2021 National Hospital Week May 9 – 15

From the American Hospital Association

National Hospital Week is an opportunity to highlight our hospitals, health systems and health care workers and the innovative ways they are supporting the needs of their community members, especially during this pandemic.

FDA authorizes Pfizer COVID vaccine for 12- to 15-year-olds

From Axios:

The Food and Drug Administration authorized the emergency use of the Pfizer-BioNTech coronavirus vaccine for 12- to 15-year-old adolescents, the agency announced on Monday.

Why it matters: The emergency authorization marks a critical milestone in the push to get more Americans vaccinated and fully reopen schools for in-person learning this fall.

  • Pfizer has said its vaccine was 100% effective at protecting against COVID-19 in a trial of more than 2,200 children between the ages of 12 and 15.
  • The FDA has already authorized Pfizer’s vaccine for people 16 and older. Moderna and Johnson & Johnson also have trials for teens underway.

Hit by higher prices for gear, doctors and dentists want insurers to pay

From Fierce Healthhcare:

Treating patients has become more expensive during the pandemic, and doctors and dentists don’t want to be on the hook for all the new costs.

For instance, the box of 100 gloves that cost $2.39 in February 2020 costs $30 now, said Dr. Judee Tippett-Whyte, president of the California Dental Association, who has a private dental practice in Stockton.

Her practice used to rely on surgical masks that cost 20 cents each but has upgraded to N95 masks at $2.50 a pop. On top of that, her office is scheduling two or three fewer patients each day to accommodate physical distancing and give staff members time to disinfect between patients, she said.

California’s dentist and doctor lobbies say insurance companies are flush with cash after collecting premiums during the pandemic but paying fewer claims than usual—and should foot the bill. The California Medical Association, which represents doctors, has sponsored legislation that would require insurers to reimburse medical and dental practices for pandemic-related expenses like personal protective equipment, disinfectant and the staff time required to screen patients for symptoms before an appointment.

An app that swiftly sends CPR volunteers to heart attack sufferers has made a big difference in Denmark. Could this be copied in the U.S.?

From the Post:

Denmark has seen a dramatic increase in survival from heart attacks after it began recruiting volunteers and arming some of them with smartphone technology that alerts them to nearby cardiac emergencies and helps them locate automated external defibrillators, or AEDs. The volunteers are then asked to enter residences and perform CPR until an ambulance arrives.

There are similar apps in the United States, but concerns about safety and willingness of people to accept untrained volunteers into private homes have prevented a similar wide use of PulsePoint, a North American responder app. But if those concerns are overcome, the United States could “significantly improve” its survival rate, leading experts say.

Most Labeled Penicillin-Allergic Are No Longer Intolerant

From Medscape:

Most people whose medical record says they are allergic to penicillin are not actually intolerant, an allergist said Thursday during the first day of sessions for the American College of Physicians (ACP) Internal Medicine Meeting 2021.

The mislabeling has implications for patient outcomes and efforts to fight antibiotic resistance, said Olajumoke Fadugba, MD, program director for the Allergy and Immunology Fellowship at University of Pennsylvania Health System in Philadelphia.

About 10% of the general population reports a history of penicillin allergy (up to 15% of hospitalized patients), but up to 90% of patients with that label are able to tolerate penicillin, Fadugba said. The mislabeling comes either because reactions were improperly characterized early on or people have outgrown the allergy.

After the Pandemic: Will Emergency Medicine Ever Be the Same?

From MedPage Today:

The entire infrastructure of healthcare underwent seismic shifts and challenges with COVID-19. The pandemic revealed more than anything how friable the whole system is, and how incentives of different interest groups within healthcare are not only misaligned, but sometimes completely oppositional to one another. Administrators versus physicians versus insurance versus pharmacies versus pharmaceuticals versus regulators versus public health versus mid-levels versus hospitals versus primary care versus specialists — the different stakeholders of our country’s health exist in an extremely complicated, cumbersome, and often counterproductive web, one that’s not as geared towards “patient-centered care” as we would like to see. The concept that there were “winners” and “losers” at different stages of COVID-19 should say more than enough as to the fact that the system needs to be completely revamped and thoughtfully redesigned with the patient truly at the center, not patched between competing interests of an industrial machine. This is a critical topic I’ve written about before.

Penn study reveals how opioid supply shortages shape emergency department prescribing behaviors

Press Release:

When evaluating the opioid crisis, research reveals that external factors – such as the volume of pre-filled syringes, or a default number of opioid tablets that could easily be ordered at discharge for the patient – can shift prescribing and compel emergency department (ED) physicians to administer or prescribe greater quantities of opioids. A new study published in the Journal of Medical Toxicology reveals that opioid prescribing behavior can also be decreased by external factors, such as a supply shortage.

Led by the Perelman School of Medicine at the University of Pennsylvania, researchers evaluated pharmacy data from the electronic medical records (EMR) collected before, during, and after a period of parenteral opioid shortage across two large urban academic emergency departments – the Hospital of the University of Pennsylvania and University Hospital in Newark, New Jersey. In this case, the shortage was of parenteral morphine and hydromorphone, as a result of supply chain disruptions caused by Hurricane Maria in 2018.

Researchers found that the percentage of patients who received an opioid among all ED visits during the 2018 shortage fell significantly from 11.5% pre-shortage to 8.5% during, and did not return to baseline once the shortage abated. Further, the total number of oral or IV opioid doses administered during the shortage also decreased and remained lower than pre-shortage levels once supply chains were restored. However, the study also found that while fewer opioid doses were administered to fewer patients, there was no change in net Morphine Milligram Equivalent (MME) per patient receiving opioids.

“Although the percentage of patients who received non-opioid analgesics did not rise during the shortage, it was significantly higher in the post-shortage period,” said lead investigator Amanda Deutsch, MD, an Emergency Medicine resident at Penn. “This suggests that a subset of patients were transitioned to non-opioids, and this prescribing practice was a sustained change after the resolution of the shortage.”

The study also found that because the shortages were specifically of parenteral morphine and hydromorphone, those were replaced by parenteral fentanyl, but the overall total use in MME of opioids administered remained the same. The use of oral morphine also appeared to increase during the shortage period. These findings may suggest that the shortage may have led to a shift from IV opioid use to oral opioid formulations.

However, researchers felt that the shift in prescribing patterns during the shortage can offer an opportunity for more research into how external factors can influence ED prescribing practices. “Changing clinician prescribing behavior is challenging,” said author Jeanmarie Perrone, MD, a professor of Emergency Medicine at Penn. “This study shows encouraging data to support that there are environmental modifications that can nudge providers toward more judicious opioid use.”

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Penn Medicine is one of the world’s leading academic medical centers, dedicated to the related missions of medical education, biomedical research, and excellence in patient care. Penn Medicine consists of the Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania (founded in 1765 as the nation’s first medical school) and the University of Pennsylvania Health System, which together form a $8.9 billion enterprise.

The Perelman School of Medicine has been ranked among the top medical schools in the United States for more than 20 years, according to U.S. News & World Report’s survey of research-oriented medical schools. The School is consistently among the nation’s top recipients of funding from the National Institutes of Health, with $496 million awarded in the 2020 fiscal year.

The University of Pennsylvania Health System’s patient care facilities include: The Hospital of the University of Pennsylvania and Penn Presbyterian Medical Center–which are recognized as one of the nation’s top “Honor Roll” hospitals by U.S. News & World Report–Chester County Hospital; Lancaster General Health; Penn Medicine Princeton Health; and Pennsylvania Hospital, the nation’s first hospital, founded in 1751. Additional facilities and enterprises include Good Shepherd Penn Partners, Penn Medicine at Home, Lancaster Behavioral Health Hospital, and Princeton House Behavioral Health, among others.

Penn Medicine is powered by a talented and dedicated workforce of more than 44,000 people. The organization also has alliances with top community health systems across both Southeastern Pennsylvania and Southern New Jersey, creating more options for patients no matter where they live.

Penn Medicine is committed to improving lives and health through a variety of community-based programs and activities. In fiscal year 2020, Penn Medicine provided more than $563 million to benefit our community.

New emergency department program enables patients to recover at home safely

Press Release:

A new service piloted at Penn Medicine allowed a proportion of patients to avoid hospitalization by providing them with greater support after visiting the emergency department. The vast majority of the patients enrolled in the service – nearly 9 out of 10 – did not need to return to the hospital for care in the month that followed their initial visit. The study was published in Healthcare.

“The culture is shifting where we realize that hospitalization is not always the best option for patients – particularly patients with chronic illness,” said one of the study’s lead authors, Austin Kilaru, MD, an emergency physician at Penn Medicine. “We need to find better ways of helping patients not just get healthy in a hospital, but stay healthy at home – whenever they are ready to be there.”

Increasingly, emergency departments care for greater shares of patients with acute symptoms and illnesses. Increased visits can lead to strain on hospitals, so Kilaru, co-author David Resnick, a senior innovation manager at Penn Medicine’s Center for Health Care Innovation, and their team devised a method to open capacity in emergency departments and hospitals – by sending patients home with the right resources and support to help them recover safely.

The project, which began in 2018 within the Center for Health Care Innovation’s annual Innovation Accelerator, was named Practical Alternative to Hospitalization (PATH). It contained two important elements.

First, the PATH team deployed an advanced practice provider (APP) to screen hospital bed requests to determine which patients met criteria for discharge to home. They considered the reasons for the patient’s visit, their vital signs, medical history, and social support systems. If the patient’s emergency physician agreed with enrolling in PATH, the APP developed a comprehensive plan in partnership with that physician and the patient’s care team.

Patients enrolled in the program received personalized support at home. This included phone calls or text messages to assess their status, coordination of outpatient appointments, and additional diagnostic testing. This tailored plan might also include home nursing visits, physical or occupational therapy, or transportation assistance.

“We were concerned that emergency physicians would be reluctant to discharge patients who they would have normally hospitalized, but it turns out that they liked having the option of choosing our services,” Kilaru said. “It’s a new alternative to staying in the hospital or going home completely on their own. We were seen as an added support, acting in the best interests of patients and medical providers alike.”

In this study’s 14-day trial period set in a single hospital during December 2019, 52 patients met PATH’s eligibility requirements (of 199 possible patients). More than half of them, 30, enrolled in the program, with most of the remainder still requiring hospitalization at the discretion of the treating emergency physician.

Many of the patients enrolled in the program for common conditions, such as chest pain, high blood sugar, and congestive heart failure. The study authors estimate that patients would have spent more than two days, on average, in the hospital and eight additional hours waiting in the emergency department. Only four patients needed to return to the hospital within 30 days of their initial visit, when the PATH team recognized that patients again required hospital-level care.

“Another concern in this pilot was that patients might have worsening illness at home and need to return to the emergency department,” Kilaru said. “Fortunately, our patients did well and had good outcomes – even 30 days later. We created careful safeguards to select the right patients, so while a few patients did need to return, it was not unexpected, and we could help communicate key medical and social issues to the emergency department and hospital teams.”

The study took place just a few months before the COVID-19 pandemic swept the East Coast. While the service was paused as a result, the pandemic created a surge of interest in shifting care from hospitals to home, like Penn Medicine’s Cancer Care at Home. In addition, lessons from this study have been applied to efforts to manage COVID at Penn Medicine, including an “accelerated care pathway,” where patients who only needed short hospital stays were identified in the emergency department, efficiently treated in the hospital, and followed closely at home.

“This could be promising for payers, health systems, and patients alike,” Resnick said. “Payers benefit by having their members avoid costly inpatient stays. Patients benefit by having more safe days at home. And hospitals with busy emergency departments and full beds benefit by freeing up resources that can be utilized by the most sick and complex patients.”

Higher Dosage of Naloxone Nasal Spray Approved for Treating Opioid Overdose

From Pharmacy Times:

Officials with the FDA have approved an 8 mg dose naloxone hydrochloride nasal spray (Kloxxado; Hikma Pharmaceuticals) for the emergency treatment of known or suspected opioid overdose in adult and pediatric patients. This product is a higher dosage of naloxone hydrochloride than the 2 mg and 4 mg dosage products previously approved by the FDA.

Naloxone hydrochloride is an opioid antagonist that reverses the effects of opioids, including respiratory depression, sedation, and hypotension. According to Hikma, the drug has a long history of safe use as the standard of care for reversing opioid overdoses.

Emergency Physicians First to Safely Treat Case of Vaccine-Induced Blood Clot with Heparin Alternative

Press Release:

A new case report, detailed in Annals of Emergency Medicine, is the first known case of a patient with VITT (vaccine-induced thrombotic thrombocytopenia) treated with a heparin alternative following the Centers for Disease Control and Prevention (CDC) guidance.

An otherwise healthy female patient in her 40s came to the emergency department at UCHealth University of Colorado Hospital twelve days after receiving the Johnson & Johnson vaccine with a headache, dizziness, and vision changes. The patient was treated on April 13, 2021, the same day that the Centers for Disease Control and Prevention (CDC) announced a pause in the administration of the Johnson & Johnson vaccine. CDC guidance recommended treatment with heparin alternatives but did not recommended any specific alternative in that announcement.

Bivalirudin was given to the patient and the authors write that, “this patient’s early outcomes suggest that bivalirudin may be a safe alternative to heparin in patients demonstrating a presentation consistent with VITT.”

“Our experience shows us that these clot reactions are very rare, but they can be treated,” said R. Todd Clark, MD, MBA, lead co-author and assistant professor of emergency medicine at the University of Colorado School of Medicine. “Americans can feel comfortable getting vaccinated and should discuss any vaccination concerns with their doctor. Getting vaccinated is a critical step in combatting this pandemic so we can return to our normal lives.”

While more research is needed on the efficacy of this medicine, the early outcomes of this case may inform the decision making of other health professionals who may be selecting heparin alternatives for patients with VITT, the authors said. 

Read the case report here.

Annals of Emergency Medicine is one of the peer-reviewed scientific journals for the American College of Emergency Physicians (ACEP), the national medical society representing emergency medicine. Annals of Emergency Medicine is the largest and most frequently cited circulation peer-reviewed journal in emergency medicine and publishes original research, clinical reports, opinion, and educational information related to the practice, teaching, and research of emergency medicine.

SOURCE American College of Emergency Physicians (ACEP)