Clincal Guidelines: Chest Compression First

The American Heart Association (AHA) recommends compressions first for cardiac arrest in a new guideline for 2010:

•  Chest compressions should be the first step in addressing cardiac arrest.
• A-B-Cs (Airway-Breathing-Compressions) of cardiorespiratory resuscitation (CPR) be changed to C-A-B (Compressions-Airway-Breathing).
• Increase the speed of chest compressions to a rate of at least 100 times a minute
• Compressions should be made more deeply,  at least 2 inches in adults and children and 1.5 inches in infants
• Avoid leaning on the chest so that it can return to its starting position
• Compression should be continue as long as possible without the use of excessive ventilation.
• 9-1-1 centers are directed to deliver instructions assertively so that chest compressions can be started when cardiac arrest is suspected.
•  Dispatchers should instruct untrained lay rescuers to provide Hands-Only CPR (chest compression only) for adults who are unresponsive, with no breathing..

Health Care Reform: Meaningful Use

In the stimulus bill of 2009, Congress included funding to help incentivize physicians to convert to and electronic health record (EHR).  Who is eligible?

• Medicare Program: Physicians who demonstrate meaningful use (MU) of certified EHR technology and submit Medicare claims
• Medicaid Program: Physicians who demonstrate MU of certified EHR technology if their caseload includes at least 30 percent Medicaid patients (or at least 20 percent Medicaid patients for pediatricians).
• Physicians may not receive both Medicaid and Medicare incentives, although they are permitted a single switch from one to the other during the five years that the programs run.

What is the size of the incentive?

• Medicare: 75 percent of Medicare allowed charges for the year, up to the year's maximum incentive amount spread out over 5 years
• Medicaid: 85 percent of Medicaid allowed charges up to a different maximum spread out over 6 years.
• Diminishing amounts available to those who start in later years
• For providers in federally designated health professional shortage areas (HPSA), payments will be 10 percent greater.

What are some of the requirements?

• Must have National Provider Identifier (NPI).
• Must be enrolled in the CMS Provider Enrollment, Chain and Ownership System (PECOS).
• Most will also need to have an active user account in the National Plan and Provider Enumeration System (NPPES).
• Reporting of data on three core quality measures in 2011 and 2012: blood-pressure level, tobacco status and adult weight screening and follow-up
• Alternates include influenza immunizations for patients older than 50, weight assessment and counseling for children and adolescents, and childhood immunizations.
• Reporting of three more clinical quality measures chosen from 44 familiar National Quality Forum and/or Physician Quality Reporting Initiative (PQRI) measures.
• Only certified complete EHRs and EHR modules may be used to qualify.

What are some of the reporting requiremens:

• For 2011, CMS will allow attestations for all MU measures, along with provision of aggregate data for numerators, denominators and exclusions.
•  In 2012, CMS will continue accepting attestation for most of the MU objectives but plans to require electronic submission of the clinical quality measures.
•  States will also support attestation initially and then move to electronic submission of clinical quality measures for Medicaid providers' demonstration of MU

What is meaningful use?

• Meaningful use requires physicians to attest to using the EHR – for data collection, e-prescribing, health information exchange, clinical decision support, patient engagement, security assurance and quality reporting.
• CMS specifies a "core set" of 15 objectives and measures that must be met, along with five objective from a "menu set" of additional objectives.

What are the 15 core objectives?

• Computerized physician order entry (CPOE) for medications
•  More than 30% of patients.
•  Implement drug-drug and drug-allergy interaction checks.
•  Use e-prescribing.
•  More than 40% of all permissible prescriptions.
•  Record patient demographics.
•  More than 50% of patients
•  Maintain an up-to-date problem list.
•  More than 80% of patients
•  Maintain an active medication list.
•  More than 80% of patients
•   Maintain an active medication allergy list.
•  More than 80% of patients
•  Record and chart changes in vital signs
•  More than 50% of patients age 2 or older have height, weight and blood pressure
•  Record smoking status for patients 13 years old or older
•  More than 50%t of patients age 13 or older
•  One clinical decision support rule
•  Report ambulatory clinical quality measures to CMS or the states.
•  For 2011, provide aggregate numerator, denominator and exclusions through attestation.
•  For 2012, submit the clinical quality measures electronically.
•  Give patients an electronic copy of their health information upon request.
•  More than 50% of patients who request an electronic copy of their health information get it within 3 business days.
•  Provide clinical summaries for patients for each office visit.
•  More than 50% of all office visits within three business days.
•  Be able to exchange key clinical information with other providers and patient-authorized entities electronically.
•  Test EHR's ability to exchange key clinical information electronically.
•  Protect electronic health information.
•  Conduct or review a security risk analysis, implement security updates as necessary and correct identified security deficiencies.

Additional Menu Choices (need 5)

• Implement drug-formulary checks.
• Incorporate test results.
• More than 40% of all lab test results
• Generate lists of patients by specific conditions.
• Send reminders to patients for preventive/follow-up care.
• More than 20% of all patients 65 or older or 5 or younger.
• Give patients timely electronic access to their health information.
• More than 10% of all patients seen are provided electronic access to their health information within four business days of its updating in the EHR
• Provide patient-specific education resources.
• Use the EHR to give more than 10 percent of all patients seen patient-specific education resources.
• Perform medication reconciliation whenever appropriate.
• More than 50% of patients arriving from another setting.
• Provide summary of care records.
• More than 50% when referring patients to other providers or settings
• Be able to submit electronic data to immunization registries or immunization information systems.
• Be able to submit electronic syndromic surveillance data to public health agencies.

Clinical Reports: There's a New Blood Thinner in Town

An FDA advisory panel has recommended that dabigatran etexilate, an oral direct thrombin inhibitor, be approved for use in reducing the risk of stroke from atrial fibrillation. The doses studied included a 110 mg does and a 150 mg dose.  The FDA has subsequently approved the medication.

The newly approved drug works as well as warfarin in stroke prevention, and perhaps a 150 mg dose was more effective than warfarin.

There was more GI bleeding with both doses of dabigatran, and also more myocardial infarctions, but there was a reduced risk of hemorrhagic stroke. 

The study was an open label study of 18,113 patients with nonvalvular atrial fibrillation and one other risk factor for stroke.  The study was ongoing for two years, and patients were followed for at least one year.  Therapeutic INR's were obtained in 65% of patients on warfarin.

 Iit will be known as Pradaxa, and is the first new oral anticoagulant approved in 50 years.

Pearls: Can You Hear Me Now?

Liquid docusate is an effective agent to soften ear cerumen when treated impacted cerumen in the office.  Docusate applied to the ear canal 15 minutes before irrigation can ease or reduce the need for irrigation.  This seems to be more effective than Cerumenex or warm olive oil which are the next most effective treatments.

Pearls: Nitroglycerin Ointment for Anal Fissure

Many times patients come in with complaints of hemorroids, but what they really mean is they are having pain with bowel movements.  The most common cause of anal pain without an external lump is an anal fissure.  Anal fissures are tears in the anoderm, and are almost always posterior midline.  Usually these can be seen without a speculum on examination, just by spreading the buttocks.  Sometimes a sentinel pyle will be present at the outermost extension of the fissure, and indicate the fissure is chronic. The other major cause of anal pain, thrombosed external hemorrhoids, can be readily identified by taking a history from the patient and by examination.  If there is no external lump, most likely pain with defectation is secondary to an anal fissure.

The most common cause of anal fissures and the easiest to treat is passage of hard stools.  Some patients may deny they have constipation even if they have hard stools, so ask specifically about hard stools.  Diarrhea can also cause fissures, and this can be harder to treat.

Most fissures are posterior midline fissures, although some women will have anterior fissures.  Fissures in atypical locations can indicate inflammatory bowel disease.  If a patient has an anal fissure, an anoscopic examination will be very painful, and most fissures can be seen without inserting anything into the anal canal.

Most fissures can be healed with conservative treatment.  Treating fissures requires a two prong attack:  Softening the stools and treating anal sphincter spasm.  Anal spasm is triggered by pain, and may cause a relative ischemia to the anoderm in the posterior midline, impairing healing.

While pain is the most common symptom of fissure, bleeding can also occur.   The treating physician should make sure any rectal bleeding is not from a more serious cause, especially in older patients.



To treat the hard stools, increase dietary fiber, use fiber bulking agents (psyllium powder) and increase fluid intake.

To treat the anal spasm, and the pain, have the patient take Sitz baths (warm water, no additives, 10 minute duration) three times a day if possible, and after a bowel movement.

To further treat anal sphasm, an ointment of 0.2% to 0.4% nitroglycerin  ointment can be be applied to the perianal area, not in the anal canal, two to three times a day.   Around 5% of patients will get headaches to the nitroglycerin but will develop tachyphylaxis to this.  Tylenol is used for these headaches.  To minimize headaches, for the first 3-5 days of treatment, apply the nitroglycerin ointment once daily right before going to bed.  Being supine may minimize the nitroglycerin headaches.  Tell the patients to use a glove to apply the ointment or wash their hands immediately after application, as the ointment can be absorbed through the finger.  Only a small amount of ointment is applied.  After this initial period, if everything is going well, increase the application frequency to twice daily.

The nitroglycerin ointment can be compounded with 1% lidocaine ointment by the pharmacist.  There are no commercial products of nitroglycerin available in this strength, so compounding by the pharmacist is necessary.

The pain will resolve before the fissure is entirely healed, so have the patient continue the therapy beyond the period when symptomatic relief first occurs.   Over time, have the patient wean the Sitz baths and nitroglycerin therapy, but continue a stool softening regimen for life.

Conservative therapy should heal approximately 70% or more of anal fissures.  Surgerical referral can be made if symptoms do not resolve with aggressive conservative therapy.

Don't use 2% Nitropaste as a substitute, as this seems to cause localized discomfort when applied, along with increased risk of side effects (headache).