Conference Summary 05/28/20

Emergency Department Myths (Senior Grand Rounds) – Colin Danko, MD
 
PCN Allergy and Cephalosporin cross reactivity
Penicillin true cross reactivity with cephalosporins is 1-3%
Most occur with first gen cephalosporins
Third gen cephalosporin or later seems to be ok
 
Contrast induced nephropathy
Nephropathy seems to be a lab based issue (? Relevance, not patient centered)
The contrast has changed (low osmolar now) 
2017 Meta analysis – No AKI with contrast – observational studies
             No increased rate of CRRT or mortality
 
Lidocaine with epinephrine safety in digital nerve blocks
Lido w/ epi in digital nerve block not associated with digital necrosis
             Safe to use for digital blocks
 
Topical anesthetics in the eye (proparacaine, tetracaine)
Safe to use at home for patients with corneal abrasions, provide strict use instructions
No change in outcomes (wound healing/complications). Better pain control
 
Kayexalate
Not a great improvement in potassium
Studies are flawed that reported benefit
Side FX: Bowel necrosis - Bad
 
Cricoid Pressure aka Sellick Maneuver
            Reported to decrease rate of aspiration
Study shows doesn’t change rates of aspiration 
Makes view worse
            This is different than bimanual intubation (use of your right hand to get cords in view)
 
The Q word (Use of the word quiet in the ED)
            Not associated with a worse clinical shift or higher volume
 
 
Vascular Emergencies – Bobby Barnes, MD
 Arterial Occlusion:
Embolic cause >> Thrombotic (80%:20%)
 
ABI important to determine severity:
Best Pedal sbp / best brachial sbp
Normal > 0.8
Bad < 0.5
 
Doppler Wave Forms are important:
Triphasic -> diphasic -> monophasic -> no wave form
Good flow -> less flow -> low flow -> no flow                       
Also listen for venous hum
 
DVT causing ischemia:
Phlegmasia cerulea dolens - painful blue limb from DVT
Phlegmasia alba dolens - painful white limb from DVT
 
Rutherford Classification:
            Uses Neurological exam (strength/sensation) and doppler (arterial/venous waveforms)
            Viable (Class I), Threatened (IIa, IIb), Non-salvageable (III)
 
Management:
            ASA and Heparin for all unless contraindicated (aortic dissection)
 
Disposition:

Rutherford I and IIa
Go to IR suite for tPA
Have time to tolerate slower treatment with tPA

Rutherford IIb and III
Go to OR for bypass vs amputation 
Time is limited


Be a Top Earner. Billing and Coding – Walt Green, MD
 
Increase the RVU’s
            More patient’s per hour – push to “see one more”
            Document better – 99284 to 99283 is a big change in pay
Flow is important
            Don’t do upstairs workup in the ED, empty the bed
            Don’t be distracted at work – no Netflix, stock picking, fantasy league
1 RVU = $36
 
Don’t over-document for low acuity charts (ankle sprain, suture removal, etc)
 
Critical items for Level 5 (99285) chart
4-10-29
4-History
10-ROS
2-social, family, past medical
9-physical exam with 2 bullet points in each section

Critical Care Time – 99291
Have a template
Starts at 30 minutes and higher
Don’t lie about the time spent – High fines

Procedural Sedation
            Have a templated note so that you get the RVU/reimbursement
            EPIC/EMR charting usually does not allow coders to see and bill this activity --> Lots of money lost