ACEP News - June 2008 - (Page 5)

JUNE 2008 • ACEP NEWS NEWS partments’ going on diversion more frequently. In fact, Dr. Lewis’ center had effectively been on diversion for 4 days when it was surveyed by committee staff in March, he added. “Ours is not an isolated situation. It reflects the current state of emergency health care in the United States and a paradoxical, almost incomprehensible, lack of recognition among some policy makers regarding the cause and effect relationships that exist between the fiscal pressures that have led to decreases in hospital capacity, [emergency department] gridlock, and our dwindling surge capacity,” Dr. Lewis noted in his written testimony to the committee. In a second hearing held 2 days later, HHS Secretary Leavitt told lawmakers that the lack of emergency department capacity is a legitimate issue, but that using Medicaid dollars to shore up hospital Lawmakers Question Readiness Surge • from page 1 hundreds of millions of dollars away from hospital emergency rooms without once considering the impact on national preparedness,” he added. That contravenes a presidential directive from October 2007 that requires HHS to identify regulatory barriers to medical preparedness and to coordinate with DHS to maintain emergency care capacity, according to Rep. Waxman. The past 5 or 10 years have seen increasing demand on emergency departments, coupled with decreasing resources, testified Dr. Roger Lewis, an ACEP member and a professor in the department of emergency medicine at Harbor-UCLA Medical Center, Torrance, Calif. The result has been diminished capacity, increased boarding, and emergency de- in Washington, D.C., where the two hospitals surveyed were both running over capacity with no available treatment spaces. In light of those findings, Rep. Waxman said, it’s surprising that both the federal Department of Health and Human Services and the Department of Homeland Security failed to consider the impact of the Medicaid changes, which were scheduled to go into effect on May 26. “When the committee requested documents reflecting an analysis of the potential implication of the Medicaid regulations on hospital emergency surge capacity, neither department was able to produce a single document. This is incomprehensible,” he said. “It appears that HHS Secretary Michael Leavitt signed regulations that will take resources was not the appropriate solution. Dr. Lewis questioned that conclusion, however. “If there were a viable alternative way of maintaining the safety net hospital funding, then it becomes a reasonable argument,” he said in a follow-up interview. “The problem is that they are putting the cart before the horse. They want to withdraw existing funding, which is already inadequate, prior to having any proposition on the table to make up for it,” Dr. Lewis said. Democrats have attached to war funding legislation a proposal that would postpone the Medicaid changes for a year. ■ The congressional report “Hospital Emergency Surge Capacity: Not Ready for the ‘Predictable Surprise’” is available at http://oversight.house.gov/documents/ 20080505101837.pdf Experts Debate PCI Backup • from page 1 “Yes, it is safe and efficacious, but should it be done? It must be looked at as a system-based approach to be sure that each patient gets proper care,” commented Dr. Rick A. Nishimura, professor of medicine at the Mayo Clinic in Rochester, Minn. “Does anyone prefer to have PCI done at a low-volume center without surgical backup?” asked Dr. Timothy D. Henry in a separate talk at the meeting. “It is inappropriate to open new PCI centers that are not based on the health care needs of the community.” He noted that good coordination among regional centers and effective rapid transport programs can often speed patients who need emergency primary PCI for ST-elevation myocardial infarctions from rural locations to high-volume catheterization laboratories in less than 2 hours. In many cases, what drives the opening of catheterization laboratories that perform PCI with off-site surgical backup are financial incentives to the hospital and to physicians, added Dr. Henry, an interventional cardiologist and director of research at the Minneapolis Heart Institute. But some cardiologists passionately argued that there is a desperate need for PCI with off-site backup in remote, rural areas where transit to regional centers is unreliable and awkward. “Until someone practices in an area where primary PCI is largely unavailable in a timely manner,” it’s hard to appreciate the need, commented Dr. Melissa Walton-Shirley, a cardiologist in Glasgow, Ky., and codirector of the Kentucky pilot project for primary PCI. Transporting patients to a referral center is dependent on many uncertainties: the weather (helicopters can’t fly when the air ceiling is low), availability of an ambulance, bed space in the tertiary center, and a patient’s willingness to be transported far from home. “Bringing patients to a tertiary center in a reasonable time frame is still not as good as getting the infarcting patient onto a table” even faster. Two hours is not an optimal delay to angioplasty. “If we can do better, we should do better,” she said in an interview. The data used in the current study were collected by the National Cardiovascular Data Registry (NCDR), a database funded and maintained by the American College of Cardiology. Dr. Kutcher and his associates stressed that the hospitals participating in the NCDR, a purely voluntary database, show their commitment to quality by subjecting their clinical experience to independent peer review. He estimated that about 100 U.S. centers today perform PCI with off-site backup and also participate in a data collection and review program, such as the NCDR and the Atlantic Cardiovascular Patient Outcomes Research Team (CPORT). But he also estimated that about 200 American PCI programs currently run using off-site surgical backup and have no systematic review of their performance. States have varying regulations that allow centers with off-site backup, and by 0.4% of those treated with on-site backup. The mortality rate among patients or prevent the practice (see map). “No program should be allowed to implement prima- who needed emergency coronary bypass surgery was ry PCI without being required to report their data to a 13.6% in patients treated with off-site backup, and 12.6% among patients treated with on-site backup, a difference registry,” said Dr. Walton-Shirley. “The prestige of the [new NCDR paper presented at that was not statistically significant, Dr. Kutcher said at the i2 Summit] may inspire other PCI programs to be- the meeting, cosponsored by the American College of come part, so I think enrollment [in the NCDR] will in- Cardiology and the Society for Cardiovascular Angiogcrease,” Dr. Thomas P. Wharton Jr. said in an interview. raphy and Interventions. Overall mortality was significantly higher among paIn addition, some states are developing regulations that will require PCI programs with off-site backup to partic- tients treated with off-site backup, 1.8%, compared with ipate in programs like the NCDR, said Dr. Wharton, a those treated with on-site backup, 1.2%, but this did not coinvestigator with Dr. Kutcher and an interventional car- account for baseline differences in severity of illness and other potential confounders. diologist in Exeter, N.H. In an analysis that adjusted for potential confounding Their study used data collected by the NCDR Cath PCI registry on consecutive cases done during Jan. 1, 2004, variables, patients treated with and without on-site backthrough March 30, 2006, with 308,161 patients treated at up showed no significant differences in total mortality, 465 U.S. centers. This included 9,029 patients treated with mortality in patients undergoing primary PCI, mortality off-site surgical backup at 61 centers, and 299,132 patients in patients with elective PCI, and mortality in patients treated at 404 centers with on-site surgical backup. Comparing PCI With and Without Surgical Backup Forty-nine of the PCI done with PCI done with centers with off-site off-site backup on-site backup backup completed a PCI sites in a rural area 34% 17% survey. Responses Average annual PCI volume 168 cases 746 cases showed that the avAverage annual number of primary PCI cases 35 78 erage distance to a Sites performing fewer than 200 PCI cases/year 70% 6% surgical facility was Sites performing fewer than 36 primary PCI cases/year 57% 20% 35 miles, with 12 centers (24%) locatNote: Data from 61 U.S. sites performing PCI with off-site backup and 404 U.S. sites performing ed more than 40 PCI with on-site backup. Source: Dr. Kutcher miles from their surgical backup. The average transit time to the surgical backup facility was 25 minutes, with who did not require emergency bypass surgery. Among 13 centers (26%) located more than 30 minutes away. The patients who needed emergency bypass surgery, patients most common mode of transit available for transfer to treated at centers with on-site backup had a 59% increased the surgical site was a ground ambulance at 26 (53%), risk of death, compared with patients treated at sites with with another 11 (22%) sites relying primarily on heli- off-site backup, a difference that just reached statistical sigcopter, and 11 more sites (22%) using both helicopter and nificance (P = .049), Dr. Kutcher said. Current PCI guidelines from the American Heart Asground transport. Of the 49 surveyed PCI sites, 45 (92%) provided 24/7 sociation, American College of Cardiology, and Society coverage. Primary PCI alone was offered at 9 sites (18%), for Cardiovascular Angiography and Interventions, pubwith both primary and elective PCI offered at the other lished in 2006, said that performing elective PCI at cen40 sites (82%). The sites with off-site backup tended to be ters with off-site surgical backup is “not recommended” in more rural locations and had substantially lower an- (a class III category http://oversight.house.gov/documents/20080505101837.pdf http://oversight.house.gov/documents/20080505101837.pdf

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ACEP News - June 2008 Contents News - Time to Move Tricks of the Trade - Revealing Tips Focus On - Dengue Fever Practice Trends - EMTALA Results

ACEP News - June 2008

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