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In Case You Missed It

Posted on Fri, Feb 26, 2016
In Case You Missed It

Our weekly roundup of healthcare headlines featuring articles about physician burnout, anesthesia for orthopedics, cutting the cost of healthcare, treating the homeless, sepsis, Choosing Wisely in hospital medicine and more!

The Doctor’s New Dilemma - New England Journal of Medicine

Pay for Medical School Through Service - The Association of American Medical Colleges

In My Shoes: Facing burnout as emergency medicine physician - Richmond Times Dispatch

ER Goddess: A Career in Medicine is a Cruel Mistress - Emergency Medicine News

Anesthetic Care for Orthopedic Patients: Is There a Potential for Differences in Care? - Anesthesiology

Crash Cart: Armed guards in the ED, high deductibles and Valentine’s Day - Emergency Physicians Monthly

A Novel Plan for Health Care: Cutting Costs, Not Raising Them - New York Times

The challenges this doctor faces when caring for the homeless - KevinMD

The Third International Consensus Definitions for Sepsis and Septic Shock - JAMA

An Army of One No More: Hospitalists Choosing Wisely with Nurses - Society of Hospital Medicine

CMS and major commercial health plans, in concert with physician groups and other stakeholders, announce alignment and simplification of quality measures - CMS

7 key findings on physician placement - Becker's Hospital Review

In case you missed it, check back next week!

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Featured Clinician: John DellaRipa, CRNA

Posted on Thu, Jan 28, 2016
Featured Clinician: John DellaRipa, CRNA

It’s National CRNA Week, and we’re recognizing some of our anesthesia superstars! Meet John DellaRipa, CRNA at California Hospital Medical Center in Los Angeles.

Years with EmCare: 3 years

Years Practicing Anesthesia: Graduated as CRNA from Kaiser Permanente School of Nurse Anesthesia in 2004.

Why did you choose to become a CRNA? Like many 1970s adolescents, watching Emergency One sparked my interest in pre-hospital medicine. Ultimately, I graduated paramedic school in 1995 from Kapiolani Community College in Honolulu. Shortly after graduation, I enrolled in nursing school at Hawaii Pacific University to expand my medical knowledge for my pre-hospital career. During this time, I discovered the CRNA pathway and knew this was the natural career progression I should pursue.

Describe one of your greatest professional accomplishments. It occurred this August, when I received the award for Clinical Coordinator of the Year for the Kaiser Permanente School of Nurse Anesthesia.

What would be your ideal category on “Jeopardy”? “Regional Anesthesia” for a $1,000, of course.

How do you stay organized at work? Working with students definitely forces me to be organized and on top of all of the latest anesthesia research/techniques.

What are your tips for “leaving work at work” and not getting burned out professionally? Working out before my shift helps clear my mind for the day. I commute from South Orange County to Downtown Los Angeles (58 miles) at 4 a.m. to beat the morning traffic. This gives me 90 minutes to work out before heading into the hospital for my shift.

How are you “making healthcare work better”? I mostly work in the Orthopedic OR, where there are core teams. Working with the same OR staff and surgeons forms strong bonds and relationships that make the workplace enjoyable even during a busy stressful OR day.

What’s the best advice you’ve received about work or life? The best advice I’ve received occurred very early in my pre-hospital career and has stuck with me for more than 20 years. My paramedic mentor Mandy Shiraki, MICT (RIP) said, “Treat every patient as if they were your family member. Treat them how you would want to be treated.”

What do you enjoy outside of work? I work hard and play hard. My personal hobbies outside of work center around family activities: mountain biking, skiing, taking the Jeep out, and working out. Very soon I'm hoping to start training in Jiu Jitsu with my son Griffin.

What’s your favorite inspirational quote? One of my favorite quotes comes from Bruce Lee: “Learning is a process of discovery, a process without end.”

What are you currently reading? I’m reading “Scar Tissue,” the autobiography of Anthony Kiedis of the Red Hot Chili Peppers.

What’s your favorite TV show? Anything that's a documentary: Forensic Files, Making a Murderer, The First 48

What personal accomplishment are you most proud of? My family is my life's biggest accomplishment: my wife Catherine and kids Griffin and Giselle
 

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Featured Clinician: Patti Alexander, CRNA

Posted on Tue, Jan 26, 2016
Featured Clinician: Patti Alexander, CRNA

It’s National CRNA Week, and we’re recognizing some of our anesthesia superstars! Meet Patti Alexander, CRNA at CHRISTUS Spohn Hospital Corpus Christi - Memorial.

Years with EmCare: 15 years

Years practicing medicine: 23 as a CRNA

Why did you decide to become a CRNA? A man whom I looked up to at church told me about his rewarding career, so I looked in to it.

What career did you want to pursue when you were younger? As a child, I wanted to be a stewardess. As a teen, I wanted to be a dentist.

Describe one of your greatest professional accomplishments. My greatest professional accomplishment isn’t mine only, but is shared with my fellow CRNAs and surgical team, saving lives.

What would be your ideal category on “Jeopardy”? Dog Breeds

How do you stay organized at work? Organization at work has become a habit over the years.

What are your tips for “leaving work at work” and not getting burned out professionally? I do take my work home with me, but by talking and praying about those in tragic situations, I defuse.

How are you “making healthcare work better”? By taking a genuine interest in those I care for.

What’s the best advice you’ve received about work or life? Treat others as you want to be treated.

What do you enjoy outside of work? Being outdoors, whether mowing a lawn, hiking, boating or traveling

What’s your favorite inspirational quote? “Think the best of each other, especially of those you say you love. Assume the good and doubt the bad” by Jeffrey R. Holland

Tell us something that most people at work don't know about you. My brother and I overhauled an engine together. I love mechanics!

What are you currently reading? “Plunder and Deceit” by Mark Levine

What’s your favorite TV show? “Person of Interest”

What personal accomplishment are you most proud of? My three children

For more information about CRNA careers, visit the Careers section of our website.
 

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National CRNA Week: Our Growing Role, Especially in Rural Hospitals

Posted on Mon, Jan 25, 2016
National CRNA Week: Our Growing Role, Especially in Rural Hospitals

During National CRNA Week – January 24-30, 2016 – We will recognize some of the amazing men and women providing care in this important clinical role. Visit EmCare’s Facebook page to learn more about our CRNA superstars.

By Linda Caccamo, CRNA, MS, MBA/MHA

America’s rural hospitals are struggling. It seems that I read news of a hospital closure nearly every week. One way that financially strapped hospitals are working to deliver quality care more economically is through the use of advanced practice registered nurses, specifically Certified Registered Nurse Anesthetists (CRNAs).

CRNAs, the primary providers of anesthesia services in rural America, provide the majority of anesthesia care in U.S. counties with lower-income populations and populations that are more likely to be uninsured or unemployed, according to Nursing Economic$.

About CRNAs

CRNAs administer approximately 40 million anesthetics each year in the United States, according to the AANA’s 2014 Practice Profile Survey. The industry began credentialing registered nurse anesthetists in 1956.

CRNAs provide anesthesia in collaboration with surgeons, anesthesiologists, dentists, podiatrists and other qualified providers. They are responsible for patient safety before, during and after surgery. Nurse anesthetists administer every type of anesthesia to patients in a variety of healthcare settings. CRNAs provide continuous pain relief and sustain patients’ critical life functions during surgical, obstetrical and other medical procedures. CRNAs monitor and interpret diagnostic information throughout the course of a patient’s procedure.

Typically, the requirements to be a CRNA are:
 

  • A Bachelor of Science in Nursing (BSN) or other appropriate bachelor’s degree
  • A current license as a registered nurse
  • At least one year’s experience as a registered nurse in a critical care setting
  • Graduation with a minimum of a master’s degree from an accredited nurse anesthesia educational program
  • Pass the National Certification Examination following graduation.

To be recertified, CRNAs must obtain a minimum of 40 hours of approved continuing education every two years, document substantial anesthesia practice, maintain current state licensure, and certify that they have not developed any conditions that could adversely affect their ability to practice.

Job Outlook

Due to increased financial pressure on hospitals, there is a significant and growing need for CRNAs across the country. A 31 percent growth rate is predicted over the next decade, according to nursejournal.org.

EmCare employs CRNAs in facilities across the country. They are valued members of our clinical team, and our integrated care approach enables CRNAs to practice at the top of their licenses.

EmCare supports CRNAs in a variety of ways, including:
 
  • Leadership, teaching and mentoring opportunities
  • Flexible scheduling
  • Earn While You Learn, a program that provides a monthly stipend to providers completing a CRNA program

During National CRNA Week – January 24-30, 2016 – We will recognize some of the amazing men and women providing care in this important clinical role. Visit EmCare’s Facebook page to learn more about our CRNA superstars.

Linda Caccamo

Linda Caccamo, CRNA, MS, MBA/MHA, is Senior Vice President of Operations for EmCare Anesthesia Services. Caccamo received her master’s degree in anesthesiology from the Medical College of Pennsylvania and combined MBA/MHA from Wilmington University in Delaware. In her current role, she offers supervision and support for anesthesia site medical directors and professional staff. Before joining EmCare, she served as an executive director for a large anesthesia group practice at a Level 1 regional referral center. She is a former instructor for Advanced Cardiovascular Life Support (ACLS) and has earned a Black Belt Certification in Lean Methodology for Healthcare. She has served on numerous professional and state level committees and continues to practice anesthesia as an anesthetist in EmCare’s North Division.

 

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Trends in Perioperative Anesthesia Services Management and the Implementation of Accountable Care

Posted on Thu, Sep 10, 2015
Trends in Perioperative Anesthesia Services Management and the Implementation of Accountable Care

By Trevor S. Sutton, MD, MBA, CPE

The current and future healthcare market requires that providers, facilities and integrated healthcare systems implement business strategies that focus on optimization of population health. Evolving regulatory mandates, incentives and guidelines have initiated change in healthcare delivery models as well as change in the management of healthcare services.
 
In this rapidly changing market, effective anesthesia practice management requires forward-looking design and implementation of strategies that promote alignment between anesthesia providers, non-anesthesia providers and healthcare delivery systems in achieving the often quoted “triple aim”:
 

  1. High-quality care based on consensus standards, guidelines and performance metrics
  2. Efficient cost management
  3. Achievement of enhanced patient (and client) satisfaction in association with healthcare delivery.1 

An important consideration in population healthcare management is that the delivery of clinical services must be market-driven on multiple levels. Specifically, healthcare management strategies must incorporate evidence-based best practice when there is consensus regarding clinical decision-making and clinical outcomes associated with healthcare delivery. Moreover, healthcare management strategies must be achievable and sustainable in terms of available clinical evidence and local or regionally available healthcare resources. The ladder requirement may create a hurdle to success when loosely coordinated healthcare delivery teams serve sizeable and geographically dispersed populations with a broad array of healthcare service needs. We recognize that a monolithic approach to anesthesia services management and a non-integrated approach to anesthesia care delivery will inevitably face implementation and sustainability challenges when it’s applied to a broad variety of clinical practice settings.
 
The Perioperative Surgical Home (PSH) is a concept that has been examined and promoted by the American Society of Anesthesiologists in response to the growing mandate for accountable care.2 It’s referred to as a “disruptive innovation” because it recommends enhanced implementation of the full array of anesthesia competencies not only in clinical care, but also in perioperative health system management. The PSH targets achievement of the population health “triple aim” through anesthesia team engagement in developing, supporting and leading coordinated and disciplined healthcare delivery models that promote measureable accountability for the service and outcomes associated with the perioperative care of surgical patients.2

Scope of the Perioperative Care Continuum
 
As suggested by the PSH model, the spectrum of coordinated anesthesia services must extend throughout the care continuum to enhance both value generation and accountability. This implies the existence, development or acquisition of substantial capabilities by groups and organizations that manage the delivery of anesthesia services. The competencies required include, but are not limited to:
  • Mature and effective clinical and executive healthcare leadership
  • Robust clinical, technological and administrative competencies across the perioperative care continuum
  • A clinical operations culture that prioritizes commitment to patient safety, learning, innovation and continuous improvement 
Because these competencies must be applied in all phases of the care continuum, examination of the scope of the care continuum is an important consideration.
 
The historical model for delivery of anesthesia services has focused on day-of-surgery patient
care (Figure 1). This model remains prevalent today, with an anesthesia management strategy that is often focused on volume-based and flow-directed management of operating room service. This, in many aspects, reflects a supply chain management approach to the delivery of anesthesia services. In such models, systems for coordinated engagement of patients, medical consultants, laboratory testing and cross-specialty physician follow-up following procedural care often are not fully developed or not fully utilized.

Figure 1
 
In contrast to the historical model for anesthesia service delivery, current and future models for anesthesia services management will create opportunities for early and extended engagement of both patients and the medical consultants who drive the referral and management of surgical patients. This more sophisticated and disciplined framework for managing service delivery recognizes that the domain expertise of anesthesia providers includes interpretation and implementation of guidelines for preoperative testing, preoperative risk assessment, and preoperative risk modification as well as post-operative critical care and post-operative pain management.
 
In support of this contemporary framework for anesthesia services management, numerous case studies have demonstrated that anesthesia preoperative assessment programs promote reliable, high-quality, cost-effective care. There also is evidence that anesthesia providers have an important role in preoperative risk modification strategies (“pre-habilitation”).3 Anesthesia providers are integral in evidence-based clinical care pathways such as Enhanced Recovery After Surgery (ERAS)4. Anesthesiologists also deliver high-quality and cost-effective care in the critical care setting through expertise in ventilator management, blood product transfusion protocols, pain management protocols, and sophisticated utilization of monitors and pharmacological agents that accomplish both hemodynamic stabilization and organ protection. Finally, anesthesia providers impact patient experience and length of admission through preoperative consultation, mitigation of morbidities such as pain and nausea, as well as through targeted strategies for glucose management, fluid management and management of other clinical and physiologic parameters in coordination with surgeons and medical specialists. Patient assessment following discharge also may involve teams that include or are led by anesthesiologists, particularly as consultants for outpatient pain management and, in selected instances, to contribute to multispecialty approaches to care that monitor and improve functional status during convalescence from surgery to maximize desirable outcomes and prevent readmission.
 
In summary, the current and future models for effective delivery of anesthesia care will leverage domain expertise in the management of anesthesia clinical services across the entire surgical care continuum. Broad clinical expertise, expertise in multispecialty care coordination, and expertise associated with data analytics and utilization of technologies that efficiently bring safe care to patients in the most cost-effective settings are the requirements for the new anesthesia service delivery model. Importantly, local solutions may require flexible and selective application of these competencies since an integrated and consensus-driven approach is consistently a requirement of effectiveness and sustainability (Figure 2).


 
EmCare’s Approach to Perioperative Anesthesia Management
 
EmCare delivers quality and value in perioperative anesthesia management through maintaining focus on clinical care, clinical service, operations management and cost management.5 Our foundation for excellence in clinical quality is supported by collection of data from every patient encounter that is subsequently embedded in analysis that is indexed against national and internal practice performance benchmarks. This enables us to identify outcomes variation as well as opportunities for practice improvement. Our clinical quality reporting is transparently shared with partner facilities, and this supports alignment of our clinical providers with the performance priorities of our clients and partners.
 
Our approach for accountability in providing reliable service is supported by the data-driven outcomes program referenced above, as well as by performance metrics/incentives and data garnered through process outcomes analytics created, in part, through utilization of anesthesia information management systems (AIMS) and real-time client satisfaction survey instruments.
 
EmCare Anesthesia Services also utilizes a variety of provider engagement, risk-sharing and partnership models.5 Accountability for perioperative care is achieved by leveraging internal resources to support high-quality, reliable, cost-effective care delivery. Specifically, EmCare Anesthesia Services focuses on innovation in care transitions and integrated coordination of care between anesthesia, emergency medicine and hospitalist service lines supported by mobile and remote healthcare delivery solutions. We bring telemedicine and mobile healthcare capabilities to the perioperative continuum that extend from sister companies (Evolution Health  and American Medical Response). These resources enhance our capability to generate value through an integrated, multispecialty approach to care coordination. Our focus is to support safety, improve quality, improve satisfaction, and reduce costs through a broad array of anesthesia competencies coupled with locally customized approaches to integrated care delivery that provide innovative solutions across the perioperative continuum.

The Impact of EmCare’s Pre-Anesthesia Testing Clinics
 
EmCare Anesthesia Service’s pre-anesthesia testing (PAT) clinics have reduced operating room cancellation rates, decreased the incidence of preventable delays in the operating room, reduced operational costs, and increased growth opportunities. The table below (Figure 3) demonstrates baseline performance and performance one year following implementation of an anesthesia-directed pre-admission testing clinic at two EmCare client facilities. Hospital #1 is a regional medical center initially performing approximately 6,500 operating room procedures per year. Hospital #2 is a large tertiary care, sub-specialty referral and trauma center.6
 

 
EmCare Anesthesia’s Value Proposition in Perioperative Management
 
As a leader in anesthesia practice management services, EmCare Anesthesia Services has focused on continuous improvement and versatile expansion of integrated healthcare delivery capabilities coupled with innovative design and implementation of solutions for the current and future priorities in healthcare. Our flexible, yet comprehensive approach to patient-centered care focuses on high reliability, patient safety, quality outcomes and cost efficiency. Through embracing and using the tools of process engineering science, continuous quality management and disruptive innovation, we create an environment for learning and professional development that enables us to attract and retain talented healthcare providers and leaders. This commitment to leading-edge market strategies that promote safety, quality and excellence in clinical performance will enable us to evolve with the changing trends in anesthesia services management, while also allowing us to generate value for the patients, providers and clients we serve.     

Learn more about how EmCare ensures patients are adequately prepped for surgery during our Webinar with Becker’s Hospital Review - Practical Approaches to Improving Patient Pre-Op Preparation - Thursday, September 17 from 1 to 2 p.m. CDT.  >>Click for more information and to register

Dr. Trevor Sutton
 
Trevor Sutton, M.D., MBA, CPE, is Regional Medical Director of EmCare Anesthesia Services, North Division. He holds a bachelor’s degree in biochemistry from Harvard University, a medical degree with honors from the University of California's San Francisco School of Medicine, and a master's degree in business administration from the Isenberg School of Management at University of Massachusetts, Amherst. He completed his internship, residency in anesthesia and critical care, and fellowship in cardiothoracic and vascular anesthesia at Massachusetts General Hospital, Boston.
 
Bibliography
1. Berwick DH, Nolan TW, Whittington J (2008). The Triple Aim: Care, Health, and Cost. Health Aff Vol 27, No. 3 759-769
 
2. Kash B, Clinw K, Menser T, Zhang Y (2014). The Perioperative Surgical Home (PSH): A Comprehensive Literature Review for the American Society of Anesthesiologists
 
3. Gillis C (2014). Prehabilitation versus Rehabilitation: A Randomized Control trial in Patients Undergoing Colorectal Resection for Cancer. Anesthesiology Vol 121, 937-947
 
4. Cannesson M, Kain Z (2014). Enhanced recovery after Surgery Versus perioperative Surgical Home: Is It All in the Name? Anesthesia and analgesia Vol 118 (5), 901-902
 
5. Hicks, M (2014). EmCare’s Approach to Perioperative Management (Presentation) EmCare North Division Leadership Conference Philadelphia, PA
 
6. EmCare Anesthesia Case Studies (2014). The Impact of the Pre-Anesthesia Testing Clinic Sparks Regional Medical Center (Fort Smith, AR), Baylor University

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