The Pulse - January 2016 by ACOEP

JANUARY 2016

Presidential Viewpoints | John C. Prestosh, DO, FACOEP

A Resolute Start Toward the Future Pulse-01-2016-R7.indd 1

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The Pulse VOLUME XXXVII No. 1 Editorial Staff Timothy Cheslock, DO, FACOEP, Editor Wayne Jones, DO, FACOEP-D, Assistant Editor Tanner Granowski, DO, Associate Editor Drew A. Koch, DO, MBA, FACOEP-D, Board Liaison John C. Prestosh, DO, FACOEP Christine F. Giesa, DO, FACOEP-D Erin Sernoffsky, Editor Janice Wachtler, Executive Director Thomas Baxter, Graphic Design Manager Editorial Committee Timothy Cheslock, DO, FACOEP, Chair Wayne Jones, DO, FACOEP-D, Vice Chair Drew A. Koch, DO, MBA, FACOEP-D, Board Liaison John C. Prestosh, DO, FACOEP Robert E. Suter, DO, FACOEP-D, Foundation Member Stephen Vetrano, DO, FACOEP John Ashurst, DO Timothy Bikman John Downing, DO Tanner Gronoski, DO Peter A. Bell, DO, FACOEP-D Joe Clark, DO Anthony Jennings, DO, FACOEP Lionel Lee, DO, FACOEP William McCannon, DO Erin Sernoffsky, Editor Thomas Baxter, Graphic Design Manager The Pulse is a copyrighted quarterly publication distributed at no cost by the ACOEP to its Members, Colleges of Osteopathic Medicine, sponsors, exhibitors and liaison associations recognized by the national offices of the ACOEP. The Pulse and ACOEP accept no responsibility for the statements made by authors, contributors and/ or advertisers in this publication; nor do they accept responsibility for consequences or response to an advertisement. All articles and artwork remain the property of The Pulse and will not be returned. Display and print advertisements are accepted by the publication through ACOEP, 142 East Ontario Street, Chicago, IL 60611, (312) 587-3709 or electronically at marketing@acoep.org. Please contact ACOEP for the specific rates, due dates, and print specifications. Deadlines for the submission of articles are as follows: January issue due date is November 15; April issue due date is February 15; July issue due date is May 15; October issue due date is August 15. Advertisements due dates can be found by downloading ACOEP's media kit at www.acoep. org/advertising. The ACOEP and the Editorial Board of The Pulse reserve the right to decline advertising and articles for any issue.

TABLE OF CONTENTS Presidential Viewpoints..............................................................................................................................3 John C. Prestosh, DO, FACOEP The Editor's Desk............................................................................................................................................4 Timothy Cheslock, DO, FACOEP Executive Director's Desk........................................................................................................................5 Janice Wachtler, BAE, CBA The On-Deck Circle......................................................................................................................................6 Christine Giesa, DO, FACOEP-D Council for Women in Emergency Medicine.............................................................................8 Stephanie Davis, DO and Trecé Dotson, DO A Look Back at ACOEP’s Scientific Assembly.......................................................................9 Erin Sernoffsky What Would You Do?..................................................................................................................................11 Bernard Heilicser, DO, MS, FACEP, FACOEP-D DO Day on the Hill........................................................................................................................................12 William DiCindio, DO, FACOEP An Update on the Literature: Winter 2015.................................................................................15 John Ashurst DO, MSc Medicare Access CHIP Reauthorization Act.......................................................................... 17 William DiCindio, DO, FACOEP Calling All New Physicians in Practice!.......................................................................................20 Nicole Ottens, DO ACOEP’s RISE Exam is Changing!...................................................................................................21 Erin Sernoffsky ACOEP-RC President’s Report........................................................................................................ 22 John Downing, DO Foundation Focus........................................................................................................................................23 Sherry D. Turner, DO, MPH, FACOEP

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A Resolute Start Toward the Future

The best way to predict your future is to create it. — Abraham Lincoln Presidential Viewpoints John C. Prestosh, DO, FACOEP

am honored to serve the American College of Osteopathic Emergency Physicians as its 20th President. I follow in the footsteps of many great leaders and mentors of our college. They have worked diligently and established a solid foundation for our college. It is my earnest intent to build upon that framework and have the ACOEP continue to be a strong and relevant voice in the future of emergency medicine healthcare. I want to thank everyone who attended our annual Scientific Assembly recently held at the Loew’s Portofino Bay Hotel in Orlando, Florida. We recorded our largest attendance ever with more than 1,200 attendees. We also established a new record for resident and student attendance. Comments regarding the conference were overwhelmingly positive, and this is a reflection of the dedicated time and talents that the ACOEP staff and Continuing Medical Education committee directed towards this event. A great big “Thank You” goes to those individuals responsible for creating this most successful educational presentation. I would also like to comment on the exciting and fun-filled social event which was held at Jimmy Buffett’s Margaritaville, located at City Walk next to Universal

Studios. ACOEP had the entire restaurant exclusively to ourselves for two hours and nearly 900 people thoroughly enjoyed the music, beverages, food, and fellowship of members, families, and friends. While walking through the conference each day, I heard comments from attendees regarding the expertise of the lecturers. The information presented during the lectures was timely and pertinent to daily clinical practice. I did receive one negative comment from a long-time friend (also a former resident of mine). He stated it was difficult for him to decide at times as to what presentation to attend. Actually, I interpreted his comment as a positive remark because his quandary occurred due to the valued educational information being offered simultaneously at different

presentations. Comments on the hotel and its amenities ranged from very good to excellent, and many attendees reported they felt as though were visiting a quaint Italian village. I am looking forward to our Spring Seminar which will be held at the Westin Kierland Resort in Scottsdale, Arizona. The program schedule is nearing completion, and the list of topics and speakers is outstanding. I can assure you that you will not be disappointed if you are able to attend. It is obvious that the status of emergency medicine, and healthcare in general, has many important issues looming before us. Most of you are aware of the Single Accreditation System and the effect it Continued on Page 7

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Doctors that DO! How are we sharing the message?

As we continue to move our osteopathic residencies toward single accreditation, we are pushed every day to identify what it is that makes us unique. The Editor's Desk Timothy Cheslock, DO, FACOEP

hope that all who attended the Scientific Assembly in Orlando found it exceeded your expectations! It was an outstanding event that has surpassed any meeting we have hosted in the past.

Those of you that attended got a sneak peek at the AOA’s new branding campaign- Doctors that DO. The video presentations made during the general membership meeting will be circulating on national media over the next several months. It is sure to generate much needed attention to the plight of recognizing what Osteopathic Physicians are and what we do that makes us unique. If you have not seen the marketing campaign, you can view it online at www.doctorsthatdo.org. As we continue to move our osteopathic residencies toward single accreditation, we are pushed every day to identify what it is that makes us unique. I was exploring some YouTube videos on the differences between, MD and DO training the other day while putting this piece together and found a clip by an osteopathic medical student discussing the difference between his experience and that of his brother who is a year ahead of him in an MD institution. His take away was that one class separates the two. To him, the osteopathic

A CHART DOESN’T EMPATHIZE.

I DO.

Before reading a chart or lab report, a DO sees a human being. Doctors of Osteopathic Medicine practice their distinct philosophy in every medical specialty. A DO first considers the person within the patient.

MACHINES DO NOT LISTEN.

I DO.

Before you talk to a doctor, choose one trained to listen. Doctors of Osteopathic Medicine practice their distinct philosophy in every medical specialty. A DO is trained to first consider the person within the patient.

Learn more at DoctorsThatDO.org Learn more at DoctorsThatDO.org

manipulation class was the sole difference in his training. While that seems to be the obvious, it is by far not accurate. The philosophy of osteopathic medicine should be woven throughout medical school, graduate medical education, and practice of all osteopathic physicians. If our students don’t understand that, where are we headed as a profession? Are we really doing a good job in explaining what osteopathic medicine is to those who will follow in our footsteps? To be fair, not all of the online clips

were as limited in scope. Some discussed the broader osteopathic philosophy, but directed the discussion to primary care. The big take away I think from watching many of these clips is that the inclusion of osteopathic philosophy in our practice is not always something you can put into a metric or physical event. It is the overall attitude of the practitioner, the willingness to listen, ask the probing questions and explore beyond the obvious. It is the touch of comfort and the touch of healing. Sometimes just words Continued on Page 22

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Physician Suicide

Executive Director's Desk Janice Wachtler, BAE, CBA

don’t think I will ever forget the telephone call I received in August 2004. It was from a homicide detective on the San Francisco Police Department; he called to tell me that they were following up on my request for a well-being check. He cleared his throat several times and asked me if I was with other people. I said yes, I was at work, why? He cleared his throat again and said he had ‘bad news’ he went on to tell me that a man I dated for five years was dead.

detective said, but he didn’t know when they would release it. I got it on Christmas Eve; I opened it in 2010.

reading this article think this treatment is a right of passage, but in reality, should it be?

The letter was no great love letter, it was an apology for not living up to my expectations or those of anyone else. He felt that despite the accolades he’d received as an educator, writer, teacher, lecturer, researcher, were nothing – he felt he had failed in life and could no longer stand the failures he faced daily. He was a failure in his own mind.

Somehow, deep in my mind I knew that was why I had called, he had been sliding away into the depths of despair for almost two years. We had stopped dating in 2001, the toll of long-distance romance and other things had made us grow apart, but we still were close friends. We told each other things and shared confidences, and we wrote (yes, like letters) to each other weekly. It was easier sometimes to say things in writing than to verbalize them and it was hard to work around his schedule in the ED.

Andy isn’t the only physician who ever burned out, or thought himself a failure as a physician or person, but it appears that physicians, as a whole, have a higher rate of depression and suicide than other segments of the population. In a recent article in Time magazine (September 7-14, 2015) the author followed a class of interns throughout their day and reported these beginning physicians often experienced bouts of depression based on the lack of sleep, an inadequate work/life balance, long work hours and even disrespectful and often cruel treatment by program directors and senior residents. Because of this, a number of interns suffered from depression. Oh, I’m sure many

I am not a researcher, but I’ve been around doctors for a very long time. In my opinion, certain people become doctors; they are generally highachievers, with a specific altruistic bent, to help people. Doctors were long revered for their ability to teach or take care of people, but as societal changes have been made, the doctor has left that highly esteemed, Marcus Welby-type status. The American public has seen doctors on TV dramas and facing the same types of pressure the general public has always faced, but now with everything being on media, the physician is relegated to a regular guy status. Sure, he or she has additional training and knows more than the average Joe, but in the end they live life trying to make ends meet, paying off mortgages, marrying and divorcing, just like everyone else. Fifty years ago, a doctor’s life was private and he or she lived life in a more stratified society.

The detective said he was dead for about a week and they would contact his parents. He left me a letter, the

So, ok, we know physicians are Continued on Page 11

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Changes

The On-Deck Circle Christine Giesa, DO, FACOEP-D, President-Elect

all in Pennsylvania is a beautiful time of the year. The leaves on the maple trees are red and orange. The ground is covered with fallen leaves and their distinctive smell on crisp evening walks brings back childhood memories of jumping in huge piles of them. The colors of fall are magnificent, but they soon surrender to the bleakness of winter. And just when you think winter will never end, the earth comes alive with the blossoms of spring and the warmth of long summer days. Change is not always easy, but, like the seasons, change can bring about something beautiful. As emergency physicians, our day is always changing. We have slow periods that ramp up and become very busy and at times overwhelming. We take care of patients with splinters and sprained ankles just as gracefully as we care for patients in cardiogenic shock. We never know what will come walking through our doors. We handle this flux with the coolness and grace that few other professions can muster. As with the changing seasons, professional change can be very exciting. It can challenge us to spread our wings

Our training programs will now be accredited by the ACGME, and many of our osteopathic training programs will not maintain osteopathic emphasis once they receive ACGME accreditation.

and grow. As the new President-elect of ACOEP, I am embracing this exciting new chapter in my life. I consider it a privilege and an honor to be your President-elect. I accept this tremendous responsibility, and I will do my best to ensure the future of our college.

grace that we display in our daily practice. We cannot see what challenges lie ahead, but we will conquer these obstacles as we shape our future. ACOEP has the best team to ensure that it will remain strong - an awesome administrative staff and emergency physicians!

The world for osteopathic physicians, is also about to change. Our training programs will now be accredited by the ACGME, and many of our osteopathic training programs will not maintain osteopathic emphasis once they receive ACGME accreditation. For those of us who “grew up” in osteopathic training programs and perhaps have spent the greater part of our careers training residents, this can be unsettling. We do not know the full impact that the Single Accreditation Pathway will have on our world, but it will not affect the way we practice emergency medicine. We will still be DO’s that practice emergency medicine. It is in our nature to face the unknown and to remain standing when the dust settles around us. As we step into the future, it is important that we face the changes that confront us with the same coolness and

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"Resolute" continued from page 3 appears to be having on Osteopathic training programs, government funding of residency training, and insurance companies regulating emergency medicine payment systems. There are many more concerns to scrutinize, and I am sure every emergency medicine physician could compile a lengthy list. These matters are typically “handeddown” to physicians, and we are expected to immediately comply without a thought of resistance. All of these factors have a myriad of questions that need to be answered. The easy answer in most instances, is for physicians to quietly grumble, say nothing can be done, and accept what has been dictated to them. I wholeheartedly disagree with this easy answer. Now is the time to stop passive acceptance of following forwarded dictums from those not actively practicing medicine. Now is the time to be proactive for ourselves and our patients. Now is the

time for physicians to actively challenge what is being proposed as the “only way” to do things. Now is the time for us to speak out if we desire to remain relevant and have control of how we, as physicians, practice the art of medicine in the future. I have challenged our Board of Directors to take the TEAM approach to make a positive difference regarding the performance of ACOEP advocacy not only within the college but to everyone we meet. I realize the TEAM concept is not new; however, my interpretation is somewhat different: Tell everyone who we are, what we do, and why we do what we do. Evaluate the responses you receive, both positive and negative (you will receive both). Assimilate the constructive criticisms into your message.

Mentor college members, patients, and families, regarding ACOEP and its mission. I am here to serve the membership of the American College of Osteopathic Emergency Physicians, and all the patients, both present and future, we treat. I will endeavor to devote 100% to ensure I am placing the interests of our college above any personal feelings or actions. I know our Board of Directors share the same vision, and we will work on behalf of the college and speak with a unified voice. I am aware the future holds many obstacles, and I assure our members that the board will confront them directly. I will keep the membership updated as to what decisions are being made on behalf of the college. I ask every member of the American College of Osteopathic Emergency Physicians to have an active and tireless voice in promoting the mission of our college. Please join me, and let us proceed together toward this unknown and challenging future.

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Council for Women in Emergency Medicine Stephanie Davis, DO and Trecé Dotson, DO

e, as female physicians, have been the unknowns of Emergency Medicine from the inception of our specialty. Always present, evercapable, but often not quite visible to the naked eye as we “look like” nurses or techs, and yes even unit secretaries (yes, I do answer phones and page physicians, it’s called “multitasking”). However, as with most entities, we have found a need for solidarity in supporting and uplifting each other as women in this dynamic field. We have unique talents and experiences to share with new physicians, to assist in shaping them to be leaders one day. Fortunately, ACOEP has formed the Council of Women in Emergency Medicine, under the guidance of Christine Giesa, DO, FACOEPD. The Council will provide opportunities for mentorship and advocacy. Its inaugural meeting occurred at the Scientific Assembly in October 2015 and was quite a success. Female emergency medicine physicians came together to share different views on varying subjects, all while building up to our goals to support one another. As female physicians we face unique challenges. “We are clinicians. We are educators. We are researchers. We are department chairs and program directors,” said Christine Giesa DO, FACOEP-D. But we are also wives and mothers. We face unique challenges, yet provide distinct approaches and viewpoints to balancing our lives and our medical practice. We are multifaceted individuals who exude compassion and are driven, all while being effective caregivers.

e are clinicians. We are educators. We are W researchers. We are department chairmen and program directors. — Christine Giesa, DO Our goals are to: • E ncourage the professional advancement and leadership skills of women in Emergency Medicine • Create mentoring opportunities and provide mutual support as positive role models for medical students and residents • Nurture opportunities to meet, and develop a network of strategic alliances and friendships • Develop and present educational programs that are be pertinent to female practitioners • Cultivate a roster of public relations and legislative experts of female emergency medicine practitioners • Provide a pathway for professional leadership development within the organization.

Mission Statement: “Inspiring. Mentoring. Leading. Shaping the future of women in emergency medicine” We are developing a social media presence and platform for communication through a Facebook page helping our members connect, and share newsworthy stories and experiences with one another and the broader emergency medicine community. We encourage all members to follow us on Facebook. We also encourage members to send in share-worthy pieces to the page. Plans for our second gathering during the Spring Seminar are underway. We welcome any female practitioners who would like to attend, and we look forward to the camaraderie and growth of the council and each of our members.

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A Look Back at ACOEP’s Scientific Assembly Erin Sernoffsky

hank you to the 1,200+ physicians, students, residents, nurses, and physician assistants who joined us for the record-breaking 2015 Scientific Assembly!

he breakout sessions were T awesome!

You are the energy that keeps ACOEP growing and moving forward. Your participation made this incredible event possible, including: • T he Inaugural Meeting of ACOEP’s Council for Women in Emergency Medicine • A Presidential Panel featuring Mark Mitchell, Chuck Prestosh and John Becher • Keynote speech by author, activist, and endurance athlete Brian Boyle • The first-ever breakout lecture series • A Welcome Reception at Jimmy Buffett’s Margaritaville • The new EMS Program Directors Track • A blood drive benefitting local hospitals • The 5th Annual FOEM Legacy Gala • Nationally renowned faculty • More opportunities for CME than ever before

I enjoyed the courses but also enjoyed bumping into old colleagues.

I was able to see many nationally recognized speakers and learn from the best.

Thank you to the CME Committee and everyone who planned and participated in this wonderful event. We look forward to seeing you in Arizona for ACOEP’s Spring Seminar!

I thought that this was the best Scientific Assembly that I’ve ever attended.

his conference - from the T lectures to the hotel - exceeded expectations. Well done!

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What Would You Do? Ethics in Emergency Medicine

Bernard Heilicser, DO, MS, FACEP, FACOEP-D The following scenario was presented by a municipality EMS coordinator. A municipal ALS ambulance responded as a standby for SWAT Team activity. One of the SWAT team members was also a police paramedic from a neighboring community and informed the EMS crew that if someone was shot he would be performing care in their ambulance. He indicated that it was “his show.” How should the ambulance crew respond? Does the ambulance crew in their own town have jurisdiction? Or, can a police paramedic countermand that authority? If so, who has the liability, especially considering the equipment and transport is with the crew’s ambulance? How would you mediate this dilemma? Please send your thoughts and ideas to WhatWouldYouDo@acoep.org Every attempt will be made to publish them when we review this dilemma in the next issue of The Pulse. If you have any cases that you would like to present or be reviewed in The Pulse, please email them to us at WhatWouldYouDo@acoep.org Thank you.

"Suicide” continued from page 5 normal people, they get up shower and brush their teeth before they go to work, just like everyone else – but then why do physicians have a higher suicide rate than others? Is it because they have more access to drugs? Or because they know how to end life? Or is it because there is a stigma in the medical fields that says if Dr. X is being treated for depression, then he or she is less of a physician? I think it’s the latter. Look, it’s not easy saying you’re in therapy – I know – when I was diagnosed with cancer in 2013, I was mad, and I don’t mean just PO’d – I was face-eating MAD. So much so that I made my oncologist cry, when she failed to answer my questions – her nurse wouldn’t speak with me on the phone and the cancer nurse practitioner threw up her hands in despair. Finally, the surgeon who was my PCP sat me down and said, ‘knock it off these people didn’t make you sick, it’s not their fault.’ Ripping off a prescription he said ‘get your ass in therapy, before you kill someone,’ and shoved the paper at me with a therapist’s name on it. I went and felt foolish for a few sessions, but found that I wasn’t mad at the physicians, I was angry about being sick. I also found that I carried around an enormous amount of guilt about Andy, that I had let him down and he died alone. But Andy made that decision, he had the means and ability to reach out and he didn’t because, as his letter said, he felt he let people down.

it make anything better? Will it leave your family in a better place, financially, spiritually? How will your parents, children, friends react – will they love you more? Will they be angry that you left them? How will they fill the gap that you will leave in their lives? What you will find is that you have no answer for these questions. What you need to do then is to talk to someone not necessarily a friend or contemporary, talk to a priest or a therapist or a guy sitting at the bus stop. You’ll find you have a place in the world. No one will doubt your ability to do your job, or question why you’re in therapy. They will say – there goes so-and-so, he’s really changed lately – good for him. Good for you.

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e e l y s M s s s o o t k o f s b w a a i w p

Approved for AMA PRA Category 1 Credit TM.

So, I ask you to think about this... everyone works tired, everyone gets chewed out by their boss, what makes you different? What makes you think that by taking your own life, it will make the situation better? The one thing you must do if you get to the point of chucking it all, is to think... think about people, beside yourself. Will your death change anything? Will

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H H m m a l h l a m s a

DO Day on the Hill William DiCindio, DO, FACOEP

Who, if not for us, will advocate our position in a meaningful way?

re you the least likely person to stand up and share your thoughts with a crowd of folks even if they share your career path and educational background, maybe in shared experiences, and similar training? If youâ&#x20AC;&#x2122;re like me then you do not sit alone tilting your view to see, with both eyes, who has such conviction in the subject to speak. Many bond in silence with a feeling of solidarity, standing amongst those who speak. It is easier that way. Our hearts swell with pride when colleagues speak our thoughts and leave us safely with our lips closed. We feel compelled at times to clap or raise our arms in triumph knowing that we thought the same thing; or maybe we equally internally rejoice for the fact that we were relieved of a slight personal moment, leaning towards breaking the silence we hold comfortably within folded limbs. Now you know a little about me in the realm of speaking out in an organized gathering. I feel speaking in public forums takes courage along with organized thoughts and above all, a passion for the subject. The day I signed up for DO Day on the Hill I was a bit nervous to say the least. Heck, before I had booked my trip I had many concerns about what I was getting myself into. I had no idea what an office of a senator or house representative might look like, or for that matter what building held the offices of our congressional leaders. The questions began to take off and my imagination began to spurn off more challenging situations. What level of security might I encounter? How will I get around DC? What should I wear? What

if it snows or rains? When will I eat if the day is long? Who will be with me? WILL I BE ALONE?

be part of something so important for our college. In the few weeks before DO Day, I looked up Senator Mendez and Congressman Lobiondo and their staff and the bills they were working on, in case I had a chance to mention some common goals. I read their web pages, found the committees they served on and

I had never placed myself out front like this before. Being aptly silent about my political views except amongst those closest to me was so comfortable. And I had no experience with political discussions, none-theless going to Washington DC and speaking with an actual person in congress. I had visions of me being vetted on my political views before I I was getting excited to actually be part of was able to get something so important for our college. into the office. I began to feel like I was going I searched to see if they were on board to be the one without the knowledge. with the bills supported by the AOA. Were The one asking for something to help me they sponsors or had they co-sponsored better my situation. The one seeking help any of them? I felt confident that I had with my problem. I was going to be the some background knowledge of the political patient searching for answers two and the goals set out by the AOA from my assigned provider who I had advocacy teams. I was ready to face the never met and who likely has no records challenge. on me to refer to (hopefully). This is not so comfortable. What did I get myself into? The day came and I sort of felt prepared for my first time going to the I had signed up. I was determined to DO Hill as they say. The Omni Hotel was so it. I booked my room. I booked my seat busy with many white coats, but it was on the train. I received emails weeks in a small fraction compared to the huge advance of the date keeping me prepared numbers of student doctors from all over for the day of advocacy for Osteopathic the country waiting to be briefed on the Medicine; I was getting excited to actually

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final instructions for the day. The amount of preparation that goes into setting up so many meetings for all states is amazing. Schools of Osteopathic medicine from every state had their signs up sorting the chaos of student physicians that filled the huge ball room. Upon arrival we were given our schedule for the day, a metro ticket for the whole day and lunch tickets to dine in the office buildings of congress. There was a large center stage and did I mention there were thousands of people all wearing white coats? It was inspiring to see. What had me fearful before was now getting me pumped up. Then we were asked to sit and listen. The president of the AOA spoke and then we heard an inspirational talk from a congressman; advocacy staff gave some instructions on conducting our meetings; we were given a few more rousing remarks by a congresswoman and a review of the briefing packet we were each given to assist us with our meetings and then we began our journey to DO Day the Hill. I was teamed first with one other physician and a handful of students. We gathered at the Rayburn building to meet first with Congressman Lobiondo (NJ-R). After a brief wait in the entry way we were escorted into the office and began our meeting. It was very cordial. We had 30 minutes with him and the time flew by. His healthcare advocate joined us and spoke at times for the representative. It was a successful meeting, in that, he heard our concerns especially for the SGR changes. He was able to speak to our concerns adding he

was in support of our issue but having no answers on how to budget this and this was the elephant in the room. After lunch in Rayburn we walked across the capital grounds and had our meeting with Senator Mendez (NJ-D) in the Hart building. This was a larger group with 22 students and 9 physicians. We

train ride home I reflected on this truly worthwhile day! I had always lingered amongst feelings of laxity toward the world of advocacy. I tend to think that someone else was better fit for it than me. I can say from experience now, that there are not that many doing it for me. Advocacy in youthful students so great to see as maybe there is hope with this experience they will carry this torch their whole career. I worry though, that so few physicians schedule time to join in. There is a strength in numbers and there can never be too many when it comes to advocacy. Many physicians choose to avoid any advocacy all together not writing to congresspersons, avoiding contributions of any time or money towards any political agendas even if it were to fix their problems. I guess the expectation is that those that do that sort of thing will take care of me and my needs. This lack of involvement is often why we wait for 15 years of threatened cuts from the SGR. If we mass in numbers much greater than in the past, or give more of our time or money to advocate for our profession we can witness our impact sooner. Advocacy begets change for the better.

all sat in a large conference room and met for 35 minutes. The liaison informed us of the senators positions as he was unable to be there. Many students voiced their concerns for loans and debt and on items we discussed; and again we were able to bring our perspective as the voice of unified Osteopathic physicians and advocate for our profession. On the

What can be better than contributing to that impact? Who is better than you to say how those changes should be shaped? Have a voice and write a letter, send a check, spend some time learning the impacts of legislation and schedule some time to DO it! Even better, DO it on DO Day on the Hill and feel the reward first hand.

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An Update on the Literature: Winter 2015 John Ashurst DO, MSc

physician would have to review 19 articles a day, 365 days a year in order to stay relevant in their current field of practice.1 With our busy schedules, staying current in the most up to date advances in emergency medicine can be a daunting task. Below you will find reviews on four articles that you may have missed over the last quarter that are noteworthy in our field. Continuous versus interrupted CPR for out of hospital cardiac arrest Reference: Nichol G, Leroux B, Wang et al. Trial of continuous or interrupted chest compressions during CPR. NEJM. 2015 Epub ahead of print What We Know: Approximately 10% of patients treated for out of hospital cardiac arrest will survive to hospital discharge. Adequate coronary perfusion pressure (CPP) is needed to achieve return of spontaneous circulation (ROSC). When chest compression is interrupted, both CPP and the chance of ROSC drastically diminish. Article Review: In this prospective, crossover, cluster-randomized trial, 114 EMS agencies randomized non traumatic out of hospital cardiac arrest patients into either a continuous CPR group or a interrupted CPR group. In the continuous chest compression group, participants received 200 compressions and 10 breaths per minute uninterrupted while the interrupted group received the current AHA recommendations for CPR. The primary end point of the study was survival to hospital discharge with a secondary endpoint being favorable neurologic outcome as measured by the

modified Rankin score. A total of 23,711 patients were enrolled in the study, with 9.0% of those in the continuous CPR group and 9.7% of those in the interrupted CPR group surviving to discharge (95% CI -1.5 to 0.1; p=0.07). When neurologic function was assessed, 7.0% of those in the continuous CPR group versus 7.7% of those in the interrupted CPR group had return of favorable neurologic outcomes (95% CI -0.3 to -0.1; p=0.009). Based upon this study the authors concluded that in patients with out of hospital cardiac arrest in which EMS providers were providing continuous chest compressions and positive pressure ventilation there was no difference in the neurologic outcomes or survivability to discharge as compared to those who received interrupted chest compressions during CPR.

and the combination of muscle relaxants with NSAIDs is beneficial for the treatment of low back pain.2 The Cochrane review does not comment on opioid usage in acute low back pain but notes that there is short-term efficacy of the usage of opioids to treat chronic low back pain.3

Reference: Friedman B, Dym A, Davitt M et al. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain. JAMA. 2015; 314(15): 1572 – 1580.

Article Review: This was a double blinded, prospective study conducted in the emergency department in which patients were randomized into one of three groups. All groups were instructed to take 500mg of naproxen twice a day for ten days. The participants were there randomized to take 1- 2 tabs every eight hours of either a placebo, cyclobenzaprine 5mg or oxycodone 5mg/acetaminophen 325mg. The primary outcome of the study was to determine functional outcomes and pain at 1 week and 3 months through the usage of the Roland-Morris Disability Questionnaire (RMQD). A total of 323 patients were enrolled in the study with a median RMQD of the placebo group being 20, cyclobenzaprine 19 and the oxycodone/acetaminophen group 20. At the one week follow up, the mean difference between RMQD was as follows: placebo vs cyclobenzaprine 0.3 (98.3% CI, –2.6 to 3.2; P = .77), for oxycodone/ acetaminophen vs placebo 1.3 (98.3% CI, –1.5 to 4.1; P = .28), and for oxycodone/ acetaminophen vs cyclobenzaprine 0.9 (98.3% CI, –2.1 to 3.9; P = .45). The authors concluded that for non-traumatic, non-radicular low back pain the usage of cyclobenzaprine or oxycodone/ acetaminophen is not warranted.

What We Know:: Acute low back pain is one of the most common complaints seen by physicians in the United States. The Cochrane review noted that both singular therapy with muscle relaxants

Commentary: With the growing epidemic of prescription drug abuse in the United States, this study suggest that for the treatment of acute non-traumatic, non-radicular low back pain all that is

Commentary: This study highlights that both continuous and interrupted chest compressions are equally effective in the management of out of hospital cardiac arrest. Despite your mode of chest compressions, the more important message is that high quality chest compressions are the key to survival in cardiac arrest. Emergency department treatment options for acute low back pain

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needed are NSAIDs. Given the breadth of studies in the Cochrane review, further research needs to be conducted on the usage of muscle relaxers before definitive recommendations can be made on this treatment modality. However, this research adds to the growing literature that shows that opioids appear to have no benefit for the treatment of acute low back pain.

stable ventricular tachycardia. Commentary: This modified Valsalva shows promise as a new first line therapy for supraventricular tachycardia. Given the low relative risk of the procedure in those with stable supraventricular tachycardia the modified Valsalva technique can be employed as another technique to break the arrythmia.

REVERT to new treatments for supraventricular tachycardia

Hold the diphenhydramine for migraines?

Reference: Appleboam A, Reuben A, Mann C et al. Postural modification to the standard Valsalva manoeuver for emergency treatment of supraventricular tachycardias (REVERT): A randomized controlled trial. Lancet. 2015; 386(10005): 1747 – 1753.

Reference: Friedman B, Babral L, Adewunmi V et al. Diphenhydramine as adjuvant therapy for acute migraine: An emergency department based randomized clinical trial. Ann Emerg Med. 2015. Aug 27 Epub ahead

What We Know: Although the Valsalva maneuver is recommended as a first line therapy for stable supraventricular tachycardia, it breaks the arrhythmia only 5-20% of the time.

What We Know: Antihistamines have long been used in conjunction with antidopaminergics to treat migraines in the emergency department (ED). However, little evidence exists in regards to this practice.

Article Review: The study was a prospective, parallel group, randomized control trial. Patients were randomized into two groups: the usual standard semirecumbent Valsalva maneuver used by many clinicians and a modified Valsalva maneuver in which the patient was placed semi-recumbent with supine repositioning and passive leg raise immediately after the Valsalva strain (for video see article website). A total of 433 patients were enrolled with 17% of the standard Valsalva participants and 43% of the modified Valsalva technique (95% CI 2.3 – 5.8; p<0.0001) achieved normal sinus rhythm one minute post intervention. The authors concluded that the modified Valsalva should be considered first line therapy for

Article Review: The study was a double blind, randomized trial in which patients were separated into either receiving diphenhydramine 50mg and metoclopramide 10mg intravenously or placebo and metoclopramide 10mg intravenously after meeting inclusion criteria. The primary endpoint of the study was headache relief at two hours post medication infusion and relief over the next 48 hours without the need for any additional headache medications. Other outcomes included ED length of stay (LOS), mean improvement of pain between baseline and one hour and if the patient would want the same medications next time they presented to the ED for a migraine. A total of 208 patients were

enrolled in the study and at 48 hours 40% of those in the diphenhydramine group while 37% of those in the placebo group reported sustained relief (95% CI: -10% to 16%). A total of 85% of those in the diphenhydramine group and 76% of those in the placebo group (95% CI: -2% to 20%) noted that they would want the same medication combo then next time they came to the ED and a difference of 17 minutes was noted between the groups for ED LOS. The authors noted similar rates of akathisia amongst the two groups. Based upon this study the authors noted that diphenhydramine when used in conjunction with metoclopramide does not change migraine outcomes. Commentary: This study seems to dispel a longstanding treatment regime that many ED physicians use for the treatment of migraines. Many ED physicians will argue that the usage of diphenhydramine is used to prevent akathisia in those receiving metoclopramide but the authors note similar rates of this side effect in both groups. If externally validated, a paradigm shift could be seen in how we treat migraines in the future. References 1. Davidoff F, Hanyes RB, Sackett DL, and Smith R. Evidence based medicine:

information they need. BMJ. 1995; 310: 1085 – 1086. 2. Van Tulder M, Touray T, Furlan A et al. Muscle relaxants for non-specific low back pain. Cochrane Database Syst Review. 2003; 2: CD004252. 3. Chaparro L, Furian A, Deshpande A et al. Opioids compared to placebo or other treatments for chronic low back pain. Cochrane Database Syst Review. 2013; Aug 27(8):CD004959.

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new journal to help doctors identify the

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Medicare Access CHIP Reauthorization Act

Signed into law April 16, 2015 MACRA will replace the SGR familiar to most physicians as a reliable annual threat to cut Medicare payment. But what does this mean to osteopathic physicians in emergency medicine?

William DiCindio, DO, FACOEP

or years the payment to physicians has been as feefor-service where the basis has been the volume of services delivered. Claims are that the value of services under this arrangement was missing and as costs of care increased for years there was no link between payment and quality. Recently, we are seeing more and more alternative payment models approved by Medicare with their focus on performance and value. Change is evident in our working world as electronic health records become our tool for prose in charting and quality improvement programs are considered in many of our patient evaluations each shift. Quality has been driven by the payment adjustments tied to Physician Quality Reporting System (PQRS) and Value-based Payment Modifier (VPM) and Electronic Health Record Incentive Meaningful Use (MU) program (for hospitals and office based practices). These payment measures have prepared us for mapping value and performance to the new road to payment from Medicare. In April 2015 Congress sent The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) to President Obama, who signed it on April 16, 2015 and has finally eliminating the 1997 budget deal labeled the Sustainable Growth Rate (SGR) formula for Medicare payments. Most physicians are familiar with the cataclysmic year of 2002 when physicians received a

4.8% cut in Medicare reimbursement and looming yearly cuts continued after that from 2003 thru 2015. Well, now we can move on to the challenges of navigating the new road to Medicare payment where some lanes are still in the construction phase and not yet ready for traffic. Here, we will begin to get you up to speed on MACRA and how it will impact Medicare payments in the coming years. Remember the theme will be value based rewards. The vocabulary. Within the Medicare Access and CHIP Reauthorization Act of 2015 you will come across many acronyms. It is important to understand the complexity of MACRA language. Be thankful you do not have to read the Federal Registry! This new law bases payment on performance by way of two participation pathways. Two of MACRAâ&#x20AC;&#x2122;s main paths to value are: 1.) Merit-based Incentive Payment System (MIPS) still a fee-for -service system and 2.) Alternative Payment Models (APMs) through Physician Focused Payment Models (PFPMs) EPs (Eligible Professionals) are physicians, physician assistants, nurse

practitioners, clinical nurse specialists, nurse anesthetists are the eligible professionals being paid by Medicare. Merit Based Incentive System (MIPS). (Table 1)

Payment

The Merit Based Incentive Payment System will utilize the premise of PQRS, VBM and Meaningful Use EHR incentive payment adjustments by combining all of these elements into a single program with weighted performance categories: Quality (30 points), Resource Use (30 points), Clinical Practice Improvement Activities (15 points) and Meaningful Use (MU) of Certified EHR Technology (25 points) A Composite Performance Score for each EP will be based on these four categories (total of 100 points possible). This score will then be used to provide a payment adjustment upward, downward or no adjustment; ranges of impact are from +/- 4% for the 2019 payment year and increasing to a maximum of +/- 9% for 2022 and subsequent payment years. CMS will define the performance years and the payment years in the final rule to be published by the end of 2016. Currently this time frame is 2 years apart meaning

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performance year 2017 would be the basis for payment in year 2019. It is likely that 2017 will begin the performance year for MIPS. The only way to receive no payment adjustment is to be exactly at the Performance Threshold (PT). If a participant is above or below the PT then a linear calculation will take place based on the composite score. Since this is a budget neutral portion of the law, (meaning for every provider that reaps benefit from the new program there will be a provider that makes less) we have to multiply each maximum by a scale of 3 (for 2019 +4% x 3.0 ) to achieve budget neutrality. In the law there is some description given to CMS as an example year over year improvement for low scoring EPs in quality and resource use will be considered for credit at the discretion of CMS.

Table #1: MIPS Payment Adjustment MIPS Score

2019

2020

2021

2022

*Bonus

10%

100 pts

+4%x3

+5%x3

+7%x3

+9%x3

PT to100

linear (0% to max postive adjustment)

0 to PT

linear (0% to max negative adjustment)

0 pts

-4%

-5%

-7%

-9%

Table #2: APM’s Required Percentage of Medicare Revenue 2019-2020

2021-2022

2023 and on

25% in Medicare

50% in Medicare

75% in Medicare

25% in Medicare

50% in all-payer

75% in all-payer

Table #3: Medicare Reimbursement Stable Increase Period

PT is the performance threshold determined annually by CMS. Additionally, there will be an exceptional performance bonus of up to 10% for the EPs who exceed the 25th percentile of positive MIPS scores. There are three exclusions to MIPS eligibility: • those participating in APMs. • those enrolling for the first time in Medicare (will have to wait to participate in the subsequent year), and • those who have low-volume thresholds (still being defined) MIPS scores will be posted on the Physician Compare website with ranges of scores for all EPs on a scale of 0 - 100. CMS has been soliciting public comment on MIPS since July 2015 and requests for information (RFI) are ongoing into November of 2015. A proposed 2017 MIPS rule is estimated to be completed by July 2016 and the estimated final rule will be posted by November of 2016. Alternative Payment Models (APMs).

2016

2017

2018

2019

0.5%

Table #4: Medicare Reimbursement Update After Stable Period 2019-2024

2026

MIPS

MIPS payment adjustments

0.25%

APMs

5% bonus

0.75%

Alternative Payment Models are a bit more involved in structuring a practice to meet performance based requirements and contract with CMS. These include Accountable Care Organizations (ACOs), Patient Centered Medical Homes (PCMH), bundled payment models, and others. EPs in APM entity will be exempt from the MIPS adjustments. Here, CMS is pushing EPs to take on risk in performance based contracts. Participants in these entities will receive, in addition to their contracted shared savings, a lump sum incentive payment of 5% of the prior year’s estimated aggregate expenditures under their Medicare fee schedule. This will be available for years 2019 thru 2024. In payment year 2026 the fee growth

rate will be set higher for qualifying participants in APMs than in MIPS (0.75% vs 0.25% respectively). Again, the push to participate in APMs is evident. In order to be considered an APM at least 25% of the EPs reimbursement must have been through an eligible APM structured entity such as an ACO for the payment years 2019 and 2020. In the years 2021 and 2022 at least 50% of the EPs Medicare payment must have been through an APM structured entity. The law will accept APMs participation in nonMedicare sources, i.e. private payers, as long as they have at least 25% Medicare participation and 50% of the sum of allpayer reimbursements through an eligible

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APM or APM-equivalant programs. This payer portion rises to 75% in year 2023 and beyond. Any participant in an APM entity who fails to meet the thresholds will be subject to MIPS and those below threshold patients are subject to the quality and cost measurement rules applying to the APM entity they belong to. The APM entity is required to have its participants: • use certified EHR technology, • paid based on quality measures comparable to those used in the MIPS quality category and • take on material risk in the form of monetary losses.

that there are solo practices and remote practices. CMS will help solo and small group practices of 15 or less EPs with transitions to APMs or give technical help with performance of MIPS. Small practice groups will be able to decide to report individually or as “virtual” groups and will be able to organize by specialty or geographic area. There are assurances that for all EPs the quality standards under the ACA or Medicare /Medicaid cannot be considered an established standard of care for liability purposes. In addition, MACRA requires the Medicare Administrate Contractors (MACs), which process Medicare claims in designated regions across the United States, to provide assistance to EPs with high claim error rates and to assist them in avoiding errors or correcting them.

Some types of eligible entities are: • C MS’s Center for Medicare and Medicaid Innovation (CCMI) ACO model • Medicare Shared Savings Program (MSSP) for ACOs • Healthcare Quality Demonstration Program Within MACRA there is recognition

The good news is that for the next few years while physicians learn and hopefully participate in shaping portions of MACRA there will be a stable increase in continued fee-for-service reimbursement from Medicare. There will be an 0.5% annual increase for years 2015-2018. The time line for implementation of Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) will

begin payment in year 2019 and continue going forward. At this time there is no predetermined structure for many specialties to base a decision on which path to take, MIPS or APM. The requirements for MIPS are onerous and ill-fitting to emergency medicine. As Emergency physicians we deliver a unique set of health care services. We work in hospitals, yet we provide outpatient services for acute medical needs. We are not a medical home yet we are the safety net for all at any time. At this time, we neither fit neatly into any current or proposed definition of an APM nor do the suggested requirements outlined in the MIPs program fully measuring the value of our services. We are looking to all physicians, specifically our emergency medicine physicians, to continue to research MACRA and provide feedback regarding a payment structure that will work best for emergency medicine physicians. For more information or learn how you can get involved, visit our newly launched Advocacy and Policy Website at www. acoep.org.

WE WANT TO HEAR FROM YOU! Emergency Physicians do incredible things every day and we want your stories! Send your story ideas to ThePulse@acoep.org, we would love to share your experience with our members. We also encourage you to email ThePulse@acoep.org to share your thoughts on specific articles that you read here. We want to keep the conversation rolling, whether you agree or disagree with a point of view represented in our articles, we want to highlight various perspectives from our diverse membership.

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N C N

Calling All New Physicians in Practice! Nicole Ottens, DO Committee Member, Publication Chair New Physicians in Practice Committee

ormerly a special interest group devoted to those of us out of residency five years or less, the New Physicians in Practice Committee (NPIP) is now a fully operational committee set to address the needs and issues related to the fastest growing segment of our general membership. We know that transition from resident to attending is a big jump with lots of adjustments, and we’re here to help. Got questions about taking your boards? Wondering about COLA and continued certification? Interested in becoming a fellow? Starting to need CME? Want help navigating contracts for employment, debt management and financial planning? Ever wonder where you fit in now that you’re no longer a resident and out into the world of an attending? We’re here to help! We’ve got answers to those questions and so much more! We want to help you navigate this transition and to be your resource for all those needs and questions. We have our own section on the ACOEP website at www.acoep.org/npip and a Facebook page under “ACOEP New Physicians in Practice” where you can reach out and keep connected. We will have updates in The Pulse and the Beat.

We have committee meetings ACOEP’s Spring Seminar and Scientific Assembly that you are welcome and encouraged to attend. We are distributing information packets to graduating residents that touch on the top items you need to know about. And officially this fall, we now have a CME track just for you! Starting in Orland at the 2015 ACOEP Scientific Assembly we had lectures geared to where you are at in your career with topics specifically relevant to those in their final years of residency or out in practice five years or less. This year’s track included talks on wealth management, preparing for the AOBEM oral boards and political advocacy and awareness. We also had a time for mentoring and information sharing during our sponsored lunch. Thanks to all those who helped this successful launch happen! We are already working on topics for next fall’s CME track. If there is a particular topic you’d like to see, feel free to contact us. We look forward to your involvement and questions! Want to get involved? Great! We’d love to have you! Reach out on Facebook, the ACOEP website or contact Gina Schmidt at gschmidt@ acoep.org

IMPORTANT DATES IN 2016 • January 14-18: ACOEP Written Board Prep: An Intense Review • February 2016: Application deadline for Cognitive Assessment Examination • March 1st: Deadline for Fellowship applications for ACOEP • March 9-10: Part II Oral Boards, Chicago, IL • March 18: Part 1 Computerized Exam • March 28: April 2, ACOEP Spring Seminar • April 13th: DO Day on the Hill, Washington, DC

tarting in Orland at the 2015 ACOEP Scientific Assembly we had lectures geared S to where you are at in your career with topics specifically relevant to those in their final years of residency or out in practice five years or less.

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ACOEP’s RISE Exam is Changing! Erin Sernoffsky

hroughout its history, ACOEP has always focused on bringing members the tools and support for success; carefully studying the changing medical landscape and adjusting as necessary. This ability to adapt keeps ACOEP on the cutting edge and is the driving force behind a new and exciting change— ACOEP’s RISE Committee is undergoing a fundamental change, becoming the Committee for Board Prep Emergency Medicine (BPEM). For years the RISE Committee, or the Resident In-Service Exam, has provided a valuable tool for Residents, a mock exam to aid in preparations for the Board Exam. With the success of the RISE Exam the Committee has taken it upon themselves to reform and expand this exam to benefit both attending physicians as well as Residents. The BPEM Committee will prepare a mock exam giving attending physicians preparing to recertify, as well as attending physicians the opportunity to test their progress, knowledge, and to help identify areas in need of improvement.

Kristen Kennedy, ACOEP’s Director of Education Services is managing this change from an administrative perspective. “Currently, there are not a lot of practice materials available for individuals who need a refresher,” says Kennedy. “Also, ABEM does not require that their residents take an in-service exam, this will also allow for initially ACGME Accredited programs to decide if they would like to use the exam as well.” Taking the exam as preparation for Boards is not the only way to benefit from this change. The BPEM Committee is currently seeking qualified physicians to serve as question writers. “Writing these questions meets both ACOEP and ACGME standards for scholarly activity, it can be done from the comfort of your home,” says Uberti. “Participation as a committee member

also counts towards faculty development.” Committee members and question writers commit to attending a one-time workshop at ACOEP’s Spring Seminar, and write 10 assigned topic questions each Spring and Fall. They also review and suggesting changes biannually to 10 questions written by fellow committee members. “This is an excellent opportunity for ACOEP members to gain excellent experiences in medical education, and to provide an invaluable service for fellow physicians, all in a format designed to fit into every members’ specific lifestyle,” says Kennedy. The new exam will be released in 2016 and any interested committee members can contact Kristen Kennedy at KKennedy@acoep.org.

ITEM WRITERS WANTED! As the RISE Committee transitions into the Committee for Board Prep in Emergency Medicine (BPEM) ACOEP is recruiting members who can serve as item writers for the new practice exam.

Writers Commit to: “The test is a comprehensive exam of the medical knowledge required in the practice of emergency medicine,” says Jill Uberti, Chair of the BPEM Committee, and driving force behind this change. “Taking the test provides a marker of the participant’s knowledge and simulates the board exam in format and content. Whenever you take a prep exam, you have a better feel for the areas of medicine you are not comfortable in as well as it helps with your test taking skills.”

• Attending a one-time training at ACOEP’s Spring Seminar • Writing ten exam questions on an assigned topic each spring and fall • Review questions written by other committee members

Benefits of Being an Item Writer:

• Receive ACOEP and ACGME scholarly activity • Faculty development through the workshop • Recognition as a national committee member To be considered for membership, please contact Kristen Kennedy at the ACOEP, kkennedy@acoep.org or 312-445-5708. Upon inquiry, you will be asked to include your most current CV, as well as write and submit three audition exam questions based on a preassigned topic which the committee will then review to determine eligibility.

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ACOEP-RC President’s Report The ACOEP RC is excited to move forward into 2016 with revamped programing for our Spring Conference in Scottsdale. We have been working the College and office to coordinate for continued quality offerings for our resident members. This Spring Conference will provide a quality US course as well as didactic lectures geared towards residents and of course FOEM events to showcase research and cases. Shortly after, we are looking forward to D.O. Day on the Hill and continued discussion on the single accreditation system.

supported by the college. We appreciate your continued support of our resident members and look forward to seeing you all in Scottsdale! Sincerly,

John Downing, DO ACOEP Resident Chapter President ACOEP Board of Directors

The new ACOEP RC officers are already in full swing to continue the quality resident programming

OFFICIAL ACOEP COFFEE MUGS

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Physicians need their caffeine! Have your morning cup in an ACOEP mug or travel mug. Purchase yours today by contacting Jaclyn McMillin: 312.445.5702 or jmcmillin@acoep.org

"Doctors that DO” continued from page 4 of reassurance or a gentle touch can help ease the fears of a scared or anxious patient. We can all perform technically and we all perform competently, but are you performing osteopathically? What does an osteopathic physician do? It is sometimes asked out of curiosity, lack of understanding, or just pure jest. Whatever the reason, it is important that you can provide an intelligent response. As practicing osteopathic emergency physicians, we utilize the osteopathic philosophy daily. We look at the patient and their needs, not just the numbers and diagnostic images on the computer screen. How many times does a chief complaint not reveal the true reason for a visit? How do we ensure that a patient’s needs are met and criteria for a safe and functional discharge are in place? We recognize the futility of some cases or just the sheer exhaustion of patients in dealing with their chronic disease and assist with palliative care and hospice services. We have the hard talk about end of life care that is so often overlooked. There are so many instances that illustrate how the osteopathic philosophy is alive and well in the practice of emergency medicine that it is impossible to name them all. This is not to say that our practice is better or superior to our allopathic colleagues. It is just different. This is also not to say that our allopathic partners do not practice good medicine. They may be practicing osteopathically and not even realize it. That is why we need to educate everyone about what it is that we do. In the coming months the AOA will reach out to us to join in this movement. They will invite our members to submit pictures and perspective to be published with our logo on it. I sincerely hope that all members will join in and send pictures and quotes. It is so important that we speak out for ourselves, our identity as osteopathic physicians, and in support of the entire osteopathic family.

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masthead_Layout 1 4/18/13 10:24 AM Page 1

• A FOUNDATION DEDICATED TO RESEARCH IN OSTEOPATHIC EMERGENCY MEDICINE

is a predictor of performance on the osteopathic emergency medicine resident in-service exam (RISE)

Sherry D. Turner, DO, MPH, FACOEP President

Foundation Focus

he Foundation for Osteopathic Emergency Medicine had quite a showing at ACOEP’s Scientific Assembly this October. The week started off with the FOEM Resident Research Competitions, which debuted a new digital format. Attendance at the competitions-the posters, papers, oral abstracts, and CPCs—was incredibly strong, no doubt due in part to the excellent quality of participants year after year. Congratulations to this year’s winners! Research Paper Competition sponsored by:

1 st Place: Stefan Meyering, DO and Ryan Stringer, DO; Lakeland Health – MSUCOM Parenteral acetaminophen for treatment of generalized headache presentations in the emergency department nd Place: Holly Ringhauser, DO; Good 2 Samaritan Hospital Medical Center T he comprehensive osteopathic medical licensing exam (COMLEX)

rd Place: Jason Crofts, DO; St. Vincent 3 Hospital Direct versus video laryngoscopy for intubating adult patients with gastrointestinal bleeding Clinical Pathological Case Competition sponsored by:

Research Poster Competition sponsored by

1st Place: Jake Halvorson, DO, St. John Macomb-Oakland Hospital, Warren, MI 2nd Place: Mina Attaalla, DO, St. Barnabas Hospital, Bronx, NY 3rd Place: Matthew Tanis, DO, Metro Health Hospital, Wyoming, MI Oral Abstract Competition

1 st Place: Adam Sadowski, DO, Ohio Valley Medical Center, Wheeling, WV nd Place: Joseph Sedlock, DO, St. 2 Barnabas Hospital, Bronx, NY rd Place: Michelle Ischayek, DO, Aria 3 Health, Philadelphia, PA

Six-way tie! • Michael Dalley, DO, Mount Sinai Medical Center, Miami Beach, FL • Nikolai Butki, DO, McLaren Oakland Hospital, Pontiac, MI • Anne Newbold, DO, Midwestern University, Downers Grove, IL • Rebecca Mills, MD, Aria Health, Philadelphia, PA • John Schroeder, DO, Aria Health, Philadelphia, PA DO,

nd Place: Danielle Turrin, DO, Good 2 Samaritan Hospital Medical Center, West Islip, NY 3rd Place: Samantha Margaritas, OMS IV, Midwestern University Chicago College of Osteopathic Medicine, Downers Grove, IL

CPC Faculty Discussants

• Scott Plasner, Philadelphia, PA

1 st Place: Nicholas Graff, DO, Lakeland Health, Saint Joseph, MI

Aria

Health,

The Foundation’s also showcased the next installment of the Faculty Development Track. This year’s track included lectures from ACGME experts, as well as a Program Directors’ Panel Discussion. Attended by dozens, the track served to prepare Program Directors and Core Faculty for the changes presented by the Single Pathway. And of course we celebrated the highlight of the week: the 2015 FOEM Legacy Gala. This year’s theme was a masquerade ball, and the attendees dressed the part! Donning mysterious masks, our guests enjoyed delicious hors d’oeuvres, an open bar, and a five-star meal. Please make sure to go to FOEM’s

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Facebook page to look at all the pictures!

Florence and Joseph Wachtler Spirit Award

• • • • • • • • • • •

Presented to donors with a lifetime donation level of $50,000.00 or more

• •

A very sincere thanks to everyone who made the events at Scientific Assembly such a wonderful success. And a very special thank you to the generous donors who have helped to transform FOEM’s vision into a tangible reality.

• Joseph Kuchinski, DO, FACOEP FOEM Pillar Award Presented to donors with a lifetime donation level of $5,000.00 or more • F ahim Shan Ahmed, DO, M.S., FACOEP, FACEP • Jack Field, DO • Drew Koch, DO, FACOEP-D • William Lynch, Jr. • Jon Pierre Pazevic, DO, FACOEP-D, FACEP • John C. Prestosh, DO, FACOEP • Theodore Spevack, DO, FACOEP-D

• •

Timothy J. Cheslock, DO, FACOEP Joseph Dougherty, DO, FACOEP-D Jack B. Field, DO Steven D. Hollosi, DO Drew A. Koch, DO, FACOEP-D Joseph J. Kuchinski, DO, FACOEP-D Beth A. Longenecker, DO, FACOEP William Lynch, Jr. Mark A. Mitchell, DO, FACOEP-D Victor J. Scali, DO, FACOEP-D Jeremy Kent Selley, DO, FACOEP & Victoria H. Selley, DO, FACOEP Bryan D. Staffin, DO, FACOEP-D Robert E. Suter, DO, MHA, FACOEP-D, FACEP, FIFEM James Turner, DO, FACOEP & Sherry Turner, DO, FACOEP Janice Wachtler

• Bernadette Brandon, DO, FACOEP • Joseph Dougherty, DO, FACOEP-D • Gregory Frailey, DO FOEM 500 Club Presented to donors with an annual donation level of $500.00 or more • Juan F. Acosta, DO, FACOEP-D • Fahim Shan Ahmed, DO, M.S., FACOEP, FACEP • Michael Allswede, DO • Gregory J. Beirne, DO, FACOEP, FACEP • Aimee Blagovich, DO

Objectives: The study attempts to determine the efficacy of IV Acetaminophen as an adjunct to a standard therapy for the treatment of patients who present to the emergency department with a chief complaint of “headache” or variants thereof. Design: Randomized, double-blind, placebo-controlled trial. Institutional IRB approval was obtained prior to implementation.

FOEM Research Flame Award Setting: Academic Community Hospital. Presented to the ACOEP Residency Program with the highest average score for research papers St. John Medical Center, Westlake, OH *Winning Abstracts 1st Place Research Paper (Please see page 27 for full Research Paper)

FOEM Partner Award Presented to donors with a lifetime donation level of $2,500.00 or more

of patient presentations to EDs across the country. There are many proposed methods and clinical guidelines of treating acute headache presentations however data on intravenous acetaminophen usage in these settings are lacking.

Parenteral Acetaminophen for Treatment of Generalized Headache Presentations in the Emergency Department Stefan H. Meyering, DO; Ryan Stringer, DO; Matthew K. Hysell MD Lakeland Healthcare, Department of Emergency Medicine. Michigan State University College of Osteopathic Medicine Abstract Introduction: Headaches represent over 3 million Emergency Department visits per year comprising 2.4 percent of all ED visits. Headaches are thought to be one of the three most common complaints

Patients: Key elements of eligibility included adults ages 18-65 who had no mental or physical hindrances to pain assessment or to receiving acetaminophen. Exclusion criteria included those who had received total cumulative dose of acetaminophen >2600mg within past 24 hours, documented or suspected pregnancy, dementia, psychosis, liver cirrhosis, hemodynamic instability or other medical conditions prohibiting acetaminophen use. Ability to understand informed consent was necessary. Interventions: All patients received prochlorperazine, diphenhydramine, 1000ml 0.9% normal saline IV, and were randomized to receive either parenteral acetaminophen (1000mg/100ml) or 100ml of 0.9% NS as control in the placebo group. Main outcome measures: Subjective pain scores rated on a 1-10 Visual Assessment Scale were assessed repeatedly at 30 minute intervals. Length of stay and time to disposition were also noted. The incidence of rescue medications required outside of the initial regimen was also noted, with particular attention to narcotic utilization.

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Results: Of the (n=45) patients who received IV acetaminophen, 36 reported a statistically significant decrease by pain score of 2 or greater from presentation at the 90 minute mark. Of the (n=45) patients who received placebo, 25 reported a statistically significant decrease by pain score reporting from presentation at the 90 minute mark. (p 0.01, >95% CI). For the acetaminophen group the initial mean VAS pain score was 8.7, for the placebo group 8.6. At 90 minutes 2.2 for Acetaminophen, 4.0 for placebo group. (p<0.01, >99% CI). Length of stay was decreased a mean 36.6 minutes in the Acetaminophen group. 17 patients in the IV acetaminophen and 24 patients in the placebo group received rescue medications, with 18% less in the acetaminophen group requiring narcotics (p 0.01, CI >95). Conclusion: In Emergency Department patients with acute headache, IV Acetaminophen when used as an adjunct to prochlorperazine and diphenhydramine resulted in increased pain reduction, decreased length of stay and less rescue medications utilized including narcotics when compared to treatment with prochlorperazine and diphenhydramine alone. 1st Place Poster Modified HEDIS criteria for Lower Back Pain Better Identifies Early Intervention and Imaging Utilization in the Emergency Department Observation Unit. Jake Halvorsen, DO Background: The Choosing Wisely Campaign identified lower back pain as an area for improvement to standardize radiographic utilization and cost containment in the ED and ED observation unit (EDOU). The Agency for Healthcare Research and Quality recommends the Healthcare Effectiveness Date and Information Set (HEDIS) criteria to guide radiographic utilization and to identify serious back injury that may or may not need intervention.

Common practice for lower back pain ED patients involves the utilization of an observation unit to provide further diagnostic testing, consultation evaluation, and treatment.

Identification of a high risk EDOU group included lower back pain score of 10/10 on ED presentation and at least one modified HEDIS criteria. This high-risk group had a 35% early intervention rate and a length of stay of 2.7 ±3 days.

Objective: Conclusions: Our objective was to evaluate other factors related to acute lower back pain not included in the current HEDIS criteria that are related to MRI imaging, resource utilization and early procedural or surgical intervention within 30 days. Methods: A multi-center retrospective cohort review of ED patients with a primary diagnosis of acute back pain placed in an EDOU over a 1 year period. Data collection included patient demographics, imaging performed, back surgical history and 2012 HEDIS criteria including history of back trauma, IVDA, cancer or presence of neurologic deficit. Statistical analysis included univariate and multivariate analysis to identify statistical significance, p<0.05. Results: During the study period, 280 ED patients were placed in the EDOU for acute low back pain with 106 meeting HEDIS criteria, and 174 without HEDIS criteria. The avg pain score out of 10 was similar: HEDIS 8.7 ±1.8 vs no HEDIS 8.7 ±2.2 (p=0.9). Other factors not related to current HEDIS criteria that were significant for early procedural or surgical intervention was severe pain score of 10 out of 10 and history of back surgery was associated with early intervention (p<0.001). Proposed modified HEDIS criteria included the addition of history of back surgery to current HEDIS criteria included 143 meeting modified HEDIS and 137 without HEDIS criteria. The modified HEDIS criteria which includes prior back surgery compared to no HEDIS criteria had a significant difference in MRI utilization 48% vs 37%, (p=0.049), early intervention 24% vs 12% (p=0.02), and longer length of stay 2.0 ±2.6 days vs 1.2 ±1.3 days (p<0.01) respectively.

We identified severe lower back pain 10 out of 10 at ED presentation and history of back surgery which are not part of the current HEDIS criteria to be associated with increased radiographic utilization and increased prevalence of early intervention. The proposed modified HEDIS criteria was associated with higher MRI utilization, early intervention and longer length of stay. In addition, a highest risk lower back pain group identified had presented with severe 10 out of 10 pain and modified HEDIS criteria. Modified HEDIS criteria and including severe pain 10 out of 10 score may better identify ED /EDOU patients requiring imaging and early intervention. 1st Place Oral Abstract The Streamlining Sepsis Initiative Nicholas Graff, DO and Robert Nolan, DO Introduction In the United States over 1 million patients suffer from sepsis annually with in-hospital mortality ranging from 14.7% to 29.9%, with an estimated cost of $17 billion nationally, and there still remains multiple treatment barriers within the hospital setting. Objective At Lakeland Health, an 80,000 patient per year community hospital system in Saint Joseph, MI, we set out to overcome barriers previously shown to impede sepsis therapies by taking advantage of the novel and adaptable aspects of an electronic medical record with the goal of improved treatment of septic Continued on Page 27

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Join the Foundation for Osteopathic Emergency Medicine at the 2016 ACOEP Spring Seminar in Scottsdale, AZ!

Wednesday, March 30, 2016 at 6 p.m. Early bird rate $45.00 until February 1, 2016 (includes t-shirt) $60.00 after February 1, 2016 (includes t-shirt) Get the blood flowing for a good cause! All conference attendees and their families/ guests – from walkers and novice runners to seasoned marathoners – are welcome to join the FOEM 5K Run for Research and one-mile DO-Dash! Proceeds will benefit the Foundation for Osteopathic Emergency Medicine (FOEM).

FOEM Case Study Poster Competition Wednesday March 30, 2016 from 2:00 – 5:00 p.m. The Foundation for Osteopathic Emergency Medicine (FOEM) is proud to present the annual Case Study Poster Competition, in which students and residents present interesting or unique cases that have presented at their hospital. Winners receive certificates, cash prizes, and recognition in FOEM publications throughout the year. The deadline for submission of applications and abstracts is January 31, 2016. For more information or to register for an event, please contact Stephanie Whitmer at swhitmer@foem.org, or register online. FOEM BEACON | JANUARY 2016

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"Foundation” continued from page 25

1st Place Research Paper

patients. We predict that the introduction of an electronic medical record based sepsis identification tool in the emergency department will lead to earlier implementation of sepsis treatment.

Parenteral Acetaminophen for Treatment of Generalized Headache Presentations in the Emergency Department

Method A Retrospective cohort study of clinically effectiveness in the treatment of 3,076 patients with the diagnosis of sepsis was performed. Patient charts were identified for this study who met the criteria of: ≥18 years old; emergency department evaluation; ICD-9 code of sepsis, sever sepsis, or septic shock. Data was placed into two treatment groups, pre- and post-best practice advisory sepsis identification tool, with our primary outcome being in-patient mortality. Secondary outcomes measured include, time from emergency department arrival to intravenous fluids and antibiotics. Our institutional review board has approved the study. Result 1,266 patients were treated prior to and 1,810 treated after best practice advisory implementation with in-patient mortality 10.5% and 7.5%, respectively (difference of 3%; P value < .05). Additionally, we found a decrease in time to intravenous fluids in the first 60 minutes of emergency department arrival from 49.9% to 34% (difference of 15.9%; P value <.05) and time to antibiotics in the first 180 minutes of arrival from 56.8% to 40.3% (difference of 16.5%; P value <.05). Conclusion Our study has demonstrated effective earlier implementation of sepsis therapy. This earlier resuscitation correlates with implementation of an electronic sepsis identification tool in the emergency department that may have contributed to decreased mortality of septic patients.

of acute headache as an adjunct to standard therapy as part of a multi-modal approach may display increased efficacy in terms of pain reduction and purported narcotic-sparing effects. Aims

Stefan H. Meyering DO, Ryan W. Stringer DO, Matthew K. Hysell MD Lakeland Health, Emergency Medicine

Department

Michigan State University College of Osteopathic Medicine Introduction Headaches represent over 3 million Emergency Department (ED) visits per year comprising 2.4 percent of all ED visits10, and are thought to be one of the three most common complaints of patient presentations to EDs across the country. The most prevalent group presenting to Emergency Departments across the U.S. range in ages between 18-44 with 1626 visits per 100,00010. Expenditures totaling over $408 million were reported as of 2008 in terms of hospitalization costs11. Treatment of headache presentations in the acute setting remains complex, often requiring an individualized regimen that is patient-tailored. There are many proposed methods and clinical guidelines of treating acute headache presentations however data on intravenous acetaminophen usage in these settings is lacking11,12. Intravenous acetaminophen in the postoperative period has been found by retrospective medical use evaluation (MUE) surveys to reveal significant success at sparing narcotics as a part of a multi-modal approach to analgesia23. It has also displayed effectiveness in the setting of treatment of acute renal colic when compared to morphine directly33. While current recommendations for acute headache treatment do not routinely include opiates, many patients regularly use or require some form of opiate analgesia, complicating current approaches. Assessing the usage of intravenous acetaminophen in the setting

1. A randomized, double-blind, placebocontrolled trial investigating the clinical efficacy of IV acetaminophen as an adjunct to a standard therapy for the treatment of patients who present to the emergency department with a chief complaint of “headache” or variants thereof. Protocols included administration of prochlorperazine, diphenhydramine, 1000ml 0.9% normal saline IV bolus, and randomization to receive either 1,000mg parenteral acetaminophen (1000mg/100ml) or 100ml of 0.9% normal saline as control in the placebo group. 2. Independent of the clinician’s ultimate disposition of the patient, data collection was performed to ascertain three primary outcome measurements: 1) The presumed efficacy of parenteral acetaminophen as an adjunct treatment for headache in addition to a standard therapy. The primary end-point was reduction in visual analog scale pain scores on a 1-10 level at 90 minutes. 2) Decreased requirement of “rescue” pain medicines (with particular interest to narcotic sparing) during ED visit

3) Decreased time to disposition

Hypothesis: Parenteral acetaminophen will provide measurable analgesic effect for treatment of headaches. Presumptively, patients will require less “rescue” medications after initial treatment with the IV acetaminophen

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therapy and have notable results in terms of pain score reduction. Additionally, previous clinical trials in postoperative pain management have revealed a narcotic sparing effect of IV acetaminophen. This study could demonstrate such an effect for the treatment of cephalgia. Anticipated effects of the drug’s properties and bioavailability are presumed to provide adequate analgesia which will additionally result in a shortened clinical course. Methods: Protocol Patients presenting with chief complaint of headache or variant thereof were provided informed consent. After initial assessment of the patient by the provider including review of exclusion criteria, an order set was utilized in the electronic medical record to select a pre-selected order cluster including prochlorperazine 10mg IV bolus, diphenhydramine 25mg IV bolus, 1000ml 0.9% normal saline bolus, and “study drug”. The “study drug” was either 100ml 0.9% sodium chloride in a minibag, or 1000mg IV acetaminophen transferred from the manufacturer’s vial into a 100cc minibag. All patients received both prochlorperazine, diphenhydramine, and 1000ml 0.9% normal saline immediately and then subsequently the ‘study drug’. This was sent from Pharmacy via tube system to ensure blinding. Both IV acetaminophen and placebo were administered via IV infusion over a 15 minute interval as is required by the manufacturers dosing administration instructions. The study was designed to be double blinded to both physician and patient, therefore patients were randomized by the pharmacist to either treatment arm “A” or “B”, where “A” represented acetaminophen, and “B” represented placebo. The pharmacists used a numeric identifier in a logbook to track whether patients received the study drug or placebo. The study blinding was able to be broken at any time by the ED physician if necessary.

Patient assessment: ED staff in the Emergency Department completed a stratification form that noted the patient age, chief complaint, and pain assessment intervals at time of arrival, time of “study drug” administration, reassessment at 30 minute intervals thereafter, and additional reassessment if a “rescue” medication was later used. A standardized Visual Assessment Scoring scale was utilized on a scale of increasing pain intensity from 1-10. The screening form was also used to delineate which patients met inclusion or exclusion criteria. The treating ED physician discussed the study in detail with the patient and obtained informed consent for enrollment Adverse events: In the event of adverse reaction to the IV infusion of the “study drug”, the infusion would be stopped and pharmacy contacted if required to “break” the double blinding to determine which medication was administered. During the study, no requirements for cessation of infusions were noted. Any and all methods to treat the patient for an adverse drug reaction were available using current clinical standard of care. Inclusion/Exclusion criteria: Inclusion criteria: 1. Any patient presenting with chief complaint of headache, migraine headache, tension headache, cluster headache or headache not otherwise specified 2. Adults age 18 – 65 years 3. Reporting pain as >4 using 10-point visual analog scale Exclusion criteria 1. Age < 18 years

3. Total cumulative dose of acetaminophen >2600mg within past 24 hours. 4. Physical or mental disability hindering adequate response to assessment of pain 5. Mental disability limiting ability to give consent 6. Hemodynamic instability or medical condition requiring acute lifesaving intervention 7. Documented or suspected pregnancy or active breastfeeding 8. Any known contraindication to acetaminophen use such as liver failure, cirrhosis, hypersensitivity, allergic reactions, etc. 9. Any contraindication or reported allergy to the use of prochlorperazine and/or diphenhydramine Results An estimated 100 patients were needed for the study to have an 80% power to detect a difference at an alpha of 5%. 100 patients were enrolled in the study in total utilizing convenience sampling methods. 4 enrolled patients were excluded from data analysis secondary to age cutoff, 2 patients were excluded secondary to repeat enrollment (only the initial enrollment was factored into consideration) and 3 patients excluded secondary to insufficient data recording by either physician, ancillary staff or EHR reporting. Excluded additionally in the study was 1 patient who was found to have a brain mass possibly noted as a glioma. 45 patients were administered placebo and 45 administered IV acetaminophen. Both groups received diphenhydramine, prochlorperazine, and 1L 0.9% NS bolus. At no time was the study blinding required to be broken secondary to patient decompensation or deleterious effects.

2. Age > 65 years Of the 90 patients sampled in the

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Demographics Black or African American

White, Hispanic, or Caucasian

Asian/Pacific Islander

American Indian or Alaskan Native

Figure 1. Individual Race as per hospital federal reporting regulations. study, 51% reported their race as Black or African American, 47% as White, Hispanic or Caucasian, 1% as American Indian or Alaskan Native (fig1). No patients reported race of Eastern Indian, Western Indian or Asian or Pacific Islander. Figure 2. Demographics in age range categories A significantly higher portion of women (n=70) when compared to men (n=20) were noted as participants in the study. The mean age of participants was 31 in males and 38 in females. Age groups of study participants were further divided with notable findings of the majority of males being within ages 18-29, and females being ages 30-39 (fig 2). Pain scores were analyzed at 0, 30, 60, and 90 minutes after study drug administration. Pain scores were reported on a 1-10 scale based on current Visual Analog Scale guidelines. Of the (n=45) patients who received IV acetaminophen, 36 reported a statistically significant decrease by pain score reporting of ≥ 2 from presentation at the 90 minute mark. Nine patients reported pain scores which were unchanged from initial presentation, increased, or decreased by <2 at the 90 minute assessment. Of the (n=45) patients who received placebo, 25 reported a statistically significant decrease by pain score reporting of ≥ 2 from presentation at the 90 minute mark. 20 patients reported pain scores which were either increased, unchanged from initial presentation, or decreased by <2 at the 90 minute assessment. (P <0.01, CI >95%). (Fig.3). 41 patients required some form of ‘rescue’ medication in addition to the initially administered medications. 17/45 (38%) of patients who received IV acetaminophen required rescue analgesia, opposed to

24/45 (53%) of patients in the placebo group. (p 0.13, CI >90) (Fig 4,6) . Seventeen out of the 41 patients who required rescue analgesia received NSAIDS (IV ketorolac in all instances) as part of the rescue regimen, 8 in the IV acetaminophen treatment arm and 9 in the Figure 3. Improvement of VAS pain score reporting ≥ 2 placebo arm. Nine patients from presentation at the 90 minute mark received narcotics as part of a rescue formulation, 4 in the IV acetaminophen treatment arm, Mean pain intensity scoring (VAS) and 5 in the placebo arm. The narcotics was noted for both groups. For the administered included hydrocodone, acetaminophen arm the initial mean pain hydromorphone, meperidine, and fentanyl. score was 8.67, for the placebo arm 8.61. Some patients received combination At 30 minutes 6.61 for Acetaminophen, rescue medications including narcotics 7.14 for placebo. At 60 minutes 4.41 for and NSAIDS alone, in combination or in Acetaminophen, 5.12 for placebo. At 90 addition to other medications including minutes 2.23 for Acetaminophen, 3.99 for orphenadrine, triptans, and steroids placebo. (P<0.01, >99% CI). (Fig 6) depending on clinician discretion (fig 5). Mean length of stay was approximately Mean time to two point decrease in pain 186 minutes for the acetaminophen arm score was 49.2 minutes post administration and 226 minutes for the placebo arm of IV acetaminophen, prochlorperazine (Fig 6). Time to disposition and overall and diphenhydramine. Mean time of length of stay (LOS) were decreased in statistically significant score decrease the Acetaminophen arm by a mean of was 71.3 minutes post administration 36.6 minutes when compared to placebo. of IV 0.9% NS, prochlorperazine and Length of stay was extrapolated from the diphenhydramine. time to disposition entered in the electronic health record (EHR) and included (in both

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Figure 4. Comparative percentages of those requiring rescue analgesia in both IV acetaminophen and Placebo

Figure 5. Numeric comparison of rescue analgesics for both IV acetaminophen and placebo arms.

Figure 6. Mean reduction in pain at predefined intervals from time of patient arrival in IV acetaminophen and placebo arms. an evidence-based and often patient tailored approach, as there is a paucity of published data suggesting optimal migraine therapy29. The American Headache society recommendations have endorsed certain medications Figure 7. Mean total length of stay between IV acetaminophen as effective for and Placebo various headache presentations groups) additional rescue medications including triptans, ergotamine derivatives, and additional reassessment times. The NSAIDs, opioids, and combination maximum LOS for either treatment arm medications12,32. As of late, there has been a significant driving force in the was 361 minutes. medical community to reduce the application of opiates in settings where Discussion multi-modal therapies may be used in its place3,11. Narcotics used routinely in Treatment of headaches in the headache presentations are not widely clinical setting is difficult and requires

considered standard monotherapy, as they can contribute to rebound effects, increased reliance and addiction12,29. Colman et al discovered a significantly increased likelihood of patient return to the emergency department within seven days (p=0.011) with first-line narcotic treatment of headache35. Several adverse effects are associated with opioid monotherapy to include allergic reactions, sedation, confusion or altered mental status, respiratory depression, hypotension, urinary retention, constipation, nausea and vomiting3. The limitations of narcotic medications include prolonged recovery times, increased length of hospital stay, and higher incurred costs to the institution when applied to postoperative pain management strategies. Using multimodal therapy with additional agents helps to reduce the narcotic burden and thus this type of approach is likely to be beneficial to both physicians and patientsâ&#x20AC;&#x2122; alike.11,16 Literature in current state is significant for several papers addressing the issue of multi-modal analgesia gaining recognition as an effective post-operative regimen for surgical patients. Clinical strategies utilizing parenteral acetaminophen as an adjunct have become increasingly popular as there are notable narcotic sparing effects demonstrated in surgical and anesthesia literature3-5,7-8,15-17,19,22-23 with minimal side effects and a low risk/benefit ratio4. Intravenous acetaminophen has a diverse and broad compatibility with other

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agents making it a successful adjunct to other agents, additional NSAIDS, and opiates15. It also synergistically has been shown to increase analgesic affect in multimodal analgesia15,18. Minimal literature is present regarding the narcotic sparing effects of parenteral acetaminophen outside of peri-operative settings7. To our knowledge, only one study exists in the emergency medicine literature investigating the use of parenteral acetaminophen. Bektas et al32 compared 1000mg IV paracetamol to morphine (0.1mg/kg) and placebo for the treatment of renal colic in the emergency department. Mean pain reduction and rescue analgesia was similar to morphine, with a noted interesting trend in superiority in early pain assessment at fifteen minutes. A recently published American headache society evidence assessment of migraine pharmacotherapies cited Level A evidence by Lipton et al demonstrating the efficacy of 1000mg of oral acetaminophen vs. placebo in treatment of acute migraine with regards to pain relief, functional disability, phonophobia, and photophobia28, though the study population was limited to those with minimal nausea and need for bed rest. This is a select population of patients that are perhaps less likely to present to the emergency department for treatment, though the documented efficacy of acetaminophen is quite profound. A pharmaceutical sponsored study of OFIRMEV速 (acetaminophen 1000mg/100ml cadence pharmaceuticals) demonstrated peak plasma and CSF concentrations were higher than oral acetaminophen (P<0.0001) and rectal acetaminophen (P<0.0001)13,14 Additionally it does not undergo first pass metabolism in the liver thus reducing exposure of the liver to acetaminophen by half13 which may reduce the potential for hepatic injury13,20,22. Additionally, the use of IV acetaminophen as primary therapy for headaches would decrease the pitfalls of using primary NSAIDS such as ketorolac or Ibuprofen, in cases such as possible headache associated with intracranial hemorrhage where there is a platelet aggregation

inhibition34, potentially worsening clinical outcomes. Single doses of OFIRMEV速 up to 3000 mg and repeated doses of 1000 mg every 6 hours for 48 hours have not been shown to cause a significant effect on platelet aggregation nor have any immediate or delayed effects on small vessels13. Reviewing data findings, various pain scores were obtained in 30 minute intervals, of which, only the first 3 pain scores (after the initial assessment) for a total of 90 minutes post-medication administration were considered. Pain scores were reported on a 1-10 scale given the integration with the EHR and assistance with data collection and ease of nursing documented pain assessments essential to the study. We assessed for a 2 point decrease in Visual Analog System pain score as this is a commonly used measure in hospital settings for nursing and clinician pain score reporting36. Of the 90 patients sampled in the study, 46 reported their race as Black or African American, 43 as White, Hispanic or Caucasian, 1 as American Indian or Alaskan Native, with no Asian or Pacific Islander participants in the study. Religion and creed were not assessed. We can draw no statistically significant conclusions from this data other than a representation of our local population. The mean age of participants was 31 in males and 38 in females. This is consistent with reported headache sufferer demographics according to the American Headache Society.10,12,32 A significantly higher portion of women (70) when compared to men (20) were noted as participants in the study. This demographic trend is consistent with data published by the Agency for Healthcare Research and Quality who state women typically outnumber men 3:1 in terms of presenting to EDs seeking treatment for acute headaches.10 The definition of rescue medications administered In this study included narcotics, additional NSAIDS, orphenadrine, ergot-amines, triptans or

additional anti-emetics. Length of stay was extrapolated from the time to disposition entered electronically per the EHR and included in both groups additional rescue medications and additional reassessment times. Notably, it is unclear if participants treated with IV acetaminophen truly had a decreased length of stay secondary to the administration of the drug, or if this was an effect observed due to decreased utilization of rescue medications thus decreased time required in the emergency department. The maximum LOS for either treatment arm was 361 minutes in which the particular patient required significantly longer assessment due to refractory presentation. When compared to the additional subjects this was an outlier and did not greatly alter the data significance. During enrollment, several physicians cited concern with excluding analgesic medications such as ketorolac from initial treatment. Several studies have demonstrated the superiority of combination metoclopramide plus diphenhydramine over NSAIDS26,30. Regarding the efficacy of dopamine antagonist therapies for treatment of cephalgia, studies suggest a superiority of prochlorperazine to metoclopramide24,25,37 though Friedman et al37 did not achieve statistical significance between treatment arms as opposed to prior studies. Diphenhydramine was administered to all patients due to the significantly reduced akathistic response with prophylactic administration.31 We believed the initial treatment regimen would be a reasonable and efficacious baseline regimen despite patients randomized to the placebo group not being given an NSAID medication upon initiation of treatment. Some limitations were identified during trial completion. Our intention was to enroll a consecutive series of eligible patients, but this relied on both patient and physician participation and consent to trial participation, which were both factors not within controlled limits of the study. Based on the projected sample size to achieve appropriate power, a sample size of (n=100) was deemed optimal, due to

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exclusion criteria and other factors as noted before, a sample size of (n=90) was ultimately available for analysis. While the ultimate study population was smaller than initially intended, we observed a greater outcome effect than anticipated such that statistical significance was still achieved. Individual emergency medicine providers were encouraged to enroll all eligible patients according to the study protocol, however data displayed non-consecutive enrollment. We speculate this may be due to some provider reluctance to participate in the study or patient refusal preventing consecutive series enrollment. The degree of subject refusal was not recorded during the enrollment period for further reflection. At time of patient enrollment, treatment was initiated in both arms with initial administration of prochlorperazine and diphenhydramine within several minutes. In either arm, the ‘study drug’ required the blinded product to be sent from pharmacy to the Emergency Department, resulting in subsequent administration to the initial medications as noted above. The level of significance of this on study outcomes is difficult to determine, since as noted in the placebo group the time to significant pain score decrease was slower than the acetaminophen group, and pain score decrease more profound in the acetaminophen group, although both arms had delayed ‘study drug’ administration by up to 15 minutes post initial medications. To maximize our sample size and decrease exclusion burden, we did not target a specific subset of headache populations. It would be beneficial to delineate in a larger trial if the observed benefit of IV acetaminophen is specific to certain headache conditions. Going forward, it would be worthwhile to study a head to head comparison of IV acetaminophen alone with a standard NSAID or opiate therapy to ascertain if similar efficacy exists in treatment of cephalgia as it was reported in treatment of renal colic by Bektas et al33. Results may further support evidence suggesting avoidance of opiates in treatment of headache presentations is wise. It is also worthwhile to note that a cost analysis was not performed in this

trial, which is important as OFIRMEV® as currently available in clinical practice does carry moderate increase in patient cost compared to therapies which have been traditionally utilized.

ucm239821.htm. 3. Jones, V.M. Acetaminophen Injection: A review of clinical information. Journal of pain & palliative care pharmacotherapy. 2011;25:340-349 4. Macario, A., Royal, MA. A literature review

Based on results of this trial, Intravenous acetaminophen when used as an adjunct with prochlorperazine and diphenhydramine to treat acute headache presentations in the Emergency Department setting resulted in increased pain reduction, decreased length of stay, and less rescue medications including narcotics utilized when compared to prochlorperazine and diphenhydramine alone.

of randomized clinical trials of intravenous acetaminophen (paracetamol) for acute postoperative pain. Pain Pract. 2011 MayJun;11(3):290-6. DOI: 10.1111/j.15332500.2010.00426.x. Epub 2010 Nov 28. 5. Memis, D., Inal, M.T., Kavalci, G., Sezer, A., Sut, N. Intravenous paracetamol reduced the use of opioids, extubation time, and opioid-related adverse effects after major surgery in intensive care unit. J Crit Care. 2010;25:458462. 6. OFIRMEV TM(acetaminophen) injection

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