The EMPSF Newsletter
The Newsletter for Members of the Emergency Medicine Patient Safety Foundation
Autumn 2006
www.empsf.org

Mission Statement: The Emergency Medicine Patient Safety Foundation (EMPSF) is dedicated to improving patient safety in America’s emergency departments (ED).

In This Issue:
Chairman’s Update
Heart Disease: Not Just for Men Only
Clinical Alerts
Patient Advocacy
EMPSF-SAEM Research Fellowship Grant
2006 Stuart Fleming Patient Safety Award
Board of Directors
How to Join

Chairman's Update
Graham Billingham, MD, FACEP

2006 has been a busy year for EMPSF!  It is my pleasure to announce that we received a definitive ruling from the IRS approving EMPSF as a 501(c)(3) public benefit charity.  We have since been moving full steam ahead to develop partnerships and seek funding for our patient safety intiatives.

EMPSF is funding a $75,000 grant for the 2007-2008 Emergency Medicine Patient Safety Research Fellowship in collaboration with the Society of Academic Emergency Medicine (SAEM).  This is an exciting new opportunity for those emergency physicians seeking to advance patient safety in emergency medicine and impact their practice organizations.  We are pleased to have SAEM as our partner on this important project and hope to make it a sustainable and ongoing annual Fellowship Program. Please see specific information about this Award in the body of the newsletter. 

Please join me in welcoming our two newest members to the EMPSF Board of Directors. Sue Dill Calloway, RN, MSN, JD is currently the Director of Hospital Risk Management of the OHIC Insurance Company and has over 25 years of experience as a nurse, attorney, and medico-legal consultant.  Sue is a highly accomplished national speaker and has authored over 60 books. Michelle Hoppes, RN, MS, AHRMQR, DFASHRM is the President & CEO of Patient Safety & Risk Solutions.  She is a nationally recognized expert in risk management, patient safety and performance improvement and has over 27 years experience in the health care industry.  She has served as president of a national risk management consulting company, has completed the AHA/ASHRM leadership program as a patient safety fellow and is currently serving as a Board member for ASHRM. 

The Annual Stuart Fleming Patient Safety Award, recognizing the Emergency Physicians Insurance Company (EPIC) ED group that has demonstrated an outstanding commitment to patient safety, will be given to the 2006 recipient at the EPIC/EMPSF reception to be held at the ACEP Scientific Assembly in New Orleans.

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Heart Disease: Not Just for Men Only

It’s time to dispel some common myths about women and cardiovascular disease (CVD). Did you know that CVD (including coronary heart disease, stroke, and other CVDs) is the leading cause of death in American women, accounting for 39 percent of deaths, beating out all forms of cancer combined?[1] In 1999, females accounted for 53.5% of all deaths from CVD.[2] And it is not just an older women’s problem. While it is true that coronary heart disease (CHD) is the leading cause of death among women age 65 and older, it is also the third leading cause of death among women 25 – 44 years old, and second among women ages 45 – 64.[3]

According to a June 2006 report from the Agency for Healthcare Research and Quality[4], half the women who had a first heart attack had heart disease that was undiagnosed. These women tended to be younger than age 55 or women of color. And they reported shortness of breath as their chief symptom.

We have been educated to think that CHD is only of concern to older women and to primarily recognize symptoms that are “typical” for men. Because women don’t consider heart disease a threat or because their symptoms are “atypical,” when experiencing symptoms of CHD – both early and acute – they have a tendency to delay seeking treatment or to report potential diagnostic clues to their physician.

When delays occur in seeking or receiving treatment for CVD, more damage to the heart muscle may occur. This has an adverse effect on post-heart attack outcomes. Indeed, 42 percent of women die within one year of a heart attack, compared to 24 percent of men.[4] And, women are more likely to have a second heart attack within six years of their first.[2]

Risk Factors
The National Women’s Health Information Center provides the following list of risk factors for CHD[2]:

• Smoke or use tobacco products
• Have diabetes
• Have high blood pressure
• Have high cholesterol, including a high LDL (bad cholesterol), low HDL (good cholesterol) or high triglyceride levels
• Have a sedentary lifestyle, or get little physical activity
• Are overweight
• Have a family history of heart disease
• Had early menopause (before age 40)
• Already had a heart attack
• Have high levels of stress or feeling little control over your environment

Warning Signs
A 2003 study[5] of women who had suffered a heart attack found that many of the participants had early symptoms that might have been useful as predictive clues. And the researchers speculate that these may be female-specific warning signs. The symptoms were experienced one month or more prior to the heart attack, either daily or several times a week.

The most frequent early warning signs were:

1. Unusual fatigue (70.7%)
2. Sleep disturbance (47.8%)
3. Shortness of breath (42.1%)
4. Indigestion (39.4%)
5. Anxiety (35.5%)

Only 29.7 percent identified chest discomfort as an early symptom, which they described as aching, tightness, pressure, sharpness, burning, fullness, and tingling.

The most common symptoms experienced during a heart attack were:

1. Shortness of breath(57.9%)
2. Weakness (54.8%)
3. Unusual fatigue (42.9%)
4. Cold sweat (39%)
5. Dizziness (39%)
6. Discomfort in the back (37%) and high chest (27.7%)

Chest discomfort/pain has long been thought to be the hallmark symptom of heart attack. However, 43 percent of the women interviewed reported no chest discomfort at all.

Act Quickly
Some treatments, such as “clot busting” drugs and balloon angioplasty are most effective during the first hour of a heart attack. Use of these treatments can greatly reduce damage to the heart muscle, improving survival rates and quality of life after a heart attack. Seek medical attention quickly if you suspect you are having a heart attack.

Women must start paying attention to cardiac health, learn the early warning signs of CVD, and recognize the symptoms of heart attack. Talk with your doctor. Know the risk factors associated with developing cardiovascular disease, and begin to take steps now to reduce your risk.
 
To Learn More
Agency for Healthcare Research and Quality, www.ahrq.gov
American Heart Association, www.americanheart.org
Centers for Disease Control and Prevention, www.cdc.gov/DHDSP
Heart Healthy Women, www.hearthealthywomen.org
National Women’s Health Information Center, www.4women.gov
National Heart, Lung and Blood Institute (NHLBI), www.nhlbi.nih.gov/actintime
WomenHeart: The National Coalition for Women with Heart Disease, www.womenheart.org

Resources

1. American Heart Association. Facts about women and cardiovascular disease. Available at: http://www.americanheart.org/presenter.jhtml?identifier=2876. Accessed October 9, 2006.
2. The National Women’s Health Information Center. Women: warning! it could be a heart attack! Available at: http://www.4woman.gov/OWH/pub/factsheets/heartattack.htm. Accessed October 9, 2006.
3. Centers for Disease Control and Prevention: Division for Heart Disease and Stroke Prevention. Women and heart disease fact sheet. Available at: http://www.cdc.gov/DHDSP/library/fs_women_heart.htm. Accessed October 10, 2006.
4. Agency for Healthcare Research and Quality. Research on cardiovascular disease in women. Available at: http://www.ahrq.gov/research/womheart.htm. 2006: Publication No. 06-P016. Accessed October 10, 2006.
5. McSweeney, JC, Cody, M, OSullivan, P, et a., Women’s early warning symptoms of acute myocardial infarction, Circulation. 2003; Available at: http://circ.ahajournals.org/cgi/reprint/01.CIR.0000097116.29625.7Cv1.pdf. Accessed October 9, 2006.

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Clinical Alerts

Detecting Cardiac Ischemia in Women
Prepared by Graham Billingham, MD, FACEP
EMPSF Formation Chairman

Recent claims experience mandates that we increase our awareness of this fatal disease

• Young patients (35-45) have this disease
• Careful history of cardiac risk factors – particularly diabetes, smoking and menopause
• Must ignore gender bias in considering differential diagnosis
• 1:5 have some form of cardiovascular disease
• Frequently present with shortness of breath, nausea, back pain, abdominal pain and/or jaw pain
• Kills more woman then men each year
• Current recommendations for the treatment and diagnosis of heart disease are based on studies conducted primarily on white, middle-aged men.
• After a heart attack, women are more likely to die in the hospital than men.
• Heart disease is the leading cause of death among women, killing six times more women than breast cancer.
• Cannot rule out on the basis of one EKG, one enzyme or GI cocktail
• Studies indicate outpatient stress testing should be done within 48 hours

State by State Disclosure Laws
Prepared by Michelle Hoppes, RN, MA,AMRSQ, DFASHRM
President & CEO, Patient Safety Risk Solutions

A recent article published by ASHRM shows State by State Disclosure Laws. If you are licensed in one of these states you should be aware of these laws. States listed in blue have a link to the verbiage. Click on the link below and then click on the name of a state (in blue) to see the actual law in that state.
http://www.ashrm.org/ashrm/resources/disclosurelaws.html

States with Mandatory Notification of Adverse Events to Patients (EPIC Group States only)

Nevada NRS §439.855 (2004)

States with Use of Sympathy/Apology
29 states have enacted laws excluding expressions of sympathy after accidents as proof of liability:

Arizona A.R.S. §12-2605 (2005)
Illinois Public Act 094-0677 Sec. 8-1901 (2005)
Missouri HB 393 (2005) §
Ohio  ORC Ann §2317.43 (2004)
South Carolina Ch.1, Title19 Code of Laws 1976, 19-1-190  (2006)
Texas Civil Prac and Rem Code §18.061(1999)
Washington  Rev Code Wash §5.66.010 (2002)
 
Prevention Works!
Prepared by Graham Billingham, MD, FACEP
EMPSF Formation Chairman
Prevention works!!  I was recently contacted by EPIC leaders regarding cases they nearly missed.  I was asked to share them with you.

Case #1
Post Partum Patient. A 19 yr old female presented to the ED with fever and vomiting.  She had slight diarrhea, complains of dysuria and frontal headache. Denies back pain, lightheadedness, dizziness, cough, sore throat or chest pain.  She was 6 days post delivery by c/s.  The pt had a B/P of 190/110.  She had bacteria and WBC’s in her urine. The pt was treated with antibiotics and discharged.  She returned to the ED via ambulance about 12 hours later with grandmal seizures. 

Lessons learned:

• Consider eclampsia for post partum pts up to 23 days post delivery ( this is rare, but reported)
• 20-25% of eclampsia cases occur in post-partum pts
• The disease is most common in mothers under the age of 20, or over the age of 35. African-American women have higher rates of preeclampsia than do Caucasian women. Other risk factors include poverty, multiple pregnancies (twins, triplets, etc.), pre-existing chronic hypertension, diabetes and renal disease.
• Symptoms to be knowledgeable of are:
• Headache (82.5%)
• Hyperactive reflexes (80%)
• Marked proteinuria (52%)
• Generalized edema (49%)
• Visual disturbances (44.4%)
• Right upper quadrant pain or epigastric pain (19%)

• Prior to a seizure, some patients may present with the following:
•  Lack of edema (39%)
• Absence of proteinuria (21%)
• Normal reflexes (20%)
• An increase in blood pressure, 30 mm Hg in the systolic pressure, or 15 mm Hg in the diastolic pressure, or a blood pressure reading greater than 140/90 mm Hg is considered indicative of eclampsia
• If the diastolic blood pressure is over 100 mm Hg, or if other symptoms like headache, vision problems, abdominal pain, or blood abnormalities develop, then the patient may require medications to prevent seizures. Magnesium sulfate is the most common drug given. Medications that lower blood pressure are reserved for patients with very high diastolic pressures (over 110 mm Hg)

Sources: Web MD and Gale Encyclopedia of Medicine, Published December, 2002 by the Gale Group

Case #2
Young female patient presented with an injury water skiing 2 days ago and came in with vague paresthesias around the rectum but good tone on examination.  Based on the mechanism of injury and the complaint, a stat MRI was ordered.  The test showed L5-S1 herniation with total occlusion of the spinal canal.  Physician commented “These cases seem to be coming out of the wood work suddenly or else we just didn't look close enough.”

Lessons learned:

• Importance of documenting mechanism of injury in all trauma patients
• Any complaints of numbness or paresthesia should be taken seriously and should be followed by a detailed examination
• May present with bladder or bowel dysfunction – either incontinence or retention/constipation
• Stat MRI is the study of choice to make the diagnosis of cauda equina syndrome
• Young patients have real disease, don’t discount the age factor
• This is a true surgical emergency – morbidity and outcome directly correlate to length of time for decompression

Case # 3
Young female presented with right upper quadrant pain and nausea.  Patient was worked up for biliary disease with labs which were normal.  Bedside ultrasound revealed possibility of sludge.  Final ultrasound was normal.  On repeat exam, patient did have cardiac risk factors and had an indeterminate EKG.  Despite cardiologist objections, patient was admitted for further work up.

Lessons learned:

• Consider cardiac disease in young women
• Cardiac ischemia may present with RUQ or upper abdominal pain
• If your primary diagnosis has a negative w/u re-evaluate the patients and reconsider the differential
• Stick to your guns, despite what the consultant says

• Meningitis claims resulted in the highest indemnity payment—with an average  payment of $443,000
• Missed MI’s resulted in indemnity payments 55% of the time
• Other claims issues—improper procedures, procedures not performed and failure to supervise or monitor a case

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Patient Advocacy

More than one in three Americans visited an emergency department in 2004, an increase of 18 percent in 10 years. During that same time period, the number of hospial EDs decreased by 12.4 percent.[1] We have all heard that the emergency care system in the United States is in crisis. The June 2006 Institute of Medicine three-part report, The Future of Emergency Care, cites several key issues, including overcrowding in emergency departments, lack of available specialists, lack of pediatric services, and a fragmented emergency medical services delivery system.[2] Given the trend, it seems clear that patients must make an effort to become better informed, better prepared, and better participants in their own care.

Be Informed

• Get to know your local emergency departments. What level of care are they equipped to provide? Level I and Level II trauma centers have the capability to offer comprehensive services, including access to trauma surgeons and other specialists. Level III and Level IV trauma centers have more limited facilities and may need to transfer more seriously injured patients to a higher level center.
• Does your local emergency department have pediatric care facilities and specialists? Is there one nearby that does?

Learn How to Recognize an Emergency
The American College of Emergency Physicians has posted this list of emergency warning signs.[3]

• Difficulty breathing, shortness of breath
• Chest or upper abdominal pain or pressure
• Fainting, sudden dizziness, weakness
• Changes in vision
• Confusion or changes in mental status
• Any sudden or severe pain
• Uncontrolled bleeding
• Severe or persistent vomiting or diarrhea
• Coughing or vomiting blood
• Suicidal feelings
• Difficulty speaking

Be Prepared

• Keep a personal medical history form in your wallet, including a list of medications, allergies. If you are unconscious or unable to speak, this will assist the emergency team in giving you timely care.
• Keep names and phone numbers of people to contact in case of emergency.
• If you have an existing medical condition, use medical identification jewelry.
• Program “ICE” (in case of emergency) contacts into your cell phone.
• Keep first aid kits at home, at work, and in your car.
• Know when to dial 9-1-1. Note that calls from cell phones to 9-1-1 are not automatically located, so it is important that you be ready to identify the location of the emergency.
• Take a first aid class. Knowing what to do in the first few minutes of an emergency can save a life.

For More Information
American College of Emergency Physicians: www.acep.org/webportal/PatientsConsumers/
Institute of Medicine: www.iom.edu/CMS/3809/16107/35007.aspx
American Red Cross: www.redcross.org

Resources

1. McCaig, LF, Nawar, EW. National hospital ambulatory medical care survey: 2004 emergency department summary. Advance Data No. 372. 2006. Available at: http://www.cdc.gov/nchs/data/ad/ad372.pdf. Accessed October 10, 2006.
2. Committee on the Future of Emergency Care in the United States Health System. The future of emergency care: key findings and recommendations. 2006. Available at: http://www.iom.edu/CMS/3809/16107/35007/35040.aspx. Accessed October 10, 2006.
3. American College of Emergency Physicians. When should I go to the emergency department? Available at: http://www.acep.org/webportal/PatientsConsumers/HealthSubjects ByTopic/emcare /whentogotoed.htm. Accessed October 12, 2006

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New Emergency Medicine Patient Safety Research Fellowship Award Available

The Emergency Medicine Patient Safety Foundation (EMPSF) has developed and will sponsor, in collaboration with SAEM, a one year Patient Safety Research Fellowship focused on emergency medicine.  The primary goal of the program is to conduct original research that leads to the improvement of patient care through patient safety initiatives in the emergency department. The award provides up to $75,000 funding for a one-year research fellowship in the area of patient safety.

The Emergency Medicine Patient Safety Foundation (EMPSF) is an 1100 member non-profit organization whose mission is to improve patient safety in emergency medicine through analyzing risk in the ED, education, and research. EMPSF was formed in July of 2003 and is funded through membership fees, sponsorship fees, charitable donations, and grants.

The Fellowship will be offered to senior residents and junior faculty who are board eligible or board certified in the field of emergency medicine. The fellow will be required to have a mentored experience in a supportive research environment and complete a scientific project.

Specific project examples could include research of existing medical malpractice claims data, development of risk reduction and prevention tools, development of emergency medicine protocols and guidelines, or improving pediatric care in the emergency department.

EMPSF intends to model the Patient Safety Research Fellowship after SAEM’s existing successful research fellowship programs. SAEM will have responsibility for administering the grant including the intake and review of applications, selection of the recipient, and program monitoring.

For this academic year, application deadline will be January 30, 2007. Selection of the recipient will occur by March 31, 2007.  If a qualified application is received, the award will begin July 2007.  In future academic years, the award will be on the same cycle as other SAEM research fellowship awards.

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2006 Stuart Fleming Patient Safety Award

EMPSF presented the 2006 Annual Stuart Fleming Patient Safety Award to Stark County Emergency Physicians of Canton, Ohio on October 15, 2006. The award was accepted by Stark County’s medical director, Dr. Frank Kaeberlein, at a reception in New Orleans during the American College of Emergency Physicians Annual Scientific Assembly. Stark County Emergency Physicians also received $10,000 from their insurer, the Emergency Physicians Insurance Company Risk Retention Group (EPIC), as part of the award.

EPIC policyholders are required to join EMPSF as part of their commitment to patient safety. Stark County Emergency Physicians’ award-winning patient safety improvements were accomplished through collaboration and compliance with their EPIC Risk Management and Patient Safety Program.

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EMPSF Board of Directors

Graham T. Billingham, MD, FACEP Formation Chairman
CMO, NCG Enterprises LLC

Robert A. Bitterman, MD, JD, FACEP
Health Care Law Practice

Sue Dill Calloway, RN, MSN, JD
Director of Hospital Risk Management OHIC Insurancy Company

Michael J. Gerardi, MD, FACEP
President, Superior Insurance Company, RRG

Michelle Hoppes, RN, MS, AHRMQR, DFASHRM
President & CEO, Patient Safety & Risk Solutions LLC

John  A. Marx, MD, FACEP
Carolinas Medical Center

Miles A. McGrane, III, Esq.
President, McGrane & Nosich, PA

Bartholomew G. Nyhan, MBA, CLU
President & CEO, NCG Enterprises LLC

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How to Join

Membership

To become a member of EMPSF, contact empsf@empsf.org.

Individual Membership
Emergency Physician - $250
Medical Student/Resident - $125
Nurse/Health Care Provider - $125
Individual (non-physician) - $ 50

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The EMPSF Newsletter

The EMPSF Newsletter is published quarterly by the Emergency Medicine Patient Safety Foundation (EMPSF) for its members. Letters to the editor and articles, to be edited and published at the editor’s discretion, are welcome. Views expressed in letters to the editor are those of the writer and do not necessarily reflect the opinion or official policy of EMPSF. Please sign letters and address them to the editor or send them via email to editor@empsf.org.

Publisher: Emergency Medicine Patient Safety Foundation
Editor: Dianne Vass
Managing Editor: Shawn Mountcastle
Web Master: Jason Fontaine

The Emergency Medicine Patient Safety Foundation (EMPSF) publishes The EMPSF Newsletter to inform EMPSF members on issues pertinent to emergency medicine and professional liability insurance. Any recommendations found in the newsletter are intended as guidelines, not standards of care, and do not ensure successful outcomes. Any guidelines address principles of the practice of emergency medicine, and are not inclusive of all proper methods of care nor exclusive of other appropriate methods. Treatment decisions must be made by individual health care providers within the context of specific situations and in accordance with the laws of the jurisdiction in which the care is provided.

© 2006 Emergency Medicine Patient Safety Foundation. All rights reserved.

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