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From the President
... Dennis McGill, MD, FACEP
September's board meeting in Atlantic City
was well attended. We reviewed our recent meetings
with State legislators on the pediatric legislative
initiatives. Dr. Michael Gerardi's candidacy was discussed
and our full support will be behind him in Chicago next
month. The initial data compiled by NJHA on Psych holds is
being collated and analyzed by the NJHA. They received over
1300 responses over the 4 week collection period that have
documented Psych holds greater than 12hrs and close to 90%
that involve placement taking 48hrs. The joint position
paper is enclosed further in this newsletter. It should
open some eyes.
We will host our ED directors dinner meeting on December 8th
at the Heldrich Hotel in New Brunswick. We will be
discussing the National ED report cards and have invited
Congressman Frank Pallone with be our lead speaker. We
invite anyone interested to join us Saturday at the ACEP
Council Meeting in Chicago as we review the resolutions and
attend the sessions. Let Bev know if you plan to be in
Chicago over the first weekend and we will work to get you
credentials. For all those heading to Chicago be sure the
NJ - ACEP reception is on your calendar for Tuesday, October
28 at 8pm for a Jersey Rock n Roll good time! We'll be in
Continental Ballroom A at the HQ Hotel, the Chicago Hilton.
Statehouse News....Beverly J. Lynch
The Legislature is back in the swing of
things - with committee hearings and voting sessions
scheduled between now and mid-December. Assemblyman Gary Schaer (D-Passaic) has been named chairman of the powerful
Assembly Financial Insitutions and Insurance Committee,
replacing Neil Cohen who resigned in August.
Top priority issues facing the New Jersey physician
community include ambulatory surgery center referral
legislation, Horizon conversion into a for-profit company,
universal health care, legislation permitting assignment of
benefits, and expansion of wrongful death.
There is a physician-only fundraiser being held for Assembly
Speaker Joe Roberts on Tuesday, December 9. Please mark
your calendar and plan to join your colleagues on this
special evening. Invitations and RSVP information coming
out shortly.
The Assembly Health and Senior Services Committee has
released a new bill from Assemblyman Herb Conaway
(D-District 7). A-1380, which supplements the "Health Care
Quality Act," is intended to reduce the administrative
burden and delay, both for providers and their patients.
It provides that a health insurance carrier which offers a
managed care plan must permit a covered person to receive
covered services from a health care provider in its provider
network without obtaining a referral from the covered
person's primary care physician. The bill is scheduled to
receive full Assembly consideration on September 25.
I met on September 25, with new Deputy Commissioner Mary
Sibley, who heads up the Medicaid office. Mary was
previously health policy director in the McGreevey
Administration. I was joined by Claudine Leone, who
represents the family physicians, and Laurie Clark,
representing the osteopathic physicians. The purpose of our
meeting was to reintroduce the physician organizations to
her, and discuss the multitude of issues and problems with
the Medicaid system. Mary promised to reactivate the
Physician's Advisory Group and open up the lines of dialogue
between the physicians and the program.
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Dates to Remember |
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2008 |
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Oct. 15
6:30 pm |
On the Road Series |
Frog and the Peach
New Brunswick |
Oct. 28
8:00 pm |
Annual NJ
Chapter Reception
at the Scientific Assembly |
Chicago |
Nov. 11
8-3 pm |
Women in
Emergency Medicine
Conference |
Forsgate Country Club
Jamesburg, NJ |
Nov. 12
6:30 pm |
On the Road
Series |
Grand Cafe
Morristown |
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2009 |
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May 12 |
NJ-ACEP
Scientific Assembly |
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Register today
for the
On the Road
Series
sponsored by Sanofi-Aventis US
Guidelines for Antiplatelet and
Antithrombin use in the ED and the transition to Cath and
PCI
Presented by
Marc Cohen, MD, FACC
Director, Division of Cardiology
Newark Beth Israel Med Center
Two dates/locations to choose from:
Wednesday, October 15, 2008 - 6:30 PM
Frog and the Peach
29 Dennis Street, New Brunswick, NJ
732-846-3216
or
Wednesday, November 12, 2008 - 6: 30 PM
Grand Cafe
42 Washington Street, Morristown, NJ
973-540-9444
Dinner and
education are complimenatry.
RSVP to
ppassman@blynchassociates.com
or call
(609) 392-1213
 The
Chair of EM at Lutheran Medical Center (LMC), Brooklyn, NY
is seeking full-time emergency medicine physicians. LMC is a
Level I Trauma Center and a designated stroke center. With
an annual volume of 63,000, LMC offers a wide range of major
clinical programs, a cutting edge 30-bed rehab unit and 476
acute beds. Candidates must be BC/BP EM and have current EM
experience. Competitive compensation and bonus program
offered. Administrative duties also available. Contact:
Bonnie Simmons DO FACEP, Chair, Emergency Medicine, at
718.630.8383.
New Jersey Hospital Association
& NJ-ACEP
Lack of Access to Behavioral Health Care
Forcing Unnecessary Emergency Department Gridlock
The Issue: New Jersey emergency departments
are facing a critical breaking point. Providers are
attempting to address overcrowding and excessive holds of
the increased number of psychiatric patients who are being
left to wait for days to access services.
o Recommendations from the Governor's Task
Force on Mental Health in March 2005 focus on shifting care
for patients to a least restrictive, community-based model,
however those services are not yet available, nor is there a
reasonable expectation that they will be on line in the near
future. The recommendations date back almost four years, and
plans addressing the system of acute care have just begun,
absent any significant background information to help drive
decision making. There has been no systematic approach to
statewide planning based on data.
o There is no resolution on any of the
assurances made over the past three years by the state's
leadership to implement systems that will support patients
who are being warehoused in emergency departments for
excessive periods of time. An NJHA survey conducted in 2007
showed that both children and adults, on average, wait in
the emergency departments for 24 to 48 hours awaiting
transfer to an appropriate level of care, while some
patients can wait as much as 8 to 10 days for transfer to
another facility. More recently, NJHA conducted a 24/7 Fast
Fax study to capture information relative to excessive
emergency department holding of patients in need of
behavioral health services. Key demographic information was
gathered for psychiatric patients who remain in the
emergency department at 12 hour intervals. In one four week
period, participating hospitals reported that there were
more than 1,300 episodes where a patient was made to wait
more than 12 hours. Of those episodes, more than 93% waited
at least 48 hours, with others waiting even longer.
o There is a lack of communication between
state agencies responsible for coordinating services to the
mentally ill, and the spillover effect impacts the acute
care system. Providers are consistently receiving
conflicting messages regarding policy, and patients suffer
as a result. For example, while the Division of Mental
Health Services has assured NJHA that there is no cap on
admissions to the state psychiatric facilities, those
responsible for admissions at AncoraPsychiatric Hospital
have advised that there is a daily cap on admissions, and a
"no admission" policy on the weekends. There continues to be
inconsistent practices in medical clearance, and providers
are deflected from one state facility to another during
evening hours and on the weekends. Providers, although well
intended, cannot provide quiet, stabilizing care for the
mentally ill when they are forced to hold at times dozens of
patients seeking care for their psychiatric or substance
abuse issues.
o A very high percentage of those entering
emergency departments in need of mental health services have
a co-occurring need for substance abuse treatment. When a
patient presents at the emergency room to detox and the
patient does not meet the medical criteria for an inpatient
bed, the patient has three options: (1) Go into a sub-acute
care bed and pay out of pocket, (2) go into a sub-acute care
bed that is subsidized by a county contract, or (3) detox in
the emergency room. Because there are a limited number of
subsidized sub-acute detox units in the state, many patients
are presenting and remaining in the emergency departments
for this care.
o The bifurcated system of care for the
mentally ill does not provide for consistent policy and
practices when addressing the needs of children, adolescents
and adults. There is little training for screening
professionals in the area of the needs of children,
adolescents or the developmentally disabled, and the
requirement to work with these populations is viewed as
another unsupported, unfunded mandate.
o Hospitals have an ethical obligation to
treat patients with dignity. Providers are unable to meet
that responsibility when they are forced to hold patients in
an emergency department for days at a time, when an
individual should be cared for in a different setting.
New Jersey's behavioral health patients and
the state's hospitals seek legislative support for the
following priorities:
1. Require DMHS to develop standardized
admission processes and medical clearance criteria for
admissions to state psychiatric facilities, county
facilities, and those specifically earmarked for the
forensic population, which is part of a centralized
admissions function that operates 24/7, including weekends.
2. Establish a time frame in which DMHS
is responsible for implementing a mechanism to map
behavioral health needs throughout the state, taking into
consideration projected patient care level needs and
availability of services. This mapping will facilitate the
development of systems that will help move patients through
the system of care to address their needs most
appropriately. This mechanism should have measurable goals,
timeframes for implementation and defined outcomes based on
clinically recognized best practice.
3. Require DHSS, in conjunction with
DMHS, to release calls for psychiatric beds, based on a
nationally benchmarked methodology, according to a standing
calendar, no less than every six months.
4. Commission a panel of mental health
leaders, led by experts outside of state government, that
will identify the issues that consistently plague the acute
care system for mental health and, based on clinical best
practices, provide oversight to assure that the priorities
identified are tied to realistic plans of action with
measurable goals, outcomes and timeframes for
implementation.
5. Establish child screening
legislation that sets forth requirements for consistent,
appropriate screening and assessment supported by meaningful
education and training for specialists in this field.
ED Directors
Dinner Monday, December 8, 2008 at 6 PM
The Heldrich Hotel
10 Livingston Avenue
New Brunswick, New Jersey
The New Jersey Chapter of AmericanCollege of
Emergency Physicians (NJ-ACEP) is sponsoring a dinner for
all New Jersey Emergency Department Directors.
Join us for a complimentary dinner with your
fellow ED Directors at the new Heldrich Hotel in New
Brunswick. We have invited Congressman Frank Pallone as our
guest. Congressman Pallone (D-NJ 6), chairs the powerful
Congressional Subcommittee on Health, and will discuss the
emerging healthcare issues that will affect your ED.
You will also receive the State of Emergency
Medicine Report Card, prepared by ACEP, which will be
released on Tuesday, December 9, 2008. We will have a great
PR professional, Liz Thomas from Thomas/Boyd Communications,
who will guide you through the public/media relations
component as it will impact you and your hospital.
Don't miss out on this great opportunity to
network with your Director colleagues.
Register today - click here
NJ Office of the
Attorney General
Division of Consumer Affairs
Changes to NJ Prescription Blanks
In March 2008, the Division of Consumer
Affairs notified you of recent changes to the format of NJ
prescription blanks. The regulation was amended to require
that prescription blanks be numbered consecutively and that
the blanks include the prescriber's or healthcare facility's
National Provider Identifier (NPI). By prior notification,
these requirements were to be met by October 1, 2008.
The Division has been alerted to the fact
that the supply of prescription blanks preprinted to conform
to the new requirements may be inadequate to meet the
October 1, 2008 deadline. As this may affect a patient's
ability to receive reimbursement, the Division is extending
the deadline for preprinting until regulations are adopted
to address this issue. All prescription blanks are still
required to include consecutive numbers, however, you will
be permitted to write in or stamp these numbers onto the
blanks until regulations are adopted, provided you maintain
a system for tracking the consecutive numbers.
For the full memo from the Division of
Consumer Affairs, please visit
www.njconsumer
affairs.gov/drug/dchome.htm.
New Jersey Association of Health
Plans
The New Jersey Association of Health
Plans has put together an updated list of contact
information for each of their member's credentialing units
Carrier Contact Information to Check on
the Status of Provider Credentialing Applications
Aetna:
Call 800-353-1232 for Aetna's national toll free customer
service line direct to its Credentialing Customer Service
staff.
AmeriChoice of New Jersey:
Providers can first call the National Credentialing Center
("NCC") to see if their application has been received and
where it stands in the verification process, that number is
877-842-3210, after which, they can also call the plan to
see if the application has been approved by the NCC and/or
PAS. NOTE: Please have your tax identification number
available. The providers also can contact either the NCC,
or Credentialing in regards to missing or expired documents
that need to be submitted in order to complete the
credentialing process.
AmeriGroup:
Call 732-452-6000 and ask for the Provider Relations or your
provider Representative by name.
AmeriHealth:
Call the Credentialing Support Hotline at 866-227-2186 or on
the web at:
credentialingsupport@amerihealth.com.
CIGNA:
Call 1.800-88CIGNA (1-800-882-4462) to check on your
credentialing status with the Customer Support Center.
HealthNet:
Call Network Operator at 203-225-3921 or visit the web at
www.healthnet.com.
Click on Provider Tab.
Horizon:
Call 888-345-1235 at Horizon to check on application status
and to request an application.
UnitedHealthcare/Oxford Health Plans:
After initiating the credentialing process with the National
Credentialing Center (NCC) providers may call the United
Voice Portal (UVP) number to hear an automated update
regarding the credentialing status. To access this
information: call 877-842-3210; select Other Professional
Services, then Credentialing, then Get Status. NOTE:
Please have your tax identification number. The caller will
be prompted to enter the provider's SSN to obtain status.
Providers may also use the UVP line to
contact the NCC Customer Service Team to obtain
credentialing status updates.
University Health Plans:
Call the Credentialing Department at 732-476-1121
REGISTRATION IS
OPEN!
Women in
Emergency Medicine
Tuesday, November 11, 2008
8:00 AM - 3:00 PM
Forsgate Country Club
Monroe Township, New Jersey
Keynote presentations from
Joanne Conroy, MD
Executive Vice President
Atlantic Health System
And
Amy Mansue
President and CEO
Children's Specialized Hospital
Robert Wood Johnson Health System
Breakout workshops will include
discussions on
Financial Planning
Medical Liability
Stress and Time management
Legal Issues
Self Defense
For more information on registation,
contact NJ-ACEP at (609) 392-1213.
Application for CME has been made.
Feature Article
from the
New Jersey Poison Information & Education System
The case of Missed opportunity to
Treat:
Asymptomatic Acetaminophen Toxicity
by Steven M Marcus, MD
Executive Director
New Jersey Poison Information & Education System
A 32 yo female was admitted through the ED
for altered mental status. Her initial laboratory workup
revealed no significant abnormalities. She became
progressively obtunded and developed a metabolic acidosis
and a urine analysis revealed the presence of many
crystals. The poison center was called to discuss the
management of a possible toxic alcohol but when the hospital
staff reported abnormal liver function studies, with
transaminases in the thousands and a normal BUN, suggested
that as well as 'covering' for any toxic alcohol that a
missed acetaminophen ingestion should be considered and
antidotal therapy be immediately commenced although the
usually considered "window of effectiveness" had passed[1].
An acetaminophen level drawn 24 hours into her hospital
stayed showed a level of over 200 mcg/ml. The patient
deteriorated despite all efforts and expired.
This case represents the worst outcome of a
missed overdose as seen recently. The New Jersey Poison
Information and Education System has documented several
cases, this year, in which the first question about a
possible acetaminophen overdose arose when the patient
developed clinical symptoms and or signs of hepatic damage.
In the other cases, luckily, the patients rallied and
recovered. We are puzzled by this lack of sensitivity to
the possibility and caution all ED staff to look carefully
for this possible "silent" killer.
Although controversial, many believe that it
is not cost effective to screen everyone for an
acetaminophen or aspirin overdoses[2][3][4][5].
We believe this case represents the counterpointal evidence
that this is not the case. The cost of such testing is
infinitesimal when compared to the increased cost of care
required once hepatic insult is produced or the potential
risk of litigation. Although there is evidence that the use
of antidotal therapy (n-acetyl cysteine) in a patient with
fulminant hepatitis increases the patient's chance for
survival, such a situation still carries a significant
mortality of over 20%[1].
The presence of hepatitis without detectable
acetaminophen does not rule out the involvement of the
medication nor eliminate the possible advantage of antidotal
therapy. A recent abstract presented at the North American
Congress of Clinical Toxicology reported the inability to
detect acetaminophen in 21% of cases of apparent repeated
supratherapeutic ingestions[2]. In fact, the
absence of detectable levels seemed to be a predictor of
poor outcome. The lack of suicidal ideation also does not
eliminate the possibility of a "hidden" acetaminophen
overdose since a recent prospective study suggested that
48%, and possibly as many as 56% of patients with
acetaminophen-induced acute liver failure did not intend to
hurt themselves[3]. We believe that all patients
who present with poisonings or with evidence of hepatitis
should have acetaminophen levels and consideration for
antidotal therapy, the case of patient-centered and tailored
therapy[4][5].
We suggest that an acetaminophen and
salicylate level be obtained on any individual presenting
with an overdose. Further, we believe that the antidotal
therapy is relatively inexpensive, effective and safe. The
choice to begin therapy early should be made whenever
possible in order to prevent the development of hepatic
dysfunction. The specialists and toxicologists at NJPIES
are available to help you make the decision to treat or
withhold therapy. Help is a phone call away - 800-222-1222.
[1] Keays R,
Harrison PM, Wendon JA et al. intravenous acetylcysteine in
paracetamol induced fulminant hepatic failure: a prospective
controlled trial. BMJ (1991) 303:1026-1029
[2] Alhelial MA, Hoppe JA, Rhyee Sh , Heard KJ. Clincal
Course of Repeated Supratherapeutic Ingestion (RSTI) of
Acetaminophen (APAP) Clin Tox (2008)46(7)627.
[3] Larson AM, Polson J, Fontana RJ et al.
Acetaminophen-induced acute liver failure: results of a
United States multi-center, prospective study. Hepatology
(2005)42:1364-1372..
[4] Tsai C, Chang W, Weng T et al. A Patient-Tailored N-acetylcysteine
Protocol for Acute Acetaminophen Intoxication. Clin Therap
(2005)27(3):336-341.
[5] Patient-Tailored Acetylcycteine Administration. Ann Emrg
Med. (2007)50(3)280-281.
[1] Smilkstein
MJ, Knapp GL, Kulig KW et al. Efficacy of oral N-acetylcysteine
in the treatment of acetaminophen overdose:analysis of the
national multi-center study (1976-1985) NEJM
(1988)319:1557-62.
[2] Dargan PI, Ladhani S, Jones AL. Measuring plasma
paracetamol in all patients with drug overdose or altered
consciousness: does it change outcome? Emerg Med J. (2001)
18(3):178-82
[3] Sporer KA, Khayam-Bashi H. Acetaminophen and salicylate
serum levels in patients with suicidal ingestion or altered
mental status. Am j Emerg Med (1996) 14(5):443-6.
[4] Chan TY, Chan AY, Ho CS, Critchley JA. The clinical
value of screening for paracetamol in patients with acute
popisoning. Hum Exp Toxicol (1995) 14(2):187-9
[5] Chan TY, Critchley JA, Ho CS, Chan AY. Unrestricted
availability of a plasma paracetamol assay service resulting
in an increased number of inappropriate requests. Postgrad
Med (1995) 71(841):678-80.
For further
information, contact
Steve M. Marcus, MD
Executive Director, New Jersey Poison Information &
Education SystemProfessor, Department of Preventive Medicine
and Community Health and Associate Professor of Pediatrics
New JerseyMedicalSchool
University of Medicine & Dentistry of New Jersey
PO Box 1709
140 Bergen Street, Suite G-1600
Newark, NJ07101-1709
 A
Day of Fun for a Good Cause
The Medical Society of New Jersey would like
to invite you all to join us in supporting a very good cause
while having some tax deductible fun. Please join us on
Monday, October 20, 2008, for a relaxing day of golf, food,
drinks, conversation, and fabulous gifts and prizes at the
beautiful Spring Lake Golf Club. The cost is $385 and
includes lunch, greens fees, cocktails and hors d'oeuvres,
and dinner. The cause is the Institute for Medicine and
Public Health of New Jersey (IOMPHNJ), which is a 501(c)(3)
charitable organization, which makes a chunk of the cost
tax deductible. IOMPHNJ's mission is to improve the health
status of New Jersey residents through innovative public
health practice and high quality medical care by developing
solutions to New Jersey's public health and healthcare
challenges through continuing medical education,
partnerships, policy development, research, and the law. For
more information, please contact Judith Martin Waterman at
waterman@msnj.org, or
609.896.1766, ext. 259. She will be delighted to answer any
questions you might have.
R. Prasad Gupta, MD, President
NJ Department of
Health & Senior Services
 The
New Jersey Department of Health and Senior Services has just
released its fifth annual report on health quality, the New
Jersey 2008 Hospital Performance Report. The report
contains comparative information on the quality of treatment
provided by all New Jersey acute care hospitals, using
nationally accepted measures. This year's report has
expanded the number of measures reported for pneumonia and
prevention of surgical infections. The measures reported
for treating hear attack and heart failure patients remain
the same.
Check out the Department's interactive
website,
www.nj.gov/health/hpr, which contains the full report
and additional quality information and resources not found
in the hard copy report. The web site also allows the user
to compare hospitals by county, region or medical condition.
Fulfill Your
Cultural Competency Requirements
New Jersey Physicians licensed on or before
June 29, 2007 are required to comply with the cultural
competency training requirement by the next license renewal
after March 24, 2008. Physicians licensed on or after June
30, 2007 are required to comply with the requirement by the
end of the next complete renewal cycle after licensure.
The cultural competency training requirement can not be
included in the 100 hour CME requirement for licensure
renewal. The law specifically required that physicians
complete this training in addition to the usual CME required
for relicensure.
Licensees must complete at least 6 hours of CME training in
cultural competency in the following six topics:
1. A context for the training, common
definitions of cultural competence, race, ethnicity and
culture and tools for self assessment.
2. An appreciation for the traditions
and beliefs of diverse patient populations, at multiple
levels- as individuals, in families and as part of a larger
community.
3. An understanding of the impact that
stereotyping can have on medical decision making.
4. Strategies for recognizing patterns
of health care disparities and eliminating factors
influencing them.
5. Approaches to enhance cross-cultural
skills, such as those relating to history-taking, problem
solving and promoting patient compliance.
6. Techniques to deal with language
barriers and other communication needs, including working
with interpreters.
Licensees should maintain certificates
documenting CME attendance for a minimum of 6 years.
Additionally, in order to demonstrate compliance with each
of the topic areas required in the cultural competence
regulation you should keep evidence of the specific
curriculum covered in the course(s) along with your
certificates of completion. (e.g. brochures, course
outlines, materials distributed in the course etc.). Any
properly accredited CME course that meets the requirements
is acceptable regardless of its format. For more
information on these requirements, go to
http://www.njconsumeraffairs.gov/bme/press/cultural.htm
Here's information on a free CME course that
will satisfy the new NJ regulation: The US Department of
Health & Human Services has a FREE 9-hour CME course online
for cultural competency. The CME course has 3 modules of 3
hours each:
https://cccm.thinkculturalhealth.org
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