"In Case You Missed It" is a weekly roundup of popular healthcare articles.
Clinical Hot Topics: The Paradoxical Pulse of Sepsis - An Early Clinical Clue to the Presence of Sepsis: http://ow.ly/BoIhI
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Four Lessons Learned from the Death of Joan Rivers. What can we learn from Joan Rivers death that can help others better prepare for safe medical procedures? Find out in this article from TheDoctorWeighsIn.com.
Who is the most Productive Hospitalist in the Country? Guess what? It's not You. This article from HospitalMedicine.org tells you who is.
Virus hitting the U.S. could be 'tip of iceberg,' CDC official says. Read more at CNN.com.
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Hosted by Al Sacchetti, MD, FACEP as moderator, Don’t Blink or You Will Miss It - Clinical Hot Topics can feel much like the “speed dating” of training presentations. The 12 hyper-paced presentations covered a wealth of information for the 2014 EmCare Leadership Conference attendees. Each week, we’ll publish highlights from select clinical hot topics presented at the conference.
In honor of National Sepsis Month, the first clinical hot topic summary is from Michael Pauszek's presentation, "The Paradoxical Pulse of Sepsis - An Early Clinical Clue to the Presence of Sepsis."
Written by Kim Mills
While teaching medical and mid-level students, the team observed that a paradoxical pulse was present in several patients with clinical sepsis, Systemic Inflammatory Response Syndrome or SIRS.
Could this simple finding, so readily available and free, be an early marker for sepsis? Is it a test that could be done in a few seconds, at triage or even by EMS?
During a four-month period, all patients at least eighteen years of age or older who met the SIRS criteria were included in the study. As their blood pressure was measured, they were checked for a paradoxical pulse.
- 105 patients met SIRS criteria
- 48 of the 105 were ultimately diagnosed with sepsis and 39 of those 48 (or 81 percent) had a paradoxical pulse
- Specificity for SIRS criteria was 46 percent
- Only 17 (or 34 percent) of the patients presenting with sepsis had an elevated serum lactate
- Of the 57 non-infected patients meeting SIRS criteria, 6 were found to have a paradoxical pulse
- 5 of the 6 presented with bronchospasm and were diagnosed with acute exacerbation of COPD, the other patient presented in anaphylactic shock from amoxicillin
- 11 (or 23 percent) of the non-infected patients had an elevated serum lactate
The findings suggest that Sepsis should join Bronchospasm and Pericardial Tamponade as recognized causes of a paradoxical pulse.
Good documentation is important for new physicians as well as veteran caregivers. While documenting can seem like a very straightforward skill, there are often “best practices” that can be utilized. As a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, FL I write a “weekly documentation tip” email to help physicians improve their clinical documentation. I also share these documentation strategies with the residents I teach.
by: Timothy N. Brundage, M.D., CCDs
A secondary diagnosis is a condition that coexists at the time of admission, develops subsequently or that affects the treatment received and/or length of stay of the patient. Remember that secondary diagnoses support the severity of illness (SOI) and show that your patient is as sick on paper as they are in the bed.
Secondary diagnoses are defined as those conditions that consume one of the following hospital resources:
• Clinical evaluation
• Therapeutic treatment Further evaluation by diagnostic studies, procedures or consultation Extended hospital length of stay (LOS)
• Increased nursing care and/or other monitoring
For example, if you are monitoring tele and continuing home amiodarone, DO NOT document “history of A. Fib.”This would meet the criteria for the secondary diagnosis of chronic A. Fib and coders cannot code a “history of.”
Timothy N. Brundage, M.D., CCDs is a Certified Clinical Documentation Specialist and Diplomate of the American Board of Internal Medicine.
This article was originally published in the June 2014 issue of EmCare's EmPressions Magazine.
by: JENNIFER WHITUS
EmCare Marketing Communications Manager
A dramatic redesign has allowed the busiest emergency department in Florida to drastically decrease wait times while improving other key metrics. This dynamic turnaround not only improved operations for the Lakeland Regional Medical Center’s emergency department (E.D.), but also earned the redesign team the prestigious 2014 Genesis Cup award.
The Genesis Cup is an award for healthcare innovation presented each year by EmCare, a leading national physician practice management company. This year’s Genesis Cup honoree, a team that works in the Lakeland E.D. in Lakeland, Fla., presented its award-winning redesign during EmCare’s Annual Leadership Conference at The Wynn in Las Vegas.
“The Lakeland E.D. [emergency department] is the busiest single-site E.D. in Florida,” said Dr. Jim Melton, III, medical director for the Lakeland E.D. “It had roughly 170,000 ED visits in 2012 and is on track to have more than 180,000 E.D. visits this fiscal year. Despite the increase in volume, the E.D. has managed to decrease wait time, length of stay rate and rate of patients leaving without being treated. These improvements are the result of an E.D. redesign that began in 2011, driven by the hospital’s executive leadership.”
Melton’s Genesis Cup-winning redesign team includes:
- Maureen Leckie, R.N., MSN, the associate vice president of clinical operations at LRMC
- April Novotny, R.N., MSN, the CEN director of emergency services
- Pam Carter, R.N., BSN, the assistant director of emergency services
- Joanne Fuell, R.N., BSN, the assistant director of emergency services
Before this redesign, LRMC’s E.D. had a long-standing practice of segregating adult patients by levels of clinical acuity into either a critical care area or an immediate care area.
The redesigned E.D. care model grouped rooms into nine pods: one for triage, six that serve adults, one that serves children and one for minor non-urgent conditions. A registered nurse (R.N.) acts as a “bed traffic controller” for the triage pod, assigning triaged patients to one of the pods on a rotational basis so no single pod becomes overwhelmed by multiple patient arrivals.
Because the E.D. relies on multiple hospital departments to deliver care, an E.D. redesign required changes outside of the E.D. as well. LRMC created a team with representatives from the E.D., radiology, lab, pharmacy, respiratory department, transportation and patient placement. The team met weekly to review data and ensure the E.D. was regularly maintaining or improving its patient flow.
Data analysis was another driving component of the redesign. The redesign team received daily and weekly summaries of detailed data from the hospital’s strategic analysis team. One unique tool Lakeland had in its redesign was a simulation model developed by an industrial engineer. The model uses existing data to predict outcomes, such as wait times, under various situations, including staffing levels and patient volumes.
The redesign clearly led to improvements for Lakeland Regional Medical Center’s E.D.:
- E.D. volume increased 16.5 percent from January 2011 to January 2013
- On average, patients are now assessed by a physician in 20 minutes or fewer
- The time from when a patient arrives in the E.D. to when he/she is seen by a healthcare practitioner is 38 percent faster than the national average
- The number of E.D. patients who left without treatment decreased from four percent to 0.3 percent
- The average length of stay is about two hours
- Most patients are treated and discharged in fewer than three hours – a 50 percent decrease resulting from the redesign
- Patients are admitted 30 percent faster than the national average
- Patients get to a bed after admission 56 percent faster than the national average
EmCare also recognized two runners-up in this year’s Genesis Cup program. Dr. Harry Jung, III, an anesthesiologist who practices at Seton Regional Medical Center Harker Heights and a regional medical director for EmCare, earned runner-up honors through reports of the effectiveness of ultrasound-guided regional nerve blocks. These nerve blocks have been shown to reduce pain, shorten hospital stays and speed recovery post-operatively better than more common pain medications and narcotics.
The second runner-up for the Genesis Cup is E.D. team from Sinai Hospital of Baltimore. The Sinai team was recognized for their Ambulance Immediate Offload Project, and was made up of:
- Diane Bongiovanni, M.A., BSN, R.N., CHEP, NEA-BC, director of emergency department and critical care
- Amy Riesner, MSN, BSN, R.N., CHEP, NREMT-P, the E.D. clinical leader and EMS liaison
- Lakecia Lewis, BNS, R.N., CEN, emergency department RN2
- Alma Ta-Asan, BSN, RN, emergency department RN2
- Chandresh Shelat, M.D., E.D. physician and EMS coordinator
- William Jaquis, M.D., chief of emergency medicine
- Will Williams, captain of EMS quality assurance and improvement officer with city emergency medical services
- Christian Griffin, NREMT-P, fire director of county emergency medical services
This new offload program has been very successful: since the faster offload times translated directly to faster EMS response times, in September of 2013 the Sinai E.D. was ranked number one by the City Fire Department.
“All three of these groups personify EmCare’s mission of making healthcare work better,” said Dr. Dighton Packard, EmCare’s chief medical officer. “When you are able to reduce wait times, improve patient flow, better manage pain – it ultimately leads to improved outcomes for the patient.”
EmCare designed The Genesis Cup program to recognize and celebrate the creativity and innovation of everyday physicians as part of the company’s never-ending pursuit to improve the delivery of patient care. In addition to recognizing the inventor/ innovator, The Genesis Cup recognizes those involved in the initiative, including the emergency department, radiology department, hospitalist team, anesthesia team and the regional office in supporting such endeavors.