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Fear About Disease Progression Prompts ER Returns

Patients also cite perceived inability to access timely follow-up care as motivator for return to ER

THURSDAY, Sept. 11, 2014 (HealthDay News) -- Perceived inability to access timely follow-up care and uncertainty and fear about disease progression are the main reasons for return visits to the emergency department, according to a study published online Sept. 2 in the Annals of Emergency Medicine.

Kristin L. Rising, M.D., from Thomas Jefferson University in Philadelphia, and colleagues conducted 60 semistructured, qualitative interviews of adult patients with an unscheduled return to the emergency department within nine days of an index emergency department discharge. A modified grounded theory approach was used to identify themes.

The researchers found that most patients were satisfied with the index discharge process, but many had complaints about the clinical care, including inadequate assessment and treatment. Fear or uncertainty about their condition was cited as the primary reason for returning to the emergency department. Although most patients had a primary care physician, visits to the physician were rare before returning to the emergency department. Convenience and more expedited evaluations were cited as the main reasons for seeking care in the emergency department versus the clinic.

"Further work is needed to develop alternative pathways for patients to ask questions and seek guidance when and where they want," write the authors.

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White Matter Measure Predicts Longer Concussion Recovery

Is a stronger predictor than initial symptom severity, particularly in males

THURSDAY, Sept. 11, 2014 (HealthDay News) -- A measure of white matter in the brain, particularly in males, is an independent predictor of longer time to symptom resolution (TSR) after mild traumatic brain injury (mTBI), according to a study published in the September issue of Radiology.

Saeed Fakhran, M.D., from the University of Pittsburgh, and colleagues assessed diffusion-tensor imaging in 69 patients with mTBI (47 male and 22 female patients) and 21 control subjects (10 males and 11 females) whose conventional magnetic resonance images were normal. Fractional anisotropy maps were used as a measure of white matter integrity. Serial neurocognitive testing with Immediate Post-Concussion Assessment and Cognitive Testing was performed in mTBI patients.

The researchers found that compared with female patients with mTBI and control subjects, male patients with mTBI had significantly lowered fractional anisotropy values in the uncinate fasciculus bilaterally (P < 0.05). Male mTBI patients also had a significantly longer TSR (P = 0.04). Sex and uncinate fasciculus fractional anisotropy values were independently correlated with >3-month TSR (adjusted odds ratios [OR], 2.27 and 2.38; P = 0.04 and P < 0.001, respectively), but initial symptom severity was not (adjusted OR, 1.15; P = 0.35).

"Relative sparing of the uncinate fasciculus is seen in female compared with male patients after mTBI, with sex and uncinate fasciculus fractional anisotropy values as stronger predictors of TSR than initial symptom severity," the authors write.

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Pediatricians Have Important Role in Preoperative Process

Pre-op preparation includes making sure patient's condition is optimized, educating families

THURSDAY, Sept. 4, 2014 (HealthDay News) -- Pediatricians have an important part in preparing surgical patients and their families for procedures, according to a policy statement published online Aug. 25 in Pediatrics.

Kenneth R. Goldschneider, M.D., from the American Academy of Pediatrics' Section on Anesthesiology and Pain Medicine, and colleagues discuss the role primary care providers play in the preparation of children and their families before a procedure requiring anesthesia or sedation.

The researchers note that one primary step in preoperative preparation is to determine whether the child is in the best possible health given the underlying medical condition. In addition, the family of the patient should be educated about the process of going into the operating room. Preoperative preparation is multifaceted, with different options available at different institutions. Some hospitals allow parental presence during induction of anesthesia. Preoperative sedation is recommended for some patients, including those at higher risk of being stressed or uncooperative. The authors write that pediatricians should be aware of anesthesia-related hospital policies at operative facilities. Primary health care providers should consider special issues relating to coexisting health problems, including cardiac disease, airway anomalies, former preterm infants, and developmental delay/autism. Furthermore, religious considerations should be taken into account and pediatricians should counsel families to discuss options with the anesthesia team.

"Pediatricians are in a unique position to help prepare children and their families for surgery and help the perioperative team optimize care," the authors write.

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In Case You Missed It: Week of Sept. 12, 2014


"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 theclinical hot topics Presence of Sepsis: 

Here’s how fast viruses spread in your office.  "According to research presented at the American Society for Microbiology's 54th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC)" ... continue to>>

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

Who is the most Productive Hospitalist in the Country? Guess what? It's not You. This article from tells you who is. 

Virus hitting the U.S. could be 'tip of iceberg,' CDC official says. Read more at

Join us at these upcoming events!

emcare eventsJoin us at the AANA 2014 Nurse Anesthesia Annual Congress. September 13, 2014. Details: 

WEBINAR. How Integrated Clinical Services and Technologies are Making Healthcare Work Better. Register now for this webinar presented by Dr. Kirk B. Jensen and Mark Hamm, to discover the benefits of hospital-wide integration. Wednesday, September 17, 2014 | 1:00 PM - 2:00 PM CDT. Register at now!

CAREER. 12 Hospitals. 1 All-Expense Paid Trip. Register Now for EmCare's Hiring Conference! September 25-26. Click here to find out how you can pre-qualify


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Clinical Hot Topics: The Paradoxical Pulse of Sepsis - An Early Clinical Clue to the Presence of Sepsis


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

clinical hot topics

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?

The Study

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.

Tips to Boost Your Documentation Process: Secondary Diagnoses


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

Secondary Diagnoses

A secondary diagnosis is a condition that coexists at the time of admission, developsbrundage documentation 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.

EmCare’s Genesis Cup Honors Innovation, Creativity in Healthcare


This article was originally published in the June 2014 issue of EmCare's EmPressions Magazine.


EmCare Marketing Communications Manager

A dramatic redesign has allowed the busiest emergency department in Florida to drasticallydescribe the image 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.

Malnutrition Ups Risk of Elective Spine Surgery Complications

Pre-op serum albumin level is independent risk factor for complications post-elective surgery

WEDNESDAY, Sept. 3, 2014 (HealthDay News) -- Preoperative hypoalbuminemia, as a marker for malnutrition, is an independent risk factor for postoperative complications after elective spine surgery for degenerative and deformity causes, according to a study published in the Aug. 15 issue of Spine.

Owoicho Adogwa, M.D., M.P.H., from Duke University in Durham, N.C., and colleagues reviewed the medical records of 136 consecutive patients undergoing spine fusion at the institution. Preoperative serum albumin level was measured and utilized to quantify nutritional status (albumin <3.5 g/dL was recognized as hypoalbuminemia or malnourished).

The researchers found that 29.4 percent of patients experienced at least one postoperative complication. Malnourished patients undergoing elective surgery had more complications (35.7 percent, versus 11.7 percent in nourished patients; P = 0.03), whereas similar complication rates were seen for malnourished and nourished patients undergoing nonelective surgery (46.5 and 42.1 percent, respectively; P = 0.75). Preoperative serum albumin level was a significant predictor of postoperative complications for patients undergoing elective spinal surgery (odds ratio, 4.21; P = 0.04; adjusted odds ratio, 4.54; P = 0.04).

"Preoperative hypoalbuminemia is an independent risk factor for postoperative complications after elective spinal surgery for degenerative and deformity causes, and should be used more frequently as a prognostic tool to detect malnutrition and risk of adverse surgical outcomes," the authors write.

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Review: Surgery Doesn't Benefit Age-Related Meniscal Tears

Middle-aged patients with mild or no osteoarthritis may not benefit from arthroscopic knee surgery

TUESDAY, Aug. 26, 2014 (HealthDay News) -- Evidence suggests that arthroscopic surgery does not benefit middle-aged patients with degenerative meniscal tears, according to research published online Aug. 25 in CMAJ, the journal of the Canadian Medical Association.

Moin Khan, M.D., of McMaster University in Hamilton, Canada, and colleagues conducted a systematic review of the literature and performed a meta-analysis using data from seven randomized, controlled trials, involving 805 patients. The authors sought to assess the efficacy of arthroscopic meniscal debridement in patients with mild or no osteoarthritis.

The researchers found that, compared with patients with knee pain undergoing sham operative treatments or nonoperative treatments, those undergoing arthroscopic surgery did not have a significant or minimally important difference (MID) in long-term functional outcomes (standardized mean difference [SMD], 0.07; 95 percent confidence interval [CI], −0.10 to 0.23). Short-term functional outcomes differed significantly between the groups but did not exceed the threshold for MID (SMD, 0.25; 95 percent CI, 0.02 to 0.48). Compared with patients receiving the other treatments, those receiving arthroscopic surgery did not have significant improvement in short-term pain scores (mean difference [MD], 0.20; 95 percent CI, −0.67 to 0.26) or long-term pain scores (MD, −0.06; 95 percent CI, −0.28 to 0.15).

"With limited evidence supporting arthroscopic meniscal debridement for degenerative meniscal tears in the setting of mild or no concomitant osteoarthritis, an initial trial of nonoperative interventions should play a large role for middle-aged patients," the authors write.

One author disclosed financial ties to pharmaceutical and medical device companies.

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Vitamin D Deficiency Worsens Outcomes With B-Cell Lymphoma

Deficiency impairs rituximab-mediated cellular cytotoxicity; substitution improves RMCC

TUESDAY, Aug. 26, 2014 (HealthDay News) -- Vitamin D deficiency (VDD) contributes to worse outcomes in elderly patients with diffuse large B-cell lymphoma (DLBCL) treated with rituximab, according to a study published online Aug. 18 in the Journal of Clinical Oncology.

Jörg Thomas Bittenbring, M.D., from Universitätsklinikum des Saarlandes in Germany, and colleagues examined the impact and mechanisms of VDD in patients with DLBCL. Chemoluminescent immunoassays were used to evaluate 359 pretreatment 25-hydroxyvitamin D3 serum levels from the RICOVER-60 study (Six Versus Eight Cycles of Biweekly CHOP-14 With or Without Rituximab) and 63 from the RICOVER-noRTh study (an amendment to the RICOVER-60 study).

The researchers found that RICOVER-60 patients treated with rituximab with VDD (≤8 ng/mL) had three-year event-free survival (EFS) of 59 percent and three-year overall survival (OS) of 70 percent, while those with vitamin D levels >8 ng/mL treated with rituximab had EFS and OS of 79 and 82 percent, respectively. In multivariate analysis adjusting for International Prognostic Index risk factors, these differences remained significant, with hazard ratios of 2.1 (P = 0.008) for EFS and 1.9 (P = 0.040) for OS. In all seven individuals with VDD, there were significant increases in rituximab-mediated cellular cytotoxicity (RMCC; P < 0.001) after substitution and normalization of their vitamin D levels.

"That VDD impairs RMCC and substitution improves RMCC strongly suggests that vitamin D substitution enhances rituximab efficacy," the authors write.

One author disclosed financial ties to the pharmaceutical industry.

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