- Email: [email protected]
From the Feds: Research, programs, and products
FROM THE FEDS
From the Feds: Research, Programs, and Products Laurie Flaherty, RN, MS, Washington, DC Department of Health and Human Services (DHHS) Mortality from Coronary Artery Disease and Acute Myocardial Infarction–United States, 1998
PUBLIC HEALTH SERVICE
Centers for Disease Control and Prevention (CDC) New Anticoagulant Approved
Mortality from coronary artery disease and acute myocardial infarction–United States, 1998: According to a recent
0099-1767/2001 $35.00 + 0 18/9/117209 doi:10.1067/men.2001.117209
CDC report, coronary heart disease (CHD) remains the leading cause of death in the United States, despite significant advances in acute care, public awareness, and health maintenance.1,2 The decline in death rates that began during the 1960s slowed during the 1990s.3 An estimated 12 million people in the United States have CHD,3 and during 2001, more than 1 million people are expected to have a CHD event.1 The report contains compelling information: • During 1998, CHD was reported as the underlying cause of 459,841 deaths; 203,551 (44%) of these deaths were attributed to acute myocardial infarction (AMI). • For men, CHD death rates were highest among white men (440 per 100,000) and second highest among African American men (421.6 per 100,000). • For women, African American women had the highest rates for CHD (301.9 per 100,000), followed by whites, American Indian/Alaskan natives, and Asian/Pacific Islanders (263.8, 160.2, and 148.1, respectively). • Compared with African American and white men and women, Hispanics had lower death rates for CHD (285.4 and 189.8, respectively). • State variations in death rates ranged from 80.5 in New Mexico to 440.6 in New York.
August 2001 27:4
JOURNAL OF EMERGENCY NURSING
First Drug Approved for Cervical Neck Muscle Dystonia
Emergency Medical Treatment and Labor Act Survey of Hospital Emergency Departments
Laurie Flaherty, Mid-Maryland Chapter, is Emergency Nurse at Suburban Hospital, Bethesda, Md, and a Contract Employee of the National Highway Traffic Safety Administration in Washington, DC. For reprints, write: Laurie Flaherty, RN, MS, 3519 Rittenhouse St, NW, Washington, DC 20015; E-mail: [email protected]. J Emerg Nurs 2001;27:357-9. Copyright © 2001 by the Emergency Nurses Association.
357
FROM THE FEDS/Flaherty
Although much improvement has occurred in prevention behaviors, including cessation of smoking and control of high blood pressure, the incidence of other risk factors, such as obesity and diabetes, have increased. A general improvement in the acute and preventative care of cardiac patients has occurred in the United States, yet each year, approximately 220,000 people die as a result of sudden, fatal CHD events that occur outside the hospital walls,1 and disparities still exist for many racial groups. Obviously more work remains to be done to reduce CHD and AMI. Emergency nurses are on the “front lines” of this battle every day and have opportunities for such strategies as screening cardiac patients for risk factors and taking advantage of “teachable moments.” FOOD AND DRUG ADMINISTRATION (FDA)
in Dublin, Ireland. Myobloc was approved on the basis of 2 multicenter, double-blind, placebo-controlled trials in which the effectiveness was measured with a tool called the Toronto Western Spasmodic Torticollis Rating Scale. The most frequently reported adverse events associated with Myobloc were dry mouth, difficulty swallowing, dyspepsia, and pain at the injection site. The incidence of adverse events tends to increase with increasing doses of the drug. Caution should be used when administering Myobloc to patients with peripheral motor neuropathic diseases or neuromuscular junctional disorders, because such patients may be at increased risk of severe dysphagia, respiratory compromise, and other systemic adverse effects. Office of the Inspector General (OIG)
New anticoagulant approved: The FDA has approved
bivalirudin for use as an anticoagulant in patients with unstable angina who are undergoing percutaneous transluminal coronary angioplasty. Bivalirudin is intended for use only in patients who are also receiving aspirin. Its safety and efficacy have not been established when used in conjunction with other platelet inhibitors, such as glucoprotein Ib/IIIa inhibitors, in patients not undergoing percutaneous transluminal coronary angioplasty, or in patients with other acute coronary symptoms. The drug was approved on the basis of the results of 2 randomized, double-blind, multicenter studies of more than 4000 patients with unstable angina, including 741 patients with postmyocardial infarction angina. The drug will be marketed under the brand name Angiomax and will be made available by The Medicine Company in Cambridge, Mass.
Emergency Medical Treatment and Labor Act (EMTALA) survey of hospital emergency departments: In 1985,
The FDA has approved an injectable solution of botulinum toxin type B, the first drug to reduce the severity of neck and shoulder muscle contractions and the resulting abnormal head position and neck pain associated with cervical neck muscle dystonia. Botulinum toxin type B works by interrupting the cholinergic transmission between the nerve and the affected muscle, causing the muscle to relax. The drug, which will be marketed under the brand name Myobloc, will be made available by Elan Corporation
Congress passed EMTALA as part of the Consolidated Omnibus Reconciliation Act (COBRA) to address the problem of inappropriate interfacility patient transfer, otherwise known as “patient dumping.” According to COBRA, hospitals participating in Medicare must provide a medical screening examination to any person who comes to an emergency department and requests examination or treatment for a medical condition. If a hospital determines that a person has a medical emergency, the patient must be stabilized, or an appropriate transfer must be arranged. The hospital is obligated to provide these services regardless of the individual’s ability to pay and without delay to inquire about the individual’s method of payment or insurance status. Failure to comply with COBRA is considered a breach of the Medicare provider agreement and grounds for termination. COBRA became effective on August 1, 1986, and it requires hospitals to perform several specific tasks: • post signs informing patients of their rights to screening and treatment; • keep a central log of ED visits; • maintain patient transfer records; • report any inappropriate patient transfers; and • maintain a back-up call panel for any specialty service for which the hospital promotes itself to the community.
358
JOURNAL OF EMERGENCY NURSING
First drug approved for cervical neck muscle dystonia:
27:4 August 2001
FROM THE FEDS/Flaherty
DHHS recently conducted a survey of emergency departments. Here are some of the survey’s findings: • Overall, more than 80% of ED staff are familiar with at least 12 of the 15 EMTALA positions listed on the survey. ED physicians and nurses are more likely to be familiar with EMTALA than either registration staff or on-call specialists. However, within this group, discrepancies in awareness existed. Fewer than 70% of those surveyed knew that transfer records must be kept for 5 years and that hospitals are forbidden to take retaliatory action against employees who refuse to authorize inappropriate transfers or who report violations. Only 65% of ED directors were aware of interpretive guidelines published by the Health Care Financing Administration in June 1998. • Almost two thirds of ED physicians, nurses, and registration staff have received some training on EMTALA compared with only about one fourth of on-call specialists. Aside from emergency physicians, staff in high-volume emergency departments are less likely to be trained than are their counterparts in less busy environments. • Respondents believe that some aspects of EMTALA are unclear or questionable. Staff believe they need more precise definitions of the terms “emergency medical condition” and “medical screening exam.” • Although ED directors believe that EMTALA has generally had a positive or no effect on delivery of emergency medical services, they also believe that it has resulted in some problems. Staff say that EMTALA creates administrative entanglements, creates layers of unnecessary bureaucracy, and complicates routine procedures. Although they were not specifically asked about financial problems, ED directors volunteered that EMTALA has contributed to financial problems in many hospitals by mandating medical screening and stabilization of emergency conditions without providing a source of funding. • According to many ED directors, the reimbursement policies of private managed care plans exacerbate stresses created by EMTALA. Although EMTALA cautions hospitals against seeking prior authorization, many private plans will not pay without it. This leaves hospitals with the difficult choice of violating EMTALA or wait-
ing until after the examination is provided and risking nonpayment. • Many hospitals have problems filling on-call rosters. Specialists are increasingly refusing to take call because they believe they stand a good chance of not being reimbursed for services that they are required to provide. Areas for which specialist coverage is a problem, in rank order, are the following: 1. Neurosurgery 2. Cardiovascular surgery and cardiology 3. Pediatrics and subspecialties 4. Orthopedic surgery 5. Obstetrics/gynecology and neonatal services 6. Neurology 7. Plastic surgery 8. Psychiatry and subspecialties The OIG concluded that DHHS should continue to support legislation that would require managed care plans to reimburse hospitals for EMTALA-related services, including screening examinations that do not reveal the presence of an emergency condition. To obtain copies of this report, contact the San Francisco Regional Office at (415)437-7900. Reports are also available at the following Internet address: http://www.dhhs.gov/progorg/oei.
August 2001 27:4
JOURNAL OF EMERGENCY NURSING
REFERENCES 1. American Heart Association. 2001 Heart and stroke statistical update [online] [accessed February 2001]. Available at: URL: http://www.americanheart.org/statistics/index.html 2. Centers for Disease Control and Prevention. Decline in deaths from heart disease and stroke—United States, 1900-1999. MMWR 1999;48:649-56. 3. Cooper R, Cutler J, Desvigne-Nickens P, Fortmann SP, Friedman L, Havlik R, et al. Trends and disparities in coronary heart disease, stroke, and other cardiovascular diseases in the United States: findings of the national conference on cardiovascular disease prevention. Circulation 2000;102:3137-47.
359
From the Feds: Research, Programs, and Products Laurie Flaherty, RN, MS, Washington, DC Department of Health and Human Services (DHHS) Mortality from Coronary Artery Disease and Acute Myocardial Infarction–United States, 1998
PUBLIC HEALTH SERVICE
Centers for Disease Control and Prevention (CDC) New Anticoagulant Approved
Mortality from coronary artery disease and acute myocardial infarction–United States, 1998: According to a recent
0099-1767/2001 $35.00 + 0 18/9/117209 doi:10.1067/men.2001.117209
CDC report, coronary heart disease (CHD) remains the leading cause of death in the United States, despite significant advances in acute care, public awareness, and health maintenance.1,2 The decline in death rates that began during the 1960s slowed during the 1990s.3 An estimated 12 million people in the United States have CHD,3 and during 2001, more than 1 million people are expected to have a CHD event.1 The report contains compelling information: • During 1998, CHD was reported as the underlying cause of 459,841 deaths; 203,551 (44%) of these deaths were attributed to acute myocardial infarction (AMI). • For men, CHD death rates were highest among white men (440 per 100,000) and second highest among African American men (421.6 per 100,000). • For women, African American women had the highest rates for CHD (301.9 per 100,000), followed by whites, American Indian/Alaskan natives, and Asian/Pacific Islanders (263.8, 160.2, and 148.1, respectively). • Compared with African American and white men and women, Hispanics had lower death rates for CHD (285.4 and 189.8, respectively). • State variations in death rates ranged from 80.5 in New Mexico to 440.6 in New York.
August 2001 27:4
JOURNAL OF EMERGENCY NURSING
First Drug Approved for Cervical Neck Muscle Dystonia
Emergency Medical Treatment and Labor Act Survey of Hospital Emergency Departments
Laurie Flaherty, Mid-Maryland Chapter, is Emergency Nurse at Suburban Hospital, Bethesda, Md, and a Contract Employee of the National Highway Traffic Safety Administration in Washington, DC. For reprints, write: Laurie Flaherty, RN, MS, 3519 Rittenhouse St, NW, Washington, DC 20015; E-mail: [email protected]. J Emerg Nurs 2001;27:357-9. Copyright © 2001 by the Emergency Nurses Association.
357
FROM THE FEDS/Flaherty
Although much improvement has occurred in prevention behaviors, including cessation of smoking and control of high blood pressure, the incidence of other risk factors, such as obesity and diabetes, have increased. A general improvement in the acute and preventative care of cardiac patients has occurred in the United States, yet each year, approximately 220,000 people die as a result of sudden, fatal CHD events that occur outside the hospital walls,1 and disparities still exist for many racial groups. Obviously more work remains to be done to reduce CHD and AMI. Emergency nurses are on the “front lines” of this battle every day and have opportunities for such strategies as screening cardiac patients for risk factors and taking advantage of “teachable moments.” FOOD AND DRUG ADMINISTRATION (FDA)
in Dublin, Ireland. Myobloc was approved on the basis of 2 multicenter, double-blind, placebo-controlled trials in which the effectiveness was measured with a tool called the Toronto Western Spasmodic Torticollis Rating Scale. The most frequently reported adverse events associated with Myobloc were dry mouth, difficulty swallowing, dyspepsia, and pain at the injection site. The incidence of adverse events tends to increase with increasing doses of the drug. Caution should be used when administering Myobloc to patients with peripheral motor neuropathic diseases or neuromuscular junctional disorders, because such patients may be at increased risk of severe dysphagia, respiratory compromise, and other systemic adverse effects. Office of the Inspector General (OIG)
New anticoagulant approved: The FDA has approved
bivalirudin for use as an anticoagulant in patients with unstable angina who are undergoing percutaneous transluminal coronary angioplasty. Bivalirudin is intended for use only in patients who are also receiving aspirin. Its safety and efficacy have not been established when used in conjunction with other platelet inhibitors, such as glucoprotein Ib/IIIa inhibitors, in patients not undergoing percutaneous transluminal coronary angioplasty, or in patients with other acute coronary symptoms. The drug was approved on the basis of the results of 2 randomized, double-blind, multicenter studies of more than 4000 patients with unstable angina, including 741 patients with postmyocardial infarction angina. The drug will be marketed under the brand name Angiomax and will be made available by The Medicine Company in Cambridge, Mass.
Emergency Medical Treatment and Labor Act (EMTALA) survey of hospital emergency departments: In 1985,
The FDA has approved an injectable solution of botulinum toxin type B, the first drug to reduce the severity of neck and shoulder muscle contractions and the resulting abnormal head position and neck pain associated with cervical neck muscle dystonia. Botulinum toxin type B works by interrupting the cholinergic transmission between the nerve and the affected muscle, causing the muscle to relax. The drug, which will be marketed under the brand name Myobloc, will be made available by Elan Corporation
Congress passed EMTALA as part of the Consolidated Omnibus Reconciliation Act (COBRA) to address the problem of inappropriate interfacility patient transfer, otherwise known as “patient dumping.” According to COBRA, hospitals participating in Medicare must provide a medical screening examination to any person who comes to an emergency department and requests examination or treatment for a medical condition. If a hospital determines that a person has a medical emergency, the patient must be stabilized, or an appropriate transfer must be arranged. The hospital is obligated to provide these services regardless of the individual’s ability to pay and without delay to inquire about the individual’s method of payment or insurance status. Failure to comply with COBRA is considered a breach of the Medicare provider agreement and grounds for termination. COBRA became effective on August 1, 1986, and it requires hospitals to perform several specific tasks: • post signs informing patients of their rights to screening and treatment; • keep a central log of ED visits; • maintain patient transfer records; • report any inappropriate patient transfers; and • maintain a back-up call panel for any specialty service for which the hospital promotes itself to the community.
358
JOURNAL OF EMERGENCY NURSING
First drug approved for cervical neck muscle dystonia:
27:4 August 2001
FROM THE FEDS/Flaherty
DHHS recently conducted a survey of emergency departments. Here are some of the survey’s findings: • Overall, more than 80% of ED staff are familiar with at least 12 of the 15 EMTALA positions listed on the survey. ED physicians and nurses are more likely to be familiar with EMTALA than either registration staff or on-call specialists. However, within this group, discrepancies in awareness existed. Fewer than 70% of those surveyed knew that transfer records must be kept for 5 years and that hospitals are forbidden to take retaliatory action against employees who refuse to authorize inappropriate transfers or who report violations. Only 65% of ED directors were aware of interpretive guidelines published by the Health Care Financing Administration in June 1998. • Almost two thirds of ED physicians, nurses, and registration staff have received some training on EMTALA compared with only about one fourth of on-call specialists. Aside from emergency physicians, staff in high-volume emergency departments are less likely to be trained than are their counterparts in less busy environments. • Respondents believe that some aspects of EMTALA are unclear or questionable. Staff believe they need more precise definitions of the terms “emergency medical condition” and “medical screening exam.” • Although ED directors believe that EMTALA has generally had a positive or no effect on delivery of emergency medical services, they also believe that it has resulted in some problems. Staff say that EMTALA creates administrative entanglements, creates layers of unnecessary bureaucracy, and complicates routine procedures. Although they were not specifically asked about financial problems, ED directors volunteered that EMTALA has contributed to financial problems in many hospitals by mandating medical screening and stabilization of emergency conditions without providing a source of funding. • According to many ED directors, the reimbursement policies of private managed care plans exacerbate stresses created by EMTALA. Although EMTALA cautions hospitals against seeking prior authorization, many private plans will not pay without it. This leaves hospitals with the difficult choice of violating EMTALA or wait-
ing until after the examination is provided and risking nonpayment. • Many hospitals have problems filling on-call rosters. Specialists are increasingly refusing to take call because they believe they stand a good chance of not being reimbursed for services that they are required to provide. Areas for which specialist coverage is a problem, in rank order, are the following: 1. Neurosurgery 2. Cardiovascular surgery and cardiology 3. Pediatrics and subspecialties 4. Orthopedic surgery 5. Obstetrics/gynecology and neonatal services 6. Neurology 7. Plastic surgery 8. Psychiatry and subspecialties The OIG concluded that DHHS should continue to support legislation that would require managed care plans to reimburse hospitals for EMTALA-related services, including screening examinations that do not reveal the presence of an emergency condition. To obtain copies of this report, contact the San Francisco Regional Office at (415)437-7900. Reports are also available at the following Internet address: http://www.dhhs.gov/progorg/oei.
August 2001 27:4
JOURNAL OF EMERGENCY NURSING
REFERENCES 1. American Heart Association. 2001 Heart and stroke statistical update [online] [accessed February 2001]. Available at: URL: http://www.americanheart.org/statistics/index.html 2. Centers for Disease Control and Prevention. Decline in deaths from heart disease and stroke—United States, 1900-1999. MMWR 1999;48:649-56. 3. Cooper R, Cutler J, Desvigne-Nickens P, Fortmann SP, Friedman L, Havlik R, et al. Trends and disparities in coronary heart disease, stroke, and other cardiovascular diseases in the United States: findings of the national conference on cardiovascular disease prevention. Circulation 2000;102:3137-47.
359