News & Updates

Dallas Observer Source | Comments Courtesy of Matt Zavadsky

Interesting perspective from the reporter, and the American Society of Anesthesiologists…

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Don't Wanna Be Sedated

Sometimes law enforcement officers need assistance restraining people in custody. Sometimes they enlist the help of EMTs and powerful sedatives.

JACOB VAUGHN

JULY 24, 2020 

https://www.dallasobserver.com/news/police-and-emts-use-of-anesthetics-to-control-suspects-debated-11927060

In 2016, Tony Timpa had a run-in with the police. As he stood outside a porn shop on Mockingbird Lane, Timpa called the cops, telling them he was scared, off of his medication and suffering from mental illness. By the end of the night, the 32-year-old Timpa was dead, dying in the custody of the police he had called not long before.

In the time it took the officers to show up, a nearby security guard saw Timpa crossing the street, walking into traffic, and put him in handcuffs until police arrived. When three Dallas Police officers arrived, they switched out his handcuffs and rolled him onto his stomach. One of the cops, Dustin Dillard, held Timpa's face down in the grass with his knee on his back.

This position was held for over 13 minutes. 

When paramedics arrived, they administered Versed, a strong sedative. According to The Dallas Morning News, by the time Timpa was given the sedative, officers on the scene were already questioning whether he was awake.

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The Academy of International Mobile Healthcare Integration honors the legacy of Jack Stout. Jack was an innovative leader, who pioneered the high-performance, high-value EMS systems our members carry on today. His friendship and mentorship will be sorely missed, though his legacy lives on through his son, Todd, and the work of emergency medical services around the world. Our thoughts are with the Stout family during this very sad time. Rest in peace, Jack.

The Standard source article 

Despite being so severely short-staffed, Chief Kevin Smith said paramedics managed to get through the crisis thanks to a substantial reduction in calls for service as well as increased efficiency at Niagara hospital emergency departments that eliminated offload delays in delivering patients to the care of medical staff.

“At one point we had upwards of 70 paramedics required to be self-isolating out of an abundance of precaution. It certainly does take a hit on your human resources,” Smith said.

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Many EMS systems reported similar trends...

Special thanks to Jimmy Pierson of Medic Ambulance for sharing this story…  The referenced study is available in the JAMA hyperlink in the article.

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COVID-19: 'Dramatic' Surge in Out-of-Hospital Cardiac Arrests in NYC

Megan Brooks

June 24, 2020

https://www.medscape.com/viewarticle/932913

The COVID-19 pandemic in New York City led to a surge in out-of-hospital cardiac arrests (OHCAs) that placed a huge burden on first responders, a new analysis demonstrates.

During the height of the pandemic in New York, there was a "dramatic increase in cardiopulmonary arrests, nearly all presented in non-shockable cardiac rhythms (>90% fatality rate) and vulnerable patient populations were most affected," David Prezant, MD, chief medical officer, Fire Department of New York (FDNY), told Medscape Medical News.

In a news release, Prezant noted that "relatively few, if any, patients were tested to confirm the presence of COVID-19," making it impossible to distinguish between cardiac arrests as a result of COVID-19 and those that may have resulted from other health conditions.

"We also can't rule out the possibility that some people may have died from delays in seeking or receiving treatment for non–COVID-19-related conditions. However, the dramatic increase in cardiac arrests compared to the same period in 2019 strongly indicates that the pandemic was directly or indirectly responsible for that surge in cardiac arrests and deaths," said Prezant.

The study was published online June 19 in JAMA Cardiology.

New York City has the largest and busiest EMS system in the US, serving a population of more than 8.4 million people and responding to more than 1.5 million calls every year.

To gauge the impact of COVID-19 on first responders, Prezant and colleagues analyzed data for adults with OHCA who received EMS resuscitation from March 1, when the first case of COVID-19 was diagnosed in NYC, through April 25, when EMS call volume had receded to pre-COVID-19 levels.

Compared with the same period in 2019, the COVID-19 period had an excess of 2653 patients with OHCA who underwent EMS resuscitation attempts (3989 in 2020 vs 1336 in 2019, P < .001), an incidence rate triple that of 2019 (47.5 vs 15.9 per 100,000).

On the worst day – Monday, April 6 – OHCAs peaked at 305 cases, an increase of nearly 10-fold compared with the same day in 2019.

Despite the surge in cases, the median response time of available EMS units to OHCAs increased by only about 1 minute over 2019, a non-significant difference. Although the average time varied, median response time during the COVID period was less than 3 minutes.

A More Vulnerable Group

Compared with 2019, patients suffering OHCA during the pandemic period were older (mean age 72 vs 68 years), less likely to be white (20% white vs 33%) and more likely to have hypertension (54% vs 46%), diabetes (36% vs 26%), physical limitations (57% vs 48%) and cardiac rhythms that don't respond to defibrillator shocks (92% vs 81%).

Compared with 2019, the COVID-19 period had substantial reductions in return of spontaneous circulation (ROSC) (18% vs 35%; P < .001) and sustained ROSC (11% vs 25%; P < .001). The case fatality rate was 90% in the COVID-19 period vs 75% a year earlier.

From JAMA Network Open | Comments Courtesy of Matt Zavadsky

Tip of the hat to Dr. Marshal Isaacs from the UT Southwestern/BioTel system in Dallas for this excellent find!

Might be interesting for other systems to conduct a similar analysis of the pre-hospital system, including dispatch and field encounters.

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Clinical Characteristics of Patients With Coronavirus Disease 2019 (COVID-19) Receiving Emergency Medical Services in King County, Washington

JAMA Netw Open. 2020;3(7):e2014549. doi:10.1001/jamanetworkopen.2020.14549

July 8, 2020

Betty Y. Yang, MD1; Leslie M. Barnard, MPH2; Jamie M. Emert, MPH2; et al

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2767993

 

Question  What is the clinical presentation to emergency medical services among persons with coronavirus disease 2019 (COVID-19)?

 

Findings  This cohort study of 124 patients with COVID-19 revealed that most patients with COVID-19 presenting to emergency medical services were older and had multiple chronic health conditions. Initial concern, symptoms, and examination findings were heterogeneous and not consistently characterized as febrile respiratory illness.

 

Meaning  The findings of this study suggest that the conventional description of febrile respiratory illness may not adequately identify COVID-19 in the prehospital emergency setting.

 

Abstract

Importance  The ability to identify patients with coronavirus disease 2019 (COVID-19) in the prehospital emergency setting could inform strategies for infection control and use of personal protective equipment. However, little is known about the presentation of patients with COVID-19 requiring emergency care, particularly those who used 911 emergency medical services (EMS).

 

Objective  To describe patient characteristics and prehospital presentation of patients with COVID-19 cared for by EMS.

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This may also be the future for most EMS agencies…  Tough fiscal times ahead…

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Hospitals will take $320B hit this year, AHA says

MICHAEL BRADY

June 30, 2020

https://www.modernhealthcare.com/finance/hospitals-will-take-320b-hit-this-year-aha-says

Hospitals and health systems will lose over $320 billion in 2020 due to the COVID-19 pandemic, according to an American Hospital Association report Tuesday.

More than $200 billion in financial losses occurred from March to June. But the AHA expects hospitals to lose another $120 billion—about $20 billion per month—through year-end, mostly driven by lower patient volumes.

The report probably underestimates 2020's total financial losses because "the analysis does not account for currently increasing case rates in certain states or potential subsequent surges of the pandemic occurring later this year," the AHA said in a statement.

"Hospitals and health systems are in the midst of the greatest financial crisis in our history," AHA CEO Rick Pollack said.

"While we appreciate the support to date from Congress and the (Trump) administration, this report clearly shows that we are not out of the woods. More action is needed urgently to support our nation's hospitals and health systems and front-line staff."

According to the report, average inpatient volume is down about 20% compared with 2019, while average outpatient volume has slipped nearly 35% relative to last year.

"Most hospitals and health systems do not expect volume to return to baseline levels in 2020," the AHA said in a news release.

The AHA's report doesn't account for hospitals' direct COVID-19 treatment costs or other expenses like higher acquisition costs for drugs and non-PPE supplies and equipment.

Nearly all providers rely on payments closely tied to fee-for-service models. When the COVID-19 pandemic struck the U.S. in March, patient volumes fell off a cliff, dragging down hospitals' revenue. The lack of fee-for-service revenue led many hospitals and group practices to lay off or furlough staff, slash office hours, cut pay, and delay or cancel investments, just as the crisis ramped up and the economy cratered.

Congress passed a series of financial relief packages to make sure providers would be able to keep their doors open during the public health emergency. But many hospitals and group practices have had trouble getting hold of the money, and some of the funds are starting to dry up. If the federal government doesn't step up with more aid soon, hospitals and health systems will have to make more tough decisions.

In the long term, providers may shift more of their business to value-based arrangements and take on added financial risk to stabilize their revenue streams and guard against future declines in patient volume, which have proven catastrophic. Providers that rely more heavily on capitation and other value-based arrangements report that their businesses have experienced less financial distress than those dependent on traditional fee-for-service payments.

Experts say that while value-based payments aren't a cure-all solution, the pandemic has shown that volume-based payments aren't as safe as many providers thought.

This is important as the continuation of some of the innovations that have been implemented require a PHE being declared.

The article mentions that the CMS waivers are actually authorized under the Presidential declaration of an emergency, activating the Stafford Act.  Some of us were concerned about the potential ‘expiration’ of either declaration.

One of NAEMT’s Government Relations groups, Winning Strategies Washington, provides some commentary on that process that we’ve included in the section below the article.

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HHS will renew public health emergency

June 29, 2020 08:09 PM

RACHEL COHRS

https://www.modernhealthcare.com/government/hhs-will-renew-public-health-emergency

HHS spokesperson Michael Caputo on Monday tweeted that HHS intends to extend the COVID-19 public health emergency that is set to expire on July 25.

The extension would prolong the emergency designation by 90 days. Several payment policies and regulatory adjustments are attached to the public health emergency, so the extension is welcome news for healthcare providers.

"[HHS] expects to renew the Public Health Emergency due to COVID-19 before it expires. We have already renewed this PHE once," Caputo said.

Provider groups including the American Hospital Association have urged HHS to renew the distinction.

Some notable policies attached to the public health emergency are the Medicare inpatient 20% add-on payment for COVID-19 patients, increased federal Medicaid matching rates, requirements that insurers cover COVID-19 testing without cost-sharing, and waivers of telehealth restrictions.

Adjustments CMS made to the Medicare Shared Savings Program for accountable care organizations are also connected to the length of the public health emergency. The number of months the emergency lasts affects the amount of shared losses an ACO must pay back to CMS.

Even if HHS maintains the public health emergency, some changes the Trump administration has made to help healthcare providers are also dependent on a separate Stafford Act national emergency declaration staying active. These changes include CMS Medicaid waivers that allow bypassing some prior authorization requirements, temporarily enrolling out-of-state providers, delivering care in alternative settings, and pausing fair hearing requests and appeal times.

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From Winning Strategies:

The National Emergency declared by the President does not have a set expiration. A national emergency issued pursuant to the NEA can be terminated by a subsequent presidential proclamation or by a joint resolution of Congress.

 

Please see below a few more details in the situation. 

 

Charla

 

A top spokesman for HHS tweeted Monday night the department "expects to renew" the public health emergency for COVID-19 currently set to expire at the end of next month.

 

HHS did not respond to requests for further comment Tuesday morning. No official statement from the department has addressed the issue, but the tweet from Michael Caputo uses the official account of the HHS assistant secretary for public affairs.

 

Extending the emergency will allow providers to continue to use flexibilities and waivers meant to help them respond to the COVID-19 pandemic, including those that promote the use of telehealth and adjust requirements for CMS value-based payment models.

 

There are two emergencies currently in effect:

• The first one, a Public Health Emergency issued pursuant to Section 319 of the Public Health Services Act, is a Public Health Emergency initially issued by HHS Secretary Azar on January 31, 2020.   The PHS was extended by Secretary Azar on April 21, renewed effectively on April 26, 2020. This PHE is set to expire on July 25. 

 

• The second one is the President's declaration under the National Emergencies Act pursuant to Section 501(b) of the Stafford Disaster Relief and Emergency Assistance Act, issued on March 13, 2020. But the National Emergency declared by the President does not have a set expiration. A national emergency issued pursuant to the NEA can be terminated by a subsequent presidential proclamation or by a joint resolution of Congress. https://www.lawfareblog.com/whats-trumps-national-emergency-announcement-covid-19

 

The PHE declaration by the Secretary is not contingent on a Presidential NEA declaration.

 

The question is what HHS related waivers are tied to which Emergency Declaration, Sec. Azar’s PHE or the President's NEA. 

• The 1135 Medicaid waivers, both individual and blanket waivers, issued by HHS need BOTH the National Emergency and the Public Health Emergency declarations. 
• The CARES Act had provisions about telehealth that are linked to the duration of the PHE.  So, some of the telehealth flexibilities are linked only to the PHE and others need both types of declaration to continue.
• • However, there is a special dispensation in the CARES statute that ties the telehealth-related waivers specifically to the public health emergency for Covid-19. (See (g)(1)(B) of SSA Section 1135).
  • Azar could probably keep extending the Covid-19 public health emergency declaration for 90-days at a time and keep the telehealth-related waivers in effect. The other 1135 waivers likely would expire if/when POTUS ends the national emergency declaration, but telehealth is a special case.
• The NEA permits FEMA to provide assistance under Sections 502 and 503 of the Stafford Act, which describe the scope and amount of federal emergency assistance. The declaration also instructs the FEMA administrator to coordinate and direct other federal agencies in providing assistance under the Stafford Act.

Fierce Healthcare Source Article | Comments Courtesy of Matt Zavadsky

The same analysis could be applied to the EMS delivery model. 

Many have shared a similar concern about the payer mix of the future!

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Moody's: Patient volume recovered a bit in May, but providers face long road to recovery

by Robert King | Jun 22, 2020

 

https://www.fiercehealthcare.com/hospitals/moody-s-patient-volume-recovering-may-but-providers-face-long-road-to-recovery

Patient volumes at hospitals, doctors' and dentists' offices recovered slightly in May but lagged well behind pre-pandemic levels, according to a new analysis from Moody’s Investors Service.

In all, the ratings agency estimated total surgeries at rated for-profit hospitals declined by 55% to 70% in April compared with the same period in 2019. States required hospitals to cancel or delay elective procedures, which are vital to hospitals' bottom lines.

“Patients that had been under the care of physicians before the pandemic will return first in order to address known health needs,” officials from the ratings agency said in a statement. “Physicians and surgeons will be motivated to extend office or surgical hours in order to accommodate these patients.”

Those declines narrowed to 20% to 40% in May when compared to 2019.

Emergency room and urgent care volumes were still down 35% to 50% in May.

“This could reflect the prevalence of working-from-home arrangements and people generally staying home, which is leading to a decrease in automobile and other accidents outside the home,” the analysis said. “Weak ER volumes also suggest that many people remain apprehensive to enter a hospital, particularly for lower acuity care.”

The good news:  The analysis estimated it is unlikely there will be a return to the nationwide decline of volume experienced in late March and April because healthcare facilities are more prepared for COVID-19.

For instance, hospitals have enough personal protective equipment for staff and have expanded testing, the analysis said.

For-profit hospitals also have “unusually strong liquidity to help them weather the effects of the revenue loss associated with canceled or postponed procedures,” Moody’s added. “That is largely due to the CARES Act and other government financial relief programs that have caused hospital cash balances to swell.”

However, the bill for one of those sources of relief is coming due soon.

Hospitals and other providers will have to start repaying Medicare for advance payments starting this summer. The Centers for Medicare & Medicaid Services doled out more than $100 billion in advance payments to providers before suspending the program in late April.

Hospital group Federation of American Hospitals asked Congress to change the repayment terms for such advance payments, including giving providers at least a year to start repaying the loans.

Another risk for providers is the change in payer mix as people lose jobs and commercial coverage, shifting them onto Medicaid or the Affordable Care Act’s (ACA's) insurance exchanges.

“This will lead to rising bad debt expense and a higher percentage of revenue generated from Medicaid or [ACA] insurance exchange products, which typically pay considerably lower rates than commercial insurance,” Moody’s said.

Niagara EMS is recruiting for the position of Deputy Chief! This is an exciting opportunity to join the leadership team of a progressive organization that is advancing the modernization of EMS to a Mobile Integrated Health service model. If this sounds interesting to you, read more and consider submitting your application today! 
https://bit.ly/3d9KU4z

Modern Healthcare source article | Comments courtesy of Matt Zavadsky

Way to go Michigan! Model for other states?

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Michigan Legislature approves $220M for frontline pandemic healthcare workers

6/17/20

 

https://www.modernhealthcare.com/safety-quality/coronavirus-outbreak-live-updates-covid-19

 

(AP) The Michigan Legislature on Wednesday unanimously approved spending $880 million in federal relief aid in response to the coronavirus pandemic, setting aside funding for frontline workers, municipalities and child care providers.

 

Democratic Gov. Gretchen Whitmer, whose administration was involved in negotiations, will sign it.

 

The legislation includes $220 million to give pay raises to certain health workers ($2 an hour) and first responders (up to $1,000), $200 million to reimburse local governments for virus-related spending and $125 million to reduce child care costs.