Author Archives: Keri Scott
The United States is currently experiencing a large, multi-state outbreak of measles linked to an amusement park in California. The outbreak started in December 2014 and has spread to more than a dozen other states. CDC urges healthcare professionals to consider measles when evaluating patients with febrile rash and ask about a patient’s vaccine status, recent travel history, and contact with individuals who have febrile rash illness.
Measles is an acute viral respiratory illness. It is characterized by a prodrome of fever (as high as 105°F) and malaise, cough, coryza, and conjunctivitis -the three “C”s -, a pathognomonic enanthema (Koplik spots) followed by a maculopapular rash. The rash usually appears about 14 days after a person is exposed; however, the incubation period ranges from 7 to 21 days. The rash spreads from the head to the trunk to the lower extremities. Patients are considered to be contagious from 4 days before to 4 days after the rash appears. Of note, sometimes immunocompromised patients do not develop the rash.
CDC’s Dr. Jane Seward describes measles clinical features and what to do if a healthcare provider suspects measles, in this 5-minute video.
Measles is caused by a single-stranded, enveloped RNA virus with 1 serotype. It is classified as a member of the genus Morbillivirus in the Paramyxoviridae family. Humans are the only natural hosts of measles virus.
In the decade before the live measles vaccine was licensed in 1963, an average of 549,000 measles cases and 495 measles deaths were reported annually in the United States. However, it is likely that, on average, 3 to 4 million people were infected with measles annually; most cases were not reported. Of the reported cases, approximately 48,000 people were hospitalized from measles and 1,000 people developed chronic disability from acute encephalitis caused by measles annually.
Advice for Travelers
Plane flying around globeCheck that your patients 6 months of age or older who will be traveling internationally are protected against measles.
Travel Notice: Watch (Level 1): Measles in the Philippines
In 2000, measles was declared eliminated from the United States. Elimination is defined as the absence of endemic measles virus transmission in a defined geographic area, such as a region or country, for 12 months or longer in the presence of a well-performing surveillance system. However measles cases and outbreaks still occur every year in the United States because measles is still commonly transmitted in many parts of the world, including countries in Europe, Asia, the Pacific, and Africa. An estimated 20 million people become infected with measles worldwide each year, of whom 146,000 die.
Since 2000, when measles was declared eliminated from the U.S., the annual number of cases has ranged from a low of 37 in 2004 to a high of 644 in 2014. The majority of cases have been among people who are not vaccinated against measles. Measles cases in the United States occur as a result of importations by people who were infected while in other countries and from transmission that may occur from those importations. Measles is more likely to spread and cause outbreaks in U.S. communities where groups of people are unvaccinated.
Outbreaks in countries to which Americans often travel can directly contribute to an increase in measles cases in the United States. In recent years, measles importations have come from frequently visited countries, including, but not limited to, England, France, Germany, India, and the Philippines, where large outbreaks were reported.
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Common complications from measles include otitis media, bronchopneumonia, laryngotracheobronchitis, and diarrhea.
Even in previously healthy children, measles can cause serious illness requiring hospitalization.
One out of every 1,000 measles cases will develop acute encephalitis, which often results in permanent brain damage.
One or two out of every 1,000 children who become infected with measles will die from respiratory and neurologic complications.
Subacute sclerosing panencephalitis (SSPE) is a rare, but fatal degenerative disease of the central nervous system characterized by behavioral and intellectual deterioration and seizures that generally develop 7 to 10 years after measles infection.
People at High Risk for Complications
People at high risk for severe illness and complications from measles include:
Infants and children aged 20 years
People with compromised immune systems, such as from leukemia and HIV infection
Measles is one of the most contagious of all infectious diseases; approximately 9 out of 10 susceptible persons with close contact to a measles patient will develop measles. The virus is transmitted by direct contact with infectious droplets or by airborne spread when an infected person breathes, coughs, or sneezes. Measles virus can remain infectious on surfaces and in the air for up to two hours after an infected person leaves an area.
Diagnosis and Laboratory Testing
Healthcare providers should consider measles in patients presenting with febrile rash illness and clinically compatible measles symptoms, especially if the person recently traveled internationally or was exposed to a person with febrile rash illness. Healthcare providers should report suspected measles cases to their local health department within 24 hours.
Laboratory confirmation is essential for all sporadic measles cases and all outbreaks. Detection of measles-specific IgM antibody and measles RNA by real-time polymerase chain reaction (RT-PCR) are the most common methods for confirming measles infection. Healthcare providers should obtain both a serum sample and a throat swab (or nasopharyngeal swab) from patients suspected to have measles at first contact with them. Urine samples may also contain virus, and when feasible to do so, collecting both respiratory and urine samples can increase the likelihood of detecting measles virus. For more information, see Measles Lab Tools.
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Evidence of Immunity
Acceptable presumptive evidence of immunity against measles includes at least one of the following:
written documentation of adequate vaccination:
one or more doses of a measles-containing vaccine administered on or after the first birthday for preschool-age children and adults not at high risk
two doses of measles-containing vaccine for school-age children and adults at high risk, including college students, healthcare personnel, and international travelers
laboratory evidence of immunity
laboratory confirmation of measles
birth in the United States before 1957
Healthcare providers should not accept verbal reports of vaccination without written documentation as presumptive evidence of immunity. For additional details about evidence of immunity criteria, see Table 3 in Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013: Summary Recommendations of the Advisory Committee on Immunization Practices (ACIP).
Measles can be prevented with measles-containing vaccine, which is primarily administered as the combination measles-mumps-rubella (MMR) vaccine. The combination measles-mumps-rubella-varicella (MMRV) vaccine can be used for children aged 12 months through 12 years for protection against measles, mumps, rubella and varicella. Single-antigen measles vaccine is not available.
One dose of MMR vaccine is approximately 93% effective at preventing measles; two doses are approximately 97% effective. Almost everyone who does not respond to the measles component of the first dose of MMR vaccine at age 12 months or older will respond to the second dose. Therefore, the second dose of MMR is administered to address primary vaccine failure 
CDC recommends routine childhood immunization for MMR vaccine starting with the first dose at 12 through 15 months of age, and the second dose at 4 through 6 years of age or at least 28 days following the first dose.
Students at post-high school educational institutions
Students at post-high school educational institutions without evidence of measles immunity need two doses of MMR vaccine, with the second dose administered no earlier than 28 days after the first dose.
People who are born during or after 1957 who do not have evidence of immunity against measles should get at least one dose of MMR vaccine.
People 6 months of age or older who will be traveling internationally should be protected against measles. Before travelling internationally,
Infants 6 through 11 months of age should receive one dose of MMR vaccine
Children 12 months of age or older should have documentation of two doses of MMR vaccine (the first dose of MMR vaccine should be administered at age 12 months or older; the second dose no earlier than 28 days after the first dose)
Teenagers and adults born during or after 1957 without evidence of immunity against measles should have documentation of two doses of MMR vaccine, with the second dose administered no earlier than 28 days after the first dose
Healthcare personnel should have documented evidence of immunity against measles, according to the recommendations of the Advisory Committee on Immunization Practices[48 pages].
For more information, see measles vaccination recommendation.
CDC. Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013: Summary Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2013;62(RR04);1-34.
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People exposed to measles who cannot readily show that they have evidence of immunity against measles should be offered post-exposure prophylaxis (PEP) or be excluded from the setting (school, hospital, childcare). MMR vaccine, if administered within 72 hours of initial measles exposure, or immunoglobulin (IG), if administered within six days of exposure, may provide some protection or modify the clinical course of disease.
MMR vaccine as post-exposure prophylaxis
If MMR vaccine is not administered within 72 hours of exposure as PEP, MMR vaccine should still be offered at any interval following exposure to the disease in order to offer protection from future exposures. People who receive MMR vaccine or IG as PEP should be monitored for signs and symptoms consistent with measles for at least one incubation period.
If many measles cases are occurring among infants younger than 12 months of age, measles vaccination of infants as young as 6 months of age may be used as an outbreak control measure. Note that children vaccinated before their first birthday should be revaccinated when they are 12 through 15 months old and again when they are 4 through 6 years of age.
Except in healthcare settings, unvaccinated people who receive their first dose of MMR vaccine within 72 hours after exposure may return to childcare, school, or work.
Immunoglobulin (IG) as post-exposure prophylaxis
People who are at risk for severe illness and complications from measles, such as infants younger than 12 months of age, pregnant women without evidence of measles immunity, and people with severely compromised immune systems, should receive IG. Intramuscular IG (IGIM) should be given to all infants younger than 12 months of age who have been exposed to measles. For infants aged 6 through 11 months, MMR vaccine can be given in place of IG, if administered within 72 hours of exposure. Because pregnant women might be at higher risk for severe measles and complications, intravenous IG (IGIV) should be administered to pregnant women without evidence of measles immunity who have been exposed to measles. People with severely compromised immune systems who are exposed to measles should receive IGIV regardless of immunologic or vaccination status because they might not be protected by MMR vaccine.
IG should not be used to control measles outbreaks, but rather to reduce the risk for infection and complications in the people receiving it. IGIM can be given to other people who do not have evidence of immunity against measles, but priority should be given to people exposed in settings with intense, prolonged, close contact, such as a household, daycare, or classroom where the risk of transmission is highest.
After receipt of IG, people cannot return to healthcare settings. In other settings, such as childcare, school, or work, factors such as immune status, intense or prolonged contact, and presence of populations at risk, should be taken into consideration before allowing people to return. These factors may decrease the effectiveness of IG or increase the risk of disease and complications depending on the setting to which they are returning.
The recommended dose of IGIM is 0.5 mL/kg of body weight (maximum dose = 15 mL) and the recommended dose of IGIV is 400 mg/kg.
Post-exposure prophylaxis for healthcare personnel
If a healthcare provider without evidence of immunity is exposed to measles, MMR vaccine should be given within 72 hours, or IG should be given within 6 days when available. Exclude healthcare personnel without evidence of immunity from duty from day 5 after first exposure to day 21 after last exposure, regardless of post-exposure vaccine. 
Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.
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Infected people should be isolated for four days after they develop a rash. Healthcare providers should follow respiratory etiquette and airborne precautions in healthcare settings. Regardless of presumptive immunity status, all healthcare staff entering the room should use respiratory protection consistent with airborne infection control precautions (use of an N95 respirator or a respirator with similar effectiveness in preventing airborne transmission). Because of the possibility, albeit low, of MMR vaccine failure in healthcare providers exposed to infected patients, they should all observe airborne precautions in caring for patients with measles. The preferred placement for patients who require airborne precautions is in a single-patient airborne infection isolation room (AIIR).
People without evidence of immunity who have been exempted from measles vaccination for medical, religious, or other reasons and who do not receive appropriate PEP within the appropriate timeframe should be excluded from affected institutions in the outbreak area until 21 days after the onset of rash in the last case of measles.
There is no specific antiviral therapy for measles. Medical care is supportive and to help relieve symptoms and address complications such as bacterial infections.
Let’s begin by tearing down some of the more famous assumptions about nurses right off the top:The Nurse as Sex Kitten:
Any man who lived through the early seventies or has made it a point to rent such famous videos as “Night Duty Nurses” or “Student Nurses” or “Night Duty Student Nurses” or any one of several dozen nurse-centric skin flicks will mmediately believe that all nurses have heaving bosoms, just millimeters away from popping out of skin tight white uniforms. You will also believe that nurses always wear white garters, fishnet hose, and stilettos. This, of course, is a handy dress code because movie nurses spend *a lot* of time hopping in and out of patient’s beds.
The reality is that most nurses wear scrubs – Shapeless, draping hunks of cotton that could cause you to breeze past Pamela Anderson without a second look. Shoes are white and chunky with blobs of things on them better left Unexplored. Socks replace white hose and garters, and when is the last time Anyone saw a nursing cap? Graduation, perhaps?
The Nurse as an Angel:
You have just learned an important lesson. On the nurse scale of emergencies, yours is about a minus 9! As my wife has told me, “when you are on a ventilator, with six drips running, your head down and your feet up, then you’re sick. Anything less than that isn’t worth getting excited over!”
The Nurses Mutual Benefit Network:
As a male either dating or married to a nurse, you should realize one important thing. There are nurses everywhere. That, in itself, is no big deal. The fact is, every nurse knows other nurses who know more nurses, so that by the time you are finished, a nurse on the Island Nation of Chuuk who observes you doing something you shouldn’t has the immediate capability of getting word to your wife. This system is way more reliable and efficient than the Internet and has existed for a much longer time. Take it for
granted that your nurse wife will know about anything you have done, good or bad, before you get home!
Your Social Life with Nurses:
Nurses hang out with other nurses and soon you may find that all your friends are married to nurses. The reason this happens is because in situations where nurses mingle with nonmedical folks things can get ugly. For example, you are out to dinner with your nurse wife, another nurse couple, and two civilian couples. The nurses sit and chat, discussing fun things like bleeding bowels, open sores, how much fat was sucked out of some patient, projectile vomiting, traumatic amputations, etc., all over a nice pasta dinner. The nurses carry on talking as the civilian couples turn funny colors, make faces and suppress their gag reflexes (and this is if the nurses don’t have any really gross things to share like the homeless guy with maggots in his bleeding sores)!
After several dinners and gatherings like this, you will soon find your circle of friends has shrunk significantly. The key to avoiding this is to do the following: Never go out in mixed groups with more than one nurse. A lone nurse is OK. The trouble starts when you have more than one, and when that happens, keep the regular folks away. Also get used to the idea that some friends and neighbors will take advantage of the fact that your wife is a nurse by calling at all hours of the day and night for advice. This may include male friends “dropping by” to show your sweetie his rash. The best
advice I can give is to just deal with it and hope it isn’t contagious.
Nurse: The Health Ramifications
Most nurses have been described as having the constitution of horses, which isn’t true because I’ve been around horses and they get sick more often. The reason for this is pretty simple. After about 3-5 years on the job, nurses have been exposed to so many bugs that they either end up dead or full of every antibody known to mankind. (If you want the ultimate booster shot, just get a blood transfusion from a nurse who’s worked in a hospital for 20 years!) You don’t have all these antibodies, though, so when she does come home with mild sniffles, a week later you’re flat on your back with the worse case of the flu of your life!! Oh, and if you are the least bit squeamish, don’t even think about the bugs she brings home on her clothes. It will mess with your mind as she talks about her Resistant TB patient, the patient full of body lice, or the one with poison ivy in his mouth! So don’t
Ah such mysterious, wondrous creatures are nurses.
You know, they really are and I thank God every day for my nurse!
How do you know you’re a nurse? Here are 16 surefire ways to tell!
1. When you show up to work on your off day for a 7 a.m. mandatory meeting:
2. When you arrive at work the next day, bright-eyed and bushy-tailed:
3. Two minutes later…when things get real and you start to regret your decision to get out of bed:
4. When the attending physician writes an order that makes absolutely no sense, no matter how many times you read it:
5. When your patient starts having family drama and you wonder if anyone remembers you’re still in the room:
6. When you try to send secret messages to your nurse buddy without anyone else seeing:
7. When you realize that you’ll never get used to smelling C. diff. Never:
8. When you’re overwhelmed and the charge nurse tries to assign you “just ONE more” patient:
9. When you hand over a patient to the incoming nurse and neglect to mention that he/she is a complete train wreck:
10. When you accidentally let unpleasant thoughts slip out of your mouth (hey, it happens when you’re hungry and sleep-deprived!):
11. When a patient starts a sentence with “Well, WebMD said…”:
12. When you start to wonder what will make you snap first, hunger or fatigue:
13. When you finish your shift, but lack the energy to make it out of the front door on your own:
14. When you get home and try to make sense of your day:
15. When you wake up the next morning and realize that you have to do it ALL over again:
16. When you remember that you’re an amazing nurse and no matter what you go through, it’s ALL worth it!
When Linda Moody and her husband Clifford moved from Florida to Albuquerque, New Mexico, three years ago, they had to pick both a doctor and a health insurer. Moody’s boss recommended Presbyterian Healthcare Services, an eight-hospital system with its own health plan and 600 doctors and other clinicians on staff.
Moody, 66, director of business and finance at the National Education Association of New Mexico, is very glad she listened to her boss. Within a year, Clifford, 67, was rushed to Presbyterian Hospital with breathing problems resulting from an egg-sized tumor in his throat. Though doctors warned “he might not make it out of surgery,” Moody says, today he is cancer-free.
Besides the operation, she says, it was what happened afterward that brought them through the crisis. “Kristin,” she says, “came into our lives.”
Kristin Berg is half of Presbyterian Hospital’s “intensive transition of care team,” tasked (along with a social worker) with figuring out which patients are apt to land back inside and making sure they don’t. Besides cancer, Clifford Moody would be dealing with a tracheostomy and a new diagnosis of diabetes. So, in addition to chemo and radiation and care by an oncologist, he would need to see his otolaryngologist, pulmonologist, primary care doctor and a dietitian.
Berg, a nurse case manager, lined up medical appointments and home services, accompanied Clifford to see his primary care doctor and was on call for the Moodys 24/7. She worked with Clifford’s doctors to fine-tune his medicines, expedited orders when there were problems with the trach tube, secured a suction machine and trained the nurse caring for him to use it. “I probably saved them four to five ER visits,” she says. “The goal was to avert rather than react to a crisis.”
This, in a nutshell, is where health care is headed. Far from being a fortress with beds full of sick people, the hospital of the future will be a dynamic system whose tentacles reach deep into the community, aimed at keeping people well and making sure they “get the right care at the right time in the right setting,” says James Hinton, Presbyterian Healthcare’s president and CEO, who is also chairman of the board of trustees at the American Hospital Association.
From coast to coast, the medical profession is experimenting with ways to care for people differently. Hospitals are hiring primary care doctors and coaching the people in their communities to stay well. They’re sending doctors on house calls, and putting nurses in the YMCA. A growing number are now screening patients for mental and behavioral health problems, which so often complicate or cause disease and interfere with treatment. And they’re using telemedicine and mobile devices to help patients better care for themselves.
The big motivator behind all this outreach, of course, is money. The end appears to be coming for fee-for-service payment systems that encourage a piling on of tests and treatments even when less would be more. Indeed, payment systems are changing in all sorts of ways that reward hospitals for keeping people well and make it costly to admit them.
Some insurance plans provide predetermined monthly payments per patient, and hospitals have to provide all care for that amount or lose money. Others hand over a lump sum for every element of care related to a heart attack or knee replacement, say, so hospitals have an incentive to keep stays short and provide treatment at home.
Tightly integrated health systems like Presbyterian and Intermountain Healthcare in Salt Lake City have a head start, partly because they are putting patient data to good use. By culling electronic records to look for good candidates for house calls, Presbyterian has been able to send doctors and nurses out to treat some 900 pneumonia, heart failure and other patients in their own bedrooms, for example. Telemonitoring allows instant access to clinicians and the checking of vital signs between daily visits.
Compared to traditional patients, the people participating in this “Hospital at Home” program die at rates 2.6 percent lower, get readmitted 7 percent less often, are more satisfied, and are some 20 percent less costly to care for.
“There’s no question about it, this was better than being in the hospital,” says Ben Guhrke, 87, who recently underwent surgery to repair a broken femur and had some post-surgical edema treated as a Hospital at Home patient. The service, he marvels, was “so responsive.”
Intermountain Healthcare, a system of 22 hospitals and 185 clinics in Utah and Idaho, relies on sophisticated number-crunching and is developing predictive analytics to identify its highest-cost patients – the 1 percent who account for fully a quarter of spending on care – and is changing the way it attends to them. These “hotspotter” patients visited hospitals or doctors an average of 41 times each in five years, versus six times for the typical patient. That doesn’t cut it in a system where a growing proportion of patients are served through an affiliated health plan that provides fixed premium payments to cover all the care they need.
Betting that “a better investment might be in helping patients to help themselves,” Intermountain this year launched two different interventions for hotspotters, says Scott Pingree, chair of high-cost patients and hotspotting.
Members of a new community care management team (a primary care doctor, a nurse, a care manager, a pharmacist, a social worker and a “transitionist”) travel to see them, coaching and cajoling them to better manage their medication, eat well and call on team members for home health visits rather than go to the ER. The team also helps get patients in touch with other assistance that can be key in heading off a health crisis, from Meals on Wheels to fuel or housing help to a contractor to fix a mold problem or to add a ramp or railing.
Helping patients help themselves is not a traditional hospital competency, but mobile technology is laying a pathway for it to become one. Davie Rivera of New York City, 41, says the text messages he began getting last fall from Montefiore Medical Center, which were programmed in by his care manager, have “helped a lot” in his effort to lose weight.
On disability for scoliosis and weighing more than 300 pounds a year ago, Rivera felt paralyzed by a lack of confidence. Getting regular texts reminding him of appointments with his nutritionist and for his spine condition and offering personal affirmations and tips for healthy eating helped him drop almost 100 pounds. They made him feel that the hospital “is in your corner,” he says.
Montefiore started its own health plan and began tightly managing patients two decades ago, as part of a struggle – in one of the country’s poorer counties, the Bronx – to stay solvent. Today, it’s one of the nation’s most successful Pioneer Accountable Care Organizations, a new government-supported model emphasizing prevention and high-quality care that avoids redundant or unnecessary tests and procedures and readmissions. ACOs share in any money they save Medicare, or they share the losses.
Montefiore was able to collect $14 million in shared savings for 2013, says Andrew Racine, senior vice president and chief medical officer, by moving a big proportion of care outside the hospital walls and substantially reducing readmissions.
As at Presbyterian, a “Medical House Calls” program brings doctor to patient. People who have suffered heart failure are equipped with smart scales that record and transmit daily weights to their providers, who can actively manage their condition using real-time data. The unacceptably high local diabetes rate has prompted a concerted effort by doctors and social workers to make sure patients understand their treatment plans and follow them. And Montefiore has set up more than 20 primary care locations throughout the area.
Most of these are “patient-centered medical homes” that provide primary and preventive care for every stage of life, with a focus on wellness and improved health. Medical homes combine the advantages of the old-fashioned family doctor, who makes the time to sit and talk with you, with a modern team approach to care that supports patients with psychologists, pharmacists, care managers and social workers. Evening and weekend hours help to accommodate busy schedules. By visiting MyMontefiore.net, patients can email their doctor, request a medication refill, create their own personal health record and access a library to help them find answers to their health concerns.
Presbyterian, too, has organized its 130 primary care providers, all of whom are on the payroll, into 10 patient-centered medical homes. In addition to routine care, doctors and nurse practitioners tell overweight patients to use the walking trails along the Rio Grande river, and prescribe fresh fruit and vegetables at the local farmers’ markets. Doctors can refer patients to mental health professionals down the hall.
Clinic care managers run weekly reports showing which of 14,000 patients with diabetes are overdue to get their hemoglobin A1C, LDL and blood pressure levels checked. Those patients are contacted to schedule appointments. “We’ve honed in on prevention that works,” says Dion Gallant, director of primary care services.
In some places, the hospital front lines are moving into other institutions. Carolinas HealthCare System, a 7,800-bed network based in Charlotte, North Carolina, embeds registered nurses, dietitians and athletic trainers in a dozen YMCA locations around the city. People dealing with diabetes or heart disease, say, or who are trying to lose weight, can get health coaching and exercise regimens to reach goals set by their doctors. The Y-based clinicians can view medical records and update them. So far, more than half of the people in the program who started off with above-normal blood pressure have lowered it significantly, and those with high LDL cholesterol levels have seen reductions averaging 15 points.
In Wyoming, Delaware, Susan Hoffmann, a school nurse at W.B. Simpson Elementary School, recently assembled a care plan for a first-grade boy who had just been diagnosed with diabetes. Hoffmann was able to access the boy’s medical information through an electronic health records system that Nemours/Alfred I. DuPont Hospital for Children created with schools in the state earlier this year so the Wilmington children’s health system could enlist other pediatric clinicians in an effort to improve kids’ health. Hoffmann’s plan included steps his teachers and school bus driver should follow if the boy became hypoglycemic. “It made a huge difference in the child’s seamless transition back to school,” she says.
A big part of keeping people physically healthy, it turns out, is making sure that their mental health needs are met. Not only do issues like substance abuse and depression cause physical harm and exacerbate ailments, but also they interfere with patients’ ability to comply with doctors’ orders. Montefiore this year established behavioral health services for children and adults in each of its primary care sites so it can quickly get them needed treatment; Intermountain has also been moving the two types of care into single clinics.
“Untreated childhood mental health problems cause more than half of the chronic medical problems in the country,” says Michael Hogan, former commissioner of the New York State Office of Mental Health. A report this past spring by Seattle-based consulting firm Milliman concluded that integrating the two can save the nation as much as $48 billion annually.
At Carolinas, the goal is to build access to mental health screening and consults into all locations, from the hospital bedside to the ER to the doctor’s office, so emotional well-being becomes “another vital sign,” says John Santopietro, chief clinical officer of behavioral health.
Since 1997, Carolinas has been providing telepsychiatry to people in the ER; some 300 consults a month now occur in the Charlotte area, a number expected to triple over the next year. Next, Carolinas is poised to beam the support of mental health professionals farther outward, to vulnerable people in hospital beds and primary care offices across its network.
The Patient Protection and Affordable Care Act may have provided health care insurance to an estimated 20 million Americans who lacked coverage, but it has not eased the demand on the nation’s emergency departments. In fact, since the law’s passage, reliance upon the nation’s emergency rooms for non-emergency care has increased.
That’s the finding of a study published online in the American Journal of Emergency Medicine by a second-year medical student at the Wayne State University School of Medicine and his colleagues.
In “Access to care issues and the role of EDs in the wake of the Affordable Care Act,” lead author Alexander Janke notes that Americans who received public insurance under the Affordable Care Act now use the emergency room more frequently than before they were insured. The overwhelming reason: Many urban and rural areas of the nation lack primary health care providers, so the emergency department becomes the only source of health care.
“Of course, we are not the first to highlight the significance of the general problem of lack of access to primary care,” said Janke, originally from Grand Rapids, Mich. “Part of the challenge is political: We need more resources in communities with many un- and underinsured, as in Detroit. Managed care approaches to health care delivery, and especially case management, have found success reducing emergency department utilization for high-frequency users. The Patient Centered Medical Home is a great example of an innovative care delivery model that makes primary care relevant to patients, high-frequency emergency department users or not, who might otherwise visit the emergency department. These kinds of innovations are certainly part of the overall solution. Emergency departments, which remain very much at the front lines of this problem, can also play a role.”
Co-authors and study researchers include Daniel Overbeek, a fourth-year student graduating in May and applying to residency programs in emergency medicine; Justin Bedford, a second-year student and a coordinator for the student Emergency Medicine Interest Group; Aaron Brody, M.D., clinical assistant professor of Emergency Medicine; Robert Welch, M.D., M.Sc., associate professor of Emergency Medicine; and Phillip Levy, M.D., M.P.H., associate professor of Emergency Medicine.
The team reviewed data from the 2013 National Health Interview Survey, administered by the U.S. Department of Health and Human Services. Their analysis utilized 7,233 respondents who reported at least one emergency department visit in the preceding 12 months.
Among emergency room users who reported no usual source of care and who reported relying on the emergency room, 27.7 percent and 35.1 percent, respectively, said lack of access forced them to the emergency room. None of those said their issue was a true emergency.
Patients lacking a stable usual source of health care were more likely to report using the emergency room because it was their “usual place to get care,” it was their “closest provider” or because they “didn’t have another place to go.”
Previous research has shown that Americans who lack access to a usual source of care, such as a family physician, use emergency departments more frequently. This study, the authors said, is the first population-level study to demonstrate their propensity for turning to emergency rooms in the face of a dearth of primary care access.
Emergency departments, the study said, will need to “evolve into outlets that service a wider range of health care needs rather than function in their current capacity, which is largely to address acute issues in isolation.” Otherwise, the overcrowding of emergency rooms for non-emergency issues will remain problematic.
“We found that insurance status is a far less significant predictor of lack of access-based emergency department utilization than usual source of care,” Janke said. “As health care services utilization increases in the era of the Affordable Care Act, the shortcomings of primary care accessibility will become increasingly salient. Many patients will simply present to our nation’s emergency departments. Policymakers should consider providing resources for emergency departments in under-resourced communities to address the full range of health care needs for patients lacking a stable usual source of care.”
The study also points out that if newly insured patients cannot access primary care and instead rely upon the emergency rooms, they may not enjoy the full benefits of health care services provided under the act.
Research has shown that poor health and disruptions in access to primary health care providers are key predictors of emergency room use. The study authors predict that reliance upon emergency rooms will increase as enrollment under the ACA continues. The trend is troubling because prior research indicates stable access to primary care providers is critical for effective health care services utilization. Moreover, studies have found that Americans with an established usual source of care are more likely to follow recommended preventive care measures, and demonstrate better rates of awareness, treatment and control of chronic conditions such as hypertension and elevated cholesterollevels.
The authors recommend the emergency department serve as a case study in accessibility, as well as a “fulcrum to contain costs through improved resource utilization.” They recommend new policies that provide incentives for emergency departments to participate in more holistic care for patients lacking a stable usual source of care.
“We are moving toward a more patient-centered and integrated health care system,” Janke said. “The emergency department has many desirable qualities for patients: accessibility, diagnostic testing, procedures and a full range of provider expertise. In the paper we say ‘policymakers should provide emergency departments with resources and incentives to better address the full range of their patients’ health care needs, especially as utilization picks up under the Affordable Care Act.’ Emergency departments can coordinate better referral and follow-up, and address health issues not related to patients’ acute or emergent conditions, for example, as a checkpoint in long-term hypertension management. Ultimately, though, we will need substantial financial investment to do these things. Emergency department staff already have plenty to do.”
CDC recommends vaccination and rapid treatment with antiviral drugs for people at high risk from flu
January 5, 2015 – Flu continues to expand its reach in the United States this season, with the latest CDC FluView report showing that 43 states are experiencing either high or widespread flu activity, mostly resulting from circulation of drifted H3N2 viruses. Patient visits to doctors for influenza-like-illness (ILI) are now almost even with the peak of 2012-2013 season, the last time H3N2 viruses predominated. Relatively higher flu hospitalization rates seen so far this season are similar to what has been observed during some past H3N2-predominant seasons. CDC continues to encourage influenza vaccination and prompt treatment with flu antiviral drugs for people at high risk of serious flu complications, including people 65 and older, children younger than 5 years (and especially those younger than 2 years), pregnant women and any person with certain health conditions.
For the week ending December 27, 2014, ILI visits accounted for 5.9% of all clinic visits, and had been elevated for 6 consecutive weeks. For the past 13 seasons, ILI has remained elevated for between 1 and 19 weeks each season, with an average of 13 weeks.
Also for week 52, overall flu-related hospitalizations were 12.6 per 100,000 people, which is comparable to the 13.3 per 100,000 overall hospitalization rate seen during the same week of the 2012-2013 season, but higher than the 8.9 per 100,000 rate observed during week 52 of 2013-2014, which was an H1N1-predominant season. Hospitalization rates are almost always highest among people 65 years and older. During week 52 this season, the hospitalization rate for people 65 and older was 51.8 per 100,000 people. During week 52 of the 2012-2013 season, the hospitalization rate for people 65 and older was 52.8 per 100,000. During 2013-2014, it was 16.4 per 100,000. Hospitalization rates are cumulative, so this season’s rates will likely continue to rise. The end-of-season hospitalization rate for people 65 and older during 2012-2013 was 183.2 per 100,000.
Additionally, another 6 flu-associated pediatric deaths are being reported this week, bringing the total number of flu pediatric deaths that have been reported this season to 21. With the exception of the pandemic, the number of flu-associated pediatric deaths has ranged from 37 to 171 since 2004-2005, when pediatric flu deaths became nationally reportable.
Another indicator used to track deaths associated with influenza is the 122 Cities Mortality Reporting System — which tracks the total number of death certificates processed in 122 representative cities and the number of those for which pneumonia or influenza (P&I) is listed as the underlying or contributing cause of death. Last week P & I was at the “epidemic threshold” for that week (6.8%), meaning more deaths than expected were being seen, but this week, P & I is once again below epidemic threshold. Flu seasons typically follow a pattern where influenza-like illness rises, followed by increases in hospitalizations, which are in turn followed by an increase in reported of deaths. P & I is likely to rise again before the season concludes. During 2012-2013, P & I peaked at 9.9 percent. This was the highest recorded P & I in nearly a decade, but was comparable to recorded percentages for past severe seasons, including 2003-2004 when P&I reached 10.4 percent.
H3N2 viruses continue to predominate in the United States this season, accounting for more than 95 percent of all influenza reported to CDC from U.S. WHO and NREVSS collaborating laboratories. In the past, H3N2-predominant seasons have been associated with more severe illness and higher mortality, especially in older people and young children, relative to H1N1- or B-predominant seasons. Between 1976 and 2007, for example, CDC estimates that an average of 28,909 people died from flu during H3N2 seasons, compared to 10,648 people during non-H3N2 predominant years. Estimates of the number of flu deaths among people older than 18 are not available for this season. Only pediatric flu deaths are nationally reportable. CDC uses modeling to estimate the total number of deaths each season but this data won’t be available until after the season has concluded.
Most of the H3N2 viruses circulating are “drifted” or different from the H3N2 vaccine virus; suggesting that the vaccine’s ability to protect against those viruses may be reduced. Two factors play an important role in determining the likelihood that flu vaccines will protect a person from flu illness: 1) characteristics of the person being vaccinated (such as their age and health), and 2) the similarity or “match” between the flu viruses in the vaccine and those spreading in the community.
CDC conducts studies throughout each influenza season to help determine how well flu vaccines are working. These studies are called “vaccine effectiveness” studies or “VE” studies, for short. Recent studies by CDC researchers and other experts indicate that flu vaccine reduces the risk of doctor visits due to flu by approximately 60% among the overall population when the vaccine viruses are like the ones spreading in the community. If the viruses in the vaccine are different from circulating flu viruses, vaccine effectiveness can be lowered. For example, during 2007-2008, drifted H3N2 viruses circulated during the flu season. VE estimates against H3N2 during that season were 43%. CDC anticipates publishing vaccine effectiveness estimates for the current season in mid- to- late January.
CDC continues to recommend flu vaccination even when there are drifted viruses circulating because the vaccine can still prevent infection and also prevent serious flu-related complications in many people. Anyone who has not gotten vaccinated yet this season should do so now. This includes people who may already have gotten the flu this season because flu vaccines protect against three or four different viruses and it’s possible that other viruses will circulate later in the season. It’s fairly common for there to be two waves of flu activity during a season, the second wave is often caused by an influenza B virus. The Flu Vaccine Finder may be helpful locating vaccine.
As of December 5, 2014, an estimated 145.4 million doses of seasonal flu vaccine had been distributed. As of early November, only 40% of people in the U.S. had reported getting a flu vaccine this season. Final vaccine uptake estimates for this season are expected in the fall of 2015.
CDC also recommends flu antiviral drugs for treatment of influenza illness in people who are very sick with flu or people with the flu who are at high risk of serious flu complications. Influenza antiviral drugs are a second line of defense against the flu to treat flu illness. These prescription drugs work best when started soon after influenza symptoms begin (within 2 days), but persons with high-risk conditions can benefit even when antiviral treatment is started after the first two days of illness. People at high risk from flu should see a doctor if they develop flu-like symptoms. While doctors may prescribe antiviral drugs for non-high risk patients with flu, all high risk patients with suspected influenza should be receiving antiviral drugs. There are now three flu antiviral drugs approved and recommended for use this season: oseltamivir (Tradename Tamiflu®), zanamivir (Tradename Relenza®) and peramivir (Rapivab®), the latter is an intravaneous formulation approved for use in people 18 and older by the Food and Drug Administration (FDA) this season.
Nationally the country is likely to continue to experience several more weeks of flu activity as flu spreads to other states that have not yet had significant activity. Activity has been elevated in the Southern states for six weeks now. The mid-west saw increases in activity more recently. Most of the northeast and west of the country has yet to experience the full brunt of the flu season.
Percentage of Visits for Influenza-like Illness (ILI) Reported by the U.S. Outpatient Influenza-like Illness Surveillance Network (ILINet), Weekly National Summary, 2014-15 and Selected Previous Seasons
This graph compares data on influenza-like illness (ILI) collected by the U.S. Outpatient Influenza-like Illness Surveillance Network (ILINet) by week across seven different flu seasons (2003-2004, 2007-2008, 2009-2010 , 2011-2012, 2012-2013, 2013-2014 and the current season, 2014-2015.) The graph illustrates the fact that ILI activity for the current season (2014-2015 ) is most similar to ILI activity during the 2012-2013 flu season. H3N2 viruses were the predominant flu viruses reported during the 2003-2004, 2007-2008, 2011-2012 and 2012-2013 seasons and are currently the predominant flu viruses reported so far this season.
The 2003-2004 season had the highest ILI curve (as high as the pandemic). While 2007-2008 has a similar ILI trajectory to 2012-2013 and to the current season, that year the flu season did not begin until much later.
ILI is defined as fever (100⁰F or higher) and a cough and/or sore throat without a known cause other than flu. (The current national baseline of 2.0% was calculated for the 2014-2015 season and should not be used for previous flu seasons).