A Physician Advisor Referral from the Emergency Department - The 3 Cs

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A Peer-Reviewed Journal for Case Management and Transitions of Care Professionals I S S U E

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In This Issue:

A Technical Solution to Medicare Inpatient-only Write-offs



GRAND ROUNDS A Physician Advisor Referral from the Emergency Department—The 3 Cs Dani Hackner, MD, MBA; Lory Wiviott, MD; Marc Adler, MD; Ariana Peters, DO; Stephen Crouch, MD This article is an expert panel discussion regarding a case scenario on a topical issue involving care management, population health and physician advising. The panel consists of several members of the Association of Physician Leadership in Care Management. CASE SCENARIO: A 62-year-old woman presents to the clinic with flu-like symptoms and diarrhea. The advanced practitioner (APP) notes a rash on the head and chest as well as conjunctivitis. The history is fragmented, as the patient speaks Spanish and a Guatemalan native language, and the clinic APP speaks neither. The APP also notes moderate dehydration and goes to the waiting area to speak with the family to get more history and about transporting the patient to the emergency department. The family is frightened because ‘a lady from the government has been calling’ and the patient recently lost her job. After reassurance, the family is agreeable to transfer, and the APP calls ahead. While waiting for the ambulance, the APP takes additional history and finds out the patient works as a house cleaner for a family with eight children, two of which have been hospitalized recently.


The patient arrives in the emergency department (ED) and the triage nurse places the patient in a bed in the open urgent care section. A physician sees the patient and orders fluids and labs and places an inpatient order pending hospitalist co-signature. A hospitalist taking admissions in the ED sees the patient and cosigns the admission orders with a working diagnosis of dehydration. A social worker with a Spanish translator takes a detailed history. A UM nurse reviews the case remotely and calls the physician advisor about bedding classification. Question from Dr. Hackner: As an emergency physician and physician advisor, what is your immediate concern? Answer from Dr. Stephen Crouch: As a physician advisor and emergency physician, my first concern is to identify the clinical plan and obtain an enhanced history on illness contacts. The case is concerning for an active case of measles in the setting of a suggestive exposure. Why were the children at her work hospitalized? If the exposure was not to measles, then the likelihood of measles is far lower.

As far as this patient, the age places the patient at the threshold of suspected immunity (born before 1957) but the rural origin and poor history raise red flags. The clinical presentation with a cranio-caudal rash, coryza, conjunctivitis and diarrhea are highly suspicious. Finally, before taking any further history, this patient needs to be masked along with providers and moved to a negative pressure room. If unavailable, the patient should be placed in a room with a closed door. Question from Dr. Hackner: What are the relevant issues regarding bedding this patient as an inpatient or providing observation services? Answer from Dr. Ariana Peters: Dehydration and diarrhea can be common complications of measles and in a 62-yearold patient it would be clinically reasonable to expect two midnights in-hospital. Hence, it is clinically reasonable to admit the patient as an inpatient. However, there is risk to staff of hospitalization and if the patient can be rapidly stabilized, returning the patient to the community, in isolation/quarantine with public health tracking may be safer level of care pending workup. My initial approach


would be to observe the patient, but to do so in a negative pressure room with Airborne Isolation procedures pending workup. In most states, public health will be involved in decisions to discharge or quarantine. Many dedicated observation units do not have the capability for Airborne Isolation, so involvement of nursing/bed flow leadership is important. It is especially important to document the plan in detail in such cases. An observation order should not prompt routine observation services in an open observation unit. Question from Dr. Hackner: What are the public health, population health and community concerns? Answer from Dr. Marc Adler: From a public health perspective, we need to initiate hospital protocols and isolation from the outset. In the clinic, I would expect masking and isolation immediately, and notification of the emergency department and infection prevention department. Transport should also be aware of the need to isolate. Infection Prevention/Control typically works closely with the local department of health, which also needs to be notified promptly. However, failure to isolate and risk assess early can lead to an avalanche of contacts needing follow up. With employee exposures, occupational health needs to be involved. In addition, this should prompt an employee health service to review all staff for documented vaccination status. The chief of staff, chief medical officer and chief of training must be notified about a measles exposure. Vaccination statuses of voluntary medical staff, visitors and even students/trainees should be known or verified. Finally, from a hospital administration perspective, the CEO and community outreach leadership need to be notified early to craft timely community communication. Question from Dr. Hackner: Once prevalent throughout the United States, in 2000, measles was declared eliminated from the United States. Many health care providers have never seen a case of measles. What are the clinical considerations in care of measles-exposed individuals or acutely ill patients with measles?

Answer from Dr. Lory David Wiviott: Measles is a vaccine-preventable illness caused by a single stranded RNA virus in the paramyxoviridae family. Although measles was declared as eliminated from the United States in 2000, the incidence of the highly communicable disease has risen. The index cases for outbreaks in the United State are most often travelers to or from countries where measles transmission remains high, with subsequent development of outbreaks spreading through unvaccinated populations. THE THREE CS The classic illness presents with fever, rash and “the three Cs”: cough, coryza and conjunctivitis. Importantly, patients may be contagious for four days before onset of illness, and the characteristic rash and enanthem (“Koplik’s spots”) may not occur until several days after the onset. Additionally, persons who received the killed measles vaccine deployed between 1963 and 1967 may have an attenuated, “atypical” presentation, further confounding diagnosis. A high index of suspicion is thus required for both optimal patient care and Public Health indications. Through the first quarter of 2019 there have been 465 cases of measles confirmed in 19 U.S. states. This total already exceeds the annual cases from 2018. IMMUNITY First, we need to take a history and determine who is immunized. Babies under age of three months in vaccinated mothers have passive immunity, children age one with one or more with an MMR vaccination have active immunity and children age five or older with two MMR vaccinations are immunized. Other immunized individuals include those with a history of acute measles infection. Patients born before 1957 are assumed to be immunized due to the high prevalence prior to 1957. For patients with uncertain immune status, a serum IgG can confirm immune status in less than an hour typically. ADMIT OR NOT? Patients with a certain immunity status or with serological immunity (IgG levels) do not need to be admitted to hospital. In cases of true measles exposure without immunity, additional testing is required for active disease. In cases without active disease, postexposure prophylaxis may be required. In

cases of active disease, the acute condition will need to be managed supportively while the patient is cared for in respiratory isolation (Airborne Isolation). IP/DPH will need to investigate contacts to exposed or ill patients. Familiarity with local and hospital protocols and the clinical fundamentals are important for current practicing physician advisors and care management staff. DIAGNOSIS OF ACUTE MEASLES Diagnosis of acute measles is usually established with an IgM serology, along with nasopharyngeal and urine viral cultures. Molecular assays are becoming more widely available as well. Airborne isolation is required, as is immediate involvement of both hospital-based infection control professionals and community public health departments. Management is largely supportive in that there are no approved measles antivirals, but many experts recommend administration of vitamin A for children upon diagnosis. MAJOR COMPLICATIONS Major complications include encephalitis and respiratory compromise with an overall mortality rate in children of one to two per thousand. Persons at high risk for poor outcome include the immunocompromised, under five years old, adults greater than 20 years old, and pregnant women. Postexposure prophylaxis with MMR or immunoglobulin may be considered for these high-risk patients with no documented evidence of immunity. QUARANTINE Some patients transitioned back to the community will require quarantine for up to 21 days pending testing and treatment. This is coordinated through public health officials, and care management staff will need to assist in transitions from acute to community. Statement from Dr. Hackner: As a physician advisor, it is important to maintain current clinical competencies. Physician advisors and care managers should recognize the emerging threat of unvaccinated conditions such as measles in patients presenting to healthcare organizations. In general, when physician advisors and care management professionals assess common questions like bedding status in



complex cases, it is important to maintain clinical awareness. Communicable diseases such as measles pose a risk to staff, other hospitalized patients and the community. Stable patients who do not require the hospital as ‘the least restrictive’ level of care may be able to more safely complete their workup in the community. Reportable infectious conditions such as measles require rigorous compliance with infection prevention protocols, including masking and isolating prior to close contact with all staff, limiting and tracking healthcare contacts, rapid assessment of immunity status, and involvement of department of health and infection control professionals early.

Did You Know?

Cases with sparse histories, poor documentation and weak communication pose additional risks to patients, staff,


institutions and the community. Early history taking, including professional translation, timely information-sharing and consultation of infection prevention, can be a key to preventing a cascade of exposures and harm to patients, staff and community.

officer of Southcoast Health/SHG in Massachusetts.

For more information about the measles, excellent patient and provider materials are available through the www.CDC.gov website.

Ariana Peters, DO, FACOI, FHM is a physician advisor and hospitalist/ instructor in medicine at the Mayo Clinic in Phoenix, Arizona.

For more information about the Association for Physician Leadership in Care Management in association with ACMA, reach out to Robert Grant MD, (President), Deb McElroy MPH RN (liaison) or any of the board members (www.aplcm.org). ABOUT THE PANEL Dani Hackner, MD, MBA is pulmonary/critical care, chief clinical

Stephen Crouch, MD, is medical director of care management at Advocate Aurora Health System.

Marc Adler, MD, is a physician advisor in internal medicine, and medical director/physician advisor at NYU Langone Medical Center. Lory David Wiviott, MD, is a physician advisor in infectious diseases and chairman of medicine/medical director at the California Pacific Medical Center.

Do You Know Where the Medical Term Grand Rounds Came From? The tradition of medical grand rounds can be traced back to William Osler, the first professor of medicine, beginning in 1889, at Johns Hopkins hospital in Baltimore. He introduced a novel physician-tophysician teaching forum to disseminate cutting-edge medical knowledge. This collaborative approach became known as a “grand round” because the original Johns Hopkins building created in the 1880s had a round dome with patient units. Osler and his trainees had to walk circular hallways to see their patients. The term has stuck with us, and today just about every discipline from prehospital to rehab medicine use it. Now you know!

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