The study’s objective was to quantitate the reduction in formal complaints by emergency department patients using a real time patient satisfaction survey tool and provider-driven service recovery. This was performed with a third party surveyor using a nine question survey taken in real time. One of the questions specifically asked if the patent he/she had any concerns about their care. After the survey was administered, the surveyor would notify the provider of any concerns.

With an N of 5969, the survey found a 5.6% complaint rate regarding the care these patients received. The surveyor notified the provider only 53.4%% of the time, for reasons not well established in the document. The provider returned to the patients’ room to address the patients concerns 74.2% of the time. 2.9% of these patients filed a complaint with the hospital after patient discharge. Of the 54 instances when the provider failed to return to the room to address the patient concerns, 22.2% OF THESE PATIENTS SUBSEQUENTLY FILED A FORMAL COMPLAINT WITH THE HOSPITAL.
The investigators concluded that they showed an 87% reduction in the number of formal complaints made by patients, demonstrating the value of service recovery before patient discharge. They added that this also served to reduce costs of handling the complaints by $900.00/patient complaint. This study reiterates the well-established precept that service recovery opportunities have a profound effect on patient satisfaction.

Though this study looks at its data from a slightly different perspective than an overall change in patient satisfaction percent, it supports the survey recovery process that HPP offers to our partners. Furthermore, the methodology we use allows us to eliminate the ‘3rd party’ which gives the providers directly caring for the patient the opportunity to review all of the feedback in real time. We can then self-determine which situations would benefit from another visit with the patient. Our method also offers the surveyee the potential perception that feedback can be more candidly provided, as they are in a less judgmental situation while responding to the survey.

Ultimately, this gives the opportunity to have the real issue addressed, leading to building a more favorable relationship between the patient and the provider. This will translate into happier patients, leading to better patient aftercare compliance and subsequently improved patient outcomes. There are some less obvious, but more significant, financial benefits that can come from this success. Namely, the potential for less litigant situations and an increase in the emergency department census generated from the more satisfied community service base.

Reference: Landsburg. J.M. Et.al, Utilizing Real-time Patient Satisfaction data to Perform Service Recovery for Dissatisfied(PATIENTS) Who Present to the Emergency Department., Annals of Emerg. Med Volume 60 No4s, Oct. 2012, P S112

Hospital Physician Partners sponsored and produced its annual director’s conference the week of April 21st. The physical setting was a good environment to foster productivity. The conference was graced with a series of lectures and demonstrations focusing on concepts and methods to bring the directors up to date on subjects we can use to meet the demand s of the continuous changes in the business and science of medicine. The academic lectures were state of the art and thought provoking.

As has been customary in the past, the attendees were required to create and perform a self-learning exercise. (see pic below) They again found themselves being placed a bit out of their comfort zone to learn and critique the intricacies of adapting to unique situations.

The ultimate goal of these conferences is to provide our HPP family of doctors and mid-levels with innovative tools to make their jobs more satisfying, rewarding and productive. Once again it is clear this conference was productive based on the feedback. The utility of the information gathered at the program showed in the participant’s motivation and satisfaction. They were inspired by the content and plan to bring these revolutionary ideas and ideals back to the practitioners in the trenches.

It would be hard to walk away from this event without finding yourself better prepared to bring leadership to HPP. Most of the attendees were engaged to the point that the content presented in this conference will generate benefits for all HPP providers throughout the country.

To read more about this year’s conference and HPP’s Medical Director award winners, click here.

Located in central Mississippi just 14 miles from Jackson, Brandon is in the amazing Pine Region, also referred to as the Black Prairie because of its rich, dark soil, white-tailed deer, and large flocks of turkey. This region has over 200,000 acres of land open for public hunting, fishing, and other outdoor recreations in the pines. Geographically, it’s just outside of Jackson in Rankin County, voted the tenth best place to live in America by Progressive Farmer Magazine. Brandon has a total area of 21.3 square miles and a population of 21,705. In the past three years, assessed valuations have increased by 26% and the population has grown from 115,327 to 121,758.

If you love the country and being outdoors, then you’ll discover the beauty of Brandon’s country-side and be able to experience the cities exclusive and unique farm tours including shrimping tours, U-pick farms, catfish farm tours, & Christmas tree farms. Other popular venues to visit include the local fairs, festivals, and farmer’s market. End the night dancing under the stars in a clear night at the many private “Barn Dances.”

One of the reasons you chose Emergency Medicine because you wanted your flexibility and personal freedom and Brandon, Mississippi offers plenty of it for you to enjoy! For more information about the opportunities available at Crossgates River Oaks Hospital, contact Christina Plain at 800-815-8377, ext. 5295.

CLICK HERE to hear from your peers who work with HPP and learn more about our company’s unique Family Culture.

The positive influences of doctor–patient communication, treatment expectations, and sham treatments (termed the placebo effect), have been demonstrated scientifically for subjective symptoms such as pain and nausea. Many of us have seen the efficacy of a placebo.

As Emergency Medicine Physicians or Hospitalists, patient self-induced illnesses caused by internet medical care recommendations and treatment/medication noncompliance are etiologies that may cause these patients to seek medical evaluations. Then there’s the nocebo effect defined as the induction of a symptom perceived as negative by sham treatment or by the suggestion of negative treatment expectations. A nocebo response is a negative symptom caused by the patient’s own negative expectations or by negative suggestions from clinicians in the absence of any treatment. In fact, information about possible complications and negative expectations on the patient’s part has been found to increase the likelihood of adverse effects.

A recently published study from Germany was designed to determine the impact of nocebo effects on adverse events (AEs) in drug trials for fibromyalgia syndrome (FMS) and painful diabetic peripheral neuropathy (DPN). There were a total of 5065 patients in the placebo groups. The pooled estimate of the event dropout rate due to AEs in placebo groups was 9.6 in placebo and 16.3 in true drug groups of FMS trials; and was 5.8 in placebo and 13.2 in true drug groups of DPN trials. The investigators concluded that nocebo effects accounted for substantial numbers of AEs in drug trials of FMS and DPN. They recommended the need for development of strategies to minimize nocebo effects in both clinical trials and clinical practice. With any acute patient complaint presentation, our job is to rule out an emergency medical condition without introducing personal biases, minimizing the chief complaint or attributing the problem to potential nocebo effects.

Care standard requires us to inform patients of the potential complications of our proposed treatments. Concurrently we should make a conscious effort to minimize the likelihood of complications caused by a potential nocebo effect. When we place a patient on a new medication, it has been suggested that we should emphasize the fact that the proposed treatment is usually well tolerated. Another suggestion is to obtain the patient’s permission to incompletely inform them about the treatments’ possible side effects.

Words are one of the most powerful tools we have in our armamentarium. Communication lessons provided during training and with continuing medical education are ways that we can learn to more effectively utilize the spoken word. We need to remember that doctor–patient communications and the patient’s treatment expectations can influence the course of their medical therapy.

References:
1. Häuser, W et.al. Adverse Events Attributable to Nocebo in Randomized Controlled Drug Trials in Fibromyalgia Syndrome and Painful Diabetic Peripheral Neuropathy: Systematic Review, June 2012 – Volume 28 – Issue 5 l
2. Häuser, W et.al. Review Article Nocebo Phenomena in Medicine Their Relevance in Everyday Clinical Practice; Dtsch Arztebl Int. 2012 June; 109(26): 459–465. Published online 2012 June 29.

Biloxi Regional Medical Center in Biloxi is the first touch of Mississippi Magic we are highlighting. Residents can enjoy the sugar-white sand beaches, great deep-sea, freshwater fishing and various outdoor activities. The city is within minutes from the ocean waters where you can ride a ferry out to Ship Island by the historic Fort Massachusetts, discover dolphins swimming in the ocean, or visit several delicious seafood restaurants overlooking the Crystal clear waters. Choose from landing “the big one” on one of the many fishing charters or sinking a 40-footer at a professional-grade tough southern golf course.

Biloxi is a great city of entertainment and thus its nickname: The Playground of the South. Enjoy the “Grillin on the Green” every March; a family fun event featuring a BBQ competition, arts & crafts vendors, live entertainment, and children’s activities. Mississippi’s Gulf Coast offers weekend’s FILLED with events, parades, festivals, & FUN! And of course, for those who love games of chance, win big at the nationally known Biloxi Hard Rock Hotel & Casino open 24/7 a week.

You chose Emergency Medicine because you wanted your flexibility and personal freedom and Biloxi, Mississippi offers plenty of it for you to soak up! For more information about the opportunities available at Biloxi Regional Medical Center, contact Christina Plain at 800-815-8377, ext. 5295.

As I was writing the news release today announcing that HPP was taking the reigns for eight Health Management Associates Inc. (HMA) contracts in Mississippi over the next 90 days, I got pretty excited. This new portfolio of business triples our Emergency Medicine programs in the state. Then I looked at the growth stats since January 1st and was shocked again to see that since the start of the year, we have begun 22 new Emergency and Hospital Medicine contracts. I was blown away. Although I am the VP of Marketing and know that we have started a number of new contacts recently, it was the first time I looked at everything in aggregate and frankly, I was just blown away.

Why was I blown away? Honestly, it is because while we have earned all this new business, are growing steadily, and dealing with all the pressures that come with such growth; here was my CEO, Jeffrey Schillinger, leading a “huddle” with our management team and asking how WE were doing. Earlier in the day, I spoke to our President and Chief Medical Officer, (and Jeffrey’s twin brother) Dr. David Schillinger, who was fresh off working a 24 hour clinical shift with about 4 hours sleep. He was returning my call from the day before to discuss some minor details about our upcoming Medical Director’s conference. He’s flying all over the country, working crazy hours on shifts, leading our clinical operations team, and oh yeah, helping run a national medical management company. Yet, he took the time to call me back promptly and personally. This is the culture of Hospital Physician Partners.

That’s why I am blown away. We have the opportunity to now save even more lives in Mississippi and help provide quality care for the communities we will be serving throughout the state. It feels awesome knowing that leading the way are two ordinary people, twin brothers no doubt, who care as much about their employees as our physicians do about their patients. Here at HPP, there are no ivory towers or “gates to the C-Suite.” We are a family whose mission is Saving Lives. We are guided by a simple premise: What’s Important to YOU…Is What Matters to US!® and we look forward to proving it to our patients and our new hospital partners in Mississippi.

Patient handoffs serve a critical function. They constitute a major responsibility with patient management while performing our jobs as Hospitalists and Emergency Medicine physicians. A recently published abstract in the Annals of Emergency Medicine evaluated the frequency of errors made during transfer of patient care.

The focus of the study was to describe the prevalence of errors related to communicating abnormal vital sign findings from the ED provider to the receiving physician. Specifically, hypotension and hypoxia were studied since these conditions are independently associated with poor clinical outcomes. Of the 434 patients studied, 58% of the handoffs took place in a critical care unit and 42% in the emergency department. The primary outcomes sought were errors of omission in the communication of an episode of hypotension (defined as systolic blood pressure <90 mm of Hg) or hypoxia (defined as oxygen saturation < 92%). A secondary analysis attempted to identify predictors of handoff errors which included: interruptions for patient care, verbal interruptions of primary communicator, and requests for vital signs by other providers.

The investigators found that nearly 20% of hypotensive episodes occurring in the emergency department were not reported during patient handoffs. They also found that there was a failure to report the history of hypoxic episodes 4.4% of the time. Interestingly, no predictors of handoff variables were found to be significant. Furthermore, the experience of the primary communicator (Residents, P.A.s, Attending physicians) was not determined to be a factor.

Since this aspect of patient care is a National Patient Safety Goal, this study’s findings are magnified by the patient’s need for this information being relayed without errors. The historical, diagnostic, therapeutic and medicolegal relevance of relaying the occurrence of an abnormal or life threatening vital sign finding during the handoff cannot be understated. We have to admit these findings represent a serious deficiency in communicating to the receiving physician salient observations relevant to our patient’s care. This study should remind us to concentrate on attention to important details during patient handoffs.

Reference: Venkatesh, K et al. Effectiveness of Communicating Vital Signs at Emergency Department Handoffs, Annals of Emergency Medicine, Volume 60, Issue 4, Supplement , Pages S49-S50, October 2012

What does that do to the doctor? There is a myriad of thoughts and feelings coursing through your veins to decide how to best prepare for this challenge. Is it the excitement of the challenge, or just wanting to cut the throat of the person that used the taboo word “Quiet” just before the emergency medical services calls this in trauma? Is it the sense of responsibility or the sense of dread? Then there is fear, logic, and anxiety. You tell yourself to get a grip. And you’re off to the races.

For some of us it is the memory of a lifetime. For others it is Deja vu. And for a few it’s the nightmare of the century. Either way we are there for the duration and can take pride in making a difference in as many of those people’s lives as we possibly can. We will be what we need to be selflessly, for each and every one of those people injured. We’ll be proud of the fact that we will perform better than we ever have because that’s what makes us whole. Now you have had a glimpse of the rest of the story…a view from the heroes.

The HPP Physician Services team feverishly began making calls. The hour was late and many were putting children to bed and getting ready themselves for lights out. However, they stepped away from what they were doing to help strangers miles away. In the end, within an hour, assets were marshaled and the HPP staff, in coordination with the Whitesburg nursing staff and administration, were able to find doctors to be on standby and ultimately come in to help the students as soon as they were found.

One hospital nursing staff leader said, “The teamwork involved was wonderful. All of our resources were utilized and implemented with great success. It was breathtaking to see our administration and department managers at the bedside offering comfort measures and advocating for our patients as they communicated our patient’s needs. I want to add thanks to HPP for providing us with the doctors in the ER. They arrived promptly and were awesome.” Of course, most important was the fact that all 40 of the college students were safe and okay.

At HPP, our tagline is “Partnering For Results.” Sometimes, taglines and marketing slogans can be viewed as fluff. However, this is one time where we can all stand a little taller. Everyone teamed together to save lives and partner for results!

However, a study abstract published in the Annals of Emergency Medicine reveals a very significant morbidity and mortality consideration for this modality. The study was designed to compare flow rates of blood administered through an IO needle in various extremity sites under high pressure in an adult hypovolemic swine model. The striking finding from this study was that histopathologic lung examination of the study participants revealed fat emboli present in 14/14 (100%) of the tibia study arm, 10/11 (91%) of the humerus study arm, and 8/14 (57%) of the femur study arm group. They concluded that the rate of IO infusion of blood through the swine humerus was greater than the femur and tibia but that fat emboli were detected in the lungs of MOST of the study animals.

We all know that patients with increased mass, age, multiple underlying medical problems, and/or decreased physiologic reserves have worse outcomes than other patients with fat emboli. Paradoxically these are often the people that may need IO access the most.

What practical lessons can Emergency Medicine and Hospitalist specialists take away from this study? A lot of bacon gave its’ all to show us something could be happening in our patients with IO infusions that many of us probably didn’t know about. Considering the mortality rate of fat embolism is 10-20% 2, we have a significant reason for adhering to the indications for this method of infusion instead of defaulting to the IO modality too quickly. Our prehospital crews should also be reminded of this significant morbidity and mortality as a reason to place these lines according to their protocols.

References:
1. Lairet, JR et al. Comparison of Intraosseous Infusion Rates of Blood Under High Pressure in an Adult Hypovolemic Swine Model in Three Different Limb Sites. Annals of EM, Vol. 60 NO48 Oct 2012 page S75
2. Kirkland,L., Fat Embolism, Emedicine.medscape, Sep 8, 2011

Hospital Physician Partners (HPP) announced recently that they have expanded their management agreement with Lovelace Health System to manage an extended portfolio of contracts throughout New Mexico.

HPP, which partners with more than 90 hospitals in over 20 states, currently has the responsibility of managing and recruiting Emergency Medicine clinical providers Lovelace Health System’s Albuquerque campuses: Lovelace Medical Center, Lovelace Women’s Hospital, Lovelace Westside Hospital and Heart Hospital of New Mexico at Lovelace Medical Center. This footprint has now grown to include the Hospital Medicine programs those facilities as well as the Emergency Department at Lovelace Regional Hospital-Roswell.

This expansion of services is an honor says HPP Chief Executive Officer, Jeffrey Schillinger. “We have enjoyed a strong partnership over the past four years,” said Schillinger. “The expansion into Roswell and addition of the Hospitalist services is a great opportunity to help improve the quality of care for Lovelace patients.” HPP’s clinical leadership team actively practices in New Mexico and has a keen understanding of the market which is key to achieving the goals Lovelace has for attaining quality patient outcomes.

“This partnership will enhance care coordination at our hospitals,” said Dr. John Cruickshank, Chief Medical Officer at Lovelace Health System. “By having the Emergency Department physicians and hospitalists working together as one team we will be able to improve quality, service and efficiency for our patients.”

HPP’s growth 12 new additions to its portfolio in the Emergency and Hospital Medicine industries between fourth quarter 2012 and first quarter 2013 with more set to begin in the second and third quarters this year. “HPP’s experience and size provides valuable resources in the form of recruiting physicians, billing and management, to the hospitals, physicians, and communities we serve,” says Schillinger. “My brother, who is an actively practicing ER physician, and I strongly believe success comes from being accessible, in touch, and involved. Our entire company is constantly focused on the one thing that keeps us grounded – We Save Lives.”

About Hospital Physician Partners

Hospital Physician Partners (HPP) is a physician-led, privately held Emergency and Hospital Medicine Management company that partners with hospitals and clinical providers to deliver quality patient care and physician recruitment services. HPP contracts with over 1,200 providers and will treat more than 2 million patients in 2013; maintaining corporate headquarters in Hollywood, Florida with offices in Jacksonville and Ft. Lauderdale, Florida as well as Durham, North Carolina. More information is available at www.hppartners.com.

This study’s goal was to compare interpreter errors and the potential consequences involving encounters using professionals, ad-hoc interpreters, or no interpreters. The proportion of errors that may cause potential consequences was significantly lower for professional (12%) versus ad hoc interpreters (22%) versus no interpreters (20%). Additionally, professional interpreters with greater than 100 hours of training committed a significantly lower proportion of errors of possible consequence (2% versus 12%) in every error category.

The investigators concluded that the use of a professional interpreters skills results in a significantly lower likelihood of significant errors than other interpreters. They further stated that requiring at least 100 hours of training for interpreters could have a significant impact on reducing interpreter errors and their consequences in health care while improving care quality and patient safety.

Considering the importance of the history in the clinical evaluation of these patients, this is valuable information we should factor into the equation when working with these patients. This significance would also have an impact on the ever important after care instructions, which may influence their care plan, treatment compliance, and subsequent case liability concerns.

Reference: 1. Flores, G et.al., Errors in Medical Interpretation and Their Potential Clinical Consequences in Pediatric Encounters. Annals of emergency medicine, Vol. 60 Number 5, Nov. 2102 pages 545-553

An emergency medical condition is defined as manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the individual’s health (or the health of an unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs. There have even been EMTALA cases charging that physicians have discharged the patient before adequately treating their pain thereby not satisfying the EMTALA requirement of stabilization. How these cases are treated is still under consideration by the courts.

What does this situation mean for you? If you perceive that the processes in place at your institution may allow the aforementioned scenario (or any other EMTALA violation) to take place, it is incumbent upon you to address these deficiencies immediately. Ultimately, being well-informed about EMTALA law is a mandatory requirement for anyone who treats hospital patients in an emergency situation. We must continually maintain a healthy respect for the laws of the EMTALA. The safest approach is to know the laws well. Additionally we must always do the right thing by placing the health and welfare of the patient as paramount practice goal. Anyone may file a claim. But if we are doing our jobs correctly as emergency physicians and hospitalists (along with good documentation), we can practice with confidence… as long as there are no violations in our practice.

References:
1. Zibulewsky J. Ignorance of the law is no excuse. Knowledge of the statute by the medical staff of a large, tertiary-care hospital. Ann Emerg Med (submitted for publication, May 2001).
2. Zibulewsky J.Proc The Emergency Medical Treatment and Active Labor Act (EMTALA): what it is and what it means for physicians, (Bayl Univ Med Cent). 2001 October; 14(4): 339–346.

Speaking of increased work, many of us can relate to a law taken from the Samuel Shem book, “The House of God”. The law states, “Show me a medical student that doesn’t triple my work and i’ll kiss your feet.” An abstract recently published in the Annals of Emergency Medicine has examined an aspect of this law in some detail. Their findings may someday play a roll in the way we function with our jobs as emergency medicine physicians and hospitalists.

The investigators looked for factors associated with and the rate of adverse events caused by medical errors made by emergency physicians while caring for, managing, and admitting their patients. The authors concluded that emergency physician’s adverse events are common for patients hospitalized from the ED. Of the 225 patients included in the study, 130 errors were detected. Of these errors, 34 were categorized as adverse events (defined as medical errors that caused harm to the patient). They noted only two factors that lowered the risk of adverse events in this study: a) the transition of care involving a handoff within the ED, and b) the involvement of a Junior Doctor (resident) in addition to the senior physician. Essentially, instead of tripling their work they found that the residents were improving patient safety. The French investigators went on to say that crosschecking every major decision is mandatory in many other professions and could be beneficial in emergency medicine. Imagine the consequences and permeations of this becoming a Joint Commission standard.

Our post-graduate training programs have reinforced this paradigm for many of us, effectively hardwiring this method into our care plan. This is especially true in the highly litigious specialties. But as for the studies newly recognized value of the “junior doctor,” I guess I better not believe everything I have read in “The House of God” to be the gospel I thought it was. I should probably just stick to Rosens, Tintinalli and Harrisons.

Reference: Goulet, F. et al., Factors Associated with Adverse Events Resulting from Physician Medical Errors in the Emergency Department: Two Doctors Safer than One. Hausfater P/Freoupe Hospitalier Pit`e-Salpentriere, Paris France.

The American Journal of Pathology in 2003 reported findings that nicotine accelerated wound healing in diabetic mice. Interestingly, these effects are mediated by neuronal nicotinic acetylcholine receptors nAChRs and that nicotine-induced wound healing is mediated, at least in part, by its effects to increase wound angiogenesis. Other studies including a study published in the Annals of Medicine, 2004 also reported nicotine as a potent angiogenic agent. The Journal of Cardiology 2007 concluded intramuscular administration of nicotine for 3 weeks was capable of significantly promoting intramyocardial angiogenesis. Nicotine has also been found to accelerate intimal proliferation and thickening of balloon catheter denuded iliac artery injury.

Current evidence about the therapeutic potential of nicotine is strongest for ulcerative colitis. The Department of Gastroenterology at the, University Hospital of Wales, in the U.K concluded that ulcerative colitis (UC) is predominantly a disease of non-smokers and nicotine is thought to be the agent responsible for this association. Transdermal nicotine was shown to improve disease activity and sigmoidoscopic appearance in active disease patients. Attempts to reduce systemic levels and improve drug tolerance have been let to colonic delivery systems of nicotine (also an ancient treatment for resuscitation of drowning victims!). Preliminary observations with nicotine enemas in UK have been shown to be clinically beneficial.

Tebanicline, developed by Abbott as partial agonist at nAChRs, showed potent analgesic activity against neuropathic pain in human trials. It was designed to be a less toxic analogue of a potent frog-derived compound which is some 200x stronger than morphine as an analgesic. It was dropped from development due to an unacceptable incidence of gastrointestinal side effects. The development of new nAChR agonists continues. Several new nAChR agonists have advanced to Phase II clinical trials demonstrating efficacy in Alzheimer’s disease, attention deficit hyperactivity disorder, cognitive deficits of and schizophrenia. Nicotinic receptors and Parkinson’s disease studies done between 1961 and 2000 demonstrated that there may be nearly a 50% decrease in the incidence of Parkinson’s disease in tobacco users.

Ultimately how one acquires their nicotine has a lot to do with its risk versus benefit. A cigarette contains 9-30 mg of nicotine. Cigars can contain up to 40 mg. Chewing tobacco carries 6-8 mg per gram, gum is 2-4 mg per piece and patches 8.3-114 mg. The fatal dose of nicotine has been estimated to be 0.5-1.0 mg/kg in an adult. The lethal dosage for adult humans according to the CDC is 5 mg/ m3 based on oral toxicity data in humans. It is pretty unlikely that any studies will ever conclude that those intriguing contraband habanos Cuban cigars are going to be “healthy” or a” one a day” staple to the fountain of youth. However they do contain at least one chemical with multiple potential therapeutic indications and perhaps will one day offer benefits beyond the cigar aficionados’ universally purported “relaxing, flavorful, enjoyable” appeal.

Hospital Physician Partners is now providing Emergency Medicine staffing and management services for six hospitals in Oklahoma including five from the INTERGIS system; Blackwell Regional Hospital, Clinton Regional Hospital, Marshall County Medical Center, Mayes County Medical Center, Seminole Medical Center, as well as Medical Center of Southeastern Oklahoma. Researching these cities and communities has not only been fun as I learn about new parts of the country I probably would not have looked at previously, but it is also educational. Long gone are the history and geography books from my aging and forgetful mind so a little refresh was a good thing. For example, I forgot that Oklahoma was part of the 1803 Louisiana Purchase and is one of the nations youngest states. I didn’t know that Oklahoma has more man-made lakes than any other state, is the third largest gas-producing state in the nation, and that forests cover approximately 24 percent of Oklahoma. Now, while all this may do is make me sound more intelligent during the next Trivial Pursuit family challenge, it has driven me to learn on the job which is what we all should be doing anyway isn’t it?

Hospital Physician Partners is now a new partner in the care of patients in the Oklahoma communities we serve. In addition to providing Emergency Medicine jobs in Oklahoma, we will be caring for ten’s of thousands of patients across the state. As an employee of Hospital Physician Partners, I am proud of this. In our day to day jobs, (especially in our industry) it is easy to get lost in the crush of work as we staff, recruit, manage, and most importantly, save lives everyday. However, this new venture into Oklahoma has reminded this marketer that part of the excitement of what we do is also engaging in new communities, developing new recruitment strategies, and expanding our scope of knowledge as purveyors of quality patient care.

On the other hand, if you’re not one of those individuals with one foot on the banana peel and the other one in the grave, there are some differing opinions on this. Some fitness experts suggest why should we restrict this feast at all? Since a Thanksgiving Day feast happens only 1 day a year, why not just eat as much as you want? If you are healthy enough, one day of feasting out of a full year is NOT going to make or break ones’ fitness routine.

Even if you decide to feast on every holiday that you celebrate throughout the year, this is still only going to be 5 or 6 feasts per year. That calculates out to only about 1 feast every 2 month which they say is certainly nothing that is worth worrying about in terms of a fitness plan. And if you have been fasting prior to this onslaught, occasional overeating may have the benefit to revamping your metabolic rate via the leptin hormone response, which has been suggested to up-regulate your metabolism. This physiologic concept actually originated from studies in the 1950s on obese mice that showed when this subset of mice was treated with injections of leptin, they lost their excess fat and return to normal body weights. So if you’re healthy enough to withstand the stress test at the dinner table, dig in. After all its better to burn out than to fade away. (Neil Young from the song: My My, Hey Hey)

References:
Pamela Peeke, MD, MPH, FACP, Assistant clinical professor at the University of Maryland School of Medicine
Ingalls AM, Dickie MM, Snell GD (December 1950). “Obese, a new mutation in the house mouse”. J. Hered. 41 (12): 317–8. PMID 14824537.
http://jhered.oxfordjournals.org/cgi/reprint/41/12/317

We all realize how important a job it is as Emergency Medicine Physicians and Hospitalists to generate an accurate medication list for the care and safety of our patients at their hospital admission. It is vital to prevent medication errors and adverse drug events during the hospital stay and after discharge. Unidentified errors can result in the patient receiving harmful, inaccurate treatment. As such, in todays clinincal environment where more and more ER physicians and Hospitalists travel to work locums-based Emergency Medicine jobs and Hospitalist jobs, the challenge is even greater.

A recent study published in the British Medical Journal attempted to describe the frequency, type and predictors of errors in the patients medication history, and to evaluate the extent to which standard care corrected these errors. They also tried to determine the degree to which standard care identified errors in the medication history when the pharmacists performed a medication reconciliation. In the study, the medication list generated at admission was compared with the patient’s medication list in the hospital medical records. The errors were identified by pharmacists performing medication reconciliations for patients admitted to a Swedish hospital, and generated predictors for those medication errors. Addition, withdrawal of a drug, or changes to the dose or dosage form in the hospital medication list was considered a medication discrepancy. Medication discrepancies for which no clinical reason could be identified were considered medication history errors.

The study population constituted 670 patients. At least one medication history error was identified by pharmacists conducting medication reconciliations for 313 of these patients, (47%)! The most common medication error was an omitted drug, followed by an incorrect dose. Analysis showed that a higher number of prescribed drugs listed at admission, and the patient living in their own home without any care-givers were predictors for medication history errors. The results indicated that the usual care by non-pharmacist patient care staff partly corrected the errors in affected patients by four days after admission. However, a considerable proportion of the errors made in the initial medication history at admission remained undetected by standard hospital operating procedures.

The investigators concluded that medication history errors generated at hospital admission are common. This highlighted the importance of introducing processes for ensuring that the medication lists are accurate and complete as soon as possible to reduce the risk of medication errors. They concluded that clinical pharmacists conducting medication reconciliations have a high potential for correcting errors in medication history. They noted that there is limited potential for predicting which patients are at highest risk of experiencing errors in their medication history. They recommended that systematic medication reconciliations should be conducted in all patients admitted to hospital and noted that older patients being prescribed many drugs could benefit the most from admission medication reconciliations by clinical pharmacists.

As purveyors of Emergency Medicine management and Hospitalist Medicine management, clearly we should educate the staff caring for our patients on the critical nature of this portion of the patient assessment and encourage them to acquire an accurate valuation of the patient’s medication list. Those of us who are writing admit orders as part of our patient management must be vigilant for this error potential and be diligent with our medication orders. At the very least, we can write an order to contact the patient’s personal pharmacy for their medications and dosages.

Lina M Hellström; Åsa Bondesson; Peter Höglund; Tommy Eriksson, Errors in Medication History at Hospital Admission: Prevalence and Predicting Factors., BMC Clinical Pharmacology BMC Clin Pharmacol. 2012 Apr 3;12:9

Occasionally, our job as Hospitalists and Emergency Medicine physicians is to decide who should return to work and who really needs a work note. Sometimes we need to decide if WE are too sick to make it through the shift. I personally have worked shifts while enduring an active GI bleed, an acute pulmonary embolus and a stroke in evolution. That is not saying that I demonstrated or used the common sense God gave a tack. But I’m admittedly on the other end of the extreme and in my defense, most of these weren’t infectious. A recent article by Sue Shellenbarger in the Wall Street Journal brought up a few salient items for us to ponder about calling in sick. Surveys have disclosed that 1 in 7 women and 1 in 5 men have called into work and lied about being sick. With that, the following are the results of a survey listing the most creative excuses for missing work.

• The employee’s toe was stuck in a faucet
• The employee’s dead grandmother was being exhumed for a police investigation.
• The employee got sick from reading too much.
• The employee was suffering from a broken heart
• The employee was upset after watching Hunger Games
• The employee’s bird bit her
• The employee’s hair turned orange while dyeing her hair.
• The employees sobriety tool wouldn’t allow the car to start
• The employee’s dog was having a nervous breakdown

In truth, these statements fail to document the details that may make the difference between credibility and laughability. Maybe they just want to take Halloween off to spend with their kids. Still, we have all have heard patients tell us things that are nearly as outrageous as these statements.

We can easily convince our diehard patients in our ED that they are too sick to work. Some may need some prodding by asking them, to paraphrase an office manager from New York; “You don’t look very good. What kind of flowers do you want at your funeral?” Or perhaps, ‘Would you like me reserve you a horse-drawn U-Haul behind your hearse’? Considering the years’ projected outbreaks of whooping cough, and the concerns for outbreaks of hantavirus and norovirus, we need to be diagnostically vigilant. Not to mention the occasional patient sauntering into the ED or our office with the chief complaint of ‘a cough’, hacking away in our faces with multidrug resistant TB!
We all have an obligation to not gift our own infectious diseases to our susceptible patients. Additionally, our patients and their coworkers count on us to not allow highly contagious people to bring said diseases to the workplace. And in reality, in this day of a cornucopia of information technologies, patients can now work at home or Skype into the meetings from home.

So, let’s just say I made these things up. Maybe they just want to take Halloween off to spend with their kids. What can we take away from these ingenious but inane justifications for skipping work? We must wade through the various presentations and complaints in an attempt to weed out the malingerers. There must be a happy medium where we serve the patient and the communities best interest by using a modicum of common sense, a good physical exam and the applicable testing available to these patients at our health care facilities.

The American College of Osteopathic Emergency Physicians (ACOEP) Scientific Assembly was attended by two of HPP’s physician recruiters who engaged the participants at every opportunity with personable and meaningful dialogue. The interest Scott Bradford and Benny Rossner generated in HPP was remarkable. They offered a nearly unique presentation format from the recruiters at this conference by genially engaging the participants in front of booth, demonstrating the personal touch that HPP offers to its members. The resulting quality of the responses from the participants was readily apparent and well received.

The ultimate goal of HPP presenting ourselves at these conferences is to offer to the attendees the chance to become a part of the HPP family of health care providers and learn about our nationwide opportunities. We introduce them to the prospect of experiencing a more satisfying, rewarding and productive career in Emergency Medicine.

Now I’m sure some of you are saying this is another review dripping with syrupy propaganda. But the interest generated at these conferences will clearly bear fruit which will be realized by HPP facilities throughout the country. And, as a physician myself, I can full appreciate the value of a meaningful conversation with a recruiter versus mindless banter about the weather and how nice the conference is. HPP’s team did a great job and made it fun for attendees who visited their booths

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