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VEP Selected to Modern Healthcare’s Best Places to Work

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VEP Healthcare and Hospitalist Services Medical Group is excited to announce that that for the third year in a row, VEP Healthcare has earned the honor of being named to Modern Healthcare’s Best Places to Work 2012. Only 100 healthcare companies nationwide are selected to receive this high honor. In 2011, only 25% of all recognized companies were selected to receive the award three years in a row. The selection process includes questions to employees about compensation, benefits, leadership, strategic planning, opportunities for advancement, and dozens of other issues facing employees and the Company on a daily basis. Congratulations and Thank You to our valued employees for honoring us with this amazing award. Modern Healthcare will release the ranking of the Top 100 Best Places to Work in Healthcare in October.

The post VEP Selected to Modern Healthcare’s Best Places to Work appeared first on VEP Healthcare.


Sutter Solano Medical Center ED Rated as “Kid-Qualified” by VEP

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August 11th, 2012 Sutter Solano Medical Center was rated “Kid-Qualified” by VEP Healthcare, the group practice that provides emergency services at Sutter Solano and 35 other hospitals state-and-nationwide, hospital officials announced. Sutter Solano’s Emergency Department treats more than 7,000 children each year, officials said. The hospital received the “Kid-Qualified” certification this month, after a confirmation process, officials said. “This certification demonstrates to the community that our physicians and nurses are fully prepared to serve the community and provide outstanding pediatric care,” Sutter Solano’s Emergency Department medical director William Melton, said in a statement. “As a mother and a former pediatric nurse, I know how a parent feels when their child is in the emergency room,” Sutter Solano CEO Terry Glubka said during the presentation ceremony. “This certification will provide an extra level of comfort to parents who bring their young ones to our Emergency Room — they’ll know they are in good hands.” Sutter Solano’s Emergency Department has implemented several innovative treatment techniques, like a rapid pain relief method for children, officials said. Since many children are uneasy around needles, Sutter Solano staff members are trained to administer pain killers through a special syringe that aerosolizes the medication into the nose, they said.

The post Sutter Solano Medical Center ED Rated as “Kid-Qualified” by VEP appeared first on VEP Healthcare.

Holly Mesikmen Named the Provider of the Year for 2012!

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January 1st, 2013 Holly Meskimen was named the Physician (Provider) of the Year for 2012!!! Congratulations to Holly! She was honored at a luncheon at Hidden Brooks last week in front of many hospital employees and admin leadership. Holly’s service to patients and multiple Sutter Spirit awards from patients and staff were recognized with this well-deserved award.

The post Holly Mesikmen Named the Provider of the Year for 2012! appeared first on VEP Healthcare.

UCLA Medical Center helps kids be less afraid of the ER, doctor

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By Denise Dador ABC7.com Article Featured On ABC7.com LOS ANGELES (KABC) — During a visit to the emergency room, 5-year-old Julian Lander feels at home. I know there’s doctors, paramedics, firemen, police officers,” he said. They’re all friends now, but a few weeks ago the staff was all strangers. He cut his head on a coffee table corner and his mom brought him in. “There’s always a little bit of apprehension, what’s going to happen to me, what are they going to do to me,” said Carmen Pinto, Julian’s mother. Fortunately for her son, the staff at UCLA Medical Center, Santa Monica are working on creating a so-called “ouchless ER” experience for kids. <>”It’s scary when they’re hurt or sick and so we are trying to change the environment and the way that we practice medicine so that we can make it as comfortable and friendly an experience as possible for them,” said ER physician Dr. Lisa Dabby. The first step: Establish a rapport with young patients. Child life specialist Katie Kolbeck greets them and explains what’s going to happen in ways kids understand. “Using these different tools that we have for medical play allows them a little bit of control in the situation and helps them understand why the doctors and nurses are doing what they’re doing,” said Kolbeck. Dabby also implements “ouchless” medicine into her practice. “We are doing everything from trying to use glue instead of stitches, trying to give oral medications when we can instead of poking, we have a new nasal atomizer device to administer medication in the nose, instead of a poke,” said Dabby. When you do have to poke, an ultrasound helps minimize them. “So we use this tool to get a good look at the vein and we can get the IV on the very first stick,” said Dabby. While avoiding needles, understanding doctors and caring nurses make the ER more inviting for children, experts say parents also play a key role. “Children are comforted by being around their parents, so if their parent is calm and there to hold them, I think that’s the best advice I can give,” said Dabby. It was such an ouchless experience for the young Julian, he says someday he might even be a doctor. “I was happy I felt better,” he said. Julian avoided stitches completely and is healing well. His mother said having the child life specialist also helped her manage her son’s twin sister, who was also there for the long ER visit. (Copyright ©2014 KABC-TV/DT. All Rights Reserved.)

The post UCLA Medical Center helps kids be less afraid of the ER, doctor appeared first on VEP Healthcare.

Formerly with VEP at Sutter Solano Medical Center, Dr. Carson is featured in Contra Costa Times’“Hometown Hero” article!

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By Robert Rogers Contra Costa Times Article Featured On Contra Costa Times “SAN PABLO — Minutes after the crackling gunfire and screeching rubber, the fallout hits Dr. Desmond Carson. As an emergency room physician, Carson has seen hundreds of young men, women and children wheeled in with bullet-riddled bodies. He can’t unsee the dead, the last breaths and the miraculous recoveries. Nor does he want to. ‘You get tired of seeing black boys and Mexican boys killed, it’s depressing, but it also is right there, a truth you can’t hide or gloss over,’ Carson said. ‘It’s a public health disgrace. If this kind of carnage happened in a white community, there would be a national uproar.’ Carson, 52, has been saving lives in the Doctors Medical Center emergency room since 1998, Dr. Desmond Carson and medical student Pam Schwendy discuss treatments for a patient in the emergency department of Doctors Medical Center. Carson, 52, named a Hometown Hero, has been saving lives in the Doctors Medical Center emergency room since 1998 and been a fierce advocate for his chronically underfunded hospital and public health in West Contra Costa County. (Anda Chu/Bay Area News Group) and is a fierce advocate for his chronically underfunded hospital and public health in West Contra Costa County. In April, Carson earned the Richmond Excellence Serving our Community award, granted by Richmond and the Richmond Community Foundation. The award committee noted Carson’s cofounding of a team of health care professionals to provide free stroke and heart attack-prevention clinics, mentoring Richmond High School students interested in medicine, and coaching the Richmond Steelers, a pee-wee football team. ‘Desmond is a guy with a sterling educational background who could work anywhere in the country,’ said Eric Zell, who served five years with Carson on the hospital’s board of directors. ‘But he chooses to work at a safety-net hospital that serves low-income and uninsured or underinsured people. You don’t see a lot of people do that.’ Carson grew up in south Richmond, just off Carlson Boulevard near what is now the Crescent Park housing complex. Eastshore Park, since renamed Booker T. Anderson Park, was where he played after-school sports. Carson and his two younger sisters went to St. Joseph’s Catholic School in Berkeley and later to El Cerrito High School. Dad worked at a packaging company in Berkeley, and Mom was a nurse at Kaiser Hospital in Richmond. Carson went to UC Berkeley, where he studied biophysics, and later studied medicine at the Medical College of Wisconsin. It was during his residency at Martin Luther King Jr. medical center in Los Angeles that Carson saw firsthand the toll of grinding inner-city violence. In the 1980s and 1990s, the crack cocaine epidemic gripped the Los Angeles area, and gang violence was on the rise. Carson remembers the September 1996 night that rap star Tupac Shakur was shot and killed in Las Vegas. The MLK medical center looked like a war zone, he said. ‘We had 18 people shot that night, in the head, the chest, the stomach, arms and legs,’ Carson said. ‘That was the most I’ve ever seen. It seemed like I was performing surgery on trauma victims all night.’ Today, Carson is that rare physician who is totally in sync with the community he serves, trusted by generations of patients and possessing an empathy and understanding befitting his local background. ‘He knows everybody, and everybody knows him, I have never seen anything quite like it,’ said Dr. Malcolm Johnson, the emergency department medical director. ‘In this community, the ER doctor is also a de facto primary care doctor, and Desmond plays that role as well as it can be done.’ Johnson said Carson, whom he describes as a ‘mentor,’ is at his best in times of crisis. When a massive fire broke out at the nearby Chevron refinery in August, Carson, a veteran of many other chemical spills and industrial explosions in West Contra Costa County, took command. ‘I recall him saying to everybody, “Get the tents out!”‘ Johnson said, referring to emergency triage tents to handle the imminent surge of patients. More than 15,000 people sought medical treatment in the hours and days after the fire, several thousand at Doctors Medical Center. ‘That was the impetus, and when the patient surge came, we were ready, and Desmond performed marvelously,’ Johnson said. Carson, who lives in the city where he grew up, said he isn’t immune to the emotions that come with working in an emergency room. ‘It’s tough,’ Carson said. ‘I lean on my wife and my kids for support, and I have no problem getting on my knees and asking God’s help.’ Carson said that whatever emotional toll the bloodshed has on him, it pales in comparison with what young people in the community face. ‘These kids out here in Richmond and North Richmond see this violence every day, and there aren’t any psychologists running around these communities to treat these kids for post-traumatic stress disorder,’ he said. ‘You can’t see the scars on someone’s soul, but they are there.’ Looking ahead, Carson expects to transition away from the emergency room and spend more time doing public health outreach, volunteering with the Richmond Steelers football program and advancing public health initiatives as a director of For Richmond, a coalition of business and labor leaders dedicated to improving Richmond. ‘There’s always this fear of being the old guy on the basketball court who can’t play anymore, and somebody else has to tell him it’s time to move,’ Carson said. ‘I don’t want to be that old guy trying to run with these youngsters on the ER floor.”

The post Formerly with VEP at Sutter Solano Medical Center, Dr. Carson is featured in Contra Costa Times’ “Hometown Hero” article! appeared first on VEP Healthcare.

Valley Emergency Physicians welcomes three new members to our Board of Directors

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January 1, 2014 VEP Healthcare is excited to welcome three new members to our Board of Directors: Adin Levine, MD, Marc Futernick, MD & Ivan Ventura, PA-C Doctor Marc Futernick, M.D, Board Member

Marc Futernick, MD, FACEP, joined VEP in 2011 as the Medical Director of Emergency Services at California Hospital Medical Center. CHMC is a trauma center and is the oldest hospital in Los Angeles. Dr. Futernick has been the Medical Director at CHMC since 2006 and worked at Santa Monica-UCLA prior to that. Dr. Futernick received his Bachelor of Science degree in Biochemistry from the University of California, Los Angeles and his MD from Tulane University Medical School. He completed his Emergency Medicine residency at University of California, San Francisco-Fresno.

Dr. Futernick serves on the Board of Directors of the California Chapter of the American College of Emergency Physicians. His current focus is to improve the quality of care given to patients with psychiatric emergencies. He lives in Pasadena with his wife, Christy, and his two teenage sons, Ben and Matthew.

[divider style=”1″ align=”center” size=”normal” scrolltext=””][/divider] Doctor Adin Levine, M.D, Secretary

Dr. Levine is an Emergency Physician and serves as Chief of Staff Elect at Dameron Hospital in Stockton, CA. He attended college at the Universities of California and London, and received his MD from USCF. His career with VEP began in 1986, shortly after completing his internship at the SF General Hospital. He is board certified in Family Practice and Emergency Medicine. Over the years, Dr. Levine has worn many hats at VEP in both clinical and management roles, and has served on the BOD for most of this century. He lives in Berkeley with his wife Ella, four children (three of whom are now young adults and only show up occasionally), one cat, and one not-yet-domiciled bird.

[divider style=”1″ align=”center” size=”normal” scrolltext=””][/divider] Doctor Ivan Ventura, PA-C, Board Member

Ivan Ventura is a Physician Assistant graduate from University of California, Davis PA program in 2003. He worked in family practice for 2 years and worked per diem in the emergency room where he discovered his true passion for emergency medicine and the challenges it poses. Mr. Ventura became the AHP Director at Mercy Medical Center – Merced and shortly after Regional Director of AHPs for VEP. In this role he has the privilege of interacting with many of VEP’s sites and assists in department flow with implementation of Rapid Patient Management (RPM) system, and Human Resources issues. He has participated in many contract start-ups that have now become profitable sites for VEP.

Mr. Ventura’s hobbies are swimming (when he has the opportunity!) and watching movies. He is a father of 3 wonderful children; Eli 4, Evan 3 and Elyse 1mo (yes…they like names that start with “E”); which along with work give him little time to swim or watch movies! Ivan was recently given the honor to serve in VEP’s Board of Directors. He looks forward to the learning experience and the opportunity to continue VEPs legacy of success in providing quality medical care; and continuing participation in shareholder and provider camaraderie.

The post Valley Emergency Physicians welcomes three new members to our Board of Directors appeared first on VEP Healthcare.

HEALTHeCAREERS Featured Employer Profile: Valley Emergency Physicians Medical Group

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Wednesday, February 26, 2014 by Kristianna Berger View original on HEALTHeCAREERS’ blog EXCELLENCE IN EMERGENCY MEDICINE AND PRIMARY CARE! BACKGROUND VEP Healthcare (VEP) operates emergency departments in 32 hospitals throughout California, New Mexico, Tennessee, and Texas. Our hospitals partners range from major urban trauma centers to rural community hospitals. We also provide hospitalist services in several California hospitals. Created in 1981, VEP is a democratic medical group owned solely by our practicing physicians, advanced practice clinicians, and office personnel. VEP corporate headquarters are in Walnut Creek, California. QUALITY MEDICAL CARE At VEP we dedicate substantial resources to ensure that our patients receive the highest quality medical care. At each ED we comprehensively track our performance in dozens of key metrics so that we can identify anything that may need attention. Our extensive quality program includes ED Medical Director training and mentoring by our physician executive team. Evidence for the efficacy of our quality program is a malpractice claim rate that is far below the national average. BOARD CERTIFIED PHYSICIANS Over 700 physicians and advanced practice clinicians are in the VEP family. Over 90% of our physicians are board certified or eligible in emergency medicine or a primary care specialty. PATIENT SATISFACTION At VEP we strive for and achieve top patient satisfaction scores. We do this not because it is required, but because we truly believe patients and their families deserve to be treated with expertise, efficiency, and compassion. Our ED Medical Directors receive training and monitoring to ensure patient satisfaction success in every VEP emergency department. HOSPITALIST PROGRAMS The VEP Hospitalist program affords physicians the opportunity to deliver comprehensive hospital-based care without the constraints of an office practice. We carefully monitor key hospitalist metrics to ensure high clinical quality, high patient satisfaction, and optimal utilization of resources.

The post HEALTHeCAREERS Featured Employer Profile: Valley Emergency Physicians Medical Group appeared first on VEP Healthcare.

Voting is currently in process for this year’s California ACEP Board of Directors!

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Voting is currently in process for this year’s California ACEP Board of Directors! There are 3 VEP physicians running who will all serve our patients and specialty well: Dr. Stephen Liu, VEP’s Medical Director at White Memorial in Los Angeles. Dr. Andrew Kassinove, VEP’s Medical Director at JFK Hospital in Indio, California. Dr. Kevin Jones, this year’s health & advocacy fellow for California ACEP & VEP physician at Mercy Medical Center Merced. If you are a CAL/ACEP member – please immediately go HERE and cast your vote now before the deadline of April 15!

The post Voting is currently in process for this year’s California ACEP Board of Directors! appeared first on VEP Healthcare.


Valley Emergency Physicians’ Phil DaVisio, PA-C, published in the June 2014 ACEP Democratic Group Practice Section Newsletter!

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Congratulations and thank you to VEP Healthcare’ Phil DaVisio, PA-C, for his recent article published in the June 2014 ACEP Democratic Group Practice Section Newsletter! Phil wrote about “The Case for Advanced Practice Provider (APP) Ownership in Democratic Groups” which can be viewed in the original newsletter HERE.

The post Valley Emergency Physicians’ Phil DaVisio, PA-C, published in the June 2014 ACEP Democratic Group Practice Section Newsletter! appeared first on VEP Healthcare.

VEPeds White Paper

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VEP Healthcare is proud to announce release of a new white paper featuring best practices for pediatric care in the emergency department. Learn more about the VEPeds program and how it can improve care delivery in your community! VEPeds Whitepaper

The post VEPeds White Paper appeared first on VEP Healthcare.

Long Bone Fracture Pain Meds

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Dear VEP Providers,

Below is a link to a one-page handout on OP-21, the national core measure for PAIN MEDS FOR LONG BONE FRACTURE.  Study it for 2 minutes to learn all you need to know about OP-21.  Be aware that starting in January, carpal bones will be included.

Most of our EDs have median times that are better than the national average of 54 minutes.  Some of our EDs are in the top 10% nationally with median times under 34 minutes!  Our goal for 2016 is to have every VEP ED in the top 10%.
Bottom line:  Treat any painful condition as soon as possible, not just long bone fractures.

LINK TO VEP OP-21 HANDOUT

 

Thanks,

Robert Wyman, MD  |  Vice President of Quality
Tel: 925-482-2802  |  Fax: 925-482-2838
rwyman@vephealthcare.com

 

The post Long Bone Fracture Pain Meds appeared first on VEP Healthcare.

Clinical Decision Rules And Smartphone Medical Aps

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Dear VEP Providers,

This link will take you to an excellent video that was recorded at the recent VEP Directors and Shareholders Meeting: https://kevinjones20.wistia.com/projects/gbe68q3640

The video is about Clinical Decision Rules (CDRs) and the best smartphone medical apps.  The presentation was given by two of our VEP colleagues:

  • Dr. Justin Chatten-Brown, ED medical director at Woodland Hospital in Woodland, CA, and VEP board member.
  • Dr. Kevin Jones, ED assistant medical director at Sutter Solano Medical Center in Vallejo, CA, and Cal/ACEP board member.

CDRs can reduce testing, decrease turnaround times and LWBS, and increase patient satisfaction.  Smartphone medical apps provide quick and easy access to useful tools and a wealth of information.  Enhance your ability to provide high-quality, efficient, evidence-based care by viewing the presentation and incorporating the material in your practice.

Thanks.

Robert Wyman, MD  |  Vice President of Quality
Tel: 925-482-2802  |  Fax: 925-482-2838
rwyman@vephealthcare.com

The post Clinical Decision Rules And Smartphone Medical Aps appeared first on VEP Healthcare.

Ebola Scare In A VEP ED

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Dear Providers,

Fortunately, despite all of the Ebola preparations at VEP emergency departments over the past few months, only a couple of patients have had histories and symptoms suspicious for Ebola (so far).  Below is the experience of Justin Chatten-Brown, MD, our ED medical director at Woodland Memorial Hospital in Woodland, CA, who initially thought he was being summoned to the ED for an Ebola drill this week.  One lesson they learned at Woodland was that greater care is needed for PPE use.  The following link is for a one-week old CDC video on PPE, so hopefully it is still current!

http://www.medscape.com/viewarticle/833907?src=ppc_google_acq_bola_vid

Rob Wyman, MD
Vice President of Quality
925-482-2802
rwyman@vephealthcare.com

 

If your experience is anything like mine, you’ve received over 200 emails with constantly changing updates regarding Ebola. Knowing the very small chance that any of us will actually see a patient with Ebola, and the amount of time, energy, and resources which are going into Ebola preparedness, I’m sure that you, as I have, feel like we may be making a mountain out of a mole hill. While I’ve stayed positive and on point with my staff, I’ve felt at times like the degree of scrutiny we are under is absurd. I had an experience today which gave me new perspective on the issue.

I thought 6 AM was a little early for an Ebola drill, but dragged myself out of bed at 5. I walked into the emergency department thinking I would find us getting ready for a mock patient, but was instead met with a sense of urgency and seriousness I had not expected. I looked on the board and the patient in our isolation room had been in the department for an hour and a half. The administration and my colleagues told me it wasn’t a drill after all. I laughed it off, thinking they were pulling my leg. They told me to look through the window into the room, and it was only upon seeing the patient sitting in the bed, pale, diaphoretic, tachycardia in the 130s, that I realized this would have been a bit too hard to fake. The nurse sitting next to him at the computer in full PPE’s also appeared to be taking the situation very seriously.

It wasn’t much later that we were able to clear the patient for Ebola after obtaining more history, and in consultation with our public health department. It turns out our patient had very limited contact with a colleague who recently returned from Africa, but the symptoms were alarming. The patient had been in the emergency department for nearly 2 hours when we finally were able to run his laboratories and discover just how critically ill he was.

I imagine our extensive debriefing was much better than it would have been had this been a true “mock” patient. We were fortunate enough that this occurred early in the morning with a relatively empty department. We were also fortunate that the patient didn’t have Ebola, since at least two of our staff would likely have been exposed based upon improper donning and doffing of PPEs. Amongst numerous lessons learned from this experience, the standout is that while the Ebola scare may blow over soon, we are never as prepared as we would like to think. We all need to practice our preparedness, contingency plans, and how we will protect each other and our patients for whatever the next epidemic may be. As with our regular pediatric mock codes, we practice handling low incidence events knowing that if we don’t, lives will be lost. We should all consider our own biases and readjust our attitudes towards the current initiatives for Ebola preparedness.

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ACEP Choosing Wisely Recommendations

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Dear VEP Providers,

Below is a link to the updated ACEP “Choosing Wisely” list of 10 recommendations.  The recommendations are based on input from an expert panel of emergency physicians and the ACEP Board of Directors.  The goal is to present evidence-based recommendations to providers about tests and procedures that may not be cost effective in some situations.  When appropriate, you should consider discussing these recommendations with your patients in order to both educate them and gain their agreement regarding avoidance of such tests and procedures.

ACEP Choosing Wisely Recommendations

 

“Choosing Wisely” is a multi-year effort of the American Board of Internal Medicine Foundation to avoid care when harm may outweigh benefits.  More than 80 medical specialty societies and consumer groups are participating along with ACEP.

Feel free to contact me if you have any questions, comments, or suggestions.

Thanks.

Rob Wyman, MD
Vice President of Quality
rwyman@vephealthcare.com

The post ACEP Choosing Wisely Recommendations appeared first on VEP Healthcare.

VEP: 2 Minutes On Asymptomatic Elevated Blood Pressure In The ED

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ASYMPTOMATIC ELEVATED BLOOD PRESSURE IN THE ED

As emergency department providers, we see elevated blood pressures on a daily basis. In some cases, this is reflective of an emergency medical condition which must be identified and stabilized.  But what if the patient with elevated blood pressure is:

  1. asymptomatic, and
  2. denies any related symptoms, and
  3. has a normal physical exam?

The American College of Emergency Physicians (ACEP) periodically publishes clinical policies that answer specific clinical questions. ACEP recently released a policy addressing Asymptomatic Elevated Blood Pressure in the ED.  Although these policies are not meant to establish a standard of care, you should feel very comfortable practicing in accordance with these recommendations. I encourage you to read the clinical policy yourself which outlines the evidence for the recommendations.  See the link to the policy at the bottom of this email.

The short version of this policy is:

You do not need to do any screening tests, nor provide any medical treatment, for patients with asymptomatic elevated blood pressure.

The policy addresses whether performing screening tests to detect target organ injury, which would indicate a hypertensive emergency, is useful or necessary.  This recommendation assumes that your history and physical exam are essentially normal (with respect to the hypertension).

Your chart documentation should include:

  • History:  absence of chest pain, shortness of breath, severe headache, or neurologic symptoms.
  • Physical exam:  normal cardiovascular, pulmonary, and neurologic exams.

For the purposes of the policy, the screening tests that you do not need to do are:

  • ECG.
  • CXR.
  • Blood or urine tests to detect clinically occult abnormalities (e.g., anemia, cardiac ischemia, CHF, renal insufficiency).

In a nutshell, the ACEP recommendation for the asymptomatic patient with elevated blood pressure is:

Routine screening is not required.  However, in select populations (poor follow up is their example), screening for an elevated creatinine may identify kidney injury that could affect disposition.

Similarly, the ACEP recommendation for the asymptomatic patient with markedly elevated blood pressure (considered by ACEP to be >180/110) is:

ED medical intervention is not required.  However, in select populations (again, poor follow up is the example given) emergency physicians may treat in the ED and/or initiate outpatient therapy.

All of these patients should be referred for follow up.

These are Level C recommendations from ACEP.  This means there are limited data but there is some level of consensus among experts regarding the recommendation.  Of course, you should use your best medical judgment in any clinical scenario.

I think this policy really gives us the freedom to practice the way we see fit.  There is a lack of evidence to support ordering any screening tests or acutely controlling asymptomatic elevated blood pressure.  This may be a deviation from your usual practice, or what other healthcare workers and patients may be accustomed to.  This information is for you to incorporate into your practice along with what you’ve learned in training and from your experience, colleagues, and continuing education.

Click for ACEP’s Asymptomatic Elevated Blood Pressure

I welcome your feedback on this topic. What do you do?  What do you think is best practice?

Marc Futernick, MD
ED Medical Director at California Hospital Medical Center, Los Angeles, CA
Member of VEP Board of Directors
marcfuternick@aol.com

The post VEP: 2 Minutes On Asymptomatic Elevated Blood Pressure In The ED appeared first on VEP Healthcare.


Bronchiolitis Update In 3 Minutes

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Dear VEP Providers,

Some providers may not be aware of the more recent evidence-based guidelines for bronchiolitis showing that most patients do not require blood tests, chest x-rays, or ED medications.  These and other key facts are in a PDF “slideshow” (see link below) that was prepared by Jeff Lackore, PA-C (APC Regional Director) and edited by Ron Dieckmann, MD, MPH (Director of Pediatrics).  The guidelines can reduce all of the following:  ED length of stay, radiation exposure, number of painful needlesticks, and cost of care.

Bronchiolitis: Beware of ED Over-Management!

 

Please take 3 minutes to review the PDF.  Feel free to contact me if you have any questions or concerns.

Thanks.

Robert Wyman, MD | Vice President of Quality
Tel: 925-482-2802 | Fax: 925-482-2838
rwyman@vephealthcare.com

The post Bronchiolitis Update In 3 Minutes appeared first on VEP Healthcare.

The Case For Advanced Practice Provider Ownership In Democratic Groups

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VEP Physicians’ Phil DaVisio, PA-C,
Published in ACEP Newsletter!

Congratulations and thank you to VEP Physicians’ Phil DaVisio, PA-C, for his recent article published in the June 2014 ACEP Democratic Group Practice Section Newsletter! Phil wrote about “The Case for Advanced Practice Provider (APP) Ownership in Democratic Groups” which can be viewed in the original newsletter HERE.

The post The Case For Advanced Practice Provider Ownership In Democratic Groups appeared first on VEP Healthcare.

CDC Influenza Alert

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Dear VEP Providers,

The flu has arrived. The CDC reports an increasing incidence of severe influenza across the country. The link below will take you to an important CDC alert about this. Below are excerpts from the alert and additional information about influenza. Please contact me if you have any questions or concerns. Thanks.

CDC Influenza Alert

 

Rob Wyman, MD
Vice President of Quality
VEP Healthcare, Inc.
rwyman@vephealthcare.com

 

  1. Clinicians should rapidly treat suspected influenza in:
    •    high-risk outpatients (see list in final item below);
    •    patients with severe, complicated, or progressive symptoms;
    •    all hospitalized patients.
  2. The CDC recommends treatment with either oral Tamiflu (oseltamivir), inhaled Relenza (zanamivir), or IV peramivir.  Note that inhaled Relenza probably should not be used in patients prone to bronchospasm.  Be sure to check dosages and precautions before prescribing or ordering any of these drugs.
  3. RIDTs (rapid influenza diagnostic tests) have a high potential for false negatives.  Therefore, decisions about starting antiviral treatment should not wait for laboratory confirmation.
  4. A history of influenza vaccination does not rule out influenza in an ill patient with clinical signs and symptoms compatible with influenza.  Therefore, vaccination status should not impede the initiation of prompt antiviral treatment.
  5. For previously healthy, symptomatic outpatients who are not at high risk, antiviral treatment can be considered, especially if treatment can be initiated within 48 hours of illness onset.  However, in these patients, antiviral treatment may afford only modest reductions in symptoms and length of illness.
  6. Patients with influenza should be advised not to work or go to school until afebrile to avoid infecting others.
  7. Early antiviral treatment is more effective at reducing morbidity and mortality.  However, delayed treatment may offer benefit when started up to 5 days after symptom onset, which is something to consider except in previously healthy, low-risk patients.
  8. Patients admitted to the hospital with suspected influenza should be placed in respiratory (droplet) isolation.
  9. High-risk outpatients for whom treatment should be considered include:
    •    age < 2 or >64;
    •    chronic pulmonary (including asthma), cardiovascular (except hypertension alone), renal, hepatic, hematological (including sickle cell disease), or metabolic disorders (including diabetes mellitus);
    •    neurologic and neurodevelopment conditions (including disorders of the brain, spinal cord, peripheral nerve, and muscle such as cerebral palsy, seizure disorders, stroke, intellectual disability, moderate to severe developmental delay, muscular dystrophy, or spinal cord injury);
    •    immunosuppression, including that caused by medications or by HIV infection;
    •    pregnancy through 2 weeks after delivery;
    •    age <19 on long-term aspirin therapy;
    •    American Indians and Alaska Natives;
    •    morbid obesity;
    •    patients in nursing homes or chronic-care facilities.

    Again, please contact me if you have any questions or concerns.  Thanks.

    Rob Wyman, MD
    Vice President of Quality
    VEP Healthcare, Inc.
    rwyman@vephealthcare.com

The post CDC Influenza Alert appeared first on VEP Healthcare.

VEP: 3 Minutes On Seizures – Part 2 of 2

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SEIZURES  IN ADULTS – STATUS EPILEPTICUS

A  few weeks ago I wrote to you about the workup, treatment, and disposition of ED patients with unprovoked seizures, as well as the route of medication administration for ED patients with known seizures.  A link to that article is below.

3 Minutes on Seizures: Part 1

Although we frequently encounter patients with seizures in the emergency department, it is less common to encounter patients with status epilepticus, which is recurrent seizures without recovery of consciousness between them.  We will now focus on the optimal management of status epilepticus in the ED.

ACEP recently addressed which agents should be used to terminate ongoing seizure activity in adults.  The policy affirms that the first line treatment is optimal doses of benzodiazepines, and assumes this has been initiated but has failed to abort the seizure activity.

The Level A recommendation is pretty obvious, and I expect that we are all doing this already.

  • EPs should administer additional antiepileptic medication to patients with status epilepticus who have failed treatment with benzodiazepines.  
The Level B recommendation addresses the first line agents.
  • EPs may administer IV phenytoin, fosphenytoin, or valproate for refractory status epilepticus.
The level C recommendation addresses some additional agents that are becoming more commonly used, and supports their use despite a lack of scientific evidence, based upon common use and expert experience.
  • EPs may administer IV levetiracetam (Keppra), propofol, or barbiturates for refractory status epilepticus.
Similar to the previous discussion of first-time seizues, the policy stresses the importance of seeking treatable causes of status epilepticus, such as:
  • Hypoglycemia
  • Hyponatremia
  • Hypoxia
  • Drug toxicity
  • CNS infection
(Don’t forget INH overdose in the category of drug toxicity, which has a unique treatment, pyridoxine.)

Regarding your first line options following optimal dosing of benzodiazepines, IV valproate appears to be as effective as phenytoin, and has fewer adverse effects.

In terms of second line agents, levetiracetam has a low incidence of hypotension and respiratory depression, which are both drawbacks of propofol.  However, for intubated patients, propofol appears to be a very effective option.

Optimal Loading Of Antiepileptic Medication:

Finally, the ACEP policy on managing seizures in adults provides some guidance for optimal loading of antiepileptic medication, both for routine management and for status epilepticus.  You can refer to the actual policy for more detail (see link below), but here are some key points.

  • Carbamazepine:  8 mg/kg oral suspension is recommended as a single oral load, noting that oral tablets have slow and erratic absorption.
  • Lamotrigine (Lamictal): This medication is usually titrated up due to high incidence of serious rashes, so only load if the patient has been using continuously for > 6 months and has been off of it for less than 5 days.  The dose is 6.5 mg/kg single oral load.
  • Levetiracetam (Keppra):  1500 mg single oral or IV load.  Doses up to 30-50 mg/kg IV can be used for status epilepticus with a maximum rate of 100 mg/minute.
  • Phenytoin:  20 mg/kg oral load should be divided into maximum doses of 400 mg every 2 hours. 18 mg/kg is the suggested IV load with a maximum rate of 50 mg/min in adults.  IV is faster, but carries more side effects, and the evidence shows that there is no advantage of either route in terms of seizure recurrence.  For status, you may increase the dose to 30 mg/kg total.
  • Fosphenytoin:  18 PE (phenytoin equivalents) per kg total IV load at max rate of 150 PE/minute.  This can also be given IM.
  • Valproate:  20-30 mg/kg IV load at maximum rate of 10 mg/minute.  The rate can be increased to 40 mg/minute in status.
For status epilepticus, propofol can be given in 2 mg/kg boluses every 3-5 minutes as tolerated, with a maintenance infusion of 5 mg/kg/hr.  Phenobarbital is loaded at 10-20 mg/kg IV, with an additional 5-10 mg/kg given 10 minutes later as needed.  Beware of hypotension and respiratory depression with both of these medications.

To summarize, controlling ongoing seizures is essential.  Be sure you are searching for treatable causes of seizure activity, and address those promptly.  Initial treatment for status epilepticus is optimal doses of benzodiazepines.  If that isn’t successful, there are a variety of medications available, so pick one and treat aggressively with multiple medications until control is achieved.

It is educational to review the details in the policy (see link below).  Please let me know if you have any questions or comments.

Marc Futernick, MD, FACEP
ED Medical Director at California Hospital Medical Center, Los Angeles, CA
Member of VEP Board of Directors
marcfuternick@aol.com

The post VEP: 3 Minutes On Seizures – Part 2 of 2 appeared first on VEP Healthcare.

Excellent Mnemonic For Treating Critically Ill Patients In The ED

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Dear Providers,

The following link takes you to an excellent 10 minute video that expands on the routine ABCs:
http://www.medpagetoday.com/EmergencyMedicine/EmergencyMedicine/46846

The video is summarized in the article below which has multiple links to very good online resources.  The video and article are from Reuben Strayer, MD, Assistant Clinical Professor of Emergency Medicine at Mount Sinai Hospital in New York City.

I hope you enjoy it.

Robert Wyman, MD
Vice President of Quality
rwyman@vephealthcare.com

 

Resuscitation in the ED: Beyond the ABCs

Approaching a critically ill patient can be nerve-racking, and when your nerves are racked it can be hard to remember what to do. However, when you remember what to do, your nerves get less racked. So, I’m going to present a top-down approach to resuscitation that uses an expanded ABC’s mnemonic to jog your memory and unrack your nerves:

DC3, A through J

For many years now, I go through this sequence in my head every time I’m confronted with a critically ill patent, and it makes me calm and organized, and a better doctor.

D for Danger

Danger to you the provider. Is it safe to approach the patient? In the emergency department this usually means protecting yourself from body fluid or airborne infectious diseases. Occasionally, there may be other concerns like the patient having something dangerous on their clothes or skin requiring decontamination. We deal with agitated or potentially violent patients all the time. Like many of these bullet points, this is a talk unto itself, but from the perspective of resuscitation, if a critically ill patient is too agitated to be properly assessed, it is an absolutely crucial lifesaving maneuver to immediately and aggressively sedate. There are a variety of effective agents I recommend: Droperidol, midazolam, and ketamine. If an IV is not yet available the agents should be given IM or IO.

C3

The first C in C3 is “Call for help,” move the patient to resus, call for your defibrillator, crash cart, airway cart, or whatever else is indicated. In big centers, you generally want more nurses and tech than usually show up and fewer doctors than usually show up.

Now that everyone is in the room you have to get them to be quiet. The second C is “Calm.” Noise and shouting raise the ambient catecholamine level which makes it harder to take care of the patient. A forceful “Quiet please!” is usually all that’s necessary to take everyone down a few notches. In big centers, there are usually too many people in the resus room when the patient arrives. Big resus cases are good for learning and occasionally someone in the peanut gallery has a good idea — occasionally — so I don’t like to ask folks to leave the room.

Get them away from the action by announcing something like, “If you are not directly taking care of the patient please move to the perimeter of the room.” If there is an orthopedist hanging out, he won’t know the word “perimeter,” so try “Please move away from the bed.”

This is the time to determine who the resus leader is; if you’re not sure, maybe it’s you. All right, now that we’ve established the conditions in which the patient can be properly resuscitated, it’s time to resuscitate the patient.

The third C in C3 stands for “Cardiac Arrest.” Cardiac arrest has to be recognized straight away and is surprisingly easy to miss especially in a patient who arrives intubated by EMS. The first two priorities in cardiac arrest are immediate uninterrupted high-quality chest compressions and defibrillation of v-fib and pulseless v-tach.

Cardinal ABCs

Now, we start in with the cardinal ABCs and A is of course “Airway.” Our question is whether the patient needs an airway intervention. To answer this question, start with the patient’s voice. The patient speaking comfortably with a normal voice is very unlikely to require an airway maneuver in the immediate term. Patients who are not speaking, demonstrate a patent and defended airway by handling their secretions.

Drooling and gurgling, coughing and gagging, are your clue that you may have an airway problem. But do not elicit a gag reflex as a way to test airway integrity. It’s inaccurate and may induce vomiting and is exactly the person you do not want to vomit. Stridor is another sign and patients with a good level of consciousness and an airway obstruction may assume an airway posture, which is sniffing position.

Sometimes, the patient just needs repositioning of the head, but this is also the time to suction out the oropharynx, place oral or nasal airways or even an LMA if indicated, and determine if intubation is required or soon will be. If so, call for medications if needed and prepare for definitive airway management.

Move on to “Breathing,” which is oxygenation and ventilation. Do yourself and patients a favor and put a nasal cannula on every critically ill patient from the start and then any additional oxygen or ventilation on top of that. Unless the patient is truly crashing, I apply the nasal cannula and keep the wall-oxygen off until I get a room air oxygen saturation, which provides much more information about oxygenation and ventilation than a saturation with supplemental oxygen.

Ventilate the patient if needed. Your initial exam maneuvers are pulse oximetry, respiratory rate, effort, and then breath sounds. Auscultating the lungs is a reflex action taken by many junior clinicians as a response to a distressed patient. I think that’s because it makes it seem like you’re doing something when you don’t know what to do. In most cases, listening to the lungs is not helpful and is always less important than evaluating oxygenation and ventilation using respiratory effort and saturation. What you’re listening for is air entering both sides, and the presence of wheezes or crackles. This should take no longer than seven second — 3.5 seconds per lung.

Therapies to consider in the first five minutes relevant to breathing include needle finger or tube or ostomy, albuterol, epinephrine, or nitro. Call for a portable chest x-ray if indicated.

The initial “Circulation” priorities include immediate establishment of either intravenous or intraosseous access, measurement of heart rate and blood pressure, which is usually accomplished by putting a patient on a monitor, and the assessment of the adequacy of perfusion, feel for pulses, and assess the skin at the hands and feet. Immediate therapies to support circulation include IV fluids and uncrossed matched blood products and call for EKG when indicated.

Hyperkalemia is so common and so dangerous it should specifically be considered in a primary survey. C can also stand for “Calcium” in a critically ill dialysis patient with bradycardia or a wide complex rhythm.

D for Neurologic Disability

In the first phase of resuscitation, this calls for four maneuvers. Assessment of level of consciousness, usually using a responsiveness scale like GCS as well as the quality of the patient’s mentation. Agitation or confusion are as important as decreased consciousness. Measure the pupils and their response to light. Determine movement at four extremities and rule out or treat hyperglycemia.

We don’t have a problem with getting to do head CTs, but to be complete I must mention that this is the time to consider a STAT brain scan.

E for Exposure

Remove all clothing. And visualize every inch of skin. It is ideal if you can get this done at the initial assessment. It really sucks when the ICU team comes down and pulls the nitro patch off your hypotensive patient. Have someone check the pocket for pill bottles, the pacemaker wallet card, or a summary of their medical history. Use the opportunity to do a rectal temp if needed, and initiate active cooling or warming if indicated.

F Stands for Family and friends

If the history isn’t clear, get a better story. Ask about goals of care, if appropriate. Give the patient’s family an update on a patient’s status within a cautious prognosis. If you say, “I’m very concerned about grandma,” and she does well that’s not a big problem. In fact, it makes you look like a very skillful doctor. If you say, “Grandma is doing great,” and the next time the family sees her they have to unzip a body bag, you’re not going to get a rave review on Healthgrades.com. If the family is outside the resus area, ask them if they wish to be present during the resuscitation.

G Is for Analgesia

Do not forget to treat your patient’s pain. I have looked back at many resuscitations and realized the only thing I did that actually helped the patient was morphine. Give it early and in appropriate doses: IV, IM or IO. If hypertension is a concern use fentanyl. If you don’t have a line in a child, intranasal fentanyl is very effective. And for the patient in severe pain, adding an analgesic dose of ketamine is magic.

H Is for HCG

This is easy to forget and pregnancy changes everything. The bedside urine HCG assay works just as well with two drops of whole blood or capillary blood from a finger stick. In the clearly gravid female who is hypotensive, push the uterus to the left, And if she is dying or dead, consider a perimortem C-section. Don’t worry about how many weeks or how many minutes mom has been arrested — perimortem cesarean section is for mom more than for baby.

I Is for Infection

Consider whether the patient should be isolated, and do not delay the administration of broad spectrum antibiotics in a patient thought to be critically ill from an infection. If source control is required, this needs to be done expeditiously.

J Is for Ultrasound Jel The last part of the first 5 minutes is ultrasound. Let me know if you have a better way of getting the word ultrasound to work with the letter J. All patients with hypotension of unclear etiology should have a comprehensive point of care ultrasound for shock. There is an ever expanding list of indications of point of care ultrasound. Get the probe on the chest early in a critically ill patient.

There is another C I left out: If you are using a mnemonic to study for oral board exams, add one more C after Cardiac Arrest — as in C for spine immobilization collars. These have minimal if any utility in few, if any patients, and certainly cause harm, but we’re probably a long way away from standard of care catching up to science in this domain. So if you’re resuscitating a patient while wearing your best suit seated uncomfortably in a hotel across from somebody with gray hair who doesn’t want to be there any more than you, add a C for C spine precautions.

In real life for the first 5 minutes of resuscitation: DC3, A through J.

The post Excellent Mnemonic For Treating Critically Ill Patients In The ED appeared first on VEP Healthcare.

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