In this Issue:
- President's Message
- Sepsis 3.0: How will this affect Emergency Departments and Hospitals?
- Indiana Update
- Iowa Update
- Michigan Update
- Wisconsin Update
- Resident Corner
Michael Walters, MD JD FAAEM
President, GLAAEM Board of Directors
Happy New Year!
Many of you are maybe wondering if I am off my rocker. But for many of us, July 1st marks the beginning of a new year. For some this is a new fiscal year, others a new academic year with new residents. For GLAAEM, July 1st marks the addition of new board members and a focus on our goals for the next year.
This year we welcome several new state representatives. These include Brady McIntosh representing Wisconsin, Thomas Short representing Indiana, and Anthony Hammond as one of our resident representatives. While not new, we welcome Dipul Patadia for a second term representing Illinois. Please see some of their comments elsewhere in the newsletter.
In addition to new board members we have set several goals for this year. First, we would like to increase our membership. Currently our membership is at 912. We want to continue to grow. So if you know a fellow emergency physician that is an AAEM member but not a GLAAEM member, get them to join. Likewise, if a colleague is not an AAEM member, then get them to join both! Second, we plan on having a presence this year at the Midwest Medical Student Symposium on September 17th at Loyola University in Chicago. If you would like to participate, please let us know. This will give us an opportunity to educate medical students about AAEM, GLAAEM, and our missions. Finally, we would like to fill any vacancy on the board most notably the representative position from Minnesota. So if you are from the Land of 10,000 Lakes please consider representing your fellow emergency physicians.
So, happy New Year. As always if you have ideas or comments feel free to contact us at email@example.com. We are here to serve you.
Ronny M. Otero, MD FAAEM
Vice President, GLAAEM Board of Directors
There has been a lot of buzz about sepsis over the last couple of years. A trilogy of multi-center trials from around the world have called into question the benefits of protocolized care for sepsis. These controversial studies randomized patients after receiving IV fluid resuscitation and antibiotics.1, 2, 3
In February 2016, the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) was published.4 This recent publication sets out to propose new criteria for defining sepsis and septic shock using components of a popular score used in intensive care units, the Sequential Organ Failure Assessment (SOFA) score.5 The gist of the new definition is that sepsis does not exist without some level of organ dysfunction. The authors define sepsis as: “life-threatening organ dysfunction caused by a dysregulated host response to infection.”
The controversy is multi-faceted because although it is well documented that Systemic Inflammatory Response Syndrome (SIRS) criteria (Table 1) have several limitations these criteria are used in many settings and are the basis for many case definitions when searching for patients with sepsis. The SOFA score requires several laboratory studies to calculate. The authors of Sepsis 3.0 created a “quick” or “qSOFA” scoring system, an abbreviated method to identify patients who are at risk for developing sepsis. The issue with qSOFA is that it has not been prospectively validated. In addition, the parameters of qSOFA, respiratory rate, altered mental status and hypotension, suggest the patient is much more ill than current screening criteria. Most clinicians who identify these findings would be unlikely to pass over these discoveries as compared to patients with only mild derangements in respiratory rate or heart rate. The actual sensitivity for qSOFA in the “real world” is not known.
Moreover, payors including Medicare and CMS use current scores and definitions to monitor quality and determine level of compensation for individual patients.
The Sepsis CMS Hospital Inpatient Quality Reporting (Hospital IQR) rewards hospitals with a financial incentive for reporting the quality of their services. Hospitals, which do not achieve or report these measures, are penalized. The National Quality Forum (NQF) currently uses SIRS criteria as well as measurement of lactate level. The definition for sepsis that is used is: two SIRS criteria plus suspected infection. Lactate >2 or organ dysfunction defines severe sepsis.
Septic shock is defined as persistent hypotension in the setting of sepsis requiring vasopressors to maintain a MAP >65 mmHg and a serum lactate >2mmol/L despite adequate volume resuscitation. Sepsis 3.0 eliminates the term “severe sepsis” due to the belief that sepsis does not exist without some level of organ dysfunction.
Some of the criticisms of Sepsis 3.0 also stem from the effect application of these criteria will have on research and for “case acquisitions” in quality improvement measures. Lastly, the recently rolled out ICD-10 coding rules have specific codes for sepsis and sepsis with organ dysfunction. It will be challenging for clinicians and coders in the next few months to years to confidently document “sepsis” with such dramatic differences in the definitions between Sepsis 2.0 and Sepsis 3.0. What will also be incredibly challenging is that sepsis in the current iteration of ICD-10 does not consider sepsis a “primary code” rather it is coded only after a suspected organism is coded. For example, coders will code A41.9: “unspecified organism” then code R65.20: for “severe sepsis (sepsis with organ dysfunction) without septic shock” if present, or R65.21: when “septic shock” is identified. So all hospitals will have to wait until October of 2016 to find out if updates will be made to ICD-10 and the Official Guidelines for Coding and Reporting (OCG) and whether their compensation for reporting core measures will be endangered.5
Table 1. Comparison of SIRS and q SOFA
- Investigators, T.P., A Randomized Trial of Protocol-Based Care for Early Septic Shock. New England Journal of Medicine, 2014. 370: p. 1683-1693.
- Group, A.I.a.t.A.C.T., Goal Directed Resuscitation for Patients with Early Septic Shock. New England Journal of Medicine, 2014. 371: p. 1496-1506.
- Mouncey, P., T. Osborn, and G. Power, Trial of Early Goal-Directed Resuscitation for Septic Shock. New England Journal of Medicine, 2015. 372: p. 1301-1311.
- Singer, M., et al., The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA, 2016. 315(8): p. 801-810.
- Vincent, J., R. Moreno, and J. Takala, The SOFA ( Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/ failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med, 1996. 22(7): p. 707-710.
Thomas M. Short, MD FAAEM
Indiana Representative, GLAAEM Board of Directors
I am a practicing emergency physician at Community Hospital Anderson in Anderson, Indiana, part of a six physician democratic group. In addition to clinical practice, I am president of the group of physicians, chief of the department of emergency medicine, president of the medical staff, and was medical director for EMS services in Madison County.
I attended medical school at Indiana University School of Medicine, and completed residency in emergency medicine at Methodist Hospital of Indiana. I have been board certified by the American Board of Emergency Medicine since 2004.
Michael Takacs, MD MS FAAEM
Iowa Representative, GLAAEM Board of Directors
I would like to thank Josh Pruitt, MD FAAEM, for his service as Iowa Representative to GLAAEM for the last two years.
I am currently the residency director at the University of Iowa. I am proud to say that 100% of our residents are AAEM/RSA and GLAAEM Chapter Division members!
I have been working in Iowa for 10 years. It is great to see the number of board certified emergency medicine physicians grow in number. When I first came to Iowa, there was only one group in the state that was 100% board certified and the number of board certified EM physicians in the entire state was probably less than 50. We have certainly grown in the last 10 years with many of our graduates staying in Iowa and many of them continuing to be members of AAEM.
I look forward to promoting AAEM for Iowa physicians and being a part of GLAAEM.
Robert A. Hoogstra, MD FACP FAAEM
Michigan State Representative, GLAAEM Board of Directors
Recently much attention has focused on physician burnout and emergency physicians are at or near the top of the list of subspecialties experiencing burnout. Recently I attended the American College of Physicians (ACP) national meeting in Washington, D.C. where one of the sessions focused on finding joy in the practice of medicine. Some thoughts along those lines can be captured by the acronym ME HALT.
M- Find what brings you Meaning in your practice of Medicine and find an organization to practice in that has a value system that aligns with yours
E- Enjoy life outside your practice through taking time to Exercise regularly, Enjoy nature and/or other activities
H- This stands for Hunger, meaning eat Healthy
A- Identify the things that make you Angry, and Accept those things you have no control over and Attempt to change those that you do have control of (a serenity prayer, of sorts)
L- Don't go through life Lonely, surround yourself with good support systems both at work and outside of work
T- Balance your Time both in terms of work/life balance and finding Time to sleep (at least 7-8 hours a night)
There are many pressures on physicians today that make practicing medicine a challenge. If we focus on the negatives we can surely find them. However, if we choose to look back at the things that motivated us to embark on this journey and choose to focus on them, just maybe we will once again find joy in what is truly the noble calling of being a physician.
Brady McIntosh, MD FAAEM
Wisconsin State Representative, GLAAEM Board of Directors
Hello all, my name is Brady McIntosh. I am an emergency physician practicing at the Medical College of Wisconsin in Milwaukee. I graduated from the Indiana University Emergency Medicine residency in 2010, and after spending three years in the private sector in Oklahoma City, I’ve moved back to the Midwest. It is truly an honor to represent Wisconsin for the Great Lakes Chapter Division of AAEM.
Updates from the state of Wisconsin legislature that may affect emergency medicine:
The “Advancing a Healthier Wisconsin” initiative has committed nearly $20 million to community coalitions to help improve behavioral health care over the next eight years. This may provide some relief to the Milwaukee area as the government considers closing the Psychiatric Crisis Center and privatizing care, leaving those without other means with nowhere else to turn.
Anthony Hammond, MD
Resident Representative, GLAAEM Board of Directors
As an introduction, my name is Anthony Hammond, and I am the resident representative from Ohio. I completed medical school at University of Illinois College of Medicine in 2015. I will complete residency in emergency medicine at University Hospitals Case Medical Center in 2018 with completion of a dual Master in Science Management and Master in Business Administration from Case Western Reserve University in 2019. I am passionate about health care economics, health policy, patient advocacy, and critical care. As such, you can expect to see newsletter articles pertaining to these areas as applied to our field of emergency medicine. Outside of work, I enjoy time spent with family and friends, time spent trying new foods, and time spent in nature – so, do not be surprised if resident wellness, food, or wilderness medicine become short topics of discussion during my time as a representative.
Keeping in tune with a light introduction, we will briefly review the easy-to-digest Choosing Wisely Campaign as applied to emergency medicine. This campaign was a multi-disciplinary collaboration by our colleagues throughout medicine to promote conversation between patients and clinicians in a way that helps choose care that is: evidence-based, non-duplicative of already performed tests and procedures, free from harm, and truly necessary. By fostering and maintaining conversations with patients, we as clinicians empower patients to become active participants in their care and co-stewards of our health care system’s limited medical resources. As applied to the emergency department, our colleagues at ACEP were able to identify the top 10 things to avoid in order to reduce overall cost while improving cost effectiveness and increasing patient benefits during relatively short emergency department visits with patients. New interns, this is a great list to review. If you can remember three things: be mindful of your imaging, be stewards of your antibiotics, and avoid the Foley.
- Avoid ordering a head CT in patients with minor head injuries and low risk as based on validated clinical decision rules. Unnecessary CT scans increase lifetime risk for cancer and can cost over $2,000.
- Avoid Foley catheters in stable patients who can void or in those whom can successfully manage with condom catheters. Indwelling catheters have increased risk of UTI after just three days of use. Treatment can approach nearly $1,000. Only use if the patient cannot urinate after several attempts or is critically ill and requires hourly monitoring of urine output.
- Avoid delaying palliative care and hospice services from the emergency department. Early referral to these services can increase patient satisfaction as well as improve the quality and quantity of life in certain patient populations.
- Avoid antibiotics and wound cultures in uncomplicated, simple skin and soft tissue abscesses after successful I&D with adequate follow-up. We must be antibiotic stewards. Unnecessary antibiotics breed resistance to an already small list of effective antibiotics and can expose patients to unnecessary side effects. Cultures rarely change management and cost nearly $100.
- Avoid IV fluids in pediatric patients without a trial of PO rehydration in uncomplicated, mild-to-moderate dehydration. Consider anti-emetics early if there is associated nausea or emesis. This can prevent the physically and emotionally traumatic experience of establishing IV access for both pediatric patients and their parents.
- Avoid ordering a head CT in asymptomatic, non-elderly adult patients with syncope, insignificant trauma, reassuring history of present illness, and a normal neurological exam.
- Avoid CT PE studies in patients with low pretest probability and are either negative PERC or with a negative VTE D-dimer. Not only is there the expense and radiation burden of traditional CT imaging, there is additional consideration of possible contrast-induced nephropathy.
- Avoid lumbar spine imaging for adults with non-traumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a severe underlying condition. Remember some of the basic red flags for pursuing further evaluation of back pain: fever, weight loss, history of malignancy, known trauma, IVDA, immunosuppression, bony tenderness, fever, and weight loss. Routine imaging in absence of red flags only adds cost.
- Avoid prescribing antibiotics for uncomplicated sinusitis. Nearly 98% (almost all) acute sinusitis cases are viral and resolve in 10-14 days without treatment. Again, we must be vigilant in our antibiotic stewardship. Consider addressing the symptoms of uncomplicated sinusitis instead.
- Avoid abdominal and pelvis CT scans in otherwise healthy patients under 50-years-old, have a history of nephrolithiasis or ureterolithiasis presenting with symptoms consistent with uncomplicated renal colic. Rarely do additional CT studies change management.
Larisa Coldebella, MD
Resident Representative, GLAAEM Board of Directors
Hi all, my name is Larisa Coldebella. I am in my final year of training as an emergency medicine resident at the Medical College of Wisconsin in Milwaukee. I graduated from the University of Illinois College of Medicine in 2014. This year I have had the pleasure of serving as Resident Education Chief for our program, a role that has allowed me to become more involved in curriculum development. One of my goals has been to reach beyond core content to include other important topics, such as health policy, advocacy and wellness. I look forward to representing emergency medicine residents in this new position.
Opinions expressed are those of the authors and do not necessarily represent the official views of AAEM, its chapter divisions or affiliates. These articles are intended for the individual use of AAEM members.