The objective of this case report is to present the successful use of regional cerebral oxygen saturation (rScO2) monitoring guided cerebral protection for cesarean delivery in a parturient with Takayasu's arteritis at 38weeks' gestation. The parturient presented with impaired cerebral and renal perfusion. Titrated epidural anesthesia was performed. During the procedure, we used rScO2 guided cerebral protection strategies, which helped to optimize cerebral oxygen delivery and prevent cerebral complications.
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Πέμπτη 28 Απριλίου 2016
Regional cerebral oxygen saturation guided cerebral protection in a parturient with Takayasu's arteritis undergoing cesarean section: a case report
Influence of dexmedetomidine on cognitive function in volunteers
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Triple A to triple S: From diagnosis, to anesthetic management of Allgrove syndrome
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What it takes to be an EMT
In the first episode of this small online series, we meet Gabe. Learn how Gabe went from a small town volunteer EMT to a Navy Corpsman and emergency dispatcher. What journey will you take?
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Ambulance rollover crash test video
Braun Industries teamed up with CAPE Testing to conduct the Fire/EMS industry's first rollover ambulance crash test. They crashed a 10 year old unit in a test that most closely compares to the anticipated SAE J3057. The test focused on the modular body and roll impact loading, or how well the box holds up in the event of a rollover.
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What it takes to be an EMT
In the first episode of this small online series, we meet Gabe. Learn how Gabe went from a small town volunteer EMT to a Navy Corpsman and emergency dispatcher. What journey will you take?
from EMS via xlomafota13 on Inoreader http://ift.tt/1rlr6DT
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Ambulance rollover crash test video
Braun Industries teamed up with CAPE Testing to conduct the Fire/EMS industry's first rollover ambulance crash test. They crashed a 10 year old unit in a test that most closely compares to the anticipated SAE J3057. The test focused on the modular body and roll impact loading, or how well the box holds up in the event of a rollover.
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The role of single-balloon colonoscopy for patients with previous incomplete standard colonoscopy: Is it worth doing it?
Abstract
Background
The rate of cecal intubation is a well-recognized quality measure of successful colonoscopy. Infrequently, the standard colonoscopy techniques fail to achieve complete examination. The role of single-balloon overtube-assisted colonoscopy (SBC) in these situations has only been sparsely studied. This prospective single-center study aimed to investigate the technical success (rate of cecal intubation) and the diagnostic gain of SBC.
Methods
The study recruited consecutive patients with previous incomplete standard colonoscopy who were admitted for SBC at our tertiary center in Eastern Switzerland between February 2008 and October 2014. The primary outcome was defined as successful cecal intubation. Data on patient characteristics, indication, technical details of procedure, and outcome were collected prospectively. The Olympus enteroscope SIF-Q180 was used.
Results
The study included 100 consecutive patients (median age 70 years; range 38–87 years; 54 % female) who were examined using a single-balloon overtube-assisted technique. The cecal intubation rate was 98 % (98/100). The median time of total procedure was 54 min (range 15–119 min); the median time to reach the cecal pole was 27.5 min (range 4–92 min). Passage of the sigmoid colon was not possible in two cases with a fixed, angulated sigmoid colon. The diagnostic gain was 21 % regarding adenomatous polyps in the right colon. The complication rate was 2 % (2/100, minor) without need for surgery.
Conclusions
This prospective patient cohort study shows that single-balloon colonoscopy is a safe and effective procedure to achieve a complete endoscopic examination in patients with a previous failed standard colonoscopy. A significant diagnostic and therapeutic gain in the right colon justifies additional procedure time.
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The impact of postoperative complications on the recovery of elderly surgical patients
Abstract
Background
While the negative impact of postoperative complications on hospital costs, survival, and cancer recurrence is well known, few studies have quantified the impact of postoperative complications on patient-centered outcomes such as functional status. The objective of this study was to estimate the impact of postoperative complications on recovery of functional status after elective abdominal surgery in elderly patients.
Methods
Elderly patients (70 years and older) undergoing elective abdominal surgery, with a planned length of stay >1 day, were prospectively enrolled between July 2012 and December 2014. The primary outcome was time to recovery to the preoperative functional status measured by the short physical performance battery (SPPB) preoperatively and at 1 week, 1, 3, and 6 months after surgery. The comprehensive complication index was calculated to grade the severity and number of postoperative complications. A Weibull survival model with interval censoring was performed, controlling for age, sex, body mass index (BMI), comorbidities (Charlson comorbidity index−CCI), frailty, presence of cancer, nutritional status, wound class, preoperative functional status, and surgical approach.
Results
Hundred and forty-nine patients (79 men and 70 women) were included in the analysis. Mean age was 77.7 ± 4.9 years, mean BMI was 27.2 ± 5.5 kg/m2, and the median CCI was 3 (IQR 2–6). The mean preoperative SPPB score was 9.62 ± 2.33. A total of 52 patients (34.9 %) experienced one or more postoperative complications, including four mortalities, and a total of 72 complications. The mean comprehensive complication index score for these patients was 25.7 ± 23.8. In the presence of all other variables included in the model, a higher comprehensive complication index score was found to significantly decrease the hazard of recovery (HR 0.96, CI 0.94–0.98, p value = 0.0004) and hence increase the time to recovery.
Conclusion
Following elective abdominal surgery, elderly patients who experience a greater number and more severe postoperative complications take longer to return to their preoperative functional status.
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Fluorocholangiography: reincarnation in the laparoscopic era—evaluation of intra-operative cholangiography in 3635 laparoscopic cholecystectomies
Abstract
Background
The introduction of laparoscopic cholecystectomy (LC) resulted in the decline of routine intra-operative cholangiography (IOC). Common bile duct stones are being diagnosed preoperatively using magnetic resonance cholangiopancreatography (MRCP). We aim to evaluate the use and benefits of IOC during laparoscopic biliary surgery at a high-volume biliary surgery unit.
Methods
Prospective data from 4088 patients undergoing LC over 22 years were analysed. Referral protocols allow one firm to receive the great majority of biliary emergencies and all suspected ductal stones. All patients with gall stones on ultrasound scanning, fit for surgery, will undergo LC during the index admission. MRCP and ERCP are not part of preoperative investigation. A four-port LC is performed with a size 5Fr ureteric catheter within an open cannula to obtain an IOC through right sub-costal port.
Results
Of 4088 patients, IOC was attempted in 3691 (90.2 %) and 3635 had a successful IOC (98.4 %). 75 % were females. The mean age was 59 years. Patients presented with one or more of the following: chronic biliary pain in 60 %, acute pain 26.7 %, acute cholecystitis 8.4 %, gallstone pancreatitis 7.8 % and jaundice with or without cholangitis in 19.2 %. A total of 1328 patients (36.5 %) had risk factors for CBD stones. The IOC was abnormal in 975 cases (26.8 %), recording 1599 abnormalities. IOC identified 774 patients with CBD stones (21.3 %), including previously unsuspected CBD stones in 4.7 %. IOC was false negative in 20 cases (0.5 %) found to have stones on basket exploration. A decision not to perform IOC in 453 cases (11 %) was made preoperatively in 74.2 % and intra-operatively in 12.3 %.
Conclusion
IOC can be safely and routinely performed in LC. It helps to identify CBD stones, even in patients with no known risk factors, delineate bile duct anatomy and facilitate single-stage management of CBD stones.
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Application of clips assisted with foreign body forceps in defect closure after endoscopic full-thickness resection
Abstract
Background
This study was designed to evaluate the feasibility and efficacy of metallic clips assisted with foreign body forceps closing the gastric wall defect after endoscopic full-thickness resection (EFR) for gastric submucosal tumors (SMTs).
Methods
Eighteen patients with gastric SMTs originated from the muscularis propria were treated by EFR between September 2012 and June 2014. Twelve patients underwent endoscopic closure of the gastric wall defects after EFR with endoloop and metallic clips (endoloop string suture method, ESSM), and six patients with clips and foreign body forceps (clips assisted with foreign body forceps clip method, CFCM).
Results
No significant differences existed between the two groups in terms of demographics, clinical characteristics, and the size of the gastric wall defects. The average time spent in closing the gastric wall defects (14.83 ± 1.94 min for the CFCM group and 22.42 ± 5.73 min for the ESSM group) and hospitalization fees of the CFCM group were significantly lower than those of the ESSM group. The average hospitalization time of the two groups had no statistical significance. No single case had surgical intervention or complications, such as gastric bleeding, perforation, peritonitis, or abdominal abscess.
Conclusion
The CFCM and the ESSM are safe and effective techniques for gastric defect closure after EFR for gastric SMTs. Because of the "chopsticks effect," the CFCM more suitable for the lesions located at the gastric fundus, the greater curvature or anterior wall of the gastric body and gastric antrum.
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Trans-oral cricomyotomy using a flexible endoscope: technique and clinical outcomes
Abstract
Introduction
Zenker's diverticulum (ZD) is a rare upper esophageal pathology that is most prevalent in the sixth and seventh decade. Three different therapeutical options are available: (1) open trans-cervical approach, (2) rigid endoscopy and (3) flexible endoscopy. Our hypothesis is that a flexible endoscopic cricomyotomy represents a safe and effective treatment of ZD as well as cricopharyngeal spasm.
Methods
A retrospective analysis of all patients that underwent a flexible endoscopic cricomyotomy at our institution between October 2008 and May 2014 was performed. Preoperative and postoperative (1 month and long-term follow-up) symptom scores and clinical outcomes were collected. Briefly, the ZD is carefully identified endoscopically and the common wall is divided using needle knife cautery with the help of an endoscopic cap. Clips are used to close the mucosal defect starting with the apex.
Results
Twenty-six patients underwent a flexible endoscopic myotomy for a ZD. Of 26 patients, five (19.2 %) had a history of previous open or stapled trans-oral myotomy and four (15.4 %) underwent a concomitant foregut procedure. Mean length of stay was 1.5 days (range 1–11). Mean operative time was 68 min (range 28–149). One patient presented with a postoperative leak, and one patient presented with a retained clip. Both were treated endoscopically. Recurrent weekly dysphagia was present in 3/26 (11.5 %). One patient (3.8 %) underwent an endoscopic bougie dilatation postoperatively. With regard to clinical outcomes, there was a statistically significant improvement in both short-term (1 month) and long-term (median follow-up 21.8 months; range 1–68.2 months) dysphagia (p < 0.001; p < 0.001), regurgitation (p = 0.001; p = 0.017), cough (p = 0.006; p = 0.025) and aspiration (p = 0.013; p = 0.013).
Conclusion
Flexible endoscopic cricomyotomy offers durable relief of dysphagia, regurgitation, cough and aspiration in ZD patients. It appears to have a good safety profile with symptomatic recurrence occurring in up to 11.5 % of cases.
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Outcome of laparoscopic gastrectomy with D1 plus lymph node dissection in gastric cancer patients postoperatively diagnosed with locally advanced disease or lymph node metastasis
Abstract
Background
Some laparoscopic gastrectomy (LG) patients are postoperatively diagnosed with locally advanced disease or lymph node metastasis. Few reports have reviewed the outcomes or validity of LG in such patients.
Methods
We retrospectively compared the outcomes of LG for gastric cancer patients postoperatively diagnosed with T3 (subserosal invasion) or higher or N1 (metastasis in 1–2 regional lymph nodes), or higher disease (n = 36), with open gastrectomy (OG) for c-stage I gastric cancer patients (n = 62).
Results
D1 plus lymph node dissection was performed in all patients in the LG group. Blood loss was significantly lower in the LG group than in the OG group (P < 0.0010). The mean postoperative hospital stay duration was significantly shorter in the LG group than in the OG group (P = 0.0016). In the LG group, lymph node metastasis occurred in 1 patient, peritoneal dissemination in 2 patients, and liver metastasis in 1 patient. The 5-year survival rate did not significantly differ between the LG and OG groups (90.00 vs. 94.52 %; P = 0.6517).
Conclusions
Given the similarity in long-term outcomes between the LG and OG groups, LG is an appropriate indication for gastric cancer patients postoperatively diagnosed with locally advanced disease or lymph node metastasis.
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The uncinate process first approach: a novel technique for laparoscopic right hemicolectomy with complete mesocolic excision
Abstract
Background
Current evidence suggests that complete mesocolic excision (CME) for right-sided colon cancer could be beneficial in terms of long-term survival. However, CME is a considerably more complex operation than standard right hemicolectomy; this is especially true for the laparoscopic approach. Consequently, we have explored a new laparoscopic approach that provides surgical radicality at the mesenteric root on the one hand and maximum safety on the other hand.
Methods
The key feature of the uncinate process first approach (UFA) is the commencement of the dissection at the fourth part of the duodenum using a medial to lateral approach, thus mobilizing the whole mesenteric root posteriorly before the central parts of the mesenteric vessels are accessed. Twenty-eight selected patients with right-sided colon cancer underwent surgery using the UFA and were compared with 51 patients who underwent an open CME procedure (CON). In 11/28 and 51/51 patients in the UFA and CON groups, respectively, a planimetric assessment of the specimen was performed.
Results
Surgical time was longer (144.8 vs. 202.5 min; p < 0.000) and postoperative stay shorter (8.0 vs. 10.5 days; p < 0.01) for the laparoscopic approach. The area of the resected mesentery (UFA, 15,097 mm2; CON, 15,788 mm2; p = 0.47) and the lymph node count (UFA, 59.0; CON, 51.0; p = 0.09) was not significantly different; additionally, no difference was observed regarding anastomotic leakage (both n = 0) and postoperative mortality (UFA, 0/28; CON, 1/51; p = 1.0).
Conclusion
Laparoscopic right hemicolectomy with CME using the UFA provides adequate radicality according to the CME principles and seems feasible and as safe as an open technique. However, future trails will have to demonstrate whether the theoretical advantages of the UFA, with a higher degree of mobility and accessibility of the mesenteric root, translate into a significant clinical benefit, especially relative to the other laparoscopic techniques.
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Percutaneous aspiration of the gall bladder for the treatment of acute cholecystitis: a prospective study
Abstract
Background
Urgent laparoscopic cholecystectomy has been established as the best treatment for acute cholecystitis. However, conservative treatment is advocated for high-risk patients. Failure of conservative treatment can result in high-risk operations with relatively high rates of operative morbidity. Percutaneous cholecystostomy is a good option for these patients. Recently, percutaneous aspiration of the gall bladder without drain has been described.
Methods
A protocol of initial conservative management in high-operative-risk patients admitted with acute cholecystitis was prospectively assessed. Patients who did not respond to antibiotics were treated with percutaneous trans-hepatic aspiration of the gall bladder under ultrasound guidance. Following discharge, the patients were seen in the outpatient clinic and elective laparoscopic cholecystectomy was considered and scheduled as necessary.
Results
Between January 2011 and December 2012, 33 patients with persistent clinical and sonographic signs of acute cholecystitis after failure of initial antibiotic treatment underwent gall bladder aspiration under ultrasound guidance. No complications related to the procedure were reported. In 25 patients (76 %), the procedure was successful and they were discharged. Seven patients needed repeated aspiration. Eight patients (24 %) who did not improve underwent percutaneous cholecystostomy and were discharged with a drain and later reevaluated for elective surgery. The mean hospital stay of patients with successful aspiration was 3 days. During the follow-up period, 23 patients underwent elective interval laparoscopic cholecystectomy. Two were converted to open surgery (8.7 %).
Conclusions
Conservative treatment and delayed operation is an acceptable option for acute cholecystitis. Percutaneous gall bladder aspiration is a simple and effective procedure, with a high success rate and low morbidity. Laparoscopic cholecystectomy after drainage of the gall bladder has low morbidity with a relatively low conversion rate.
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Lap band outcomes from 19,221 patients across centers and over a decade within the state of New York
Abstract
Introduction
We sought to determine the rate of revision and explant of the laparoscopic adjustable gastric banding (LAGB) over a ten-year period in the state of New York.
Methods
Following IRB approval, the SPARCS administrative database was used to identify LAGB placement from 2004 to 2010. We tracked patients who underwent band placement with subsequent removal/revision, followed by conversion to either Roux-en-Y gastric bypass (RYBG) or sleeve gastrectomy (SG) between 2004 and 2013. McNemar test and Chi-square test were used to compare complications between primary procedure and subsequent revision and to compare complication rates and mortality rates, respectively. Log-rank test was used to assess patient characteristics and comorbidities. p < 0.05 was considered significant.
Results
During a 7-year period, there were 19,221 records of LAGB placements and 6567 records of revisions or removal. We were able to follow up 3158 (16.43 %) who subsequently underwent a band removal or revision over the course of this period. An additional 3606 patients had no records in the state of New York following the procedure, thus making the rate of revision 20.22 %. Initial revision procedures were coded as band removal in 32.77 % (n = 1035), band revision in 30.53 % (n = 964), band removal and replacement in 19.09 % (n = 603), removal and conversion to SG in 5.64 % (n = 178), or removal and conversion to RYGB in 11.97 % (n = 378). From the 3158 patients, 2515 (79.64 %) required only one revision. Six hundred and forty-three patients underwent two or more revisions. Thirty-one out of 3158 (0.0098 %) patients had complications at their initial operation, but 919 (29.1 %) had complications during revision (p < 0.0001).
Conclusions
Over a 7-year period, at least 20.22 % of LAGB required removal or revision. Based on all case numbers, total revision rate may be as high as 34.2 %. Although the band is believed to be a reversible procedure, revisional procedures are significantly more morbid than the initial procedure.
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Eleven years of primary closure of common bile duct after choledochotomy for choledocholithiasis
Abstract
Background
The choice of surgical technique to extract stones from the common bile duct (CBD) depends on local experience, anatomical characteristics and also on the size, location and number of stones. Most authors consider choledochotomy an alternative to failed transcystic exploration, although some use it exclusively. Although the CBD is traditionally closed with T-tube drainage after choledochotomy, its use is associated with 11.3–27.5 % morbidity. This study examined the efficacy of laparoscopic CBD exploration (LCBDE) with primary closure for the treatment of CBD stones using intraoperative cholangiography (IOC).
Methods
Retrospective study of 160 patients who underwent LCBDE with primary closure after choledochotomy between January 2001 and December 2012.
Results
The diagnosis of choledocholithiasis was definitively made in all cases by IOC. The overall complication rate was 15 % and the biliary complication rate was 7.5 %. Bile leakage was reported in 11 patients (6.8 %). In over half the cases (63.6 %), no further action was required and the leak closed spontaneously. Six patients were reoperated (3.75 %), two for bile peritonitis and four for haemoperitoneum. The success rate for stone clearance was 96.2 %. The mortality rate and CBD stricture rate were 0 %.
Conclusion
Primary closure after choledochotomy to clear stones from the CBD is a safe technique that confers excellent results and allows one-stage treatment.
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Long-term outcomes of percutaneous endoscopic intragastric surgery in the treatment of gastrointestinal stromal tumors at the esophagogastric junction
Abstract
Background
The treatment options for gastrointestinal stromal tumors (GITSs) at the esophagogastric junction (EGJ) are controversial. There have been reports on enucleation for EGJ GISTs in order to avoid gastrectomy. But the number of patients is too small, or the follow-up period is too short to evaluate it. The purpose of this study was to review our experience of 59 patients with EGJ GISTs treated by enucleation by percutaneous endoscopic intragastric surgery (PEIGS) and assess the clinical outcomes.
Methods
PEIGS is performed as described below. Access ports are placed through the abdominal wall and the anterior wall of the stomach. Through the access ports, an endoscope and surgical instruments are inserted into the gastric lumen and tumor enucleation and closure of the defect are carried out. In this study, 59 patients with EGJ GISTs treated by PEIGS between 2005 and 2013 were enrolled. Their hospital records were reviewed, and follow-up data for 8 years were collected to analyze the outcomes.
Results
En-bloc enucleation was achieved without tumor rupture in all. Average operation time was 172.3 min. Postoperative complications occurred in 3 (one localized peritonitis, one bleeding, and one surgical site infection). Average tumor size was 35.6 mm. Pathological findings confirmed negative margin in all specimens. The maximum follow-up period was 101 months. Multiple liver metastases were detected in two patients (at 12 and 29 months). The survival rate was 100 %. The disease-free rate was 98.3 % at 12 months and 96.6 % at 29 months, respectively.
Conclusions
As far as the short- and long-term outcomes of our experience are reviewed, PEIGS seems as curative as other aggressive resection methods such as proximal gastrectomy. Tumor enucleation by PEIGS, offering a chance to preserve the stomach, can be a preferable option in carefully selected patients with EGJ GISTs, when performed by a skilled surgeon.
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Basket-in-catheter access for transcystic laparoscopic bile duct exploration: technique and results
Abstract
Background
When common bile duct (CBD) stones are detected during laparoscopic cholecystectomy, the insertion of baskets via the cystic duct (CD) can be difficult and may occasionally cause complications. We introduced a new technique 'basket in catheter' (BIC) for transcystic CBD exploration.
Methods
Although cannulating the CD using a cholangiography catheter is successful in most cases, it may occasionally be difficult. Cystic duct anatomy may prevent the usually stiffer sharper tip of the basket, from entering the CBD, resulting in failure, perforation or a false passage. In the majority of our cases, the cholangiography catheter (CC) is not withdrawn from the duct should the intraoperative cholangiography show CBD stones. The tip of a basket is inserted into the CC and advanced to a predetermined distance, allowing the tip of the basket to exit the end of the CC into the CBD. The basket is then opened, advanced to feel the lower end and manipulated to trap the stone. The common hepatic duct is compressed gently to prevent stones from slipping upwards. The catheter and basket are pulled back together to extract the stone.
Results
We have used this technique in 274 cases since 2010. The rate of transcystic versus choledochotomy stone extraction has increased, saving unnecessary choledochotomies. The percentage of transcystic exploration increased from 55 % for the period 2005–2009 to 70 % for the period 2010–2014. There were no conversions to open surgery and no retained stones. The morbidity rate was 4.0 % with no mortality.
Conclusions
We demonstrate a technique to facilitate the insertion of extraction baskets into the common bile duct using the cholangiography catheter as a guide. The 'basket-in-catheter' (BIC) technique for transcystic CBD exploration is easier and safer than inserting the basket alone.
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Laparoscopic sleeve gastrectomy with 27 versus 39 Fr bougie calibration: a randomized controlled trial
Abstract
Background
Laparoscopic sleeve gastrectomy (LSG) has become a widely used primary bariatric surgery. As this is a restrictive procedure, calibrating bougie size is assumed to impact on both morbidity and weight loss. However, no prospective studies have confirmed this hypothesis. The objective of this trial was to compare LSG outcomes using different calibrating bougie diameters.
Materials and methods
A randomized controlled trial: 126 patients undergoing LSG were randomized to either a 27-Fr (group A) or a 39-Fr (group B) calibrating bougie. Inclusion criteria were BMI 40–50 kg/m2, aged 20–70 and absence of prior gastric surgery. All surgeries were performed by the same surgeon. Sample size was calculated to detect a six-point difference in percentage of excess weight loss (%EWL) at 1 year after surgery, considering an α error = 0.05 and a β error = 0.2. The volume of resected stomach, morbidity and weight loss at 6 months and at 1 year after surgery were analyzed.
Results
Groups (group A n = 62, group B n = 64) were similar in BMI (44.3 vs. 43.5), aged (41.9 vs. 42.2) and female percentage (87.1 vs. 84.3 %). A 1-year follow-up was achieved in 90.1 and 87.1 %, respectively. Two major complications occurred, one leak in each group (1.6 %). The volume of resected stomach was similar (426 vs. 402 ml, P = 0.71), as well as 6 months %EWL (66.3 vs. 66.6 %; P = 0.91) and 1 year %EWL (75.6 vs. 71.3 %, P = 0.21). A 1-year %EWL higher than 50 was achieved in 96.5 % of patients in group A versus 85.2 % in group B (P = 0.11).
Conclusions
The use of different bougie diameters had no impact on the volume of resected stomach, morbidity or short-term weight loss after LSG, although a trend was seen toward better weight loss with the smaller bougie. A longer-lasting follow-up will be necessary to further assess differences.
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Is adding paid staff to a volunteer agency the beginning of the end or the start of a new future?
Is adding paid staff the beginning of the end for your volunteer agency"
Or is it an opportunity to make your service better, stronger, faster and smarter"
The answer to these questions depends on how the decision to integrate career personnel into your organization is arrived at and managed. What may initially seem overwhelming or an admission of defeat is in reality the opportunity to build a stronger, better, faster, smarter volunteer EMS agency with the capability to provide reliable and excellent medical response to your community.
Commitment to the community
If your agency is considering supplementing volunteer EMT and paramedics with paid EMS providers, chances are good that you already recognize one or more of these problems:
- The schedule is not filled for every shift, every day.
- You are passing calls or abusing mutual aid agreements.
- Multiple tones are needed to scramble a crew resulting in response delays.
- The core group of responders is getting discouraged, resentful and burned out.
- Members have begun to rationalize that occasional failed responses are OK or normal because the surrounding towns have the same problem.
If any of these are true for your department, it is time to get help with staffing.
Failure to do so because of pride, tradition or fear of outsiders staffing the ambulance does not excuse a volunteer service from failing to provide the safety net it has committed to providing the community.
Taking responsibility for employees and the community
Many volunteer ambulance agencies and rescue squads began generations ago with little or no formal planning. Often bylaws, policies, leadership roles and culture have developed piecemeal over the years.
As a result, the organizational structure has likely been built on personalities and emotion rather than sound business principles. The informal, often clannish nature and sometimes questionable operating practices of some agencies may have worked 80 or even 20 years ago with the respect and support of a grateful public, but the world and EMS has changed dramatically. EMS will continue to change at light speed.
As your volunteer agency moves forward with adding paid staff, it needs a clearly defined mission statement, vision statement or strategic plan for the near and distant future. These documents are a foundation that must now be in place to effectively run a modern EMS organization.
Your agency will from now on be in the business of saving lives and providing for the livelihood of EMTs who have chosen to make EMS their vocation. This is a responsibility not to be taken lightly, and the groundwork needs to be in place to manage this change successfully.
Making the transition to paid staff successful
The first step is to hold a special meeting of your members with mandatory attendance. Insist on polite and respectful discourse and stick to the facts:
- There must be scheduled coverage 100 percent of the time.
- Adding paid staff is the morally and ethically responsible thing to do for the community when volunteer participation alone cannot accomplish this.
To achieve buy in, every member must have a voice. If decisions about major changes, including staffing, are made by officers or a board of directors without the input of the membership, there is exactly zero hope of successfully implementing those changes, and likely no hope of salvaging the organization as a volunteer effort for any length of time. Resentment, conflict — a hostile us versus them environment — and the continued attrition of volunteer members is the probable result.
"The most important thing in communication is to hear what isn't being said."
— Peter Drucker
A new beginning for the department
This is a perfect opportunity to reimagine, rethink and redesign your volunteer agency. Strong leadership will be needed to guide the conversation towards focusing on the positive. Ask, "What do we want for the future"" not on, "How do we avoid what we don't want""
Ask your members to answer the following questions:
- In a perfect world, how will your volunteer squad operate"
- What is preventing a perfect vision from happening today"
- What is the department's role — 911 response, education and prevention, community outreach — in the community"
- What traits and characteristics are you seeking in new paid staff, as well as new volunteers"
- What qualifications are required for paid position applicants"
- Who should lead the new paid staff" Why"
- How can the department take advantage of the opportunity provided by bringing experienced and career-oriented EMS providers in-house to help make those changes"
Focus on creating a partnership
Bringing in the right people is critical to the future success and stability of your squad, regardless of pay status. Be thoughtful, focused and deliberate with the job description and interview process. Look for applicants who will have the patience and experience to mentor new recruits and bring confidence to part-time volunteer members.
Consider hiring a crew chief or operations manager who can provide shift coverage and take care of day-to-day administrative functions including scheduling, inventory management, equipment checks, in-service training and chart review for continuous quality improvement. Having the daily operations taken care of will take a big load off of the volunteer members who have been running the business part-time, and allow those members to focus on the patient care aspect that they originally signed up for.
Be proactive in adding paid staff
Make the decision to add paid staff before being forced to by a sentinel event. Panic hiring just to put meat in the seat because a response failure resulted in a poor outcome or death of a patient, will send your department down a rabbit hole of chaos, shame, resentment and possibly financial ruin.
Managing the change deliberately with a positive outlook, and the support of the membership and community will prevent the division, morale issue and human resource problems that can plague this initiative. Intentionality also honors your department's commitment to the safety of the community.
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Scheduling EMS personnel: 5 best practices for paramedic chiefs and HR managers
The shift schedule for EMS personnel is one of the most important, vital and often overlooked aspects of EMS operations. It determines an agency's ability to effectively provide service, it sets call receiver and dispatcher expectations of resources available to respond and it has a direct impact on the morale of providers.
In order to make the most out of your agency's schedule to benefit the organization, the patients it serves and the providers, here are five best practices for scheduling EMS personnel.
1. Clearly communicate the schedule
While communication plays a vital role in everything that we do, clearly communicating the schedule is essential. The schedule should be accessible to agency management, operation supervisors and especially the providers so that they actually know when they are expected to be on shift.
The easiest way to accomplish across the board accessibility to the schedule is to use an online scheduling application. There are many systems available, some geared specifically for the EMS industry and others that are more generic.
If your agency continues to do scheduling via spreadsheet programs or by hand, communicating that schedule is both harder and time-consuming but must still be done. Make sure to follow a consistent and predictable schedule to announce the schedule, accept change requests, grant schedule changes and to announce the final schedule.
Although tedious and time-consuming, this will ensure that your schedule has been communicated, that your providers know what is expected of them and most importantly that everything has been documented should an issue arise down the road.
2. Have the schedule ready in advance
Having a schedule available in advance has benefits for both the agency and the provider's planning purposes. An agency can plan for resource management, such as the number of vehicles needed on any given day and time, which allows vehicles to be scheduled for preventive maintenance and downtime. A provider can plan for childcare, class schedules or some much-needed sleep.
How far in advance the schedule can be set and available to providers depends on agency operations. Agencies with hyperdynamic scheduling, where every week is different than the week before, will at best be able to schedule a week in advance. Agencies that divide their scheduled resources between core always available units and flex units to dynamically cover special events or peak demand times will be able to schedule their core units two weeks or more in advance and add the flex units as needed. Agencies that have a set schedule with few changes can schedule a full month or more in advance.
3. Consider provider preferences
Provider preferences play a large role in both the ability to provide service and the quality of that service. Managers should be looking to make things easier, not harder, for everyone involved.
Knowing your provider's preferences will make scheduling easier for you, makes their ability to balance the things outside of work easier for them, and that makes coming in for their shift more enjoyable for everyone. Not taking their preferences into consideration can lead to poor morale, a negative disposition towards the agency, more work for the scheduler and directly result in a poor quality of service that they provide.
Shift trading is a common occurrence in EMS. If your agency allows shift trades, make sure to approve or deny the trade as soon as possible. The same applies to when someone requests time off. There is a reason they are requesting the time off or looking to trade the shift. Not knowing whether a request has been approved can result in both unnecessary anxiety for the provider and a harder time covering the shift from the operational end.
In a hyperdynamic scheduling model, it is important to set the deadline for the submission of provider availability. Make sure this deadline and what is expected of it is clearly communicated to everyone. Provide friendly weekly reminders of the deadline. Once that deadline is set, stick to it and make the schedule available on time.
4. Prioritize agency needs
The needs of your agency must be prioritized. Is it more important to cover a shift or manage overtime" Can two providers from last week's orientation class work together or are experienced providers being paired with new providers for a certain length of time or hours"
Once you fully understand what your agency has as the main priority, you can better adjust the schedule to ensure those priorities are met. Create a scheduling priority matrix or flowchart and communicate it to operational staff and management. This will help provide consistency in scheduling during all hours by the operational team.
Deciding par levels of unit resources will also help to establish the base number of resources your agency needs. Define what the levels are and at what point going below those levels triggers an agency-wide alert. This internal state of emergency can result in a number of actions to help rectify the situation, including mandating employees to stay past their scheduled shift end time.
If you find that you are mandating your employees to stay past their scheduled end time greater than 10 percent of the time, this is perhaps an indicator that you need to revisit your base schedule and make adjustments. While mandating is an option, it should be used sparingly since doing so often results in lower morale, frustration, and general anger from the providers who it affects. Low morale can manifest as sub-standard customer service, higher absentee rates and a lack of efficiency.
5. On-call lists
Life happens, even to EMS providers. Sickness, doctor appointments, court dates, childcare issues and sudden situational emergencies will happen over the course of time. When they happen at an EMS agency the effect can be disastrous in terms of being able to meet response times and other metrics that measure the agency's performance.
To fill vacancies quickly, maintain an on-call list of personnel who are not scheduled to work, but able to cover a shift if needed. The list should be accessible to anyone on the operational end to utilize.
What are your best practices for EMS provider scheduling" Share your ideas and questions in the comments.
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Scheduling EMS personnel: 5 best practices for paramedic chiefs and HR managers
Follow these scheduling practices to improve provider morale, patient care and operational efficiency
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What it takes to be an EMT
In the first episode of this small online series, we meet Gabe. Learn how Gabe went from a small town volunteer EMT to a Navy Corpsman and emergency dispatcher. What journey will you take?
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Ambulance rollover crash test video
Braun Industries teamed up with CAPE Testing to conduct the Fire/EMS industry's first rollover ambulance crash test. They crashed a 10 year old unit in a test that most closely compares to the anticipated SAE J3057. The test focused on the modular body and roll impact loading, or how well the box holds up in the event of a rollover.
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What it takes to be an EMT
In the first episode of this small online series, we meet Gabe. Learn how Gabe went from a small town volunteer EMT to a Navy Corpsman and emergency dispatcher. What journey will you take?
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Ambulance rollover crash test video
Braun Industries teamed up with CAPE Testing to conduct the Fire/EMS industry's first rollover ambulance crash test. They crashed a 10 year old unit in a test that most closely compares to the anticipated SAE J3057. The test focused on the modular body and roll impact loading, or how well the box holds up in the event of a rollover.
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Effects of dexmedetomidine on hemodynamics and respiration in intubated, spontaneously breathing patients after endoscopic submucosal dissection for cervical esophageal or pharyngeal cancer
Abstract
Purpose
We evaluated the hemodynamic and respiratory effects of dexmedetomidine in intubated, spontaneously breathing patients after endoscopic submucosal dissection (ESD) for cervical esophageal or pharyngeal cancer.
Methods
This retrospective study included 129 patients aged 66.5 ± 8.3 years, who underwent ESD under general anesthesia, and who were kept intubated overnight to prevent airway obstruction, receiving sedation with dexmedetomidine. Constant dexmedetomidine infusion at 0.51 ± 0.16 μg/kg/h was started intraoperatively (n = 109) or postoperatively (n = 20), following (n = 29) or not following (n = 100) loading doses, and continued until extubation. Hemodynamic and respiratory variables, and Richmond Agitation-Sedation Scale (RASS) score, were recorded.
Results
Postoperatively, 129 patients remained intubated while breathing spontaneously for 16.4 ± 3.3 h, and 124 patients could be sedated solely with dexmedetomidine, whereas 5 required rescue sedatives. During infusion, blood pressure decreased progressively until 12 h, whereas heart rate decreased only at 3 h. Hemodynamic alterations during dexmedetomidine infusion greatly depended not only on its hemodynamic effects but also on baseline hemodynamics before anesthesia. No serious adverse effect was noted.
Conclusion
Dexmedetomidine in intubated, spontaneously breathing patients after ESD was safe and effective. Patient baseline hemodynamics could significantly affect hemodynamics during drug infusion. Without loading doses, plasma drug concentrations were expected to increase progressively. A progressive decrease in blood pressure and unchanged heart rate after an initial decrease suggested that hemodynamic effects of dexmedetomidine in our patients might differ from those reported in young volunteers, although further studies are required to elucidate these points.
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Medical supply inventory management systems for EMS
Today's complex EMS environment requires administrators to constantly juggle issues like tightening budgets, drug shortages, strict governmental regulations and a highly engaged and connected staff — all while operating in a litigious society. Using yesterday's approach to inventory management and supply and logistics is no longer an acceptable practice [1].
There are several significant aspects to automated inventory control and management for today's EMS agencies, in both the public and private sectors. Having a reliable, effective and efficient inventory management system can help an organization reduce costs, limit waste, improve employee relations and limit liability. It can also positively impact patient care by having the right supplies and drugs available when needed [1].
For some time now, private-sector EMS agencies have used automated solutions to improve their fiscal bottom line by reducing costs and limiting waste. Increasingly, public-sector EMS agencies are seeing a similar need as their local funding from government or donations from stakeholders have declined or remained stagnant.
EMS agency leaders cannot continue to rely on emotional appeals to their stakeholders to justify their fiscal needs. The trend in local governments is for transparency and accountability to show taxpayers where and how their money is being spent [1].
EMS agencies across the board are also facing more demanding requirements for reimbursement from medical insurance companies, Medicare and Medicaid for the supplies and drugs used when rendering patient care. The health care environment is rapidly changing with reduced reimbursements, new government regulations and an increased focus on compliance. This added complexity makes managing billing and coding in house much more challenging [2].
Inventory control and management software benefits
Current and developing technologies in ICM can enable EMS agencies to improve both their efficiency and effectiveness in a variety of ways including, but not limited to [3]:
- Preventing medical inventory from expiring or being overstocked
- Centralizing inventory control among departments and vehicles
- Improving EMS medical staff productivity and performance
- Ensuring that every ambulance is fully equipped with life-saving medications and devices
- Logging the movement or usage of medical inventory
Inventory control to prevent narcotics diversion
Diversion is the theft of any pharmaceutical to be sold or traded for personal gain. Resale of narcotics is not limited to common street crime but also can involve Medicare fraud, theft from other providers, organized crime and a host of other crimes [4].
In its simplest form, detection of the loss of pharmaceuticals is a basic inventory control function. The three variables are replenishment of warehouse or central inventory, documented usage, and replenishment of in-station or in-ambulance inventory. Depletion of inventory is fairly predictable over time and can therefore be forecast as well [5].
Here is a common sense, simplistic example of monitoring inventory: You order what you use. There is no reason to order anything more than at the rate you use it and by using percentages of increase, the variances become highly recognizable. Use percentages because in drug inventories, units may not raise a flag [5].
For example, an increase of 10 units of morphine in this months requested inventory for Station #6 may not seem out of line compared to the stations ordering history, but if those 10 additional units of morphine represent a 15 percent increase over what's previously been ordered each month that might be cause for a closer look.
Electronic tracking of supplies
Barcoding has become the basis for the majority of ICM systems on the market today. A barcode-based system streamlines the process by enabling an agency to track the life-cycle of any item: from the initial receipt of an item at the warehouse; the distribution of the item into the supply chain such as sending it to a specific EMS station; use of the item for patient care. Key inventory management and control functions that lend themselves to barcoding include [5]:
1. Managing Inventory of Standard Medical Consumables
Keep it simple by barcoding and tracking standard inventory items by location, number and quantity. Track a variety of standard stock inventory like bandages, gauze, and more.
2. Tracking Medication Inventory
Categorize medication using batch-lot numbers to efficiently and effectively keep track of expiration dates. Having an accurate picture for medication ins and outs, as well as on-hand quantity and reorder levels, can ensure that each EMS vehicle has the right medication inventory on board when an emergency strikes.
3. Serialized Inventory Tracking
Track chemicals and oxygen tanks individually using serial numbers to meet government mandated requirements, and to better prepare yourself when serialized inventory items are needed.
Electronic medication dispensing systems
Cart-mounted electronic medication dispensing systems, also known as med carts, have been a fixture in most medical facilities, such as hospitals and nursing homes, for many years and are now making their way into the EMS realm. Keeping medications under lock and key is an inventory security control measure for sure, but it's not an effective strategy for managing and controlling how those medications are used.
Electronic medication dispensing systems provide benefits for both EMS providers and managers. Providers benefit from:
- Secure, automated access to narcotics and supplies
- Better adherence to controlled substance policies
- Intuitive and easy-to-use software to accurately and completely document usage
- Integration of usage into the patient care/billing report
The management/ownership benefits of an electronic medication dispensing systems include improved:
- Compliance with state and DEA regulations for medication storage and dispensing
- Inventory control and dispensing of narcotics
- Control of EMS provider access rights
- Inventory tracking and documentation of drugs used in patient care
- Billing accuracy for medications used in patient care
Biometric security
One of the top components of inventory control and management is biometric security, which uses an individual's biometric finger print to verify all transactions. This prevents someone from making false transactions or supervisors or managers having to make sense of illegible paper signatures. For added speed and security the biometric reader can also be used to login to inventory control software.
Beyond paper-based data collection and information management
In addition to inventory control and management, today's electronic information management systems for EMS operations can include a host of other data collection and reporting features that improve an EMS agencies efficiency and effectiveness. One example is performing vehicle inspections with an electronic check sheet. If the inspection check sheet is integrated with inventory management and fleet maintenance software it can greatly enhance an agency's operational intelligence. By replacing time-consuming paper check sheets crew members can be more accountable for supplies and equipment. All information captured during the inspection processes can be used to manage and report on an agency's operations performance and needs [6,7].
Another example is the use of a web-based inventory check sheet to conduct inventory of on-hand supplies. Expiration dates on medical supplies are also captured to ensure that inventory is safe and ready for administration. On-hand inventory is balanced against par stocking levels to automatically generate supply requests. Optimally those supply requests are sent electronically to the supply room and processed based on an agency's operational procedures.
Asset verification
The equipment used by EMS providers to provide patient care, particularly biomedical equipment such as defibrillators and medication pumps, represent a significant financial investment by the agency. Keeping track of that equipment as it moves through the operation is a critical risk management activity.
Electronic asset tracking enables end users to verify that equipment checked out to a station or vehicle is indeed at the location or report the missing equipment. If equipment is subsequently located, they can add it to their inspection and automatically transfer ownership to the new location or vehicle allowing missing assets and assets in motion to be recovered. If an asset requires maintenance the user can also record the maintenance while in the field using the check sheet.
Logging supplies by call
Using electronic reporting also enables the EMS provider to capture the supplies used on a per call basis. Crew members can enter the run number or ePCR number and enter the supplies used on the call. Once completed, the vehicle's inventory is updated and a supply request is created. These electronic call records can later be used to report on supply usage and matched up with an agency's ePCR records for quality assurance reviews.
General inspection questionnaires
Electronic reporting programs on the market today enable an agency to create customized questionnaires for any type of location or equipment inspection. These questionnaires are a basic element to any inspection process and provide supervisors and fleet managers with timely alerts on anything from narcotics usage to vehicle mileage and repair orders.
Fleet management integration
Fleet managers can receive information from electronic reporting check-sheets that will provide them with vehicle mileage, operating hours and any repair orders in real time. This makes planning scheduled maintenance and handling off-schedule repairs much easier.
Before you get started
Before purchasing any software vendor's product, it is useful for an agency's leadership to conduct a self-assessment to answer some key questions.
- Why do we need to collect and analyze data"
- What data should, or must, be collected"
- Who will be responsible for entering the data"
- How will the responsible parties enter the data"
These are important internal assessment questions. Far too often software purchasing decisions are made by those in leadership or technology positions within an organization without much thought about one of the most important components in any automated system: the end user who needs to integrate use of the software with their primary mission of patient care.
A majority of the data that most EMS agencies need to collect and analyze for their ICM originates at the level in the organization where the services get delivered. The earlier in the process that an agency's managers gain input from these stakeholders, the greater the chance that whatever reporting software is eventually chosen will be the right one.
References
1. 4 ways to better manage EMS inventory http://ift.tt/1lsIMUO
2. Avsec, R. 5 steps to buying fire department reporting software. FireRescue1.com http://ift.tt/1zEy4G7
3. McKesson. EMS Medical Billing & Revenue Cycle Management. http://ift.tt/1SvEeQV
4. ASAP Systems. Barcode Inventory System for Fire Rescue & EMS. http://ift.tt/24mRbAr
5. nMed. Prescription Drug Theft & Pharmacy Security. http://ift.tt/1SvEgIr
6. ASAP Systems. Barcode Inventory System for Fire Rescue & EMS. http://ift.tt/24mRbAr
7. OperativeIQ. Electronic Check-sheets. [Available on-line] http://ift.tt/24mR9Zz
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Pharmaceuticals in EMS: Are you compliant?
Today EMS agencies EMS agencies purchase pharmaceuticals from a variety of sources [1]. Whether you purchase/ obtain your pharmaceuticals through a hospital, wholesaler/ distributor or other entity, it's important to know your responsibilities in ensuring the integrity of the pharmaceutical supply chain as well as ensuring you are in compliance with State and Federal Regulations.
Before 2013, EMS services were not considered part of the pharmaceutical supply chain and were generally beyond the radar of the U.S. Food and Drug Administration. However, due to the Drug Supply Chain Security Act requirements, EMS entities are now considered an accountable part of "dispenser-to-first-responder transactions" and subject to DSCSA requirements [2,3]. Although EMS can continue to purchase drugs and supplies from most of their previous vendors, certain track-and-trace documents need to be maintained.
The Affordable Care Act has mandated numerous pharmaceutical-related regulatory changes that affect EMS and the Medicare ambulance community. These changes include [4,5,6,7]:
- State-driven Medicaid requirements
- Increased monitoring of ambulance billing suggested by the Office of the Inspector General at the U.S. Department of Health and Human Services
- Ambulance claims processing changes from the Centers for Medicare Services
- Requirements of Drug Quality and Security Act and the Drug Supply Chain Security Act
- Requirements of the International Statistical Classification of Diseases and Related Health Problems or ICD-10 diagnosis codes
Implementing the DSCSA requirements likely remains a challenge for many EMS agencies. Conveniently, some components of the required DSCSA provider-level documentation correlate with the recent ICD-10 diagnostic code documentation recommendations, which also affect EMS reimbursement.
What is the DSCSA"
On November 27, 2013, the Drug Quality and Security Act became law. Title II of the DQSA, the Drug Supply Chain Security Act mandates new definitions and requirements related to pharmaceutical product tracking and tracing [5,8,9]. Product tracing includes identifying transaction information for each drug while tracking includes keeping records for six years of those entities that have been in possession of the drug starting with the manufacturer to wholesale distributors to dispensers including EMS services [5,8,9].
The intent of the law is to enhance the FDA's ability to protect consumers from exposure to drugs that may be counterfeit, stolen, contaminated, or otherwise harmful by improving detection and removal of potentially dangerous drugs from the drug supply chain to protect patients. The development of the system will be phased in with new requirements over a 10-year period [5]. The market has responded by offering many software programs to help all parties in the pharmaceutical chain achieve compliance.
EMS agencies can only accept ownership of a prescription drug if the previous owner — wholesale supplier or distributor — provides an official transaction report. These transaction reports must be maintained for six years. In most cases when an EMS entity purchases a medication, the wholesale supplier will provide the transaction report in the shipment. Since the supplier must also keep copies of the report, if an EMS agency misplaces a report they should be able to contact the supplier for another copy. This mandate may be problematic for EMS agencies with limited administrative capacities or financial resources.
Details required to be provided on a transaction report include the:
- Proprietary or established name or names of the
- Strength and dosage form of the product
- National Drug Code number of the product
- Container size
- Number of containers
- Lot number of the product
- Date of the transaction
- Date of the shipment, if more than 24 hours after
- Date of the transaction
- Business name and address of the person from whom ownership is being transferred
In addition to the transaction report a transaction statement is a paper or electronic form which documents that that the entity transferring ownership in a transaction:
- Is authorized as required under the Drug Supply Chain
- Received the product from a person that is authorized as required under the Drug Supply Chain Security Act
- Received transaction information and a transaction statement from the prior owner of the product, as required under section 582
- Did not knowingly ship a suspect or illegitimate product;
- Had systems and processes in place to comply with verification requirements under section 582
- Did not knowingly provide false transaction information; and
- Did not knowingly alter the transaction history.
EMS services can only purchase prescription drugs from a supplier that has a federal and state license. Drug suppliers must be licensed in the states that they ship into. A supplier holding a license in their home or headquarters state doesn't necessarily mean the supplier can ship drugs into other states.
Before purchasing medications from a supplier verify the supplier's licenses. License verification, by state, is available on the FDA Verify Wholesale Drug Distributor Licenses website.
Also, each EMS agency must also have on file a copy of their medical director's Drug Enforcement Administration license to purchase drugs and a vast array of other drug administration related supplies from the licensed vendor. This requirement affects all training entities. If a training entity, such as a college, university, or private school, wishes to purchase intravenous supplies, simulated medications, or even normal saline for the sole purpose of education, they must produce for the vendor the same required documentation.
EMS agencies should carefully order only the pharmaceuticals they need. Although it is near impossible to use all stored medications before they expire, ordering more than is needed is costly. Due to the DSCSA requirements, most suppliers are expected to not allow returns of prescription drugs [8]. Returning unused medications may be allowable for hospital-based EMS systems in which drugs are obtained from the hospital's own pharmacy service.
However, regardless of the EMS system, a tracking system must be in place to trace where the drug went once it was received from the distributor. In most cases the drugs will either be in a storage room, on an ambulance, or in another vehicle such as a supervisor's vehicle. Although some of the DSCSA requirements remain unclear, many EMS agencies are also preparing to track the administration data of each drug, such as who administered the drug, when — date and time and to whom it was administered, and from what ambulance it was dispensed.
The role of the field care provider
EMS field providers can assist with drug tracking-and-tracing by implementing medication documentation standards and by strictly adhering to their established EMS agency restocking, storing, and administration policies. As previously mentioned some components of the required DSCSA provider-level documentation correlates with the recent ICD-10 diagnostic code documentation recommendations. Therefore, adhering to medication documentation and administration standards will improve compliance with both DSCSA and ICD-10 code requirements while improving your service's opportunity to maximize reimbursement [10].
Document with DSCSA and ICD-10 codes in mind
Field care is rarely mentioned when national clinical practice guidelines and professional standards are developed. However, when it comes to DSCSA and ICD-10 code requirements, EMS is held to the same standards as other health care providers [10,11]. Here are some important documentation considerations.
1. Document medication orders and administration in the following format: Drug, dose, route, frequency [12,13,14,15].
For example, contacting Medical Command might be necessary for analgesia when caring for a patient with acute abdominal pain. The order should be documented as "Contacted Dr. Langenkamp who ordered Morphine Sulfate 5 mg intravenous push every 30 minutes". If offline medical direction permits analgesia without direct medical control, simply documenting the procedure as "Morphine Sulfate 5 mg administered intravenous push" is sufficient.
2. Avoid nonmedical or slang terms when documenting medication administration.
For example, while the phrase "Hung bag of NS KVO" is understandable to most field providers, this type of documentation does not meet any documentation standards.
3. Avoid confusing and vague terms of fluid administration such as keep vein open (KVO), to keep open (TKO), and wide open (WO).
Since 1998, professional standards have called for all intravenous therapy fluid orders to contain a specific infusion rate [15,16,17,18,19]. A common infusion rate for KVO is 25 mL/hour, but this may vary. An example of a properly documented IV infusion would be "Intravenous 0.9% normal saline infusion at 25 mL/hour " or "IV 1 liter bolus 0.9% normal saline infusion at 1000mL/hour initiated".
In addition, your administration practice should also represent sound medication safety by using an IV pump or a simple rate flow device. There are many safe low cost products on the market.
5. Document why certain medications were not given.
For example, not all patients with ischemic chest pain symptoms can receive nitroglycerin. Perhaps the patient took tadalafil (Cialis®), vardenafil (Levitra®), sildenafil (Viagra®), or another medication for erectile dysfunction in the past 48 hours. Document why the medication was not given because of the patient meeting exclusion criteria in the chest pain treatment protocol.
Certain states have implemented time critical diagnosis programs that require EMS documentation to be more specific for conditions such as stroke, STEMI, and trauma. For example, if a TCD process for the treatment of Non ST elevation myocardial infarctions (NSTEMI) includes heparin and clopidogrel (Plavix®), carefully document why these medications were given, the inclusion criteria, or not given.
6. Document reassessment findings after treatments.
Reassessment after medication administration should always include objective and subjective findings. This is important because it measures and evaluates the therapeutic value of the medication. For example, after administering albuterol 5 mg by nebulizer, objective findings would include post treatment work of breathing, respiratory rate, pulse, blood pressure, lung sounds, pulse oximetry, and waveform capnography. The patient reports the subjective data by describing his interpretation of the therapy, such as "breathing easier now".
Both components of your reassessment are important findings to support DSCSA requirements, ICD-10 codes and CMS reimbursement. If there was no change in the patient's condition, or if the condition worsens, these too must be reported.
7. Perform serial physical exams and diagnostic tests as applicable.
For example, the patient who received the albuterol treatment would most likely need several lung sound assessments. The patient who received sublingual nitroglycerin for chest pain would most likely receive another 12-lead ECG when his chest pain resolves or becomes worse. Performing and documenting all appropriate reassessments assists EMS agencies in satisfying DSCSA and ICD-10 code requirements.
Implementing the DSCSA requirements will no doubt remain a daunting task for EMS administrators, medical directors, and field professionals. Although some of the requirements are clear, they may elicit more questions than answers. Successful compliance with the requirements, as well as billing for services, likely requires an open and frequent dialogue with reliable legal counsel with specific knowledge of your EMS agency and its protocols. You can also submit questions to the FDA through the FDA's DSCSA website.
References
1. The Kaiser Family Foundation. (2005, March). Follow the pill: Understanding the U.S. pharmaceutical supply chain. Retrieved from http://ift.tt/1SvEeAu
2. Barlas, S. (2011). Track-and-trace drug verification: FDA plans new national standards, pharmacies tread with trepidation. Pharmacy and Therapeutics, 36(4), 51-68. doi:10.1201/b18697-5
3. Ducca A. (2012, October). Re: Determination of system attributes for the tracking and tracing of prescription drugs. (docket no. FDA-2010-n-0633). Fed. Reg. 2011 January 7;1182:76. Retrieved from http://ift.tt/24mR9Zn.
4. Centers for Disease Control and Prevention (CDC). (2016). International Classification of Diseases, tenth revision, clinical modification (ICD-10-CM). Retrieved from http://ift.tt/1mro1sj
5. U.S. Food and Drug Administration (FDA). (February 2016). Requirements for transactions with first responders under section 582 of the Federal, Food, Drug, and Cosmetic Act—Compliance policy guidance for industry. http://ift.tt/1VQYFHc
6. Government Health Administrators. (2016). Ambulance providers ICD-10 CM planning and preparation. http://ift.tt/1SvEeQK
7. Centers for Medicare & Medicaid Services (CMS). (2015, October). Medicare claims processing manual: Chapter 15—Ambulance. Retrieved from http://ift.tt/1ypWu2W
8. Brennan, Zachary. (2016, February 29). New FDA guidance for first responders as track-and-trace requirements take effect. Retrieved from http://ift.tt/1SvEeQM
9. U.S. Food and Drug Administration (FDA). (2013). Drug Supply Chain Security Act (DSCSA). Retrieved from http://ift.tt/1qNzwSf
10. American Pharmacists Association (Apha). (2015). Apha Policy Manual. Retrieved from http://ift.tt/1eMJnwU"ids=p-929421&tids=t-929417
11. American Medical Association (AMA). (2017). CPT 2017 Professional Edition. Washington, DC: AMA.
12. Institute for Safe Medication Practices (ISMP). (2011). ISMP acute care guidelines for timely administration of scheduled medications. Retrieved from http://ift.tt/24mRbk6
13. Institute for Safe Medication Practices (ISMP). (2011, February). Preventing medication errors during codes. Retrieved from http://ift.tt/1SvEeQR
14. Institute for Safe Medication Practices (ISMP). (2015). ISMP safe practice guidelines for adult IV push medications. Retrieved from http://ift.tt/24mRbka
15. Institute for Safe Medication Practices (ISMP). (2016). 2016-2017 medication safety best practices for hospitals. Retrieved from http://ift.tt/1SvEgIl
16. Infusion Nurses Society. (2006). Infusion nursing specialty practice. Journal of Infusion Nursing, 29(Supplement), 1s, S18. doi:10.1097/00129804-200601001-00005
17. Infusion Nurses Society. (2006). Infusion nursing specialty practice. Journal of Infusion Nursing, 29(Supplement), 1s, S35-36. doi:10.1097/00129804-200601001-00005
18. Hadaway, L. C. (2004). Closing the case on the keep-vein-open rate. Nursing, 34(8), 18. doi:10.1097/00152193-200408000-00015
19. Infusion Nurses Society. (1998). An infusion of independence. Journal of Infusion Nursing, 21(1), 1st ser., S1-S91. doi:10.1097/00000446-199804000-00015
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Medical supply inventory management systems for EMS
Inventory control and management enables EMS agencies to improve efficiency and effectiveness
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Pharmaceuticals in EMS: Are you compliant?
The Drug Supply Chain Security Act mandates pharmaceutical tracking, tracing and documentation for EMS agencies
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Orthotic-style off-loading wheelchair seat cushion reduces interface pressure under ischial tuberosities and sacrococcygeal regions
Publication date: Available online 27 April 2016
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Barbara Crane, Michael Wininger, Evan Call
ObjectiveTo assess the efficacy of an off-loading wheelchair seat cushion in removing pressure from high-risk ischial tuberosities and coccyx/sacrum in wheelchair sitting.DesignRepeated measures designSettingPrivate research laboratoryParticipantsManual wheelchair users with chronic spinal cord injuries (N=10)InterventionsThree configurations of an off-loading wheelchair seat cushion compared with a flotation style (4" air inflation) wheelchair seat cushion.Outcome MeasuresOutcome measures included peak pressure index (PPI), ischial tuberosity peak pressures and the "dispersion index" or ratio of pressures under the ischial and sacral regions to the total of all pressures recorded.ResultsPPI and IT Peak Pressure ranged from a low of 39 ± 18 and 68 ± 46 mmHg in the fully off loaded cushion to a high of 97 ± 30 and 106 ± 34 mmHg, respectively for the flotation style cushion (two-way ANOVA main effect across four conditions p < .001). Dispersion Index ranged from a low of 8 ± 3% in the fully off loaded cushion, to a high of 16 ± 3% in the flotation style cushion. Pair-wise comparisons yielded significance in all cushion-pair analyses (P<0.05 after multiple corrections).ConclusionsWe conclude that the force-removal approach of this orthotic off-loading cushion design effectively reduces a known extrinsic risk factor for pressure ulcers – interface pressure – in the high-risk ischial tuberosity and sacral/coccygeal regions of the buttocks.
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PARAMEDIC & EMT-B - COMPASS AMBULANCE SERVICES
We are looking for Paramedics and EMT-B's who are committed to making a difference and who want a positive place to work. Paramedics will be required to provide advanced and basic life support for emergent and non-emergent transports. EMT-B will be required to provide basic life support for emergent and non-emergent transports.
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Reexpansion pulmonary edema after treatment of secondary spontaneous pneumothorax
2016-04-28T09-08-28Z
Source: International Journal of Medical Science and Public Health
Babaji D Ghewade, Saood Ali, Swapnil Chaudhari, Smaran Cladius.
Reexpansion pulmonary edema is an unusual, but commonly fatal, clinical state. It is denoted by the occurrence of unilateral pulmonary edema in a lung that has been speedily reinflated following a variable duration of collapse secondary to a pleural effusion or pneumothorax. Unilateral pulmonary edema is connected with a variable degree of hypoxia and hypotension, occasionally needing intubation and mechanical ventilation, and at times causing lethality. The exact pathophysiologic anomalies linked with this disorder are still not known, although reduced pulmonary surfactant levels and a proinflammatory status are supposed mechanisms. Early diagnosis is important because prognosis is based on early recognition and right treatment. Preventive means are still the best applicable approach for patient handling. Here, we report a case of a 25-year-old male patient who developed reexpansion pulmonary edema after intercostal drainage for secondary spontaneous pneumothorax.
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Morbidity profile of transport sector workers and its correlation with social and work factors
2016-04-28T09-08-28Z
Source: International Journal of Medical Science and Public Health
Kiran Shetty, Sudhir Prabhu, Delma D'Cunha, Oliver D'Souza, Amrita Suvarna, Betty Jacob.
Background: Musculoskeletal disorders consequent to demanding working conditions are not uncommon nowadays. A number of risk factors contribute to these problems thereby affecting occupational productivity. Most commonly affected are the transport sector workers, who are subjected to harsh conditions of the environment, traffic noise, pollution, difficult shifts, lack of sleep, prolonged abnormal posture, and so on. This study was undertaken to assess the social and work factors of transport sector workers, mainly drivers and conductors, in Dakshina Kannada district and to make an association between these and the morbidity status of the individuals. Objectives: The study was undertaken to assess the type and degree of work-related musculoskeletal disorders in transport sector workers. The effect of duration in the occupation on co-morbidities present among these drivers and conductors was also analyzed. The study was also aimed at evaluating ocular symptoms in these workers. Materials and Methods: The present study was a cross-sectional, community-based descriptive study. A total of 522 transport sector workers were included as part of the study. A prestructured, pretested, and validated questionnaire for sociodemographic details and occupational-related morbidity were used for data collection. Results: All study subjects were male and in the age range of 2155 years. The stressors responsible for morbidities were identified. A positive correlation was found between long working hours and ill-health. Drivers were found to have additional issues in terms of ocular symptoms. Individuals working for more than 5 years in the transport sector were found to have the most number of medical complaints. Conclusion: Long working hours, postural strain, and exposure to noise, environmental pollution, sunlight, and dust are all factors contributing to transport sector morbidities. Drivers were found to face the maximum brunt of all these factors compared to conductors. Mental strain and stress were found to be present in all of these individuals.
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Cross-sectional study on availability and affordability of some essential child-specific medicines in Uttar Pradesh
2016-04-28T09-08-28Z
Source: International Journal of Medical Science and Public Health
Neelkanth M Pujari, Anupam Kr Sachan, Yatindra Kumar.
Background: Uttar Pradesh ranks fourth highly populous state of India and having about 14.9% population of age ≤5 years. The state records very high mortality of children. Continuous availability of affordable medicines in appropriate formulations is essential to reduce morbidity and mortality in children. Objective: The study aims at documenting the availability and affordability for purchasing essential child-specific medicines in the state of Uttar Pradesh, India. Materials and Methods: The survey of ten essential medicines was conducted in six randomly selected districts of Uttar Pradesh. Data were collected from medicine outlets of the public, private, and other sector (Nongovernmental Organization [NGO]/mission sectors) of all six randomly selected districts, using survey questionnaire. Results: Both public sector and NGO/mission sector health facilities procure only one brand of medicines, mean percentage availability of medicines being 17% and 21.8%, respectively. In the private sector, the mean percentage availability of the high- and low-priced medicines for a particular drug product was 10.8% and 38.5%, respectively. ORS (for 1L) and paracetamol suspension (antipyretic-analgesic group) was widely available with more than 90%, nearly more or less in all three sectors. Availability of antibiotics was consistently less in most of the outlets except cotrimoxazole suspension (81.9%) in public sector and amoxicillin + clavulanic acid dry syrup (53.7%), azithromycin syrup (68.3%) in public sector. Conclusion: The availability of children's medicines in public sector facilities of Uttar Pradesh state is poor. Medicines for children cost relatively high in private sector. The availability of medicines should be improved on an urgent basis to improve access to medicines for children.
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Utilization of antenatal care services in periurban area of Aligarh
2016-04-28T09-08-28Z
Source: International Journal of Medical Science and Public Health
Poonam Kushwaha, Saira Mehnaz, M. Athar Ansari, Salman Khalil.
Background: Utilization of antenatal care (ANC) services is poor in the peri-urban areas, causing increased maternal morbidity and mortality. Objective: (i) To determine the current status of utilization of ANC services and (ii) to asses factors affecting utilization of ANC services. Materials and Methods: A community-based cross-sectional study was conducted in peri-urban field practice area of urban health training center, J N Medical College, Aligarh, India. The data were collected by home visit using a pretested, structured, semi-open questionnaire from 200 recently delivered women, who utilized ANC services. Data were tabulated and analyzed by using SPSS-20. Proportion, frequencies, and χ2-tests were used to interpret the data. Result: Full utilization of ANC services was found to be 59%. Home deliveries were 23% and all were conducted by untrained persons. Utilization of ANC services was significantly associated with education, socioeconomic status, parity, and age at marriage. Main reasons for inadequate (partial/no) utilization of ANC services were financial constrains (34.14%) and lack of awareness (30.48%), whereas for home deliveries it was tradition (23.91%) and financial constrains (21.74%). Conclusion: Utilization of ANC services was not satisfactory and home deliveries by untrained person were still present. Prevailing barriers to utilization of ANC services and institutional deliveries must be identified and taken into consideration in planning and policy making.
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Measuring undernutrition by composite index of anthropometric failure (CIAF): a community-based study in a slum of Nagpur city
2016-04-28T09-08-28Z
Source: International Journal of Medical Science and Public Health
Rajeshree S Dhok, Subhash B Thakre.
Background: In any community, under-five children constitute one of the most vulnerable groups for nutritional deficiencies. The estimation of growth in children is vital for screening health status, identifying divergences from normality, and evaluating the efficiency of interventions. Composite index of anthropometric failure (CIAF) offers a single number to the overall evaluation of malnourished children in a population, which no other conventional indicators do. Objective: To estimate the overall prevalence of undernutrition among under-five children in an urban slum using CIAF and study some covariates associated with undernutrition. Materials and Methods: This community based cross-sectional study was conducted in an urban slum area of Nagpur city. Study subjects were under-five children residing in the slum, and respondents were their mothers. Data collection was done by conducting house-to-house survey, and information was recorded in predesigned pretested questionnaire. Anthropometric measurements were recorded using standard techniques. Overall prevalence of undernutrition was estimated using CIAF. Result: The overall prevalence of undernutrition by CIAF among under-five children in urban slum area was found to be 58.59%. Covariates found to be significantly associated with undernutrition were lower socioeconomic status, illiteracy of mother, low birth weight, birth order, narrow birth interval, exclusive breastfeeding, immunization status, and childhood morbidities. Conclusion: The overall prevalence of undernutrition among under-five children was found to be 58.59%, which was higher than that estimated by conventional measures of undernutrition (underweight, stunting, and wasting). An aggregate and comprehensive measure of the total magnitude of undernutrition such as CIAF is a useful tool to quantify undernutrition, especially to identify children with multiple anthropometric failures.
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Timing of Last Preoperative Dose of Infliximab Does Not Increase Postoperative Complications in Inflammatory Bowel Disease Patients
Abstract
Background
The association between preoperative use of infliximab and postoperative complications in patients with inflammatory bowel disease (IBD) is a subject of continued debate. Results from studies examining an association between the timing of last preoperative dose of infliximab and postoperative complications remain inconsistent.
Aims
To assess whether timing of last dose of infliximab prior to surgery affects the rate of postoperative complications in patients with Crohn's disease or ulcerative colitis.
Methods
Retrospective chart review of IBD patients who have undergone surgery while receiving therapy with infliximab was conducted. Forty-seven patients were included in the analysis.
Results
No significant association was found between timing of infliximab and the rate of postoperative complications. Age, gender, disease type, steroid use, preoperative status, surgery type, or surgeon type was not associated with increased rate of postoperative complications.
Conclusion
Timing of last dose of infliximab does not affect the rate of postoperative complications in patients with Crohn's disease or ulcerative colitis.
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Mich. paramedic saves own daughter's life
Jeffrey Ballard's 8-year-old daughter, who suffers from asthma, stopped breathing and became unconscious in the car
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A Clinician’s perspective on clinical exome sequencing
Abstract
Clinical exome sequencing has clearly improved our ability as clinicians to identify the cause of a wide variety of disorders. Prior to exome sequencing, a majority of patients with apparent syndromes never received a specific molecular genetic diagnosis despite extensive diagnostic odysseys. Even for those receiving an answer to the question of what caused their disorder, the diagnostic odyssey often spanned years to decades. Determining the particular genetic cause in an individual patient can be challenging due to inherent phenotypic and genetic heterogeneity of disease, technical limitations of testing or both. Blended phenotypes, due to multiple monogenic disorders in the same patient, are true dilemmas for traditional genetic evaluations, but are increasingly being diagnosed through clinical exome sequencing. New sequencing technologies have increased the proportion of patients receiving molecular diagnoses, while significantly shortening the time scale, providing multiple benefits for the health-care team, patient and family.
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Deciphering intratumor heterogeneity using cancer genome analysis
Abstract
Intratumor heterogeneity within individual cancer tissues underlies the numerous phenotypes of cancer. Tumor subclones ultimately affect therapeutic outcomes due to their distinct molecular features. Drug-resistant subclones are present at a low frequency in tissues at the time of biopsy, but can also arise as a result of acquired somatic mutations. A number of different approaches have been utilized to understand the nature of intratumor heterogeneity. Clonal analysis using whole exome or genome sequencing data can help monitor subclones in the context of tumor progression. Multiregional biopsies permit the molecular characterization of subclones within tumors. Deep sequencing has also provided researchers with the ability to measure the low allele fraction variant within a small number of cells. Ultimately, single-cell sequencing will enable the identification of every minor population within a tumor microenvironment. In the clinical context, the ability to identify and monitor the subclonal architecture of a tumor is valuable for the development of precise cancer therapeutic methods.
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Biological findings from the PheWAS catalog: focus on connective tissue-related disorders (pelvic floor dysfunction, abdominal hernia, varicose veins and hemorrhoids)
Abstract
Pelvic floor dysfunction, specifically genital prolapse (GP) and stress urinary inconsistency (SUI) presumably co-occur with other connective tissue disorders such as hernia, hemorrhoids, and varicose veins. Observations on non-random coexistence of these disorders have never been summarized in a meta-analysis. The performed meta-analysis demonstrated that varicose veins and hernia are associated with GP. Disease connections on the molecular level may be partially based on shared genetic susceptibility. A unique opportunity to estimate shared genetic susceptibility to disorders is provided by a PheWAS (phenome-wide association study) designed to utilize GWAS data concurrently to many phenotypes. We searched the PheWAS Catalog, which includes the results of the PheWAS study with P value < 0.05, for genes associated with GP, SUI, abdominal hernia, varicose veins and hemorrhoids. We found pronounced signals for the associations of the SLC2A9 gene with SUI (P = 6.0e−05) and the MYH9 gene with varicose veins of lower extremity (P = 0.0001) and hemorrhoids (P = 0.0007). The comparison of the PheWAS Catalog and the NHGRI Catalog data revealed enrichment of genes associated with bone mineral density in GP and with activated partial thromboplastin time in varicose veins of lower extremity. In cross-phenotype associations, genes responsible for peripheral nerve functions seem to predominate. This study not only established novel biologically plausible associations that may warrant further studies but also exemplified an effective use of the PheWAS Catalog data.
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