Thursday, February 26, 2015

Fighting Sepsis in the Emergency Department

by Jeffrey F. Jones, MD, FACEP
Medical Director & Chair, Trinity Medical Center Department of Emergency Medicine

Sepsis is an infection and subsequent immune response that causes whole-body inflammation. Sepsis is usually caused by a bacterial infection, and the resulting mortality can be 30-50%. Severe sepsis has an even poorer prognosis, and is defined as sepsis along with poor organ function as a result of insufficient blood flow to tissues. Signs of organ dysfunction with severe sepsis include altered mental status, tachypnea, tachycardia, decreased urine output, and delayed capillary refill.

Sepsis is defined as infection plus the systemic inflammatory response syndrome, or SIRS. A technical diagnosis of sepsis requires presumed infection and at least 2 of the following SIRS criteria:

• Temperature < 96.8° F or > 100.4° F

• Heart rate > 90 beats per minute

• Respiratory rate > 20 breaths per minute

• White blood cell count < 4000/mm3, > 12,000/mm3, or >10% bands (immature forms)

In a major study in 2001, Dr. Manny Rivers reported a great reduction in the mortality of septic patients with an aggressive treatment approach he called "early goal-directed therapy". Starting in the emergency department, Dr. Rivers attempted to keep a patient's central venous pressure, mean arterial pressure, urine output, venous oxygen saturation, and hematocrit above certain levels. This often involved early and aggressive use of mechanical ventilation, fluid resuscitation, vasopressors, and transfusions.

This work led to the Surviving Sepsis Campaign. This group of experts issues guidelines for the treatment of sepsis. They favor "bundles", or groups of evidence-based interventions that result in better outcomes when implemented together. The campaign has a 6-hour bundle that applies for inpatient care, and the following elements of a 3-hour bundle that are intended to be completed within 3 hours of patient presentation (usually in the emergency department):

• Measure lactate level

• Obtain blood cultures before giving antibiotics

• Administer broad spectrum antibiotics

• Administer 30 mL/kg of crystalloid solution for hypotension or for a lactate > 4 mmol/L

Many hospitals are adopting protocols for the early identification and aggressive treatments of sepsis. At Trinity Medical Center, every patient presenting to the emergency department is screened for signs of sepsis (questioned regarding possible infection or altered mental status; measurements taken for hypotension, hypoxia, and the above SIRS criteria). If a patient is positive for the screening criteria items, the ED provider is notified. He or she then has access to computerized order sets to efficiently order all tests and interventions that are part of the sepsis bundles or are likely to be necessary for a septic patient. Additional protocols are in place for inpatient use. These efforts and more will hopefully achieve the 25% reduction in sepsis mortality that is the goal of the Surviving Sepsis Campaign and of Trinity Medical Center.

Monday, February 23, 2015

Soccer Injury Prevention is a Care Partnership

By: Darin Tessier, MD with Brookwood Sports and Orthopedics

I recently attended a youth soccer event in South Florida where hundreds of parents and participants saw the inevitable; a serious soccer injury. Current statistics from the STOP Sports Injuries association show 22% of all youth sports injuries occur in soccer.

As an orthopedic surgeon with a primarily focused sports medicine practice, I am committed to treating patients that are injured in sports and must get back to the field or court as quickly as is safe. However, my primary responsibility to my patients is the ongoing prevention of injury.

As with all successful athletes, soccer players spend a great deal of time of working on their own perfecting their skills. Many times these athletes neglect proper warm-up routines as they see this as impeding their actual practice times. Too often coaches and parents adopt this same approach. Stretching and proper warm-ups can and do reduce injury risk.

Other injuries occur because soccer players do not use proper technique as they play. Again, in the name of competition, a player may extend him/herself from an overexertion perspective to aggressive play that causes serious to permanent injury. From heat stroke to head injuries, many of these can be controlled through prevention. Proper hydration in hot and cold conditions, proper heading techniques, falling and tumbling drills, and regular agility drills can prevent needless soccer injuries.

Injury prevention is a care partnership between the coach, athlete, parent, and healthcare provider. Each has a role to play in injury prevention on the soccer field. No one in this care partnership should be seen as an adversary. Rather, each should work to support the ideas of safety, time management, and competitive spirit.

Should an injury occur I advocate the following protocol with my patients.

1. RICE. Rest, Ice, Compression, and Elevation are essential for immediate care of extremity injuries. The proper management of swelling can make the difference in accurate diagnosis to speedy recovery.

2. Communication. Each member of the care partnership must communicate effectively and honestly in order to establish an accurate care plan. This requires scheduling, initiative, resources, and motivation to accomplish.

3. Rehabilitation. I appreciate the work that my athletic trainers and physical therapists provide in the care partnership. When I order these services I make sure that the service is close the patient’s work or home. Unless this is the case, many patients are deterred from fully engaging in the benefits of training and therapy.

4. Surgery. I prefer a conservative course of treatment prior to surgery, but many times it is the only recourse.

Darin Tessier, MD is an orthopedic surgeon at Brookwood Sports and Orthopedics in Birmingham, Alabama. He received his training at the Medical College of Texas in San Antonio, Texas, and his fellowship in Sports Medicine with Dr. James Andrews. Dr. Tessier can be reached at 205-877-BONE (2663) or by email at

Thursday, February 19, 2015

The Long Range Plan in Medical Real Estate

By Richard A. Campbell III, CCIM with Veritas Medical Real Estate Advisors

When was the last time you assessed the long range plan for your clinic space? Do you have enough space? Do you have too much space? Are you looking to hire another MD, PA or NP in the next 5-10 years? Where do you want to be in the next 10-15 years? Are you a small practice, large practice or solo practice? Do you need to be near a hospital campus? Are you located conveniently to your patients? Is your clinic easily accessible? Do you have growth options? All of these questions affect your occupancy costs, and ultimately your bottom line. Therefore, they should be evaluated on a regular basis.

While pondering your office/clinic space, you should start with this……where are you in the life cycle of your practice? Are you in the early years with decades ahead of you? Or perhaps you are the veteran who wants to retire in 5-10 years. Most likely, however, you are somewhere in between. As a result, you will need a regular assessment of your space needs.

Controlling fixed costs has never been more important than now as we face a new healthcare environment driven by recent Federal changes. Whether you are a dermatologist with a three doctor practice, or a solo family practice doctor, you are likely concerned about the bottom line. After the cost of your employees (including health insurance), real estate is likely your next largest expense. Controlling that expense should be near the top of your list to keep a healthy bottom line. So… you see major changes in partnerships or practice employment? Are you a solo doctor who plans to remain that way throughout your career or are you on a path to build a multi doctor practice with potential for new satellite locations? Either way, you should regularly go through a comprehensive space planning and forecasting process.

The key to effective planning and decision-making today involves thinking about where you want to be in 15 years. Medical real estate decisions are almost certainly tied to longer commitments, oftentimes 10-year terms. Building owners will dangle enticing “carrots" in front of you in return for a long-term deal, but it may not always be in your best interest. In particular, that commitment could be problematic if it confines you to a direction that is not part of your long-range plan. You must know and understand ALL of your options. If your decision is based on a well thought out, long-range plan, it will work out even if you have to make some shorter-term sacrifices.

Here are some key points to help you assess your current practice state:

1) Do not get caught up in the false belief that owning your own building is always the best thing. Sometimes it may be a reasonable option but often times it is not financially feasible.

2) Think in terms of total occupancy costs as opposed to per square foot rates. For example, it’s possible to negotiate an excellent rental rate but lease 2,000 sf of space that you don’t need and your resulting total occupancy costs ends up too high.

3) Term is gold to property owners. Make sure you get the weight worth the gold you pay for longer term commitments.

 4) Always be familiar with your next best alternative. Whether you are leasing or buying, knowing your options is fundamental.

5) Seek the advice of a specialists in medical real estate.

Richard A. Campbell III

Wednesday, February 18, 2015

A Meaningful Use Post-payment Audit? - “Say It Ain’t So, Joe!”

By: Susan Pretnar, President KeySys Health, LLC

Oh, what I mean is “Say it ain’t so, Mr. Figliozzi, CFA, CFF, FCPA”. Who knows if Shoeless Joe really threw the 1919 World Series, but in our world, if you attested to Meaningful Use, you know for sure that CMS could come calling to see if what you attested to is indeed what happened back in the day. And, that ‘day’ could be the very first year you attested to Meaningful Use.

In 2014, CMS audited just 5% of the providers who had attested to Meaningful Use (for any year). How in the world could they find you? Just 5% was still 20,000+ providers. The rub: the government paid out more than $20B and CMS was blasted for not auditing enough to assure the money was properly spent. Is there fraud in the Medicare and Medicaid programs? Just sayin…might that also be the case with Meaningful Use?

I thought I’d offer a first hand account of what might happen if you receive an email (yes, it comes as an email of High Importance) notifying you that one of your physicians has been selected for a HITECH EHR Meaningful Use audit for payment year XX. It is important to remember the contact email address that was given when you attested to Meaningful Use, because that is the person who will receive the email from . Is that person still with your practice? There are all kinds of un-pleasantries if the selection email bounces back to

     Make a note - recheck the contact information on your attestations

By the way, at the end of their notification email, it advises you to add this email address to your safe sender list, otherwise their correspondence might be blocked as spam. You cannot respond back to this address mind you, but you had best let them contact you!

     2nd note – ask the tech people to let the figliozzi email address come flying through the firewall      3rd note – ask the tech people to check everybody’s spam folder - what the heck, better safe than sorry

Then what? The person who has been assigned as your very own personal auditor is named in the email and his/her contact information is included. You email and talk to that person, not . They are probably not coming on site, after all, 20,000+ of these emails were sent out last year. They prefer a desk audit (much cheaper and faster), with your personal auditor sitting comfortably at his/her desk waiting for your stuff, while you probably have not been allowed to sit down since the selection email arrived.

The selection email gives clear directions of how to send in a list of requested documents and how to identify each file. My small sample of just two examples indicates the selection notification email will give you a month to reply. Though not a statistically valid sample, I’d go out on a limb and say that is the norm.

So, what happens in a practice in order to respond to a selection email? While every practice will be a unique scenario, the following is a brief synopsis of some generously shared notes from one practice about the time dedicated to complete their response (retrieving documents, correctly labeling and emailing files, rebuttal opportunities, etc.), the number of people who participated in the response, and what they wish they had and hadn’t done ‘back in the day’. In retrospect, this practice did not feel that the total ‘cost’ of the audit was significant enough to try to compute.

The practice was given 3 opportunities to submit documentation for specific core measures, because their first submission was not completely satisfactory. Because so many practices lack a comprehensive risk assessment, it was a primary document Figliozzi focused on and one that the practice had to clarify further, necessitating a request to their outsourced IT managed service provider for additional documentation.

Another stumbling block was the fact that the practice’s attestation in question was based on a certified EMR that had subsequently been sold, and sold again. The original product certification was no longer on CMS’s system, so there was much ado about when or whether their EMR was truly a certified system. The practice’s current EMR vendor was able to research and substantiate the original vendor certification. In addition, their EMR had been upgraded several times; recreating reports from prior periods was problematic because of configuration changes and enhancements to the reporting tool, therefore, research and correcting of records for unmatched statistics was required.

The final hurdle was the inability to electronically submit syndromic surveillance data to a state public health department. The practice was given a waiver since their EMR was incapable of electronically creating syndrome-based public health surveillance information in the required format. At one time, there was a requirement to attempt a transmission, regardless of the ability of your State Department of Health to accept it, because ONC supplied test data and the criteria for testing this capability. There was significant confusion about whether a ‘failed’ test was sufficient, and whether it could even be attempted in Alabama during the first year of attestations. Apparently, there was enough confusion that Figliozzi granted the waiver.

In summary, this practice was complementary of their treatment by their auditor, who was generous with extensions due to the holidays overlapping their audit period. Because of the way they had stored their backup information, the practice had to recreate or separate results for just one doctor, even though some of the data applied to all of them. However, this practice was able to rely almost entirely on one manager to formulate their responses, who was also instrumental in their attestation process. The audit did not cause a major disruption in their day-to-day operations, nor much concern by the management team.

By the way, there was also a happy ending. Just wanted you to know.

Tuesday, February 10, 2015

MRI/Ultrasound Fusion Prostate Biopsy

By: Dr. Bryant Poole with Urology Centers of Alabama

New technology is now available that allows urologists to detect prostate cancer with more accuracy. The procedure is called MRI/Ultrasound fusion prostate biopsy. Urologists at Urology Centers of Alabama started using this technology in December, 2014 making them one of the few centers in the southeast offering this service. The technology takes advantage of magnetic resonance imaging’s (MRI) ability to identify lesions within the prostate that look suspicious for prostate cancer. The first step is to do the multiparametric MRI at the hospital. The radiologist will read the MRI, and if he identifies an area within the prostate, he will then outline it, thus creating a target that the urologist will be able to see on ultrasound. The targeted lesions are graded 1 through 5 (5 being “highly suspicious” and 1 being “not suspicious”). The urologist will usually biopsy any lesion that is graded as 3 or higher. The next step is to perform the biopsy in the office. Transrectal ultrasound is used to visualize the prostate during the biopsy, but the urologist will take the MRI image with the outlined target and “fuse” it with the ultrasound image that is used in the office. Instead of having an ultrasound image that only shows you the prostate, now the urologist can see an outlined target within the prostate and can now aim the biopsy needle directly at the suspected lesion. Before this technology became available, urologists could only do random biopsies of the prostate. We believe this procedure will allow urologists to more accurately detect prostate cancers.

In the past, the concern was that urologists were diagnosing too many non-aggressive cancers and missing some of the aggressive prostate cancers. A recent study showed that MRI/US fusion biopsy detected 30% more aggressive cancers that would have been missed by the old random biopsy method. The overall cancer detection rate for the MRI/US fusion biopsy is about 54%, whereas the cancer detection rate for the random biopsy method is about 32%.

Currently, MRI/US fusion biopsy is recommended for patients who have had a previous prostate biopsy that showed no cancer, but their urologist feels they need another biopsy because the PSA (prostate specific antigen) continues to rise or if they develop a nodule that can be palpated on their prostate. The procedure is also indicated for patients who have been previously diagnosed with a cancer that is presumed to be non-aggressive and are currently doing active surveillance. Sometimes these patients may have an aggressive prostate cancer that may co-exist with the non-aggressive cancer, and the MRI may be the only way to detect it. This procedure will not only allow the urologist to diagnose prostate cancer more accurately, it may also cut down on the number of unnecessary biopsies. If the MRI fails to show a suspicious lesion, the patient may be able to forego the biopsy. In the long run, we believe this procedure will save on costs because we can reliably stratify patients that will need more aggressive treatment versus those who do not.

Thursday, February 5, 2015

New Device Reduces CHF Readmissions

By: Barry K. Rayburn, MD, FACC with Cardiovascular Associates

Congestive heart failure (CHF) remains a prevalent and morbid condition, affecting millions of Americans and accounting for the largest number of hospitalizations under the Medicare program. With annual spending in excess of $30 billion, a great deal of attention has been paid to strategies that reduce rehospitalization.

Hospitalization and subsequent rehospitalization are often triggered by acute decompensation in previously stable heart failure patients. Often these episodes are initiated by either changes in patient behavior with medications or diet or the occurrence of comorbid conditions that upset the delicate balance often seen in heart failure patients. Strategies to reduce rehospitalization have long been focused on patient education regarding compliance with medications and diet, appropriate guideline-driven management by physicians and heart failure management programs that try to proactively identify problems before they result in hospitalization. These measures are variably successful and despite fairly wide implementation, heart failure admissions and readmissions continue to be problematic.

The CardioMEMS Heart Failure Management System has recently been approved by the FDA for use and physicians at Cardiovascular Associates of the Southeast have implanted this device in patients in an effort to reduce hospital admissions. The device consists of a small sensor (smaller than a dime) implanted in the pulmonary artery of a heart failure patient and a home monitoring unit. The patient lays on a pillow which activates the device and takes a recording of the patient’s pulmonary artery pressures (a very useful surrogate for volume status) and transmits the data to a secure website. By following trends over time, the system can reliably identify increasing problems early – often weeks in advance of the need for hospitalization – and allow for medication adjustment. In the CHAMPION Trial, patients with Class III heart failure and a prior hospitalization were shown to have a 37% reduction in rehospitalization when the device was used as part of their management program. The sensor is unique, having no internal power supply and therefore offering monitoring capabilities for prolonged periods. Implantation can be done as an outpatient procedure and monitoring requires only a few minutes each day. Clinicians can set thresholds based on individual patient needs and are notified by email if a patient exceeds preset thresholds. This device offers another tool in the ongoing fight to improve the lives of our patients with heart failure.

Wednesday, February 4, 2015

Sickeningly Sweet: The Silent Killer

By: Mary Beth Dearmon, MD_ Internal Medicine at Medical West UAB Tannehill Health Center

In America today, a silent killer is lurking – and, for many, has already begun to wreak its havoc.

What is this medical menace, we may ask?

The answer is obesity.

According to the CDC, approximately one-third of Americans is obese; that proportion rises to two-thirds in the state of Alabama. In addition, Generation X is the first in which parents are expected to live longer than their offspring. Furthermore, the annual healthcare cost of an overweight patient is estimated to be $1,429 higher than that of a person with normal weight.

The reason obesity is a silent killer is that many years may elapse before its damage is fully evident. Excess weight, particularly its distribution around the midsection (i.e. “pot belly”), is a sure sign of insulin resistance – the stage immediately preceding the development of diabetes. The higher blood glucose rises, usually in response to the glycemic index of the foods we consume, the more “visceral” fat is stored in the mid-abdomen.

Since mid-abdominal obesity is a harbinger of Type II, or “adult-onset”, diabetes, we may further ask why diabetes is so sinister for health and longevity. Over the long term, particularly if poorly controlled, diabetes can lead to renal failure, blindness, heart disease, strokes, and limb-threatening infections. Intriguingly, multiple acclaimed studies in recent years link high blood sugar (“hyperglycemia”) in general to the formation of “advanced glycemic end products”, or “AGE” products. These products, formed between glucose and the proteins in the body, have been hailed as a possible explanation of aging itself – in addition to so many of the long term effects of diabetes.

Prevention, as we know, is worth a pound of cure.

Avoiding high glycemic index foods, such as carbohydrates in general as well as sugary sodas and desserts, is most critical. Second, achieving 1 hour of aerobic exercise 5 days per week is also important for weight control -- as well as cardiovascular health in general.

If you are already a Type II diabetic, tight glucose control is key to both your quantity and quality of life.

If you do not already have a primary care provider, I invite you to come see me at Tannehill Clinic. I am committed to your health and well being – both treatment AND prevention of disease!

Warmest wishes,
Mary Beth Dearmon, MD

To schedule an appointment, please call the Medical West Tannehill Health Center at (205) 481-8640. -