Emergency

Sheridan Emergency Medicine was created in 1994, and we treat more than 600,000 patients annually.

We transition weak emergency department programs into strong programs that meet our client’s throughput reporting metrics. Our devotion to patients gives us high marks in patient satisfaction, low patient wait times and outstanding national quality measures compliance.

Sheridan’s Seamless Emergency Department Transition

  • Ensures quality care and productivity, and that providers are directly accountable for their performance.
  • Our on-site clinical and operations teams offer tangible solutions to department leadership and management issues, including billing and revenue cycles.
  • Our programs focus on lean enterprise, peer review, PQRS, leadership and risk occurrence define best practices and process improvements.
  • Offers flexible, scalable solutions and dedicated recruitment for the best EM staff results in stable, longstanding programs for any facility.

Learn more about our emergency medical solutions.

Read our emergency medicine related posts:

17 May2017

Grateful Patients, Families Help Emergency Physicians Cope with Burnout

The physician burnout epidemic in the United States continues to worsen. Alarmingly, according to the new Medscape Lifestyle Report 2017: Race and Ethnicity, Bias and Burnout, Emergency medicine now has a burnout rate of nearly 60 percent—the highest of any medical specialty.

Most physicians enter the medical profession because the work is meaningful and gives them a sense of purpose. According to a recent article in NEJM Catalyst, “burnout becomes epidemic” when physicians’ frustration with the current healthcare system’s “demands, limitations, and inconsistencies” impede their efforts to deliver excellent care. 

A survey discussed in a recent Mayo Clinic Proceedings article found that “physicians who experience more burnout are less likely to identify with medicine as a calling,” and that when a doctor’s sense that medicine is his or her calling is eroded, it can negatively impact both the physician and patients.

Benjamin Thomas, M.D., an Emergency medicine resident at Highland Hospital in Oakland, California, recently wrote about another contributor to burnout: feelings of failure when things go wrong with patients. In a recent article in ACEP Now, Dr. Thomas explained that, as an intern, he had believed that burnout only affected physicians who had been in practice for a very long time. But that belief changed dramatically the first time a patient under his care died and he had to break the news to her family, including her young daughter. “Leaving the hospital that night, I questioned whether I was meant to do this and began to understand that burnout was a real phenomenon,” he remembered. Every subsequent bad outcome exacerbated those negative feelings and self-doubt and chipped away at his empathy and compassion. 

He had an epiphany several months later, when he saw the brother of that first patient who had passed away in the emergency department. Instead of the criticism or contempt that Dr. Thomas had been expecting, the brother expressed his gratitude for the physician’s care and his efforts to save his sister. For the doctor, whose feelings of having failed her were still raw, her brother’s words were like a balm. Dr. Thomas began to realize that his focus on negative outcomes during the prior few months had made him lose sight of “the overwhelmingly positive things that manifest on a daily basis.” From that point forward, he “began to accept the gratitude for the simple laceration repair or basic shoulder reduction.”

He cautioned Emergency medicine physicians that “ignoring the reality of burnout” is a setup for failure and encouraged them to focus on appreciating patients’ everyday expressions of gratitude to help restore meaning, purpose, and personal satisfaction to the practice of medicine.   

28 March2017

Northside Team Saves Mother, Baby in Complicated Delivery

Air Force major Jerry Gay and his pregnant wife, Mary, were looking forward to the expected February 9 arrival of their new daughter. Mary was at home in Georgia and Jerry was deployed in Qatar, in the Middle East. But the couple’s joy became tempered with fear when Mary’s ob-gyn, Dr. Alex Eaccarino, noticed a spot that didn’t look quite normal during Mary’s 30-week checkup, per a recent story on Fox 5 Atlanta

The spot turned out to be uterine scarring from Mary’s prior cesarean-section deliveries. The scarring increased her risk for a placenta accreta, a potentially life-threatening obstetric condition that occurs when part or all of the placenta invades the uterine wall and is inseparable from it, preventing the placenta from detaching as it should during birth. "The biggest risk factor to the mom would be the risk of post-partum hemorrhage or uncontrollable bleeding," Dr. Eaccarino told Fox 5 Atlanta. Mary was told that she would need a C-section and that it was likely she also would need a hysterectomy to remove all or part of her uterus. Jerry immediately rushed home from the Middle East on emergency leave and was with Mary at Northside Hospital’s Forsyth campus on January 4 for her surgery.

Mary’s three surgeons and the anesthesia team from Sheridan practice Northside Anesthesiology Consultants (NAC) were extremely experienced in dealing with this type of complicated, high-risk delivery. Northside has the busiest obstetric practice in the country, delivering more than 25,000 babies and performing roughly 7,000–8,000 C-sections each year, according to John Kimbell, CAA, MMSC, NAC’s administrative chief anesthetist. 

Anticipating the possibility of hemorrhage, the anesthesia team placed invasive monitoring lines pre-operatively, and a large supply of blood products had already been cross-matched and were available, if needed—preparations that helped saved Mary’s and her unborn daughter’s lives.

The C-section went better than expected, with minimal bleeding, and it appeared that the placenta accreta was not as extensive as the surgeons had originally thought, Dr. Eaccarino told Fox 5. At that point, he said, they agreed it would be best to preserve Mary’s uterus and decided against performing a hysterectomy. Jerry told the reporter that while he was in the NICU with newborn daughter Sinclair, he was ecstatic to receive a call from Mary's surgical nurse, who told him that she was doing well and was being moved to the recovery area.

Unfortunately, this best-case scenario didn’t last long. When Mary woke up from the anesthesia, she was in severe pain and her nurse quickly realized Mary was bleeding excessively. The nurse "got my doctor back in there really quickly and the anesthesiologist back into the OR,” she recalled to the reporter. By then, Mary was hemorrhaging and needed more than 30 units of blood to replace the blood she was losing.

The anesthesia team, which included Stephen Grice, MD, Jeff Mims, CAA, Jeff Thomas, CAA and Patty Flaherty, CAA, among others, activated its Massive Transfusion Protocol that allows quick coordination with the blood bank and enables predetermined packages of different blood products to be delivered quickly and constantly. Thanks to that team’s prior preparations and the Massive Transfusion Protocol, the surgeons were able to stop the bleeding and remove part of Mary's uterus. Jerry told Fox 5 that it "the longest hour and a half of my life." 

When Mary woke up in the ICU, on a ventilator, she immediately asked to see her baby, Sinclair. "I don't think you can go through things like that and have it not change you,” she told the reporter. “I appreciate things a lot more."

In their interview with Fox 5 Atlanta, Mary and Jerry expressed their gratitude for Dr. Eaccarino and the entire Northside team, whose skill and alertness helped save both Mary’s and Sinclair’s lives, and for the dozens of strangers whose blood donations helped make the life-saving surgery possible.

16 March2017

New FDA-Approved Drug Proven Effective in Reducing Recurrent C. diff Infections

Among the healthcare associated infections that may arise during a patient’s hospitalization, Clostridium difficile is an especially dangerous ailment due to its easy dissemination and antibiotic resistance. Transmission may occur if medical staff touch surfaces contaminated with feces during and between treatment of patients. The few available antibiotics that can be used to treat the initial infection do not prevent its recurrence in about 20 percent of those affected. To improve the efficacy of current standard-of-care antibiotic treatments, the healthcare community has long sought after an antibiotic that will further reduce the rate of C. diff infection recurrence. According to a study published in the January 2017 New England Journal of Medicine, researchers seem to have found an antibiotic capable of treating recurrent C. diff.

In two extensive, double-blind trials conducted between 2011 and 2015, researchers tested the effects of actoxumab and bezlotoxumab on 2,655 patients receiving standard-of-care antibiotic treatments for their C. diff infections. Actoxumab and bezlotoxumab are human monoclonal antibodies designed to bind to and neutralize C. diff toxins A and B, respectively, thereby preventing infection recurrence. In separate studies known as MODIFY I and MODIFY II, patients were given antibiotic treatments that fell into four test groups: actoxumab-only, bezlotoxumab-only, both actoxumab and bezlotoxumab and a placebo.

At the end of each 12-week study, researchers found that C. diff infection recurred significantly less frequently in patients who received bezlotoxumab alone or both actoxumab and bezlotoxumab when compared with the placebo. In MODIFY I, the rate of recurrence was 17 percent under bezlotoxumab alone and 16 percent under the combined treatment, while recurrence under placebo was 26 percent. MODIFY II showed nearly identical results with 16 percent recurrence under bezlotoxumab, 15 percent under both antibiotics and 26 percent under placebo. 

To confirm that bezlotoxumab was the cause of reduction in infection recurrence, during MODIFY I, researchers compared results of the actoxumab-only group and the placebo group. Patients in these groups demonstrated similarly high recurrence rates of 26 percent and 28 percent. When researchers supplemented patients’ antibiotic treatments with actoxumab, they found high rates of adverse effects such as diarrhea and nausea following frequent C. diff infections. Adverse effects occurred at 67 percent under actoxumab alone, 61 percent under bezlotoxumab alone, 58.6 percent under combined actoxumab and bezlotoxumab and 61.2 percent under placebo. 

Overall, researchers concluded that bezlotoxumab accounted for a significant 38 percent reduction in C. diff infection recurrence when combined with standard-of-care therapy. As a result of MODIFY I and MODIFY II, the U.S. Food and Drug Administration recently approved the use of bezlotoxumab for C. diff infection treatments. While further research is warranted, the findings are a promising development toward the potential eradication of this costly and debilitating healthcare concern.

9 March2017

NICU Clinical Trial Studies Probiotics Use to Prevent NEC

Sheridan Clinical Research is participating in a multicentered, randomized, double-blind clinical trial using an Investigational probiotic for the prevention of necrotizing enterocolitis (NEC) in premature infants. The research is sponsored by Sigma-Tau Pharmaceuticals, Inc.  Sheridan’s NICU Medical Director Mitchell Stern, MD, is the Principal Investigator for the Phase Ib/IIa trial being conducted at Plantation General Hospital in Plantation, Florida, to study the safety and efficacy of once-daily dosing of STP206 in premature very low birth weight (VLBW) and extremely low birth weight (ELBW) neonates to decrease the incidence of NEC.

NEC is the most common serious acquired disease of the gastrointestinal tract in preterm infants. The majority of NEC occurs in infants weighing less than 1500 g at birth. It affects the bowel of premature infants in the first few weeks of life and has been reported to occur in approximately 10 percent of VLBW infants, although the incidence varies among countries and neonatal centers. The mortality rate of VLBW infants with NEC is approximately 20 percent. In addition, infants with NEC often require surgical intervention, have an increased rate of complications related to total parenteral nutrition (TPN) and require extended hospitalizations. In a study by National Institute of Child Health and Human Development Network (NICHD) published in JAMA in 2004, researchers also found an increase in neurodevelopmental impairment rates among infants with NEC and sepsis.

A 2010 analysis of previous clinical trials, published in Evidence-Based Child Health, found that the use of probiotics, dietary supplements containing potentially beneficial bacteria or yeast, reduces the occurrence of NEC and death in VLBW premature infants, but that there was insufficient data on the benefits and potential adverse effects in ELBW neonates.

The four-year Phase Ib/IIa clinical trial is intended primarily to assess the safety and tolerability of once-daily dosing of two dose levels of an investigational probiotic versus control in four different birth weight strata in premature neonates. Plantation General Hospital’s NICU has historically been involved in multiple trials with Dr. Stern as the Principal Investigator. For the current probiotic trial, Dr. Stern has had the highest enrollment for cohort 3b, which closed in May 2016, and was one of the highest enrollers for newly closed cohort 4a.

As Jessy Tharakan, NNP, knows very well, obtaining informed consent for clinical trials in the NICU setting is particularly challenging, because the patient population is both delicate and vulnerable. As the authors of the 2014 Pediatrics Perspectives article “Honesty, Trust and Respect During Consent Discussions in Neonatal Clinical Trials” wrote, “Participation in neonatal clinical trials is often viewed as risky, ethically challenging, burdensome for parents, and a favor that altruistic families are performing for future generations of babies.” But they pointed out that the consent process also can empower and reassure families, as long as certain conditions are met. For example, the investigators and clinicians must believe that the research is both safe and important and must agree that participation in the proposed research would be meaningful and safe for each prospective participant. And the research team should strive for an open, trusting relationship with the parents and enable them to make an informed decision about what is best for their baby, rather than focusing on getting the consent form signed. 

 

 

 

 

 

 

 

 

 

Kochuthresia (Jessy) Tharakan, NNP with Mitchell Stern, MD 

 

7 March2017

CDC Opioid Guideline App: A Valuable Prescribing Tool

Last March, the United States Centers for Disease Control and Prevention published the “CDC Guideline for Prescribing Opioids for Chronic Pain.” The document provides recommendations for appropriate prescribing of opioid pain relievers and other treatment options in order to improve pain management and patient safety. Recently, the agency launched the CDC Opioid Prescribing Guideline Mobile App to educate providers and inform clinical decision-making when prescribing opioids outside of active cancer treatment, palliative care and end-of-life care. This free mobile app puts the opioid prescribing guideline and other helpful content, tools and resources into prescribers’ palms at the point of care. 

The tab bar at the bottom of the screen lets providers access the main tools and content—Overview, Calculator, Guideline, Interviews and Glossary—with a single tap. A “hamburger menu” (three vertical bars) at the top left also provides access to the Resources section and About page. 

Overview

The brief overview emphasizes the rapid escalation of this country’s epidemic of opioid abuse and overdose deaths; acknowledges healthcare providers’ key role in protecting their patients and providing safe and effective pain management, as well as the “nuanced challenges of providing care;” and summarizes the goal of the app.

Calculator

The MME (Morphine Milligram Equivalent) calculator is one of the app’s most valuable tools. It allows prescribers to quickly calculate the morphine milligram equivalent of a patient’s total daily opioid dose.

The provider selects a drug from a drop-down list, manually enters or selects the dosage, depending on the drug, and then, in most cases, selects the amount from another drop-down list. The options for dosage and amount change automatically based on the drug. For example, if codeine is selected, the provider taps in the dosage in milligrams and then selects the number of tablets daily from a drop-down list. If fentanyl transdermal is selected, the provider selects from a drop-down list of dosage options in micrograms/hour and the amount defaults to one patch every three days.

The calculated MME/day is displayed immediately after the drug, dosage and amount are entered and/or selected. If multiple opioids are prescribed, they can be entered into the calculator in succession and it will display the total MME. If the MME total for one or more opioids exceeds the guideline’s recommendation, an alert icon appears along with a Guideline button that opens a pop-up window with a cautionary statement and a summary of the relevant guideline.

Guideline

This tab breaks out the CDC Guideline for Prescribing Opioids for Chronic Pain into the 12 Recommendations. A brief summary of each recommendation with key points and links to additional information make the essential information easy to access at the point of care. A Learn More button at the bottom of each summary page links to the complete guideline on the CDC website. 

Interviews

The Motivational Interviewing (MI) section provides an overview of this patient-centered approach to eliciting behavior change and guides prescribers through the MI framework “to help patients identify and change behaviors that place them at risk or prevent optimal chronic pain management.” Most notable are the interactive examples of patient and provider dialogue that allow providers to practice effective MI communication skills and develop confidence in both motivational interviewing and prescribing. 

Glossary

The Glossary defines terms such as drug abuse, drug misuse, opioid names, medication-assisted treatment (MAT), opioid use disorder and prescription drug monitoring programs (PDMPs).

Resources

The Resources section provides easy access to nearly two dozen relevant online resources:

The app is available for download on Google Play and Apple’s App Store for use on Android and iOS devices. Although accessing the full guideline and some of the other content and resources requires an internet connection, the MME calculator, the 12 key guideline summaries, the interactive Motivational Interviewing feature and the glossary are all accessible offline.

Douglas Maurer DO, MPH, FAAFP, an associate editor at iMedicalApps who recently reviewed the CDC Opioid Prescribing Guideline mobile app in MedPage Today, called it “a must have for anyone who prescribes opioids.”

2 March2017

ID Genomics IDs UTIs and Best Antibiotics in 25-45 Minutes

Urinary tract infections (UTIs) are one of the most common hospital-acquired infections in the U.S. UTIs can be quite painful, and since it usually it takes a lab about two to three days to identify the specific bacteria causing a patient’s infection, most doctors don’t want to wait that long to treat it. Instead, they make an educated guess as to which antibiotic to administer. Given that approximately 80 percent of UTIs are caused by E. coli bacteria, there’s a good chance the physician will choose an appropriate antibiotic. But that means that 20 percent of those patients may receive an ineffective or non-optimal antibiotic. And even if E. coli is the culprit, an increasing number of E. coli strains have become resistant to commonly used treatments, such as ciprofloxacin (e.g., Cipro). According to a recent Modern Healthcare article, E. coli strains are resistant to Cipro in about 30 percent of patients for whom it is prescribed. 

Startup company ID Genomics says its mission is “to guide antibiotic prescription choices correctly the first time by matching the infecting bug with the correct drug.” The company’s rapid diagnostic tool, CLoNeT, “assigns proprietary ‘barcodes’ to infecting bacteria by identifying a few fingerprint regions of bacterial DNA.” Once the bacteria have been identified, the “barcode” is matched against the company’s BactNeT microbial surveillance database of individual bacterial strains’ antibiotic resistance profiles to help the physician choose the most effective antibiotic to prescribe. 

That database is being compiled in partnership with a consortium of healthcare providers and with funding from a three-year, $3 million grant by the National Institutes of Health (NIH). The consortium members will help ID Genomics populate the database. Company founder Dr. Evengi Sokurenko said in the Modern Healthcare article, “It is like we are creating a criminal dossier of bacterial strains. Just based on the fingerprint we can already say what is the best way to deal with it and what antibiotics should be used.” The article also reports that CLoNeT is awaiting FDA approval for clinical use and the consortium members will help the company refine the technology, making the test data easier for physicians to understand “so they can analyze the results quickly and accurately” in clinical settings. 

According to ID Genomics, early-stage, urgent-care clinical trials conducted in partnership with GroupHealth Research Institute in Seattle, Washington, show that the first-generation CLoNeT diagnostic tests deliver results in 25-40 minutes and reduce the antibiotic prescription error rate for UTIs from 25 percent to less than 3 percent.

Although the first-generation tests target UTIs, the company says its unique barcoding approach “has broad applicability to diverse pathogens” and the potential to improve clinical outcomes for other diseases that face increasing antibiotic resistance. ID Genomics also asserts that its technology will help identify global infection outbreaks.

In a press release regarding the launch of the consortium, James R. Johnson, MD, Professor of Medicine at the University of Minnesota and an infectious diseases specialist at the VA Medical Center in Minneapolis, which is a member of the consortium, said, “The importance of having such a universal epidemiological surveillance resource linking bacterial DNA fingerprints with drug resistance profiles as part of point-of-care diagnostics can’t be overstated. With this novel approach, the global health community will have a powerful new tool to rapidly diagnose, treat and contain the spread of multidrug-resistant bacteria, and also to identify drug-susceptible strains that can be treated safely with traditional, inexpensive antibiotics.”

7 February2017

Grand Strand Medical Center Adds Neonatology Program

Grand Stand Medical Center in Myrtle Beach, South Carolina has launched a new neonatology program that has been in the works for about a year. The hospital is working to recruit two permanent, local neonatologists. Until those positions can be filled, neonatologists from other counties in South Carolina are working at the hospital, making Grand Stand Medical Center the only hospital in Horry County to have a neonatologist either in the hospital or on-call at all times.

Dr. Art Shepard, the Sheridan neonatologist who worked on staff at the hospital during the first week of the new program, told local ABC News affiliate WPDE that the hospital delivers about 1,000 babies a year, and that 8-10 percent of all babies need specialty neonatal care. “If babies need respiratory support or prolonged tube feeding, for example, because they're early those babies would ordinarily have to go to [a NICU in] Charleston or Florence, and so that's about a hundred babies a year that have to leave just for those reasons," Shepard said. Because Grand Strand has a level II nursery and not a NICU, he explained, some seriously ill babies will still need to be transported to either the Florence or Charleston NICUs.

"We can take care of babies as young as 32 weeks gestational, so about 8 weeks early, we can take babies that are as small as 1500 grams at birth, which is about 3 1/2 pounds, and we can maintain babies on mechanical ventilation for as long as 24 hours,” he continued. “If babies are smaller than that, less mature than that, or require more respiratory therapy than that, they still need to go to the regional perinatal center."

Both Shepard and OB/GYN Dr. Tracey Golden are excited that more babies will be able to be treated locally, near their mothers and families. "We are looking forward to the opportunity to keep those babies here. Keeping babies and moms together is so important. It's important to facilitate breast feeding, we want to encourage that. And keeping families together is the best way to get a family off to a healthy start," Shepard said. Golden added, "It's priceless, because unfortunately the NICUS are at least an hour and a half to two hours from this local region, and for many families that means they're taken away from their other children or their support network."

Emerald Rabon, who has a high-risk, complicated pregnancy, is comforted by the availability of a neonatologist at the hospital. “I'm going to be delivering really early, and she's going to be super small and not as developed, so that's even more scary," she told WPDE. After meeting with Dr. Shepard, she was reassured to learn that even if her baby girl arrives weeks early, there’s a good change she will be able to remain in Myrtle Beach. "You think of a pregnancy and the baby just pops out and they're doing great and mine is going to be hooked up to machine and tubes going in and out of her. It's scary," she said. 

31 January2017

Learning Health System (LHS) Pilot Saved Nationwide Children’s Hospital $1.36 Million in 12 Months

Researchers from Nationwide Children's Hospital and The Ohio State University (OSU) found that a learning health system (LHS) pilot program at Nationwide combining tailored electronic health records system entry, care coordinators and evidence-based clinical data and research reduced total inpatient days by 43%, reduced inpatient admission by 27%, reduced ER visits by 30% and reduced urgent care visits by 29% during the first year. Per a recent article in HealthLeaders Media, those reductions generated an impressive $1.36 million savings in health care costs during the 12-month period in 2010 and 2011.

The National Academy of Medicine’s Learning Health System Series defines a learning health system (LHS) as a system in which “science, informatics, incentives, and culture are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the delivery process and new knowledge captured as an integral by-product of the delivery experience.”

The findings by the team of Nationwide and OSU researchers were published by the journal Developmental Medicine and Child Neurology. The study authors said they “developed, implemented, and evaluated a model of EHR-supported care in a cohort of 131 children with cerebral palsy that integrated clinical care, quality improvement, and research, entitled ‘Learn From Every Patient’ (LFEP).“ A multidisciplinary team of key stakeholders was recruited for this pilot program, which was designed to fully integrate research, clinical care and quality improvement. 

The findings were also cited in an editorial published in JAMA, which said the LFEP pilot included initial standardized care for all patients, both evidence-and expert opinion-based; routine clinical data collected in the EHR as discrete data fields and data elements (categories and choices within those categories, respectively); physician-inspired research data collection in the EHR; content-specific quality control of EHR data entry; and provision of standard care coordination. Per the HealthLeaders Media article, special data entered into the patients' EHRs was used to coordinate care, with the goal of reducing treatment duplication and errors. LFEP data were extracted into an Epic Clarity enterprise data warehouse, which also housed billing information, and providers used clinical documentation templates created in Epic that presented them with a prioritized list of research questions designed to drive specific improvements in clinical care.
 
The HealthLeaders Media article also said the total cost of implementing the pilot program, including care coordination services, was about $225,000 during the first year; but since that represented only 16% of the reduced health care costs during that same year, the program yielded savings of roughly $6 for every $1 invested. And the study authors believe that similar programs could yield even greater potential healthcare system savings in adult patients, since the chronic conditions of the children with CP resemble those of chronic multi-symptom conditions in adults.
 
For hospitals and health systems considering investing in learning health systems, the National Academy of Medicine discussion paper “Generating Knowledge from Best Care: Advancing the Continuously Learning Health System” provides strategies and examples of operational and research collaborations within U.S. delivery system settings.

19 January2017

Integrating Telemedicine Responsibly

Providers and patients alike view telemedicine as an increasingly important healthcare delivery modality. Per a recent article in Medical Economics, “How to balance telemedicine advances with ethics,” the American Telemedicine Association (ATA) reports that more than half of all U.S. hospitals use some form of telemedicine; and IHS Technology predicts the number of patients using telehealth services will jump from fewer than 350,000 in 2013 to 7 million in 2018.

But this modality can also be challenging to implement responsibly.

Telehealth Benefits

The dramatic growth of telemedicine is driven by its ability to further the goals of the “quadruple aim” framework for value-based care.

More Efficient Care

The recent American Hospital Association (AHA) issue brief on telehealth cited several examples of significant telehealth-driven savings, including the Veterans Health Administration’s “nearly $1 billion in system-wide savings associated with the use of telehealth in 2012.” A major contributor was the dramatic decrease in hospitalizations.

In addition, doctors who offer telehealth services can spend more time caring for additional patients – time that otherwise would have been spent traveling between offices or facilities.

Better Outcomes

The AHA brief also describes the efficiencies and improved outcomes resulting from the innovative Hospital at Home (HaH) care model developed by Johns Hopkins researchers. HaH is being used effectively to provide hospital-level care at home in place of acute hospital care for older adults. Per the brief, “When a patient is treated at home, clinical staff travel to the home as needed to provide treatment, while telehealth is used to monitor the patient’s condition and enable daily meetings with the physician.” According to the program’s website, HaH patients experience better clinical outcomes, higher patient and family satisfaction, reduced caregiver stress and better functional outcomes compared to similar hospitalized patients.

Expanded Access to Care

Traveling to medical facilities can be a hardship for people who are physically challenged/housebound, live far from the nearest medical center or cannot afford to take time off from work. The ability to meet with a clinician remotely via a secure audiovisual device or application can mean the difference between those patients seeking – and getting – the care they need versus going without.

More Convenient Care

While it’s early days yet, “virtual visits” are beginning to be offered for more and more types of medical care. For example, St. Vincent Heart Center in Indianapolis is piloting a telecardiology program, per a recent article in Cardiovascular Business.

There is also increasing demand by health care consumers for “at home” virtual visits. A recent ATA-WEGO Health survey of active health care users found that consumers are very interested in using telehealth to complement (or even replace) their in-person care, primarily because of convenience. Other commonly cited reasons included scheduling conflicts and issues with transportation. 

Expanded Access to Specialized Clinical Expertise

Many small or rural hospitals often don’t have the budget or volume to support staffing a range of staff specialists or subspecialists. Even hospitals that have the budget may be in areas that make it difficult to recruit those types of physicians.

Dr. Lynn Palmeri, National Medical Director of Telehealth for Sheridan’s Women’s and Children’s Division, explains that telehealth carts can allow doctors at these facilities to consult remotely with specialists or subspecialists as needed. For example, an obstetrician may see an expectant mother with high-risk findings that require her to be referred out to see a perinatologist. Rather than having the mother drive three or four hours to the nearest perinatologist – potentially putting her and her baby at even greater risk – the obstetrician could have a remote telehealth consult with the subspecialist to determine whether the mother can be given appropriate care locally with the help of follow-up telehealth consults with the perinatologist.

Telemedicine is equally valuable in emergency medicine. Physicians in the adult emergency department (ED) at Jupiter Medical Center consult remotely with neurologists at the Cleveland Clinic using a telehealth cart approximately 10–30 times per month, most often to expedite implementation of tissue plasminogen activator (tPA) therapy for stroke patients.

Sophisticated telemedicine robots can allow remote specialists and subspecialists to perform much more in-depth examinations. Dr. Palmeri says “there are robots with sensors that can, for example, allow a neonatologist to remotely inspect a patient, auscultate bowel, breath and heart sounds, examine a neonate’s eyes for retinal findings, and even palpate to see if there is abdominal pathology or edema. These patient care modalities augment the in-person physical examinations by the nurse and neonatal nurse practitioner at the bedside.”

Radiology’s many subspecialties make it a prime candidate for expanding access to highly specialized clinical expertise remotely while also increasing efficiency. For example, Sheridan’s distributed teleradiology network includes hundreds of the country’s best radiology subspecialists who can provide hospitals of any size with affordable, 24/7/365 coverage and faster turnaround times for final reads. 

Challenges to Responsible Implementation

The promise of telemedicine is exciting, and pertinent logistical and quality matters will be ensured prior to its implementation and expansion.

Protecting Patient Privacy

Maintaining patient confidentiality is a cornerstone of ethical medical practice. Telemedicine systems will be HIPAA-compliant and hospitals must make data security a top criterion when selecting robot cart and software options.

Maintaining Care Quality

The same standards of care must be maintained regardless of the delivery modality, and that’s a key challenge of telemedicine. The American Medical Association (AMA) released its Guidance for Ethical Practice in Telemedicine in June. In the policy announcement, AMA Board Member Jack Resneck, M.D. said, "Telehealth and telemedicine are another stage in the ongoing evolution of new models for the delivery of care and patient-physician interactions. The new AMA ethical guidance notes that while new technologies and new models of care will continue to emerge, physicians' fundamental ethical responsibilities do not change.” The AMA also released its Principles to Promote Safe, Effective mHealth Applications in November. 

Telemedicine can make continuity of care challenging, especially when patients seek care from doctors who are not affiliated with their primary care physicians or who use different EHRs. But in some situations telehealth can improve care continuity. “In a pediatric unit, for example, an attending physician might see the baby during morning rounds, but by the time the parents can come to the hospital that evening after work that physician’s shift may have ended and the parents may not speak directly to that same doctor,” explains Dr. Palmeri. “Telemedicine has the potential to overcome those types of scheduling conflicts so that parents can speak with the doctor ‘face-to-face’ through the telemedicine robot screen whenever needed.”

Telehealth will play an increasingly important role in care delivery and physicians will carefully adopt remote care technology in a manner that ensures patient safety and privacy.

17 January2017

Study Identifies Risk Factors for Congenital Heart Disease in Infants

A study in the Canadian Medical Association Journal identified the chronic conditions that may predispose women to give birth to infants with congenital heart disease, also known as congenital heart defects or CHD.

The study reviewed the Taiwan Maternal and Child Health Database’s records of 1,387,650 live births from 2004 to 2010. The researchers investigated three data sets including:

  • Birth Registrations data on the sociodemographic characteristics of live births
  • Birth Notifications data on prenatal care and the lifestyles of pregnant women
  • Medical claims data from Taiwan’s National Health Insurance program

The researchers found that several maternal chronic diseases were associated with higher rates of CHD in babies. These conditions include type 1 and type 2 diabetes, hypertension, CHD, anemia, connective tissue disorders, epilepsy and mood disorders. Pregnant women who are identified as at risk can receive preconception counselling and developing fetuses can be more closely screened for CHD via fetal echocardiography. Early recognition of CHD can additionally help clinicians optimize the care of both women and infants.

That said, there are some limitations to the study. The detection period for the study was restricted to the first year of life. Potential cases of CHD may have developed in later years; however, under-identification should be minimal, given the high frequency of prenatal care and health checkups for infants under National Health Insurance coverage. Additionally, researchers noted that maternal lifestyle factors, including smoking and alcohol consumption, were likely to be underreported in the Birth Notifications data set.

About CHD

CHD affects nearly 1 percent of births per year in the United States and is a leading cause of birth defect-associated infant illness and death, according to the CDC. About 25 percent of babies with CHD have a critical CHD and generally require surgery or other procedures in their first year of life.

Although a few states track CHD among newborns and young children, no tracking system exists for older children and adults with heart defects. A study published last July estimates that approximately 2.4 million people – including 1.4 million adults and one million children – were living with CHD in the U.S. in 2010. Nearly 300,000 of those individuals had severe CHD.

Research projects like the review published in the CMAJ continue to improve care for people affected by CHD. Improved counseling and screening procedures for CHD have the potential to both reduce the prevalence of CHD and its resulting fatalities.

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