Study: Nearly half of all ER physician care goes uncompensated

From the Orlando Business Journal, via Chris Perrin:

Increased numbers of uninsured patients coming into Florida emergency rooms may worsen overcrowding, adversely affect quality of care and lead more ERs to close their doors, a new University of South Florida study shows.

USF researchers surveyed 188 Florida hospital emergency physician groups about the uncompensated care they provided in 1998. The 83 physician groups responding provided substantial uncompensated emergency care, ranging from 26 to 79 percent with an average of nearly 47 percent.

Uncompensated services are those for which no payment is received from either the patient or from a public or private insurer, such as charity care for patients who cannot afford to pay, bad debt from patients who choose not to pay their portion of the bill and denial of payment for emergency services by health plans.

The study also shows that emergency physician groups providing the highest levels of free care tended to practice in urban hospitals serving large populations of Medicaid and uninsured patients.

Verichip files for an IPO

From The Street:

Verichip, the Applied Digital (ADSX:Nasdaq - commentary - research - Cramer's Take) unit that makes and sells radio-frequency chips for use in humans, filed for an initial public offering Friday.

"We believe that our patient identification solution is compelling for emergency room physicians as well as for patients who have cognitive impairment, chronic diseases or implanted medical devices," the prospectus says. "Using our scanners, an emergency room physician can rapidly obtain the patient's name, primary care physician, emergency contact and other pertinent pre-approved data, such as personal health records. We expect that this rapid and accurate identification process will reduce the risk of a patient being misdiagnosed and the potential liability associated with medical errors."

Blue Cross & Blue Shield strikes deal with emergency room doctors

From Boston.com

Dozens of emergency room doctors reached an agreement with Blue Cross & Blue Shield to remain in the insurance company's network.

Fifty doctors at Miriam Hospital, Rhode Island Hospital and Hasbro Children's Hospital planned to leave Blue Cross' network on Jan. 1 because they were unhappy with the payment rates the company offered

But the two sides announced an agreement Thursday that will allow Blue Cross to cover doctors' services and emergency-room care at those hospitals. Had the doctors left the network, patients would have still been able to receive emergency treatment at the hospitals but would have faced more paperwork and higher costs.

A two-paragraph statement announcing the agreement did not say what led to the deal, but says Blue Cross and the doctors had "agreed to work cooperatively to address issues of mutual interest such as appropriate use of emergency department services."

Patient Attacks Officer in the ED

From KATU.com


PORTLAND, Ore. - A hospital patient is under arrest after police say he tried to stab a corrections deputy with a knife in an attack that was caught on tape.

The incident happened Tuesday around 2 p.m. inside the emergency room at Portland Adventist Medical Center.

Police say the patient, 35-year-old James Edward Stevens, approached a Multnomah County Sheriff's Deputy who was in the emergency room supervising an inmate (not Stevens) and asked him to step out into the hallway.

Police say Stevens then tried to stab the deputy with a knife. The deputy was able to quickly disarm him by shooting him with a Taser.

Here's a link to the video

CPT and ICD-9 Changes

From ACEP:

The American Medical Association recently released its annual refinement of the Current Procedural Terminology (CPT) codes and descriptions. For 2006, paramount CPT changes for emergency medicine concern emergency department after-hours services and moderate (conscious) sedation. The previous related codes were frequently denied by payors as not being applicable to the emergency department or the emergency physician. CPT has clarified these services by creating new codes, which should decrease emergency physician denials for these commonly provided services. Providers must account for these changes starting Jan. 1, 2006.

JAMA Study on Anticoagulant Therapy

From the NY Times:

Patients being treated for heart attacks involving narrowed arteries and clots that reduce blood flow to the heart are often given overdoses of powerful blood-thinning drugs in the emergency room, increasing their risk of serious bleeding, a study has found.

Excessive bleeding occurred at catheter sites, from existing stomach ulcers and in the brain, where it was particularly dangerous, said Dr. Karen Alexander, a researcher at Duke University and the lead author of the study, which is to be published Wednesday in The Journal of the American Medical Association.

Of 30,136 heart patients treated last year at 387 hospitals in the United States, 42 percent were given excessive doses of blood thinners. Those given extra amounts of two blood thinners - low molecular weight heparin and glycoprotein IIb/IIIa blockers, which are sometimes called super-aspirin - had about a 30 percent greater chance of major bleeding than those given the recommended dose.

"Presenteeism"

From MedPage Today:

Sometimes it's better for everyone if dedicated, hard-working employees stay home from the job if they're under the weather.

We're not just talking about use of the occasional "mental health day" -- calling in sick even though there's really nothing much wrong but the worker just can't take it any more.

But we are also looking at the flip side of the equation, the employee who grits his or her teeth and marches into the office, despite chronic or acute illness.

In the best-case scenario, "presenteeism" -- coming to work when you shouldn't -- results in a job that's not done as well as it could be. In the worst case, it causes a cascade of illness that depopulates the office -- and the job is still not well done.

"It's really perverse," said Graham Lowe, Ph.D., a sociologist and consultant whose Kelowna-based company analyzes workplace health issues. The phenomenon extends to physicians and nurses.

During his research career at the University of Alberta, Dr. Lowe found that the positive motivations that drive medical professionals also lead them to come in when they're sick.

"Nurses on teams feel an incredible commitment to their patients and to their co-workers," Dr. Lowe says. "And it's good that they're committed to their patients, good that they have strong bonds with their co-workers."

But "the unintended consequence is that they put their own health as a second priority."

It's pretty easy to see why absenteeism is a concern to employers. According to one survey, unscheduled absences cost the boss nearly $700 a year for every employee.

"Presenteeism" is a lot harder to nail down, although the Harvard Business Review last year estimated that the cost could be as high as $150 billion a year in the U.S., with workers fighting through a range of illnesses, including allergies, asthma, headaches, depression, back pain, arthritis, and gastrointestinal disorders.

Oxycontin ring based in ER?

More on the Oxycontin accusations in PA, from the Daily Courier:

Egleston, a former emergency room doctor at Aliquippa Community Hospital, would meet patients in the emergency room's waiting area, take them to a private room and issue a prescription, Corbett said.

Agents were tipped to the ring when nurses at Aliquippa said they became suspicious because some patients would come to the emergency room asking to see Egleston for treatment but leave if he wasn't working, according to a presentment by a state grand jury, which investigated the ring for nine months, Corbett said.

Shooting in the ER

From Omaha's WOWT.com:

A Kearney police officer fatally shot a 29-year-old man in the emergency room of Good Samaritan Hospital early Sunday.

The name of the deceased and the officer who shot him were not immediately released.

The man was armed with a knife, acted in a threatening manner and refused to comply with multiple verbal commands of police officers before the shooting at 3:28 a.m., according to a news release from the Buffalo County Attorney's Office.

Can you hear me now?

From the Kansas City Star:

A Blue Springs woman was taken to the emergency room early Friday with a cell phone lodged in her throat.

Blue Springs Police Sgt. Steve Decker said the woman apparently tried to swallow the telephone because she didn’t want her boyfriend to have it. Decker said no crime was committed.

After police responded to a call about the incident, the 24-year-old woman was taken to the emergency room at St. Mary’s Hospital. Her condition was not released, but she was expected to recover, Decker said.

Budget Bill Includes Changes to Medicaid for Emergency Departments

From an e-mail from the Emergency Department Practice Management Association (EDPMA):

Budget Bill Includes Changes to Medicaid for Emergency Departments
 
The vast budget reconciliation bill contains numerous provisions affecting Medicaid and Medicare.  Many of the Medicaid provisions have been touted as reforms by the [ http://www.nga.org/portal/site/nga ]National Governors Association that would allow greater program flexibility for States.  One such flexibility that would affect Emergency Departments is in the area of beneficiary cost sharing and co-payments.    
 
Medicaid Emergency Room Co-payments for Non-Emergency Care Provided in the ED

The budget reconciliation report would create a State option under Medicaid to allow hospitals to impose cost sharing for non-emergency care provided in an emergency department.  The State option would be available through the Medicaid state plan amendment process beginning January 1, 2007.  States would be able to allow hospitals to impose co-payments where the individual has actual access to an alternate non-emergency services provider that can competently provide the relevant services.  Non-emergency services is defined as any care or services furnished in an emergency department of a hospital that the physician determines do not constitute an appropriate medical screening examination or stabilizing examination and treatment required by EMTALA.  Alternate non-emergency services provider means a health care provider, such as a physician’s office, health care clinic, and community health care center, hospital outpatient department, which can provide clinically appropriate services for the diagnosis or treatment of a condition.
 
Requirements on the ED and Hospitals

A hospital would be required to inform the Medicaid beneficiaries of the following: 
(1) The hospital may require the payment of cost sharing prior to the provision of services,

(2) The name and location of an alternate non-emergency service provider that is actually available and accessible,

(3) That the alternative provider can provide the services without cost sharing, and

(4) The hospital provides a referral to coordinate the scheduling of treatment with the alternate provider. 

Note that additional requirements could be enacted through legislation, developed by the States in their Medicaid State plan amendment, or enacted under State law or regulation. 
 
Limitations on Cost Sharing

The statute limits the amount of cost sharing.  For most beneficiaries and services, the statute would limit cost sharing to twice the standard nominal cost sharing amount allowable under Medicaid.  For those populations and services that are otherwise not subject to cost sharing in Medicaid, cost sharing is limited to the standard nominal amount allowable under Medicaid.  Note that other sections of the Budget Reconciliation Conference Report would allow states greater flexibility to require higher levels of cost sharing in Medicaid than is currently allowable under law.  These changes in federal law and those changes that could follow at the state level could raise the cost share limitations that hospitals could collect under this new legislation. 
 
Liability Shield for Hospitals and Physicians

The House-passed version of the budget reconciliation bill would have created limited liability shield for hospitals and physicians wherein liability in a civil action of proceeding for the imposition of cost-sharing under this specific federal law would be barred absent a showing of gross negligence.  This protection would have been very limited because traditional state laws and EMTALA requirements would still apply to hospitals and would not have been affected by this new law.  This provision is one of three in the budget bill that was stricken by the point of order by the Senate on December 21 (see above). 
 
Authorized Grants to States for Alternate Non-Emergency Services Providers

The law authorizes $50 million in grants to states in order to establish alternate non-emergency service providers or networks of such providers.  Preference is to be given to rural or underserved areas or providers that are in partnership with local community hospitals.  Note that this legislation authorizes these funds but does not have the authority to appropriate the funds.  Therefore, any such program would be contingent upon future appropriations. 
 
EDPMA worked on your behalf to improve these provisions during the drafting of the legislation.  Improvements included a specific mention that the prudent layperson standard would not be affected, clarification that co-payments would be for NON-emergency services, language indicating that the physician id the determination of whether the service qualifies as “emergency services” or “non-emergency services.”     
 
State Flexibility on Cost Sharing

The House-passed Budget Reconciliation Conference Report would allow States greater flexibility to impose cost sharing on Medicaid beneficiaries including premiums and co-payments.  Such requirements are to be means tested with only traditional (nominal) cost sharing allowable for beneficiaries with incomes below 100 percent of the federal poverty line, some additional cost sharing allowable for beneficiaries with incomes between 100 and 150 percent of the federal poverty line, and the most state flexibility to impose cost sharing on beneficiaries with incomes higher than 150 percent of the federal poverty line. 
 
The legislation specifically excludes emergency services from such cost sharing.  However, as fully described above, states would have the option to allow cost sharing for non-emergency services furnished in the emergency department. 
 
Emergency Services Provided by Non-contract Providers for Medicaid Managed Care Enrollees

Another provision of the budget reconciliation conference report would require Medicaid providers that provide emergency services to a beneficiary enrolled in a Medicaid managed care organization in which the provider does not have a contract to accept as maximum payment the Medicare fee-for-service rate.

Protective Power of Potter?

From MedPage Today:

When we last left Harry Potter his life was in mortal peril from Lord Voldermort and his Death Eaters, but the teen wizard was still able to cast a Protego spell to keep muggle (non-magical) kids from harm.

That's the opinion of researchers here, who found that when the latest installments of the Harry Potter books came out, the number of kids showing up in the emergency room with broken bones, sprains, scrapes and bruises went down significantly.

Apparently, kids were just so wild about Harry that they didn't have time to ride a skateboard down a flight of stairs, or weave a scooter through heavy traffic.

"It may therefore be hypothesized that there is a place for a committee of safety conscious, talented writers who could produce high-quality books for the purpose of injury prevention," wrote Stephen Gwilym, M.D., and colleagues in the department of Orthopaedic Trauma Surgery at the John Radcliffe Hospital here.

They published their magical findings in the Dec. 24-31 issue of the BMJ, the annual year-end issue when the normally staid journal lets its hair down with off-beat research, often tongue-in-cheek but legitimate nonetheless.

Pennsylvania doctor accused in OxyContin ring

From the Post-Gazette:

An emergency room doctor was the central figure in a large OxyContin ring, writing hundreds of fraudulent prescriptions and charging up to $2,000 for each one, authorities said Thursday.

Seven others - including two prison guards and two former county employees - were also charged in the case, state Attorney General Tom Corbett said.

Authorities were tipped to the ring after nurses at Aliquippa Community Hospital got suspicious when patients would come to the emergency room asking for treatment, but would leave if Dr. Alan Egleston wasn't working, the indictment says.

Agents pulled a state database that tracks prescriptions of Schedule II drugs and discovered multiple prescriptions for some individuals, notably Mr. O'Brien, who had numerous OxyContin prescriptions filled at pharmacies around Allegheny County.

Investigators questioned several of Dr. Egleston's patients, including Mr. Welsh, who said he had never met Dr. Egleston and had never been at the Aliquippa hospital, but had filled numerous prescriptions in his name obtained by Mr. O'Brien, the prison guard. Mr. Welsh said he was introduced to Mr. O'Brien by Mr. Huck, the county parking attendant. Mr. Huck said he was addicted to OxyContin and purchased it from Mr. O'Brien.

"Welsh said that O'Brien told him that he knew a doctor who could give him prescriptions for OxyContin," the presentment said. "O'Brien went on to explain that Welsh would receive a percentage of the OxyContin pills in return for allowing his name to be used on the prescriptions and for Welsh's cooperation in having the scripts filled."

According to the charges, Mr. O'Brien was paying Dr. Egleston from $1,000 to $2,000 for each prescription, depending on the strength of the drug.

Euthanasia Post-Katrina?

From CNN.com:

More than one medical professional is under scrutiny as a possible person of interest as Louisiana's attorney general investigates whether hospital workers resorted to euthanasia in the chaotic days after Hurricane Katrina shattered New Orleans, a source familiar with the investigation has told CNN.

CNN first reported in October that staff members at Memorial Medical Center had discussions about euthanizing patients after the hurricane flooded the city on Monday, August 29, cutting off power and stranding hundreds of thousands of residents. Now, for the first time, Louisiana Attorney General Charles Foti has told CNN that allegations of possible euthanasia at Memorial Medical Center are "credible and worth investigating."

Billboard and Bus

From (Chicago) NBC5.com:

The billboard encourages uninsured people to call for information about free health care, but the group, Advocate said it encourages people to use emergency rooms when they should be seeing private doctors or free clinics.

"It is a disservice to have patients who have non-urgent problems present to the emergency room, because it really delays care to those who need it the most," said Dr. Michael Davenport of Advocate Trinity Hospital.

Particularly hard hit has been Advocate System Hospitals like Lutheran General where on two occasions, people from as far as 40 miles away have allegedly been bused to their emergency room. NBC5's Charlie Wojciechowski reported.

"That's dangerous," said Dr. Douglas Propp of Advocate Lutheran General Hospital. "That's bad -- that's wrong. So when that bus arrived at our facility, we added those seven or eight patients to our typical load at that particular time of day."

Advocate officials said they have seen seven similar incidents in the past three months. In one incident, a nurse said the patients appeared scripted and had a coach along with them.

Left AMA or Failed to Report Child Abuse?

From SGVTribune.com:

Garfield Medical Center has submitted a "plan of correction" after its emergency room staff failed to report possible abuse in the case of a 2-year-old girl who later died, officials said Monday.

Calls to Garfield Medical Center's spokesperson were not returned.

Sarah Chavez, who was found dead in her Alhambra home Oct. 11, was taken to the hospital by her mother's aunt and caretaker, Frances Abundis, the night of Oct. 10 with an unexplained broken arm. She was released from the hospital after four hours, and her doctor signed a form saying she left "against medical advice."

The Los Angeles County Coroner's Office ruled the toddler's death a homicide, the result of blunt force trauma to her lower abdomen. Abundis, 35, and her husband, Armando Abundis Sr., 32, were arrested and later charged with murder, child abuse and assault in connection with Sarah's death.

A report from the California Department of Health Services said the emergency room doctor and two nurses who saw Sarah failed to report possible child abuse. In the department's report, an unidentified nurse told Dolores Braithwaite, a registered nurse and health facility evaluator, that "the child was staring at me in a way that bothered me a lot" but added that she "did nothing about it."

Imaging Request Preapproval

From MSNBC:

Blue Cross Blue Shield of Wisconsin will require doctors to get prior approval for some imaging services starting in March 2006 to stem the increasing cost of those services, a move that likely will be unpopular with doctors.

Physicians ordering outpatient CT and PET scans, MRIs, and nuclear cardiology services for Blue Cross members will have to get approval via the Internet or from a call center, said Dr. Lowell Keppel, medical director for Blue Cross. The authorization will be required only for outpatient services and not for imaging scans performed in the emergency room or in urgent care, he said.

Alternative to JACHO?

From Medlaw.com:

The Centers for Medicare & Medicaid Services (CMS) has begun formal evaluation of the just-completed application by TÜV Healthcare Specialists (TÜVHS) to become the first new accreditation service for U.S. hospitals in 40 years.

If granted full deeming authority in the coming months, TÜVHS will not only accredit hospitals (deem them in compliance with Medicare’s Conditions of Participation) but will introduce the breakthrough management disciplines of ISO 9001 to help reverse declining quality indicators in healthcare.

Each year quality lapses in healthcare delivery exact a staggering financial and human toll. Inefficiency and mistakes cost each American $1,200 to $2,500 every year1; and prescription errors – a preventable lapse in quality control – cause 25,000 deaths annually.2

Responsibility for accrediting hospitals was first conveyed to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in 1965. The Joint Commission, a private non-profit organization, today accredits the overwhelming majority of hospitals in the United States.

Lack of EMS Volunteers in South Dakota

We have the same concern in Iowa. From the Sioux Falls Argus Leader:

In the past, when a person from small-town or rural South Dakota had a heart attack or was involved in a car accident, volunteers scrambled to provide emergency medical care, leaving their jobs at grain elevators, cafes, drugstores and farms.

But those days are disappearing quickly. Now, in communities such as Humboldt, Dell Rapids and Garretson, residents leave town each morning for jobs in Sioux Falls. The number of farmers living in the area has dwindled significantly. When emergency calls come in during the day, no one is around to respond.

So for the past several months, volunteer ambulance services in the Sioux Falls area have been sounding the alarm to their communities, saying they cannot operate on volunteers alone anymore. They need to to hire staff members to cover daytime hours, they say, or they won't be able to provide emergency care

Dissatisfied Cell Phone Customer

A big day for Iowa news. From the Council Bluffs Nonpareil (must be a pretty good newspaper):

A disgruntled cell phone customer rammed his truck into the deck of the Chit Chat Wireless store on Thursday.

Council Bluffs Police reports state that at approximately 5:45 p.m. an employee working at the store, located at 2034 W. Broadway, said that a truck hit the deck in the front of the store.

After ramming the deck, the suspect, later identified as Michael Grosvener, 48, of Council Bluffs, got out of his vehicle and walked up to the front of the business.

The employee realized that Grosvener was "up to no good," and locked the door. The employee told officers that Grosvener told him to open the door, but he refused. Grosvener then became upset and allegedly started to punch and kick the glass door, causing it to break.

After breaking the door, the employee said that Grosvener threw his cell phone at the door and fled the scene in his truck.

Approximately an hour after the incident, Alegent Health Mercy Hospital staff informed officers that a man driving a truck similar to Grosvener's checked into the emergency room to have his hand looked at. Grosvener admitted to officers that he was the person who rammed his truck into the business and broke the door.

Orthopedics in Fort Dodge, IA

From the Fort Dodge Messenger:

All four orthopedic surgeons on the medical staff of Trinity Regional Medical Center have resigned. Wednesday the hospital formally accepted their resignations, which become effective on various dates early in 2006.

The four physicians are Drs. Emile C. Li, C. Mark Race, Samir Wahby and James D. Wolff, all affiliated with Fort Dodge-based Orthopaedic and Sports Medicine Specialists.

In the immediate future, however, Trinity will experience less than optimal orthopedic coverage of its emergency room. Additionally, starting early in 2006 some of the patients who expected to have surgery performed at Trinity by the surgeons who resigned will need to make alternate arrangements.

This is the latest, and possibly final, development in what in the last month became an increasingly confrontational dialogue between the hospital and the four physicians whose resignations have now been accepted. Those talks began several months ago and intensified in October.

A crisis point was reached when the four surgeons requested that the hospital permit them to provide less on-call emergency coverage than hospital officials said the TRMC’s medical staff bylaws required them to accept. Tibbitts said they advised the hospital that as of Nov. 1 they were no longer willing and able to provide 24-7, on-call response to orthopedic emergencies. He said that left the hospital with several days each month when no local orthopedic surgeon would respond to the needs of its emergency room.

This was a departure from the full coverage Trinity’s orthopedic physicians had provided for a number of years and precipitated a crisis for the hospital, Tibbitts said.

Healthcare Facilities on Google Earth

Moragan Stanley created and has made available this free tool. You'll need to have Google Earth installed. In the Modern Healthcare magazine article that mentions the program, this information is also provided: Username: Morgan, Password: Stanley.

Gary Lieberman, Morgan Stanley's Healthcare Facilities analyst, has mapped every hospital and ambulatory surgery center (both for-profit and not-for-profit) using Google Earth.

But this isn't just any old map! Google Earth is a powerful application that allows users to zoom in on satellite imagery and in most cases see the actual facility! If you haven't tried Google Earth yet you have to see it to believe it!

Spend some time with the file we created to better understand individual market dynamics for over 10,000 facilities. Facilities are grouped by the major for-profit companies and larger not-for-profit systems, allowing you to highlight a single facility or every facility in a chain. In addition, each facility location includes key data points such as number of acute care beds, psych beds, rehab beds, parent owner and address.

Teen survives bizarre knife-in-head accident

From the Tooele Transcript Bulletin:

When the Scout leader tried to stop the boy's fall, the knife, which was hanging from the leader's glove, flew about 16 feet behind him.

Kevin says he saw the knife flying through the air right before it lodged in his forehead. He knew the knife was stuck in his head "because I saw and felt it."

At that point, Kevin started to hyperventilate, a situation which most definitely could have made the matter worse.

Because it was dark, the leader who first reached Kevin did not initially see the knife in the boy's forehead. But sensing that something was terribly wrong, the leader quickly laid the teen onto the grass.

"They came back and told us the knife had actually gone through our son's sinus cavity, then into his brain and lodged there," Bryan said. "We were told that surgery would be required to remove the knife. Doctors said there was no telling what would happen if they pulled the knife out of our son's head. Pulling it out could have severed a major blood vessel."

VisualDx

From the Syracuse Post-Standard:

Emergency room doctors at St. Joseph's Hospital Health Center have never seen a case of smallpox because the highly contagious and sometimes fatal disease was virtually eradicated in 1980 by worldwide vaccination efforts.

But if someone walked in with the virus, the doctors could quickly identify it using a recently installed computer database containing more than 8,700 photos of smallpox and 500 other conditions.

Doctors and nurses can type in a list of symptoms and the database, known as VisualDx, quickly matches them with diseases. The software systems combine photos with text to help clinicians diagnose and treat diseases.

The system was purchased with a $20,700 federal grant arranged through the Onondaga County Health Department.

The U.S. government has been taking precautions to deal with the possibility of a deliberate release of smallpox since the anthrax attacks in 2001. In addition to rarely seen diseases such as smallpox and anthrax, VisualDx can be used to identify common, visually diagnosed conditions, such as sexually transmitted diseases.

Using VisualDx is much quicker than leafing through dog-eared reference books, according to Neal Gracen, manager of clinical services in St. Joe's emergency room.

"Most physicians are not dermatologists," Gracen said. "When you see a funky rash, you don't know what it is. You're making a best guess. This improves your ability to make an educated determination."

"Pain Free" ER

From Tampabays10.com:

Lorri Hunt, Nurse Manager, St. Joseph's Children's Hospital:
"We are the only hospital in the country that's incorporated a whole entire philosophy that every child will be offered some type of 'pain-free' initiative."

Hunt says the 'pain free' kit includes a cool laser that allows a numbing product to be effective in seven minutes--instead of the typical hour, which means a shorter delay to insert an IV. And the device isn't intimidating; they call it the 'fish kiss or ouch eraser.

There's also team members who are a part of 'Child Life' who stay by the child's bedside reading or playing games. That way children are distracted when the doctor or nurse performs whatever procedure is needed. For the smaller patients, pacifiers are dipped in a sucrose solution, and when babies suck on it, they stop crying immediately. Hunt says all of these things will help ease the fears of children--and parents who are just as worried.

Chutes Malfunction; Skydiver Lives

From CBS News:

The saying "lucky to be alive" is anything but a cliché when it comes to Shayna Richardson.

She began skydiving when she turned 21 in May. Two months ago, in Siloam Springs, Ark., the Joplin, Mo., woman was making her 10 dive and first solo jump with a brand new parachute when things suddenly went wrong.

Her main chute and her reserve failed to open properly, and she spiraled out of control, falling thousands of feet.

It's estimated Richardson was going 50 mph at impact.

She landed face-first in a parking lot and lived to tell about it. Richardson now has 15 plates in her face for fractures after four operations. She also suffered two breaks in her pelvis, as well as a broken right fibula.

But there was one shock still to come.

Richardson learned in the emergency room that she was two-weeks pregnant and, "The baby had survived the free fall as well, survived the free fall and the 50 mile-an-hour impact, and then, on top of that, survived all four surgeries that I've been through as well."

Asheville man seriously injured in attack at hospital emergency room

From the Asheville, NC Citizen-Times:

An Asheville man suffered a brutal beating early Monday in the waiting area of a hospital emergency room at the hands of a suspect with a history of mental illness, authorities said.

Johnny West, 57, was at the St. Joseph’s campus of Mission Hospitals with his wife Sharon to visit the daughter of a friend when he was attacked at about 12:25 a.m.

West was hospitalized in the neuro-trauma intensive care unit with a fractured skull, broken nose and bruising of the brain.

Shawn Michael Pettie, 30, of Rutherfordton, was jailed on charges of assault inflicting serious injury and ethnic intimidation.

Working Night Shift, but Not Heavy Lifting, Is Risk Factor for Preterm Birth

From MedPage Today:

Pregnant women who work the graveyard shift face a significantly higher risk of preterm delivery, yet long hours, standing all day, and heavy lifting were not risk factors, investigators here reported.


Working between 10 p.m. and 7 a.m. during the first trimester raised the risk by at least 50% (relative risk 1.5, 95% confidence interval 1.0-2.0), according to Lisa A. Pompeii, Ph.D., of the University of Texas School of Public Health here.

EMTALA Concerns in Florida

Excerpted from an article entitled "ER patients still face possibility of dumping" in the Palm Beach Post:

Nearly two years after the The Palm Beach Post first identified life-threatening issues with patient dumping at several of the region's emergency rooms, state inspection records show a crisis still exists. Moreover, the 11 cases since November 2004, in which state health officials confirmed that Palm Beach County and Treasure Coast hospitals failed to treat emergency patients appropriately, point up — despite even an intervention by Gov. Jeb Bush last year — how difficult it is to find a solution.

Hospitals nationwide are required by law to treat all patients who come to their emergency rooms. The law is intended to deter hospitals from dumping patients. But the problem identified by The Post in a series of stories in spring 2004 has continued, and some fear it is getting worse, according to hospital administrators and doctors.

"This is a countywide problem that is as bad as it's been," said Dr. Michael Collins, director of the emergency department at Jupiter Medical Center.

Showing the seriousness with which the federal government takes patient-dumping violations, U.S. health officials threatened this year to terminate four area hospitals from the Medicare program if they did not immediately fix problems that led to the violations, according to the state documents. In all four instances, involving Jupiter, West Boca, Wellington Regional and St. Lucie medical centers, the hospitals complied.

Although local hospital officials say most ER patients get the medical care they need, they acknowledge the violations illustrate a growing problem in the region's health system: the shortage of doctors willing to treat emergency patients.

ACEP Standard of Care Review

From the American College of Emergency Physicians. (As of this writing two cases are posted):

ACEP members can request a review of questionable expert witness testimony regarding emergency medicine’s standards of care.

A 12- member Standard of Care Review Panel will examine selected questions about testimony that is possibly false, misleading or without medical foundation. Names and other identifiers will be removed so that the review will be blinded. The decision resulting from the review will not be used in any punitive way, and this initiative is designed strictly for educational purposes.

100,000 Lives Campaign

From Newsweek, and excellent summary of the 100K Lives Campaign, excerpted below:

On Dec. 14, 2004, the Institute for Healthcare Improvement, a nonprofit organization headquartered in Cambridge, Mass., launched the 100,000 Lives Campaign, a broad national effort to achieve the most urgent reforms. Mainstream leadership groups like the American Medical Association, the American Nurses Association and the Joint Commission on Accreditation of Healthcare Organizations immediately signed on to the campaign. Several federal agencies—including the Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Services, the Veterans Health Administration and the Agency for Healthcare Research and Quality—pledged support as well.

We have identified six basic measures that could save as many as 100,000 lives a year if even 2,000 hospitals adopted them. It's surprising to learn that these standards aren't already the norm—but the norms may finally be changing. Nearly 3,000 American hospitals have enrolled in our 100,000 Lives Campaign over the past year, and more than half are reporting their monthly death rates so that we (and they) can track progress. That takes courage in a world where hospitals, fearing blame and lawsuits, too often feel the need to hide their mistakes.

1. PREVENT RESPIRATOR PNEUMONIA
VAPs, or ventilator-associated pneumonias, are often deadly lung infections that people on respirators can get (after surgery, for example). A few simple maneuvers, like elevating the head of the hospital bed and frequently cleaning the patient's mouth, can eliminate them. Dominican Hospital in Santa Cruz, Calif., just celebrated one full year without a single VAP—a result most doctors would have thought impossible.

2 PREVENT IV-CATHETER INFECTIONS
Central-line infections occur when bacteria contaminate catheters that deliver food and medicine intravenously. Dr. Peter Pronovost of Johns Hopkins University recently reported that 70 hospitals in Michigan, California, Iowa and Indiana cut their central-line infections by half, saving an estimated $165 million from complications to boot. How did they do it? They made it easy for doctors and nurses to wash their hands between patients, adopted simple procedures for changing the bandages around the catheters and made absolutely sure that no catheter remained in a vein even one hour longer than needed.

3 STOP SURGICAL-SITE INFECTIONS
Surgical-site infections are a major cause of complications and deaths after operations. Last year Mercy Health Center in Oklahoma City operated on 1,200 consecutive patients without a single wound infection—by adopting a series of simple preventive measures. These include giving the right antibiotics at the right time during surgery, enforcing strict hand-washing and avoiding shaving the surgery site before the operation (clipping hair avoids nicking the skin and is safer).

4 RESPOND RAPIDLY TO EARLY-WARNING SIGNALS
A nurse or visitor is often the first person to notice that a patient is in trouble. By setting up special rapid-response teams, hospitals can ensure that these critical warnings are never missed or ignored. Busy physicians may resent the false alarms, but lives are saved when hospitals take nurses' concerns seriously and respond within minutes. Australian researchers have found that rapid-response teams may be able to cut hospital death rates by 20 percent or more. The University of Pittsburgh Medical Center is testing an even more innovative way to use rapid-response teams. The staff trains patients' visiting family members to call for assistance whenever they sense trouble. The new protocol, dubbed Condition H (for "Help"), has already saved lives.

5 MAKE HEART-ATTACK CARE ABSOLUTELY RELIABLE
The scientifically correct treatments for heart attacks could save far more lives if we used them reliably. The 100,000 Lives Campaign simply asks hospitals to ensure that every patient gets every medication and treatment recommended by the American College of Cardiology and other expert bodies. These measures include aspirin and a beta blocker on arrival and a stent or clot buster promptly after admission. McLeod Regional Medical Center in Florence, S.C., has cut the death rate among its heart-attack patients from 10 per-cent (the U.S. average) to about 4 percent. All the hospital had to do was ensure 100 percent reliability.

6 STOP MEDICATION ERRORS
Medication errors kill tens of thousands of patients a year, yet many are easily prevented. One secret is to "reconcile" medications whenever patients move from one care setting to another—from hospital to home, or even from one place to another within a hospital. The reconciliation protocol assigns a doctor or nurse at every step to check and recheck: are the medicines the patient gets after the transfer exactly the ones planned before the transfer? If not, the mistake gets corrected right away.

Couple calls emergency room doctor's actions disrespectful

From the Newport News-Times:

Samaritan Pacific Communities Hospital policy indicates "the behavior of all individuals providing services on behalf of Samaritan Health Services" is based on a set of principles, the first one denoting that "patients, employees, medical staff members, and visitors deserve to be treated with dignity, respect for their rights, fairness, and courtesy."

A Newport couple believes an emergency room physician violated hospital policy and possibly state law by ignoring medical power of attorney papers during a medical crisis that sent one of them to the ER by ambulance. They also believe being a same-sex couple might have played a role.

In the early morning hours of November 30, Karen Dammann made an urgent 9-1-1 call on behalf of Meredith Savage, her partner of 10 years. When emergency medical personnel arrived, Meredith "was conscious, but unable to move or speak." The ambulance crew whisked her to the hospital's emergency room, with Karen not far behind.
Dammann expected ER personnel to allow her in the treatment area with Meredith, especially since her partner could not clearly communicate any special medical conditions or needs. Instead, Dammann said they - by order of the attending physician - repeatedly denied her access, allegedly because she wasn't "related" to the patient. They continued to bar Dammann's presence in the room after she went home and returned with medical power of attorney papers (what's known as an advanced directive) giving Dammann the legal right to make medical decisions for Meredith if she is incapacitated and unable to make or communicate those decisions herself.

Relocation of Critical Access Hospitals

From CMS:

If any CAH plans to relocate to a new location, CMS would need to determine if this would be a relocation of the current provider or a cessation of business at one location and establishment of a new business at another location. In the event of relocation, the CAH must ensure to the RO that it is functioning as essentially the same provider serving the same community in order to maintain and operate under the same provider agreement. A provider changing locations is a closure of the old facility if the original community can no longer be expected to be served at the new location. The distance moved from the old location will be considered but will not be the sole determining factor in granting the relocation of a CAH under the same provider agreement. For example, the relocation of a CAH a relatively short distance may greatly affect the community served. In other areas with vast distances between providers, a large distance may have little effect on the community served. Clearly,
mileage alone is not valid as a single criterion but it may be used if it clearly demonstrates that the provider has left the original community.

Virtual ER

From the Sun Herald:

Welcome to State University of New York - Upstate Medical University's new virtual ER, where the patients are computerized mannequins - known as human patient simulators. They speak, moan, bleed, drool, urinate, blink their eyes and perform many other lifelike functions. Complex internal wiring and software allow each dummy to have a heart attack, break into a sweat from a bioterrorism attack or feign just about any other injury or illness.

The emergency medicine training center is equipped with oxygen, patient monitors, ventilators, a defibrillator and all the other equipment normally found in a real emergency room. Upstate got a $350,000 federal grant to buy three mannequins - two adults and a child - and set up the emergency simulation center. The center will add an infant simulator soon.

Human patient simulators are becoming an increasingly popular teaching tool for doctors, nurses and paramedics nationwide. The military uses them to train for mass casualties and NASA has used them to develop procedures for handling medical emergencies in space.

"If they make a mistake on the mannequin, it's not hurting a patient," said Richard Cherry, the center's technical director who orchestrates the emergency scenarios.

"You have the ability to stop, rewind the patient and start over again," said Dr. John McCabe, chairman of emergency medicine. "That's a wonderful teaching technique."

The simulators allow the medical school to create situations that can't be scheduled in the ER. "I might want to be sure my residents know how to manage an airway obstruction," McCabe said. "And yet those are pretty rare events."

Faculty apply makeup to the dummies to mimic bruises, cuts and head injuries. Packages of crushed saltine crackers are sometimes tucked under fake skin covering the dummy's rib cage to simulate the feel of broken ribs.

Residents are not told in advance what's wrong with the patient. They begin with the limited amount of information they can glean from the patient's chart. Residents respond to the exercises as if they were the real thing.

"Even though it's a rubber mannequin, they suspend their disbelief," Rodriguez said. "They get anxious and sweaty."

Chest Radiology Basics

From Medgadget.com, a link to an excellent chest radiography teaching website , "An Introduction to Chest Radiology", from the University of Virginia.

ACEP Resource: QTIPS

A "tip" from our friend Dr. Robert Broida:

A new resource, courtesy of the American College of Emergency Physicians (ACEP):

QTIPs - Quality Tips to Improve Patient Safety - are practical, easy to implement and intended to improve patient outcomes. For more, visit our Quality Improvement & Patient Safety section of membership.

Stroke Care at 38,000 Feet

Excerpted from the Kansas City Star:

That was the day the 40-year-old Ohio lawyer nearly died from a sudden stroke that began to paralyze her as she flew from Cleveland to Phoenix.

Her life was saved by an emergency room doctor from Akron, Ohio, who happened to be on the flight and recognized her symptoms.

And by the America West pilots who made an emergency landing at Kansas City International Airport.

And by stroke specialists at St. Luke’s Hospital who repaired the carotid artery problem that was keeping blood and oxygen from getting to her brain and set her on the road to what they expect to be a full recovery.

It just happened that Maureen Vaughan, a pediatric emergency room doctor at a children’s hospital in Akron, was on the flight. She stepped in and asked Robertson to do some simple tests, like touching her nose, to help her determine whether Robertson was having a stroke.

Vaughan’s emergency room experience was critical, Rymer said. It would have been good to have any doctor, regardless of his or her specialty, on board. But emergency room doctors are especially aware of how important it is to have rapid diagnosis and action for major problems, and they often know how to check for signs of a stroke, she said.

Vaughan decided Robertson probably was having a stroke.

She asked the flight attendants to tell the pilots to land immediately.

Combat Medical Training... in Brooklyn

From the NY Times:

Ms. Meagher, 57, manages a building with 190 patients, overseeing everything from admittance and discharge to family relations. Although she is a registered nurse, she has not practiced bedside nursing since 1979.

But over the last year, she has polished and even surpassed the nursing skills she learned long ago. As a lieutenant colonel in the Army Reserve, she volunteered for a pilot program at Kings County Hospital Center in Brooklyn that prepares reserve medics for the battlefield.

The other morning, she tended to a man in intensive care who had been hit by eight bullets in his back.

"Shootings, stabbings, persons falling off a 20-story building and still being alive," Colonel Meagher ticked off as she made her rounds. "What don't we see here? The ambulances keep coming and coming."

The program, called the Academy of Advanced Combat Medicine, started at Kings County two years ago when officers from the 5,300-person Eighth Medical Brigade, based at Fort Wadsworth on Staten Island, decided to train their reservists in a civilian emergency room. The academy was modeled after a program for active duty medics at the Ryder Trauma Center in Miami.

The Brooklyn hospital proved an ideal partner for the program, the first of its kind in the country for reservists. The hospital's highly regarded, extremely busy emergency room admits 1,200 major trauma patients each year, among the most in the city. About half of those have penetrating wounds, often stabbings or gunshots, just the kind of wounds a medic might encounter in war, according to Dr. Patricia O'Neill, co-director of the hospital's division of trauma and critical care.

"The purpose of this program is to get them more facile with real-world trauma," Dr. O'Neill said, "so when they're deployed, they're not scared to death."

Maj. Gen. Robert J. Kasulke, the deputy surgeon general of reserve affairs who is based in Falls Church, Va., started the program along with Col. Consuelo Dungca, the chief nurse of the Eighth Medical Brigade, and staff members at Kings County. General Kasulke said the program helped close the gap between many reservists' small-town health care backgrounds and what they are likely to experience overseas.

"If you're a general surgeon in Utica, N.Y., the most trauma you may see is from a car accident," General Kasulke said. "You don't have a lot of violent activity in communities like that. What we add at Kings County is the kind of experience you might see in a war zone."

Pneumothorax CME

The American College of Emergency Physicians (ACEP) has posted a new Continuing Medical Education activity, "Focus On: Treatment Options for Pneumothorax" on their website.

The activity's objectives:
"After reading this article, you should be able to:

Define the various types of pneumothoraces.

Describe the indications for needle aspiration and small-bore catheter placement in the management of pneumothoraces as outlined by the American College of Chest Physicians and British Thoracic Society.

Discuss the controversies surrounding needle aspiration and small-bore catheter placement for management of pneumothoraces. You should also be able to identify the advantages and disadvantages in terms of cost, length of stay and patient comfort.

Identify the characteristics of those patients with pneumothoraces unlikely to be successfully treated with needle aspiration and small-bore catheter placement.

Identify sub-sets of patients who have had their pneumothoraces successfully treated with needle aspiration and small-bore catheter placement as reported in emergency medicine, trauma, and radiology literature."

TelaDoc

From an AP story, as published in the Beloit Daily News:

DALLAS - Peter Beasley is a busy man who currently has no health insurance. He's also a customer of TelaDoc Medical Services, a setup that allows him to call an unknown doctor and get medicine prescribed sight unseen.

Within an hour or so of his call to an 800 number, he gets a call from a doctor who discusses his symptoms and will often write a prescription.

TelaDoc provides its members _ which the company estimates at 30,000 _ with access to a doctor 24 hours a day, seven days a week.

While members like Beasley praise the service as a convenient way to address nagging medical needs at odd hours, others in the health care industry say treating patients without seeing them in person is worrisome, perhaps dangerous. California's medical board is investigating TelaDoc's activities in that state.

TelaDoc chief executive Michael Gorton said the Dallas-based company is merely providing a needed service and is not meant to replace the family physician. The company began offering its services nationwide this year after an earlier test run.

"For the vast majority of Americans, being able to talk to a doctor in an hour is next to impossible," Gorton said. "Our motto is we're there when your normal doctor is not."

TelaDoc subscribers are guaranteed to hear back from a doctor within three hours of their phone call. After paying a registration fee of $18 and completing a medical history, an individual subscriber pays $4.25 a month and a $35 fee per consultation.

Crash mistake to face probe; Doctor, paramedics incorrectly ruled wreck victim dead

From Newszap.com

DOVER - The state Division of Public Health has asked for an additional investigation of the medical response to a fatal accident on Del. 1 last month in which a Frederica woman was mistakenly pronounced dead.

Two Kent County paramedics and a physician responding to the Nov. 19 crash pronounced Brenda Lee Pitner, 42, dead about 6:10 a.m.

Ms. Pitner was pinned under her vehicle, which rotated 180 degrees after hitting the pickup and continued approximately 50 feet southward before coming to a stop.

Medical responders pronounced Ms. Pitner dead at about 6:10 a.m., but Delaware state troopers investigating the crash found her alive about an hour later.

Emergency crews were called back and rescuers from Dover's Robbins Hose Co. freed Ms. Pitner from her car. She was flown to Christiana Hospital near Wilmington, where she was treated for a cut to her head.

Hospitals Starting To Bill At Time Of Service

From The Day (New London, CT):

Nowadays, when you visit the hospital, you'd better make sure you bring your checkbook, cash or a credit card along with your insurance card.

The Westerly Hospital announced this week that it would start asking patients to make their insurance co-payment when they come in for care, rather than wait for a bill. Co-payments –– the portion of medical bills that private health insurance companies expect patients to pay –– vary widely, but $50 or $75 for an Emergency Room visit isn't uncommon.

The Westerly Hospital is simply following the lead of other nonprofit hospitals, said Cristine Vogel, commissioner of the Connecticut Office of Health Care Access, which regulates hospitals. She noted that physicians' and dentists' offices have long collected co-payments from patients when they come in for their appointments, and hospitals should be no different. Hospitals are waiving the practice whenever care is needed immediately, she added, and are not withholding care from anyone who is unable to pay.

Medical Device Update

Two interesting posts in MedGadget today:

The ResQPOD


Advanced Circulatory Systems, Inc., an Eden Prairie, MN manufacturer, says that its ResQPOD® has been given a Class IIa recommendation by the American Heart Association in its recently released guidelines for CPR (covered by Medgadget here). Moreover, according to the company, "the ResQPOD is now more highly recommended by the AHA than any other device or drug used by emergency personnel for increasing circulation during CPR and improving resuscitation rates."

The main benefit of the device, that is placed between a ventilation source (e.g., bag-valve or demand-valve resuscitator) and an airway adjunct, it seems to us, is in its ability to selectively impede inspiratory gases from entering the lungs of patients receiving assisted ventilation during the release phase of CPR.

and the
Q-CPR

CNNMoney.com is covering the latest innovation in resuscitative equipment: "a new defibrillator from Philips [that] talks paramedics through CPR and shuts up when they get it right." Philips Electronics describes its FDA cleared Q-CPR™ technology for CPR measurement and feedback (currently configurable on company's HeartStart MRx monitor/defibrillator)

Unwiring the Ambulance

From Wi-Fi Planet (tip from Medgadget):

Next time the paramedic comes rushing in, don't be surprised to see a medical bag under one arm and a laptop under the other. Driven by the need for speed coupled with new regulatory pressure, ambulance-based Wi-Fi could be a thing of the not-too-distant future.

Ambulance service provider American Medical Response (AMR) recently unveiled a technologically advanced vehicle that includes, among other features, an In Motion Technology system that pairs a cellular Internet backhaul connection with the Wi-Fi-driven ability to take information beyond the vehicle.

With their PDAs and laptops hooked up to home base via Wi-Fi, paramedics "can take those devices and go outside of the vehicle," says In Motion CTO Larry LeBlanc. "When they arrive on the site, they can take a laptop to the patient and fill in the care information that they are giving."

Breaking the worst possible news in the best possible manner

From the University of Washington:

Hearing that a loved one has died after trauma could be the most emotionally devastating news one might ever hear. How this news is delivered has an immense impact on how people will later reflect on those initial moments of loss.

"You have to know that you?re creating a lifelong memory ? people will likely remember every detail of the conversation. Even if they don?t remember the words, they will remember the feelings," says Becky Pierce, nurse manager of the Trauma Intensive Care Unit (TICU) at Harborview Medical Center in Seattle, who has spoken on the topic nationwide.

At Harborview, a study began in 1996 on how to best break bad news to people close to trauma victims. Interviews were conducted with 50 family members about six months following the death of a loved one who was treated in the Emergency Room or the TICU. The findings were presented Sept. 17 at the American Association of the Surgery for Trauma in Boston by Dr. Gregory Jurkovich, chief of trauma at Harborview Medical Center and professor of surgery at the University of Washington School of Medicine.

The nurses who conducted these interviews sensed that those who felt their situations were handled well were able to move on more easily. "Although several people refused to respond initially, they later changed their minds," says Pierce. "It was found that people were hungry to talk about their experiences and that everything was crystallized in their minds. If their memories were bitter, the anger was instantly expressed."

The most important aspects of delivering bad news were attitude, clarity of information and privacy. "People didn?t like being strung along, and didn?t want any sugar-coating," she says. "They also didn?t think that touch or hugs were important ? in fact all the men said that anything more than a handshake was inappropriate. According to social workers, unwelcome touch interrupts with the necessary flow of emotions."