New Epinephrine Labeling:
There has been a change to the labeling of epinephrine. Epi 1:1000 used for anaphylaxis and asthma is now labeled 1.0mg/ml. Epi 1:10,000 used for cardiac arrests is now labeled 0.1 mg/ml. There has been concern that the current labeling caused confusion and inappropriate dosing. 

New Crowding Solutions Resource: 
A new information paper on the causes, impacts and solutions to the crowding and boarding problem has been approved by the Board of Directors.  Members are encouraged to distribute this reader-friendly paper to their hospital administrators or local policymakers who may benefit from a better understanding of why they must, and how they can, address this vexing and dangerous problem. A link to the new paper entitled “Emergency Department Crowding: High Impact Solutions” is available at: https://www.acep.org/Clinical---Practice-Management/Emergency-Medicine-Crowding-and-Boarding/

Blood Clot Information for Patients Developed:

ACEP (through an educational grant from Bristol Myers Squibb) is providing UNBRANDED resources to patients with newly diagnosed VTE/PE. The program provides text messages to connect patients to video based education which discusses the importance of taking medication and getting follow up. No product name is mentioned or implied. The program is called Know Blood Clots, and is explained on the website www.knowbloodclots.com. Patients can also text CLOTWEB to 412-652-3744 to sign up for the Know Blood Clots program. If you have questions, feel free to email sschneider@acep.org and I will try to supply further details.

New Sections at ACEP:
A sufficient number of members have come together to officially form three new Sections in the College. The Pain Management Section was formed earlier this year and is now being followed by the creation of the Medical Directors Section and the Event Medicine Section. The new Sections will meet at ACEP16 for the first time. Members interested in any of these topics are invited to attend the Section meetings and/or join the new Sections. 

Bobby Redwood, M.D., M.P.H.
President
Wisconsin Chapter, American College of Emergency Physicians

For the past two years, national ACEP has released five practice changing recommendations each October under their Choosing Wisely Campaign. These recommendations (see below) represent ways that the emergency physician can contribute to the triple aim of efficient, equitable, and patient-centered care. Inspired by ACEP's campaign, my group began to practice these ten recommendations routinely in our rural emergency department with a consensus that we feel more career fulfillment after agreeing to follow these evidence-based, patient-centered practices.

The current Choosing Wisely recommendations are written for a national audience. Given that regional practice patterns vary widely, my question for our membership this October is this: What would Wisconsin-specific choosing wisely recommendations look-like? Are there evidence-based, best EM practices being implemented in your ED that exemplify the triple aim? Are you willing to share? Send your recommendations to WACEP@badgerbay.co. With you help, we at Wisconsin ACEP can publish our own local edition of the Choosing Wisely Campaign for the Badger State! 

For your reference, ACEP's Choosing Wisely to date: 

1. Avoid computed tomography (CT) scans of the head in emergency department patients with minor head injury who are at low risk based on validated decision rules.
   
2. Avoid placing indwelling urinary catheters in the emergency department for either urine output monitoring in stable patients who can void, or for patient or staff convenience.
3. Don't delay engaging available palliative and hospice care services in the emergency department for patients likely to benefit. 
4. Avoid antibiotics and wound cultures in emergency department patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up.*
5. Avoid instituting intravenous (IV) fluids before doing a trial of oral rehydration therapy in uncomplicated emergency department cases of mild to moderate dehydration in children.
6. Avoid CT of the head in asymptomatic adult patients in the emergency department with syncope, insignificant trauma and a normal neurological evaluation.
7. Avoid CT pulmonary angiography in emergency department patients with a low-pretest probability of pulmonary embolism and either a negative Pulmonary Embolism Rule-Out Criteria (PERC) or a negative D-dimer.
8. Avoid lumbar spine imaging in the emergency department for adults with non-traumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition (such as vertebral infection, cauda equina syndrome, or cancer with bony metastasis).
9. Avoid prescribing antibiotics in the emergency department for uncomplicated sinusitis.
10. Avoid ordering CT of the abdomen and pelvis in young otherwise healthy emergency department (ED) patients (age <50) with known histories of kidney stones, or ureterolithiasis, presenting with symptoms consistent with uncomplicated renal colic. 

*a recent NEJM study by Talan et al has revived this as a topic of discussion

Planning to attend ACEP's 2016 Scientific Assembly in Las Vegas? WACEP is coordinating a Wisconsin Chapter Dessert & Drink Reception! We hope you can join us for this complimentary mix and mingle!

Monday, October 17, 2016; 8:30 to 10:30 pm
Vice Versa Patio & Lounge at Vdara Hotel & Spa
2600 W. Harmon Avenue, Las Vegas, NV 89158

Find us on the Patio! We look forward to seeing many of you in Vegas!

Lisa Maurer, MD, WACEP Treasurer

I recently had an opportunity to participate with other WACEP board members and our Chapter lobbyist at two important events affecting emergency physicians in Wisconsin.

On September 1, we met with a group of emergency physicians from the Milwaukee-based group ERMED to discuss both our top legislative priority, improving Medicaid reimbursement for EMTALA-related services, and how our membership can work with ERMED to help with the effort. Thanks to the physicians of that group for their time and enthusiasm! Many expressed an interest in helping with our Chapter efforts to improve reimbursement, and were willing to contribute to our Political Action Committee. Please consider making a PAC donation today! 

Also on September 1, I was among several WACEP board members who attended a round-table discussion hosted by Senator Ron Johnson (R-Wis) regarding the opioid epidemic. A primary focus of the discussion was the important Promoting Responsible Opioid Prescribing (PROP) Act, which aims to exclude certain pain-related measures for purposes of calculating incentive payments under the value-based purchasing program. Senator Johnson highlighted the need to reeducate ourselves as physicians on alternatives to opioids, as well as the crucial need to educate our patients about safer and more effective modes of pain control.  

A big thanks goes out to WACEP member Tim Westlake, MD, who serves as Vice Chair of the Medical Examining Board, for his participation on the panel. His presence shed light on the EM physician perspective relating to this important issue.

WACEP congratulates five well-deserving members for being among the newest group to meet the eligibility requirements and achieve Fellow Status of the American College of Emergency Physicians. The following individuals will be recognized next month during ACEP16 in Las Vegas:

• Gemma C L Bornick, MD of Green Bay
• Suhas Channappa, MD of Marshfield
• Alex A Pasquariello, MD of Fitchburg
• Brian W Patterson, MD of Madison
• Louis J Scrattish, MD of Madison

ACEP Fellowship was first established in 1982 to honor members who made special contributions to the College and the specialty of emergency medicine. Requirements for Fellow Status include Active membership status for three continuous years; board certification by ABEM, AOBEM, or ABP certification for pediatric emergency physicians; and additional service to the specialty. In Wisconsin, 176 WACEP members are currently Fellows of the American College.

August 17, Wisconsin Health News

Wisconsin hospitals saw more visitors to their facilities and emergency rooms last year, but patients were there for shorter periods of time, according to a report recently released by the Wisconsin Hospital Association.

Emergency room visits shot up 4.7 percent in 2015 to 1.79 million, compared to 1.71 million in 2014, while hospitalizations at general medical-surgical hospitals inched up 0.2 percent to 580,881. The average length of stay decreased 0.5 percent from 4.2 days to 4.1.

Meanwhile, the average charge per hospitalization grew 5.2 percent to $32,197.

Brian Potter, senior vice president at the Wisconsin Hospital Association, said charges are going up because of rate increases, as well as the trend of lower cost discharges moving to the outpatient setting, increasing the acuity of inpatient stays. 

The downward trend of length of stays, which were 4.7 days in 2000, is significant because many of the short stay cases are now done on an outpatient basis, according to Potter. He attributed the increase in ER visits to the federal health reform law's coverage expansion.

"People with coverage tend to use more services and if they are new to the system, they often begin with an ER visit," he said.

The most common reason for going to the hospital was childbirth, representing 16 percent of all hospitalizations. In the emergency room, abdominal pain was the most frequent diagnosis, accounting for 6 percent of visits.

View WHA data here.

Bobby Redwood, M.D., M.P.H.
President, Wisconsin Chapter, American College of Emergency Physicians

August is national immunization awareness month and a great opportunity to discuss the role that Wisconsin emergency physicians play in immunization care. We all know that every emergency is a failure of prevention, so some careful planning now can help us stave off the flood of infectious diseases that is bound to hit our ED's during the winter months.

While the southern US is scrambling to deal with Zika, we northerners already know who our enemy will be this winter: influenza. Wisconsin department of health services releases weekly influenza reports and rates this week remain low in all regions of Wisconsin. Typically our influenza numbers start to skyrocket in the second week of November and don't level off again until the second week of May. That's seven months of headaches, body aches, and pediatric fevers that we would rather not have end up on our doorstep. In the 2015-2016 flu season, Wisconsin saw 5,136 cases of influenza...and that's just the cases that were confirmed.

So let's talk prevention! For those vaccine geeks out there, the trivalent vaccines for use in the 2016-2017 influenza season will contain the following virus-like strains: A/California/7/2009 (H1N1); A/Hong Kong/4801/2014, and B/Brisbane/60/2008. No one knows (yet) what strains the 2017-2018 vaccine will contain...let's hope its not called A/Wisconsin/2016. We'll find out soon enough, CDC expects the 2016-2017 vaccine to available later this month for at-risk populations and available for all populations by the first week of September. 

On your next shift, take some time to educate your patients about the importance of getting their flu shot early. How about celebrating August by taking the WACEP national immunization awareness month challenge: try to educate one patient in each of the following age groups about the importance of vaccination in general:

• Parents: Emphasize the important role vaccines play in protecting their child's health;
  
• College students: Remind them to talk to their healthcare professional about any vaccines they may need for school entry;
• Adults, especially older adults and adults with chronic conditions: When appropriate, encourage vaccines for shingles, pertussis, pneumococcus, and flu;
• Pregnant women: Talk about getting vaccinated to protect newborns from diseases like pertussis and flu;
• Everyone: Let Wisconsinites know that the next flu season is only a few months away.

August 4, Wisconsin Health News

Gov. Scott Walker on Thursday appointed Linda Seemeyer to serve as secretary of the Department of Health Services. Seemeyer served as director of the Walworth County Department of Health and Human Services from 2007 to 2015. She was also director of the Milwaukee County Department of Administrative Services and deputy secretary of the Department of Administration under Gov. Tommy Thompson.

Seemeyer starts Aug. 22. She succeeds Kitty Rhoades who passed away in June. Interim Secretary Tom Engels will resume his duties as deputy secretary.

August 3, Wisconsin Health Information Organization

The Wisconsin Health Information Organization (WHIO) has named Dana Richardson its new CEO. Richardson succeeds Josephine Musser who is retiring.

Richardson has been serving since April as Acting Executive Director of the non-profit PCPI® Foundation in Chicago. Previously, she served six years at the American Medical Association (AMA) as Director of Operations and Strategic Initiatives for the PCPI, which was originally convened by the AMA. From 2002-2010, Richardson was Vice President for Quality Initiatives at the Wisconsin Hospital Association (WHA).

With a BS in Nursing and an MA Business, Health Service Administration from the University of Wisconsin-Madison, and prior experience at St. Mary’s Hospital in Madison and the Dean Health System, Richardson has deep ties to Wisconsin’s health care system, as both a provider and administrator, beginning in 1983.

“Dana Richardson is a proven leader who thinks strategically and acts decisively, setting goals, solving problems and seeing tangible results,” said WHIO Board Chair Linda Syth. “Her background in quality and efficiency at the local and state level in Wisconsin, along with her work at the national level with physician societies and performance measurement, make her uniquely qualified to engage caregivers where their heart is – great patient care. We’re delighted to welcome Dana to WHIO,” Syth said.

WHIO provides health care information to consumers, clinicians, providers, employers and payers to support decision-making. “I am excited to be joining an organization focused on the quality, safety and affordability of health care. Knowing that Wisconsin is a high value state for health care services, my goal is to further leverage the WHIO information to set a higher bar,” said Richardson.

Richardson will assume her new post on August 30th and collaborate with outgoing CEO Jo Musser until the end of the year to ensure a smooth transition.

The Wisconsin Health Information Organization (WHIO) is a non-profit 501(c)(3) organization dedicated to improving the quality, affordability, safety and efficiency of health care in Wisconsin.

The Wisconsin Medical Examining Board (MEB) approved best practice guidelines for opioid prescribing at its monthly meeting in Madison in July. This action is a result of Wisconsin State Assembly Rep. John Nygren’s HOPE legislative package; 2015 Act 269 granted the MEB authority to post the guidelines, which are inspired by those already in place from the Centers for Disease Control and Prevention and the state’s Worker’s Compensation program.

While the guidelines are not mandatory practice parameters, they are expected to assist physicians with making more informed decisions about their prescribing practices. Click here to view the guidelines.

The MEB also moved closer to finalizing new continuing medical education (CME) rules that will eventually require physicians to include coursework on the new guidelines as part of their 30 hours per biennium requirement. The likely outcome of this CME-related rule will be:

All physicians who have a Drug Enforcement Administration (DEA) number will be required to take two credits of CME in prescribing-related areas as part of their biennial 30-credit total.

This requirement will take effect for the next two complete CME reporting cycles (essentially for 2017-2019 and then again for 2019-2021).

The first time a physician satisfies that two-credit requirement, the CME will need to include information on the new opioid prescribing guidelines. (It is likely the Wisconsin Medical Society’s opioid prescribing webinar series, which is now available on-demand, will be grandfathered in as satisfying the guidelines-related subject matter requirement.)

The second time the physician satisfies the two-credit requirement, it can be in the arena of “responsible controlled substances prescribing.”

This requirement COULD end after two CME cycles—it will depend on the status of the opioid crisis and whether or not the MEB continues the requirement for future cycles.

The MEB is expected to finalize these requirements at its meeting later this month.