2017 PACEP News October Newsletter

PENNSYLVANIA COLLEGE OF EMERGENCY PHYSICIANS OCTOBER 2017

Executive Privilege Maria K. Guyette, MD, FACEP PACEP President The name and the chief complaint didn’t seem to fit together. The name I knew very well from prior encounters, and I expected that it would be paired with “intoxication” or “EtOH” or “sleeping outside”. On this day, the chief complaint was “shoulder pain”. I, of course, anticipated that I would be walking in to see him with a shoulder injury after a fall while intoxicated.

Instead I found him completely sober, awake, and smiling as he sat on the edge of the bed. Turns out, when he is sober, he paints – by his description “like Jackson Pollock”. And the shoulder pain (worse with movement, tender on palpation) was wholly compatible with an overuse injury.

Unfortunately, his sobriety didn’t last long, and I have since seen him many times with the chief complaint “intoxication”. But now I see him with fresh eyes.

The social history is a required checkbox. And checkboxes and requirements can be unpleasant. There is an argument to be made that the social history is always relevant – but on a focused ED exam, there are times when we are asking the questions just to check the box. It’s a reminder of the larger collection of checkboxes that are a part of every shift, and the extra time that it takes to do that part of our jobs.

It doesn’t have to be just a checkbox.

We spend a lot of time listening to the stressful and painful reasons that bring patients to our doorstep. It takes only a short time to ask them about what they do for work, with whom they live, and if they continued on page 3

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Executive Privilege continued from page 1 have travelled recently. Their answers allow a glimpse into their lives outside the chaotic places we see them in; often actually help with the medical assessment, and help the patient and the physician take a step back from the crisis that brings them to the ED.

But, in between those boxes are the patients – and that’s what we all got into this business for.

Emergency medicine involves a lot of checkboxes. But, in between those boxes are the patients – and that’s what we all got into this business for. This year, PACEP has been focused on removing the checkboxes and getting you back to the bedside. We have a newly-formed Wellness Committee that is working on activities for next year’s Scientific Assembly. We are spending time with our legislators fighting for fair reimbursement. We have joined with our colleagues across the state to stand up to unfair payer policies.

I can’t remove the requirement to document a social history (or a 10- point ROS), but PACEP will continue to work on mitigating the challenges and barriers that take too much time away from patient contact.

Outstanding ED Physician Needed State College, PA Home of Penn State University • • • • • • • • • • • • • • • •

Independent democratic group 60-bed Emergency Department completed in 2013 All EM residency-trained and EM-boarded physicians Physicians work with their own scribe every shift Fee for service/Excellent Compensation Package/ACEP Membership paid Single hospital contract Years of stable amicable relationship with administration ED Patient Volume: 60,000+ 50-60 hours of physician coverage per day/ 8.5 hour shifts 40 hours of PA coverage per day Fully computerized/Meditech EMR Voice recognition dictation/transcription Excellent nursing/ ED techs/ IV team Superb admitting and consulting staff/ 2 Hospitalist Services CT/Ultrasound/MRI available 24/7 plus our own Sonosite University community: Great schools and all the amenities without crime E-mail: Tziff@Mountnittany.org or mail: Theodore L. Ziff MD, FACEP 1800 East Park Ave., State College, PA 16803 (814) 278-4851

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Assistant/Associate Residency Program Director Emergency Medicine Core Faculty Pediatric Emergency Medicine Faculty Community-Based Site Opportunity

The Emergency Medicine Department at Penn State Health Milton S. Hershey Medical Center seeks energetic, highly motivated and talented physicians to join our Penn State Hershey family. Opportunities exist in both teaching and community hospital sites. This is an excellent opportunity from both an academic and a clinical perspective.

As one of Pennsylvania’s busiest Emergency Departments treating over 75,000 patients annually, Hershey Medical Center is a Magnet® healthcare organization and the only Level 1 Adult and Level 1 Pediatric Trauma Center in PA with state-of-the-art resuscitation/trauma bays, incorporated Pediatric Emergency Department and Observation Unit, along with our Life Lion Flight Critical Care and Ground EMS Division.

We offer salaries commensurate with qualifications, sign-on bonus, relocation assistance, physician incentive program and a CME allowance.

Our comprehensive benefit package includes health insurance, education assistance, retirement options, on-campus fitness center, day care, credit union and so much more! For your health, Hershey Medical Center is a smoke-free campus.

Applicants must have graduated from an accredited Emergency Medicine Residency Program and be board eligible or board certified by ABEM or AOBEM. We seek candidates with strong interpersonal skills and the ability to work collaboratively within diverse academic and clinical environments. Observation experience is a plus.

For additional information, please contact: Susan B. Promes, Professor and Chair, Department of Emergency Medicine, c/o Heather Peffley, Physician Recruiter, Penn State Hershey Medical Center, Mail Code A590, P.O. Box 850, 90 Hope Drive, Hershey PA 17033-0850, Email: hpeffley@hmc.psu.edu OR apply online at www.pennstatehersheycareers.com/EDPhysicians

The Penn State Health Milton S. Hershey Medical Center is committed to affirmative action, equal opportunity and the diversity of its workforce. Equal Opportunity Employer – Minorities/Women/Protected Veterans/Disabled.

Feature

I Saved Your Life… Surprise, Here’s Your Bill!

The Politics Of Balance Billing Heather Walker, MD, FACEP Co-Chair, PACEP Medical Economics Committee

What is a Surprise Balance Bill?

Pennsylvania Senate Bill 678 defines a balance bill as “a bill for a covered service provided to an insured that seeks to collect from the insured the difference between an out-of-network providers fee for a covered service received by the insurer from the out-of-network provider and the reimbursement received by the out-of- network provider from the insured health care plan.”

A similarly themed House Bill (HB 1553) defines the process as such: “Surprise balance billing happens when someone gets medical care from providers and at facilities they believe are in their health insurance plan’s network, but unknowingly receives services from an out-of-network provider.”

More simply summarized, it is a bill sent to a patient to cover the cost difference between in-network and out-of-network services and care.

Both the House and the Senate seek to limit patient’s exposure to these types of “surprise” bills with mechanisms that include: • Allowing insurers to arbitrarily set the level of reimbursement.

• Requiring providers to negotiate with insurers for each bill to determine fair payment for the services provided.

• Mandating a cumbersome arbitration process to determine fair payment when the insurer and provider are unable to come to an agreement on reimbursement. (*NOTE: SB 678 places

significant emphasis or arbitration for resolution in these situations.)

While these are laudable goals, their implementation will make it difficult for emergency physicians to continue to provide high quality care to anyone who comes to the emergency department.

Why does this matter?

Emergency physicians have been specifically targeted in the media when patients have received a surprise bill. The commonly-cited scenario is that the hospital or health system that houses the emergency department is in-network, but the physician group is not. The patient would not typically have prior knowledge of this.

Patient bills are often affected by high-deductible plans that place a larger out-of-pocket burden on the patient, not solely on balance billing.

PACEP leadership has been actively and positively involved in reaching out to our senators and representatives regarding this matter. There is concern that the message of emergency medicine has yet to be fully understood. continued on page 6

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Feature continued from page 5

Emergency medical physicians know time is of the essence.

WE NEED YOUR HELP What can you do?

• Become Educated o Visit www.pacep.net for PACEP talking points and resources.

o Find out with which insurance carriers your group is in-network and out-of-network. As this topic becomes more publicized patients may start to ask.

o Find out if your group balance bills for out-of-network care and services.

o Learn what your group rates are for reimbursement to understand the recommendations contained in the emergency medicine balance billing talking points.

o Join the PACEP Governmental Affairs Committee or the PACEP (state-focused) 911 Network for updates and instructions.

• Contact your government officials

PinnacleHealth has multiple open positions to help meet the community’s increasing need for Emergency Department Services.

Open positions include: Emergency Physician  Observationalist  Emergency Site Director

o

o

We are hoping for a grassroots, informational attack on this issue. Our senators and representatives will not know or understand our concerns unless we can and do articulate them accurately. Write a letter, schedule an appointment, make a phone call.

To locate your Pennsylvania elected officials, look for our zip sticker at www.pacep.net on the ‘Current Issues’ page.

We are stronger together. We all have busy personal and professional lives, but taking a few moments to announce PACEP’s cause helps all Pennsylvania emergency physicians in the long run.

PACEP will continue to update membership on this issue. Keep an eye on your email and visit PACEP’s website at www.pacep.net.



For more information or to apply please visit: pinnaclehealth.org/providers

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PACEP News, October 2017

PACEP’s NEW WEBSITE! We are pleased to announce the launch of our brand-new website at

www.pacep.net

Advocacy

Robert R. Whipkey, MD, FACEP PEP-PAC Chair Have you ever heard of the term “angel investor”? If so, have you ever considered being one?

Usually, angel investors are sought for new start-ups.

Statistically, angel investments are not profitable. Attorneys, whose primary job is to instill fear in others, usually forbid guaranteeing a return on such investments. However, I have no fear in telling you, your investment in THIS will definitely be REWARDING. Our “company” is well-established and has been in business since 1979. Our “company” has outstanding consumer recognition, a limitless supply of consumers, a monopoly in our business niche, consumers waiting in line to purchase our product, and nationwide income before taxes, interest, depreciation and amortization (IBIDA) in excess of $50 BILLION. We are in our 38th consecutive year of growth and experts say that growth will continue.

Our opportunity is for you to invest in the specialty of emergency medicine. Our “Angel Investment Group” is called PEP-PAC. Membership dues are certainly helpful, but a contribution to the Pennsylvania Emergency Physicians’ Political Action Committee (PEP-PAC) is additional insurance that our specialty will be acknowledged, protected, and strong. Our modest goal for 2017 is $20,000 to fund our continued growth, prosperity and market strength. So far, we have secured $15,000 toward our goal.

However, even though our business is strong, we continue to face many threats in the marketplace: 1. Balance billing 2. Prescription regulations 3. Continued interference in the physician-patient relationship

Don’t let these awful things happen to us! Help us reach our goal!

Some emergency physicians are not savvy investors. Several are likely in your department. We suggest you encourage them to join you and invest in emergency medicine. You, as a savvy investor, know a good opportunity when you see it, and will help us reach our goal.

Here is how you and your friends can donate to PEP-PAC and have a positive impact on our work lives and the well-being of our patients: • Mail a donation to PEP- PAC, 200 North 3rd St., Suite 1500, Harrisburg, PA 17101-1590 • Your employer may also have a payroll deduction plan to donate regularly to PEP-PAC. (Interested in payroll deductions? Contact PACEP at info@ pacep.net or (877) 373-6272 for details.

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Legislative Update BUDGET UPDATE

SENATE FALL SESSION SCHEDULE October

16, 17, 18, 23, 24, 25

November

13, 14, 15

December

11, 12, 13, 18, 19, 20

HOUSE FALL SESSION SCHEDULE

Milliron & Goodman Government Relations

October

At the time this article was written, lawmakers continued to debate the legislation necessary to complete the state budget. That includes a $2-plus billion revenue package to cover a $1.5 billion deficit from the 2016/17 budget and a projected $700 million gap in this year’s budget. Also pending is in the Legislature are bills directing how the state budget dollars are spent and funding for Pennsylvania’s state-related universities.

2017 FALL LEGISLATIVE SESSION SCHEDULES ANNOUNCED The 2017 Fall Session Schedules for the Pennsylvania House of Representatives and State Senate are now available. The Fall Session is scheduled to resume the week of September 11 with the return of the state House.

2, 3, 4, 16, 17, 18, 23, 24, 25

November

13, 14, 15, 20, 21, 22

December

4, 5, 6, 11, 12, 13, 18, 19, 20

LEGISLATION Milliron Goodman continues to work with PACEP’s leadership on legislation affecting your profession, your colleagues, and your patients. Here is a look at some of the noteworthy bills.

E-Prescribing (HB 353 – Rep. Tedd Nesbit, R-Mercer): This bill amends the Controlled Substance, Drug, Device and Cosmetic Act to require electronic prescriptions of a Schedule II, III and IV controlled substance. Working with various stakeholders, PACEP clarified exceptions in the bill. As amended, the electronic prescription requirement shall not apply if the prescription is issued: By a veterinarian; Under circumstances when an electronic

Emergency Medicine Opportunity – Rural Pennsylvania $25,000 Starting Bonus and Loan Repayment St. Luke’s Hospital - Miners Campus is recruiting for full-time Emergency Medicine physicians to be an integral part of our successful physician team. The hospital is a fully accredited, not-for-profit, 45-bed acute care hospital located in Coaldale, Pennsylvania in Schuylkill County. It boasts a state of the art 14-bed Emergency Department and is on pace to treat more than 18,000 patients per year and is the first certified Level IV Trauma Center in Pennsylvania.

We possess our own full-time 24/7 EMS transport team who work alongside our very experienced and patient focused nursing team. Candidate must be ABEM board certified. 32 hours of physician coverage daily (12 and 8 hour shifts) with 10 hours of PA coverage. Supported by state of the art radiology.

This employed position offer: •

$25,000 starting bonus and up to $100,000 in loan repayment

•

Location and retention bonuses

•

Competitive salary with incentive plan

•

Rich benefits package, including relocation, malpractice, health & dental insurance, CME allowance

St. Luke’s Miners Memorial Hospital is a member of the nationally recognized St. Luke’s University Health Network, a nonprofit network comprised of physicians and hospitals, providing care in eastern Pennsylvania and western NJ. The Network includes more than 200 locations and seven hospitals and employs more than 450 physicians and 200 advanced practitioners.

The Miners Campus is just 12 miles west of The Pocono Mountains of Jim Thorpe, PA. The location is ideal for skiers, mountain biking, hunting and fishing yet is just 35 minutes north of the Lehigh Valley, 90 minutes of Philadelphia and 2 hours to Downtown Manhattan. Please send CV to Drea Rosko at physicianrecruitment@sluhn.org.

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PACEP News, October 2017

Legislative Update prescription is not available due to a temporary technological or electrical failure; By a practitioner and dispensed by a pharmacy located outside of this commonwealth; By a practitioner who or health care facility that does not have internet access or an electronic health record system; or By a practitioner treating a patient in an emergency department or a health care facility under circumstances when the practitioner reasonably determines that electronically prescribing a controlled substance would be impractical for the patient to obtain the controlled substance prescribed by electronic prescription or would cause an untimely delay resulting in an adverse impact on the patient’s medical condition. The bill as amended unanimously passed the state House by a vote of 194-0. The bill is now in the Senate Health and Human Services Committee.

Involuntary Commitment for Individuals with Substance Use Disorders (HB 713 – Rep. Matt Baker, R-Tioga): This bill amends the Mental Health Procedures Act to include individuals with substance use disorder, which has caused an overdose within 30 days, as an individual subject to involuntary commitment. This will subject individuals with substance use disorder to emergency examination and treatment to be undertaken at a treatment facility.

The bill would expand that definition of “clear and present danger” to include the ingestion of drugs to the point of unconsciousness, or in need of medical treatment to “prevent imminent death or serious bodily harm.” From an emergency medicine standpoint, this legislation would likely have far-reaching implications that would hinder rather than augment shared goals of enhancing substance use disorder treatment and decreasing overdose deaths in the Commonwealth of Pennsylvania. PACEP submitted a letter expressing concerns to the state House. The bill is currently in the House Appropriations Committee. Similar legislation has been introduced in the state Senate (SB 391 – Sen. Jay Costa, D-Allegheny).

Bed Registry Act (HB 825 – Rep. Doyle Heffley, R-Carbon): While there are no simple solutions to combatting the heroin and opioid epidemic, PACEP has proposed several recommendations, including a comprehensive, real-time statewide tracking system of available psychiatric and drug and alcohol treatment facility beds to allow for enhanced and timely placement of appropriate patients from the emergency department. This bill provides for a psychiatric and detoxification bed registry. PACEP is working with the sponsor to enhance the legislation. The bill was unanimously voted out of the House Human Services Committee.

Assault of a Health Care Practitioner (HB 646 – Rep. Judy Ward, R-Blair): This legislation will raise the penalty for an assault on a health care practitioner, while in the performance of duty where there is bodily injury, from a misdemeanor of the second degree to a felony of the second degree. PACEP supports this bill.

HB 646 passed the House by a vote of 188-6 and is currently in the Senate Judiciary Committee. Similar legislation has been introduced in the state Senate (SB 445 – Senator Don White, R-Indiana).

EMS Reimbursement for Non-Transport Services (HB 1013 – Rep. Steve Barrar, R-Delaware): This legislation would require managed care plans to pay all reasonably necessary costs associated with the provision of emergency services when an

emergency medical services agency is dispatched by a 911 call center to provide medically necessary emergency care, including advanced life support services, to an individual covered by such plans, even if the covered individual does not require transport or refuses to be transported. Patients routinely experience emergent scenarios, such as diabetic emergencies, asthma exacerbations, and opioid overdoses that require immediate, life-saving care. Some patients don’t require or refuse transport. If the patient is not transported, the cost of providing the service is directly assumed by the ambulance company - a burden which could be so significant that the company would need to close, and the public would inadvertently be put at risk. PACEP voiced its support for HB 1013. The bill unanimously passed the House by a vote of 190-0 and is currently in the Senate Banking and Insurance Committee.

Balance Billing (SB 678 – Senators Judy Schwank, D-Berks, Don White, R-Indiana, and Jay Costa, D-Allegheny)/HB 1553 – Reps. Matt Baker, R-Tioga and Tina Pickett, R-Bradford): This legislation seeks to address “surprise” balance bills, also known as “surprise out-of-network medical bills”. Among the concerns, the legislation would rely on health insurance companies to set and pay “the out-of-network amount due under the health insurance policy” without an impartial, transparent standard and require providers to ask for cost-sharing amounts rather than the information being automatically provided to the provider by the insurance company any time a bill is sent to the insurer. In addition, the bill provides for the use of arbitration as a dispute-resolution mechanism with a “loser pays” payment model that would mandate best-offer binary decision making, require deposit of arbitration costs prior to resolution, and lacks a floor above which arbitration would kick in. Insurance companies have more personnel and resources to contest reasonable charges by physicians who have already provided emergent care to patients at times of crisis without knowledge or concern for insurance network status. PACEP has added its voice to discussions with lawmakers and key decision makers and is working with other hospital-based specialties. Pennsylvanians should be able to use the closest and most appropriate emergency department when they have an acute need.

No patient at a time of medical crisis should have to worry about insurance network coverage. At the same time, insurance companies should be required to pay fair and reasonable reimbursement rates to emergency care providers, regardless of whether they are considered in- or out-of-network. SB 678 is currently in the Senate Banking and Insurance Committee and HB 1553 is in the House Health Committee. Please stay alert for updates as Milliron & Goodman and PACEP’s leadership continue discussions with lawmakers and stakeholders. We will need you to join the effort to urge legislators to vote NO on the balance billing legislation.

CONTACT If you have any questions regarding this legislative update or would like to get involved, please do not hesitate to contact us at 717.232.5322. We have an open-door policy.

PACEP News, October 2017

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Mark Your Calendar

and Clear Your Schedule for These Important 19 Events!

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October

ACEP17 Scientific Assembly October 29 - Nov 1, 2017 Walter E. Washington Convention Center, Washington,DC

March

PACEP18 Scientific Assembly

PACEP Leader Now Leads PA “House of Medicine’ Theodore A. Christopher, MD, FACEP, is professor and chairman of the Department of Emergency Medicine at the Sidney Kimmel Medical College (SKMC) of Thomas Jefferson University, Philadelphia.

He becomes the 168th president of the Pennsylvania Medical Society (PAMED) on October 14, 2017.

Since becoming a physician, Dr. Christopher has been active in emergency medicine clinical practice, administration, education, and research. Under his leadership, Jefferson’s Department of Emergency Medicine has treated millions of patients and has helped establish Thomas Jefferson University Hospital as one of Philadelphia’s premier safety net hospitals.

He has volunteered extensively in his community and assumed leadership positions not only in his medical institution, but also within several medical organizations.

In addition to his roll at PAMED, Dr. Christopher is the past president of the Association of Academic Chairs of Emergency Medicine, the Pennsylvania College of Emergency Physicians, receiving the Chapter’s Meritorious Service Award, and the Philadelphia County Medical Society, serving as its liaison to the Philadelphia Health Management Corporation (PHMC). He has also served as a Pennsylvania Delegate to the American Medical Association for many years.

The Pennsylvania College of Emergency Physicians proudly supports our esteemed colleague Theodore A. Christopher, MD, FACEP as he begins his journey as President of the Pennsylvania Medical Society.

Congratulations, Dr. Christopher!

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PACEP News, October 2017

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March 19-21, 2018 Harrisburg, PA

May

ACEP Leadership and Advocacy Conference May 20-23, 2018 Grand Hyatt, Washington, DC

SAVE THE DATE

Virginia | Maryland | Washington, DC | West Virginia EMA, an established twenty-four hospital regional, physicianpartnership, physician-managed group seeks full and part-time BC or BP Emergency physicians to practice in Virginia, Maryland, Washington, D.C. and West Virginia. Since 1971, EMA has offered our physicians an unmatched quality-of-life with the secruity of our 100% contract stability.

• Partnership opportunities • Quality-of-life centered practice • Administrative & clinical opportunities • Full benefits package for physicians and family Send CV: Se V: Emergency Medicine Associates, P.A., P.C. Phone: 1-800-942-3363 Email: Recruitment@EMAonline.com www.EMAonline.com

L iv e, Wor k & Play With U s !

Wellness Update

The Importance of Physician Wellness Jennifer Savino, DO Chair, PACEP Wellness Committee Over the past few years there has been an increased focus on the importance of physician wellness. Wellness is the deliberate process of working toward a healthy and fulfilling life. This is especially important for emergency physicians, given that we are among the specialties with the highest burnout rate (2012).

I felt energized to go back to work and to implement a few of the techniques I’ve learned.

The next time you find yourself feeling burned out in the emergency department, I suggest you sign up for a conference on a topic that is interesting to you. Choose a place that removes you from your usual environment. When you are there, really immerse yourself in the experience. Network with your colleagues and open yourself up to making a new friend. It may just medicine you need to help you on your next shift.

Burnout can affect our personal lives and the quality of care we provide. This is what makes wellness so important. There are many techniques offered to help physicians maintain wellness such as better work hours, mindfulness and engaging in activities that make us more integrated in our medical communities. I would like to offer up another option. Attend a conference.

Here’s a helpful hint: Plan to attend PACEP’s Scientific Assembly next spring, held March 19-21, 2018 in Harrisburg.

I make this recommendation from personal experience. I just returned from a week-long ACEP teaching fellowship conference.

I was expecting to passively sit in a classroom and be fed information. What actually happened was that I learned different ways of looking at problems, as well as different ways to solve them. I came back with ideas for projects and ideas for how to improve my practice. Most importantly, I made some new friends and connections with really interesting people from all over the world. I was both humbled by my colleagues and reassured about my abilities. While it was hard to be away from my spouse and kids for the week, I returned home a satisfied partner and parent.

We hope you’ll join us in fighting for a healthy work/life balance.

The PACEP Education and Wellness Committees are planning an event chock-full of professional insight and tools. Watch for new wellness-focused content and activities too!

References

1. Shanafelt, TD et al. Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population. Intern Med. 2012;172(18):1377-1385.

2. https://www.acep.org/wellnesssection/ 3. https://cordemblog.wordpress.com/2016/08/25/cordresilience-committee-resource-task-force-update/

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PACEP News Editor Maria K. Guyette, MD, FACEP Executive Director Cicely D. Elliott Meeting Managers Sharon Fahrer and Jessica Winger Administrative Secretary Jan Webb Writer/Assistant Executive Director Connie Benson All correspondence should be addressed to: PACEP News 777 East Park Drive, PO Box 8820 Harrisburg, PA 17105-8820 717-558-7750 ext 1589 or (877) ER-DOC-PA (373-6772)

PACEP News is published by the Pennsylvania College of Emergency Physicians and is printed in the USA. Opinions expressed in this newsletter do not necessarily reflect the PA College’s point of view. All advertisements appearing in PACEP News are printed as received from the advertisers.

Advertisement in PACEP News does not imply endorsement of any product or service

by PACEP. PACEP receives and publishes advertisements but neither review, recommends, or endorses any individuals, groups, or hospitals who respond to these advertisements.

info@pacep.net

WESTERN PENNSYLVANIA

EMERGENCY MEDICINE UPMC and University of Pittsburgh UPMC has a long history of emergency medicine excellence, with a deep and diverse EM faculty also a part of the University of Pittsburgh. We are internationally recognized for superiority in research, teaching and clinical care. With a large integrated insurance division and over 20 hospitals in Western Pennsylvania and growing, UPMC is one of the nation’s leading health care systems. We do what others dream — cutting edge emergency care inside a thriving top-tier academic health system.

We can match opportunities with growth in pure clinical or mixed careers with teaching, research, and administration/ leadership in all settings — urban, suburban and rural, with both community and teaching hospitals. Our outstanding compensation and benefits package includes malpractice without the need for tail coverage, an employer-funded retirement plan, generous CME allowance and more. To discuss joining our large and successful physician group, email emcareers@upmc.edu or call 412-432-7400.

EOE Minority/Female/Vet/Disabled

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PACEP News, October 2017

72714B HRI&E 02/17

Welcome New PACEP Members Erin Albery, DO Jamie Allen, DO Caitlin Azzo, Ryan Bailey, DO William Balshuweit Jonathan Bar, MD Kathryn Bartlett, DO Dahlia Bergmann-Dumont Brandon Blakey, MD Thomas Bloom Michael Briskey Dylan Brown Jordan Brown Catherine Burdett Cortnie Carlheim Kurt Channick Kin Chew, MD Jennifer Cipullo, MD Andrew Clark, DO Patrick Collins Corinne Cricco Uma Damle, MD Duc Dang Nikita Desai, MD Mario DeYulis Harrison Diaber, DO Jessica Downing Matthew Ellenberg Matthew Fennema, MD Edmond Fenton Tierney Flodine Alec Freling Kimberly Fugok, DO Rachel Gartland, MD Ryan Gifford-Hollingsworth Paul Ginart Brittney Giuffre Kelly Goodsell Cody Grace David Gregory, MD Michael Grimaldi, MD Daniel Halvorsen, Student Sarabeth Hedge, DO Adam Hemminger JJ Hoff Alexandria Holmes Emily Howell Brandon Intrieri, DO Umang Jain, MD Joshua Kaminski Kristen Kelly

Kristen Kish Ludwig Koeneke-Hernandez Justin Leach Ian Leopold Jessica Lerman Joseph Levi, DO Philip Lieberman James Longenbach, MD Eussra Magbri, MD Pamela Maisey Nathan Marcinkowski, MD Tucker Maute Alexander McGinley Lynn McGowan Daniel McLaughlin, MD Alex Mercado Seth Merker, MD Luke Messac Lauren Moore Olivia Munizza Jessica Patterson, MD Joseph Pietropaoli, MD Justin Putnam, MD Neil Ray, MD Faisal Rehman, MD Lilia Reyes, MD R.J. Roll, DO Kelsey Row Kim Rutherford, MD Praveen Sabapathi Jennifer Sadowski, DO Claire Shaffer Whitney Sheppard, DO Alex Sloboda, MD Brandon Somwaru Charles Springer, MD Gregory Stoner Sathyaseelan Subramaniam, MD Sydney Tabaac Daniel Tannenholtz Stephen Taylor Alexander Tiesi, MD Jessica Tolbert, MD Abdul Wasey, MD Benjamin Watkins, DO Ryan Wetzel, MD Anna Yang, MD Alexander Yang, MS, OMS-3, NRP Homaira Zaman Ethan Zimmerman

POLST Update Quality and Safety Considerations for Patients With a POLST or Living Will Ferdinando L. Mirarchi, DO, FAAEM, FACEP, and Kate Aberger, MD, FACEP The National Academy of Sciences released its groundbreaking report on end-of-life (EOL) care, confirming EOL care is not only broken but accounts for $170 billion in annual spending.

To make an impact, living wills (LWs) and physician orders for life-sustaining treatment (POLST) are here to stay. Additionally, Medicare now reimburses for advance-care planning (ACP) conversations.

Physicians have tried to embrace LWs. More recently, the POLST paradigm has emerged to the national forefront. This growth has led to concerns that states cannot educate fast or well enough to ensure their safe and effective utilization. Both LWs and POLST are good documents. How they are applied by others in clinical situations, such as critical illness, has led to the unintended consequences of both over- and under-resuscitation. We have essentially introduced a new patient safety risk that has no quality oversight. We must recognize these risks and act to improve patient outcomes.

Can we accurately interpret POLST or LWs? Most LWs are created by attorneys years in advance of the onset of medical conditions.

Often, POLST are completed by other providers (eg, social workers or registered nurses) and signed by physicians who may or may not have been involved in the conversation. So how do frontline emergency physicians interpret these during a brief interaction?

Emergency physicians do not know these patients or families and have no established trust or rapport, yet within seconds they are expected to understand the patient’s wishes to either accept or decline lifesaving interventions based upon a form. “Full Code” appears understood. However, with a do-not-resuscitate (DNR) order, things are less clear. With POLST, there are many combinations of treatment options, which make the water murkier.

The TRIAD studies have questioned whether providers understand what to do with LWs, DNR orders, and POLST. We need to figure out who is better off with a LW versus a POLST. We need to set quality standards and abide by them universally. More important, we need to standardize goals-of-care conversations so they are balanced and accurately predict the patient’s wishes. That information then will need to be conveyed to a totally different and disconnected medical provider in a safe and effective manner that ensures no risk to the patient.

At this time of escalating costs, are we also trampling on patients’ wishes? The pioneering work of Volandes, Wilson, and ElJawahri has shown that educational videos can help patients make informed decisions about CPR. Could we then utilize patient video testimonials to help providers make informed medical decisions for patients in a safe and effective manner? Recently accepted for publication by the Journal of Patient Safety is the TRIAD VIII study. This was a multicenter evaluation to determine if patient video testimonials can safely help to ensure appropriate critical versus EOL care. We can now say that we can do things better to ensure we get it right for patients.

With patient video testimonials, we can now hear from patients when they are critically ill and receive their guidance rather than providers guessing after reviewing a form that may or may not have been completed correctly. Resuscitations are complex, and we need to know what to do in the first seconds to 15 minutes—paper forms do not do this well. We will still need POLST and LWs, but we also need to hear from the patients, and with emerging technologies, we need to be able to do this in a safe and costeffective manner.

In conclusion, we have a safety problem with documents, and TRIAD VIII presents an opportunity to do better. When appropriate, we have to rethink the concept of “treat first, ask questions later.” We need to embrace both LWs and POLST and be sure we set quality standards for their completion and understanding. We further need to investigate technologies to allow us to hear from patients to accurately guide their care.

-This article was reprinted with permission from ACEP Now.

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PACEP Residents

The Resident-Student Team Dhimitri Nikolla, DO PACEP Resident Representative As a resident, teaching students during a shift can be challenging. We are often so preoccupied with our own patient care that dedicating brain power to our “MiniMe” can be difficult. But, we are not too far removed from school to remember those residents who educated us and made us a member of their team.

Here are some tips to improve your resident-student team dynamic: •

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Take a couple minutes for introductions. Getting to know a little about each other not only makes your team more personal, but gives you the opportunity to tailor your teaching and learning. It would be nice to know that your student was an urgent care PA prior to medical school, before you begin teaching suturing techniques. Likewise, if your student is applying to orthopaedic surgery residency, you may have a few questions about how to reduce the forearm fracture that just came in.

Orient them to the department. Ever bend the wire during a central line and the only person who seems to be available to retrieve another wire is your student? Walk them through the department before the shift. Students want to be a team member as much as they want to learn.

And, if they can contribute to the care of the patient, even if it is running to grab an extra wire or syringe, that is a rewarding experience.

Focus on the presentation. This is the most critical part of their learning, because a focused, concise presentation requires underlying knowledge of the differential diagnoses and management approaches to various chief complaints. Challenge them to limit their histories and physical exams to pertinent positives and negative. Encourage them to present an assessment and plan on their own.

Guide them through procedures. It is easy to bump a student from the head of the bed when they cannot visualize the vocal cords. But, guiding them through the adjunctive maneuvers of readjusting the laryngyscope, patient head positioning, their body positioning, and external laryngeal manipulation is much more difficult. Directing someone else through a procedure takes a more thorough understanding of the

PACEP News, October 2017

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technique. Challenge yourself to be a backseat driver!

Provide feedback. Take a couple minutes at the end of the shift to let them know what they did well and what they can improve on. Encourage them to provide you with feedback as well. Whether a resident or student, nobody wants to be oblivious to their weaknesses.

As residents, we are not expected to be master educators, but students count on us to be engaged in and devoted to their learning. Likewise, the resident-student team is as much a learning experience for us as it is for students. Embrace the opportunity!

Further Reading

Bandiera G, Lee S, Tiberius R. Creating effective learning in today’s emergency departments: how accomplished teachers get it done. Ann Emerg Med. 2005 Mar;45(3):253-61.

Davenport C, Honigman B, Druck J. The 3-minute emergency medicine medical student presentation: a variation on a theme.

Acad Emerg Med. 2008 Jul;15(7):683-7.

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PACEP News, October 2017

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