, a nationwide grassroots lobbying team of emergency physicians. The mission of the Network is to Educate and Engage legislators, while Expanding the “footprint” of emergency medicine in the development of quality health care legislation and policy on the federal level.

More than 136 million people visit the emergency department annually in every state and congressional district in the United States. As the safety net providers in our nation’s health care system, emergency physicians are uniquely qualified to share this front-line experience and knowledge with policymakers. This “grassroots power” can positively impact the future of the specialty and help ensure lifesaving emergency will be available when and where patients need it across the country.

From hosting an ED visit for your legislator, responding to an Action Alert, attending the annual Leadership and Advocacy Conference in Washington, DC or simply staying up-to-speed on ACEP’s top legislative issues by reading the 911 Network Weekly Update, there are many opportunities for you to get involved and stay engaged. Remember, you have a voice in Washington – let it be heard!

To join the ACEP 911 Network, please go to Advocacy area of the ACEP website.

You can also contact Jeanne Slade,  ACEP’s Political Affairs Director for more information.

Welcome New Members

Benjamin S. W. Belknap
Cullen J. Clark
Michael Greene, II
Courtney D. Maiden
Evan L. Vincent