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Mandated Coding Change Means Difficult Autumn Ahead for EDs

CHICAGO – Forget goblins and witches this October. The changeover to ICD-10 required by the first of the month is much scarier than anything likely to occur on Halloween, according to a new study published recently in the American Journal of Emergency Medicine.

University of Illinois Chicago researchers suggest that nearly a quarter of all emergency department clinical encounters could pose difficulties. Justifying hospital admissions and reporting certain diseases to public health departments also might become more difficult, they posit.

Nearly 500 common used emergency ICD-9 codes – 27% of 1,830 – have convoluted mappings that could create problems with reporting or reimbursement, according to study results. In addition, when reviewing more than 24,000 actual ED clinical encounters, 23% of those codes with convoluted mappings were likely to be assigned incorrectly if CMS recommendations were followed.

"Despite the wide availability of information and mapping tools, some of the challenges we face are not well understood," said principal investigator Andrew Boyd, MD, assistant professor of biomedical and health information sciences at UIC. Boyd and his team have developed a free tool, available online, that reports the ICD-9 to ICD-10 code mappings.

Correct classification of diagnoses in the ED is necessary for proper hospital reimbursement, clinical documentation, case-mix acuity indices, medical necessity for procedures, services and admissions, and reporting of disease to public health departments, the study points out.

CMS provides forward and backward mappings between ICD-9-CM and ICD-10-CM classifications, but study authors point out that many codes “share complex reciprocal relationships that may lead to confusion and incorrect coding. This issue has potential to be exacerbated by the fact that a significant percentage of the billed codes are highly complex, pointing to the problem of ICD-10-CM conversion complexity and the increased number of clinically incorrect codes used under the ICD-10-CM classification.”

The researchers suggest that, because of increased complexity, emergency physician groups attempting to perform coding internally instead of outsourcing are likely to “encounter challenges in adoption that will require dramatic changes to current procedures and operations.”



ED Buprenorphine Treatment Improves Likelihood of Addicts Getting Helpllsa 2016 Ad padding

NEW HAVEN, CT – When opioid dependent patients seek medical care, standard operating procedure for many emergency departments is to deal with their immediate medical issues and then refer them to a treatment program. In some cases, a brief motivational consultation is provided.

Going a step beyond, however, can make a big difference in the likelihood of those patients getting help and cutting back on drug use, according to a new study.

The results of a randomized trial, published recently in the Journal of the American Medical Association, found that patients given the medication buprenorphine in the ED were more likely to engage in addiction treatment and reduce their illicit opioid use.

The study, led by Yale School of Medicine researchers, notes that patients addicted to opioids often seek ED medical care usually are referred for addiction treatment.

“ED physicians take care of the immediate concern, but don’t treat the underlying problem,” said first author Gail D’Onofrio, MD, MS, chair of emergency medicine at Yale.

For the study testing efficacy of an intervention including buprenorphine, the researchers conducted a randomized trial of more than 300 opioid-dependent individuals in an urban teaching hospital.

“Prior research at Yale has demonstrated that buprenorphine treatment is highly effective in primary care, and this study was designed in part to expand the reach of this treatment to this critical ED patient population,” said co-author Patrick O’Connor, MD, MPH, professor of medicine and chief of general internal medicine.

Study participants were screened and then randomized into three groups: a referral group that received a list of treatment services; a brief intervention group that received a motivational consultation and referral; and a third group given a brief intervention and treatment with buprenorphine that was continued in primary care.

Results indicate that 78% of patients in the buprenorphine group, compared to 37% in the referral group and 45% in the brief intervention group, were engaged in addiction treatment on the 30th day after randomization. In addition, the buprenorphine group reduced the number of days of illicit opioid use per week from 5.4 days to 0.9 days as opposed to a reduction from 5.4 days to 2.3 days in the referral group and from 5.6 days to 2.4 days in the brief intervention group.

“The patients who received ED-initiated medication and referral for ongoing treatment in primary care were twice as likely than the others to be engaged in treatment 30 days later,” D’Onofrio noted. “They were less likely to use illicit opioids of any kind.”

The patients treated with buprenorphine in the ED also were less likely to require inpatient treatment in a residential facility.

 “Effectively linking ED-initiated buprenorphine treatment to ongoing treatment in primary care represents an exciting new model for engaging patients who are dependent on opioids into state-of-the-art care,” O’Connor said.

D’Onofrio noted that this is “another expanded use of the ED to increase access to treatment options for people with this chronic and relapsing condition.”

The study authors called for replication in other centers before widespread adoption.

Traumatic injury is the leading cause of death among people under age 45, but if trauma physicians could deliver plasma to these injury victims within minutes of their arrival in the emergency room, more of them would stand a better chance of survival.


New Guideline Calls for Quicker Delivery of Plasma for Trauma Patients

TUCSON, AZ – Emergency physicians are well aware of the agonizing wait for trauma patients to receive plasma, knowing that more of them would survive if the product could be delivered more quickly.

A new study on a rapid deployment plasma protocol, published recently in the journal Transfusion, points out that the traditional way of giving patients plasma involves two time-consuming steps – testing for blood type and then thawing frozen plasma – but maintains the process doesn’t have to take 30 or more minutes, as it usually does now.

"There's a golden hour after trauma where you need to be able to stabilize the patient," explained lead study author Deborah Novak, MD, of the University of Arizona in Tucson.

Through the Pragmatic, Randomized Optimal Platelets and Plasma Ratios (PROPPR) clinical trial conducted at 12 urban trauma centers, researchers determined that trauma teams using a new clinical guideline could consistently deliver plasma to trauma patients three times faster than the traditional delivery method.

The new guideline calls for delivering thawed plasma to trauma patients’ bedsides within 10 minutes of arrival; 11of 12 sites were consistently able to deliver six units of thawed universal donor plasma to their trauma-receiving unit within 10 minutes and 12 units in 20 minutes. Approximately 4,700 units of plasma were given to the 680 patients enrolled in the trial in which investigators evaluated the utility of guidelines for massive transfusion developed by the American College of Surgeons Trauma Quality Improvement Program.

Traditional trauma resuscitation involves giving the patient crystalloid fluids and red blood cells early on, and then administering plasma and platelets later, according to background information in the report, which notes that plasma is typically stored frozen and thawed only when trauma staff request it.

The method successfully treats most trauma victims with mild or moderate injuries, according to study authors, but military and civilian researchers have found that individuals with massive bleeding benefit when they receive plasma at the same ratio as red blood cells.

"A renewed look at the process resulted in the concept of transfusing plasma earlier, with red blood cells and plasma in ratios that approximate the reconstitution of the original unit of whole blood," Novak pointed out, adding that less blood was wasted than researchers had feared.

While PROPPR focuses on the use of universal-donor plasma, three trial sites used blood type A plasma instead without complications because universal-donor plasma was scarce, which ended up being an important side note of the trial, Novak noted.

"What we found out and what other places have found is that trauma teams can safely use AB or limited amounts of A plasma for that small window when the patient's blood type is not yet known," she said, emphasizing that the finding could help sustain supplies of unthawed plasma for trauma use.


International Groups Seek More Urgent Treatment of Acute Heart Failure

DES PLAINES, IL – Why is acute coronary syndrome (ACS) treated as an urgent diagnosis requiring immediate response but acute heart failure (AHF) often is not?

That question led the Society for Academic Emergency Medicine and several European groups to issue joint recommendations which were published recently in the European Heart Journal.

"This is the first guidance to insist that acute heart failure (AHF) is like acute coronary syndrome (ACS) in that it needs urgent diagnosis and appropriate treatment,” noted lead author Alexandre Mebazaa, MD, PhD, of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC). “In ACS, when the coronary is occluded we say 'time is muscle' which means that the quicker the vessel is dilated, the more heart muscle is saved. The same principle is true for AHF."

Mebazaa said the goal is to achieve in AHF similar reductions in mortality and morbidity as seen with ACS. The way to do that, he added, is by “introducing the time to therapy concept together with new medications for AHF.”

Early treatment of AHF patients can decrease mortality and morbidity, added co-author Professor Abdelouahab Bellou, MD, PhD, past president of the European Society for Emergency Medicine.

"Failure to treat quickly aggravates underlying chronic heart failure and can induce complications including cardiogenic shock and acute respiratory distress,” Bellou said. “Patients may need to be intubated which can increase their risk of mortality."

The joint recommendations include:

  • An algorithm for the management of AHF;
  • Tests and treatments to be performed pre-hospital, and in the ED, coronary care unit (CCU) or intensive care unit (ICU);
  • Guidance on the role of nurses in the management of AHF;
  • Instructions on how to use oxygen therapy and ventilation support;
  • Advice on managing new and currently prescribed medicines, and
  • Criteria for discharge from hospital and recommendations for follow up.

AHF treatment is complicated by patient anxiety, Mebazaa pointed out, explaining, "Dyspnea causes more anxiety for patients, families and doctors than chest pain. Anxiety is also caused by low oxygen levels in the brain. Unfortunately there are no medications to relax patients without worsening their respiration and blood oxygen levels. But we can reduce anxiety by talking to patients and families and giving oxygen."

Background information in the study notes that from 30-40% of discharged AHF patients are back in the hospital within 30 days.

"Inconsistency in medicine is never good for patients,” Mebazaa added. “Many patients with AHF are hospitalized many times and may receive different treatment for the same event in the emergency room, ICU or CCU. We hope to standardize care by recommending best contemporary practices based on the latest evidence."


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