This month look out for:
-LEAN process for reducing ED LOS
-Case law on EMTALA and psych emergencies
-Press Gainey scores and ED analgesics: not what they thought
-Randomized trial of anti-emetics: no better than placebo???
and much much more!
Email any time, firstname.lastname@example.org,
Ebola Grabs Attention, Headlines
The work ACEP members and staff did to make sure our colleagues were well-equipped with the best information available for diagnosis and treatment of Ebola was outstanding. We immediately convened a panel of eight emergency care infectious disease experts to review materials pertinent to emergency care for dissemination to members and respond to questions posted by members via an easily accessible form on the www.acep.org/ebola resource page. We developed a curated repository of best practices for managing the patient with suspected and confirmed Ebola and worked with CDC, WHO, and other federal, state and local agencies to develop protocols for hospitals with limited resources. We added numerous resources to the ACEP website and identified short and long-term legislative initiatives designed to assist our members and other health care providers to enhance their disaster preparedness. We also linked reporters with ACEP experts in infectious disease and disaster preparedness. ACEP managed 10-20 calls a day from reporters on this issue.
A round-up of ACEP Spokespersons in the News can be found at http://www.acep.org/Content.aspx?id=80956. We also added courses to the ACEP14 session lineup and made the audio from those courses available for free to all emergency physicians, worldwide, at the end of the conference. We developed an Ebola response survey for dissemination through our Emergency Medicine Practice Research Network (EMPRN) to gather data on preparedness for Ebola, EV-D68 and other infectious diseases, and we surveyed the Disaster Medicine Section, EMS Committee and Section and ACEP infectious disease experts about response needs and preparedness.
To make sure we were getting the most accurate and up-to-date information, we also met with high-level officials at the CDC and convened meetings with American Hospital Association, Emergency Nurses Association, National Association of EMS Physicians, Emergency Medicine Residents’ Association, and other key stakeholders for information/resource sharing. ACEP acted quickly and collaboratively to help prepare our colleagues.
Leadership and Advocacy Conference A Major Success
More than 550 ACEP members attended LAC this year to review and discuss the major issues of health care reform affecting the practice of emergency medicine. In addition to getting up to speed on the issues, practicing physicians, residents, and medical students also learned how to be more effective advocates for our patients and our specialty. As always, the highlight of the meeting was ACEP’s Lobby Day. This year’s key issues were psychiatric patient boarding in the ED the lack of resources for mental health care, expansion of residency slots and funding for graduate medication education, and the need for liability protection for EMTALA care provided in the ED. Here is a rundown of the bills ACEP members spoke with Members of Congress and their staffs about during LAC:
The Helping Families in Mental Health Crisis Act of 2013 (H.R. 3717): Improve research and data collection of existing mental health programs, promote evidence-based medicine systems of care for patients with mental health issues.
The Health Care Safety Net Enhancement Act of 2013 (H.R. 36/S. 961): Provide liability protection for EMTALA-related services in the emergency department to emergency physicians and on-call specialists as federal employees under the Public Health Safety Act.
The Resident Physician Shortage Reduction Act of 2013 (H.R. 1180/S. 577): Expand the current cap, in place since 1997, on the number of Medicare-supported graduate medical education slots in the United States. It would create 15,000 new training slots over five years.
The SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (H.R. 4015): Completely repeal the SGR and replace it with a workable formula.
The Saving Lives, Saving Costs Act (H.R. 4106): Provide increased liability protection in the form of legal safe harbors to physicians who demonstrate they followed clinical guidelines developed by a multidisciplinary panel of experts.
ACEP Announces New Building Plans
In 1983, when the current ACEP headquarters was built, emergency medicine was fairly new as a recognized specialty. Now, with more than 33,000 ACEP members, the needs of this dynamic, growing medical organization and its members have greatly evolved. Just as many aspects of emergency medicine were different 30 years ago, our building was designed for a very different organization with different staffing and space needs, as well as technological requirements.
In the 21st century, ACEP needs a headquarters that better represents the specialty and meets the needs of its members and its mission. In advance of the June meeting of the ACEP Board of Directors, the Finance Committee provided due diligence to make sure we could continue to advance and meet our financial benchmarks. The Board analyzed the options and decided that the best course of action is to buy land in Irving, Texas, near the DFW Airport and build a new ACEP headquarters building. The land, a 6.06-acre tract close to DFW Airport, was officially purchased on Oct. 20. ACEP commissioned a top-level space needs analysis and found that at ACEP’s current staff size, we need a building of approximately 42,527 square feet; currently we have 30,474 square feet. If staff grows by 25 percent in the next five years, we would need approximately 50,000 square feet. If we were to grow by 40 percent in 10 years, we could use a building of around 57,000 square feet.
For the convenience of our Board, committees, and members who visit, the purchased land is adjacent to a full-service hotel and can situate a 55,000 – 60,000 square-foot office building with adequate parking. The Board approved a plan to meet the total project cost of $14.5 million with $7 million down and financing of $7.5 million. ACEP has healthy financial reserves, with a substantial portion in very low-yielding CDs and fixed income investments. Additionally, when the current building is sold, ACEP can expect to net about $3.5 million. Groundbreaking will most likely be in the Spring of 2015 and take about18 months or more before move in. We believe value to our members and future members will be the result of this investment, and we anticipate more effective and efficient service for our Board, committees and chapters. A newer, modern headquarters presents further opportunities for ACEP to reflect, develop and disseminate our values and goals.
Steven Stack, MD, FACEP, Named AMA President-Elect
In June, emergency physician Steven J. Stack, MD, FACEP, was named President-Elect of the AMA, the first emergency physician to ever hold that position. Dr. Stack will be the youngest President in the past century when he takes over in June 2015. He currently practices in Lexington and surrounding central Kentucky and is a very active member of ACEP, speaking numerous times throughout the year on behalf of the specialty and advocating for emergency physicians everywhere. He delivered the Rorrie Lecture at ACEP14 and demonstrated his expertise in the Affordable Care Act and Health Information Technology. I congratulate Dr. Stack on his new office and know that he will continue to do great work for emergency medicine and indeed, for the entire house of medicine. If you have any membership dollars available in your professional budget, I hope you consider making this year one in which you might become an AMA member to bolster our ACEP delegation at the AMA. There are certain things that are more do-able when we have a strong delegation within the AMA, whether advancing our cause within the house of medicine or in our negotiations at the RUC.
My Condolences to the Families of Emergency
Medicine Leaders Who Have Passed Too Soon
Emergency medicine lost some of its founders and leaders during my term, so I’d like to recognize them and offer my condolences. Dr. Gail Anderson, the first professor and chairman of an academic department of emergency medicine in the United States, died in September. Another early pioneer of our specialty and ACEP Past President, Dr. George Podgorny, passed away in November. I was honored to deliver a eulogy at Dr. George Podgorny’s memorial service. Just before ACEP14 in Chicago, we learned the sad news about the passing of Dr. Richard V. Aghababian, who founded the Department of Emergency Medicine at the University of Massachusetts and served as ACEP’s President from 1994-95. Dr. Aghababian died in October at his home in Southborough, Massachusetts. Dr. Francis Fesmire, a national leader in emergency medicine, former Chair of ACEP’s Clinical Practice Committee and recipient of ACEP’s “Hero of Emergency Medicine” award in 2009, died in January. In my home chapter, PACEP, we lost Dr. Noelle Rotundo, all too soon. Noelle was a widely respected Pennsylvania EM educator and leader whom will always be remembered. The contributions that these men and women made to the specialty are immeasurable. My thoughts are with their families and the families of other ACEP members who have passed away this year.
ACEP Launches 2014 PQRS Registry Reporting System
ACEP announced in late August that it developed a PQRS registry reporting option and provided it o ACEP, EMRA and SEMPA members at a discount. The registry comes in response to the Centers for Medicare and Medicaid Services announcement that failure to satisfy the 2014 PQRS requirements equals up to 4 percent of Medicare payments, approximately $2,500 per provider. For more information on these requirements, please visit www.acep.org/quality.
Report Card Garners Major Media Attention
In January, we released the 2014 State-by-State Report Card on Emergency Medicine. The nation’s grade of D-Plus was abysmal, but we hope that this grade will stimulate a positive effort for improvement. In fact, the report card not only sounds an alarm, it offers a road map for a better future, supporting the delivery of emergency medical care. Our Report Card has already fostered many a conversation with state legislators. Media outlets have pointed out what we already knew – that several states don’t have the resources and policies in place to support high-quality emergency care. Stories about the Report Card appeared in major newspapers, including The Washington Post, Chicago Tribune, New York Daily News, Forbes, The Huffington Post, Los Angeles Times, San Francisco Chronicle, The Philadelphia Inquirer, Houston Chronicle and The Seattle Times, to name a few. Along with print stories, nearly 800 broadcast stories aired on news organizations including ABC’s World News Tonight with Diane Sawyer, MSNBC, CNN, Fox News’ Your World with Neil Cavuto, Fox Business News, CNBC’s Kudlow and Kramer, WNBC New York, and Telemundo as well as dozens of local television stations across the country. The estimated audience reach was 72.2 million. Our dedicated spokespersons will continue to make sure the results of this study resonate nationwide. Keep up with the progress at www.emreportcard.org.
ACEP Now Launched
When the calendar flipped to 2014, ACEP turned its monthly publication up a notch. We wanted to blend the needs of our membership with an edgy editorial vision related more closely to the world we work in. Beginning with a round-table discussion cover story and a compelling piece on breaking down racial barriers in the ED, the new-look ACEP Now hit mailboxes in mid-January and began receiving rave reviews from ACEP members. I hope you like the direction of our new medical editor-in-chief Kevin Klauer, DO, EJD, FACEP, and our new publishing partner, Wiley Press. The new ACEP Now is not only bigger, it features more incisive opinions, real articles regarding our decision making and advice from some of emergency medicine’s most renowned physicians. The news from ACEP and events related to the College will always be a part of the magazine, so none of that has changed. What has changed is the attention to detail and open dialogue when opinions differ on controversial issues. If you haven’t seen ACEP Now lately, grab a copy soon. Your feedback is welcome at www.acepnow.com
Strategic Plan Taking Shape
In leading the annual Board retreat late last year, top-level goals and objectives for the college from now until 2017 were debated, prioritized and built for impact. Goal 1 focused on care transitions and improvement as the reform of the health care delivery system continues in full gallop. Goal 2 received particular attention with the formation of the Membership Engagement Task Force, the Membership Bylaws Task Force and the Residency Visit Task Force. Your fellow member leaders of these groups, their Board of Director Liaisons, and assigned top-level staff are poised for success in member engagement and satisfaction. Here’s an overview of the Strategic Plan:
Goal 1 – Reform and Improve the Delivery System for Emergency Care
Objective A – Identify, support, and promote delivery models that provide effective and efficient emergency medical and acute care in different environments.
Objective B – Promote quality and patient safety, including development and validation of quality measures.
Objective C – Pursue strategies for ensuring fair payment and practice sustainability.
Objective D – Pursue solutions for workforce issues that ensure access to high quality emergency care.
Objective E – Advocate for meaningful liability reform at the state and federal levels.
Objective F – Communicate the value of emergency medicine as an important component of the health care system.
Goal 2 – Enhance Membership Value and Member Engagement
Objective A – Increase total membership and transitioning resident retention.
Objective B – Provide robust educational offerings, including novel delivery methods.
Objective C – Support member well-being.
Objective D – Ensure adequate infrastructure to support growth.
Each December, your Board reviews and modifies its strategic plan for the year. We will continue strong efforts to protect fair reimbursement, continue to press for liability reform, and demand an end to boarding and especially psychiatric patient boarding.
Building Bridges and Strengthening Relationships
One of my goals as President was to align ACEP with others who share our passion for quality health care. If we build bridges and enhance our synergy with other health care organizations, we benefit and so do our patients. Our relationship with CORD continues to grow, as does our joint work with CORD and SAEM in GME matters. EMRA has a new executive director and our relationship with EMRA could not be stronger. We’re proud to announce the ACEP/SEMPA EM Academy last spring drew rave reviews and more than 300 physician assistants and nurse attendees. I participated as our two organizations penned a new five-year management service contract in New Orleans in May. I directed a new task force be formed to reach out to identify opportunities for collaboration with the Society of Hospitalist Medicine. When it comes to building bridges, there are many organizations whose activities, benchmarks and plans have relevance to us and we need to continue building those relationships. Indeed, EMRA, CORD and SEMPA have renewed their management services contract with ACEP. During this past year, it was a privilege to be the first ACEP President to keynote the ACOEP annual meeting, and to be one of the first two physicians to receive the SEMPA Diplomat Award along with ACEP Past President Dr. Linda Lawrence. I would also like to recognize the strong contributions of our chapter executives to the progress of our profession.
Two Clinical Policies Reviewed
ACEP conducted two major Clinical Policy reviews during my term. In response to the Council- and ACEP Board–adopted Amended Resolution 32(13), the “Clinical Policy: Use of Intravenous tPA for the Management of Acute Ischemic Stroke in the Emergency Department” was reviewed. Also reviewed was: ““Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients with Suspected Acute Non-Traumatic Thoracic Aortic Dissection.” ACEP instituted a 60-day comment period for clinical policy development and the process meets national clearinghouse standards for guideline development.
EMF Continues Endowment Push
Over the past year, EMF has launched a new logo and continues the momentum of the ACEP $1 million match to bring the endowment to maturity with a corpus of $2.5 million. EMF has a new board, new Director and new Strategic Plan. Its Goals and Objectives are to:
Goal 1 – Position EMF as the principal sponsor of scientifically rigorous research and education to to improve the care of the acutely ill and injured and policy research that aligns with emergency care priorities
Goal 2: Increase EMF’s capacity to engage more people in emergency medicine research and award more grants
Goal 3 – Position EMF as the premier 501(c)(3) emergency medicine foundation
Goal 4 – Increase EMF revenue to fund more research grants and education projects
Please go to www.emfoundation.org, and make EMF your charity of choice.
Annals Added to eCME Options
In collaboration with ACEP’s online education program, articles from the Annals of Emergency Medicine are being offered as a CME component. As of October 2014, there were 20 Annals-based articles available to members. ACEP looks forward to seeing this educational offering become a robust element of ACEP’s overall online education program. Learn more at www.acep.org/ecme. Concurrent with the inauguration of the eCME program, Annals announced that it would continue its relationship with long-time publisher, Elsevier. The five-year contract runs through December 2018, and provides a solid and stable financial basis for journal revenues. The contract provides a generous editorial office stipend along with a guaranteed minimum royalty, enabling Annals to contribute substantially toward the overall financial success of the College.
ACEP Continues to Add Value, Enhance Image
The continued strength of our specialty requires us to do some heavy lifting in areas such as keeping prudent layperson as a recognized part of the ACA, working toward an SGR fix and changing perception about the cost of emergency care. Working together, we will make progress. As a result, our place in the House of Medicine will be enhanced. And we’re building strong connections with others while providing service to our chapters as they protect the interests of our members. Chapter efforts in Washington State and in Virginia underscore the need for our teamwork.
Thanks for the Past Year
I started my EM practice in the 1980s, and there are many reasons I value membership and the friends I’ve made over the years. I can pick up a phone and dial a colleague anywhere for advice. Like all families and all democratic groups filled with the riches of a knowledge-based constituency, we will have disagreements and some conflict. It’s all for a better result and a strong organization, as long as we stick together. The knowledge I’ve gained in reimbursement and coding and practice management has paid me back every dollar I ever contributed to ACEP, EMF and NEMPAC. The education I’ve received at conferences has made my practice better and improved the care of my patients. I was proud to join ACEP then, and I’m proud to have served as its President. ACEP is growing. ACEP is dynamic. ACEP gives you a good return on your dues investment dollars. Your partners, your colleagues, are the members of the committees, task forces, sections, Board, Council, and technical expert panels that create our future. Thank you for your contributions, and for your friendship.
Alexander M. Rosenau, DO, CPE, FACEP
ACEP Immediate Past President
“The emergency health care system must be prepared for an evolving public health event of international significance such as this. Emergency physicians are on the front lines and should be knowledgeable, up-to-date, and ready to effectively manage infectious disease threats. It doesn’t matter whether such threats arise from Ebola virus disease, Enterovirus D-68, MERS-CoV, SARS, the 2009 H1N1 pandemic, or the next big event, as yet unnamed. We should be leaders in our hospitals, EMS systems, and communities, advocating for protection of the public health, our patients, and colleagues.”
Kristi and Carl have donated a preliminary electronic draft of that chapter to the College – to all of you, really – as a resource to help you and your team prepare to screen for and treat the wide range of infectious diseases any of us could see any day of the week.
Just follow this link to download the chapter now.
Best wishes to you all, and be well. We hope to see you next week in Chicago for ACEP14.
Alex M. Rosenau, DO, CEP, FACEP
Micahael J. Gerardi, MD, FAAP, FACEP
With so much information and speculation being circulated about Ebola presentations in the United States, I want you – our members – to know what your College is doing on this issue.
The landscape about treatment and containment of this infectious disease is changing minute by minute. ACEP has been working in many ways to filter the information and provide you with a trusted source of updates. We also have many initiatives planned for next week, next month and beyond as we continue to help you in these challenging times and be a supportive advocate for our specialty and our patients. Advocating for your safety and making sure you have everything you need are our most important goals.
Here are some of the things we are doing:
Resources on ACEP Website
Identify short and long-term legislative initiatives designed to assist our members and other health care providers to enhance their disaster preparedness:
Communications with Members
Communication with the Public and the News Media
Work with Other Organizations
Regionalization will be a key discussion point in all conversations.
Alex M. Rosenau, DO, CPE, FACEP
-Patient satisfaction: is it a marker of quality care? NOPE
-Pediatric appendicitis: can EPs accurately use bedside sono?
-Navigating online EM resources: 5 tips
-Steroids for bronchiolitis: yes or no
Enjoy the ACEP 2014 SA in Chicago, find us and say ‘hello’. Also, email email@example.com any time.
ps We forgot to post it on Central Line, but Sept is up as well — download and listen, it’s a good one.]]>
As emergency physicians, we are skilled in responding to disasters and treating every kind of medical condition as part of our daily routines. We also are critical to America health care response to infectious diseases. This is because patients often show up first in emergency departments, as we saw during the anthrax attacks after 9/11 and in Dallas, Texas, yesterday when the first case of Ebola was confirmed in the United States. Clearly this disease deserves our attention and emphasis from health care providers across the country.
Ebola is a serious communicable disease. Heightened vigilance for case presentations and strict adherence by health care personnel to CDC advice, public education and a pre-planned medical response is necessary. Hospital physicians and entire health care teams have planned for these types of medical threats. Like SARS, MERS, and Hantavirus, newly identified serious population health threats continue to occur.
Even if this Ebola case is isolated, it is incumbent upon emergency physicians and other health care providers to properly screen and manage potential Ebola presentations. The CDC, the Emergency Care Coordination Center and the Assistant Secretary for Preparedness and Response, have provided materials that are excellent resources for emergency physicians and other staff in the ED to have readily available for dissemination.
These resources are available on ACEP’s website at www.acep.org/ebola.
They include screening criteria and case definition.
The CDC recommends two initial steps in screening for Ebola Virus Disease:
If both of these criteria are met, the patient should be moved to a private room, and standard-contact and droplet isolation precautions followed during further assessment.
We see dozens of patients each week, and particularly at this time of year, many will have a common cold or influenza. All health care professionals in the emergency department should know the protocols and what to ask so we can do everything possible to ensure that this Ebola case in Dallas remains isolated.]]>
Emergency physicians from top organizations representing emergency medicine traveled to Washington, DC, this week to meet with Ben Harder, managing editor and director of health care analysis at US News & World Report and Dr. Nate Gross, co-founder of Doximity, an online social networking service for U.S. physicians that conducts surveys for US News.
The purpose of these meetings was to convey the concerns of nine emergency medicine organizations about the results of a Doximity survey, which was promoted by US News & World Report, identifying the nation’s top emergency medicine residency programs.
Prior to the meeting, emergency physicians from the nine organizations held a conference call and developed a joint letter to US News and Doximity challenging the sampling method and the implications of providing misleading information to medical students and the public.
Four physicians represented the group at these meetings:
During the meetings, the physicians conveyed that the results:
The physicians conveyed there is potential value in a secure data service for communicating HIPAA-compliant messages among emergency physicians. Also, a resource that provides detailed information on residency programs and their alumni could help medical students in making decisions about their applications to specialty training. However, the collective organizations that represent all of emergency medicine could not support the data as long as the rankings were included. Both US News and Doximity agreed there were significant limitations of the data and discussed the challenges of developing objective measures for emergency medicine, because it is a unique medical specialty. Both also agreed that these data would not be promoted to the general public.
The editor at US News described the new organiza
tion’s publications that rank hospitals and medical specialties as “consumer decision support,” which are intended to help members of the general public make decisions about where to seek care for complex medical problems. Emergency medicine has never been included in these rankings in the past, and there are no plans to begin doing so. The editor conveyed that US News recognizes that, in a medical emergency, the best place to get care is the nearest emergency department.
The physicians asked to provide a companion piece to the US News article about the results. The editor agreed to review and publish, if acceptable. The co-founder of Doximity offered to discuss these issues with leaders in his organization and suggested further discussion at ACEP 14 in Chicago.
The following organizations are participating in this effort:
September 12, 2014
Mr. Ben Harder
Managing Editor and Director
Health Care Analysis
US News & World Report
105 Thomas Jefferson Street, NW
Washington, DC 20007
Dear Mr. Harder:
As leaders of the top organizations representing emergency medicine, we have been contacted by scores of emergency physicians from around the country about a survey being conducted by Doximity and publicized by US News and World Report. We appreciate your recognition of emergency medicine as an academic medical specialty with a unique core of knowledge and robust research agenda.
However, we are concerned about the sampling method chosen for this survey, because we believe it will fail to achieve your objective for this survey — to identify America’s top emergency medicine training programs. Asking only physicians enrolled in a social media website to nominate their five most preferred residencies will result in egregious sample bias and is not capable of resulting in a scientifically valid result. The results will be based solely upon opinions expressed by physicians who have no first-hand knowledge of any residency training programs other than the ones they attended themselves.
While not a formal ranking of residency programs, the results would convey that some programs provide better training than others. However, given the limitations, this would not be an accurate portrayal — to medical students or to the public. It also would not be useful to many medical students, because research shows that more than 75 percent of emergency physician residents report the number one reason for selecting a residency program is geography.
More concerning, the results could send a dangerous public health message to people with medical emergencies. It implies they should consider bypassing hospital emergency departments with residency programs that fared poorly in the survey. In a medical emergency, people should seek emergency care at the nearest emergency department, not one that scored better on a highly subjective opinion survey.
Patients need confidence in their physicians in times of crisis, especially since comparison shopping among doctors is not an option when someone is having a medical emergency. Emergency medicine residency programs train physicians in the emergent and acute conditions of just about every medical specialty in health care. As a result, emergency physicians are uniquely qualified to handle a full range of adult and pediatric emergencies. In addition, they see every kind of human drama imaginable, often treating multiple patients at a time.
The overall quality of medical care delivered in emergency departments in the United States is excellent, thanks to the uniformly high standards that govern the accreditation of residency programs in emergency medicine. Emergency medicine residencies collaborate openly with shared curricular tools built around a core model of clinical practice, an approach that is fairly unique in medical education. Ranking training programs above others is contrary to the principles of our specialty, although we recognize that certain programs are best suited for certain trainees.
Many factors contribute to a successful residency program, not all of which can be measured or compared. If your target audience is medical students contemplating a career in our field, we would be happy to work with you to identify objective, measurable factors to help students find the best program for their individual needs.
Unfortunately, our organizations, which represent more than 40,000 emergency physicians, could not recommend or encourage participation in the current survey by emergency physicians. We would, however, be happy to meet with you and help to identify the parameters that might better accomplish that purpose. If you are interested, please contact Marjorie Geist at 800-798-1822, ext. 3290.
Alex M. Rosenau, DO, CPE, FACEP
President, American College of
Meaghan Mercer, MD
President, American Academy of Emergency
Medicine Resident and Student Association
Mark Mitchell, DO, FACOEP
President, American College of Osteopathic
Jeffrey N. Love, MD, MSc
President, Council of Emergency Medicine
Jordan Celeste, MD
President, Emergency Medicine Residents’
cc: Avery Comarow, Health Rankings Editor]]>
By Andrew E. Sama, MD, FACEP
With nearly two-thirds of all admitted septic patients presenting to the ED, and with the clear time sensitivity that exists between recognition, treatment, and outcomes, our members are on the front lines to save lives from this frequently fatal disease. In the CY 2015 IPPS rule, in which CMS cited the fact that “that patients admitted through the ED had a 17% lower likelihood of dying from sepsis than when directly admitted,” CMS finalized NQF #0500: Early Management Bundle for Severe Sepsis and Septic Shock, which mandated the invasive monitoring of CVP and ScVO2 via the placement of a central line in the ED. However, late on Friday, CMS notified hospitals, that it will suspend data collection for the Severe Sepsis and Septic Shock: Management Bundle measure (NQF #0500) until further notice.
Emanuel Rivers, MD, MPH, and his team improved mortality and raised the awareness of the EM community about sepsis through their Early Gold Directed Therapy (EGDT) study in the early 2000s. A few years later, the measure was initially endorsed by the NQF in 2008 without the requirement for a central line for the emergency department. While it is certain that early intervention does reduce mortality, not all elements of the sepsis composite bundle were equally evidence-based. Many studies over the years have demonstrated dramatic improvements in sepsis-related mortality after the implementation of early interventions for septic patients, which included early antibiotic administration, source control, and aggressive fluid resuscitation without invasive monitoring of CVP and ScVO2. One study addressing this, authored by Dr. Alan Jones and colleagues, was conducted at three EDs in the US, and compared two protocols that both included central venous pressure measurement; however, one used lactate clearance and the other used central venous oxygenation monitoring as a way to guide resuscitation. Dr. Jones’ 2010 study found no differences in mortality, suggesting that using central venous oxygenation to guide resuscitation may not be necessary.
In 2012 the measure underwent routine NQF maintenance review for re-endorsement in 2012-2013. During those proceedings, under the leadership of David Seaberg, MD, FACEP and myself ACEP commented that central venous pressure (CVP) was not the only reliable measure of intravascular volume. Several members of ACEP’s Quality and Performance Committee (QPC) including chair Jeremiah D. Schuur, MD, MHS, FACEP, Michael Phelan, MD, RDMS, FACEP, Todd Slessinger, MD, FACEP, FCCM, FCCP, Christopher Fee, MD, FACEP, and others testified on conference calls and at in-person meetings, that there were equally effective and less invasive methods for monitoring septic patients. Nonetheless, the NQF endorsed the requirement for the central line, noting that they would re-consider if additional evidence warranted it.
Within a few months the Protocolized Care for Early Septic Shock (ProCESS) trial was published on March 18, 2014 and under Dr. Alexander Rosenau’s leadership ACEP immediately requested that NQF #0500 undergo an ad hoc review given the impact that this new data would have on this quality measure. After reviewing the data from the ProCESS trial, NQF questioned whether NQF #0500’s item ‘F’, which measures central venous pressure and central venous oxygen saturation, should be retained or removed from the measure. During the review, one of the PIs, Donald Yealy, MD, FACEP engaged in a scientific debate noting that the ProCESS trial enrolled 1,341 patients, with a power to detect a 6-7 percent absolute difference, yet demonstrated no difference in mortality 60-day mortality 90-day mortality, one year mortality, or the need for organ support. The ProCESS also noted no benefit in any outcome when using CVC- guided care and the simpler approaches that stressed early and ongoing care produced the same good outcomes.
CMS, NQF, and others are now also convinced that honing the sepsis bundle is a move forward for our septic patients, with or without invasive monitoring depending on the progression of their disease, their unique circumstances, and the resources available at the ED where they are being treated. As it is ACEP’s mission, we will continue to advocate on behalf of our patients presenting with a diagnosis of sepsis to ensure that they receive the highest quality of emergency care. We look forward to continuing to work with the measure developer to ensure that all septic patients receive the timely, effective care they need, and to continue to save lives from this deadly disease.
Dr. Sama is ACEP’s Immediate Past President and Chair of the Board of Directors]]>
In a recent newsletter, the American Hospital Association informed its members of a change by CMS as it relates to data collection for severe sepsis and sepsis shock. Below is the CMS announcement.
The Centers for Medicare & Medicaid Services (CMS) is notifying hospitals participating in the Hospital Inpatient Quality Reporting (IQR) Program that it will suspend data collection for the Severe Sepsis and Septic Shock: Management Bundle measure (NQF #0500) until further notice. This measure was adopted for the FY 2017 payment determination in the CY 2015 IPPS final rule.
CMS continues to believe that this is an important area for measurement given mortality rates that range from 16-49% and that sepsis is one of the top 10 most common principle causes for hospitalizations. Further, through surveillance of early effective treatment of severe sepsis or septic shock, hospitals will not only know where in the sequence of steps to treat severe sepsis and septic shock patients, but also begin to decrease mortality related to sepsis and the costs associated with inefficient care of severe sepsis and septic shock patients. With this measure CMS will gauge if care of severe sepsis and septic shock patients is improving.
This measure was initially endorsed by the NQF in 2008 for the hospital/acute care facility setting and underwent routine NQF maintenance review for re-endorsement in 2013. During the 2013 NQF endorsement proceedings it was noted that should new data be published related to the measure, that the measure would undergo an ad hoc review. With publication of the Protocolized Care for Early Septic Shock (ProCESS) trial in early 2014, NQF #0500 underwent an ad hoc review to discern if the new data would impact the measure as currently designed. After reviewing the data from the ProCESS trial, NQF questioned whether NQF #0500’s item ‘F’, which measures central venous pressure and central venous oxygen saturation, should be retained or removed from the measure. During the review two other trials were identified that might also impact NQF #0500, those trials are the Australian Resuscitation in Sepsis Evaluation Randomized Controlled Trial (ARISE) and The Protocolised Management in Sepsis Trial (ProMISe). After much discussion of the results of the ProCESS trial, the potential impact the ARISE and ProMISe trials may have on the measure, and the recommendations to remove item ‘F’ from the measure, NQF recommended that measure stewards collaborate with other stakeholders to reach a compromise on NQF #0500’s item F. NQF recommended that measure developers collaborate with other stakeholders to reach a compromise on this specific element of NQF #0500 measure.
Given forthcoming research and NQF’s recommendations, with potential changes to the measure, CMS will delay data collection for the measure until further notice. The duration of this suspension pending further information from the measure developer has not yet been determined. This delay does not affect the data collection period for any other Hospital IQR Program measures.]]>