Sonography in Hypotension and Cardiac Arrest (SHoC): Rates of Abnormal Findings in Undifferentiated Hypotension and During Cardiac Arrest as a Basis for Consensus on a Hierarchical Point of Care Ultrasound Protocol
PubMed | Saskatoon Health Region, University of Cape Town, Stellenbosch University, Dalhousie University and 2 more.
Type: Journal Article | Journal: Cureus | Year: 2016
Point of care ultrasound (PoCUS) has become an established tool in the initial management of patients with undifferentiated hypotension. Current established protocols (RUSH and ACES)were developed by expert user opinion, rather than objective, prospective data. PoCUS also provides invaluable information during resuscitation efforts in cardiac arrest by determining presence/absence of cardiac activity and identifying reversible causes such as pericardial tamponade. There is no agreed guideline on how to safely and effectively incorporate PoCUS into the advanced cardiac life support (ACLS) algorithm. We wished to report disease incidence as a basis to develop a hierarchical approach to PoCUS in hypotension and during cardiac arrest.We summarized the recorded incidence of PoCUS findings from the initial cohort during the interim analysis of two prospective studies. We propose that this will form the basis for developing a modified Delphi approach incorporating this data to obtain the input of a panel of international experts associated with five professional organizations led by the International Federation of Emergency Medicine (IFEM). The modified Delphi tool will be developed to reach an international consensus on how to integrate PoCUS for hypotensive emergency department patients as well as into cardiac arrest algorithms.Rates of abnormal PoCUS findings from 151 patients with undifferentiated hypotension included left ventricular dynamic changes (43%), IVC abnormalities (27%), pericardial effusion (16%), and pleural fluid (8%). Abdominal pathology was rare (fluid 5%, AAA 2%). During cardiac arrest there were no pericardial effusions, however abnormalities of ventricular contraction (45%) and valvular motion (39%) were common among the 43 patients included.A prospectively collected disease incidence-based hierarchy of scanning can be developed based on the reported findings. This will inform an international consensus process towards the development of proposed SHoC protocols for hypotension and cardiac arrest, comprised of the stepwise clinical-indication based approach of Core, Supplementary, and Additional PoCUS views. We hope that such a protocol would be structured in a way that enables the clinician to only perform views that are clinically indicated, which limits exposure to the frequent incidental positive findings that accompany the current one size fits all standard protocols.
English S.K.,Grand Rapids Medical Education Partners MSU Family Medicine Residency |
Vanschagen J.E.,Family Medicine Residency Program
Journal of the American Geriatrics Society | Year: 2011
The aging of the U.S. population poses one of the greatest future challenges for family medicine and internal medicine residency training. One important barrier to providing quality education and training in geriatric medicine to residents is a serious and growing shortage of practicing geriatricians and geriatrics faculty. The Accreditation Council for Graduate Medical Education currently accredits 45 family medicine-based and 107 internal medicine-based geriatric medicine fellowships in the United States. There are 13 American Osteopathic Association-certified geriatric medicine fellowship programs. In this article, the authors examine the rationale for the development of additional geriatric medicine fellowship programs and offer some practical suggestions and pointers for those interested in developing their own geriatric medicine fellowships. The authors write from the perspective of their own recent experiences with the development and accreditation of a family medicine residency-affiliated fellowship in geriatrics. Other residencies may find this article useful in determining the feasibility of developing a geriatric medicine fellowship for their programs and communities and will find practical guidance for beginning the process. © 2011, The American Geriatrics Society.
Horst M.A.,Lancaster General Research Institute |
Horst M.A.,Lancaster General Health |
Coco A.S.,Family Medicine Residency Program
Journal of the American Board of Family Medicine | Year: 2010
Background: The recent implementation of electronic medical record systems allows for the development of systems to track common illness across a defined community. With the threats of bioterrorism and pandemic illness, syndromic surveillance methodologies have become an important area of study. There has been limited study of the application of syndromic surveillance techniques to communities for tracking common illnesses to improve health system resource allocation and inform communities. Methods: We analyzed visits from 26 primary care sites and one emergency department in a health system during a 13-month period in 2007 to 2008. Visits were coded for common respiratory and gastrointestinal illnesses. Using geographic information systems techniques, we plotted home addresses and developed criteria for census tract inclusion. The spatial distribution of the illnesses patterns was analyzed using Bayesian smoothing, Kriging and SaTScan (SaTScan, Boston, MA) statistical methods. Results: The study included 857,555 visits, 107,286 of which were in the emergency department and 750,269 in the primary care sites. Patient visits were plotted and then aggregated to census tracts. We determined that at least a median of 10 visits per week was required to provide sufficient volume in defining census tracts included in the study (109 census tracts). Weekly visit rates by census tract were plotted using nearest neighbor empirical Bayesian smoothing and Kriging to produce a continuous surface. To detect statistical clustering of weekly visit rates, we used SaTScan and identified 7 weeks with statistically significant clusters for respiratory illnesses and 8 weeks with statistically significant clusters for gastrointestinal illnesses (out of 56 weeks included in the study). After adjusting for population density, the visit rate remained consistent for respiratory illnesses (analysis of variance P = .937), but the visit rate for gastrointestinal illnesses increased in the fourth population density quartile (statistically different from quartiles 1, 2 and 3; analysis of variance P < .001 with Tukey multiple comparisons test), which included the highest population density areas in the study. Conclusions: We were able to use geographic information systems to assess visit rates for common illnesses in a defined community and identified spatial variability over time. Additional research is needed to help define parameters for implementation, but we believe this can have benefit for allocation of health resources and communicating with the community.
Davis A.M.,Family Medicine Residency Program |
Cannon M.,Family Medicine Residency Program |
Ables A.Z.,Family Medicine Residency Program |
Bendyk H.,Family Medicine Residency Program
Family Medicine | Year: 2010
Background and Objectives: Use of electronic medical records (EMRs) is being advocated to improve quality of care. The objectives of this study were (1) to determine the effect of EMR template use on family medicine residents' documentation of the severity classification of asthma and (2) to determine if documentation leads to appropriate treatment. Methods: We reviewed the charts of patients with asthma seen by residents in the Center for Family Medicine (CFM) between July 1, 2007, and December 31, 2007. Data gathered from each chart included disease severity classification, medication regimen, and use of the asthma template. In July 2008, efforts at increasing residents' knowledge of asthma severity classification and documentation via EMR were made. A post-intervention chart review was performed on patients with asthma seen by the residents between July 1, 2008, and December 31, 2008. Results: Documentation of asthma severity increased significantly from 24% in the pre- to 44% in the post-intervention phase. Use of the EMR template significantly increased the rate of inhaled corticosteroid prescriptions, from 36.7% to 71.1%. Conclusions: Use of an asthma template within the EMR improves documentation of asthma severity and appropriate treatment.
PubMed | Family Medicine Residency Program
Type: Journal Article | Journal: Family medicine | Year: 2014
The studys aim was to deepen our understanding of family physicians perceptions of the strengths and weaknesses of the widely used US documentation, coding, and billing rules for primary care evaluation and management (E/M) services.This study used in-depth, qualitative interviews of 32 family physicians in urban and rural, academic, and private practices. Interviews were initiated with a series of grand tour questions asking participants to give examples and personal narratives demonstrating cost efficiencies and cost inefficiencies relating to the E/M rules in their own practices. Investigators independently used an immersion-crystallization approach to analyze transcripts to search for unifying themes and subthemes until consensus among investigators was achieved.The majority of participants reported that the documentation rules, coding rules, and common fees for procedures and preventive services were reasonable. The E/M documentation rules for all other visit types, however, were perceived by the participants as unnecessarily complicated and unclear. The existing codes did not describe the actual work for common clinic visits, which led to documenting and coding by heuristics and patterns. Participants reported inadequate payment for complex patients, multiple patient concerns in a single office visit, services requiring extra time beyond a standard office visit, non-face-to-face time, and others. The E/M rules created unintended negative consequences such as family physicians not accepting Medicare or Medicaid patients, inaccurate documentation, poor-quality care, and system inefficiencies such as unnecessary tests and referrals.Family physicians expressed many problems and frustrations with the existing E/M documentation, coding, and billing rules and felt the system undervalued and unappreciated them for the complex and comprehensive care they provide. Findings of this study could inform improved guidelines for primary care documentation, coding, and billing.
PubMed | Family Medicine Residency Program
Type: Journal Article | Journal: Family medicine | Year: 2014
The studys aim was to ascertain family physicians suggestions on how to improve the commonly used US evaluation and management (E/M) rules for primary care.A companion paper published in Family Medicines May 2014 journal describes our study methods (Fam Med 2014;46(5):378-84).Study subjects supported preserving the overall SOAP note structure. They especially suggested eliminating bullet counting in the E/M rules. For payment reform, respondents stated that brief or simple work should be paid less than long or complex work, and that family physicians should be paid for important tasks they currently are not, such as spending extra time with patients, phone and email clinical encounters, and extra paperwork. Subjects wanted shared savings when their decisions and actions created system efficiencies and savings. Some supported recent payment reforms such as monthly retainer fees and pay-for-performance bonuses. Others expressed skepticism about the negative consequences of each. Aligned incentives among all stakeholders was another common theme.Family physicians wanted less burdensome documentation requirements. They wanted to be paid more for complex work and work that does not include traditional face-to-face clinic visits, and they wanted the incentives of other stakeholders in the health care systems to be aligned with their priorities.