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#PWChat – Communication & Integration in Emergency Medicine: Has Anything Changed in 30 Years?

#PWChat – Communication & Integration in Emergency Medicine: Has Anything Changed in 30 Years?

Join us Wednesday, February 28 at 3:00pm ET for our live, interactive tweetchat with PW blogger Matthew Loxton, MKM, CKM, on whether communication and integration in emergency medicine has improved in the past 30 years since his days as an EMT. Topics to be discussed are subject to change but will likely include: Whether facts are still lost in the handoff between EMTs/paramedics and emergency department staff. Whether time is still wasted in getting ambulance crews turned around. Whether there are still missed opportunities for hospital staff to be better prepared for incoming emergency patients. Whether there are still missed opportunities for EMS to initiate specific treatment during transport based on feedback from hospital emergency physicians. Whether hospitals are alerted to the specific nature and ETA of the incoming patient in enough time to be prepared. Whether emergency departments can instruct EMS to initiate specific care or to provide specific information. Whether there are still gaps between what actions EMS crews take and data they collect and what emergency physicians would want. Are there feedback loops from emergency departments to EMS crew to inform them of the final diagnosis and provide advice on process improvements. More… How to Join PART II of the Chat Log into your Twitter account. Don’t have an account? Where have you been?! Just kidding, we don’t judge, but you should get one! It’s easy to create, and free. You’ll be glad you did. A couple minutes before 3:00pm ET on February 28, Search Twitter (top right of every Twitter page) for #PWChat. On the search results page, click Latest at the top left. This...
Talking to Teens About Vaccination

Talking to Teens About Vaccination

Despite increases in recent years, adolescent immunization rates in the United States fall short of Healthy People 2020 goals for several routinely recommended vaccines, leaving millions of teenagers susceptible to preventable diseases. However, data are lacking on the reasoning behind these continued less-than-optimal rates.   Shedding Some Light Between September 26 and October 7, 2016, the non-profit organization Unity Consortium fielded a Harris Poll among 506 adolescents aged 13 to 18, 515 parents of teenagers, 105 pharmacists, and 405 physicians specializing in family practice, general practice, internal medicine, or pediatrics. All surveyed physicians were duly licensed, spent at least 50% of their time in out-patient practice and at least 80% in direct patient care, saw at least and average of 250 patients per month, and regularly saw teenagers for well visits. According to the survey, 92% of parents and 88% of teens reported that they believe it is important for all teens to be vaccinated. However, national data from 2015 indicate that only 33% of teens aged 17 or older received their second recommended dose of the meningitis ACWY vaccine. Less than 50% of male teens and 65% of female teens received the first dose of the human papillomavirus vaccine. So, why aren’t teens getting vaccinated?   Attitudes Impede Action Misperceptions about needing to visit a healthcare provider create barriers to vaccination (Figure). The survey found that nearly all teens (92%) seemed to trust their doctors, but at the same time: Nearly 60% of teens and 41% of parents said they believe they only need to see a doctor if they are feeling sick. Nearly one-quarter of parents and...
MACRA: Proceed With Confidence at the Point of Care

MACRA: Proceed With Confidence at the Point of Care

We’ve been living in a MACRA world for some time now, and yet most physicians still aren’t ready—or even close to ready—for this new reality. As if physicians weren’t already drowning in a sea of acronyms, The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 created the Quality Payment Program (QPP), which began measuring performance on Jan. 1, 2017. In 2019, payment rates will be adjusted under the QPP for physicians choosing one of two tracks: the Merit-Based Incentive Payments System (MIPS) or Alternative Payment Models (APMs). Faced with government mandates, unfamiliar terminology, and a changing practice environment, many physicians are understandably feeling confused, anxious, and unprepared for MACRA’s quality reporting program. This program replaces the sustainable growth rate formula for calculating physician payments, as the healthcare system continues its transition from fee-for-service to value-based care. However, the good news is that technology is adapting as the industry changes. A smarter clinical engine that enhances the usability of electronic health records (EHR) systems and integrates clinical quality measures at the point of care makes quality reporting relatively simple and painless for physicians.   Why many physicians are wary First, though, let’s take a look at why MACRA is causing so much consternation among doctors. A recent KPMG-American Medical Association survey of 1,000 practicing physicians in the U.S. who have some awareness of MACRA and are involved in practice decision-making related to QPP, showed the following: Fewer than one in four physicians feel well-prepared to meet QPP requirements in 2017. Of respondents participating in MIPS in 2017, 90 percent feel MIPS requirements are slightly burdensome or very burdensome. Previous...
Creating Efficiency in the Patient Journey

Creating Efficiency in the Patient Journey

The transformation to value-based care has placed tremendous focus on delivery of care as it relates to improving patient outcomes, quality, and safety. And for good reason; improved discharge protocols and transition care management can reduce costly adverse outcomes, such as 30-day readmissions and hospital-acquired infections. However, few healthcare organizations have focused on creating efficiency along the patient journey. For instance, the vast majority of physician offices, urgent care clinics, and retail clinics still use cumbersome, paper-based intake methods and still primarily schedule appointments by phone. The delays and errors inherent in these legacy approaches are frustrating for both patients and staff, and they frequently result in avoidable productivity and revenue losses, as well as patient satisfaction issues. Some forward-thinking convenient care and urgent care clinics, as well as healthcare systems, have taken on the challenge to improve the patient journey by implementing a variety of automated processes, including digital registration and check-in via mobile tablets and onsite computer kiosks.   Healthcare Organizations Leading the Pack  Healthcare organizations, large and small, are already realizing tangible benefits from employing new technologies and processes to streamline patient registration and check-in for better accuracy, efficiency, and patient satisfaction. Here are three who are leading the pack: CareWell Urgent Care This group of 17 high-volume urgent care clinics throughout New England faced a challenge with paper registration. Since a majority of its patients were walk-ins, the check-in process often got bogged down. Many were visiting a CareWell clinic for the first time and had no patient data on file, which required patients to fill out lengthy registration forms, further slowing down the intake...
Expert-Based Opinions: A Supplement to, Not a Replacement for, Evidence-Based Content

Expert-Based Opinions: A Supplement to, Not a Replacement for, Evidence-Based Content

Nationally recognized and highly regarded health systems have a variety of ways to expand the reach of their “special sauce.” For some, it’s to launch outpatient centers in the suburbs. For others, it may be to develop clinical decision support tools based on their—laudable—best practices. While exporting best practices has a definite appeal, decision support tools linked to the expert opinion of one group of clinicians has several limitations. Ideally, decision support tools should first rely on evidence-based content in any and all circumstances in which there have been rigorous, double-blind studies confirming a particular indicated care path. Expert opinion should be used secondarily, to bolster that evidence in scenarios for which the research reveals conflicts or a lack of conclusions. Practice guidance based upon solid, gold-standard evidence requires constant diligence, rigorous exclusion of bias, and preference of scientific knowledge over opinion; adherence to these principles is demonstrably variable in recommendations from health systems and from medical specialty societies. Erasing geographical inequalities and expanding the best care to all patients is an admirable goal. But there are risks to an approach that privileges the advice of a select group of healthcare providers. For instance, these solutions may “bake in” institutional biases. These solutions may also create the assumption that what works at one health system will work equally well at another, despite differences in governance structures, patient populations, or reimbursement profiles. In addition, clinicians are rarely quick to alter their entrenched best practices. In fact, the Institute of Medicine estimates that it takes an average of 17 years for a new medical advancement to become a common practice, and...
Information Rx: The Missing Piece of Quality Care

Information Rx: The Missing Piece of Quality Care

The vast majority of healthcare takes place outside of a physician’s office. Consumers often care for themselves when they have acute problems, such as colds and the flu, and they partner with their physicians in managing chronic conditions, like diabetes, hypertension, and asthma. When people visit their doctors’ offices, they usually receive test orders and/or drug prescriptions. But the onus is on the patients to go to the lab, to fill their prescriptions, to follow other parts of their care plans, and to make follow-up visits to their doctors. Similarly, after a hospital stay for a procedure or a medical condition, it is up to patients to comply with the post-discharge care plan when they go home. This is a lot for many patients to handle. Studies show that 40% to 80% of the medical information provided by healthcare practitioners is forgotten immediately, and nearly half of what patients retain is incorrect. Written discharge instructions help, and some primary care physicians write down their recommendations for patients. Printed educational handouts can also help patients understand their conditions and how to manage them at home. In addition, patients can find a vast amount of information on the internet about health conditions and how to treat them. But this information is of variable quality and is often inaccurate. For all of these reasons, it is important for physicians to maintain communication with patients between visits. This can come in the form of online or phone consultations that offer patients a chance to ask lingering questions and to gather the information they need to better understand and manage their own health. Providers...
The Innovation Fetish

The Innovation Fetish

There is a joke shared by statisticians, scrap dealers, and emergency medicine professionals about drivers. Despite the distribution curves of driving skill, the daily admissions to the emergency department, and the clear evidence to the contrary in the scrap business, the average driver strongly believes that they are far better drivers than average. Some truly abysmal drivers feel highly confident that they are, in fact, very good drivers. So, too, does the average organization harbor images of themselves as highly innovative, while, by some accounts, fewer than 3% of them are. In truth, the other 97% of organizations range from pretty pedestrian to so terrible at innovation that it brings tears to one’s eyes. Being un-innovative is not really the problem, though, and unlike being a terrible driver, being horrible at innovation is only a problem if one has mismatched aspirations. How do you tell if your organization is truly innovative, or if it is just a bad driver with poor self-awareness? There are several online surveys, but here are three questions taken from an instrument I developed for organizational learning and knowledge behaviors. Score your organization on a 1-5 scale, in which one is “Never” and five is “Always.” There are places at work I can go to quietly think things through. I regard networking with other staff members and exchanging knowledge as part of my job. This organization treats mistakes as valuable learning experiences rather than as a reason to punish somebody. Here is my informal rating scale: 14-15: Yes, your organization probably has a string of copyrights, patents, and inventions to its name, or soon will....
Conference Highlights: CHEST 2017

Conference Highlights: CHEST 2017

Shared Decision Making & Lung Cancer Screening Shared decision-making for lung cancer screening is recommended by the U.S. Preventive Services Task Force and required for screening reimbursement by CMS. However, comparisons of the widely used Option Grid (physician-led) and ShouldIScreen (web-based) decision aids are lacking. Study investigators looking to do so randomized lung cancer screening participants to either decision prior to screening. A validated shared decision-making assessment tool (CollaboRATE) was used to assess participant experience immediately after screening. Patients were contacted 1 week later to answer questions designed to assess knowledge retention about lung cancer and the harms and benefits of screening. Knowledge retention did not differ significantly, with average scores of 62.4% and 64.7% for the online aid and Option Grid, respectively. Post-intervention/screening patient-satisfaction scores were 98.6% for ShouldIScreen and 97.4% for Option Grid. —————————————————————-   A Novel Sedative for Bronchoscopy While midazolam has been the cornerstone of moderate procedural sedation for years, the agent has a half-life of 4.3 hours. An agent with a quicker onset of action and clearance may prove more beneficial in the sedation of patients undergoing bronchoscopy. For a phase III trial, researchers randomly assigned bronchoscopy patients who had undergone pre-treatment with fentanyl to open-label midazolam or the novel agent remimazolam. Average times to bronchoscopy start were 5 minutes for remimazolam and 15.5 for midazolam. Average times to full alertness after the procedure were 6 minutes for remimazolam and 12 for midazolam. The primary endpoint—a composite of completion of the bronchoscopy, no rescue medication, and no more than five doses within a 15-minute window for remimazolam or no more than three doses within...
#PWChat – 1-Year Follow-Up on Healthcare Under President Trump

#PWChat – 1-Year Follow-Up on Healthcare Under President Trump

Join us Wednesday, January 31 at 3:00pm ET for a live, interactive tweetchat with Linda Girgis, MD, on the impact on US healtchare of President Trump’s first year in office. Topics to be discussed are subject to change but will likely include: With TrumpCare as we knew it a year ago essentially dead, where we now stand. Reactions to Pres. Trump’s touting in his 1st State of the Union address (Jan 30, 2018) of the FDA’s approval of more drugs last year than any other year on record, his plan to decrease prescription drug prices, and his goal of getting more terminally ill patients into trials of experimental drugs. The impact on the US healthcare systems as a whole, as well as on patients and healthcare professionals specifically, of Alex Azar taking office as the Secretary of HHS. The pros and Cons of Paul Ryan’s Patient’s Choice Act, where it stands, and what would result if it came to be law. What will come of Pres Trump’s administration allowing states (as of January 11) to impose work requirements on Medicaid recipients. What will result from the Obamacare tax on those who don’t get health insurance being repealed with Pres Trump’s Tax Cuts and Jobs Act. An executive order signed by Pres Trump on Oct 12, 2017 that modified Obamacare in 5  ways. What directing R. Alexander Acosta (Secretary of US Dept of Labor) to expand access to association health plans means and what will come of it. What will come of requests under the executive order for Acosta to ease restrictions on short-term health plans and allow employers to use...
Calling Responsible Parties to Task for their Role in the Opioid Epidemic

Calling Responsible Parties to Task for their Role in the Opioid Epidemic

In October 2017, President Donald Trump announced that the opioid epidemic is a public health emergency. Earlier the same week, the FDA declared that since 2001, prescription drugs (largely opioids) have been the greatest cause of overdose deaths. In fact, over the past 6 years, there have been more deaths from overdoses than guns, cars, suicides, and murder. How did we get to this point? The first use of opioids dates back to approximately 3500 BC, when the opium poppy was cultivated in lower Mesopotamia and the Sumerians referred to it as “Hul Gil” or “joy plant”. Its euphoric properties were soon passed on to the Assyrians, Babylonians, and Egyptians. In 1100 BC, it was noted that the “peoples of the sea” on the Island of Cyprus crafted special knives for harvesting opium, and they smoked it before the fall of Troy. Hippocrates, in 460 BC, first noted its usefulness as a narcotic in treating diseases. There are many references to opium in ancient times, when it was used as an anesthetic and even for ritual purposes. The ancient Egyptians, Indians, and Romans used it to treat pain, often during surgical procedures. It was a highly traded commodity for many centuries, and its use spread throughout Europe and Asia. Opium first arrived in the US in the 1620’s aboard the Mayflower. It was most likely carried in the form of laudanum (an opium/alcohol tincture first created by Paracelsus) and used as a pain killer, anti-diarrheal, and sedative. It was very useful in early frontier times during outbreaks of smallpox, dysentery, and cholera. By the time the American Revolution occurred,...
Comparing Ventilation Approaches for Pneumonia

Comparing Ventilation Approaches for Pneumonia

Pneumonia is the leading infectious cause of hospitalization in US, resulting in more than 1 million admissions annually. Roughly 60% of patients with severe pneumonia develop acute respiratory failure and require invasive mechanical ventilation (IMV). Strong evidence supports the use of noninvasive mechanical ventilation (NIV) in patients with COPD or pulmonary edema, but data on its effectiveness in patients with pneumonia are conflicting. For a study published in the Journal of Critical Care, my colleagues and I compared the outcomes of patients with pneumonia initially treated with NIV with those of patients initially treated with IMV using a large multihospital electronic medical record database that contains results of laboratory testing. We developed a propensity model for receipt of NIV and assessed the outcomes in a propensity-matched cohort. Among nearly 4,000 patients hospitalized with pneumonia who were ventilated, 28% were treated with NIV. Mortality rates were 15.8%, 29.8%, and 25.9.0% among patients treated with initial NIV, treated with initial IMV, or who failed NIV and had to be intubated, respectively. In the propensity matched analysis, the risk of death was 30% lower in patients treated with NIV than in those treated with IMV. However, in the subgroup analysis, we showed that NIV was beneficial only among patients with cardiopulmonary comorbidities. We also found that patients with pneumonia without coexistent COPD or heart failure were more likely to fail NIV than those with cardiopulmonary conditions (21.3% vs13.8%). Our results suggest that NIV is efficacious only in pneumonia patients who also have comorbid COPD or heart failure. Careful monitoring is required when managing severe pneumonia with...
Robotically Assisted PCI for Complex CAD

Robotically Assisted PCI for Complex CAD

The use of robotics in interventional cardiology offers operators the ability to safely and successfully complete PCI while minimizing occupational hazards due to x-ray exposure and wearing lead protection. Proof-of-concept of the first-generation CorPath 200 robotic system (Corindus Vascular Robotics, Waltham, MA) was demonstrated in the multicenter PRECISE registry of single-vessel R-PCI for relatively simple lesions. However, utility of R-PCI in clinical practice, especially with complex coronary anatomy, was unknown.   Comparing Robotic & Manual PCI In a study published in the Journal of the American College of Cardiology: Cardiovascular Interventions, we and our colleagues sought to identify the safety and feasibility of R-PCI for complex coronary artery disease (CAD), as well as compare outcomes with similar manually completed PCI (M-PCI). This was an all-comers study excluding those presenting with ST-segment elevation myocardial infarction (MI) or requiring procedures ineligible for R-PCI. A total of 334 procedures (108 R-PCI, 226 M-PCI) were performed during the study period (Table). The majority of R-PCI were completed entirely robotically (81.5%). Partial manual assistance occurred in 12 procedures (11.1%) and manual conversion in eight (7.4%) due to either adverse events (3 procedures, without MACE), technical limitation of the robotic platform (8 procedures), or limited guidewire or catheter support (9 procedures), resulting in 91.7% robotic technical success. Periprocedural MI occurred twice following M-PCI and once following R-PCI, resulting in 99.1% clinical success in both groups. Baseline clinical characteristics for individuals in the R-PCI and M-PCI groups were similar overall. A total of 157 lesions were addressed robotically, including left main (4.6%), ostial (7.4%), bifurcation (7.4%), chronic total occlusion (5.6%), and saphenous vein graft (1.9%) lesions....
Three Effective Ways to Pick Quality Improvement Targets

Three Effective Ways to Pick Quality Improvement Targets

My first exposure to Lean as a quality improvement (QI) approach was at a well-known automotive producer, and it was alarming. The Master Black Belt Sensei flown in from Japan spoke in short, clipped, and heavily accented barks, the meaning of which were mostly quite opaque to us. He strode purposefully across the factory floor, repeatedly bellowing “Waste!” in a very intimidating way, and suddenly lunging and jabbing his finger here and there to the great alarm of those standing near him. He examined production sheets and stabbed a finger at one quality or operational target after another, shouting out changes. He sometimes doubled, sometimes halved, sometimes just roared. Apparently, once one knew him better, understood the terminology, and grew accustomed to the process, this all made perfect sense. He wasn’t angry, just very enthusiastic. On that day though, it was a deeply mysterious, somewhat alarming, and more than a little foreboding experience—which in truth is how most people in healthcare perceive Lean Six Sigma all the time. One area in which many have particular problems is in the selection of where to intervene and what targets to set. In this blog post, I cover three practical ways to pick targets for QI initiatives that won’t be intimidating or alarming, but instead should make perfect sense. We are going to look at dreams, outliers, tight shoes, and wrapping presents. Dreams A very useful technique in QI is to picture the best a specific process could ever be, if there were no delays, no errors, and everything was running at top speed. Once that narrative is fully described, and story-boarded...
Dutch physician Lars Brouwers driving to Africa to deliver 3D printed hands

Dutch physician Lars Brouwers driving to Africa to deliver 3D printed hands

A physician from the Netherlands is attempting to drive to Sierra Leone in order to set up a program for 3D printing hand prostheses. Dutch 3D printer manufacturer Ultimaker is supplying an FDM 3D printer for the project. What’s the longest journey you’ll make in a car this week? Two hours? Three? For 29-year-old Dutch physician Lars Brouwers, things are a little more extreme: his next ride is going to take three whole weeks. As part of an ambitious project for charity, Brouwers is attempting to drive from his home in Den Bosch, Netherlands, all the way to Freetown, the capital of Sierra Leone in Africa. But this isn’t some kind of endurance race: the medical expert is bringing an Ultimaker 3D printer with him, and intends to 3D print hand prostheses for locals there. Staying with a friend who works as a doctor in Freetown, Brouwers will attempt to link up with the multi-city Innovate Salone entrepreneurial project, using an Ultimaker 3 3D printer (provided free of charge by Ultimaker) to fabricate hand prostheses with movable fingers. Each prosthesis can be 3D printed in just one day, while hinges and indestructible fishing wire provide a solid gripping function. “Many children have only a wrist or forearm due to an abnormality from before or during birth, or they have lost a hand by war violence,” Brouwers says. “The printer makes a complete hand prosthesis in one day with fingers that can move.” Dec 22, 2017 | By Benedict A physician from the Netherlands is attempting to drive to Sierra Leone in order to set up a program for 3D printing hand...
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