Grand Rounds Recap 2.1.17

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Health System-Based Provider Networks: the Role of Emergency Medicine with VISITING PROFESSOR DR. JAMES HOEKSTRA

  • Medicare reimbursement is declining, flatten by 2020
  • ED visits and inpatient admissions are declining or flat nationally
  • ED traditionally a department of profit for the hospital, money is moving from inpatient stays to outpatient sites and outpatient surgery
  • Health system responses to these changes:
    • Reducing costs via people and supplies
    • Inpatient utilization decision making
    • Large emphasis on quality outcome measures
      • linked to reimbursement
      • bad outcomes have become very expensive
    • Increased advertising to draw patients to network
    • Standardization of care processes
      • consistent use of cost effective materials in surgery, etc
    • Health system consolidation
      • Consolidation of primary care providers and specialists
      • Networks of owned facilities
      • Buying referral hospitals and joining larger health systems
      • Shared services: health systems partner contractually to combine back office scale
        • combined contracts for materials, etc. resulting in lower cost by joining forces/order size
    • Clinically integrated networks
      • Health systems or medical groups can contract together if they share quality measures and outcomes measures/monitoring
  • Why Consolidate?
    • Scale
      • contracting, supply train, corporate service, etc
    • Maintenance of referral streams
      • keep referrals within your system
    • Standardization of care
    • Defensive strategies
    • Brand awareness
    • Geographic contracting for employers
    • Clinical research facilitation
  • What are provider networks?
    • Hub and spoke model
      • Central cite with strategically placed remote sites
      • Specialty networks (EM, cancer, cardiovascular, etc)
  • Benefits to providers
    • standardization of clinical protocols and administrative processes
    • movement site to site
    • opportunities for leadership
    • economies of scale = higher pay
    • open books and democratic voice

Leadership in Emergency Medicine

  • Why emergency physicians?

    • High quality physicians
    • Team concept is inherent in the ED
    • ER docs know everybody
    • Best place for clinical training and acute care research
    • Access to network and referral sources
    • Finger on the pulse of patient and hospital system
      • growing visit number and number of admissions through ED
      • ED is the barometer of the hospital’s functionality
  • Three requirements of high performance leaders
    1. See things as they are, not better or worse
      • embrace “what is”, no spin on events
      • make no excuses for current situation
      • avoid political or positional stance
    2. See things for how they can be
      • create a vision that inspires people
      • engage and enroll people into that vision
    3. Take action to secure the future

R2 Case Follow Up with Dr. Colmer

  • The patient is a young female who was in an ATV rollover, complaining of chest pain and abdominal pain.  Vitals notable for tachycardia to 112, respiratory rate of 28, oxygen requirement (90% on 4L NC), airway intact, breath sounds diminished on left side, GCS 15, exam otherwise unremarkable.  CXR with moderate to large left pneumothorax.  Left side chest tube placed in ED.  Post chest tube CXR read as improved pneumothorax, however worsening opacity noted, increasing chest pain and continuous air leak noted, third chest X-ray noting to have worsening pneumothorax.  CT chest shows large left pneumothorax and pneumatocele and pulmonary laceration.  Patient able to be managed conservatively in consultation with thoracic surgery, multiple blood unit transfusions in ICU.  Discharged 8 days later after resolution of bleeding and removal of chest tube.  
    • Pulmonary laceration classification
      • Type I: compression rupture
      • Type II: shear
      • Type III: direct puncture
      • Type IV: adhesion tears
    • Chest tubes
      • Indications
        • Pneumothorax/hemothorax/chylothorax
        • Symptomatic pleural effusion
        • Bronchopleural fistula
      • Evaluating the air leak
        • Interruption of tubing can cause air leak
        • pulmonary laceration allows for continuous flow of air into system, resulting in continuing air leak
      • Evaluating the output
        • High suspicion for life threatening injury if initial output is 1000-1500 cc
        • Also consider if output of 200-250cc/hr over 4-5 hours.

R1 Clinical Knowledge: The Limping Child with Dr. Habib

  • LIMPSS
    • Legg-Calve-Perthes
    • Infection/inflammation
    • Malignancy
    • Pain from trauma
    • SCFE
    • Somewhere else (appendicitis, testicular torsion, etc)
  • By age
    • Worry about septic arthritis, osteomyelitis, tumor in all ages
    • Age 0-4
      • developmental dysplasia
      • foreign body (splinter in foot, etc)
      • toddler’s fracture
    • Age 4-10
      • legg-calve-perthes
      • rheumatologic
    • Age >10
      • SCFE
      • gonococcal SA
      • injuries/sports
  • HPI considerations
    • History of trauma
    • Infectious symptoms
    • Abdominal/GU symptoms
    • Recent illness
    • Activity level
  • Physical exam considerations
    • Observe and inspect exposed limbs
    • Look for hip positioning
    • Palpate LE, abdomen, and back, inspect GU area
    • Galeazzi exam
      • Place patient supine, feet together and flex knees and hips.  Inspect for symmetric knee height, if discrepancy is evidence for shortened limb
    • Gait cycle
      • Ideally view gait as they enter exam room before your encounter to gauge a “non-influenced” gait
      • A rapid “swing phase” of gait is indicative of pain.  Patient swings unaffected side quickly to spend as little time as possible on painful limb when walking.
  • Septic arthritis
    • Higher proportion of males over females
    • Kingella Kingae: respiratory pathogen, can cause septic arthritis particularly in patient’s <12 months old.  Very difficult to culture.
    • Much research into synovial fluid analysis, must have high index of suspicion based on exam
  • SCFE
    • Subacute groin, knee or thigh pain
    • Average age 12, male predominant, characteristic for larger body habits
    • Trendelenburg gait
    • Klein’s line on plain film images: drawing a line along femoral neck should intersect with femoral head at some point.  If not, have concern for this diagnosis.

Antalgic Gait.  https://www.youtube.com/watch?v=W-S8Pk63YRE