CAL/ACEP`s 40th Anniversary Scientific Assembly

Transcription

CAL/ACEP’s 40th Anniversary
Scientific Assembly, Newport Beach
LIFELINE
MAY ISSUE 2011
CAL /ACEP | A FORUM FOR EMERGENCY PHYSICIANS IN CALIFORNIA
5350 95181 Lifeline NL.indd 1
May Issue 2011 1
5/25/11 1:26 PM
Circulation 3,500
INSIDE THIS ISSUE
Scientific Assembly 40th Anniversary.................... 2-5
Reasons for More Specific Diagnosis ........................6
Ads/Dates to Remember/Call for Articles.............. 7
Advocacy Update ..........................................................8
WestJEM.........................................................................9
Welcome New Members ..............................................9
ITLS Courses ............................................................... 10
President’s Message..................................................... 12
Communicating Protected Info Safely..................... 13
Co-Sponsored Courses............................................... 13
Word Search ................................................................. 14
Career Opportunities .................................................. 16
Emergency Medicine Action Fund .......................... 19
Scientific Assembly & Ultrasound Workshop...20-23
Lifeline is published monthly by the
American College of Emergency Physicians
State Chapter of California, Inc.
1020 - 11th Street, Suite 310
Sacramento, CA 95814
(916) 325-5455 Phone (916) 325-5459 Fax
Web site: www.calacep.org
©2002 American College of Emergency Physicians
Editor-in-Chief
Deanna M. Janey
[email protected]
Medical Co-Editors
Gene Hern, MD
Mathew Foley, MD
[email protected] [email protected]
Staff Editors
Elena Lopez-Gusman, Ryan Adame,
Lucia Romo & Callie Hanft
The views expressed in these materials
are those of the authors and do not necessarily represent those of the
American College of Emergency Physicians or the California Chapter.
BOARD OF DIRECTORS 2010-2011
President
Andrea Brault, MD
Bing Pao, MD
Andrea M. Wagner, MD
President-Elect
Peter Sokolove, MD
CAL/AAEM
Representative
Steven Gabaeff, MD
Immediate
Past President
Robert Rosenbloom, MD
Vice President
Andrew Fenton, MD
Treasurer
Thomas Sugarman, MD
Secretary
Paul Christiansen, MD
Directors
Yasmina Boyd, DO
Doug Brosnan, MD
David Feldman, MD
Mathew Foley, MD
Gary Gechlik, MD
Sam2November
Ko, MD
2009
Leslie Mukau, MD
Mark Notash, MD
Rusty Oshita, MD
2 Michael
May Issue
2011 MD
Osmundson,
CAL/EMRA
President
Sam Ko, MD
CAL/EMRA
President-Elect
Alfred Joshua, MD
Cal/ENA
Representative
Linda Broyles, RN
CAL/ACEP
Advocacy Fellowship
Advocacy
Fellowship Director
Mathew Foley, MD
June 23 – 25, 2011—See pages 1 through 5 and pages 19 through 24 for
CAL/ACEP’s 40th Annual Scientific Assembly Course Descriptions,
Newport Beach Marriott information, maps, area activities and directions.
June 23 – 24, 2011—Ultrasound Workshop
CAL/ACEP 40th ANNIVERSARY
Register @ www.calacep.org
E-mail: Program
[email protected]
Scientific■Assembly
– Correction ■ Call: 916-325-5455
Scientific Assembly
June 23 – 25, 2011
In the Scientific Assembly Program Course Descriptions for the March issue of Lifeline,
we incorrectly listed Dr. Greg Hendey’s faculty background information.
The information has been corrected in this issue and on all promotional materials associated
with the Scientific Assembly program. We apologize for any confusion
& related to our mistake.
Ultrasound Workshop
June 23 – 24, 2011
Newport Beach Marriott
Time is Approaching Fast
by Dr. Frederick M. Abrahamian, D.O.
Chair, 40th Annual CAL/ACEP SA
Time is quickly approaching to the 40 th Annual Cal ACEP Scientific Assembly. The
conference is scheduled to take place from June 23 rd to June 25th at the Newport Beach
Marriott. We have been busy getting speakers lined up, submitting CME applications, and
organizing the adjunct courses. Many wonderful speakers have been invited, and will present
a variety of topics relevant to the clinical practice of emergency medicine. Our faculty
represents emergency medicine programs throughout California, and we look forward to
hearing from them all.
The first day will begin with Dr. Scott Votey from UCLA discussing anaphylaxis and
the impact of the newly released guidelines in the management of this condition in the
emergency department. Next, Dr. Mallon from USC will talk about endocrine emergencies.
With his lecture titled, “Glands Gone Wild”, I am sure it will be an entertaining and
informative talk. Next, there will be a break and you can use the time to ask further questions
from the speakers, visit the exhibitors, or chat with your friends and colleagues. After the
break, Dr. Hendey from UCSF-Fresno will talk about difficult dislocations, an issue that we
all have had to deal with in the middle of the night. The lectures on this day will conclude
with Dr. Arora from USC highlighting recent EM literature effecting a change in your
everyday emergency medicine practice.
The second day is short, and we will only have two lectures that morning. Dr.
Sharieff from San Diego, a specialist in the field of pediatric emergency medicine, will lecture
first and discuss how to deal with difficult parents. Lecture topics like this are not commonly
given and I am looking forward to hearing what she has to say. Next, Dr. Ricketts from OliveUCLA will be discussing electrolyte emergencies. I have heard her lectures in the past and let
me tell you, be prepared to learn. These will be followed by the Trainor Lecture and
President’s Message, delivered by Dr. Peter Sokolove of UC Davis, and conclude with an
awards luncheon.
The third and final day of the conference will start with Dr. Nguyen from Loma
Linda, a specialist in the field of critical care and emergency medicine, discussing therapeutic
hypothermia. He will talk about the evidence and ways of incorporating this intervention in
our daily practice of emergency medicine. Next, Dr. McCollough from USC, a well-known
pediatric emergency medicine specialist, will take us through a review of the pediatric
literature. She has a wealth of knowledge and I always learn something new from her. After
the break, Dr. Vohra, a toxicologist from UCSF-Fresno will talk about the approach and
management of poisoned patients. He has tremendous knowledge and experience in this field
and I am eager to learn cool toxicology tricks from him. The day will conclude with Dr.
Langdorf from UC Irvine discussing the reversal of anticoagulation in life-threatening
bleeding.
In addition to the above lectures, a highly sought after course, the ultrasound
workshop will also take place on June 23and 24. The LLSA review course will take place on
Friday, June 24.
I hope the location, line-up of speakers, topics and additional workshop and courses
have given you the motivation to come and be part of this awesome conference. I am looking
forward to meeting you in June. Thank you for your continued support.
Advocacy Fellows
Alexis Lieser MD
David Rankey, MD
5/25/11 1:26 PM
emergency medicine topics from fever and respiratory illness to abdominal pain and trauma, this lecture will definitely change your
practice.
40th Annual
CAL/ACEP Scientific Assembly
Rais B. Vohra, MD
Cool Tox Tricks: Simple Solutions for Poisoned Patients (1 hour)
This lecture will cover 6 clinical cases in poison management with 6 simple solutions for busy ER doctors that are easy to learn,
efficiency-boosting, and evidence-based.
& Ultrasound
Workshop
Mark I. Langdorf, MD
Reversal
of Anticoagulation
in Life Threatening Bleeding (1 hour)
Learn the indications and contraindications to reversal of anticoagulation in patients with intracranial hemorrhage; Appreciate the
controversies in management; Understand the limited research in this area; Learn reversal strategies for Coumadin, Heparin, aspirin
and Plavix.
June 23-25, 2011 - Newport Beach Marriott
Newport Beach, California
Laleh Gharahbaghian, MD and Martine Sargent, MD
ULTRASOUND IV WORKSHOP (3 hours)
David and
Francis,
MD and Brita Zaia, MD
This conference is sponsored by The American College of Emergency Physicians
CAL/ACEP.
This ultrasound workshop introduces the technique of point-of-care Ultrasound-guided peripheral & central line IV placement and
Bladder volume assessment. For those patients who have difficult access and needs an IV for emergency management, or patients who
Thursday,
Juneand23you need to know the volume of the bladder for assessing need for foley catheter placement, this course
have
urinary complaints
allows you to learn a tool that will make it easier for your care of these patients. The lecture followed by an extensive hands-on session
Anaphylaxis: Should the Recent Guidelines Change Our Practice? (1 hour)
Votey, MD
discusses
the tricks of trade, pitfalls, and allows for extensive practice with gel phantom models for IV placement andScott
human
models for
Understand the pathophysiology of anaphylaxis and how it influences treatment choices; Become aware of the range of presentations of
bladder assessment. It is safe, rapid, portable, and noninvasive; it allows rapid bedside evaluation and increases success and speed for
anaphylaxis so as to be able to promptly diagnose patients presenting atypically; Develop a severity-based pharmacologic therapy
many procedures.
regimen for anaphylaxis; Become aware of the current standards in the management of anaphylaxis including the appropriate use of
epinephrine.
William Mallon, MD
Glands Gone Wild: Endocrine Emergencies
Faculty
Endocrine emergencies represent a group of potentially life-threatening conditions that are frequently overlooked, resulting in delays in
(1 hour)
both diagnosis and treatment. Billy will highlight factors that contribute to their high mortality rates.
Frederick
M. Abrahamian,
DO (1 hour)
Gregory Hendey, MD
Vena Ricketts, MD
Gregory Hendey, MD
Difficult
Dislocations
Professor, Clinical Emergency Medicine,
Professor of Medicine, UCLA School of Medicine
Scientific Assembly Program Chair
To
demonstrate
innovative
techniques
for
the
reduction
of
difficult
dislocations,
using
multiple
video
clips;
To
the Medicine,
risk of
UCSF School of Medicine, San Francisco,
Assistant Chief, Department assess
of Emergency
Associate Professor of Medicine/Emergency Medicine
neurovascular
compromise after a joint dislocation
a reasonable
evaluation; To discuss
sedation
and
anesthesia
options
California;and
Vice plan
Chair and
Research
Olive-View
UCLA
Medical
Center, Los
Angeles, for
UCLA
School of Medicine
Director, UCSF-Fresno Emergency
California
Director
of Education,
Department
of Emergency
facilitating
reduction
techniques.
Medicine Residency Program, Fresno,
Medicine, Olive View-UCLA Medical Center
California
Martine Sargent, MD
Ultrasound Director, Assistant
Professor,
UCSF MD
Sanjay
Arora,
Recent
EM Literature
that Will Change Your Practice (1 hour)
Matthew
Strehlow,
MD
of Emergency
Medicine
Mark
I.
Langdorf,
MD
CAL/ACEP
Education
Committee
Chair
A review of the most significant studies published throughout the medical literature in past years.Department
Each article
presented
willSan
beFrancisco
assessed
Associate Residency Director Department Chair, Medical
General Hospital & Trauma Center
Clinical Assistant Professor of Surgery/Emergency
to determine
its relevance
medicine. This lecture will identify advances in emergency medicine by
Director ofemergency
Emergency Medicine
Medicine,
Associate Medical
Director to the practice of clinical
of Clinical
Medicine,on
Department
of
Director,
Clinical Decision
Area literature, describe theProfessor
Sharieff,
MD
reviewing
the recent
limitations
of Emergency
recent studies
the practice
of Ghazala
emergency
medicine,
and discuss the
Emergency
Medicine,
University of California, Irvine
Stanford
University Emergency
Division Director, Emergency Department, Rady
implications
of recentDepartment,
studies regarding clinical
emergency
medicine.
Division of Emergency Medicine, Stanford, California
Children’s hospital and health Center/ Clinical Professor,
University of California, San Diego; Director, Pediatric
Matthew Lewin, MD
Director, Center for Exploration and Travel health, California
Emergency Medicine, Palomar-Pomerado
Hospital/
Sanjay
Arora, MD FORUM (3 hours)
Matthew Lewin,
MD
RESEARCH
Academy
Sciences, San Francisco,
California
Physicians,
San Diego,
Associate
of Clinical
Emergency
Medicine,
FindProfessor
out what’s
on the
cutting
edge of research
fromofcolleagues
around the
state. Ten abstractsCalifornia
will beEmergency
presented
and Awards
forCalifornia
Best
University of Southern California, Keck School of
Research,
BestCounty
Presentation
will be given. Upon completion of this
will be able to
Medicine,
Los Angeles
Hospital and Most innovative
WilliamProject
Mallon, MD
Rais course,
B. Vohra, participants
MD
Associate Professor
of Clinicalabstract,
Emergency Medicine,
Assistant Clinical
Professor
Emergency
discuss the pros and cons of the results of a moderated
oral research
identify Keck
research/treatment
that could
beofapplied
toMedicine
clinical
School
of Medicine, University
of Southern California;
Director of Clinical Toxicology
Peter
D’Souza, and
MD explain research trends occurring
practice,
in emergency
medicine.
Clinical Instructor of Surgery, Division of Emergency
Director, Division of International Emergency Medicine; LACUCSF-Fresno Medical Center, Fresno, CA
Medicine, Stanford University School of Medicine
USC Medical Center, Los Angeles, California
Scott Votey, MD
Professor of Clinical Medicine/Emergency Medicine,
Dave Francis, MD
Maureen McCollough, MD
UCLA School of Medicine
Fellow Emergency Ultrasound, Clinical Instructor of
Associate Professor of Emergency Medicine and Pediatrics,
Dealing
with
DifficultMedicine,
ParentStanford
(1 hour)
Ghazala
Sharieff,Emergency
MD
Program Director, UCLA/Olive
View-UCLA
Surgery,
Division
of Emergency
Keck USC School of Medicine; Medical Director, Department
To beHospital
familiar
with the
impact
of antibiotic useofon
the development
asthma,
and
diarrhea;
theResidency
clinicalProgram
guidelines for obtaining
Medicine
University
& Clinics
Emergency
Medicine
Emergency
Medicine, Losof
Angeles
County
USC
Medical To know
Center,
Angeles,
Californiaon teenage drug testing.
a head CT in children with head injury; To know
theLos
AAP
guidelines
Brita Zaia, MD
Laleh Gharahbaghian, MD
Attending Physician and Clinical Instructor, Department
Associate Director, Emergency Ultrasound; Co-Director,
H. Bryant Nguyen, MD
(1 hour)
Vena
Ricketts,
MD
Electrolyte
Emergencies
of Emergency Medicine, Kaiser
Permanente
Medical
Emergency
Ultrasound
Fellowship, Stanford
University
Associate Professor, Department of Emergency Medicine and
Center,Participants
San Francisco, California
Medical
Center, Division
of Emergency
Medicine
Department
of Internal
Medicine,
Critical
Care, Loma Linda
Recognize
the clinical
presentations
of patients
presenting
to the
ED with
Electrolyte
Emergencies;
will have a distinctive
Department of Surgery, Stanford, California
University, Loma Linda, California
Friday, June 24
concise knowledge on the management of Electrolyte Emergencies; Participants will learn several
clinical
pearls
on evaluation
FACULTY:
Those involved
in the planning
and teaching of this and
activity are
required to disclose to the audience any relevant financial interest or other
management; Learn how to avoid potential disasters.
relationship. All faculty, planners, and staff in a position to control the
content of this CME activity have indicated that he/she has no relationship,
which could be perceived as a potential conflict of interest.
LLSA Review (3 hours)
Peter D’Souza, MD
The 2011 Lifelong Learning and Self Assessment (LLSA) Workshop will cover all 11 articles chosen by the American Board of Emergency
Medicine as part of the Emergency Medicine Continuous Certification (EMCC Program). The workshop will be an interactive review of
the articles with participants encouraged to share pearls from their own practice relevant to the covered topics. Key "testable" concepts
from the articles
will be
emphasized.
Participants
will also
a handout
with
a review
of key
points
fromforthethe
articles.
Physicians:
This activity
has
been planned
and implemented
in receive
accordance
with the
Essential
Areas
and
Policies
Accreditation Council of
Accreditation
Saturday, June 25
Continuing Medical Education through joint sponsorship of ACEP and CAL ACEP. The American College of Emergency Physicians is accredited by the
Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The American College of Emergency
Physicians
designates
this live activity
for a maximum
of 17.00
AMAto
PRA
Category
1 Credit(s)™. Physicians should claim only
the credit
commensurate
Therapeutic
Hypothermia
Post-Cardiac
Arrest:
Evidence
Practice
(1 hour)
H. Bryant
Nguyen,
MD
with
extentguidelines
of their participation
in the activity.
Tothe
review
for post-cardiac
arrest care; To review the evidence for therapeutic hypothermia/ targeted temperature management
ACEP:
Approvedarrest;
by the American
College
of Emergency
a maximum
17.00
hour(s) of ACEPissues
Category
post-cardiac
To discuss
cooling
methods; Physicians
To discussfor
best
practicesofand
implementation
for Iacredit.
post-cardiac arrest care
Physician Assistants: The American Academy of Physician Assistants (AAPA), The National Certification Council for Physician Assistants (NCCPA)
bundle.
and The California Department of Consumer Affairs Physician Assistant Committee (PAC) accepts AMA PRA Category 1 Credit(s)™ as equivalent to
AAPA Category 1 credit for continuing medical education.
Pediatric Literature Review (1 hour)
Maureen McCollough, MD
Nurses: CAL/ACEP is approved by the California Board of Registered Nursing for 17 contact hours, Provider Number 15059.
Bedside ultrasound has dramatically changed the practice of emergency medicine for adult patients and is just beginning to change the
EMTs/Paramedics: EMREF is approved by the Sacramento County EMS Agency for 17 Continuing Education Units, Provider Number 34-4600.
faceAmerican
of pediatric
emergency
medicine.
This recognizes
course willACCME
be a great
review
of theasmost
recent
articles
wide variety
of pediatric
DO’s:
Osteopathic
Association
(AOA)
Category
1 Credit
AOA
Category
2-A covering
Credit. Alla members
of AOA
are required
to participate in CME programs to meet the 2010-12 CME Cycle of 15 Credits ACCME Category 1 Credits and 15 AOA Category 1-A Credits.
May Issue 2011 3
4 May Issue 2011
5/25/11 1:26 PM
practice.
practice.
Rais B. Vohra, MD
Cool Tox Tricks: Simple Solutions for Poisoned Patients (1 hour)
This
lecture
will cover
6 clinical
cases
in poisonPatients
management
easy toMD
learn,
(1 hour) with 6 simple solutions for busy ER doctors that
Raisare
B. Vohra,
Cool
Tox Tricks:
Simple
Solutions
for Poisoned
efficiency-boosting,
and evidence-based.
This lecture will cover
6 clinical cases in poison management with 6 simple solutions for busy ER doctors that are easy to learn,
efficiency-boosting, and evidence-based.
Mark I. Langdorf, MD
Reversal of Anticoagulation in Life Threatening Bleeding (1 hour)
hour)
Mark I. Langdorf,
MD the
Reversal
of Anticoagulation
in Life Threatening
Bleeding
Learn
the indications
and contraindications
to reversal
of (1anticoagulation
in patients with intracranial hemorrhage;
Appreciate
Learn the indications
and contraindications
reversal
of anticoagulation
patients
with intracranial
hemorrhage;
the
controversies
in management;
Understand thetolimited
research
in this area;inLearn
reversal
strategies for
Coumadin, Appreciate
Heparin, aspirin
controversies
in management; Understand the limited research in this area; Learn reversal strategies for Coumadin, Heparin, aspirin
and
Plavix.
and Plavix.
Laleh Gharahbaghian, MD and Martine Sargent, MD
Laleh Gharahbaghian,
MD and MD
Martine
MDMD
David Francis,
and Sargent,
Brita Zaia,
David
Francis,
MD
and
Brita
Zaia,
MDand
This ultrasound workshop introduces the technique of point-of-care Ultrasound-guided peripheral & central line IV placement
This ultrasound
workshop introduces
the technique
of point-of-care
Ultrasound-guided
peripheral
& central
line IV placement
andwho
Bladder
volume assessment.
For those patients
who have
difficult access
and needs an IV
for emergency
management,
or patients
Bladder
volume
assessment.
patients
have difficult
andforneeds
an IV need
for emergency
or patients
have
urinary
complaints
and For
you those
need to
know who
the volume
of theaccess
bladder
assessing
for foley management,
catheter placement,
this who
course
have you
urinary
complaints
of the
for assessing
need for
foley catheter
placement,
this course
allows
to learn
a tool and
that you
will need
maketoit know
easierthe
forvolume
your care
of bladder
these patients.
The lecture
followed
by an extensive
hands-on
session
allows you
learnofatrade,
tool that
will make
it easier
your care
of thesewith
patients.
The lecture
followed
an extensive
session for
discusses
the to
tricks
pitfalls,
and allows
forforextensive
practice
gel phantom
models
for IVbyplacement
andhands-on
human models
discusses
the
tricks
of
trade,
pitfalls,
and
allows
for
extensive
practice
with
gel
phantom
models
for
IV
placement
and
human
models
for for
bladder assessment. It is safe, rapid, portable, and noninvasive; it allows rapid bedside evaluation and increases success and speed
bladder assessment. It is safe, rapid, portable, and noninvasive; it allows rapid bedside evaluation and increases success and speed for
many procedures.
many procedures.
Faculty
Faculty
Frederick M. Abrahamian, DO
Frederick M. Abrahamian, DO
Scientific
Assembly Program Chair
Scientific Assembly Program Chair
Associate
Professor
of of
Medicine/Emergency
Associate
Professor
Medicine/EmergencyMedicine
Medicine
UCLA
School
of of
Medicine
UCLA
School
Medicine
Director
of of
Education,
Department
Director
Education,
DepartmentofofEmergency
Emergency
Medicine,
Olive
View-UCLA
Medical
Medicine,
Olive
View-UCLA
MedicalCenter
Center
Matthew
Strehlow,
MD
Matthew
Strehlow,
MD
CAL/ACEP
Education
Committee
CAL/ACEP
Education
CommitteeChair
Chair
Clinical
Assistant
Professor
ofofSurgery/Emergency
Clinical Assistant Professor
Surgery/Emergency
Medicine,
Associate
Medical
Director
Medicine, Associate Medical Director
Director,
Clinical
Decision
Area
Director,
Clinical
Decision
Area
Stanford
University
Emergency
Stanford
University
EmergencyDepartment,
Department,
Division
of of
Emergency
Medicine,
Division
Emergency
Medicine,Stanford,
Stanford,California
California
Sanjay
Arora,
MD
Sanjay
Arora,
MD
Associate
Professor
ClinicalEmergency
EmergencyMedicine,
Medicine,
Associate
Professor
of of
Clinical
University
Southern
California,Keck
KeckSchool
Schoolofof
University
of of
Southern
California,
Medicine,
Angeles
CountyHospital
Hospital
Medicine,
LosLos
Angeles
County
Peter
D’Souza,
MD
Peter
D’Souza,
MD
Clinical
Instructor
Surgery,Division
DivisionofofEmergency
Emergency
Clinical
Instructor
of of
Surgery,
Medicine,
Stanford
UniversitySchool
SchoolofofMedicine
Medicine
Medicine, Stanford University
Dave
Francis,
MD
Dave
Francis,
MD
Fellow
Emergency
Ultrasound,Clinical
ClinicalInstructor
Instructorofof
Fellow
Emergency
Ultrasound,
Surgery,
Division
EmergencyMedicine,
Medicine,Stanford
Stanford
Surgery,
Division
of of
Emergency
University
Hospital
ClinicsEmergency
EmergencyMedicine
Medicine
University
Hospital
&&
Clinics
Laleh
Gharahbaghian,
MD
Laleh
Gharahbaghian,
MD
Associate Director, Emergency Ultrasound; Co-Director,
Associate
Director, Emergency Ultrasound; Co-Director,
Emergency Ultrasound Fellowship, Stanford University
Emergency Ultrasound Fellowship, Stanford University
Medical Center, Division of Emergency Medicine
Medical Center, Division of Emergency Medicine
Accreditation
Accreditation
Gregory Hendey, MD
Gregory Hendey, MD
Professor,
Clinical Emergency Medicine,
Professor, Clinical Emergency Medicine,
UCSF
of Medicine,
Medicine,San
SanFrancisco,
Francisco,
UCSF School
School of
California;
Vice Chair
Chair and
andResearch
Research
California; Vice
Director,
Emergency
Director, UCSF-Fresno
UCSF-Fresno Emergency
Medicine
Program,Fresno,
Fresno,
Medicine Residency
Residency Program,
California
California
Mark
MD
Mark I.
I. Langdorf,
Langdorf, MD
Associate
DirectorDepartment
DepartmentChair,
Chair,Medical
Medical
Associate Residency
Residency Director
Director
Emergency Medicine
Medicine
Director of
of Emergency
Professor
Clinical Emergency
EmergencyMedicine,
Medicine,Department
Departmentofof
Professor of Clinical
Emergency
Medicine, University
UniversityofofCalifornia,
California,Irvine
Irvine
Emergency Medicine,
Matthew
MD
Matthew Lewin, MD
Director,
for Exploration
Explorationand
andTravel
Travelhealth,
health,California
California
Director, Center for
Academy of Sciences,
Academy
Sciences, San
SanFrancisco,
Francisco,California
California
William Mallon, MD
William
MD
Associate Professor
Professor of
Associate
of Clinical
ClinicalEmergency
EmergencyMedicine,
Medicine,Keck
Keck
School of Medicine,
Medicine, University
School
UniversityofofSouthern
SouthernCalifornia;
California;
Director,
Division
of
International
Emergency
Medicine;
Director, Division of International Emergency Medicine;LACLACUSC Medical
Medical Center,
USC
Center, Los
LosAngeles,
Angeles,California
California
Maureen McCollough,
McCollough, MD
Maureen
MD
Associate Professor
Professor of
Associate
of Emergency
EmergencyMedicine
Medicineand
andPediatrics,
Pediatrics,
Keck USC
USC School
Keck
School of
of Medicine;
Medicine;Medical
MedicalDirector,
Director,Department
Department
of Emergency
Emergency Medicine,
of
Medicine, Los
LosAngeles
AngelesCounty
CountyUSC
USCMedical
Medical
Center, Los
Los Angeles,
Center,
Angeles, California
California
H. Bryant Nguyen, MD
H.
Bryant Nguyen, MD
Department of Internal Medicine, Critical Care, Loma Linda
Department of Internal Medicine, Critical Care, Loma Linda
Vena Ricketts, MD
Vena Ricketts, MD
Assistant
Chief,
Department
of Emergency
Medicine,
Assistant
Chief,
Department
of Emergency
Medicine,
Olive-View
UCLA
Medical
Center,
Angeles,
Olive-View
UCLA
Medical
Center,
Los Los
Angeles,
California
California
Martine
Sargent,
Martine
Sargent,
MDMD
Ultrasound
Director,
Assistant
Professor,
UCSF
Ultrasound
Director,
Assistant
Professor,
UCSF
Department
of
Emergency
Medicine
Francisco
Department of Emergency Medicine
San San
Francisco
General
Hospital
&
Trauma
Center
General Hospital & Trauma Center
Ghazala
Sharieff,
Ghazala
Sharieff,
MDMD
Division
Director,
Emergency
Department,
Division
Director,
Emergency
Department,
RadyRady
Children’s
hospital
health
Center/
Clinical
Professor,
Children’s
hospital
andand
health
Center/
Clinical
Professor,
University
of California,
Diego;
Director,
Pediatric
University
of California,
SanSan
Diego;
Director,
Pediatric
Emergency
Medicine,
Palomar-Pomerado
Hospital/
Emergency
Medicine,
Palomar-Pomerado
Hospital/
California
Emergency
Physicians,
SanSan
Diego,
California
California
Emergency
Physicians,
Diego,
California
Rais
B. B.
Vohra,
MDMD
Rais
Vohra,
Assistant
Clinical
Professor
of Emergency
Medicine
Assistant
Clinical
Professor
of Emergency
Medicine
Director
of of
Clinical
Toxicology
Director
Clinical
Toxicology
UCSF-Fresno
Medical
Center,
Fresno,
CA
UCSF-Fresno Medical Center, Fresno, CA
Scott
Votey,
MD
Scott
Votey,
MD
Professor
of Clinical
Medicine/Emergency
Medicine,
Professor
of Clinical
Medicine/Emergency
Medicine,
UCLA
School
of
UCLA School Medicine
of Medicine
Program
Director,
UCLA/Olive
View-UCLA
Emergency
Program
Director,
UCLA/Olive
View-UCLA
Emergency
Medicine
Residency
Program
Medicine
Residency
Program
Brita
Zaia,
MD
Brita
Zaia,
MD
of Emergency Medicine, Kaiser Permanente Medical
of Emergency Medicine, Kaiser Permanente Medical
Center, San Francisco, California
Center, San Francisco, California
FACULTY: Those involved in the planning and teaching of this activity are
FACULTY:
Those
in the
planning
teaching
of this
required
to disclose
to involved
the audience
any
relevantand
financial
interest
or activity
other are
required to
the audience
anyinrelevant
financial
interest
relationship.
Alldisclose
faculty, to
planners,
and staff
a position
to control
the or other
relationship.
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faculty,
planners,
and
staff
in
a
position
to
control
the
content of this CME activity have indicated that he/she has no relationship,
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he/she has no relationship,
which
couldofbethis
perceived
as a potential
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which could be perceived as a potential conflict of interest.
Physicians: This activity has been planned and implemented in accordance with the Essential Areas and Policies for the Accreditation Council of
Physicians:
activity
has been
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and implemented
in and
accordance
withThe
theAmerican
EssentialCollege
Areas of
andEmergency
Policies for
the Accreditation
ContinuingThis
Medical
Education
through
joint sponsorship
of ACEP
CAL ACEP.
Physicians
is accreditedCouncil
by the of
Continuing
Medical
Education
through Medical
joint sponsorship
CAL ACEP.
Theeducation
Americanfor
College
of Emergency
Physicians
is of
accredited
by the
Accreditation
Council
for Continuing
EducationoftoACEP
provideand
continuing
medical
physicians.
The American
College
Emergency
Accreditation
Council for
Education
to provide
continuing
medical
educationPhysicians
for physicians.
College
of Emergency
Physicians designates
thisContinuing
live activityMedical
for a maximum
of 17.00
AMA PRA
Category
1 Credit(s)™.
should The
claimAmerican
only the credit
commensurate
Physicians
designates
this
live activity
maximum of 17.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate
with the extent
of their
participation
in for
the aactivity.
with
the extent
of their
the activity.
ACEP:
Approved
by participation
the Americanin
College
of Emergency Physicians for a maximum of 17.00 hour(s) of ACEP Category I credit.
ACEP:
Approved
by theThe
American
College
of Emergency
Physicians
for (AAPA),
a maximum
17.00 hour(s)
of ACEP
Category
I credit. Assistants (NCCPA)
Physician
Assistants:
American
Academy
of Physician
Assistants
TheofNational
Certification
Council
for Physician
Physician
The American
AcademyAffairs
of Physician
Assistants
The(PAC)
National
Certification
for1 Physician
(NCCPA)
and The Assistants:
California Department
of Consumer
Physician
Assistant(AAPA),
Committee
accepts
AMA PRACouncil
Category
Credit(s)™Assistants
as equivalent
to
andAAPA
The California
of Consumer
Affairs
Physician Assistant Committee (PAC) accepts AMA PRA Category 1 Credit(s)™ as equivalent to
Category 1 Department
credit for continuing
medical
education.
AAPA
Category
1 credit
for continuing
education.
Nurses:
CAL/ACEP
is approved
by themedical
California
Board of Registered Nursing for 17 contact hours, Provider Number 15059.
Nurses:
CAL/ACEP isEMREF
approved
the California
Board of Registered
Nursing
forfor
1717
contact
hours,Education
Provider Units,
Number
15059.Number 34-4600.
EMTs/Paramedics:
is by
approved
by the Sacramento
County EMS
Agency
Continuing
Provider
EMTs/Paramedics:
EMREF isAssociation
approved by
the Sacramento
Agency
for 17asContinuing
Education
Units,All
Provider
Number
34-4600.
DO’s: American Osteopathic
(AOA)
recognizes County
ACCMEEMS
Category
1 Credit
AOA Category
2-A Credit.
members
of AOA
are required
to participate
in Osteopathic
CME programs
to meet the
2010-12
CME Cycle
of 15 Credits
ACCME
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and2-A
15 AOA
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DO’s:
American
Association
(AOA)
recognizes
ACCME
Category
1 Credit
as AOA
Category
Credit.
All members
of AOA are required
participate
4 May toIssue
2011 in CME programs to meet the 2010-12 CME Cycle of 15 Credits ACCME Category 1 Credits and 15 AOA Category 1-A Credits.
4 May Issue 2011
5/25/11 1:26 PM
REGISTRATION FORM
40th Annual
SCIENTIFIC ASSEMBLY
California Chapter, American College of Emergency Physicians
CONTACT
Toll-Free: (800) 735-2237 | Office: (916) 325-5455
Website: www.calacep.org | E-Mail: [email protected]
REGISTER
Online at: www.calacep.org
Mail to: 1020 11th Street, Suite 310 ▪ Sacramento, CA 95814
E-Mail to: [email protected]
Fax to: (916) 325-5459
JUNE 23 – 25, 2011
ULTRASOUND WORKSHOP
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First Name:
Last Name:
Degree/Title (Check all that apply):
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DO
RN
ACEP ID #:
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(Early Bird thru
5/15; Regular
thereafter)
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REGISTRATION RATES POLICY
Registration fee rates are determined by the date the registration is received. Except where noted, “Early Bird” rates apply through April 15, 2011; “Regular” rates apply
from April 16 – May 31, 2011; “Onsite” rates will apply to all registrations received on or after June 1, 2011. Registration fees paid by attendees include the CME
program and any optional workshops requested and paid for, as well as three breakfasts, Awards Lunch (RSVP required), Opening Reception and access to exhibits.
Guest fees include three breakfasts, Awards Lunch (RSVP required), Opening Reception and access to exhibits.
REFUND & CANCELLATION POLICY
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conferences in order to manage valuable member resources as prudently as possible; room blocks and certain portions of food & beverage costs are guaranteed in
advance in order to accomplish these goals. Therefore, CAL/ACEP can only grant full refunds for registration fees, less a $50 administrative fee, if said reservations are
canceled by Tuesday, May 31, 2011. Any refund requests made from June 1 - 15 will be refunded 50% of the registration fees, less a $50 administrative fee.
No refunds will be granted after June 15. All refunds must be submitted in writing to [email protected], faxed to (916) 325-5459 or mailed to CAL/ACEP at
1020 11th Street, Suite 310, Sacramento, CA 95814 and be received by the dates listed above. CAL/ACEP is not responsible for any hotel charges that may be incurred
by cancellations.
May Issue 2011 5
5/25/11 1:26 PM
Reasons for More
Specific Diagnosis
Documentation
by Sharon Richardson, RN
Chief Compliance Officer
Emergency Groups Office
We are only 18 months away from
implementation and mandatory use of ICD10 diagnosis codes. The change from ICD9 to ICD-10 codes will increase the possible
diagnosis codes choices from approximately
17,000 to 70,000. It will benefit physicians
to be more specific in their documentation.
But, before ICD-10 is implemented, there
are diagnosis discussions now that require
improved documentation from the provider.
Payers of physician claims and their
auditors determine medical necessity of a
service based on the diagnoses documented
in the chart. They routinely “down-code”
higher level claims that have low severity
diagnoses. Weak diagnoses often lead to
weak payment and difficulty defending
the medical complexity and severity of the
patient’s problem. You want strong diagnoses
that make clear the complexity and severity
inherent in the service.
Current ICD-9 diagnosis coding guidelines
for physician services do not allow the use
of “rule out”, “probable”, or “possible”
diagnosis codes. For example, a patient who
presents with dizziness and is diagnosed with
“R/O TIA” has a high severity condition but
outpatient coding rules require that the claim
be reported with the code that translates as
“dizziness or giddiness”. That does not sound
very serious to a payer.
Of course, if that is all that can be
determined from the workup, you must report
it as such. You must never get creative by
using unsupported diagnosis codes to secure
payment. Specificity is the point. A good HPI
and MDM discussion involving all signs and
symptoms might provide more specificity or
an alternate diagnosis code more descriptive
of the patient’s real emergency.
Physicians need to be as specific as
possible so that the claim can be coded to the
highest level of specificity that tells a more
accurate story about the reason for ED care.
If the final clinical impression is in doubt,
the provider is encouraged to document the
presenting symptoms or disease processes
discovered during the workup.
Here are some examples of how specific
documentation (or lack of it) can effect how a
claim is coded and paid:
1. ICD-9 coding guidelines require that a
physician state that diabetes is out-of-control.
If you fail to document these words, the coder
is required to use “diabetes unspecified”
which would often not support the level of
service provided by the physician. “Diabetes
with hyperglycemia” or “diabetes poorly
controlled” cannot be coded as “diabetes
OOC.” Use language that supports the
severity of the patient’s problem.
2. Hypertension that requires aggressive
management in the ED but is not documented
as “malignant/accelerated hypertension”
by the physician would be coded as
“hypertension unspecified” no matter how
high the blood pressure is or how aggressive
the work-up or treatment is. Converse to
the diabetes example above, simply stating
“hypertension out-of-control”, “hypertensive
urgency” or similar language can be perceived
by the payer as equivalent to a BP of 150/90
without medication management. The payer
will not understand the crisis unless you state
“malignant” or “accelerated” hypertension.
3. When a patient presents to the ED with
symptoms of cough with green sputum,
fever, dyspnea etc. and the final diagnosis
is bronchitis the physician should document
“acute bronchitis” rather than simply
“bronchitis”. A chronic condition might
not appear worthy of emergency care. If a
patient presents with an “exacerbation” this is
should be documented as there are different
diagnosis codes for bronchitis, COPD, and
asthma dependent on whether the condition is
acute or exacerbated. Many claims are denied
as non-emergent due to the use of chronic
or unspecified codes. Payers feel that these
sub-acute diagnoses should have been seen
in the doctor’s office rather than in a more
expensive ED visit.
4. Many patients with dialysis-dependent
renal failure are seen and treated in the ED.
If they are treated for an acute exacerbation
of chronic renal failure the final diagnosis
should be documented as such. This would
allow the claim to be coded with acute
renal failure rather than chronic. “Acute” is
emergent, “chronic” or “unspecified” is a
stable condition and unsympathetic payers
will down-code these claims.
5. Patients who present with anxiety or
other psych-related symptoms need clear
descriptions of signs and symptoms that
justify additional workup, such as an ECG,
CXR and lab tests, as would be the case with
the co-present symptoms of palpitations,
dyspnea, chest pain, headache, etc. We do not
do such testing simply because the patient
has anxiety; we usually do these workups
because of other worrisome symptoms. Many
payers do not consider the diagnosis codes
for altered mental status, decreased level or
cognition or confusion to be payable. You
must define the reason for the AMS, such as,
if encephalopathy exists, the cause should
be documented as toxic, septic, hepatic or
metabolic, if known.
6. ICD-9 coding conventions consider
symptoms such as tachycardia or dyspnea that
are drug induced to be a form of poisoning
and codes selected are related to which drug
induced the symptom. The diagnosis of “drug
abuse” does not tell the correct story. A patient
with tachycardia due to cocaine abuse should
be documented with a diagnosed condition
of tachycardia due to cocaine poisoning, not
cocaine abuse. ICD-9 is non-judgmental but
payers are not. They pay for poisoning but
not for abuse because that is deemed to be a
behavior-related condition, not an emergent
medical condition.
7. If the cause for anemia is known, it should
be used in the final diagnosis. Unspecified
anemia can simply be technical in nature, a
decimal point below the norm, for example.
There are numerous anemia codes and if the
reason is not known an unspecified code must
be used. Again, it is helpful to note “acute”
anemia.
8. If a patient with a complaint is brought
into the ED by a parent, policeman, etc., and
the history, physical and/or work-up does not
conclude with a medical or trauma diagnosis
it is very important that the physician NOT
use, in the diagnosis area of the chart,
conclusions like “well baby” “normal exam”
etc. These final diagnoses are NOT reasons
for emergency evaluation and are not payable
by any payer. It would be better to document
“baby brought in by mother with complaint
of SOB (or other), history and physical exam
ruled out acute illness”. Coders can then code
the signs and/or symptoms as the reasons for
treatment.
9. Dental diagnoses are considered dental
problems and not medical problems. MediCal, Medicare and most other payers do
not pay for dental services. When a patient
presents with a dental complaint it is important
to document any other signs and symptoms
such as facial swelling, jaw pain etc.
10. Medicare will NOT pay the facility for
specific complications that occur while the
patient is an inpatient. When preparing to
admit a patient, document UTIs in all patients
with indwelling Foleys, all decubitus ulcers
and all pneumonias when they are present in
the ED. Your business partner, the hospital,
will be helped greatly by your attention to
conditions present on admission.
Preparing for ICD-10 means learning
today how to support medical necessity by
being specific as to the causes and symptoms
that bring your patients to the ED. Appropriate
payment is not possible without supporting
documentation.
6 May Issue 2011
5/25/11 1:26 PM
11
H
A
2010-2011
Board of Directors
Meeting Schedule
June 22, 2011 (Wednesday)
11:00 AM – 5:30 PM in Newport Beach, CA
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A Call for Lifeline Articles!
Get involved!  Share ideas!  Submit an article to:
H. Gene Hern, Jr., MD
Asst. Clinical Professor of Medicine, UCSF
Assoc. Residency Director
Department of Emergency Medicine
ACMC-Highland General Hospital
1411 E. 31st Street  Oakland, CA 94602
(510) 437-4896 office  (510)382-2429 Pager
[email protected]
Deanna M. Janey
Director of Events & Marketing
CAL/ACEP
1020 11th Street, Suite 310  Sacramento, CA 95814
(800) 735-2237 Toll-free  (916) 325-5459 Fax
[email protected]
Mathew Foley, MD
Advocacy Fellowship Director
CAL/ACEP
1020 11th Street, Suite 310  Sacramento, CA 95814
(800) 735-2237 Toll-free  (916) 325-5459 Fax
[email protected]
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Please check your interest and submit an article!
Clinical Corner ___ Case of the Month ___ Legal Corner ___ Residents’ Region ___ Special Interests ___ Advocacy ___ Other ___
Articles must be submitted on the 1st of the month preceding publication!
May Issue 2011 7
5/25/11 1:26 PM
ADVOCACY UPDATE
2011 Legislative
Leadership
by Elena Lopez-Gusman & Callie Hanft
On Tuesday, April 26th, with a record
number of attendees, more than 90 white coats
descended upon the Capitol to participate in
CAL/ACEP’s Annual Legislative Leadership
Conference (LLC). And, what a successful
conference it proved to be! In the middle of
yet another multi-billion dollar budget deficit
year, the need for robust physician advocacy
on behalf of emergency medicine and the
emergency care safety net is greater than ever,
and thanks to the dedicated advocates who
came on April 26th, emergency medicine was
well-represented.
A fantastic lineup of speakers for the
2011 LLC covered topics such as access to
healthcare, ED overcrowding, fair payment
and reimbursement, and the impact of health
care reform for emergency physicians in
California.
Insurance Commissioner Dave Jones
briefed LLC participants on his first
one-hundred days in office as Insurance
Commissioner, as well as legislation his office
is sponsoring in the Legislature this year, AB
52 (Feuer) to expand his authority to reject
excessive health insurance rate hikes. Elected
to the post in November 2010, Commissioner
Jones spoke about the authorities given
to him by office to regulate many forms
of insurance, but highlighted the lack of
authority to monitor and regulate health
care service plans operating in California.
Commissioner Jones hopes to provide for
more consumer protections by enabling his
office the power to reject excessive health
insurance rate hikes. While LLC attendees
watched live, AB 52 narrowly passed out of
the Assembly Health Committee the day of
the LLC.
Assemblymember Richard Pan, MD,
spoke to LLC participants about his ambitions
in the Legislature after being newly elected
in November 2010. Dr. Pan, a Pediatrician,
represents the 5th Assembly District,
covering major parts of Sacramento. Dr. Pan
encouraged CAL/ACEP members to work
together with other specialties in the house of
medicine, and to join as one to be a force to
be reckoned with in the Legislature.
Appointed as the Secretary of the Health
and Human Services Agency, in late 2010
by Governor Jerry Brown, Diana S. Dooley
spoke candidly with LLC participants about
the realities of the crippling $13 billion
budget deficit and the future of healthcare and
healthcare delivery in California. Recently
named the 7th most powerful person in
California politics by Capitol Weekly,
Secretary Dooley engaged attendees in a
twenty minute question and answer session
after delivering her planned speech and
covered topics on emergency department
overcrowding, the impending appointment of
the Director of the Department of Managed
Health Care, and the choices she must face as
the state’s fiscal crisis continues to affect her
agency, and the programs it supports.
Following a morning of stimulating
policy discussions with an all-star lineup of
speakers, LLC attendees took to the halls
of the Capitol and lobbied members of the
Assembly and Senate Health Committees
(and anyone else who would listen!) on CAL/
ACEP’s sponsored legislation for 2011.
After a day of lobbying, participants
gathered with CAL/ACEP leadership and
members of the Legislature at a reception
hosted by CAL/ACEP Advocacy to de-brief
on the day and continue the conversation with
key current and future policy-makers.
We would like to thank all of those who
came from across the state to partake in the
LLC. Whether new to politics, or a seasoned
After of
a day
lobbying, participants
gathered
veteran, the success
the ofemergency
care
at aupon
reception
hosted by CAL/ACEP Ad
safety netLegislature
relies heavily
the contributions
conversation with key current and future policy-makers
of our Chapter- through contributions to
CEMAF or by We
walking
halls
of all
theof those who ca
would the
like to
thank
Capitol; Whether
emergency
medicine’s
future
is
in veteran, the suc
new to politics, or a seasoned
your hands.
be successful
in the through contri
uponWe
thecannot
contributions
of our ChapterLegislature
without
your help,
and we future
look is in your ha
Capitol;
emergency
medicine’s
(left to right)
CAL/ACEP President,
forward to your participation again next
year!
without your help, and
year! Andrea Brault MD
(left to right) CAL/ACEP President,
Andrea Brault, MD
and Insurance Commissioner, Dave Jones
(left to right) CAL/ACEP President-Elect,
Peter Sokolove, MD
and Assemblymember, Richard Pan
(left to right) CAL/ACEP President,
Andrea Brault, MD
and Secretary, Diana S. Dooley
8 May Issue 2011
5/25/11 1:26 PM
Western Journal of Emergency Medicine
www.westjem.org.
Supervising Section Editor: David E. Slattery, MD
Submission history: Submitted September 4, 2009; Revision Received February 7, 2010; Accepted March 1, 2010
Reprints available through open access at http://escholarship.org/uc/uciem_westjem
Therapeutic Hypothermia
Protocol in a Community
Emergency Department
by Christine E. Kulstad, MD
Shannon C. Holt, MD
Aaron A. Abrahamsen, MD
Elise O. Lovell, MD
Advocate Christ Medical Center,
Department of Emergency Medicine,
Oak Lawn, Illinois
Objectives: Therapeutic hypothermia (TH)
has been shown to improve survival and
neurological outcome in patients resuscitated
after out of hospital cardiac arrest (OHCA)
from ventricular fibrillation/ventricular
tachycardia (VF/VT). We evaluated the effects
of using a TH protocol in a large community
hospital emergency department (ED) for all
patients with neurological impairment after
resuscitated OHCA regardless of presenting
rhythm. We hypothesized improved mortality
and neurological outcomes without increased
complication rates.
Methods: Our TH protocol entails cooling
to 33°C for 24 hours with an endovascular
catheter. We studied patients treated with this
protocol from November 2006 to November
2008. All non-pregnant, unresponsive adult
patients resuscitated from any initial rhythm
were included. Exclusion criteria were
initial hypotension or temperature less than
30°C, trauma, primary intracranial event,
and coagulopathy. Control patients treated
during the 12 months before the institution
of our TH protocol met the same inclusion
and exclusion criteria. We recorded survival
to hospital discharge, neurological status
at discharge, and rates of bleeding, sepsis,
pneumonia, renal failure, and dysrhythmias
in the first 72 hours of treatment.
Results: Mortality rates were 71.1% (95%
CI, 56-86%) for 38 patients treated with TH
and 72.3% (95% CI 59-86%) for 47 controls.
In the TH group, 8% of patients (95% CI,
0-17%) had a good neurological outcome on
discharge, compared to 0 (95% CI 0-8%) in
the control group. In 17 patients with VF/VT
treated with TH, mortality was 47% (95% CI
21-74%) and 18% (95% CI 0-38%) had good
neurological outcome; in 9 control patients
with VF/VT, mortality was 67% (95% CI
28-100%), and 0% (95% CI 0-30%) had
good neurological outcome. The groups were
well-matched with respect to sex and age.
Complication rates were similar or favored
the TH group.
Conclusion: Instituting a TH protocol for
OHCA patients with any presenting rhythm
appears safe in a community hospital ED.
A trend towards improved neurological
outcome in TH patients was seen, but did not
reach significance. Patients with VF appeared
to derive more benefit from TH than patients
with other rhythms. [West J Emerg Med.
2010; 11(4): xx-xx.]
INTRODUCTION
In the United States, the incidence of
out-of-hospital cardiac arrest (OHCA) is
increasing, with approximately 166,200
patients suffering OHCA annually.1 Survival
among resuscitated patients remains
low, and the majority of survivors have a
poor neurological outcome. 2,3 Recently,
aggressive post-resuscitation care has been
recognized as an important link in the
cardiac arrest chain of survival. Therapeutic
hypothermia (TH) was used to treat patients
resuscitated from cardiac arrest during the
1950s;4 however, complications related to
the depth of cooling led to this treatment
being abandoned. Positive outcomes from
animal studies in the 1990s, rekindled
interest in this treatment modality.5 TH is
postulated to mitigate the effects of ischemia
and reperfusion injury by decreasing
cerebral metabolism, suppressing the release
of oxygen free radicals and excitatory
neurotransmitters, and by decreasing the
inflammatory response. 6,7 In 2002, two
randomized controlled trials evaluated the
effect of mild TH on comatose patients
resuscitated after ventricular fibrillation
OHCA and demonstrated improvements
in survival and neurological outcome. 8, 9
Currently, both the International Liaison
Committee on Resuscitation (ILCOR) and
the American Heart Association (AHA)
recommend the use of TH in the treatment
of persistently comatose patients resuscitated
after ventricular fibrillation OHCA. 10, 11
A number of studies published since
2002 support the use of TH after cardiac
arrest, but only one was conducted solely
at a community hospital.12-18 Also, few
data have been published on patients treated
with TH after presenting with rhythms other
than non-perfusing ventricular fibrillation
or ventricular tachycardia (VF/VT);
consequently, firm conclusions cannot be
drawn about the benefits of TH in these other
populations.9, 19-22
In November 2006, we began to treat
comatose patients resuscitated from OHCA
with TH, regardless of their presenting
rhythm. We hypothesized that establishing
this protocol in our community hospital
emergency department (ED) would decrease
mortality
and
improve
neurological
outcome in these patients without increasing
complication rates. The primary aim of
our study was to assess the impact of our
TH protocol on in-hospital mortality by
comparing the mortality rates of treated
patients with those of control patients from
the preceding 12 months. Secondarily, we
(Continued on page 11)
CAL/ACEP
Welcomes New Members
April 2011
Dean D. Cromwell, MD
James Delatorre, MD
Jeffrey Flood, MD
Kenneth A. Frausto, MD
Gene W. Kallsen, MD
Chandu A. Karadi, MD
Nadine Konia, MD
Cong T. Ly, DO
Vicki Mazzorana, MD
Troy M. Obregon, MD
Brent B. Saetrum, MD
Jeffrey Tsai, MD
Joshua B. Weil, MD
May Issue 2011 9
5/25/11 1:26 PM
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10 May Issue 2011
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West JEM...
West JEM...
(Continued
(Continued
from pagefrom
9) page 9)
of care are
of care
madearebymade
the primary
by the primary
physicianphysician
culture),culture),
pneumonia
pneumonia
(infiltrate(infiltrate
on chest
on chest
or intensivist,
or intensivist,
usually usually
in consult
in consult
with a with
a radiograph
radiograph
or clinical
or diagnosis
clinical diagnosis
recordedrecorded
on
on
neurologist,
neurologist,
but do not
butfollow
do nota follow
standardized
a standardized
chart), renal
chart),
failure
renal(new
failure
use(new
of dialysis
use of dialysis
or
or
evaluatedevaluated
the neurological
the neurological
status upon
status upon
protocol.
Study investigators
Study investigators
are not involved
are not involved
continuous
continuous
renal replacement
renal replacement
therapy),therapy),
and
and
hospital hospital
dischargedischarge
and complication
and complication
rates of rates
of protocol.
in end-of-life
in end-of-life
decisions.
decisions.
arrhythmias
arrhythmias
(requiring
(requiring
medical medical
or electrical
or electrical
both groups.
both groups.
Patients Patients
were eligible
were for
eligible
treatment
for treatment
with therapy)
with therapy)
in the first
in 72
thehours.
first 72 hours.
TH if they
TH were
if they18were
years18ofyears
age or
of older
age or older
Chart abstractors
Chart abstractors
met at the
metstart
at the
of the
start of the
METHODS
METHODS
and remained
and remained
unresponsive
unresponsive
to verbaltostimuli
verbal stimuli
study to study
definetomethods
define methods
and wereand
unaware
were unaware
of
of
following
following
return ofreturn
spontaneous
of spontaneous
circulation
circulation
patient outcomes
patient outcomes
when abstracting
when abstracting
data fromdata from
Study Design
Study Design
(ROSC) (ROSC)
after cardiac
after cardiac
arrest. Patients
arrest. Patients
with ED
withrecords.
ED records.
We
conducted
We
conducted
a
retrospective,
a
retrospective,
any rhythm
initial rhythm
and withandwitnessed
with witnessed
or
or
Our primary
Our primary
outcomeoutcome
was in-hospital
was in-hospital
observational
observational
study ofstudy
the of
mortality
the mortality
of anyof initial
arrest were
arrest
eligible.
were eligible.
Exclusion
Exclusion
mortality.mortality.
Our secondary
Our secondary
outcomesoutcomes
were were
patients patients
resuscitated
resuscitated
from OHCA
from in
OHCA
our ED
in ourunwitnessed
ED unwitnessed
criteria criteria
were pregnancy,
were pregnancy,
a systolic
a systolic
blood blood
neurological
neurological
status onstatus
hospital
on hospital
dischargedischarge
and
and
from November
from November
2006 through
2006 through
November
November
pressure
pressure
less
than
less
90mmHg
than
90mmHg
despite
despite
the
the
complication
complication
rates.
rates.
2008. The
2008.
control
Thegroup
control
consisted
group consisted
of patients
of patients
vasopressors,
of vasopressors,
traumatictraumatic
injuries, injuries,
treated in
treated
our ED
in our
during
ED the
during
preceding
the preceding
12 use12 of use
an temperature
initial temperature
less than
less30°C,
than a30°C,
a Analysis
Data
Data Analysis
months, months,
prior to prior
the implementation
to the implementation
of our ofanourinitial
intracranial
intracranial
event determined
event determined
by
by
For the For
study
the group,
study our
group,
analysis
our analysis
of
of
TH protocol.
TH protocol.
This study
This
was
study
approved
was approved
by the byprimary
the primary
physician
judgment,
judgment,
and known
andpre-existing
known pre-existing
outcomesoutcomes
includes includes
all patients
all patients
for whom
for whom
hospital’shospital’s
Institutional
Institutional
Review Board,
Reviewwith
Board,
a with
a physician
coagulopathy.
coagulopathy.
Eligible Eligible
patients patients
were treated
were treated
we initiated
we initiated
our TH our
protocol,
TH protocol,
regardless
regardless
of
of
waiver ofwaiver
informed
of informed
consent. consent.
with THwith
at the
TH discretion
at the discretion
of the treating
of the treating
whether whether
the targetthetemperature
target temperature
was reached,
was reached,
physician.
physician.
cooling was
cooling
halted,
wasorhalted,
the patient
or thedied
patient
before
died before
Study Setting
Study and
Setting
Population
and Population
We identified
We identified
patients patients
primarilyprimarily
by hospital
by hospital
admission.
admission.
We did We
not did
include
not include
This study
This was
study
conducted
was conducted
at a large
at a large
searchingsearching
records records
from ourfrom
ED our
automated
ED automated
patients patients
who hadwho
ROSC
had during
ROSC the
during
study
the study
tertiary tertiary
care suburban
care suburban
community
community
hospital hospital
and supply
andmanagement
supply management
machinemachine
period but
period
did but
not did
havenot
THhave
initiated,
TH initiated,
even even
with over
with85,000
over ED
85,000
visits
EDannually
visits annually
and medication
and medication
for documentation
for documentation
that an that
endovascular
an endovascular
if they met
if they
inclusion
met inclusion
and exclusion
and exclusion
criteria. criteria.
nearly 700
nearly
inpatient
700 inpatient
beds. beds.
cooling cooling
catheter catheter
had been
haddispensed.
been dispensed.
To Demographic
To Demographic
and clinical
and characteristics
clinical characteristics
are
are
ensure
that
ensure
we
that
located
we
all
located
eligible
all
eligible
patients,
patients,
described
described
by
means
by
with
means
95%
with
confidence
95%
confidence
Study Protocol
Study Protocol
searched
also searched
the diagnosis
the diagnosis
field of field
our ofintervals
our intervals
(CI) for (CI)
normally
for normally
distributed
distributed
data
data
For ourForTHourprotocol
TH protocol
we usewean useweanalso we
ED’s electronic
ED’s electronic
medical medical
record (EMR)
recordusing
(EMR) using
and by and
medians
by medians
with interquartile
with interquartile
range range
endovascular
endovascular
cooling catheter
cooling catheter
(ICY Catheter,
(ICY Catheter,
the keyarrest,
words:vfib,
arrest,
vtach,
vfib,fibrillation,
vtach, fibrillation,
(IQR) for
(IQR)
non-normal
for non-normal
data. Wedata.
compared
We compared
IC-3893,IC-3893,
Alsius, Irvine
Alsius,CA)
Irvine
with
CA)
thewith
goalthe the
goalkey words:
ventricular,
ventricular,
asystole,asystole,
and PEA
and(pulseless
PEA (pulseless
the mortality
the mortality
of each ofof each
the two
of the
groups
two groups
to cool to
thecool
patient
the to
patient
a target
to atemperature
target temperature
activity).activity).
with 95%
with
CI,95%
and CI,
compared
and compared
the unadjusted
the unadjusted
of 33 °Cofwithin
33 °Cfour
within
hours.
fourThe
hours.
Alsius
TheICY
Alsius electrical
ICY electrical
We identified
We identified
patients in
patients
our control
in ourgroup
control group
mortalitymortality
between between
the two the
cohorts
two with
cohorts
thewith the
catheter catheter
is only is
intended
only intended
for placement
for placement
in
in
by
searching
by
searching
our
EMR
our
diagnosis
EMR
diagnosis
field
for
field
the
for
the
χ2
test.
χ2
We
test.
considered
We
considered
values
of
values
p
<
0.05
of
p < 0.05
the femoral
the femoral
vein. Novein.
patients
No patients
were given
were given
same keywords.
same keywords.
The charts
Theextracted
charts extracted
were to
were
be statistically
to be statistically
significant.
significant.
AnalysesAnalyses
were were
cold intravenous
cold intravenous
saline. Our
saline.
protocol
Our protocol
advises advises
to determine
to determine
if the patients
if the patients
treated treated
performed
performed
using SPSS
usingversion
SPSS version
15.0 (SPSS
15.0 (SPSS
using iceusing
packsiceif packs
the target
if thetemperature
target temperature
is reviewed
is reviewed
before
institution
the institution
of our TH
of protocol
our TH protocol
met Inc.,
met Chicago,
Inc., Chicago,
IL).
IL).
not reached
not reached
in four hours,
in fourbut
hours,
theirbut
usetheir
was usebefore
was the
the sametheinclusion
same inclusion
and exclusion
and exclusion
criteria criteria
not routinely
not routinely
noted innoted
the medical
in the medical
record. record.
as or
our study
as ourgroup
studyand
group
survived
and survived
to hospital
to hospital
RESULTS
RESULTS
Temperatures
Temperatures
are monitored
are monitored
with a rectal
with or
a rectal
Seventy-two
Seventy-two
patients patients
with ROSC
with ROSC
esophageal
esophageal
temperature
temperature
probe. Patients
probe. Patients
are admission.
are admission.
survivedsurvived
to hospital
to hospital
admission
admission
during our
during our
cooled for
cooled
24 hours
for 24
from
hours
thefrom
onsetthe
of cooling,
onset of cooling,
study period.
study Of
period.
these,Of34these,
were 34
eligible
were for
eligible for
and thenand
actively
then actively
re-warmed
re-warmed
at a rate atofa0.5
rate ofMeasurements
0.5 Measurements
We created
We created
a standardized
a standardized
abstraction
abstraction
TH but TH
werebut
notwere
cooled
not for
cooled
the following
for the following
°C/hour °C/hour
to a goal
to temperature
a goal temperature
of 36.5 of
°C 36.5 °C
data for
collection
data collection
prior to prior
the start
to the
of start
of reasons:
reasons:
catheter catheter
could notcould
be placed
not be(n=7),
placed (n=7),
using theusing
endovascular
the endovascular
catheter.catheter.
Shivering
Shivering
is form
is forform
theasstudy.the
The
study.
dataThe
collected
data collected
includedincluded
patient patient
co-existing
co-existing
infectioninfection
(n=4), poor
(n=4),baseline
poor baseline
prevented
prevented
with sedative
with sedative
medications,
medications,
such as such
demographics,
demographics,
hospital hospital
length oflength
stay (LOS),
of stay (LOS),
health (n=4),
health deemed
(n=4), deemed
too unstable
too unstable
(n=3), (n=3),
propofol,propofol,
lorazepam
lorazepam
and fentanyl;
and fentanyl;
paralytics
paralytics
survival
survival
to
hospital
to
discharge,
hospital
discharge,
initial
recorded
initial
recorded
do-not-resuscitate
do-not-resuscitate
status
(n=2),
status
cooling
(n=2),
cooling
unit
unit
are added
areonly
added
if sedatives
only if sedatives
are ineffective.
are ineffective.
arrest rhythm,
arrest rhythm,
and neurological
and neurological
status atstatus
in at
use for
in use
another
for another
patient (n=1),
patient various
(n=1), various
Vital signs
Vitalaresigns
measured
are measured
every 30every
minutes
30 minutes
using the
usingGlasgow-Pittsburgh
the Glasgow-Pittsburgh
(n=6) or(n=6)
unrecorded
or unrecorded
reasons (n=6).
reasonsReasons
(n=6). Reasons
until theuntil
goalthe
temperature
goal temperature
is reached
is reached
and discharge
and discharge
CerebralCerebral
Performance
Performance
CategoryCategory
(CPC). We
(CPC).for
Wecatheter
for catheter
placement
placement
failure included
failure included
the
the
then every
then
two
every
hours.
twoAthours.
the onset
At the
of onset
cooling
of cooling
determined
the CPC the
wasCPC
determined
was determined
by chart by chart
large size
large
of the
size catheter,
of the catheter,
thrombusthrombus
in the in the
and at eight
and at
andeight
16 hours,
and 16blood
hours,tests
blood
andtests
a and
a determined
review. Abstractors
were notwere
blinded
not blinded
to the tovein,
the contractures,
vein, contractures,
skin breakdown
skin breakdown
and bodyand body
12-lead 12-lead
ECG is ECG
performed.
is performed.
The blood
Thetests
blood review.
tests Abstractors
patient’spatient’s
treatmenttreatment
group if group
it wasifspecified
it was specified
habitus. habitus.
Of the Of
six the
patients
six patients
with various
with various
include include
a complete
a complete
blood count,
bloodmetabolic
count, metabolic
in
the
inpatient
in
the
inpatient
chart.
We
chart.
also
We
recorded
also
recorded
reasons
recorded,
reasons
recorded,
two
had
two
respiratory
had
respiratory
arrest
arrest
panels, coagulation
panels, coagulation
studies, cardiac
studies, enzymes
cardiac enzymes
during the
during
first 72
thehours,
first 72using
hours, using
followedfollowed
by cardiac
by arrest,
cardiacwhich
arrest,likely
whichwas
likely was
and arterial
and arterial
blood gas.
blood
Additionally,
gas. Additionally,
two complications
two complications
pre-determined
pre-determined
definitions.
definitions.
These included
These included
interpreted
interpreted
as a contraindication
as a contraindication
for TH; one
for TH; one
sets of blood
sets ofcultures
blood cultures
are obtained
are obtained
at eight at eight
of rate
significant
of significant
bleedingbleeding
(requiring
(requiring
had pulmonary
had pulmonary
embolism;
embolism;
one had one
suspected
had suspected
hours. Other
hours.
testing
Otherand
testing
treatments
and treatments
are at theare atthetherate the
transfusion,
transfusion,
or surgical
or or
surgical
gastroenterological
or gastroenterological
aortic dissection;
aortic dissection;
one wasone
transported
was transported
for
for
discretion
discretion
of the treating
of the physicians.
treating physicians.
Patients Patients
consultation),
consultation),
sepsis sepsis
(meeting(meeting
systemicsystemic
emergentemergent
PCI before
PCI the
before
TH the
catheter
TH catheter
was
was
treated with
treated
THwith
are eligible
TH are for
eligible
percutaneous
for percutaneous
responseresponse
syndrome
syndrome
criteria criteria
coronarycoronary
intervention
intervention
(PCI) and
(PCI) antiand inflammatory
anti- inflammatory
(Continued
(Continued
on page 15)
on page 15)
plus documented
plus documented
infectioninfection
or positive
or positive
coagulation.
coagulation.
Decisions
Decisions
regardingregarding
withdrawal
withdrawal
May Issue
May
2011
Issue
11 2011 11
5/25/11 1:26 PM
PRESIDENT'S MESSAGE
Fraud, Compliance
and the OIG Work Plan
Part 2
by Andrea Brault, MD
In last month’s
letter, we addressed
that
PPACA
(Patient Protection
and
Affordable
Care Act) requires
that
providers
of
Medicare/
Medicaid services
establish
their
own
compliance
program. I suggested that whomever your
group designated as compliance leader
determine your group’s risk areas and the
areas where you need to strengthen your
compliance program. Part 1 of this series
focused on compliance standards and
procedures in the pre-billing risk areas for
an average emergency department group:
documentation styles, demonstrating medical
necessity and the risk of EMRs that produce
clone like charts. Payments for Evaluation
and Management services are in the OIG’s
work plan for this year and he/she will have
to assess this risk area for your group.
The next step is to complete the prebilling and post-billing risk assessments
and then look at the six other elements of an
effective compliance program that you need
to evaluate to see what areas of risk your
group has. He/she will also need to tailor the
efforts and work load, as appropriate, to the
size of your group.
1) Compliance Standards, Policies and
Procedures:
a. Part 1 covered the new big risk areas
mentioned above. Continuing with the prebilling assessment he/she would want to
assure that none of your providers are on
the OIG sanctioned list (http://oig.hhs.gov/
fraud/exclusions.asp).
If your group has
physician assistants, check that your hospital
bylaws and privileges are consistent with the
services performed by the PA’s. Also, that all
physicians that the PA’s work with have signed
your Delegation of Services Agreement, and
that the Agreement is consistent with the
care provided by these assistants. Your postbilling assessment should also review areas
such as the group’s discount and professional
courtesy policies, refund processing, and
denial management. However, it is unlikely
that your standards, policies or procedures
would involve just these areas.
More
common areas of concern not discussed in
this article but also important include HIPAA
privacy and security, EMTALA and EEO
policies and procedures.
2) Oversight:
a. As suggested above, the group
should appoint a Compliance Officer or
split the responsibilities. Written policies
and procedures need to be developed and
distributed. Someone needs to decide when
and which audits will be done and then
review the results and follow-up.
3) Education and Training:
a. Your educational sessions’ agendas
need to be kept as well as the sign-in sheets.
If you find the need for re-training, based on
your review of the billing statistics, someone
needs to keep track of this information
as well. You should also schedule annual
training to review your Compliance Policies
and the documentation rules specific to your
practice with all of the Group’s providers
4) Effective lines of communication:
a. If it hasn’t already been done so,
your group must establish a hot line or
other confidential method to receive
compliance concerns and complaints. All
such communications must be logged. Post
this number or address in a conspicuous
place for all of the medical staff and nursing
staff to see. If you have a provider who has
inappropriate behavior or a practice style
that is causing others concern, you want to
know. Your group’s attitude and response to
concerns and complaints must be receptive
and positive towards resolving the issue so
that members of your group and hospital staff
feel comfortable reporting concerns without
fear of retribution.
5) Monitoring and Auditing:
a.
The first step is to assess your
group’s pre and post billing risk areas.
Then the group’s compliance standards and
procedures can be designed around those
needs. Next decide how the group will
monitor and audit to these standards. Some
risk areas are fluid enough that the group
may decide to monitor them monthly or bimonthly, e.g. your individual provider E&M
billing statistics. Some areas of risk are low
enough or the process stable enough that
the group may only want to review them
annually.
6) Enforcement and Discipline:
a. Here is where the tough work begins.
The group should be able to design policies
and procedures for its risk areas fairly
quickly (from a business perspective e.g.,
months, not the ED perspective of minutes).
Your billing company should have a fairly
rigorous compliance program and can help
you develop your group’s program as well.
They can show you how they monitor various
processes for your group. The challenge
will be how you enforce the policies within
your group. For example, it is likely that you
will have a policy on timely documentation
of medical records and it will not be, “if
and when the provider feels like it.” It is
also likely that you may have a provider
whose documentation style consistently falls
outside of the group’s policy. What is the
group’s enforcement plan? How will you
document this?
7) Response and Prevention:
a. When detection of an error or noncompliant behavior occurs then the group
must take “all reasonable steps” to stop
the behavior. If the group’s annual audits
find even a few charts were “over coded”
then the group must document the refund
on these accounts (your billing company
can provide this for you). If the percentage
of over coding was outside an acceptable
range then the group must develop a process
for review of the coding. Depending on
the magnitude of the event, it may even be
necessary to obtain legal advice or begin
self-reporting. Obviously, these are areas
where the group’s and its billing company’s
compliance programs must work together.
But, for the group’s protection, it must audit
its billing company’s compliance program in
these areas.
Later this year, CMS will publish the core
elements required by PPACA. If you begin
your work now in these areas, you will be well
prepared to meet the expected requirements.
CAL/ACEP SALUTES
OUR 100%
MEMBERSHIP GROUPS
__________________________________
Central Coast Emergency Physicians
Emergency Medicine Specialists
of Orange County
Napa Valley Emergency Medical Group
Newport Emergency Medical Group, Inc.
Pacific Emergency Providers
St Jude Emergency Medicine Group, Inc.
Tri-City Emergency Medical Group
University of CA at Irvine
12 May Issue 2011
5/25/11 1:26 PM
Communicating Protected
Information Safely…
New Rules and New
Penalties in this
Hi-Tech World
by Mark E. Owen
Emergency Groups’ Office
Healthcare Compliance Specialist
Cell: 904-806-4539
The Health Insurance Portability and
Accountability act of 1996 (HIPAA) and the
HITECH Act
In this Hi-Tech environment we all want to
access and provide vital information quickly
and efficiently. In healthcare and particularly
emergency medicine the fast distribution of
information can mean the difference between
life and death. However, we must ensure
that the transfer of this highly confidential
information is adequately protected and
there are new rules and regulations affecting
this communication. All of the information
contained in this article comes from guidance
offered by HHS and the Office of Civil
Rights.
The U.S. Office for Civil Rights enforces
the HIPAA Privacy Rule, which protects
the privacy of individually identifiable
health information (“PHI”); the HIPAA
Security Rule, which sets national standards
for the security of electronic protected
health information; and the confidentiality
provisions of the Patient Safety Rule, which
protect identifiable information being used
to analyze patient safety events and improve
patient safety.
The Health Information Technology for
Economic and Clinical Health (HITECH)
Act, enacted as part of the American
Recovery and Reinvestment Act of 2009,
promotes the adoption and meaningful use
of health information technology. Subtitle
D of the HITECH Act addresses the privacy
and security concerns associated with the
electronic transmission of health information,
in part, through provisions that strengthen the
civil and criminal enforcement of the HIPAA
rules.
The HIPAA Privacy Rule provides
federal protections for personal health
information held by covered entities and
gives patients an array of rights with respect
to that information. At the same time, the
Privacy Rule is balanced so that it permits
the disclosure of personal health information
needed for patient care and other important
purposes. The Security Rule specifies a
series of administrative, physical, and
CAL/ACEP Sponsored Conferences
technical safeguards for covered entities
CAL/ACEP 40th Annual
to use to assure the confidentiality,
Scientific Assembly & Ultrasound Workshop
integrity, and availability of electronic
June 23-25, 2011 – Newport Beach Marriott
Information: 800-735-2237 or www.calacep.org protected health information. Drs., their
employees, contractors, and billing
CAL/ACEP 35th Annual
companies are such covered entities.
Emergency Medicine in Yosemite
January 11-14, 2012 – Yosemite, CA
Health information technology
Information: 800-735-2237 or www.calacep.org
(health IT) involves the exchange of
CAL/ACEP 23rd Annual
health information in an electronic
Emergency Medicine
environment.
The Department of
Legislative Leadership Conference
March-April 2012 – Sacramento, CA
Health and Human Services believes
Information: 800-735-2237 or www.calacep.org
that, widespread use of health IT within
the health care industry will improve the
Jointly-Sponsored Courses
quality of health care, prevent medical
Jointly sponsored by CAL/ACEP
and the American College of Emergency Physicians
errors, reduce health care costs, increase
administrative efficiencies, decrease
EMPSF: First Annual Patient Safety Summit
paperwork, and expand access to
Type: Live Conference
Las Vegas, NV - May 5-6, 2011
affordable health care. It is imperative
Information: 916-357-6723
that the privacy and security of
www.empsf.org
electronic health information be ensured
Point of Care US Guided Nerve Blocks
as this information is maintained and
transmitted electronically.
San Francisco, CA - June 10, 2011
The Privacy Rule expressly permits
www.ulscourse.com a covered entity to disclose PHI to a
business associate, or allow a business
Wilderness Medicine
associate to create or receive PHI on
Santa Fe, N.M – June 1-5, 2011
its behalf, so long as the covered entity
Big Sky, Montana - July 27- 31 , 2011
Big Sky, Montana - Feb. 22-26, 2012
obtains satisfactory assurances in the
Kauai - April 11-15, 2012
form of a contract or other agreement that
Santa Fe, N.M – May 28-June 3, 2012
Big Sky, Montana - July 25-29 , 2012
the business associate will appropriately
safeguard the information. See 45
www.wilderness-medicine.com
C.F.R. §§ 164.502(e), 164.504(e). A
The Center for Medical Education, Inc.
business associate is a person (other
Type: Enduring Materials: Internet Subscriptions
than a workforce member) or entity that
Emergency Medical Abstracts
Risk Management Monthly/ Emergency Medicine
performs certain functions or activities
Information: www.ccme.org
that involve the use or disclosure of PHI
Patient Safety Risk Solutions
on behalf of, or provides certain services
Type: Enduring Materials: Webinar
to, a covered entity. See 45 C.F.R.
Teamwork and Communication in
Emergency Medicine
§ 160.103 (definition of “business
The Dilemma of the Psychiatric Patient in the
associate”).
Emergency Department
Information security is the protection
Information: www.psrisk.com
of information and information
systems from unauthorized access, use,
disclosure, disruption, modification or
disclosure, disruption, modification or
destruction. Information security is achieved destruction of electronic health information.
To mitigate each risk your practice can
by ensuring the confidentiality, integrity, and
perform two important steps:
availability of information.
Assessing your electronic health
information
confidentiality,
integrity, 1. Review your existing health information
and availability needs requires you to security policies and develop new policy
first understand your practice’s health statements to address new risks to electronic
IT environment. This may include the health information. These new policy
technologies your practice deploys for both statements could require the use of certain
clinical and administrative purposes, where technology (e.g., encryption of data on mobile
those technologies are physically used computing equipment such as laptops),
and located, and how they are used within further refine who within your practice is
your practice. As you assess your health IT authorized to view and administer electronic
environment, think about those situations
that may lead to unauthorized access, use,
May Issue 2011 13
5/25/11 1:26 PM
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West JEM...
(Continued from page 11)
placed; and one patient was not treated due to
“unknown baseline mental status.”
The remaining 38 patients were treated
with our TH protocol. We were unable to
determine time-to-target temperature in
13 patients (34.2%), either because the
patient’s temperature was not recorded after
the cooling catheter was placed or because
the time of initiation of TH was not clearly
documented. In the remaining 25 patients the
median time to reach the target temperature
was 240 minutes (IQR 115 min to 405 min).
For patients treated with TH, the mortality
rate was 71.1% (95% CI 56% to 86%) with
an odds ratio of 0.94 (95% CI 0.36 to 2.42).
Eight percent (95% CI 0% to 17%) had a
good neurological outcome (defined as a
Glasgow-Pittsburgh CPC score of 1 or 2) on
hospital discharge. The initial documented
rhythms in this group were VF/VT in 44.7%
(n=17), PEA in 31.6% (n=12), and asystole in
23.7% (n=9). The arrest was witnessed in 20
patients (52.6%). The median age was 74.5
(IQR 60 – 81) years; the median hospital LOS
was 4.5 (IQR 2 – 11.5) days; and 55% were
male (Tables 1 and 2). Five patients (13.2%)
did not complete the protocol.
Complications in the TH-treated patients
were as follows: bleeding in six [16% (95%
CI 4% to 28%)]; pneumonia in eight [21%
(95% CI 7% to 35%)]; sepsis in nine [24%
(95% CI 10% to 38%)]; renal failure in two
[5% (95% CI 0% to 13%)];arrhythmias
in seven [18% (95% CI 6% to 31%)]; and
seizures in five [13% (95% CI 2% to 24%)]
(Table 1).
Our control group included 47 patients,
with a mortality rate of 72.3% (95% CI 59%
to 86%). None (95% CI 0% to 8%) had a good
neurological outcome on hospital discharge.
The presenting rhythms of the control group
were VF/VT in 19.2% (n=9), PEA in 36.2%
(n=17), asystole in 42.6% (n=20), and 2.1%
documented as slow wide complex (n=1).
Cardiac arrest was witnessed in 25 (53.2%)
patients. The median age was 75 (IQR 60
to 83) years, the median hospital LOS was
two (IQR 1 to 8) days, and 57% were male
(Tables 1 and 2).
Complications in the control group were
as follows: bleeding in 15 [32% (95% CI
18% to 46%)]; pneumonia in 12 [26% (95%
CI 13% to 38%)]; sepsis in 19 [40% (95%
CI 26% to 55%)]; renal failure in three [6%
(95% CI 0% to 14%)]; arrhythmias in 23
[49% (95% CI 34% to 64%)]; and seizures in
eight [17% (95% CI 6% to 28%)] (Table 1).
Of the 17 patients treated with TH whose
initial documented rhythm was VF/VT,
mortality was 47% (95% CI 21% to 74%).
We observed good neurological outcome in
18% of these patients (95% CI 0% to 38%).
Of the nine in the control group with an initial
documented rhythm of VF/VT, mortality
was 67% (95% CI 28% to 100%). Good
neurological outcome was seen in none of
these patients (95% CI 0% to 30%) (Table 1).
The mortality rate for all 72 patients who
had ROSC and survived to hospital admission
during the study period was 70.8% (95%
CI 59% to 80%). The 34 patients who met
the inclusion and exclusion criteria for TH
but were not treated had a mortality rate of
70.6% (95% CI 17% to 46%). Four of these
34 patients who were eligible but not treated
with TH had an initial documented rhythm of
VF/VT.
DISCUSSION
The mortality rate of patients treated with
our TH protocol was not significantly different
from that of our control patients; however, we
did find a non-statistically significant trend
towards improved neurological outcomes in
the TH group. Complication rates were also
not significantly different between the two
groups, although there was a trend towards
more bleeding, sepsis and arrhythmias
in the control group. In patients with an
initial rhythm of VF/VT, there was a trend
towards improved mortality and neurological
outcomes in the group treated with TH.
The number of published studies
supporting the use of TH in the setting of
resuscitated cardiac arrest continues to
grow. 12-15, 16, 17 A recent review of studies
of patients treated with TH after ROSC
from any presenting rhythm concluded that
its use improved survival and favorable
neurological outcome with an odds ratio
of 2.5 for both measures; of note, only one
of the included studies was performed at
a community hospital.23 In other studies
including all rhythms, much of the survival
and neurological outcome benefit was limited
to patients presenting with VF/VT cardiac
arrest. 16, 17, 24 However, a recent study by
Nielsen et al. reported a more dramatic effect
of TH in non- VF/VT rhythms. Twenty-one
percent of patients with an initial rhythm of
asystole and 22% with PEA were discharged
with good neurological outcome.25
Our overall survival rates and numbers of
patients discharged with favourable outcomes
were low compared to the landmark trials by
Bernard and the HACA group.8, 9 Unlike
those trials, we included patients with any
presenting rhythm as well as patients with
unwitnessed cardiac arrest. In addition, the
median age of our patients was 10-15 years
greater. 8, 9 All of these factors would be
expected to lower survival rates.
Some decrease in the rate of favourable
outcomes is not uncommon when a
therapy is initially studied in a community
hospital setting. 24 The one other published
study performed at a community hospital
demonstrated a lower mortality rate (61%)
and higher rate of discharge with good
neurological outcome (33%).18 Their study
population was younger (mean age of 62
compared to a median age of 75); they did
not specify presenting rhythms and used a
different neurological outcome scale. These
factors limit the ability to compare the
outcomes between studies.
Although our study did not find a
statistically significant benefit from TH,
our sample size was small, increasing the
likelihood of a type 2 error. The percentage
of patients presenting with VF/VT was low
in our study compared to others that included
all rhythms, which may have depressed
the expected treatment benefit.16, 17, 24 In
patients with VF/VT, where the evidence
of benefit from TH is stronger, our point
estimates show an improvement in the
incidence of good neurological outcome from
0 to 18%. If this effect was borne out with a
larger sample size, the use of a TH protocol
would be justified. The published evidence of
benefit for rhythms other than VF/VT is not
as robust, and none was found in our study.
ILCOR and the AHA recommend the use
of TH in unresponsive patients resuscitated
after ventricular fibrillation OHCA. It is
estimated that an additional 2,298 patients
per year in the United States would have
a good neurological outcome if TH was
fully implemented in comatose survivors of
OHCA. 26Despite this recommendation, TH
continues to be underused. In a 2005 survey
of emergency physicians, cardiologists
and critical care specialists involved in
post-resuscitation care, 74% of United
States respondents had never used TH.27
Commonly cited reasons for not using TH
included “not enough data”, “not part of
Advanced Cardiac Life Support Guidelines”,
“have not considered cooling therapy”,
and “too technically difficult to use.”27 In
developing our TH protocol, we encountered
these same barriers to implementation
despite significant educational efforts for our
physicians and nurses. In the present study,
14 of 34 potentially eligible patients were
not treated with TH for reasons that were
not clearly documented, and seven of the 34
May Issue 2011 15
5/25/11 1:26 PM
CAREER OPPORTUNITIES
CAL/ACEP cannot guarantee the validity or accuracy of advertisements.
ACEP MEMBERSHIP PREFERRED:
ACEP MEMBERSHIP PREFERRED:
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16 May Issue 2011
5/25/11 1:26 PM
Communicating...
health information, or clarify and improve
how and when electronic health information
is provided to patients or other health care
entities.
2.Institute your updated health information
security policies into your practice to mitigate
new risks to electronic health information.
This step will help your practice keep
security policies current, and decrease the
likelihood and/or impact of electronic health
information being accessed, used, disclosed,
disrupted, modified or destroyed in an
unauthorized manner.
It is important to note that the types of
safeguards you choose may be limited or
required by law, and once you have identified
the scope of those safeguards applicable to
your practice you may have some flexibility
in determining which ones are appropriate
for the risks you identified. Regardless of
the type of safeguard your practice chooses
to implement, it is important to monitor its
effectiveness and regularly assess your health
IT environment to determine if new risks are
present.
Below are questions that will help develop
a reasonable compliance program to protect
confidential information within your practice.
Remember, the objective is to prevent illegal
or inappropriate disclosure of PHI and
mitigate the damage should an inappropriate
disclosure occur.
What new electronic health information
has been introduced into my practice because
of EHRs? Where will that electronic health
information reside? E-data that is stored on
computers should always be encrypted and
access should be password protected.
Who in my office (employees, other
providers, etc.) will have access to EHRs, and
the electronic health information contained
within them? The rules indicate everyone
is on a “need-to-know” basis, so access to:
PHI should be limited to those that need the
information.
Should all employees with access to
EHRs have the same level of access? Your
employees’ access should restrict them to
view only the PHI that they need to treat
the patient, facilitate payment, or facilitate
healthcare operations.
Will I permit my employees to have
electronic health information on mobile
computing/storage equipment? If so, do
they know how, and do they have the
resources necessary, to keep electronic
health
health information
information secure
secure on
on these
these devices?
devices?
Encryption applications are inexpensive and
readily available online. They are simple to
use and while the requirement is still 128 bit
encryption;
encryption; 256
256 encryption
encryption is
is more
more secure.
secure.
You should have attachments encrypted
and the PHI on your hard drive should be
encrypted.
How will I know if electronic health
information has been accidentally or
maliciously disclosed to an unauthorized
person?
One way is you can always
require a confirmation when transferring
data, if the recipient confirmation is not the
intended recipient you have a problem. All
transmissions should have a confidentiality
statement instructing anyone that is not an
intended recipient to respond to the sender
immediately.
Are my backup facilities secured
(computers, tapes, offices, etc., used to
backup EHRs and other health IT)? Where do
you store your back-up media, does someone
take them home? Be sure that you have a
disaster plan and that all back-up data is
encrypted and if possible physically secure at
all times.
Will I be sharing EHRs, or electronic PHI
with other health care entities? If so, what
security policies do I need to be aware of and
do I have a business associates agreement
with them? Whenever you share PHI it is
important that the recipient has attested to
their commitment to protect the confidential
data at least to the requirements of state and
federal laws. You can obtain sample business
associate agreements online at no cost.
Will I communicate with other providers
or individuals electronically (e.g., through a
portal or email)? Are those communications
secured? There is a process known as a
Secure File Transfer Protocol (SFTP) and
there are other methods such as a secure
Virtual Private Network that enable the
transfer of PHI safely. These are similar to
the applications that close the little lock icon
on your computer when you transact secure
operations such as with your bank.
If I communicate with others, how do
I verify that the recipient of PHI is the
intended party? Do I have an authentication
application? The simplest and by far most
widely deployed authentication scheme
begins with a reverse DNS (domain name
system) lookup of the connecting IP address.
If there is no answer, it's a safe bet that the
address is not a legitimate sender. If there
is an answer, a forward DNS lookup of that
answer authenticates the sender if it returns
the connecting IP address. In other words, we
look up the name of the connecting IP address,
and look up the IP address of that name, and
they must match. But one should always
encrypt data regardless of the authentication
process.
Have I trained my employees on the
use of EHRs? Do they understand the
importance of keeping electronic health
information protected?
Every Practice
should have published standards of conduct
and these should include legal and moral
reasons to protect PHI and other confidential
information.
Have I identified how I will periodically
assess my use of health IT to ensure my
safeguards are effective? One way is to
engage an expert in systems security. Another
is to test your users and your systems. Using
fictitious data test how your users store,
transfer, and use PHI.
As employees enter and leave my
practice, have I defined processes to ensure
electronic health information access controls
are updated and deleted accordingly? Every
new employee should be trained on security
policies and every departing employee’s
username, password, other means of
accessing PHI should be incapacitated.
Have I developed a security incident
response plan so that my employees know
how to respond to a potential security incident
involving electronic health information (e.g.,
unauthorized access to an EHR, inappropriate
transfer of PHI to an unauthorized party)? A
red flag program should be implemented.
Ensure that every employee, associate and
contractor with access to PHI knows that
any suspected breach of confidentiality must
be reported at once. Offer an anonymous
reporting
reporting system
system to
to encourage
encourage reporting.
reporting.
Make sure everyone knows that self-reporting
and accidental breach is critical and not
reporting is a terminable offense.
Have I developed processes that
authorized individuals can use to securely
connect to a portal? Have I developed
processes for authenticating the identity of
individuals before granting them access to the
portal? An example might be a patient portal
whereby
whereby the
the patients
patients can
can pay
pay bills
bills online.
online.
Access to the portal should be restricted by
a username and password that can only be
obtained if one has the bill that was sent to
the guarantor.
If equipment with PHI is stolen or lost,
have I defined processes to respond to the
theft or loss? There are very specific reporting
requirements. Check out the link below.
http://www.hhs.gov/ocr/privacy/hipaa/
administrative/breachnotificationrule/
brinstruction.html
Have I configured my computing
environment where electronic health
(Continued from
page21)21)
on page
May Issue 2011 17
5/25/11 1:26 PM
West JEM...
ED resuscitation were implemented during
our study. However, the medical and cardiac
intensive care units (ICUs) at our hospital
were not cooled because placement of the became closed units in June 2008, which may
endovascular catheter was unsuccessful.
have impacted the care of TH patients in the
ICU as compared with historical controls. Our
LIMITATIONS
There are a number of limitations to hospital does not have a standardized protocol
our study, including its being limited to a for comprehensive post-resuscitation care,
single institution with a small sample size. although some protocols, including emergent
We chose to evaluate in-hospital mortality PCI and maintenance of euglycemia, do exist.
Although our control and study groups
and neurological outcome at the time of
hospital discharge rather than longer-term did not differ statistically with regard to
survival and disability. We used the Glasgow- baseline characteristics, the control group
Pittsburgh CPC as our neurological outcome did contain more patients with congestive
measure. The CPC has been criticized for heart failure and cancer. In addition, there
being a relatively gross assessment tool;28 were statistically fewer control patients
however, it still is a standard outcome who presented with VF/VT as opposed to
measure used in resuscitation research. Our other rhythms in comparison to the study
difference and
in mortality.
patients with
an initial rhythm
VF/VT,population.
those treated withBoth factors likely favor the
protocol
studyIndesign
designated
the of
use
showed a trend towards improved mortality and neurologic outcomes. Our TH
group
treated
ofTH
an
endovascular
catheter
for
cooling,
thus
protocol appears safe, as we found no significant difference in complication
rates with TH.
between patients
treated with
and historical our
controls.
Large collaborative descriptive
limiting
our ability
toTHgeneralize
results
studies of TH are now needed especially involving non-university institutions and
CONCLUSION
topatients
institutions
alternative
with presentingusing
rhythms other
than VF/VT. cooling
Although we demonstrated a trend
techniques.
The
2005
AHA
guidelines
Address for Correspondence: Christine E. Kulstad, MD, Department of Emergency Medicine, Advocate
Medical Center, 4440 cardiovascular
W. 95th St. Oak Lawn, IL 60453.
Emailwere
[email protected].
towards improved neurologic outcomes in
forChristemergency
care
Conflicts of Interest:
By the the
WestJEM
article submission
all authors arepatients
required to disclose
all
treated
with TH as compared with
published
before
period
of ouragreement,
historical
affiliations, funding sources and financial or management relationships that could be perceived as potential
controls,
and
no other
changes in historical controls, we found no overall
sources of bias.
The authors
disclosed significant
none.
difference in mortality.
Table 1. Summary of complications in the TH-treated patients.
Therapeutic hypothermia
Control
In patients with an
initial rhythm of VF/
% (n) or median 95% CI or IQR % (n) or median 95% CI or IQR
VT, those treated
Mortality
71.1% (27)
56% to 86%
72.3% (34)
59% to 86%
CPC 1 - 2 at discharge 8% (3)
0% to 17%
0 (0)
0% to 8%
with TH showed
Length of stay (days)
4.5
2 to 11.5
2
1 to 8
Mortality, VF/VT
47% (8)
21% to 74%
67% (6)
28% to 100%
a
trend
towards
subgroup
improved
mortality
CPC 1 - 2 at discharge, 18% ( 3)
0% to 38%
0 (0)
0% to 30%
VF/VT subgroup
and
neurologic
Complications
outcomes. Our TH
Bleeding
16% (6)
4% to 28%
32% (15)
18% to 46%
protocol
appears
Pneumonia
21% (8)
7% to 35%
26% (12)
13% to 38%
Sepsis
24% (9)
10% to 38%
40% (19)
26% to 55%
safe, as we found no
Renal failure
5% (2)
0% to 13%
6% (3)
0% to 14%
significant difference
Pulmonary edema
24% (9)
10% to 38%
19% (9)
7% to 31%
Seizures
13% (5)
2% to 24%
17% (8)
6% to 28%
in complication rates
Arrhythmias
18% (7)
6% to 31%
49% (23)
34% to 64%
between
patients
CPC = Cerebral Performance Category
treated with TH and
VF/VT = ventricular fibrillation/ventricular tachycardia
historical
controls.
Table 2. Baseline characteristics of patients.
Large
collaborative
Control
Therapeutic
descriptive
studies
% (n) or
hypothermia
P value
median (IQR)
% (n) or
of TH are now
median (IQR)
needed
especially
Gender (male)
57% (27)
55% (21)
0.840
involving
nonAge (years)
75 (60 - 83)
74.5 (60 – 81)
0.521
Diabetes mellitus
42.6 % (20)
42.1% (16)
0.967
university institutions
Hypertension
61.7 % (29)
63.2% (24)
0.890
and patients with
Coronary artery disease 42.6% (20)
42.1% (16)
0.967
presenting
rhythms
Prior CVA
14.9% (7)
13.2% (5)
0.819
Renal failure
8.5% (4)
15.8% (6)
0.300
other than VF/VT.
Congestive heart failure 31.9% (15)
15.8% (6)
Cancer
19.1% (9)
5.3% (2)
On coumadin
21.3% (10)
13.2% (5)
Presenting rhythm
VF/VT
19.2% (9)
44.7% (17)
Asystole
36.2% (17)
31.6% (12)
PEA
42.6% (20)
23.7% (9)
Other
2.1% (1)
0
Witnessed arrest
53.2% (25)
52.6% (20)
CVA = Cerebral Vascular Accident
VF/VT = ventricular fibrillation/ventricular tachycardia
PEA = pulseless electrical activity
0.087
0.058
0.329
0.008
0.068
0.657
0.366
0.959
Address
for
C o r res p o n d en c e:
Christine E. Kulstad,
MD, Department of
Emergency Medicine,
Advocate
Christ
Medical Center, 4440 W. 95th St. Oak Lawn,
IL 60453. Email [email protected].
Conflicts of Interest: By the WestJEM article
submission agreement, all authors are
required to disclose all affiliations, funding
sources and financial or management
relationships that could be perceived as
potential sources of bias. The authors
disclosed none.
REFERENCES
1. American Heart Association: Heart Disease and Stroke Statistics. Dallas,
TX: 2008.
2. Madl C, Holzer M. Brain function after resuscitation from cardiac arrest.
Curr Opin Crit Care. Jun 2004; 10:213-7.
3.Herlitz J, Bahr J, Fischer M, et al. Resuscitation in Europe: a tale of five
European regions. Resuscit. Jul 1999; 41:121-31.
4.Benson DW, Williams GR, Jr., Spencer FC, et al. The use of hypothermia
after cardiac arrest. Anesth and analg. Nov-Dec 1959; 38:423-8.
5.Safar P. Resuscitation from clinical death: pathophysiologic limits and
therapeutic potentials. Crit Care Med. Oct 1988; 16:923-41.
6.Alzaga AG, Cerdan M, Varon J. Therapeutic hypothermia. Resuscit. Sep
2006; 70:369-80.
7.Varon J, Acosta P. Therapeutic hypothermia: past, present, and future. Chest.
May 2008; 133:1267-74.
8.Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of
out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med. Feb
21 2002; 346:557-63.
9.Mild therapeutic hypothermia to improve the neurologic outcome after
cardiac arrest. N Engl J Med. Feb 21 2002; 346:549-56.
10.Nolan JP, Morley PT, Vanden Hoek TL, et al. Therapeutic hypothermia after
cardiac arrest: an advisory statement by the advanced life support task force
of the International Liaison Committee on Resuscitation. Circulation. Jul 8
2003; 108:18-121.
11.2005 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care. Circul. Dec 13 2005;
112:IV1-203.
12.Sunde K, Pytte M, Jacobsen D, et al. Implementation of a standardised
treatment protocol for post resuscitation care after out-of-hospital cardiac
arrest. Resuscit. Apr 2007; 73:29-39.
13.Holzer M, Bernard SA, Hachimi-Idrissi S, et al. Hypothermia for
neuroprotection after cardiac arrest: systematic review and individual patient
data meta-analysis. Crit Care Med. Feb 2005; 33:414-8.
14.Busch M, Soreide E, Lossius HM, et al. Rapid implementation of
therapeutic hypothermia in comatose out-of-hospital cardiac arrest survivors.
Acta anaesthesiologica Scandinavica. Nov 2006; 50:1277-83.
15.Belliard G, Catez E, Charron C, et al. Efficacy of therapeutic hypothermia
after out-of-hospital cardiac arrest due to ventricular fibrillation. Resuscit.
Nov 2007; 75:252-9.
16.Oddo M, Schaller MD, Feihl F, et al. From evidence to clinical practice:
effective implementation of therapeutic hypothermia to improve patient
outcome after cardiac arrest. Crit Care Med. Jul 2006; 34:1865-73.
17.Bro-Jeppesen J, Kjaergaard J, Horsted TI, et al. The impact of therapeutic
hypothermia on neurological function and quality of life after cardiac arrest.
Resuscit. Feb 2009; 80:171-6.
18.Scott BD, Hogue T, Fixley MS, et al. Induced hypothermia following outof-hospital cardiac arrest; initial experience in a community hospital. Clin
Card. Dec 2006; 29:525-9.
19.Arrich J. Clinical application of mild therapeutic hypothermia after
cardiac arrest. Crit Care Med. Apr 2007; 35:1041-7.
20.Oddo M, Ribordy V, Feihl F, et al. Early predictors of outcome in
comatose survivors of ventricular fibrillation and non-ventricular fibrillation
cardiac arrest treated with hypothermia: a prospective study. Crit Care Med.
Aug 2008; 36:2296-301.
21.Hachimi-Idrissi S, Corne L, Ebinger G, et al. Mild hypothermia induced
by a helmet device: a clinical feasibility study. Resuscit. Dec 2001; 51:27581.
22.Kim F, Olsufka M, Longstreth WT, Jr., et al. Pilot randomized clinical trial
of prehospital induction of mild hypothermia in out-of-hospital cardiac arrest
patients with a rapid infusion of 4 degrees C normal saline. Circul. Jun 19
2007; 115:3064-70.
23.Sagalyn E, Band RA, Gaieski DF, et al. Therapeutic hypothermia
after cardiac arrest in clinical practice: review and compilation of recent
experiences. Crit Care Med. Jul 2009; 37:S223-6.
24.Hay AW, Swann DG, Bell K, et al. Therapeutic hypothermia in comatose
patients after out-of-hospital cardiac arrest. Anaesthesia. Jan 2008; 63:15-19.
25.Nielsen N, Hovdenes J, Nilsson F, et al. Outcome, timing and adverse
events in therapeutic hypothermia after out-of-hospital cardiac arrest. Acta
anaesthesiologica Scandinavica. Aug 2009; 53:926-34.
26.Majersik JJ, Silbergleit R, Meurer WJ, et al. Public health impact of full
implementation of therapeutic hypothermia after cardiac arrest. Resuscit.
May 2008; 77:189-94.
27.Merchant RM, Soar J, Skrifvars MB, et al. Therapeutic hypothermia
utilization among physicians after resuscitation from cardiac arrest. Crit
Care Med. Jul 2006; 34:1935-40.
28.Raina KD, Callaway C, Rittenberger JC, et al. Neurological and
functional status following cardiac arrest: method and tool utility. Resuscit.
Nov 2008; 79:249-56.
_____________________________
REFERENCES
1. American Heart Association: Heart Disease and Stroke Statistics. Dallas, TX: 2008.
2. Madl C, Holzer M. Brain function after resuscitation from cardiac arrest. Curr Opin Crit Care.
Jun 2004; 10:213-7.
3. Herlitz J, Bahr J, Fischer M, et al. Resuscitation in Europe: a tale of five European regions.
Resuscit. Jul 1999; 41:121-31.
4. Benson DW, Williams GR, Jr., Spencer FC, et al. The use of hypothermia after cardiac arrest.
Anesth and analg. Nov-Dec 1959; 38:423-8.
5. Safar P. Resuscitation from clinical death: pathophysiologic limits and therapeutic potentials. Crit
Care Med. Oct 1988; 16:923-41.
5350 95181 Lifeline
6. NL.indd
Alzaga AG,18
Cerdan M, Varon J. Therapeutic hypothermia. Resuscit. Sep 2006; 70:369-80.
18 May Issue 2011
5/25/11 1:26 PM
Emergency Medicine Action
Fund– Why We All Must
Participate
by Ramon Johnson, MD
CAL/ACEP Past President
By now many of you have heard that
ACEP has approved the creation of a fund
to help move our political agenda forward in
Washington, D.C. This fund is modeled after
fund raising efforts in California to support a
number of ballot initiatives. While that effort
was met with mixed results, the state chapter
learned that additional financial resources
were critical to their ability to support the
needed increased political activity needed
beyond what could be achieved with PAC
dollars. CAL/ACEP leader and Federal
Government Affairs Committee member,
Wes Fields met with ACEP President, Angela
Gardner and together proposed the California
model to the ACEP leadership. A task
force was created and after many months, a
recommendation was brought to the ACEP
Board of Directors.
Why is this fund needed? Simply, the new
battlefield in medicine is in the regulatory
area and this is an area where PAC dollars
cannot be used. In order to proactively
and best assess and respond to rules and
regulations as they are formulated from HHS,
resources have to be expended to optimize
our position. Despite a budget of over 20
million dollars, ACEP believed that this
effort alone would cost a million dollars. The
ACEP Board discussed a number of options
including raising dues but eventually chose
to try to expand the number of participants
in the effort. By creating a new fund, anyone
and everyone from billing companies, risk
retention groups, ED groups and individuals
can contribute.
While creating the fund was simple in
concept, the governance remains a challenge.
A board of governors will be established to
work in conjunction with the ACEP board to
identify the challenges facing all members
of the specialty. It had been recommended
that to participate in leading the fund, a buy
in of $100,000 dollars would be required.
Unfortunately, this would tend to favor the
large groups who can spread this cost across
all of its EDs but this does not have to mean
that small or single contract groups cannot be
represented.
They too can have a voice but it means
coming together and forming coalitions.
This concept of bringing the small and single
contract groups together in a common interest
has been a personal goal of mine. Some of
you may remember some of my Lifeline
articles more than a decade ago that focused
on the need to form cartels, similar to what
then oil mogul, JR Ewing pontificated on the
TV show Dallas. Flash forward 15 years and
the need to unite has never been greater. It
is crucial to form a “California Small Group
Coalition” or CSGC. By combining our
resources, a seat at the board of governors
can be had. As when the state chapter was
raising money for ballot initiatives, the idea is
for every group to contribute a small amount.
Let’s for sake of argument say ten cents per
patient based on annual volume. This would
be an amount to be contributed every year by
every group.
So how do we do this? At this year’s CAL/
ACEP scientific assembly in Newport Beach,
there will be a kickoff meeting for the CSGC.
I am asking that you plan to attend this
meeting and bring your questions. Already, I
know that each contribution IS tax deductible
as the money is not going into a PAC. I will
be asking the billing companies to contact
each group and requesting that they be the
middle man and collect the contributions on
behalf of the groups and submitting them to
the EMAF. Other groups may want to join
together who share the same malpractice
company. Smaller states may even use a
chapter based coalition of small groups.
Either way, everyone MUST contribute if
we are to ALL benefit. Large group or small,
everyone gets to play and have a say. Let’s
combine our resources to show the health
care community that emergency physicians
will choose to shape our own futures to the
best of our ability.
40th Annual
CAL/ACEP Scientific Assembly
Friday Events
@ 11:15 AM
PRESIDENT'S MESSAGE
Peter Sokolove, MD
An address by the new Chapter President on the year
to come and their priorities for the Chapter
@ 12:00 PM
AWARDS LUNCHEON (RSVP Required)
The annual Chapter Awards Luncheon will honor
Chapter members who have made outstanding
contributions to emergency medicine and to the Chapter
@ 6:00 PM - $100
PRESIDENT’S RECEPTION & DINNER
Register under the Optional Events section
of CAL/ACEP’s Scientific Assembly
registration form at www.calacep.org.
May Issue 2011 19
5/25/11 1:26 PM
Transportation Fact Sheet - Newport Beach Marriott Hotel & Spa
900 Newport Center Drive - Newport Beach, CA 92660
BY AIR:
From John Wayne Airport – OC
The airport is serviced by Alaska Airlines, Alpha Air, America West,
American Airlines, Continental Airlines, Delta Airlines, Northwest
Airlines, Sky West, Southwest Airlines, TWA, United Airlines, US Air,
and Jet Blue. The airport is located 10 minutes from the hotel.
From Los Angeles International Airport:
The airport is serviced by all major air carriers.
Ground
transportation includes regularly scheduled airport bus service,
private limousine, taxi, rental cars, and shuttle vans. Driving time to
Newport Beach is approximately 55 minutes on Interstate 405 (San
Diego Freeway)
From Long Beach Airport:
The airport is serviced by Alaska Airlines, America West, American
Airlines, American Eagle, Delta Airlines, Northwest Airlines, Reno
Air, Sky West, Southwest Airlines, United Airlines, US Air Express
and Jet Blue. Ground transportation includes private limousine, taxi,
rental cars, and shuttle vans. Driving time to Newport Beach is
approximately 70 minutes.
BY AUTOMOBILE:
From John Wayne Airport – OC:
Take MacArthur south to Jamboree Road. Turn right on Jamboree
Road. Continue down Jamboree to Santa Barbara Drive. Turn left on
Santa Barbara Drive. Hotel will be on the right at the top of the hill.
From Los Angeles International Airport:
Take San Diego Freeway (405) South to San Joaquin Hills Toll Road
(73). Exit on Jamboree, turning right towards Corona Del Mar.
Continue down Jamboree Road to Santa Barbara Drive. Turn left on
Santa Barbara Drive. Hotel will be on the right at the top of the hill.
From Long Beach Airport:
Take San Diego Freeway (405) South to San Joaquin Hills Toll Road
(73), Exit on Jamboree, and turn right towards Corona Del Mar.
Continue down Jamboree Road to Santa Barbara Drive. Turn left on
Santa Barbara Drive. Hotel will be on right at the top of the hill.
From Ontario International Airport:
Take San Bernardino Freeway (10) west to Orange Freeway (57).
Take Orange Freeway south to Santa Anna Freeway (5). Take Santa
Ana Freeway south to Newport Freeway (55). Take Newport Freeway
South to San Joaquin Hills Toll Road (73). Exit on Jamboree, turning
right towards Corona Del Mar. Continue down Jamboree Road to
Santa Barbara Drive. Turn left on Santa Barbara Drive. Hotel will be
on the right at the top of the hill.
From Downtown Los Angeles:
Take Santa Ana Freeway (5) South to Newport Freeway (55). Take
Newport Freeway South to San Joaquin Hills Toll Road (73). Exit on
Jamboree, turning right towards Corona Del mar. Continue down
Jamboree Road to Santa Barbara Drive. Turn left on Santa Barbara
Drive. Hotel will be on the right at the top of the hill.
From San Bernardino/Riverside Inland Empire:
Take Riverside Freeway (91 – accessible via 15 or 60 Freeways) west
to Newport Freeway (55). Take Newport Freeway south to San
Joaquin Hills Toll Road (73). Exit on Jamboree, turning right
towards Corona del Mar. Continue down Jamboree Road to Santa
Barbara Drive. Turn left on Santa Barbara Drive. Hotel will be on the
right at the top of the hill.
From Sacramento/Northern California:
Take the 5 freeway South all the way down past Los Angeles, into
Orange County. From the 5 take the Newport Freeway (55) South to
San Joaquin Hills Toll Road (73). Exit on Jamboree Road and turn
right. Continue to Santa Barbara Drive, turn left. Hotel will be on the
right hand side at the top of the hill.
From San Diego:
Take the Santa Ana Freeway (5) North to San Joaquin Hills Toll Road
(73). Exit at Bonita Canyon and turn left continue on Bonita Canyon
which turns into Ford Road. Then turn left onto Jamboree Road,
continue to Santa Barbara Drive. Turn left on Santa Barbara Drive.
Hotel will be on the right at the top of the hill.
From Pasadena:
Take the 210 Freeway to the 605 Freeway South. From the 605
Continue to the San Diego Freeway (405) South. Exit on to the San
Joaquin Hills Toll Road (73). Exit on Jamboree Road. Continue to
Santa Barbara Drive. Turn left on Santa Barbara Drive, the hotel will
be on the right at the top of the hill.
20 May Issue 2011
5/25/11 1:26 PM
Communicating...
applications will warn you of potential threats
to your system, be sure they are always
turned on.
The following are the basics to follow in
your Compliance Program, more details can
be found on the HHS website and there are
also proprietary tools available to assist you
in developing your safeguards. All PHI in
electronic format must be encrypted (a) when
transmitted over unsecure networks including
the Internet and wireless, and (b) when at rest
on portable computing devices and portable/
removable electronic media.
The Internet is an open, public
communications medium. Wireless signals
travel through air and cannot be entirely
contained in normal business settings.
Messages and data transmitted over these
networks are not secure. Portable devices and
media are easily lost and stolen, jeopardizing
confidential data stored on them. Therefore,
you must protect PHI and confidential
business matters by requiring that confidential
information be encrypted in these highrisk circumstances. This policy should be
applied to any and all mechanisms by which
organization data may be transmitted over
wireless networks and the Internet such as
file transfer, e-mail and e-mail attachments,
web site transactions, and interactive
information resides using best-practice
security settings (e.g., enabling a firewall,
virus detection, and encryption where
appropriate)? Am I maintaining that
environment to stay up to date with the latest
computer security updates? Most commonly
used operating systems come with a firewall
system, but you should invest in virus
protection and encryption software.
Are there other types of software on my
electronic health information computing
equipment that are not needed to sustain
my health IT environment (e.g., a music file
sharing program), which could put my health
IT environment at risk? Every program on
your computer can potentially harbor a threat
or introduce a threat to your data if it has
access to outside networks. The safest bet
is do not use your work computer for any
other applications, but if you must then your
security application should be among the best
available and always maintained with current
upgrades.
Have I enabled the appropriate audit
controls within my health IT environment
to be alerted of a potential security incident,
or to examine security incidents that have
occurred? A smart firewall and smart security
sessions. This policy also applies to portable
computing devices, such as laptops and
hand-held Personal Digital Assistants (e.g.,
iPhone™, BlackBerry™), and to portable
electronic media, such as CDs, DVDs, MP3
players, and USB drives.
Virus-protection software should be
installed on all portable devices and routinely
updated. Encryption software should be
installed on devices and used to protect
any confidential data on them. Encryption
software meeting organization standards
and government-endorsed algorithms should
be used to encrypt data on portable media
leaving the practice’s office or hospital.
Portable devices must be kept locked (for
example, in a drawer or briefcase) unless they
are in use or on one’s person. Portable media
must be locked when unattended (other than
in a locked private office) and when removed
from the facility.
Penalties for violation of the HIPAA
HITECH rules can be substantial. Reporting
requirements are mandatory. The following
link provides all the details and the incentive
to maintain an effective compliance program.
h t t p : / / w w w. h h s . g o v / o c r / p r i v a c y /
hipaa/administrative/enforcementrule/
hitechenforcementifr.html
JUNE 23-24 | NEWPORT BEACH, CALIFORNIA
ULTRASOUND WORKSHOP
.
PROGRAM-AT-A-GLANCE
THURSDAY, JUNE 23
(7 CME Hrs)
7:45AM – 8:00AM
BREAKFAST
Introduction (.0)
8:00AM - 8:15AM
Physics (.50)
8:15AM - 8:45AM
8:45AM - 9:45AM Trauma: FAST Exam (1.0)
Pass the Pointer (.25)
9:45AM - 10:00AM
10:00AM - 10:15AM
BREAK
LAB (1.5)
10:15AM - 11:45AM
11:45AM – 1:00PM
LUNCH
RUQ (.75)
1:00PM – 1:45PM
Procedures (.50)
1:45PM - 2:25PM
Soft Tissue (.50)
2:25PM – 2:55PM
2:55PM - 3:10PM
LAB (1.75)
3:10PM - 5:00PM
FRIDAY, JUNE 24
(7.25 CM Hrs)
7:45AM – 8:00AM
BREAKFAST
DVT/ Aorta (.75)
8:00AM - 8:45AM
8:45AM - 9:45AM
Echo (1.0)
9:45AM - 10:00AM
10:00AM - 10:15AM
BREAK
LAB (1.5)
10:15AM - 11:45AM
LUNCH
11:45AM – 1:00PM
1:00PM – 2:00PM
Pelvic (1.0)
Rush (.50)
2:00PM - 2:30PM
2:30PM – 2:45PM
2:45PM - 4:15PM
LAB (1.5)
4:15PM - 4:45PM
Politics/ Credentialing (0)
4:45PM - 5:15PM Round Table Discussion (0.5)
Register online at www.calacep.org or complete the Conference Registration form on page 5
and fax: 916-325-5459 or email: [email protected]
Hope to see you in Newport Beach!
May Issue 2011 21
5/25/11 1:26 PM
Highlights: Fashion Island - Laguna Beach - Balboa Island – Disneyland - Knott's Berry Farm - Universal Studios - Catalina Island
Beverly Hills/Hollywood - Newport Harbor/Fishing Cruises - Verizon Wireless Ampitheatre
Local Tour Services: Catalina Ferry - Newport Beach to Avalon - Catalina Island - Catalina Tours - 1-888-317-3576
Sea Lions, Celebrity Homes, Newport Harbor - The Fun Zone Boat Company - 1-949-673-0240
Newport Harbor Gondola Tour - Newport Harbor Gondola Company of Newport Beach - 1-949-675-1212
22 May Issue 2011
5/25/11 1:26 PM
40th Annual CAL/ACEP Scientific Assembly
CALL FOR ABSTRACTS
by Matthew R. Lewin, MD, Research Forum Chairman
Thursday, June 23rd @ Newport Beach Marriott
Newport Beach, CA
Abstracts are being accepted for the Research Forum at the 2011
CAL/ACEP Scientific Assembly. Oral presentations will be conducted on
the afternoon of June 23rd at Newport Beach Marriott, Newport Beach,
CA. Authors are encouraged to submit original research in all aspects of
emergency medicine. Resident, Fellow and junior faculty participation is
strongly encouraged. Abstracts must not have previously appeared in a
peer-reviewed journal prior to the meeting date. Abstracts to be presented
at other scientific meetings (including SAEM & ACEP) are eligible for
presentation. Only 10 abstracts will be selected for presentation.
All presentations are oral presentations.
AWARDS
Awards will be presented for
BEST RESEARCH PROJECT, BEST PRESENTATION PROJECT
and MOST INNOVATIVE PROJECT. Abstracts should include
the following sections and should generally follow the SAEM guidelines:
Objectives, Methods, Results, and Conclusions. All abstracts must be
submitted by e-mail, no later than June 1st 2011. The abstract may be
typed or pasted into the text of an e-mail message or as an attached file.
Be sure to include the following information:
 Names of all authors
 Institution
 Person who will present the abstract and
 Contact phone numbers
CONTACT
Matthew R. Lewin, MD
Director, Center for Exploration and Travel Health
California Academy of Sciences, San Francisco, CA, USA
40th Annual CAL/ACEP
Scientific Assembly
LLSA Review
Dr. Peter D’Souza
th
Friday, June 24 @ 2PM - 5PM
The 2011 Lifelong Learning and Self Assessment
(LLSA) Workshop will cover all 11 articles chosen
by the American Board of Emergency Medicine as part
of the Emergency Medicine Continuous Certification
(EMCC Program). The workshop will be an interactive
review of the articles with participants encouraged to
share pearls from their own practice relevant to the
covered topics. Key "testable" concepts from the articles
will be emphasized. Participants will also receive a
handout with a review of key points from the articles.
$50
REGISTER TODAY
Register by selecting “LLSA” under the Optional Workshop
section of CAL/ACEP’s Scientific Assembly registration form.
www.calacep.org
ULTRASOUND
WORKSHOP
June 23 -24
SAVE THE DATE
$750 - $825
REGISTRATION IS LIMITED TO 50
CHAIRS: Drs. J. Christian Fox & Rusty Oshita
www.calacep.org
ULTRASOUND
IV ACCESS
BLADDER ASSESSMENT
WORKSHOP
www.calacep.org
Faculty: Laleh Gharahbaghian MD
Martine Sargent, MD, David Francis, MD, Brita Zaia, MD
Saturday, June 25th @ 9 AM (3 hours)
This ultrasound workshop introduces the technique of
point-of-care Ultrasound-guided peripheral & central line IV
Access and Bladder Volume Assessment. For those patients who
have difficult access and need an IV for emergency management,
or patients who have urinary complaints and you need to know
the volume of the bladder for assessing need for foley catheter
placement, this course allows you to learn a tool that will make it
easier for your care of these patients. The lecture followed by an
extensive hands-on session discusses the tricks of trade, pitfalls,
and allows for extensive practice with gel phantom models for IV
placement and human models for bladder assessment. It is safe,
rapid, portable, and noninvasive; it allows rapid bedside
evaluation and increases success and speed for many procedures.
REGISTER TODAY, SPACE IS LIMITED!
$119 Nurses
$140 Member / $160 Non-Member
May Issue 2011 23
5/25/11 1:26 PM
LIFELINE
CALIFORNIA CHAPTER,
AMERICAN COLLEGE OF EMERGENCY PHYSICIANS
1020 11TH STREET, SUITE 310
SACRAMENTO, CA 95814
PRSRT STD
U.S. Postage
PAID
AUTOMATE
5/25/11 1:26 PM

CAL/ACEP`s 40th Anniversary Scientific Assembly

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