From the President- Merle Hillman, MD

In December 2008, ACEP released a national report card on the state of emergency medicine in the USA. The report card provides a focused, comprehensive look at America’s emergency care system as measured in five categories: access to emergency care, quality and patient safety, medical liability environment, public health and injury prevention, and disaster preparedness. Overall the report gave the US emergency care system a grade of C-, with the lowest score in access to emergency care. This reflects the increasing emergency department visits with a decreasing number of emergency departments, resulting in overcrowding, boarding, ambulance diversions and shortages of on-call specialists. The full report may be found at www.acep.org/reportcard.

IIndividual state grades range from the highest, a B in Massachusetts, to the lowest, a D- in Arkansas. Minnesota scored the sixth highest out of the 50 states and the District of Columbia with a grade of C+. Minnesota scored highest in the disaster preparedness category with an A- reflecting our state’s all-hazards medical response plan, statewide medical communication and patient tracking system (MNTrac), frequent preparedness drills (possibly related to preparing for the RNC in 2008) and high physician and nursing enrollment in the ESAR-VHP (emergency system for advanced registration for volunteer health professionals) program. Minnesota’s lowest score was in the medical liability environment where we received a C- due to the paucity of liability reforms.

The report card notes that Minnesota lacks pretrial screening panels, medical liability caps on non-economic damages and additional liability protections for EMTALA-mandated emergency care. These have all been the focus of MNACEP advocacy efforts over the past several years. Clearly, we still have work left to accomplish. The report notes the average malpractice award in Minnesota of $347,708 is significantly higher than the national average of $285,218. Our next lowest grade came in the category of access to emergency care where we scored a C, reflecting a high number of ambulance diversions, emergency department boarding, lack of on-call specialists and lack of in-patient psychiatric beds. While we can be proud of the emergency medical care we provide in Minnesota, there are several areas of concern and improvements that need to be made to better serve our patients and our communities. Hopefully, we can utilize this report card to focus on these areas of weakness and improve emergency care in Minnesota.

Pay for Performance Improves Quality at Minnesota Ambulance Service
Brett S. Whyte, MD
Medical Director Winona Area Ambulance Service

Improving quality of care is an area of concern for most EMS medical directors. Winona Area Ambulance Service (WAAS) has developed a pay for performance program that has shown dramatic improvement in several quality benchmarks. A complete report on the program was recently published. (Whyte BS, Ansley R: “Pay for performance improves rural EMS quality: investment in prehospital care.” Prehospital Emergency Care 12[4]: 495-497, 2008.)

WAAS is an advanced life support service in Southeastern Minnesota that serves a rural patient base of 50,000 residents and completes approximately 2,200 calls a year. It employs 10 full time paramedics and 24 part time paramedics and EMT-B’s. Quality improvement efforts historically at WAAS have focused on run reviews, didactic educational sessions, and skills testing. Despite these ongoing efforts, dramatic quality benchmark improvements were elusive. A pay for performance system awarding bonuses up to $1,000 per medic that met selected quality markers was developed in an effort to incent quality care. The pay for performance program has been in effect for 4 years at WAAS. Benchmarks have changed annually if improvement was made in the targeted areas and new areas were chosen for improvement. In 2007 six benchmarks were selected and tracked in the pay for performance program:

1. Completing patient care reports within three hours
2. Meeting out-of-chute time goals
3. Performing an ECG on adults with non-traumatic chest pain
4. Giving aspirin to adults with non-traumatic chest pain
5. Assessing and providing appropriate relief of pain in patients with traumatic hip pain
6. Documenting the time of stroke symptom onset

In 2007, run report completion within three hours improved from 64% to 99%. Out-of-chute times less than 90 seconds improved from 90% to 99% of the time. In adults with non-traumatic chest pain, ECG’s completion improved from 43% to 88% and aspirin administration improved from 68% to 96%. Documenting the onset of symptoms in stroke patients improved from 97% to 100%. Finally, pain assessment and appropriate treatment in traumatic hip pain calls improved from 56% to 100%. In this rural ambulance service a pay for performance program has been very successful. This program could be modified to suit the needs and budget of any EMS service.

 

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Councillor Report

The ACEP Council met in Chicago in late October to discuss a wide range of resolutions and to elect four members of the national Board of Directors. Minnesota ACEP was represented by five councilors----Drs. Teri Gunnarson, Tom Wyatt, Dave Milbrandt, Christopher Obetz, and Brent Asplin. This year MNACEP successfully sponsored a resolution on ED categorization that was overwhelmingly supported by the Council. The resolution calls on national ACEP to study the feasibility of sponsoring an ED categorization system that would be modeled after the American College of Surgeons’ trauma center designation program. The overall goal is to give emergency physicians an opportunity to define the practice environment that is needed for high quality emergency care. There are many questions that need to be answered before ACEP actually launches a categorization program---this year’s resolution creates a task force that will provide answers to those questions so the College can decide whether to pursue the program.

One of the most controversial issues during this year’s Council meeting was the “legacy fellowship” status issue. In 2007, the Council created a pathway for long-time members of ACEP who are not board certified by the American Board of Emergency Medicine (ABEM) to become fellows of the College. Throughout 2008 a controversy developed over whether this legacy fellowship category was consistent with the College’s commitment to board certification for future members of ACEP. The MN ACEP Board discussed the issue this fall and supported a resolution that kept the legacy fellows category intact, but closed new applications in the legacy fellows pathway after December 31st, 2009. There were multiple resolutions on the topic, but ultimately the Council overwhelmingly supported the same compromise position that the MNACEP Board adopted. The legacy fellowship category remains intact; however, no new fellowship applications will be accepted in the legacy category after December 31st, 2009.

The Council re-elected three incumbent candidates for the ACEP Board of Directors, including Drs. Kathleen Cowling (Michigan), David Seaberg (Tennessee), and David Sklar (New Mexico). Dr. Michael Gerardi (New Jersey) was also elected as a new member of the Board.

It was an honor to represent MNACEP at this year’s Council meeting. Members can review a full report of the Council’s actions on the ACEP web site. If you have any questions about the process, please contact any of the five councilors listed above.

 

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Clinical News

Balance Billing Ban in California Could Have National Impact
The California Supreme Court's decision in January to ban "balance billing" in that state will force emergency care providers to dispute literally millions of underpaid claims in court, emergency medicine experts warned. And, although balance billing regulations vary by state, the influential Golden State's ruling could trigger similar shifts elsewhere.
Read the entire article.

Women Have Fewer Complications, Better Survival Following Trauma
Women are less likely than men to experience complications following acute trauma, which may account for their apparent survival advantage, according to a retrospective study of almost 700,000 patients. However, women who do experience complications from traumatic injuries are more likely to die as a result.
Read the entire article.

FDA Takes a Closer Look at Xigris Bleeding Event
The Food and Drug Administration said on Feb. 4 that it is working with Eli Lilly and Co. to review the incidence of serious bleeding events and mortality in patients receiving the company’s sepsis drug drotrecogin alfa (Xigris). The drug was initially approved in the United States in 2001 and received an updated warning in 2005. At that time, the label was amended to state that the therapy might not be appropriate for patients with single organ dysfunction and recent surgery. The FDA began its most recent review after publication of a 73-patient retrospective study that found that patients with risk factors for bleeding had a significantly higher risk of a serious bleeding event with Xigris.
Read the entire article

Hypothermia Makes Gains in Cardiac Arrest
There has been a major shift in the use of therapeutic hypothermia (TH). We've seen a substantial increase in interest," so that at the start of 2009 there is generally at least one large center routinely using TH for cardiac arrest patients in virtually every major U.S. metropolitan area, said cardiologist Dr. MaryAnn Peberdy, professor of medicine and emergency medicine at Virginia Commonwealth University in Richmond, and one of the authors of a consensusstatement on post-cardiac arrest syndrome.
Read the entire article

 

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CALS

The Comprehensive Advanced Life Support program (http://www.calsprogram.org/home.aspx ) or CALS began in 1996. Minnesota ACEP has been a sponsor of CALS from the beginning and aided in lobbying efforts to secure permanent funding from the Minnesota State Legislature. These efforts were successful and today CALS has trained over 3600 health care professionals.

CALS was initially developed and implemented by Dr. Ernie Ruiz, former Chief of Emergency Medicine at Hennepin County Medical Center. Dr. Ruiz was concerned that rural health providers were inadequately trained to anticipate, recognize and treat life-threatening emergencies. The CALS curriculum consists of three components: 1) home study, 2) two-day interactive, scenario based provider course and 3) the skills lab. 

CALS is currently being utilized by many MN emergency physicians to fulfill the Minnesota State Trauma System (http://www.health.state.mn.us/traumasystem) training requirements. The MN State Trauma System will accept either CALS or ATLS as appropriate educational training.

MN ACEP is working to further strengthen its relationship with CALS and its educational efforts. Numerous states around the nation are working to implement the CALS curriculum. MN ACEP applauds the efforts of CALS and others to improve rural critical care patient management. We look forward to working closely with CALS in the future.

Bill Heegaard, MD