Susan London

Major Finding: Some 24% of refrigerators used to store DTaP vaccine experienced freezing temperatures. The higher the percentage of refrigerators with prolonged freezing in a health region, the higher that region's rate of pertussis.

Data Source: An observational study of 54 vaccine refrigerators in 13 community health centers having about 580,000 outpatient visits annually.

Disclosures: Dr. McColloster said he did not have any conflicts of interest related to the study.

SEATTLE — Inadvertent freezing of the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine while it is being stored in vaccine refrigerators may be contributing to the rise in pertussis in the community, new data suggest.

Using continuous data loggers, investigators at the Baylor College of Medicine in Houston found that one-quarter of 54 vaccine refrigerators in the city's community health centers had temperatures that dipped into the freezing range, most commonly at night and on weekends.

There was a significant 76% correlation between the percentage of vaccine refrigerators in a health region experiencing prolonged freezing temperatures and that region's rate of pertussis, the investigators reported at the meeting.

The study establishes only correlation, and there are many possible confounders and explanations, acknowledged lead investigator Dr. Patrick J. McColloster, an associate professor of family medicine at the college.

“But I think though that one thing that has been neglected in looking at the pertussis outbreaks in the United States is inadvertent freezing and the instability of DTaP – back to the cold chain again,” he said, referring to the practice of ensuring that the vaccine is continuously kept at the recommended temperature.

In interviews, nursing staff at the centers were skeptical of the freezing because they more often noticed warm temperatures during the workday, he commented. “Whenever they would open and close the refrigerator doors, they always made sure [the temperature] was within normal range, and if it was a little too hot, they would just crank the refrigerator up a little bit more. So basically, they were freezing the vaccines like crazy.”

Explaining the rationale for the study, Dr. McColloster noted that the incidence of pertussis fell in the 10 years after introduction of the DTP (diphtheria, tetanus, pertussis) vaccine, but it actually rose in the 9 years after subsequent introduction of the DTaP vaccine.

“Currently, all the studies that are out there are saying it's due to seasonal variation, unvaccinated pediatric clusters, and declining adult immunity,” he said. “Gee, it doesn't have anything to do with DTaP, does it?”

The impact of failure of the vaccine cold chain on the occurrence of pertussis has not been studied in the United States. “DTaP uses aluminum as an adjuvant (just like DTP does), but it's a little bit different in that it's more sensitive to freezing,” he explained. In fact, the manufacturer recommends discarding any vaccine exposed to freezing temperatures.

In the study, the investigators attached data loggers to 54 vaccine refrigerators in 13 Community Health Centers in the Harris County Hospital District of Houston. The centers provide approximately 580,000 outpatient visits each year to an indigent population.

The loggers sampled the refrigerator temperature every minute for at least 6 days. Data from the first hour were discarded to allow the logger's temperature to equilibrate.

The centers' own procedure for cold chain monitoring consisted of twice-daily readings from approved digital thermometers during weekday work hours, as mandated by the Centers for Disease Control and Prevention.

The investigators obtained data on the incidence of pertussis in the district for the years 2005–2009 from the City of Houston Health Department.

Results showed that 48% of refrigerators maintained temperature in the correct range (2°C to 8°C), Dr. McColloster reported. But 19% experienced cold temperatures (0.1°C to 1.9°C) and 24% experienced freezing ones (0°C or lower). The remaining 9% had temperatures rising into the warm range (greater than 8°C), but this usually was so transient that it was unlikely to alter temperature of the vaccine itself, he said.

Among the refrigerators with freezing temperatures, the average time spent at freezing was 2 hours per day. Freezing usually occurred on nights and over weekends.

Across the six health regions within the district, the percentage of refrigerators in the region having freezing temperatures for more than 2 hours daily ranged from 14% to 80%. And the average annual pertussis rate ranged from 2.9 to 6.3 cases per 100,000 population.

The higher the percentage of refrigerators in a region experiencing freezing temperatures for more than 2 hours daily, the higher the pertussis rate for that region (P less than .05), Dr. McColloster reported.

Establishing causation will require freezing the vaccine and then testing its immunogenicity in animals, or assessing pertussis immune status in patients who have received vaccines from refrigerators experiencing freezing, he acknowledged.

To address the problem, there are several possible solutions, according to Dr. McColloster. DTaP vaccine vials could be affixed with temperature-sensitive labels that show immediately if they have been frozen. Also, clinics could use refrigerators that do not permit staff to manually adjust the temperature.

Major Finding: Some 24% of refrigerators used to store DTaP vaccine experienced freezing temperatures. The higher the percentage of refrigerators with prolonged freezing in a health region, the higher that region's rate of pertussis.

Data Source: An observational study of 54 vaccine refrigerators in 13 community health centers having about 580,000 outpatient visits annually.

Disclosures: Dr. McColloster said he did not have any conflicts of interest related to the study.

SEATTLE — Inadvertent freezing of the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine while it is being stored in vaccine refrigerators may be contributing to the rise in pertussis in the community, new data suggest.

Using continuous data loggers, investigators at the Baylor College of Medicine in Houston found that one-quarter of 54 vaccine refrigerators in the city's community health centers had temperatures that dipped into the freezing range, most commonly at night and on weekends.

There was a significant 76% correlation between the percentage of vaccine refrigerators in a health region experiencing prolonged freezing temperatures and that region's rate of pertussis, the investigators reported at the meeting.

The study establishes only correlation, and there are many possible confounders and explanations, acknowledged lead investigator Dr. Patrick J. McColloster, an associate professor of family medicine at the college.

“But I think though that one thing that has been neglected in looking at the pertussis outbreaks in the United States is inadvertent freezing and the instability of DTaP – back to the cold chain again,” he said, referring to the practice of ensuring that the vaccine is continuously kept at the recommended temperature.

In interviews, nursing staff at the centers were skeptical of the freezing because they more often noticed warm temperatures during the workday, he commented. “Whenever they would open and close the refrigerator doors, they always made sure [the temperature] was within normal range, and if it was a little too hot, they would just crank the refrigerator up a little bit more. So basically, they were freezing the vaccines like crazy.”

Explaining the rationale for the study, Dr. McColloster noted that the incidence of pertussis fell in the 10 years after introduction of the DTP (diphtheria, tetanus, pertussis) vaccine, but it actually rose in the 9 years after subsequent introduction of the DTaP vaccine.

“Currently, all the studies that are out there are saying it's due to seasonal variation, unvaccinated pediatric clusters, and declining adult immunity,” he said. “Gee, it doesn't have anything to do with DTaP, does it?”

The impact of failure of the vaccine cold chain on the occurrence of pertussis has not been studied in the United States. “DTaP uses aluminum as an adjuvant (just like DTP does), but it's a little bit different in that it's more sensitive to freezing,” he explained. In fact, the manufacturer recommends discarding any vaccine exposed to freezing temperatures.

In the study, the investigators attached data loggers to 54 vaccine refrigerators in 13 Community Health Centers in the Harris County Hospital District of Houston. The centers provide approximately 580,000 outpatient visits each year to an indigent population.

The loggers sampled the refrigerator temperature every minute for at least 6 days. Data from the first hour were discarded to allow the logger's temperature to equilibrate.

The centers' own procedure for cold chain monitoring consisted of twice-daily readings from approved digital thermometers during weekday work hours, as mandated by the Centers for Disease Control and Prevention.

The investigators obtained data on the incidence of pertussis in the district for the years 2005–2009 from the City of Houston Health Department.

Results showed that 48% of refrigerators maintained temperature in the correct range (2°C to 8°C), Dr. McColloster reported. But 19% experienced cold temperatures (0.1°C to 1.9°C) and 24% experienced freezing ones (0°C or lower). The remaining 9% had temperatures rising into the warm range (greater than 8°C), but this usually was so transient that it was unlikely to alter temperature of the vaccine itself, he said.

Among the refrigerators with freezing temperatures, the average time spent at freezing was 2 hours per day. Freezing usually occurred on nights and over weekends.

Across the six health regions within the district, the percentage of refrigerators in the region having freezing temperatures for more than 2 hours daily ranged from 14% to 80%. And the average annual pertussis rate ranged from 2.9 to 6.3 cases per 100,000 population.

The higher the percentage of refrigerators in a region experiencing freezing temperatures for more than 2 hours daily, the higher the pertussis rate for that region (P less than .05), Dr. McColloster reported.

Establishing causation will require freezing the vaccine and then testing its immunogenicity in animals, or assessing pertussis immune status in patients who have received vaccines from refrigerators experiencing freezing, he acknowledged.

To address the problem, there are several possible solutions, according to Dr. McColloster. DTaP vaccine vials could be affixed with temperature-sensitive labels that show immediately if they have been frozen. Also, clinics could use refrigerators that do not permit staff to manually adjust the temperature.

Major Finding: Some 24% of refrigerators used to store DTaP vaccine experienced freezing temperatures. The higher the percentage of refrigerators with prolonged freezing in a health region, the higher that region's rate of pertussis.

Data Source: An observational study of 54 vaccine refrigerators in 13 community health centers having about 580,000 outpatient visits annually.

Disclosures: Dr. McColloster said he did not have any conflicts of interest related to the study.

SEATTLE — Inadvertent freezing of the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine while it is being stored in vaccine refrigerators may be contributing to the rise in pertussis in the community, new data suggest.

Using continuous data loggers, investigators at the Baylor College of Medicine in Houston found that one-quarter of 54 vaccine refrigerators in the city's community health centers had temperatures that dipped into the freezing range, most commonly at night and on weekends.

There was a significant 76% correlation between the percentage of vaccine refrigerators in a health region experiencing prolonged freezing temperatures and that region's rate of pertussis, the investigators reported at the meeting.

The study establishes only correlation, and there are many possible confounders and explanations, acknowledged lead investigator Dr. Patrick J. McColloster, an associate professor of family medicine at the college.

“But I think though that one thing that has been neglected in looking at the pertussis outbreaks in the United States is inadvertent freezing and the instability of DTaP – back to the cold chain again,” he said, referring to the practice of ensuring that the vaccine is continuously kept at the recommended temperature.

In interviews, nursing staff at the centers were skeptical of the freezing because they more often noticed warm temperatures during the workday, he commented. “Whenever they would open and close the refrigerator doors, they always made sure [the temperature] was within normal range, and if it was a little too hot, they would just crank the refrigerator up a little bit more. So basically, they were freezing the vaccines like crazy.”

Explaining the rationale for the study, Dr. McColloster noted that the incidence of pertussis fell in the 10 years after introduction of the DTP (diphtheria, tetanus, pertussis) vaccine, but it actually rose in the 9 years after subsequent introduction of the DTaP vaccine.

“Currently, all the studies that are out there are saying it's due to seasonal variation, unvaccinated pediatric clusters, and declining adult immunity,” he said. “Gee, it doesn't have anything to do with DTaP, does it?”

The impact of failure of the vaccine cold chain on the occurrence of pertussis has not been studied in the United States. “DTaP uses aluminum as an adjuvant (just like DTP does), but it's a little bit different in that it's more sensitive to freezing,” he explained. In fact, the manufacturer recommends discarding any vaccine exposed to freezing temperatures.

In the study, the investigators attached data loggers to 54 vaccine refrigerators in 13 Community Health Centers in the Harris County Hospital District of Houston. The centers provide approximately 580,000 outpatient visits each year to an indigent population.

The loggers sampled the refrigerator temperature every minute for at least 6 days. Data from the first hour were discarded to allow the logger's temperature to equilibrate.

The centers' own procedure for cold chain monitoring consisted of twice-daily readings from approved digital thermometers during weekday work hours, as mandated by the Centers for Disease Control and Prevention.

The investigators obtained data on the incidence of pertussis in the district for the years 2005–2009 from the City of Houston Health Department.

Results showed that 48% of refrigerators maintained temperature in the correct range (2°C to 8°C), Dr. McColloster reported. But 19% experienced cold temperatures (0.1°C to 1.9°C) and 24% experienced freezing ones (0°C or lower). The remaining 9% had temperatures rising into the warm range (greater than 8°C), but this usually was so transient that it was unlikely to alter temperature of the vaccine itself, he said.

Among the refrigerators with freezing temperatures, the average time spent at freezing was 2 hours per day. Freezing usually occurred on nights and over weekends.

Across the six health regions within the district, the percentage of refrigerators in the region having freezing temperatures for more than 2 hours daily ranged from 14% to 80%. And the average annual pertussis rate ranged from 2.9 to 6.3 cases per 100,000 population.

The higher the percentage of refrigerators in a region experiencing freezing temperatures for more than 2 hours daily, the higher the pertussis rate for that region (P less than .05), Dr. McColloster reported.

Establishing causation will require freezing the vaccine and then testing its immunogenicity in animals, or assessing pertussis immune status in patients who have received vaccines from refrigerators experiencing freezing, he acknowledged.

To address the problem, there are several possible solutions, according to Dr. McColloster. DTaP vaccine vials could be affixed with temperature-sensitive labels that show immediately if they have been frozen. Also, clinics could use refrigerators that do not permit staff to manually adjust the temperature.

Major Finding: Among extremely preterm infants whose mothers' breast milk contained cytomegalovirus, the rate of infection was 11% in those fed only freeze-thawed milk, compared with 6% in those fed both fresh and freeze-thawed milk, a nonsignificant difference.

Data Source: Randomized trial of 140 infants born at less than 28 weeks' gestation and their 127 mothers.

Disclosures: None was reported.

VANCOUVER, B.C. — Freezing and thawing maternal milk before feeding it to extremely preterm infants does not reduce either transmission of cytomegalovirus or the severity of infection when it occurs, according to the findings of a Swedish trial that is the first to look at this issue in a randomized fashion.

Overall, only 8% of infants whose mothers were producing breast milk testing positive for cytomegalovirus (CMV) became infected. The rate of infection in infants fed only freeze-thawed milk (11%) was no lower than that in infants fed both fresh and freeze-thawed milk (6%).

None of the infections was symptomatic, and the laboratory abnormalities observed were transient and equally common between groups.

“Today, in Sweden at least, we think the benefits of giving fresh maternal milk override the risks of CMV infection,” said lead investigator Dr. Soley Omarsdottir, a pediatrician at the Karolinska University Hospital in Stockholm.

“But of course we have to follow these infants and see the long-term consequences,” she added, noting that emerging data suggest that CMV infection can cause changes in the white matter of the brain that may become clinically important later in life.

Some Swedish neonatal units routinely freeze maternal breast milk before feeding it to extremely preterm infants because they believe it reduces CMV transmission, according to Dr. Omarsdottir.

Indeed, laboratory data have shown that freezing can reduce both the viral titer and viral activity in milk. And smaller, nonrandomized studies suggest that freezing may reduce transmission to infants.

At the same time, intake of fresh milk early in life may be important. “We think that it may have benefits for the baby to colonize the gut flora with maternal breast milk very soon after birth,” Dr. Omarsdottir said at the meeting.

She and her colleagues enrolled in the trial 140 extremely preterm infants born at less than 28 weeks' gestation and their 127 mothers. The infants were randomized in nearly equal numbers to be fed only freeze-thawed maternal milk or both freeze-thawed and fresh maternal milk until they were 32 weeks of age.

When milk was frozen, it was kept at −20° C for at least 3 days. If mothers did not produce enough milk, it was supplemented with banked milk that was pasteurized and therefore virus free.

The mothers provided blood for CMV serology testing and breast milk for CMV testing by polymerase chain reaction (PCR) and viral culture. The infants were monitored for CMV infection by urinary PCR and culture performed for the first 6–12 weeks post partum.

According to study results reported in a poster session at the meeting, the mean gestational age of infants was 26 weeks in the group fed only freeze-thawed milk and 26 weeks in the group fed both fresh and freeze-thawed milk. The mean birth weights were 846 g and 836 g, respectively.

Of the 140 infants, 37 of those fed only freeze-thawed milk and 34 of those fed both fresh and freeze-thawed milk had mothers who were producing CMV-positive milk. Overall, 8% of these infants became infected, with no significant difference between groups (11% vs. 6%).

“The numbers of babies are too small to say it is more risky to freeze the breast milk,” Dr. Omarsdottir commented in an interview, and the infection rate was unexpectedly low. “We thought it is not ethical to continue the study just to get enough power to really compare [outcomes] better.”

None of the CMV infections were symptomatic. In each group, half of infected infants had transient alterations in liver function.

From the maternal perspective, 33 mothers in the freeze-thawed milk group and 29 in the combined fresh and freeze-thawed milk group were producing CMV-positive milk (49% overall), and most of these women also had positive CMV serology. The percentage whose infants became infected was not significantly different (12% vs. 7%).

“In our study, we did not see that routine freezing of maternal breast milk could reduce the risk of CMV transmission,” Dr. Omarsdottir concluded.

Major Finding: Among extremely preterm infants whose mothers' breast milk contained cytomegalovirus, the rate of infection was 11% in those fed only freeze-thawed milk, compared with 6% in those fed both fresh and freeze-thawed milk, a nonsignificant difference.

Data Source: Randomized trial of 140 infants born at less than 28 weeks' gestation and their 127 mothers.

Disclosures: None was reported.

VANCOUVER, B.C. — Freezing and thawing maternal milk before feeding it to extremely preterm infants does not reduce either transmission of cytomegalovirus or the severity of infection when it occurs, according to the findings of a Swedish trial that is the first to look at this issue in a randomized fashion.

Overall, only 8% of infants whose mothers were producing breast milk testing positive for cytomegalovirus (CMV) became infected. The rate of infection in infants fed only freeze-thawed milk (11%) was no lower than that in infants fed both fresh and freeze-thawed milk (6%).

None of the infections was symptomatic, and the laboratory abnormalities observed were transient and equally common between groups.

“Today, in Sweden at least, we think the benefits of giving fresh maternal milk override the risks of CMV infection,” said lead investigator Dr. Soley Omarsdottir, a pediatrician at the Karolinska University Hospital in Stockholm.

“But of course we have to follow these infants and see the long-term consequences,” she added, noting that emerging data suggest that CMV infection can cause changes in the white matter of the brain that may become clinically important later in life.

Some Swedish neonatal units routinely freeze maternal breast milk before feeding it to extremely preterm infants because they believe it reduces CMV transmission, according to Dr. Omarsdottir.

Indeed, laboratory data have shown that freezing can reduce both the viral titer and viral activity in milk. And smaller, nonrandomized studies suggest that freezing may reduce transmission to infants.

At the same time, intake of fresh milk early in life may be important. “We think that it may have benefits for the baby to colonize the gut flora with maternal breast milk very soon after birth,” Dr. Omarsdottir said at the meeting.

She and her colleagues enrolled in the trial 140 extremely preterm infants born at less than 28 weeks' gestation and their 127 mothers. The infants were randomized in nearly equal numbers to be fed only freeze-thawed maternal milk or both freeze-thawed and fresh maternal milk until they were 32 weeks of age.

When milk was frozen, it was kept at −20° C for at least 3 days. If mothers did not produce enough milk, it was supplemented with banked milk that was pasteurized and therefore virus free.

The mothers provided blood for CMV serology testing and breast milk for CMV testing by polymerase chain reaction (PCR) and viral culture. The infants were monitored for CMV infection by urinary PCR and culture performed for the first 6–12 weeks post partum.

According to study results reported in a poster session at the meeting, the mean gestational age of infants was 26 weeks in the group fed only freeze-thawed milk and 26 weeks in the group fed both fresh and freeze-thawed milk. The mean birth weights were 846 g and 836 g, respectively.

Of the 140 infants, 37 of those fed only freeze-thawed milk and 34 of those fed both fresh and freeze-thawed milk had mothers who were producing CMV-positive milk. Overall, 8% of these infants became infected, with no significant difference between groups (11% vs. 6%).

“The numbers of babies are too small to say it is more risky to freeze the breast milk,” Dr. Omarsdottir commented in an interview, and the infection rate was unexpectedly low. “We thought it is not ethical to continue the study just to get enough power to really compare [outcomes] better.”

None of the CMV infections were symptomatic. In each group, half of infected infants had transient alterations in liver function.

From the maternal perspective, 33 mothers in the freeze-thawed milk group and 29 in the combined fresh and freeze-thawed milk group were producing CMV-positive milk (49% overall), and most of these women also had positive CMV serology. The percentage whose infants became infected was not significantly different (12% vs. 7%).

“In our study, we did not see that routine freezing of maternal breast milk could reduce the risk of CMV transmission,” Dr. Omarsdottir concluded.

Major Finding: Among extremely preterm infants whose mothers' breast milk contained cytomegalovirus, the rate of infection was 11% in those fed only freeze-thawed milk, compared with 6% in those fed both fresh and freeze-thawed milk, a nonsignificant difference.

Data Source: Randomized trial of 140 infants born at less than 28 weeks' gestation and their 127 mothers.

Disclosures: None was reported.

VANCOUVER, B.C. — Freezing and thawing maternal milk before feeding it to extremely preterm infants does not reduce either transmission of cytomegalovirus or the severity of infection when it occurs, according to the findings of a Swedish trial that is the first to look at this issue in a randomized fashion.

Overall, only 8% of infants whose mothers were producing breast milk testing positive for cytomegalovirus (CMV) became infected. The rate of infection in infants fed only freeze-thawed milk (11%) was no lower than that in infants fed both fresh and freeze-thawed milk (6%).

None of the infections was symptomatic, and the laboratory abnormalities observed were transient and equally common between groups.

“Today, in Sweden at least, we think the benefits of giving fresh maternal milk override the risks of CMV infection,” said lead investigator Dr. Soley Omarsdottir, a pediatrician at the Karolinska University Hospital in Stockholm.

“But of course we have to follow these infants and see the long-term consequences,” she added, noting that emerging data suggest that CMV infection can cause changes in the white matter of the brain that may become clinically important later in life.

Some Swedish neonatal units routinely freeze maternal breast milk before feeding it to extremely preterm infants because they believe it reduces CMV transmission, according to Dr. Omarsdottir.

Indeed, laboratory data have shown that freezing can reduce both the viral titer and viral activity in milk. And smaller, nonrandomized studies suggest that freezing may reduce transmission to infants.

At the same time, intake of fresh milk early in life may be important. “We think that it may have benefits for the baby to colonize the gut flora with maternal breast milk very soon after birth,” Dr. Omarsdottir said at the meeting.

She and her colleagues enrolled in the trial 140 extremely preterm infants born at less than 28 weeks' gestation and their 127 mothers. The infants were randomized in nearly equal numbers to be fed only freeze-thawed maternal milk or both freeze-thawed and fresh maternal milk until they were 32 weeks of age.

When milk was frozen, it was kept at −20° C for at least 3 days. If mothers did not produce enough milk, it was supplemented with banked milk that was pasteurized and therefore virus free.

The mothers provided blood for CMV serology testing and breast milk for CMV testing by polymerase chain reaction (PCR) and viral culture. The infants were monitored for CMV infection by urinary PCR and culture performed for the first 6–12 weeks post partum.

According to study results reported in a poster session at the meeting, the mean gestational age of infants was 26 weeks in the group fed only freeze-thawed milk and 26 weeks in the group fed both fresh and freeze-thawed milk. The mean birth weights were 846 g and 836 g, respectively.

Of the 140 infants, 37 of those fed only freeze-thawed milk and 34 of those fed both fresh and freeze-thawed milk had mothers who were producing CMV-positive milk. Overall, 8% of these infants became infected, with no significant difference between groups (11% vs. 6%).

“The numbers of babies are too small to say it is more risky to freeze the breast milk,” Dr. Omarsdottir commented in an interview, and the infection rate was unexpectedly low. “We thought it is not ethical to continue the study just to get enough power to really compare [outcomes] better.”

None of the CMV infections were symptomatic. In each group, half of infected infants had transient alterations in liver function.

From the maternal perspective, 33 mothers in the freeze-thawed milk group and 29 in the combined fresh and freeze-thawed milk group were producing CMV-positive milk (49% overall), and most of these women also had positive CMV serology. The percentage whose infants became infected was not significantly different (12% vs. 7%).

“In our study, we did not see that routine freezing of maternal breast milk could reduce the risk of CMV transmission,” Dr. Omarsdottir concluded.

LAS VEGAS — Improvised medical care can be lifesaving in settings where the closest medical facility may be hours or even days away, Dr. Eric A. Weiss told attendees of the meeting.

With just some basic medical supplies, the usual backcountry gear, and a few key additional items – safety pins and duct tape – physicians can often devise temporary, makeshift treatments for commonly occurring conditions, such as lacerations and fractures, he said.

Airway Opener

In unconscious patients, safety pins can be used to keep the airway open by pinning the tongue to the lower lip, according to Dr. Weiss of the departments of surgery and emergency medicine, and director of the Wilderness Medicine Fellowship at Stanford (Calif.) University.

This technique can be especially useful in cases of trauma, given the need to avoid neck hyperextension, and it also keeps the physician's hands free when they would otherwise be tied up performing a jaw thrust.

“This works very effectively – minimal bleeding, opens the airway,” he said.

“I know what you are thinking: This sounds kind of harsh. It's really not. If you are putting a safety pin through somebody's tongue, they are obviously unconscious [and] unresponsive.”

Barrier for Rescue Breathing

When performing rescue breathing in a noninstitutional location, physicians may not have conventional barrier devices to reduce their risk of contracting infection from the patient.

In this case, Dr. Weiss recommended making a slit in the middle finger of an examination glove, placing the glove fingers in the patient's mouth, and stretching the rest of the glove over the mouth and nose.

“Now you can blow air right through there and very effectively ventilate. As air goes in, it comes out this slit. To allow for exhalation, just remove the nasal part, allowing the victim to exhale, and then put it back for ventilation once again,” he explained.

“Any back pressure, like vomiting, will cause that slit to collapse and you don't get slimed,” he added.

Surgical Airway

To create a surgical airway (cricothyroidotomy) without the usual instruments, physicians can use a knife or other sharp object to make a vertical incision in the skin over the cricothyroid membrane.

“Horizontal incisions are fine,” Dr. Weiss said. “But I like vertical ones because sometimes you are a little bit off target and once you get through the skin, you can stick your gloved finger in there and you will find it a little bit easier [to get oriented], and you may have to move north or south.”

A variety of items can be inserted through the cricothyroid membrane and into the trachea to permit ventilation: a hollow pen tube, the cut barrel of a 3-cc syringe, or the spike that comes with standard macro IV tubing, after the drip chamber has been cut in half.

If the spike is used, “you don't even have to make an incision through the skin: This spike is so sharp, you just plunge that right into the cricothyroid membrane,” he said. “You have the fastest cricothyroidotomy the world has ever seen.”

An added, serendipitous benefit is that the chamber end of the spike “fits beautifully right onto an Ambu bag,” he noted.

Pleural Decompression

In the patient with a tension pneumothorax, most physicians are familiar with the practice of inserting a needle into the pleural space to achieve pleural decompression.

But Dr. Weiss additionally recommended putting the needle through a cut finger of an examination glove to create a one-way Heimlich valve.

“When the person takes a big breath in, the negative pressure causes the glove to collapse,” he explained. “But when he exhales out, it allows air to escape.”

Posterior Nasal Packing

Persistent posterior nasal bleeding, as might occur in facial trauma, can be stopped with a Foley catheter, according to Dr. Weiss.

The catheter is advanced through the nose until it can be seen in the back of the throat. “Blow up the balloon with 30 cc of air,” he advised.

“Most people use air because there is theoretical concern that if you put water in there, which works a little better actually, if it ruptures there could be aspiration.”

The catheter should then be withdrawn until the balloon is seated in the posterior nasopharynx, where resistance can be felt. The exiting part of the catheter is then taped to the nose with duct tape.

Fracture Diagnostic

As a stand-in for x-rays, a stethoscope and tuning fork can be used to diagnose fractures in long bones, such as the tibia. The principle at work here is that intact bone is a good transmitter of vibratory sound.

“Take your tuning fork and bang it and put it on the proximal tibia. Take your stethoscope and listen over the medial malleolus, the distal tibia. Then compare it to the other side,” instructed Dr. Weiss.

“Even if there is a nondisplaced linear fracture through that bone, that sound will be dampened significantly so that you will be able to tell the difference,” he said. “It works with a 99% sensitivity when tested in 100 patients.”

Pelvic Binder

Although not much can be done for pelvic fractures in remote settings, the pelvis can be bound to reduce bleeding.

“You can use a Therm-a-Rest pad and wrap it around the pelvis and inflate it,” Dr. Weiss said.

Alternatively, an article of clothing or a sheet can be wrapped around the pelvis, centering it over the greater trochanters of the femurs.

“Then take some tent poles or something, and tie it in there, then just kind of like a windlass, like you would turn a tourniquet, you wrap it until the patient feels some pressure,” he said.

Shoulder Immobilizer

In a pinch, an injured shoulder can be immobilized with just a few safety pins and the clothing a patient is wearing, according to Dr. Weiss.

“If you have a long-sleeve shirt, you can just safety pin the sleeve to [the shirt] itself,” he explained. “If you have a short-sleeve shirt, just take the shirt, fold it up, [and] make a little pouch with two safety pins.”

Wound Irrigator

In remote settings, a plastic sandwich bag can be filled with irrigation fluid, sealed, and squeezed hard to create adequate pressure for effective wound irrigation. “You don't need sterile normal saline,” Dr. Weiss added.

“If you are still using sterile normal saline, you need to go back to the literature because there are quite a few articles … showing that tap water works just as well” in terms of infection rates, because it is usually chlorinated.

Wound Closer

Although sutures or staples are ideal for closing wounds, glue or Dermabond can be used. For scalp lacerations, hair tying also works well.

For the hair-tying technique, a piece of dental floss or suture is oriented lengthwise along the laceration. “Take some hair on either side of the wound, twirl it in your fingers, and cross it over. Then use the dental floss or the suture to tie your square knot” around the crossed hair, he explained.

In particular, this technique “works great in children who have good heads of hair,” he noted. “There is no fuss or muss. They don't have to come back and have sutures removed or staples taken out. There is no pain.”

Topical Antibiotic

After a wound has been closed, physicians can apply honey, which Dr. Weiss referred to as “nature's Neosporin.”

Roughly 20 randomized, controlled trials have compared the substance with commercial topical antimicrobial agents and have generally found honey to be superior, he noted.

“When applied topically, honey reduces infection and promotes wound healing. It's safe, and it's effective,” he commented.

“It even has some antimicrobial properties that are due to its hypertonicity, its pH, and some inhibins that it has.”

In unconscious patients, use safety pins to keep the airway open by pinning the tongue to the lower lip, said Dr. Eric A. Weiss.

Source Courtesy Stanford University

LAS VEGAS — Improvised medical care can be lifesaving in settings where the closest medical facility may be hours or even days away, Dr. Eric A. Weiss told attendees of the meeting.

With just some basic medical supplies, the usual backcountry gear, and a few key additional items – safety pins and duct tape – physicians can often devise temporary, makeshift treatments for commonly occurring conditions, such as lacerations and fractures, he said.

Airway Opener

In unconscious patients, safety pins can be used to keep the airway open by pinning the tongue to the lower lip, according to Dr. Weiss of the departments of surgery and emergency medicine, and director of the Wilderness Medicine Fellowship at Stanford (Calif.) University.

This technique can be especially useful in cases of trauma, given the need to avoid neck hyperextension, and it also keeps the physician's hands free when they would otherwise be tied up performing a jaw thrust.

“This works very effectively – minimal bleeding, opens the airway,” he said.

“I know what you are thinking: This sounds kind of harsh. It's really not. If you are putting a safety pin through somebody's tongue, they are obviously unconscious [and] unresponsive.”

Barrier for Rescue Breathing

When performing rescue breathing in a noninstitutional location, physicians may not have conventional barrier devices to reduce their risk of contracting infection from the patient.

In this case, Dr. Weiss recommended making a slit in the middle finger of an examination glove, placing the glove fingers in the patient's mouth, and stretching the rest of the glove over the mouth and nose.

“Now you can blow air right through there and very effectively ventilate. As air goes in, it comes out this slit. To allow for exhalation, just remove the nasal part, allowing the victim to exhale, and then put it back for ventilation once again,” he explained.

“Any back pressure, like vomiting, will cause that slit to collapse and you don't get slimed,” he added.

Surgical Airway

To create a surgical airway (cricothyroidotomy) without the usual instruments, physicians can use a knife or other sharp object to make a vertical incision in the skin over the cricothyroid membrane.

“Horizontal incisions are fine,” Dr. Weiss said. “But I like vertical ones because sometimes you are a little bit off target and once you get through the skin, you can stick your gloved finger in there and you will find it a little bit easier [to get oriented], and you may have to move north or south.”

A variety of items can be inserted through the cricothyroid membrane and into the trachea to permit ventilation: a hollow pen tube, the cut barrel of a 3-cc syringe, or the spike that comes with standard macro IV tubing, after the drip chamber has been cut in half.

If the spike is used, “you don't even have to make an incision through the skin: This spike is so sharp, you just plunge that right into the cricothyroid membrane,” he said. “You have the fastest cricothyroidotomy the world has ever seen.”

An added, serendipitous benefit is that the chamber end of the spike “fits beautifully right onto an Ambu bag,” he noted.

Pleural Decompression

In the patient with a tension pneumothorax, most physicians are familiar with the practice of inserting a needle into the pleural space to achieve pleural decompression.

But Dr. Weiss additionally recommended putting the needle through a cut finger of an examination glove to create a one-way Heimlich valve.

“When the person takes a big breath in, the negative pressure causes the glove to collapse,” he explained. “But when he exhales out, it allows air to escape.”

Posterior Nasal Packing

Persistent posterior nasal bleeding, as might occur in facial trauma, can be stopped with a Foley catheter, according to Dr. Weiss.

The catheter is advanced through the nose until it can be seen in the back of the throat. “Blow up the balloon with 30 cc of air,” he advised.

“Most people use air because there is theoretical concern that if you put water in there, which works a little better actually, if it ruptures there could be aspiration.”

The catheter should then be withdrawn until the balloon is seated in the posterior nasopharynx, where resistance can be felt. The exiting part of the catheter is then taped to the nose with duct tape.

Fracture Diagnostic

As a stand-in for x-rays, a stethoscope and tuning fork can be used to diagnose fractures in long bones, such as the tibia. The principle at work here is that intact bone is a good transmitter of vibratory sound.

“Take your tuning fork and bang it and put it on the proximal tibia. Take your stethoscope and listen over the medial malleolus, the distal tibia. Then compare it to the other side,” instructed Dr. Weiss.

“Even if there is a nondisplaced linear fracture through that bone, that sound will be dampened significantly so that you will be able to tell the difference,” he said. “It works with a 99% sensitivity when tested in 100 patients.”

Pelvic Binder

Although not much can be done for pelvic fractures in remote settings, the pelvis can be bound to reduce bleeding.

“You can use a Therm-a-Rest pad and wrap it around the pelvis and inflate it,” Dr. Weiss said.

Alternatively, an article of clothing or a sheet can be wrapped around the pelvis, centering it over the greater trochanters of the femurs.

“Then take some tent poles or something, and tie it in there, then just kind of like a windlass, like you would turn a tourniquet, you wrap it until the patient feels some pressure,” he said.

Shoulder Immobilizer

In a pinch, an injured shoulder can be immobilized with just a few safety pins and the clothing a patient is wearing, according to Dr. Weiss.

“If you have a long-sleeve shirt, you can just safety pin the sleeve to [the shirt] itself,” he explained. “If you have a short-sleeve shirt, just take the shirt, fold it up, [and] make a little pouch with two safety pins.”

Wound Irrigator

In remote settings, a plastic sandwich bag can be filled with irrigation fluid, sealed, and squeezed hard to create adequate pressure for effective wound irrigation. “You don't need sterile normal saline,” Dr. Weiss added.

“If you are still using sterile normal saline, you need to go back to the literature because there are quite a few articles … showing that tap water works just as well” in terms of infection rates, because it is usually chlorinated.

Wound Closer

Although sutures or staples are ideal for closing wounds, glue or Dermabond can be used. For scalp lacerations, hair tying also works well.

For the hair-tying technique, a piece of dental floss or suture is oriented lengthwise along the laceration. “Take some hair on either side of the wound, twirl it in your fingers, and cross it over. Then use the dental floss or the suture to tie your square knot” around the crossed hair, he explained.

In particular, this technique “works great in children who have good heads of hair,” he noted. “There is no fuss or muss. They don't have to come back and have sutures removed or staples taken out. There is no pain.”

Topical Antibiotic

After a wound has been closed, physicians can apply honey, which Dr. Weiss referred to as “nature's Neosporin.”

Roughly 20 randomized, controlled trials have compared the substance with commercial topical antimicrobial agents and have generally found honey to be superior, he noted.

“When applied topically, honey reduces infection and promotes wound healing. It's safe, and it's effective,” he commented.

“It even has some antimicrobial properties that are due to its hypertonicity, its pH, and some inhibins that it has.”

In unconscious patients, use safety pins to keep the airway open by pinning the tongue to the lower lip, said Dr. Eric A. Weiss.

Source Courtesy Stanford University

LAS VEGAS — Improvised medical care can be lifesaving in settings where the closest medical facility may be hours or even days away, Dr. Eric A. Weiss told attendees of the meeting.

With just some basic medical supplies, the usual backcountry gear, and a few key additional items – safety pins and duct tape – physicians can often devise temporary, makeshift treatments for commonly occurring conditions, such as lacerations and fractures, he said.

Airway Opener

In unconscious patients, safety pins can be used to keep the airway open by pinning the tongue to the lower lip, according to Dr. Weiss of the departments of surgery and emergency medicine, and director of the Wilderness Medicine Fellowship at Stanford (Calif.) University.

This technique can be especially useful in cases of trauma, given the need to avoid neck hyperextension, and it also keeps the physician's hands free when they would otherwise be tied up performing a jaw thrust.

“This works very effectively – minimal bleeding, opens the airway,” he said.

“I know what you are thinking: This sounds kind of harsh. It's really not. If you are putting a safety pin through somebody's tongue, they are obviously unconscious [and] unresponsive.”

Barrier for Rescue Breathing

When performing rescue breathing in a noninstitutional location, physicians may not have conventional barrier devices to reduce their risk of contracting infection from the patient.

In this case, Dr. Weiss recommended making a slit in the middle finger of an examination glove, placing the glove fingers in the patient's mouth, and stretching the rest of the glove over the mouth and nose.

“Now you can blow air right through there and very effectively ventilate. As air goes in, it comes out this slit. To allow for exhalation, just remove the nasal part, allowing the victim to exhale, and then put it back for ventilation once again,” he explained.

“Any back pressure, like vomiting, will cause that slit to collapse and you don't get slimed,” he added.

Surgical Airway

To create a surgical airway (cricothyroidotomy) without the usual instruments, physicians can use a knife or other sharp object to make a vertical incision in the skin over the cricothyroid membrane.

“Horizontal incisions are fine,” Dr. Weiss said. “But I like vertical ones because sometimes you are a little bit off target and once you get through the skin, you can stick your gloved finger in there and you will find it a little bit easier [to get oriented], and you may have to move north or south.”

A variety of items can be inserted through the cricothyroid membrane and into the trachea to permit ventilation: a hollow pen tube, the cut barrel of a 3-cc syringe, or the spike that comes with standard macro IV tubing, after the drip chamber has been cut in half.

If the spike is used, “you don't even have to make an incision through the skin: This spike is so sharp, you just plunge that right into the cricothyroid membrane,” he said. “You have the fastest cricothyroidotomy the world has ever seen.”

An added, serendipitous benefit is that the chamber end of the spike “fits beautifully right onto an Ambu bag,” he noted.

Pleural Decompression

In the patient with a tension pneumothorax, most physicians are familiar with the practice of inserting a needle into the pleural space to achieve pleural decompression.

But Dr. Weiss additionally recommended putting the needle through a cut finger of an examination glove to create a one-way Heimlich valve.

“When the person takes a big breath in, the negative pressure causes the glove to collapse,” he explained. “But when he exhales out, it allows air to escape.”

Posterior Nasal Packing

Persistent posterior nasal bleeding, as might occur in facial trauma, can be stopped with a Foley catheter, according to Dr. Weiss.

The catheter is advanced through the nose until it can be seen in the back of the throat. “Blow up the balloon with 30 cc of air,” he advised.

“Most people use air because there is theoretical concern that if you put water in there, which works a little better actually, if it ruptures there could be aspiration.”

The catheter should then be withdrawn until the balloon is seated in the posterior nasopharynx, where resistance can be felt. The exiting part of the catheter is then taped to the nose with duct tape.

Fracture Diagnostic

As a stand-in for x-rays, a stethoscope and tuning fork can be used to diagnose fractures in long bones, such as the tibia. The principle at work here is that intact bone is a good transmitter of vibratory sound.

“Take your tuning fork and bang it and put it on the proximal tibia. Take your stethoscope and listen over the medial malleolus, the distal tibia. Then compare it to the other side,” instructed Dr. Weiss.

“Even if there is a nondisplaced linear fracture through that bone, that sound will be dampened significantly so that you will be able to tell the difference,” he said. “It works with a 99% sensitivity when tested in 100 patients.”

Pelvic Binder

Although not much can be done for pelvic fractures in remote settings, the pelvis can be bound to reduce bleeding.

“You can use a Therm-a-Rest pad and wrap it around the pelvis and inflate it,” Dr. Weiss said.

Alternatively, an article of clothing or a sheet can be wrapped around the pelvis, centering it over the greater trochanters of the femurs.

“Then take some tent poles or something, and tie it in there, then just kind of like a windlass, like you would turn a tourniquet, you wrap it until the patient feels some pressure,” he said.

Shoulder Immobilizer

In a pinch, an injured shoulder can be immobilized with just a few safety pins and the clothing a patient is wearing, according to Dr. Weiss.

“If you have a long-sleeve shirt, you can just safety pin the sleeve to [the shirt] itself,” he explained. “If you have a short-sleeve shirt, just take the shirt, fold it up, [and] make a little pouch with two safety pins.”

Wound Irrigator

In remote settings, a plastic sandwich bag can be filled with irrigation fluid, sealed, and squeezed hard to create adequate pressure for effective wound irrigation. “You don't need sterile normal saline,” Dr. Weiss added.

“If you are still using sterile normal saline, you need to go back to the literature because there are quite a few articles … showing that tap water works just as well” in terms of infection rates, because it is usually chlorinated.

Wound Closer

Although sutures or staples are ideal for closing wounds, glue or Dermabond can be used. For scalp lacerations, hair tying also works well.

For the hair-tying technique, a piece of dental floss or suture is oriented lengthwise along the laceration. “Take some hair on either side of the wound, twirl it in your fingers, and cross it over. Then use the dental floss or the suture to tie your square knot” around the crossed hair, he explained.

In particular, this technique “works great in children who have good heads of hair,” he noted. “There is no fuss or muss. They don't have to come back and have sutures removed or staples taken out. There is no pain.”

Topical Antibiotic

After a wound has been closed, physicians can apply honey, which Dr. Weiss referred to as “nature's Neosporin.”

Roughly 20 randomized, controlled trials have compared the substance with commercial topical antimicrobial agents and have generally found honey to be superior, he noted.

“When applied topically, honey reduces infection and promotes wound healing. It's safe, and it's effective,” he commented.

“It even has some antimicrobial properties that are due to its hypertonicity, its pH, and some inhibins that it has.”

In unconscious patients, use safety pins to keep the airway open by pinning the tongue to the lower lip, said Dr. Eric A. Weiss.

Source Courtesy Stanford University

VANCOUVER, B.C. – Although physicians might be reluctant to bring up smoking cessation with their patients for many reasons, it is one of the most important preventive activities they can undertake, according to Dr. Arunabh Talwar.

Smokers are ambivalent about smoking, he said at the annual meeting of the American College of Chest Physicians. On any given day, their smoking status hangs in balance between one set of factors favoring quitting and another set favoring continuing (BMJ 2007;335:37-41).

"All we need to do is just [tip the balance]," said Dr. Talwar, who is a pulmonologist at North Shore University Hospital in Manhasset, N.Y.

Indeed, if self-reports are reliable, about 70% of smokers want to stop and 30% try each year. But only 2%-3% succeed.

Referring to the multistage model of behavioral change, he noted that making smokers aware of the link between smoking and end-organ damage is critical in starting the process. "That is the most important thing that physicians do – they move patients from a precontemplation to a contemplation stage and set the stage for the smoking cessation process to occur."

There is compelling evidence of the benefits of smoking cessation, he said. It has been identified as the single most effective step for lengthening and improving patients’ lives (BMJ 2004;328:947-9).

"Make no mistake, smoking cessation activity is very cost effective," he added. "I think it is the most cost-effective primary prevention action that a physician can take."

Brief advice to quit costs $338 per year of life saved – or less than 5% of the cost per year of life saved from giving pravastatin for primary prevention of cardiovascular disease, aspirin for secondary prevention of coronary heart disease, or simvastatin for secondary prevention of myocardial infarction (BMJ 2004;328:397-9).

Still, physicians cite numerous barriers to promoting smoking cessation with their patients, according to Dr. Talwar (J. Smok. Cessat. 2008;3:92-100). A common one is being too busy.

"But studies show us, a minimal intervention – as [little] as 3 minutes of a physician’s time – can move patients from ‘precontemplation’ to contemplation, can help improve quit status," he said. Furthermore, "as you increase the intervention, the success rate will improve."

For example, just 0.3% of smokers succeed in quitting long term on their own, but the value rises to 1.6% when physicians simply ask their smoking status, 3.3% when they ask and provide advice on quitting, and 5.1% when they ask, advise, and give a pamphlet (BMJ 1979;2:231-5).

Busy physicians can streamline efforts by using a team approach. "Some of it can be shared by other health care providers, whether they are nurses, nurse practitioners, physician assistants," Dr. Talwar explained. "We use our respiratory therapists and [pulmonary function test] lab technicians as well; that way, the load gets divided. But also, repeated messages to the patient will help move them along."

Physicians should also consider using telephone "quitlines" (now freely available in all states) and patient support groups in the behavioral modification part of cessation, he advised.

Another barrier physicians cite, lack of expertise, has a stronger negative influence on their smoking cessation activities than lack of interest, time, or materials (Eur. J. Public Health 2005;15:140-5).

Indeed, in a survey of New York City–area health care providers, Dr. Talwar and his colleagues found that only 20% believed their training had adequately prepared them to treat tobacco dependence. And less than 10% were familiar with treatment guidelines. "We are a little bit behind in this, but medical schools have made a change, and most medical schools now make an effort to make sure that standard curricula [on smoking cessation] are there," he said. In addition, comprehensive information is readily available in the ACCP’s Tobacco Dependence Treatment ToolKit.

Reassuringly, physicians who receive training in this area are 1.5 to 2.5 times more likely to perform smoking cessation tasks (Cochrane Database Syst. Rev. 2000;CD000214).

Physicians also report a lack of financial incentives to be a barrier. Dr. Talwar noted that two CPT codes – 99406 and 99407 – specifically pertain to cessation activities during visits. Physicians can usually bill for this counseling, in addition to routine office visits, four times annually.

Half of physicians still believe that reimbursement is insufficient. "But the situation is much better than 7 or 8 years ago, when it was much more difficult to get reimbursement for these activities," he commented.

Physicians also mention patients’ low likelihood of quitting as a barrier to broaching smoking cessation, according to Dr. Talwar. But the irony is that quit rates are influenced in large part by physicians’ efforts and the intensity of those efforts.

Discussing the so-called 5 A’s of smoking cessation – ask, advise, assess, assist, and arrange – he noted that physicians do fairly well on the first two, but not so well on the others.

For example, a study of 246 community-based primary care physicians found that 67% asked their patients about smoking status and 74% gave advice, but just 35% assisted with smoking cessation efforts and merely 8% arranged for follow-up (Prev. Med. 1998;27:720-9).

It is important to understand that relapses are part of the cessation process, Dr. Talwar stressed; in fact, smokers who succeed in quitting make five to seven attempts, on average, before succeeding. Hence, "you have just to have to be patient with them."

It might also be possible to improve the odds of successful quitting by approaching patients at teachable moments, he further noted. For instance, "admission [to the hospital] is an opportunity to interact, to make the change. Maybe that’s the time when you need to approach them."

His own 800-bed hospital generates a list each day of inpatients who smoke. A smoking cessation therapist then visits these patients and invites them to the smoking cessation clinic.

A final barrier is that some physicians themselves are smokers. "It’s been shown that physicians who smoke have very little faith in their own ability to promote smoking cessation," Dr. Talwar commented (Prev. Med. 2005;40:595-601).

On the other hand, this group has greater insight into the difficulties of quitting and might be able to draw on their own experiences to assist patients in this endeavor, he added.

Dr. Talwar did not report any conflicts of interest.

VANCOUVER, B.C. – Although physicians might be reluctant to bring up smoking cessation with their patients for many reasons, it is one of the most important preventive activities they can undertake, according to Dr. Arunabh Talwar.

Smokers are ambivalent about smoking, he said at the annual meeting of the American College of Chest Physicians. On any given day, their smoking status hangs in balance between one set of factors favoring quitting and another set favoring continuing (BMJ 2007;335:37-41).

"All we need to do is just [tip the balance]," said Dr. Talwar, who is a pulmonologist at North Shore University Hospital in Manhasset, N.Y.

Indeed, if self-reports are reliable, about 70% of smokers want to stop and 30% try each year. But only 2%-3% succeed.

Referring to the multistage model of behavioral change, he noted that making smokers aware of the link between smoking and end-organ damage is critical in starting the process. "That is the most important thing that physicians do – they move patients from a precontemplation to a contemplation stage and set the stage for the smoking cessation process to occur."

There is compelling evidence of the benefits of smoking cessation, he said. It has been identified as the single most effective step for lengthening and improving patients’ lives (BMJ 2004;328:947-9).

"Make no mistake, smoking cessation activity is very cost effective," he added. "I think it is the most cost-effective primary prevention action that a physician can take."

Brief advice to quit costs $338 per year of life saved – or less than 5% of the cost per year of life saved from giving pravastatin for primary prevention of cardiovascular disease, aspirin for secondary prevention of coronary heart disease, or simvastatin for secondary prevention of myocardial infarction (BMJ 2004;328:397-9).

Still, physicians cite numerous barriers to promoting smoking cessation with their patients, according to Dr. Talwar (J. Smok. Cessat. 2008;3:92-100). A common one is being too busy.

"But studies show us, a minimal intervention – as [little] as 3 minutes of a physician’s time – can move patients from ‘precontemplation’ to contemplation, can help improve quit status," he said. Furthermore, "as you increase the intervention, the success rate will improve."

For example, just 0.3% of smokers succeed in quitting long term on their own, but the value rises to 1.6% when physicians simply ask their smoking status, 3.3% when they ask and provide advice on quitting, and 5.1% when they ask, advise, and give a pamphlet (BMJ 1979;2:231-5).

Busy physicians can streamline efforts by using a team approach. "Some of it can be shared by other health care providers, whether they are nurses, nurse practitioners, physician assistants," Dr. Talwar explained. "We use our respiratory therapists and [pulmonary function test] lab technicians as well; that way, the load gets divided. But also, repeated messages to the patient will help move them along."

Physicians should also consider using telephone "quitlines" (now freely available in all states) and patient support groups in the behavioral modification part of cessation, he advised.

Another barrier physicians cite, lack of expertise, has a stronger negative influence on their smoking cessation activities than lack of interest, time, or materials (Eur. J. Public Health 2005;15:140-5).

Indeed, in a survey of New York City–area health care providers, Dr. Talwar and his colleagues found that only 20% believed their training had adequately prepared them to treat tobacco dependence. And less than 10% were familiar with treatment guidelines. "We are a little bit behind in this, but medical schools have made a change, and most medical schools now make an effort to make sure that standard curricula [on smoking cessation] are there," he said. In addition, comprehensive information is readily available in the ACCP’s Tobacco Dependence Treatment ToolKit.

Reassuringly, physicians who receive training in this area are 1.5 to 2.5 times more likely to perform smoking cessation tasks (Cochrane Database Syst. Rev. 2000;CD000214).

Physicians also report a lack of financial incentives to be a barrier. Dr. Talwar noted that two CPT codes – 99406 and 99407 – specifically pertain to cessation activities during visits. Physicians can usually bill for this counseling, in addition to routine office visits, four times annually.

Half of physicians still believe that reimbursement is insufficient. "But the situation is much better than 7 or 8 years ago, when it was much more difficult to get reimbursement for these activities," he commented.

Physicians also mention patients’ low likelihood of quitting as a barrier to broaching smoking cessation, according to Dr. Talwar. But the irony is that quit rates are influenced in large part by physicians’ efforts and the intensity of those efforts.

Discussing the so-called 5 A’s of smoking cessation – ask, advise, assess, assist, and arrange – he noted that physicians do fairly well on the first two, but not so well on the others.

For example, a study of 246 community-based primary care physicians found that 67% asked their patients about smoking status and 74% gave advice, but just 35% assisted with smoking cessation efforts and merely 8% arranged for follow-up (Prev. Med. 1998;27:720-9).

It is important to understand that relapses are part of the cessation process, Dr. Talwar stressed; in fact, smokers who succeed in quitting make five to seven attempts, on average, before succeeding. Hence, "you have just to have to be patient with them."

It might also be possible to improve the odds of successful quitting by approaching patients at teachable moments, he further noted. For instance, "admission [to the hospital] is an opportunity to interact, to make the change. Maybe that’s the time when you need to approach them."

His own 800-bed hospital generates a list each day of inpatients who smoke. A smoking cessation therapist then visits these patients and invites them to the smoking cessation clinic.

A final barrier is that some physicians themselves are smokers. "It’s been shown that physicians who smoke have very little faith in their own ability to promote smoking cessation," Dr. Talwar commented (Prev. Med. 2005;40:595-601).

On the other hand, this group has greater insight into the difficulties of quitting and might be able to draw on their own experiences to assist patients in this endeavor, he added.

Dr. Talwar did not report any conflicts of interest.

VANCOUVER, B.C. – Although physicians might be reluctant to bring up smoking cessation with their patients for many reasons, it is one of the most important preventive activities they can undertake, according to Dr. Arunabh Talwar.

Smokers are ambivalent about smoking, he said at the annual meeting of the American College of Chest Physicians. On any given day, their smoking status hangs in balance between one set of factors favoring quitting and another set favoring continuing (BMJ 2007;335:37-41).

"All we need to do is just [tip the balance]," said Dr. Talwar, who is a pulmonologist at North Shore University Hospital in Manhasset, N.Y.

Indeed, if self-reports are reliable, about 70% of smokers want to stop and 30% try each year. But only 2%-3% succeed.

Referring to the multistage model of behavioral change, he noted that making smokers aware of the link between smoking and end-organ damage is critical in starting the process. "That is the most important thing that physicians do – they move patients from a precontemplation to a contemplation stage and set the stage for the smoking cessation process to occur."

There is compelling evidence of the benefits of smoking cessation, he said. It has been identified as the single most effective step for lengthening and improving patients’ lives (BMJ 2004;328:947-9).

"Make no mistake, smoking cessation activity is very cost effective," he added. "I think it is the most cost-effective primary prevention action that a physician can take."

Brief advice to quit costs $338 per year of life saved – or less than 5% of the cost per year of life saved from giving pravastatin for primary prevention of cardiovascular disease, aspirin for secondary prevention of coronary heart disease, or simvastatin for secondary prevention of myocardial infarction (BMJ 2004;328:397-9).

Still, physicians cite numerous barriers to promoting smoking cessation with their patients, according to Dr. Talwar (J. Smok. Cessat. 2008;3:92-100). A common one is being too busy.

"But studies show us, a minimal intervention – as [little] as 3 minutes of a physician’s time – can move patients from ‘precontemplation’ to contemplation, can help improve quit status," he said. Furthermore, "as you increase the intervention, the success rate will improve."

For example, just 0.3% of smokers succeed in quitting long term on their own, but the value rises to 1.6% when physicians simply ask their smoking status, 3.3% when they ask and provide advice on quitting, and 5.1% when they ask, advise, and give a pamphlet (BMJ 1979;2:231-5).

Busy physicians can streamline efforts by using a team approach. "Some of it can be shared by other health care providers, whether they are nurses, nurse practitioners, physician assistants," Dr. Talwar explained. "We use our respiratory therapists and [pulmonary function test] lab technicians as well; that way, the load gets divided. But also, repeated messages to the patient will help move them along."

Physicians should also consider using telephone "quitlines" (now freely available in all states) and patient support groups in the behavioral modification part of cessation, he advised.

Another barrier physicians cite, lack of expertise, has a stronger negative influence on their smoking cessation activities than lack of interest, time, or materials (Eur. J. Public Health 2005;15:140-5).

Indeed, in a survey of New York City–area health care providers, Dr. Talwar and his colleagues found that only 20% believed their training had adequately prepared them to treat tobacco dependence. And less than 10% were familiar with treatment guidelines. "We are a little bit behind in this, but medical schools have made a change, and most medical schools now make an effort to make sure that standard curricula [on smoking cessation] are there," he said. In addition, comprehensive information is readily available in the ACCP’s Tobacco Dependence Treatment ToolKit.

Reassuringly, physicians who receive training in this area are 1.5 to 2.5 times more likely to perform smoking cessation tasks (Cochrane Database Syst. Rev. 2000;CD000214).

Physicians also report a lack of financial incentives to be a barrier. Dr. Talwar noted that two CPT codes – 99406 and 99407 – specifically pertain to cessation activities during visits. Physicians can usually bill for this counseling, in addition to routine office visits, four times annually.

Half of physicians still believe that reimbursement is insufficient. "But the situation is much better than 7 or 8 years ago, when it was much more difficult to get reimbursement for these activities," he commented.

Physicians also mention patients’ low likelihood of quitting as a barrier to broaching smoking cessation, according to Dr. Talwar. But the irony is that quit rates are influenced in large part by physicians’ efforts and the intensity of those efforts.

Discussing the so-called 5 A’s of smoking cessation – ask, advise, assess, assist, and arrange – he noted that physicians do fairly well on the first two, but not so well on the others.

For example, a study of 246 community-based primary care physicians found that 67% asked their patients about smoking status and 74% gave advice, but just 35% assisted with smoking cessation efforts and merely 8% arranged for follow-up (Prev. Med. 1998;27:720-9).

It is important to understand that relapses are part of the cessation process, Dr. Talwar stressed; in fact, smokers who succeed in quitting make five to seven attempts, on average, before succeeding. Hence, "you have just to have to be patient with them."

It might also be possible to improve the odds of successful quitting by approaching patients at teachable moments, he further noted. For instance, "admission [to the hospital] is an opportunity to interact, to make the change. Maybe that’s the time when you need to approach them."

His own 800-bed hospital generates a list each day of inpatients who smoke. A smoking cessation therapist then visits these patients and invites them to the smoking cessation clinic.

A final barrier is that some physicians themselves are smokers. "It’s been shown that physicians who smoke have very little faith in their own ability to promote smoking cessation," Dr. Talwar commented (Prev. Med. 2005;40:595-601).

On the other hand, this group has greater insight into the difficulties of quitting and might be able to draw on their own experiences to assist patients in this endeavor, he added.

Dr. Talwar did not report any conflicts of interest.

VANCOUVER, B.C. – Although physicians might be reluctant to bring up smoking cessation with their patients for many reasons, it is one of the most important preventive activities they can undertake, according to Dr. Arunabh Talwar.

Smokers are ambivalent about smoking, he said at the annual meeting of the American College of Chest Physicians. On any given day, their smoking status hangs in balance between one set of factors favoring quitting and another set favoring continuing (BMJ 2007;335:37-41).

"All we need to do is just [tip the balance]," said Dr. Talwar, who is a pulmonologist at North Shore University Hospital in Manhasset, N.Y.

Indeed, if self-reports are reliable, about 70% of smokers want to stop and 30% try each year. But only 2%-3% succeed.

Referring to the multistage model of behavioral change, he noted that making smokers aware of the link between smoking and end-organ damage is critical in starting the process. "That is the most important thing that physicians do – they move patients from a precontemplation to a contemplation stage and set the stage for the smoking cessation process to occur."

There is compelling evidence of the benefits of smoking cessation, he said. It has been identified as the single most effective step for lengthening and improving patients’ lives (BMJ 2004;328:947-9).

"Make no mistake, smoking cessation activity is very cost effective," he added. "I think it is the most cost-effective primary prevention action that a physician can take."

Brief advice to quit costs $338 per year of life saved – or less than 5% of the cost per year of life saved from giving pravastatin for primary prevention of cardiovascular disease, aspirin for secondary prevention of coronary heart disease, or simvastatin for secondary prevention of myocardial infarction (BMJ 2004;328:397-9).

Still, physicians cite numerous barriers to promoting smoking cessation with their patients, according to Dr. Talwar (J. Smok. Cessat. 2008;3:92-100). A common one is being too busy.

"But studies show us, a minimal intervention – as [little] as 3 minutes of a physician’s time – can move patients from ‘precontemplation’ to contemplation, can help improve quit status," he said. Furthermore, "as you increase the intervention, the success rate will improve."

For example, just 0.3% of smokers succeed in quitting long term on their own, but the value rises to 1.6% when physicians simply ask their smoking status, 3.3% when they ask and provide advice on quitting, and 5.1% when they ask, advise, and give a pamphlet (BMJ 1979;2:231-5).

Busy physicians can streamline efforts by using a team approach. "Some of it can be shared by other health care providers, whether they are nurses, nurse practitioners, physician assistants," Dr. Talwar explained. "We use our respiratory therapists and [pulmonary function test] lab technicians as well; that way, the load gets divided. But also, repeated messages to the patient will help move them along."

Physicians should also consider using telephone "quitlines" (now freely available in all states) and patient support groups in the behavioral modification part of cessation, he advised.

Another barrier physicians cite, lack of expertise, has a stronger negative influence on their smoking cessation activities than lack of interest, time, or materials (Eur. J. Public Health 2005;15:140-5).

Indeed, in a survey of New York City–area health care providers, Dr. Talwar and his colleagues found that only 20% believed their training had adequately prepared them to treat tobacco dependence. And less than 10% were familiar with treatment guidelines. "We are a little bit behind in this, but medical schools have made a change, and most medical schools now make an effort to make sure that standard curricula [on smoking cessation] are there," he said. In addition, comprehensive information is readily available in the ACCP’s Tobacco Dependence Treatment ToolKit.

Reassuringly, physicians who receive training in this area are 1.5 to 2.5 times more likely to perform smoking cessation tasks (Cochrane Database Syst. Rev. 2000;CD000214).

Physicians also report a lack of financial incentives to be a barrier. Dr. Talwar noted that two CPT codes – 99406 and 99407 – specifically pertain to cessation activities during visits. Physicians can usually bill for this counseling, in addition to routine office visits, four times annually.

Half of physicians still believe that reimbursement is insufficient. "But the situation is much better than 7 or 8 years ago, when it was much more difficult to get reimbursement for these activities," he commented.

Physicians also mention patients’ low likelihood of quitting as a barrier to broaching smoking cessation, according to Dr. Talwar. But the irony is that quit rates are influenced in large part by physicians’ efforts and the intensity of those efforts.

Discussing the so-called 5 A’s of smoking cessation – ask, advise, assess, assist, and arrange – he noted that physicians do fairly well on the first two, but not so well on the others.

For example, a study of 246 community-based primary care physicians found that 67% asked their patients about smoking status and 74% gave advice, but just 35% assisted with smoking cessation efforts and merely 8% arranged for follow-up (Prev. Med. 1998;27:720-9).

It is important to understand that relapses are part of the cessation process, Dr. Talwar stressed; in fact, smokers who succeed in quitting make five to seven attempts, on average, before succeeding. Hence, "you have just to have to be patient with them."

It might also be possible to improve the odds of successful quitting by approaching patients at teachable moments, he further noted. For instance, "admission [to the hospital] is an opportunity to interact, to make the change. Maybe that’s the time when you need to approach them."

His own 800-bed hospital generates a list each day of inpatients who smoke. A smoking cessation therapist then visits these patients and invites them to the smoking cessation clinic.

A final barrier is that some physicians themselves are smokers. "It’s been shown that physicians who smoke have very little faith in their own ability to promote smoking cessation," Dr. Talwar commented (Prev. Med. 2005;40:595-601).

On the other hand, this group has greater insight into the difficulties of quitting and might be able to draw on their own experiences to assist patients in this endeavor, he added.

Dr. Talwar did not report any conflicts of interest.

VANCOUVER, B.C. – Although physicians might be reluctant to bring up smoking cessation with their patients for many reasons, it is one of the most important preventive activities they can undertake, according to Dr. Arunabh Talwar.

Smokers are ambivalent about smoking, he said at the annual meeting of the American College of Chest Physicians. On any given day, their smoking status hangs in balance between one set of factors favoring quitting and another set favoring continuing (BMJ 2007;335:37-41).

"All we need to do is just [tip the balance]," said Dr. Talwar, who is a pulmonologist at North Shore University Hospital in Manhasset, N.Y.

Indeed, if self-reports are reliable, about 70% of smokers want to stop and 30% try each year. But only 2%-3% succeed.

Referring to the multistage model of behavioral change, he noted that making smokers aware of the link between smoking and end-organ damage is critical in starting the process. "That is the most important thing that physicians do – they move patients from a precontemplation to a contemplation stage and set the stage for the smoking cessation process to occur."

There is compelling evidence of the benefits of smoking cessation, he said. It has been identified as the single most effective step for lengthening and improving patients’ lives (BMJ 2004;328:947-9).

"Make no mistake, smoking cessation activity is very cost effective," he added. "I think it is the most cost-effective primary prevention action that a physician can take."

Brief advice to quit costs $338 per year of life saved – or less than 5% of the cost per year of life saved from giving pravastatin for primary prevention of cardiovascular disease, aspirin for secondary prevention of coronary heart disease, or simvastatin for secondary prevention of myocardial infarction (BMJ 2004;328:397-9).

Still, physicians cite numerous barriers to promoting smoking cessation with their patients, according to Dr. Talwar (J. Smok. Cessat. 2008;3:92-100). A common one is being too busy.

"But studies show us, a minimal intervention – as [little] as 3 minutes of a physician’s time – can move patients from ‘precontemplation’ to contemplation, can help improve quit status," he said. Furthermore, "as you increase the intervention, the success rate will improve."

For example, just 0.3% of smokers succeed in quitting long term on their own, but the value rises to 1.6% when physicians simply ask their smoking status, 3.3% when they ask and provide advice on quitting, and 5.1% when they ask, advise, and give a pamphlet (BMJ 1979;2:231-5).

Busy physicians can streamline efforts by using a team approach. "Some of it can be shared by other health care providers, whether they are nurses, nurse practitioners, physician assistants," Dr. Talwar explained. "We use our respiratory therapists and [pulmonary function test] lab technicians as well; that way, the load gets divided. But also, repeated messages to the patient will help move them along."

Physicians should also consider using telephone "quitlines" (now freely available in all states) and patient support groups in the behavioral modification part of cessation, he advised.

Another barrier physicians cite, lack of expertise, has a stronger negative influence on their smoking cessation activities than lack of interest, time, or materials (Eur. J. Public Health 2005;15:140-5).

Indeed, in a survey of New York City–area health care providers, Dr. Talwar and his colleagues found that only 20% believed their training had adequately prepared them to treat tobacco dependence. And less than 10% were familiar with treatment guidelines. "We are a little bit behind in this, but medical schools have made a change, and most medical schools now make an effort to make sure that standard curricula [on smoking cessation] are there," he said. In addition, comprehensive information is readily available in the ACCP’s Tobacco Dependence Treatment ToolKit.

Reassuringly, physicians who receive training in this area are 1.5 to 2.5 times more likely to perform smoking cessation tasks (Cochrane Database Syst. Rev. 2000;CD000214).

Physicians also report a lack of financial incentives to be a barrier. Dr. Talwar noted that two CPT codes – 99406 and 99407 – specifically pertain to cessation activities during visits. Physicians can usually bill for this counseling, in addition to routine office visits, four times annually.

Half of physicians still believe that reimbursement is insufficient. "But the situation is much better than 7 or 8 years ago, when it was much more difficult to get reimbursement for these activities," he commented.

Physicians also mention patients’ low likelihood of quitting as a barrier to broaching smoking cessation, according to Dr. Talwar. But the irony is that quit rates are influenced in large part by physicians’ efforts and the intensity of those efforts.

Discussing the so-called 5 A’s of smoking cessation – ask, advise, assess, assist, and arrange – he noted that physicians do fairly well on the first two, but not so well on the others.

For example, a study of 246 community-based primary care physicians found that 67% asked their patients about smoking status and 74% gave advice, but just 35% assisted with smoking cessation efforts and merely 8% arranged for follow-up (Prev. Med. 1998;27:720-9).

It is important to understand that relapses are part of the cessation process, Dr. Talwar stressed; in fact, smokers who succeed in quitting make five to seven attempts, on average, before succeeding. Hence, "you have just to have to be patient with them."

It might also be possible to improve the odds of successful quitting by approaching patients at teachable moments, he further noted. For instance, "admission [to the hospital] is an opportunity to interact, to make the change. Maybe that’s the time when you need to approach them."

His own 800-bed hospital generates a list each day of inpatients who smoke. A smoking cessation therapist then visits these patients and invites them to the smoking cessation clinic.

A final barrier is that some physicians themselves are smokers. "It’s been shown that physicians who smoke have very little faith in their own ability to promote smoking cessation," Dr. Talwar commented (Prev. Med. 2005;40:595-601).

On the other hand, this group has greater insight into the difficulties of quitting and might be able to draw on their own experiences to assist patients in this endeavor, he added.

Dr. Talwar did not report any conflicts of interest.

VANCOUVER, B.C. – Although physicians might be reluctant to bring up smoking cessation with their patients for many reasons, it is one of the most important preventive activities they can undertake, according to Dr. Arunabh Talwar.

Smokers are ambivalent about smoking, he said at the annual meeting of the American College of Chest Physicians. On any given day, their smoking status hangs in balance between one set of factors favoring quitting and another set favoring continuing (BMJ 2007;335:37-41).

"All we need to do is just [tip the balance]," said Dr. Talwar, who is a pulmonologist at North Shore University Hospital in Manhasset, N.Y.

Indeed, if self-reports are reliable, about 70% of smokers want to stop and 30% try each year. But only 2%-3% succeed.

Referring to the multistage model of behavioral change, he noted that making smokers aware of the link between smoking and end-organ damage is critical in starting the process. "That is the most important thing that physicians do – they move patients from a precontemplation to a contemplation stage and set the stage for the smoking cessation process to occur."

There is compelling evidence of the benefits of smoking cessation, he said. It has been identified as the single most effective step for lengthening and improving patients’ lives (BMJ 2004;328:947-9).

"Make no mistake, smoking cessation activity is very cost effective," he added. "I think it is the most cost-effective primary prevention action that a physician can take."

Brief advice to quit costs $338 per year of life saved – or less than 5% of the cost per year of life saved from giving pravastatin for primary prevention of cardiovascular disease, aspirin for secondary prevention of coronary heart disease, or simvastatin for secondary prevention of myocardial infarction (BMJ 2004;328:397-9).

Still, physicians cite numerous barriers to promoting smoking cessation with their patients, according to Dr. Talwar (J. Smok. Cessat. 2008;3:92-100). A common one is being too busy.

"But studies show us, a minimal intervention – as [little] as 3 minutes of a physician’s time – can move patients from ‘precontemplation’ to contemplation, can help improve quit status," he said. Furthermore, "as you increase the intervention, the success rate will improve."

For example, just 0.3% of smokers succeed in quitting long term on their own, but the value rises to 1.6% when physicians simply ask their smoking status, 3.3% when they ask and provide advice on quitting, and 5.1% when they ask, advise, and give a pamphlet (BMJ 1979;2:231-5).

Busy physicians can streamline efforts by using a team approach. "Some of it can be shared by other health care providers, whether they are nurses, nurse practitioners, physician assistants," Dr. Talwar explained. "We use our respiratory therapists and [pulmonary function test] lab technicians as well; that way, the load gets divided. But also, repeated messages to the patient will help move them along."

Physicians should also consider using telephone "quitlines" (now freely available in all states) and patient support groups in the behavioral modification part of cessation, he advised.

Another barrier physicians cite, lack of expertise, has a stronger negative influence on their smoking cessation activities than lack of interest, time, or materials (Eur. J. Public Health 2005;15:140-5).

Indeed, in a survey of New York City–area health care providers, Dr. Talwar and his colleagues found that only 20% believed their training had adequately prepared them to treat tobacco dependence. And less than 10% were familiar with treatment guidelines. "We are a little bit behind in this, but medical schools have made a change, and most medical schools now make an effort to make sure that standard curricula [on smoking cessation] are there," he said. In addition, comprehensive information is readily available in the ACCP’s Tobacco Dependence Treatment ToolKit.

Reassuringly, physicians who receive training in this area are 1.5 to 2.5 times more likely to perform smoking cessation tasks (Cochrane Database Syst. Rev. 2000;CD000214).

Physicians also report a lack of financial incentives to be a barrier. Dr. Talwar noted that two CPT codes – 99406 and 99407 – specifically pertain to cessation activities during visits. Physicians can usually bill for this counseling, in addition to routine office visits, four times annually.

Half of physicians still believe that reimbursement is insufficient. "But the situation is much better than 7 or 8 years ago, when it was much more difficult to get reimbursement for these activities," he commented.

Physicians also mention patients’ low likelihood of quitting as a barrier to broaching smoking cessation, according to Dr. Talwar. But the irony is that quit rates are influenced in large part by physicians’ efforts and the intensity of those efforts.

Discussing the so-called 5 A’s of smoking cessation – ask, advise, assess, assist, and arrange – he noted that physicians do fairly well on the first two, but not so well on the others.

For example, a study of 246 community-based primary care physicians found that 67% asked their patients about smoking status and 74% gave advice, but just 35% assisted with smoking cessation efforts and merely 8% arranged for follow-up (Prev. Med. 1998;27:720-9).

It is important to understand that relapses are part of the cessation process, Dr. Talwar stressed; in fact, smokers who succeed in quitting make five to seven attempts, on average, before succeeding. Hence, "you have just to have to be patient with them."

It might also be possible to improve the odds of successful quitting by approaching patients at teachable moments, he further noted. For instance, "admission [to the hospital] is an opportunity to interact, to make the change. Maybe that’s the time when you need to approach them."

His own 800-bed hospital generates a list each day of inpatients who smoke. A smoking cessation therapist then visits these patients and invites them to the smoking cessation clinic.

A final barrier is that some physicians themselves are smokers. "It’s been shown that physicians who smoke have very little faith in their own ability to promote smoking cessation," Dr. Talwar commented (Prev. Med. 2005;40:595-601).

On the other hand, this group has greater insight into the difficulties of quitting and might be able to draw on their own experiences to assist patients in this endeavor, he added.

Dr. Talwar did not report any conflicts of interest.

VANCOUVER, B.C. – The Centers for Medicare and Medicaid Services is currently offering providers a bonus for e-prescribing, or electronically transmitting prescriptions to pharmacies. But soon, providers will instead be hit with a penalty if they don’t get on board with this practice.

"They are really promoting this," Michael K. McCormick, a practice administrator at the DuPage Medical Group in Winfield, Ill., said at the annual meeting of the American College of Chest Physicians. But by transitioning from a bonus to a penalty over several years, "they are giving you time to get going on it."

The Medicare Electronic Prescribing (eRx) Incentive Program, which began in 2009 and runs through 2013, provides bonus payments for e-prescribing when certain eligibility criteria are met, with bonus percentages being reduced over the span of the program, according to Mr. McCormick, a registered respiratory therapist.

But the CMS also will start financially penalizing providers who do not begin e-prescribing in 2011. The penalty for failing to e-prescribe will be 1%, 1.5%, and 2% of all Medicare Part B charges in 2012, 2013, and 2014, respectively.

The bottom line is to "e-prescribe at least 10 times in the first 6 months of 2011 so you won’t be penalized in 2012," Mr. McCormick recommended. "You really need to start doing this in 2011."

The 2010 reporting criteria require that health care providers report e-prescribing for at least 25 eligible patient encounters (which can include multiple encounters for a single patient) and that Medicare account for at least 10% of the provider’s payer mix.

"The bonus returned to providers for 2010 is 2% of the total Medicare Part B Physician Fee Schedule allowed charges for services for the entire year; it will be 1% in 2011 and 2012, but only 0.5% in 2013.

All physicians (medical, osteopathic, podiatric, and chiropractic ones, among others) and a wide variety of allied health professionals (physician assistants, nurse practitioners, clinical social workers, and registered dieticians, among others) are eligible for the program.

The e-prescribing system used must meet certain criteria – for example, it must generate complete lists of all medications a patient is taking; provide information related to any lower-cost, therapeutically appropriate drugs; and, most notably, transmit prescriptions to pharmacies electronically.

Faxing of the prescription does not count, even if a computer system autogenerates the fax, Mr. McCormick cautioned. The prescription "must basically go from your computer to the pharmacy’s computer, not through a fax."

To obtain the bonus, providers can report their use of e-prescribing in any of three ways. "Probably the easiest way to get started is the claims-based reporting," he said, which entails simply adding the G8553 code to the other codes. Alternately, providers can use registry-based reporting or electronic health record (EHR)–based reporting.

The list of patient encounters considered eligible for e-prescribing is "pretty comprehensive," including all outpatient office visits (those having 992xx codes), home health visits, nursing home visits, and psychiatric care visits, he said. However, inpatient visits are not eligible.

A noteworthy caveat is that providers will not be able to earn both the e-prescribing bonus and another bonus for implementing the EHRs that the CMS is offering, because e-prescribing is among the 15 core measures of EHR implementation.

Put another way, "there is no double-dipping, starting in 2011," Mr. McCormick said. "So if you are going to go for that [EHR] bonus, which is a lot more money – $44,000 per provider paid over 5 years – you can’t put in for the eRx bonus as well."

Providers should take note that the window of eligibility for the bonus is still open for 2010. "It’s not too late ... to start e-prescribing for this year," he commented. "You can start e-prescribing any time during the year up to Dec. 31."

Certain providers will be exempt from the penalty, he added: those who generate fewer than 100 claims with eligible eRx patient codes, those for whom less than 10% of patient encounters are eligible (e.g., hospital-based physicians), and those facing relevant hardships, namely, practicing in a rural area with limited high-speed Internet service or a limited number of pharmacies able to receive prescriptions electronically.

The program’s rules, which change annually, can be found online.

VANCOUVER, B.C. – The Centers for Medicare and Medicaid Services is currently offering providers a bonus for e-prescribing, or electronically transmitting prescriptions to pharmacies. But soon, providers will instead be hit with a penalty if they don’t get on board with this practice.

"They are really promoting this," Michael K. McCormick, a practice administrator at the DuPage Medical Group in Winfield, Ill., said at the annual meeting of the American College of Chest Physicians. But by transitioning from a bonus to a penalty over several years, "they are giving you time to get going on it."

The Medicare Electronic Prescribing (eRx) Incentive Program, which began in 2009 and runs through 2013, provides bonus payments for e-prescribing when certain eligibility criteria are met, with bonus percentages being reduced over the span of the program, according to Mr. McCormick, a registered respiratory therapist.

But the CMS also will start financially penalizing providers who do not begin e-prescribing in 2011. The penalty for failing to e-prescribe will be 1%, 1.5%, and 2% of all Medicare Part B charges in 2012, 2013, and 2014, respectively.

The bottom line is to "e-prescribe at least 10 times in the first 6 months of 2011 so you won’t be penalized in 2012," Mr. McCormick recommended. "You really need to start doing this in 2011."

The 2010 reporting criteria require that health care providers report e-prescribing for at least 25 eligible patient encounters (which can include multiple encounters for a single patient) and that Medicare account for at least 10% of the provider’s payer mix.

"The bonus returned to providers for 2010 is 2% of the total Medicare Part B Physician Fee Schedule allowed charges for services for the entire year; it will be 1% in 2011 and 2012, but only 0.5% in 2013.

All physicians (medical, osteopathic, podiatric, and chiropractic ones, among others) and a wide variety of allied health professionals (physician assistants, nurse practitioners, clinical social workers, and registered dieticians, among others) are eligible for the program.

The e-prescribing system used must meet certain criteria – for example, it must generate complete lists of all medications a patient is taking; provide information related to any lower-cost, therapeutically appropriate drugs; and, most notably, transmit prescriptions to pharmacies electronically.

Faxing of the prescription does not count, even if a computer system autogenerates the fax, Mr. McCormick cautioned. The prescription "must basically go from your computer to the pharmacy’s computer, not through a fax."

To obtain the bonus, providers can report their use of e-prescribing in any of three ways. "Probably the easiest way to get started is the claims-based reporting," he said, which entails simply adding the G8553 code to the other codes. Alternately, providers can use registry-based reporting or electronic health record (EHR)–based reporting.

The list of patient encounters considered eligible for e-prescribing is "pretty comprehensive," including all outpatient office visits (those having 992xx codes), home health visits, nursing home visits, and psychiatric care visits, he said. However, inpatient visits are not eligible.

A noteworthy caveat is that providers will not be able to earn both the e-prescribing bonus and another bonus for implementing the EHRs that the CMS is offering, because e-prescribing is among the 15 core measures of EHR implementation.

Put another way, "there is no double-dipping, starting in 2011," Mr. McCormick said. "So if you are going to go for that [EHR] bonus, which is a lot more money – $44,000 per provider paid over 5 years – you can’t put in for the eRx bonus as well."

Providers should take note that the window of eligibility for the bonus is still open for 2010. "It’s not too late ... to start e-prescribing for this year," he commented. "You can start e-prescribing any time during the year up to Dec. 31."

Certain providers will be exempt from the penalty, he added: those who generate fewer than 100 claims with eligible eRx patient codes, those for whom less than 10% of patient encounters are eligible (e.g., hospital-based physicians), and those facing relevant hardships, namely, practicing in a rural area with limited high-speed Internet service or a limited number of pharmacies able to receive prescriptions electronically.

The program’s rules, which change annually, can be found online.

VANCOUVER, B.C. – The Centers for Medicare and Medicaid Services is currently offering providers a bonus for e-prescribing, or electronically transmitting prescriptions to pharmacies. But soon, providers will instead be hit with a penalty if they don’t get on board with this practice.

"They are really promoting this," Michael K. McCormick, a practice administrator at the DuPage Medical Group in Winfield, Ill., said at the annual meeting of the American College of Chest Physicians. But by transitioning from a bonus to a penalty over several years, "they are giving you time to get going on it."

The Medicare Electronic Prescribing (eRx) Incentive Program, which began in 2009 and runs through 2013, provides bonus payments for e-prescribing when certain eligibility criteria are met, with bonus percentages being reduced over the span of the program, according to Mr. McCormick, a registered respiratory therapist.

But the CMS also will start financially penalizing providers who do not begin e-prescribing in 2011. The penalty for failing to e-prescribe will be 1%, 1.5%, and 2% of all Medicare Part B charges in 2012, 2013, and 2014, respectively.

The bottom line is to "e-prescribe at least 10 times in the first 6 months of 2011 so you won’t be penalized in 2012," Mr. McCormick recommended. "You really need to start doing this in 2011."

The 2010 reporting criteria require that health care providers report e-prescribing for at least 25 eligible patient encounters (which can include multiple encounters for a single patient) and that Medicare account for at least 10% of the provider’s payer mix.

"The bonus returned to providers for 2010 is 2% of the total Medicare Part B Physician Fee Schedule allowed charges for services for the entire year; it will be 1% in 2011 and 2012, but only 0.5% in 2013.

All physicians (medical, osteopathic, podiatric, and chiropractic ones, among others) and a wide variety of allied health professionals (physician assistants, nurse practitioners, clinical social workers, and registered dieticians, among others) are eligible for the program.

The e-prescribing system used must meet certain criteria – for example, it must generate complete lists of all medications a patient is taking; provide information related to any lower-cost, therapeutically appropriate drugs; and, most notably, transmit prescriptions to pharmacies electronically.

Faxing of the prescription does not count, even if a computer system autogenerates the fax, Mr. McCormick cautioned. The prescription "must basically go from your computer to the pharmacy’s computer, not through a fax."

To obtain the bonus, providers can report their use of e-prescribing in any of three ways. "Probably the easiest way to get started is the claims-based reporting," he said, which entails simply adding the G8553 code to the other codes. Alternately, providers can use registry-based reporting or electronic health record (EHR)–based reporting.

The list of patient encounters considered eligible for e-prescribing is "pretty comprehensive," including all outpatient office visits (those having 992xx codes), home health visits, nursing home visits, and psychiatric care visits, he said. However, inpatient visits are not eligible.

A noteworthy caveat is that providers will not be able to earn both the e-prescribing bonus and another bonus for implementing the EHRs that the CMS is offering, because e-prescribing is among the 15 core measures of EHR implementation.

Put another way, "there is no double-dipping, starting in 2011," Mr. McCormick said. "So if you are going to go for that [EHR] bonus, which is a lot more money – $44,000 per provider paid over 5 years – you can’t put in for the eRx bonus as well."

Providers should take note that the window of eligibility for the bonus is still open for 2010. "It’s not too late ... to start e-prescribing for this year," he commented. "You can start e-prescribing any time during the year up to Dec. 31."

Certain providers will be exempt from the penalty, he added: those who generate fewer than 100 claims with eligible eRx patient codes, those for whom less than 10% of patient encounters are eligible (e.g., hospital-based physicians), and those facing relevant hardships, namely, practicing in a rural area with limited high-speed Internet service or a limited number of pharmacies able to receive prescriptions electronically.

The program’s rules, which change annually, can be found online.

VANCOUVER, B.C. - The Centers for Medicare and Medicaid Services is currently offering providers a bonus for e-prescribing, or electronically transmitting prescriptions to pharmacies. But soon, providers will instead be hit with a penalty if they don't get on board with this practice.

"They are really promoting this," Michael K. McCormick, a practice administrator at the DuPage Medical Group in Winfield, Ill., said at the annual meeting of the American College of Chest Physicians. But by transitioning from a bonus to a penalty over several years, "they are giving you time to get going on it."

The Medicare Electronic Prescribing (eRx) Incentive Program, which began in 2009 and runs through 2013, provides bonus payments for e-prescribing when certain eligibility criteria are met, with bonus percentages being reduced over the span of the program, according to Mr. McCormick, a registered respiratory therapist.

But the CMS also will start financially penalizing providers who do not begin e-prescribing in 2011. The penalty for failing to e-prescribe will be 1%, 1.5%, and 2% of all Medicare Part B charges in 2012, 2013, and 2014, respectively.

The bottom line is to "e-prescribe at least 10 times in the first 6 months of 2011 so you won't be penalized in 2012," Mr. McCormick recommended. "You really need to start doing this in 2011."

The 2010 reporting criteria require that health care providers report e-prescribing for at least 25 eligible patient encounters (which can include multiple encounters for a single patient) and that Medicare account for at least 10% of the provider’s payer mix.

"The bonus returned to providers for 2010 is 2% of the total Medicare Part B Physician Fee Schedule allowed charges for services for the entire year; it will be 1% in 2011 and 2012, but only 0.5% in 2013.

All physicians (medical, osteopathic, podiatric, and chiropractic ones, among others) and a wide variety of allied health professionals (physician assistants, nurse practitioners, clinical social workers, and registered dieticians, among others) are eligible for the program.

The e-prescribing system used must meet certain criteria – for example, it must generate complete lists of all medications a patient is taking; provide information related to any lower-cost, therapeutically appropriate drugs; and, most notably, transmit prescriptions to pharmacies electronically.

Faxing of the prescription does not count, even if a computer system autogenerates the fax, Mr. McCormick cautioned. The prescription "must basically go from your computer to the pharmacy’s computer, not through a fax."

To obtain the bonus, providers can report their use of e-prescribing in any of three ways. "Probably the easiest way to get started is the claims-based reporting," he said, which entails simply adding the G8553 code to the other codes. Alternately, providers can use registry-based reporting or electronic health record (EHR)–based reporting.

The list of patient encounters considered eligible for e-prescribing is "pretty comprehensive," including all outpatient office visits (those having 992xx codes), home health visits, nursing home visits, and psychiatric care visits, he said. However, inpatient visits are not eligible.

A noteworthy caveat is that providers will not be able to earn both the e-prescribing bonus and another bonus for implementing the EHRs that the CMS is offering, because e-prescribing is among the 15 core measures of EHR implementation.

Put another way, "there is no double-dipping, starting in 2011," Mr. McCormick said. "So if you are going to go for that [EHR] bonus, which is a lot more money – $44,000 per provider paid over 5 years – you can’t put in for the eRx bonus as well."

Providers should take note that the window of eligibility for the bonus is still open for 2010. "It's not too late ... to start e-prescribing for this year," he commented. "You can start e-prescribing any time during the year up to Dec. 31."

Certain providers will be exempt from the penalty, he added: those who generate fewer than 100 claims with eligible eRx patient codes, those for whom less than 10% of patient encounters are eligible (e.g., hospital-based physicians), and those facing relevant hardships, namely, practicing in a rural area with limited high-speed Internet service or a limited number of pharmacies able to receive prescriptions electronically.

The program's rules, which change annually, can be found online.

VANCOUVER, B.C. - The Centers for Medicare and Medicaid Services is currently offering providers a bonus for e-prescribing, or electronically transmitting prescriptions to pharmacies. But soon, providers will instead be hit with a penalty if they don't get on board with this practice.

"They are really promoting this," Michael K. McCormick, a practice administrator at the DuPage Medical Group in Winfield, Ill., said at the annual meeting of the American College of Chest Physicians. But by transitioning from a bonus to a penalty over several years, "they are giving you time to get going on it."

The Medicare Electronic Prescribing (eRx) Incentive Program, which began in 2009 and runs through 2013, provides bonus payments for e-prescribing when certain eligibility criteria are met, with bonus percentages being reduced over the span of the program, according to Mr. McCormick, a registered respiratory therapist.

But the CMS also will start financially penalizing providers who do not begin e-prescribing in 2011. The penalty for failing to e-prescribe will be 1%, 1.5%, and 2% of all Medicare Part B charges in 2012, 2013, and 2014, respectively.

The bottom line is to "e-prescribe at least 10 times in the first 6 months of 2011 so you won't be penalized in 2012," Mr. McCormick recommended. "You really need to start doing this in 2011."

The 2010 reporting criteria require that health care providers report e-prescribing for at least 25 eligible patient encounters (which can include multiple encounters for a single patient) and that Medicare account for at least 10% of the provider’s payer mix.

"The bonus returned to providers for 2010 is 2% of the total Medicare Part B Physician Fee Schedule allowed charges for services for the entire year; it will be 1% in 2011 and 2012, but only 0.5% in 2013.

All physicians (medical, osteopathic, podiatric, and chiropractic ones, among others) and a wide variety of allied health professionals (physician assistants, nurse practitioners, clinical social workers, and registered dieticians, among others) are eligible for the program.

The e-prescribing system used must meet certain criteria – for example, it must generate complete lists of all medications a patient is taking; provide information related to any lower-cost, therapeutically appropriate drugs; and, most notably, transmit prescriptions to pharmacies electronically.

Faxing of the prescription does not count, even if a computer system autogenerates the fax, Mr. McCormick cautioned. The prescription "must basically go from your computer to the pharmacy’s computer, not through a fax."

To obtain the bonus, providers can report their use of e-prescribing in any of three ways. "Probably the easiest way to get started is the claims-based reporting," he said, which entails simply adding the G8553 code to the other codes. Alternately, providers can use registry-based reporting or electronic health record (EHR)–based reporting.

The list of patient encounters considered eligible for e-prescribing is "pretty comprehensive," including all outpatient office visits (those having 992xx codes), home health visits, nursing home visits, and psychiatric care visits, he said. However, inpatient visits are not eligible.

A noteworthy caveat is that providers will not be able to earn both the e-prescribing bonus and another bonus for implementing the EHRs that the CMS is offering, because e-prescribing is among the 15 core measures of EHR implementation.

Put another way, "there is no double-dipping, starting in 2011," Mr. McCormick said. "So if you are going to go for that [EHR] bonus, which is a lot more money – $44,000 per provider paid over 5 years – you can’t put in for the eRx bonus as well."

Providers should take note that the window of eligibility for the bonus is still open for 2010. "It's not too late ... to start e-prescribing for this year," he commented. "You can start e-prescribing any time during the year up to Dec. 31."

Certain providers will be exempt from the penalty, he added: those who generate fewer than 100 claims with eligible eRx patient codes, those for whom less than 10% of patient encounters are eligible (e.g., hospital-based physicians), and those facing relevant hardships, namely, practicing in a rural area with limited high-speed Internet service or a limited number of pharmacies able to receive prescriptions electronically.

The program's rules, which change annually, can be found online.

VANCOUVER, B.C. - The Centers for Medicare and Medicaid Services is currently offering providers a bonus for e-prescribing, or electronically transmitting prescriptions to pharmacies. But soon, providers will instead be hit with a penalty if they don't get on board with this practice.

"They are really promoting this," Michael K. McCormick, a practice administrator at the DuPage Medical Group in Winfield, Ill., said at the annual meeting of the American College of Chest Physicians. But by transitioning from a bonus to a penalty over several years, "they are giving you time to get going on it."

The Medicare Electronic Prescribing (eRx) Incentive Program, which began in 2009 and runs through 2013, provides bonus payments for e-prescribing when certain eligibility criteria are met, with bonus percentages being reduced over the span of the program, according to Mr. McCormick, a registered respiratory therapist.

But the CMS also will start financially penalizing providers who do not begin e-prescribing in 2011. The penalty for failing to e-prescribe will be 1%, 1.5%, and 2% of all Medicare Part B charges in 2012, 2013, and 2014, respectively.

The bottom line is to "e-prescribe at least 10 times in the first 6 months of 2011 so you won't be penalized in 2012," Mr. McCormick recommended. "You really need to start doing this in 2011."

The 2010 reporting criteria require that health care providers report e-prescribing for at least 25 eligible patient encounters (which can include multiple encounters for a single patient) and that Medicare account for at least 10% of the provider’s payer mix.

"The bonus returned to providers for 2010 is 2% of the total Medicare Part B Physician Fee Schedule allowed charges for services for the entire year; it will be 1% in 2011 and 2012, but only 0.5% in 2013.

All physicians (medical, osteopathic, podiatric, and chiropractic ones, among others) and a wide variety of allied health professionals (physician assistants, nurse practitioners, clinical social workers, and registered dieticians, among others) are eligible for the program.

The e-prescribing system used must meet certain criteria – for example, it must generate complete lists of all medications a patient is taking; provide information related to any lower-cost, therapeutically appropriate drugs; and, most notably, transmit prescriptions to pharmacies electronically.

Faxing of the prescription does not count, even if a computer system autogenerates the fax, Mr. McCormick cautioned. The prescription "must basically go from your computer to the pharmacy’s computer, not through a fax."

To obtain the bonus, providers can report their use of e-prescribing in any of three ways. "Probably the easiest way to get started is the claims-based reporting," he said, which entails simply adding the G8553 code to the other codes. Alternately, providers can use registry-based reporting or electronic health record (EHR)–based reporting.

The list of patient encounters considered eligible for e-prescribing is "pretty comprehensive," including all outpatient office visits (those having 992xx codes), home health visits, nursing home visits, and psychiatric care visits, he said. However, inpatient visits are not eligible.

A noteworthy caveat is that providers will not be able to earn both the e-prescribing bonus and another bonus for implementing the EHRs that the CMS is offering, because e-prescribing is among the 15 core measures of EHR implementation.

Put another way, "there is no double-dipping, starting in 2011," Mr. McCormick said. "So if you are going to go for that [EHR] bonus, which is a lot more money – $44,000 per provider paid over 5 years – you can’t put in for the eRx bonus as well."

Providers should take note that the window of eligibility for the bonus is still open for 2010. "It's not too late ... to start e-prescribing for this year," he commented. "You can start e-prescribing any time during the year up to Dec. 31."

Certain providers will be exempt from the penalty, he added: those who generate fewer than 100 claims with eligible eRx patient codes, those for whom less than 10% of patient encounters are eligible (e.g., hospital-based physicians), and those facing relevant hardships, namely, practicing in a rural area with limited high-speed Internet service or a limited number of pharmacies able to receive prescriptions electronically.

The program's rules, which change annually, can be found online.

VANCOUVER, B.C. – The Centers for Medicare and Medicaid Services is currently offering providers a bonus for e-prescribing, or electronically transmitting prescriptions to pharmacies. But soon, providers will instead be hit with a penalty if they don’t get on board with this practice.

"They are really promoting this," Michael K. McCormick, a practice administrator at the DuPage Medical Group in Winfield, Ill., said at the annual meeting of the American College of Chest Physicians. But by transitioning from a bonus to a penalty over several years, "they are giving you time to get going on it."

The Medicare Electronic Prescribing (eRx) Incentive Program, which began in 2009 and runs through 2013, provides bonus payments for e-prescribing when certain eligibility criteria are met, with bonus percentages being reduced over the span of the program, according to Mr. McCormick, a registered respiratory therapist.

But the CMS also will start financially penalizing providers who do not begin e-prescribing in 2011. The penalty for failing to e-prescribe will be 1%, 1.5%, and 2% of all Medicare Part B charges in 2012, 2013, and 2014, respectively.

The bottom line is to "e-prescribe at least 10 times in the first 6 months of 2011 so you won’t be penalized in 2012," Mr. McCormick recommended. "You really need to start doing this in 2011."

The 2010 reporting criteria require that health care providers report e-prescribing for at least 25 eligible patient encounters (which can include multiple encounters for a single patient) and that Medicare account for at least 10% of the provider’s payer mix.

"The bonus returned to providers for 2010 is 2% of the total Medicare Part B Physician Fee Schedule allowed charges for services for the entire year; it will be 1% in 2011 and 2012, but only 0.5% in 2013.

All physicians (medical, osteopathic, podiatric, and chiropractic ones, among others) and a wide variety of allied health professionals (physician assistants, nurse practitioners, clinical social workers, and registered dieticians, among others) are eligible for the program.

The e-prescribing system used must meet certain criteria – for example, it must generate complete lists of all medications a patient is taking; provide information related to any lower-cost, therapeutically appropriate drugs; and, most notably, transmit prescriptions to pharmacies electronically.

Faxing of the prescription does not count, even if a computer system autogenerates the fax, Mr. McCormick cautioned. The prescription "must basically go from your computer to the pharmacy’s computer, not through a fax."

To obtain the bonus, providers can report their use of e-prescribing in any of three ways. "Probably the easiest way to get started is the claims-based reporting," he said, which entails simply adding the G8553 code to the other codes. Alternately, providers can use registry-based reporting or electronic health record (EHR)–based reporting.

The list of patient encounters considered eligible for e-prescribing is "pretty comprehensive," including all outpatient office visits (those having 992xx codes), home health visits, nursing home visits, and psychiatric care visits, he said. However, inpatient visits are not eligible.

A noteworthy caveat is that providers will not be able to earn both the e-prescribing bonus and another bonus for implementing the EHRs that the CMS is offering, because e-prescribing is among the 15 core measures of EHR implementation.

Put another way, "there is no double-dipping, starting in 2011," Mr. McCormick said. "So if you are going to go for that [EHR] bonus, which is a lot more money – $44,000 per provider paid over 5 years – you can’t put in for the eRx bonus as well."

Providers should take note that the window of eligibility for the bonus is still open for 2010. "It’s not too late ... to start e-prescribing for this year," he commented. "You can start e-prescribing any time during the year up to Dec. 31."

Certain providers will be exempt from the penalty, he added: those who generate fewer than 100 claims with eligible eRx patient codes, those for whom less than 10% of patient encounters are eligible (e.g., hospital-based physicians), and those facing relevant hardships, namely, practicing in a rural area with limited high-speed Internet service or a limited number of pharmacies able to receive prescriptions electronically.

The program’s rules, which change annually, can be found online.

VANCOUVER, B.C. – The Centers for Medicare and Medicaid Services is currently offering providers a bonus for e-prescribing, or electronically transmitting prescriptions to pharmacies. But soon, providers will instead be hit with a penalty if they don’t get on board with this practice.

"They are really promoting this," Michael K. McCormick, a practice administrator at the DuPage Medical Group in Winfield, Ill., said at the annual meeting of the American College of Chest Physicians. But by transitioning from a bonus to a penalty over several years, "they are giving you time to get going on it."

The Medicare Electronic Prescribing (eRx) Incentive Program, which began in 2009 and runs through 2013, provides bonus payments for e-prescribing when certain eligibility criteria are met, with bonus percentages being reduced over the span of the program, according to Mr. McCormick, a registered respiratory therapist.

But the CMS also will start financially penalizing providers who do not begin e-prescribing in 2011. The penalty for failing to e-prescribe will be 1%, 1.5%, and 2% of all Medicare Part B charges in 2012, 2013, and 2014, respectively.

The bottom line is to "e-prescribe at least 10 times in the first 6 months of 2011 so you won’t be penalized in 2012," Mr. McCormick recommended. "You really need to start doing this in 2011."

The 2010 reporting criteria require that health care providers report e-prescribing for at least 25 eligible patient encounters (which can include multiple encounters for a single patient) and that Medicare account for at least 10% of the provider’s payer mix.

"The bonus returned to providers for 2010 is 2% of the total Medicare Part B Physician Fee Schedule allowed charges for services for the entire year; it will be 1% in 2011 and 2012, but only 0.5% in 2013.

All physicians (medical, osteopathic, podiatric, and chiropractic ones, among others) and a wide variety of allied health professionals (physician assistants, nurse practitioners, clinical social workers, and registered dieticians, among others) are eligible for the program.

The e-prescribing system used must meet certain criteria – for example, it must generate complete lists of all medications a patient is taking; provide information related to any lower-cost, therapeutically appropriate drugs; and, most notably, transmit prescriptions to pharmacies electronically.

Faxing of the prescription does not count, even if a computer system autogenerates the fax, Mr. McCormick cautioned. The prescription "must basically go from your computer to the pharmacy’s computer, not through a fax."

To obtain the bonus, providers can report their use of e-prescribing in any of three ways. "Probably the easiest way to get started is the claims-based reporting," he said, which entails simply adding the G8553 code to the other codes. Alternately, providers can use registry-based reporting or electronic health record (EHR)–based reporting.

The list of patient encounters considered eligible for e-prescribing is "pretty comprehensive," including all outpatient office visits (those having 992xx codes), home health visits, nursing home visits, and psychiatric care visits, he said. However, inpatient visits are not eligible.

A noteworthy caveat is that providers will not be able to earn both the e-prescribing bonus and another bonus for implementing the EHRs that the CMS is offering, because e-prescribing is among the 15 core measures of EHR implementation.

Put another way, "there is no double-dipping, starting in 2011," Mr. McCormick said. "So if you are going to go for that [EHR] bonus, which is a lot more money – $44,000 per provider paid over 5 years – you can’t put in for the eRx bonus as well."

Providers should take note that the window of eligibility for the bonus is still open for 2010. "It’s not too late ... to start e-prescribing for this year," he commented. "You can start e-prescribing any time during the year up to Dec. 31."

Certain providers will be exempt from the penalty, he added: those who generate fewer than 100 claims with eligible eRx patient codes, those for whom less than 10% of patient encounters are eligible (e.g., hospital-based physicians), and those facing relevant hardships, namely, practicing in a rural area with limited high-speed Internet service or a limited number of pharmacies able to receive prescriptions electronically.

The program’s rules, which change annually, can be found online.

VANCOUVER, B.C. – The Centers for Medicare and Medicaid Services is currently offering providers a bonus for e-prescribing, or electronically transmitting prescriptions to pharmacies. But soon, providers will instead be hit with a penalty if they don’t get on board with this practice.

"They are really promoting this," Michael K. McCormick, a practice administrator at the DuPage Medical Group in Winfield, Ill., said at the annual meeting of the American College of Chest Physicians. But by transitioning from a bonus to a penalty over several years, "they are giving you time to get going on it."

The Medicare Electronic Prescribing (eRx) Incentive Program, which began in 2009 and runs through 2013, provides bonus payments for e-prescribing when certain eligibility criteria are met, with bonus percentages being reduced over the span of the program, according to Mr. McCormick, a registered respiratory therapist.

But the CMS also will start financially penalizing providers who do not begin e-prescribing in 2011. The penalty for failing to e-prescribe will be 1%, 1.5%, and 2% of all Medicare Part B charges in 2012, 2013, and 2014, respectively.

The bottom line is to "e-prescribe at least 10 times in the first 6 months of 2011 so you won’t be penalized in 2012," Mr. McCormick recommended. "You really need to start doing this in 2011."

The 2010 reporting criteria require that health care providers report e-prescribing for at least 25 eligible patient encounters (which can include multiple encounters for a single patient) and that Medicare account for at least 10% of the provider’s payer mix.

"The bonus returned to providers for 2010 is 2% of the total Medicare Part B Physician Fee Schedule allowed charges for services for the entire year; it will be 1% in 2011 and 2012, but only 0.5% in 2013.

All physicians (medical, osteopathic, podiatric, and chiropractic ones, among others) and a wide variety of allied health professionals (physician assistants, nurse practitioners, clinical social workers, and registered dieticians, among others) are eligible for the program.

The e-prescribing system used must meet certain criteria – for example, it must generate complete lists of all medications a patient is taking; provide information related to any lower-cost, therapeutically appropriate drugs; and, most notably, transmit prescriptions to pharmacies electronically.

Faxing of the prescription does not count, even if a computer system autogenerates the fax, Mr. McCormick cautioned. The prescription "must basically go from your computer to the pharmacy’s computer, not through a fax."

To obtain the bonus, providers can report their use of e-prescribing in any of three ways. "Probably the easiest way to get started is the claims-based reporting," he said, which entails simply adding the G8553 code to the other codes. Alternately, providers can use registry-based reporting or electronic health record (EHR)–based reporting.

The list of patient encounters considered eligible for e-prescribing is "pretty comprehensive," including all outpatient office visits (those having 992xx codes), home health visits, nursing home visits, and psychiatric care visits, he said. However, inpatient visits are not eligible.

A noteworthy caveat is that providers will not be able to earn both the e-prescribing bonus and another bonus for implementing the EHRs that the CMS is offering, because e-prescribing is among the 15 core measures of EHR implementation.

Put another way, "there is no double-dipping, starting in 2011," Mr. McCormick said. "So if you are going to go for that [EHR] bonus, which is a lot more money – $44,000 per provider paid over 5 years – you can’t put in for the eRx bonus as well."

Providers should take note that the window of eligibility for the bonus is still open for 2010. "It’s not too late ... to start e-prescribing for this year," he commented. "You can start e-prescribing any time during the year up to Dec. 31."

Certain providers will be exempt from the penalty, he added: those who generate fewer than 100 claims with eligible eRx patient codes, those for whom less than 10% of patient encounters are eligible (e.g., hospital-based physicians), and those facing relevant hardships, namely, practicing in a rural area with limited high-speed Internet service or a limited number of pharmacies able to receive prescriptions electronically.

The program’s rules, which change annually, can be found online.

LAS VEGAS – Geriatric patients – with their age-related changes, frequent comorbidities, and some unique patterns of injury – "are clearly at risk for poor outcomes with trauma," Dr. Phillip D. Levy said.

Injury severity scores among trauma patients are generally similar across age ranges (J. Trauma 2010;69:88-92). "However, at every injury severity score, the percent mortality for geriatric patients ... is much worse," he said.

Aging leads to a host of anatomical and physiological changes – including reduced cardiac and pulmonary function, altered brain anatomy, and decreased musculoskeletal mass – that play a role in the setting of serious injury, said Dr. Levy, associate director of clinical research in the department of emergency medicine at Wayne State University in Detroit.

"The net effect is that there is a diminished physiological response, and some of these things may also lead to a delayed onset of overt consequences," he said, which may initially mask the extent of injury.

The EAST (Eastern Association for the Surgery of Trauma) guidelines for trauma care in older adults highlight several key concepts, he noted, such as the risk of undertriage and the adverse impact of pre-existing conditions and postinjury complications on outcomes (J. Trauma 2003;54:391-416).

Pre-existing conditions are present in 40% of patients aged 65-74 years, 65% of those aged 75-84 years, and 90% of patients aged 85 years and older, and these patients are often taking medications. For example, trauma patients with heart failure have more than double the risk of death, compared with those without heart failure, and the elevation of risk is even greater for those who are also taking beta-blockers or warfarin (J. Trauma 2010;69:645-52).

Because of these factors, the initial evaluation, secondary survey, and management of geriatric trauma patients have some unique aspects, according to Dr. Levy.

Initial Evaluation

Although the standard ATLS (Advanced Trauma Life Support) protocols still apply in older adults with trauma, "there are some caveats with it," Dr. Levy said.

One caveat is that this population is highly vulnerable to respiratory compromise with chest trauma. "Even one or two rib fractures in an elderly patient has dramatic impact," he noted.

Age-related issues such as nasopharyngeal fragility, the presence of arthritis in the temporomandibular joint, and dentures affect airway management in geriatric patients.

"Probably the most important thing when considering the airway, though, is recognizing that there are pharmacokinetic responses that are different," Dr. Levy said. Because older adults have increased responsiveness to sedatives, the dose should be reduced by 20%-40% to avoid complications.

Hypoperfusion is often occult in the elderly. "You facilitate the search by looking at serum markers of [tissue] oxygen deficit: base deficit and lactic acid," he said. These measures predict mortality in older normotensive adults who have sustained blunt trauma (J. Trauma 2009;66:1040-4). In particular, a base deficit of –6 or less or a venous lactic acid level greater than 4.0 mmol/L is associated with a mortality rate of nearly 40%, independent of injury severity.

He cautioned that specificity is much greater than sensitivity with these markers; hence, "if it’s positive, it’s positive. If it’s negative, well, it may not really be negative; you may be just early in the phase."

Use of pulmonary artery catheters (PACs) may seem an extreme approach for hemodynamic monitoring in geriatric trauma patients, Dr. Levy acknowledged. But "it enables direct measurement of cardiac function and it does improve outcomes if you use a targeted therapeutic approach, either targeting improving cardiac index or improving oxygen consumption."

For instance, therapy using PACs has been associated with a nearly 70% reduction in the risk of death for patients aged 61-90 years with severe injuries (Crit. Care Med. 2006;34:1597-601). "You optimize the patient’s hemodynamic status and their perfusion status, and you may not have even known that it was not optimized before," he said.

Secondary Survey

In blunt head trauma, patients older than 65 years are more likely to sustain traumatic brain injury than are their younger peers, according to one study (Acad. Emerg. Med. 2006;13:302-7).

"What was really interesting was that they found that 26%, about a quarter, of all elderly patients who had an injury had an occult presentation, no symptoms," he noted.

Outward clues, such as decreased alertness, prolonged loss of consciousness, and an abnormal Glasgow Coma Scale score were all less common in the older group, meaning that physical exam findings can’t be relied on to predict whether an older patient has a head injury, he said.

On CT imaging, likely because of different mechanisms of injury, geriatric patients are less likely to have linear skull fractures and epidural hemorrhages, but more likely to have subdural hematomas and subarachnoid hemorrhages.

Cervical spine injuries are also more common in older vs. younger trauma patients, and patterns of injury differ (Ann. Emerg. Med. 2002;40:287-93), again likely reflecting differences in the mechanism, according to Dr. Levy.

"The geriatric patients were at much greater risk for C1 fractures and any fracture at C2 – most specifically, an odontoid fracture," he noted.

And importantly, "you always have to consider central cord syndrome in your elderly patients due to that [hyperextension] type of mechanism. You might have osteophytes that squeeze off the cord."

CT is indicated as the primary imaging modality in cervical spine injuries among adults older than 65 years (J. Emerg. Med. 2009;36:64-71).

"The most likely [cervical spine] area for an elderly individual to have an injury is at C2 and, coincidentally, the most likely area to be missed on plain films is C2," Dr. Levy explained. "Additionally, the elderly are at a tremendous risk of false-positive findings [on plain films]. They have a lot of arthritis."

As for chest injuries, half of all older adults who sustain rib fractures do so during simple falls from a standing position (J. Trauma 2003;54:478-85), likely from hitting something on the way down. Hence, the index of suspicion should be high even after seemingly minor spills.

"As the number of rib fractures increases, mortality increases in both elderly and nonelderly, but it increases disproportionately in the elderly," he observed.

The take-home message is early airway management: "When you see a patient with three or four rib fractures, they are not taking good deep breaths in, their saturations are hovering around 90% or 92% – that’s a patient you are probably going to want to consider intubating very early on."

Geriatric patients can get an injury unique to this age group: the sacral insufficiency fracture. "Suspect it if somebody has persistent hip pain, persistent back pain, [and] they can’t get up and walk," he advised. "The elderly person who fell, there is nothing on x-ray, you don’t see much on the CT scan, you may need to go ahead if the index of suspicion is high and make this diagnosis." In addition, relative to their younger counterparts, older adults are less likely to get open-book pelvic fractures and more likely to get acetabular and pubic rami fractures, according to Dr. Levy.

Management

Fluid resuscitation is often challenging in geriatric trauma patients because of underlying cardiac dysfunction and concerns about precipitating heart failure, Dr. Levy observed.

"You can facilitate this by using central venous pressure [CVP] guidance," he said. "If you can see what their CVP is, you can titrate their fluids to their CVP, recognizing that that might not be the best marker of preload in an elderly individual and it might not be the best marker of fluid response, but it may help."

Early consideration of blood products is important in geriatric trauma patients with hemodynamic instability, and their use has the advantages of administration of a smaller fluid volume (compared with saline) and a colloid effect.

"Rapid reversal of anticoagulation is not something a lot of us do routinely, but you should consider it in every elderly patient who comes in, especially those with traumatic head injuries. [Use] vitamin K and fresh frozen plasma," he recommended.

In a study of geriatric patients with head trauma taking warfarin, mortality was 48% in historical controls who developed intracranial hemorrhage but just 10% with use of a rapid imaging and, when indicated, reversal protocol including vitamin K and fresh frozen plasma (J. Trauma 2005;59:1131-7).

Proactive management for patients with chest trauma should include both pain control and early ventilatory support, Dr. Levy said.

"Pain control is huge," he commented. "If they are more comfortable, they are more apt to take big deep breaths in and less likely to suffer from the adverse consequences of their chest trauma."

Although strategies for ventilatory support may include intubation, "in some of these older folks with COPD [or] heart failure, when you intubate them, you may never extubate them. That’s always a concern," so a trial of bilevel pulmonary airway pressure is probably warranted if started early, he said.

Additional Considerations

Dr. Levy cautioned physicians not to forget to remove cervical collars once geriatric trauma patients have been medically cleared. "The longer they stay in that collar, the longer they stay on their back, the greater the risk they have of decubiti," he explained.

Prompt orthopedic consultation for patients with hip fracture is also key, as the time to intervention influences outcomes after this injury.

Be alert for rhabdomyolysis, especially in patients who have been immobile for a prolonged period, he said. In this setting, creatine kinase is more sensitive than urine myoglobin.

If "somebody comes in and they have multiple long bone fractures, multiple upper extremity fractures, a lot of bruising," consider the possibility of elder abuse or neglect, Dr. Levy further advised.

"And always, always, always look for medical causes in trauma," he stressed, as a patient’s accident may have been precipitated by a stroke or myocardial infarction that can be overlooked in the rush to treat their injuries.

Geriatric trauma patients are potential candidates for being discharged home if they had minor closed head trauma and are not on anticoagulation, they had a simple fall and do not have ambulatory difficulties, or they have isolated extremity fractures, provided they have adequate mobility and home support. "I would say pretty much consider admissions for most if not all others," he said.

A final consideration to be aware of is end-of-life issues in patients with little potential for recovery, Dr. Levy noted. Risk stratification tools can help physicians and families make treatment decisions in this context, he said. For example, the combination of age, base deficit, and head injury severity assessed on arrival in the emergency department can help predict if care is likely to ultimately be futile in geriatric trauma patients (J. Trauma 2004;57:37-41).

"We can consider that within the context of everything else: Are they demented, living in a nursing home, on a feeding tube? Or are they a fully functional individual in the community?" Dr. Levy said. "Certainly, these are all factors in the equation to consider when you are making that decision."

LAS VEGAS – Geriatric patients – with their age-related changes, frequent comorbidities, and some unique patterns of injury – "are clearly at risk for poor outcomes with trauma," Dr. Phillip D. Levy said.

Injury severity scores among trauma patients are generally similar across age ranges (J. Trauma 2010;69:88-92). "However, at every injury severity score, the percent mortality for geriatric patients ... is much worse," he said.

Aging leads to a host of anatomical and physiological changes – including reduced cardiac and pulmonary function, altered brain anatomy, and decreased musculoskeletal mass – that play a role in the setting of serious injury, said Dr. Levy, associate director of clinical research in the department of emergency medicine at Wayne State University in Detroit.

"The net effect is that there is a diminished physiological response, and some of these things may also lead to a delayed onset of overt consequences," he said, which may initially mask the extent of injury.

The EAST (Eastern Association for the Surgery of Trauma) guidelines for trauma care in older adults highlight several key concepts, he noted, such as the risk of undertriage and the adverse impact of pre-existing conditions and postinjury complications on outcomes (J. Trauma 2003;54:391-416).

Pre-existing conditions are present in 40% of patients aged 65-74 years, 65% of those aged 75-84 years, and 90% of patients aged 85 years and older, and these patients are often taking medications. For example, trauma patients with heart failure have more than double the risk of death, compared with those without heart failure, and the elevation of risk is even greater for those who are also taking beta-blockers or warfarin (J. Trauma 2010;69:645-52).

Because of these factors, the initial evaluation, secondary survey, and management of geriatric trauma patients have some unique aspects, according to Dr. Levy.

Initial Evaluation

Although the standard ATLS (Advanced Trauma Life Support) protocols still apply in older adults with trauma, "there are some caveats with it," Dr. Levy said.

One caveat is that this population is highly vulnerable to respiratory compromise with chest trauma. "Even one or two rib fractures in an elderly patient has dramatic impact," he noted.

Age-related issues such as nasopharyngeal fragility, the presence of arthritis in the temporomandibular joint, and dentures affect airway management in geriatric patients.

"Probably the most important thing when considering the airway, though, is recognizing that there are pharmacokinetic responses that are different," Dr. Levy said. Because older adults have increased responsiveness to sedatives, the dose should be reduced by 20%-40% to avoid complications.

Hypoperfusion is often occult in the elderly. "You facilitate the search by looking at serum markers of [tissue] oxygen deficit: base deficit and lactic acid," he said. These measures predict mortality in older normotensive adults who have sustained blunt trauma (J. Trauma 2009;66:1040-4). In particular, a base deficit of –6 or less or a venous lactic acid level greater than 4.0 mmol/L is associated with a mortality rate of nearly 40%, independent of injury severity.

He cautioned that specificity is much greater than sensitivity with these markers; hence, "if it’s positive, it’s positive. If it’s negative, well, it may not really be negative; you may be just early in the phase."

Use of pulmonary artery catheters (PACs) may seem an extreme approach for hemodynamic monitoring in geriatric trauma patients, Dr. Levy acknowledged. But "it enables direct measurement of cardiac function and it does improve outcomes if you use a targeted therapeutic approach, either targeting improving cardiac index or improving oxygen consumption."

For instance, therapy using PACs has been associated with a nearly 70% reduction in the risk of death for patients aged 61-90 years with severe injuries (Crit. Care Med. 2006;34:1597-601). "You optimize the patient’s hemodynamic status and their perfusion status, and you may not have even known that it was not optimized before," he said.

Secondary Survey

In blunt head trauma, patients older than 65 years are more likely to sustain traumatic brain injury than are their younger peers, according to one study (Acad. Emerg. Med. 2006;13:302-7).

"What was really interesting was that they found that 26%, about a quarter, of all elderly patients who had an injury had an occult presentation, no symptoms," he noted.

Outward clues, such as decreased alertness, prolonged loss of consciousness, and an abnormal Glasgow Coma Scale score were all less common in the older group, meaning that physical exam findings can’t be relied on to predict whether an older patient has a head injury, he said.

On CT imaging, likely because of different mechanisms of injury, geriatric patients are less likely to have linear skull fractures and epidural hemorrhages, but more likely to have subdural hematomas and subarachnoid hemorrhages.

Cervical spine injuries are also more common in older vs. younger trauma patients, and patterns of injury differ (Ann. Emerg. Med. 2002;40:287-93), again likely reflecting differences in the mechanism, according to Dr. Levy.

"The geriatric patients were at much greater risk for C1 fractures and any fracture at C2 – most specifically, an odontoid fracture," he noted.

And importantly, "you always have to consider central cord syndrome in your elderly patients due to that [hyperextension] type of mechanism. You might have osteophytes that squeeze off the cord."

CT is indicated as the primary imaging modality in cervical spine injuries among adults older than 65 years (J. Emerg. Med. 2009;36:64-71).

"The most likely [cervical spine] area for an elderly individual to have an injury is at C2 and, coincidentally, the most likely area to be missed on plain films is C2," Dr. Levy explained. "Additionally, the elderly are at a tremendous risk of false-positive findings [on plain films]. They have a lot of arthritis."

As for chest injuries, half of all older adults who sustain rib fractures do so during simple falls from a standing position (J. Trauma 2003;54:478-85), likely from hitting something on the way down. Hence, the index of suspicion should be high even after seemingly minor spills.

"As the number of rib fractures increases, mortality increases in both elderly and nonelderly, but it increases disproportionately in the elderly," he observed.

The take-home message is early airway management: "When you see a patient with three or four rib fractures, they are not taking good deep breaths in, their saturations are hovering around 90% or 92% – that’s a patient you are probably going to want to consider intubating very early on."

Geriatric patients can get an injury unique to this age group: the sacral insufficiency fracture. "Suspect it if somebody has persistent hip pain, persistent back pain, [and] they can’t get up and walk," he advised. "The elderly person who fell, there is nothing on x-ray, you don’t see much on the CT scan, you may need to go ahead if the index of suspicion is high and make this diagnosis." In addition, relative to their younger counterparts, older adults are less likely to get open-book pelvic fractures and more likely to get acetabular and pubic rami fractures, according to Dr. Levy.

Management

Fluid resuscitation is often challenging in geriatric trauma patients because of underlying cardiac dysfunction and concerns about precipitating heart failure, Dr. Levy observed.

"You can facilitate this by using central venous pressure [CVP] guidance," he said. "If you can see what their CVP is, you can titrate their fluids to their CVP, recognizing that that might not be the best marker of preload in an elderly individual and it might not be the best marker of fluid response, but it may help."

Early consideration of blood products is important in geriatric trauma patients with hemodynamic instability, and their use has the advantages of administration of a smaller fluid volume (compared with saline) and a colloid effect.

"Rapid reversal of anticoagulation is not something a lot of us do routinely, but you should consider it in every elderly patient who comes in, especially those with traumatic head injuries. [Use] vitamin K and fresh frozen plasma," he recommended.

In a study of geriatric patients with head trauma taking warfarin, mortality was 48% in historical controls who developed intracranial hemorrhage but just 10% with use of a rapid imaging and, when indicated, reversal protocol including vitamin K and fresh frozen plasma (J. Trauma 2005;59:1131-7).

Proactive management for patients with chest trauma should include both pain control and early ventilatory support, Dr. Levy said.

"Pain control is huge," he commented. "If they are more comfortable, they are more apt to take big deep breaths in and less likely to suffer from the adverse consequences of their chest trauma."

Although strategies for ventilatory support may include intubation, "in some of these older folks with COPD [or] heart failure, when you intubate them, you may never extubate them. That’s always a concern," so a trial of bilevel pulmonary airway pressure is probably warranted if started early, he said.

Additional Considerations

Dr. Levy cautioned physicians not to forget to remove cervical collars once geriatric trauma patients have been medically cleared. "The longer they stay in that collar, the longer they stay on their back, the greater the risk they have of decubiti," he explained.

Prompt orthopedic consultation for patients with hip fracture is also key, as the time to intervention influences outcomes after this injury.

Be alert for rhabdomyolysis, especially in patients who have been immobile for a prolonged period, he said. In this setting, creatine kinase is more sensitive than urine myoglobin.

If "somebody comes in and they have multiple long bone fractures, multiple upper extremity fractures, a lot of bruising," consider the possibility of elder abuse or neglect, Dr. Levy further advised.

"And always, always, always look for medical causes in trauma," he stressed, as a patient’s accident may have been precipitated by a stroke or myocardial infarction that can be overlooked in the rush to treat their injuries.

Geriatric trauma patients are potential candidates for being discharged home if they had minor closed head trauma and are not on anticoagulation, they had a simple fall and do not have ambulatory difficulties, or they have isolated extremity fractures, provided they have adequate mobility and home support. "I would say pretty much consider admissions for most if not all others," he said.

A final consideration to be aware of is end-of-life issues in patients with little potential for recovery, Dr. Levy noted. Risk stratification tools can help physicians and families make treatment decisions in this context, he said. For example, the combination of age, base deficit, and head injury severity assessed on arrival in the emergency department can help predict if care is likely to ultimately be futile in geriatric trauma patients (J. Trauma 2004;57:37-41).

"We can consider that within the context of everything else: Are they demented, living in a nursing home, on a feeding tube? Or are they a fully functional individual in the community?" Dr. Levy said. "Certainly, these are all factors in the equation to consider when you are making that decision."

LAS VEGAS – Geriatric patients – with their age-related changes, frequent comorbidities, and some unique patterns of injury – "are clearly at risk for poor outcomes with trauma," Dr. Phillip D. Levy said.

Injury severity scores among trauma patients are generally similar across age ranges (J. Trauma 2010;69:88-92). "However, at every injury severity score, the percent mortality for geriatric patients ... is much worse," he said.

Aging leads to a host of anatomical and physiological changes – including reduced cardiac and pulmonary function, altered brain anatomy, and decreased musculoskeletal mass – that play a role in the setting of serious injury, said Dr. Levy, associate director of clinical research in the department of emergency medicine at Wayne State University in Detroit.

"The net effect is that there is a diminished physiological response, and some of these things may also lead to a delayed onset of overt consequences," he said, which may initially mask the extent of injury.

The EAST (Eastern Association for the Surgery of Trauma) guidelines for trauma care in older adults highlight several key concepts, he noted, such as the risk of undertriage and the adverse impact of pre-existing conditions and postinjury complications on outcomes (J. Trauma 2003;54:391-416).

Pre-existing conditions are present in 40% of patients aged 65-74 years, 65% of those aged 75-84 years, and 90% of patients aged 85 years and older, and these patients are often taking medications. For example, trauma patients with heart failure have more than double the risk of death, compared with those without heart failure, and the elevation of risk is even greater for those who are also taking beta-blockers or warfarin (J. Trauma 2010;69:645-52).

Because of these factors, the initial evaluation, secondary survey, and management of geriatric trauma patients have some unique aspects, according to Dr. Levy.

Initial Evaluation

Although the standard ATLS (Advanced Trauma Life Support) protocols still apply in older adults with trauma, "there are some caveats with it," Dr. Levy said.

One caveat is that this population is highly vulnerable to respiratory compromise with chest trauma. "Even one or two rib fractures in an elderly patient has dramatic impact," he noted.

Age-related issues such as nasopharyngeal fragility, the presence of arthritis in the temporomandibular joint, and dentures affect airway management in geriatric patients.

"Probably the most important thing when considering the airway, though, is recognizing that there are pharmacokinetic responses that are different," Dr. Levy said. Because older adults have increased responsiveness to sedatives, the dose should be reduced by 20%-40% to avoid complications.

Hypoperfusion is often occult in the elderly. "You facilitate the search by looking at serum markers of [tissue] oxygen deficit: base deficit and lactic acid," he said. These measures predict mortality in older normotensive adults who have sustained blunt trauma (J. Trauma 2009;66:1040-4). In particular, a base deficit of –6 or less or a venous lactic acid level greater than 4.0 mmol/L is associated with a mortality rate of nearly 40%, independent of injury severity.

He cautioned that specificity is much greater than sensitivity with these markers; hence, "if it’s positive, it’s positive. If it’s negative, well, it may not really be negative; you may be just early in the phase."

Use of pulmonary artery catheters (PACs) may seem an extreme approach for hemodynamic monitoring in geriatric trauma patients, Dr. Levy acknowledged. But "it enables direct measurement of cardiac function and it does improve outcomes if you use a targeted therapeutic approach, either targeting improving cardiac index or improving oxygen consumption."

For instance, therapy using PACs has been associated with a nearly 70% reduction in the risk of death for patients aged 61-90 years with severe injuries (Crit. Care Med. 2006;34:1597-601). "You optimize the patient’s hemodynamic status and their perfusion status, and you may not have even known that it was not optimized before," he said.

Secondary Survey

In blunt head trauma, patients older than 65 years are more likely to sustain traumatic brain injury than are their younger peers, according to one study (Acad. Emerg. Med. 2006;13:302-7).

"What was really interesting was that they found that 26%, about a quarter, of all elderly patients who had an injury had an occult presentation, no symptoms," he noted.

Outward clues, such as decreased alertness, prolonged loss of consciousness, and an abnormal Glasgow Coma Scale score were all less common in the older group, meaning that physical exam findings can’t be relied on to predict whether an older patient has a head injury, he said.

On CT imaging, likely because of different mechanisms of injury, geriatric patients are less likely to have linear skull fractures and epidural hemorrhages, but more likely to have subdural hematomas and subarachnoid hemorrhages.

Cervical spine injuries are also more common in older vs. younger trauma patients, and patterns of injury differ (Ann. Emerg. Med. 2002;40:287-93), again likely reflecting differences in the mechanism, according to Dr. Levy.

"The geriatric patients were at much greater risk for C1 fractures and any fracture at C2 – most specifically, an odontoid fracture," he noted.

And importantly, "you always have to consider central cord syndrome in your elderly patients due to that [hyperextension] type of mechanism. You might have osteophytes that squeeze off the cord."

CT is indicated as the primary imaging modality in cervical spine injuries among adults older than 65 years (J. Emerg. Med. 2009;36:64-71).

"The most likely [cervical spine] area for an elderly individual to have an injury is at C2 and, coincidentally, the most likely area to be missed on plain films is C2," Dr. Levy explained. "Additionally, the elderly are at a tremendous risk of false-positive findings [on plain films]. They have a lot of arthritis."

As for chest injuries, half of all older adults who sustain rib fractures do so during simple falls from a standing position (J. Trauma 2003;54:478-85), likely from hitting something on the way down. Hence, the index of suspicion should be high even after seemingly minor spills.

"As the number of rib fractures increases, mortality increases in both elderly and nonelderly, but it increases disproportionately in the elderly," he observed.

The take-home message is early airway management: "When you see a patient with three or four rib fractures, they are not taking good deep breaths in, their saturations are hovering around 90% or 92% – that’s a patient you are probably going to want to consider intubating very early on."

Geriatric patients can get an injury unique to this age group: the sacral insufficiency fracture. "Suspect it if somebody has persistent hip pain, persistent back pain, [and] they can’t get up and walk," he advised. "The elderly person who fell, there is nothing on x-ray, you don’t see much on the CT scan, you may need to go ahead if the index of suspicion is high and make this diagnosis." In addition, relative to their younger counterparts, older adults are less likely to get open-book pelvic fractures and more likely to get acetabular and pubic rami fractures, according to Dr. Levy.

Management

Fluid resuscitation is often challenging in geriatric trauma patients because of underlying cardiac dysfunction and concerns about precipitating heart failure, Dr. Levy observed.

"You can facilitate this by using central venous pressure [CVP] guidance," he said. "If you can see what their CVP is, you can titrate their fluids to their CVP, recognizing that that might not be the best marker of preload in an elderly individual and it might not be the best marker of fluid response, but it may help."

Early consideration of blood products is important in geriatric trauma patients with hemodynamic instability, and their use has the advantages of administration of a smaller fluid volume (compared with saline) and a colloid effect.

"Rapid reversal of anticoagulation is not something a lot of us do routinely, but you should consider it in every elderly patient who comes in, especially those with traumatic head injuries. [Use] vitamin K and fresh frozen plasma," he recommended.

In a study of geriatric patients with head trauma taking warfarin, mortality was 48% in historical controls who developed intracranial hemorrhage but just 10% with use of a rapid imaging and, when indicated, reversal protocol including vitamin K and fresh frozen plasma (J. Trauma 2005;59:1131-7).

Proactive management for patients with chest trauma should include both pain control and early ventilatory support, Dr. Levy said.

"Pain control is huge," he commented. "If they are more comfortable, they are more apt to take big deep breaths in and less likely to suffer from the adverse consequences of their chest trauma."

Although strategies for ventilatory support may include intubation, "in some of these older folks with COPD [or] heart failure, when you intubate them, you may never extubate them. That’s always a concern," so a trial of bilevel pulmonary airway pressure is probably warranted if started early, he said.

Additional Considerations

Dr. Levy cautioned physicians not to forget to remove cervical collars once geriatric trauma patients have been medically cleared. "The longer they stay in that collar, the longer they stay on their back, the greater the risk they have of decubiti," he explained.

Prompt orthopedic consultation for patients with hip fracture is also key, as the time to intervention influences outcomes after this injury.

Be alert for rhabdomyolysis, especially in patients who have been immobile for a prolonged period, he said. In this setting, creatine kinase is more sensitive than urine myoglobin.

If "somebody comes in and they have multiple long bone fractures, multiple upper extremity fractures, a lot of bruising," consider the possibility of elder abuse or neglect, Dr. Levy further advised.

"And always, always, always look for medical causes in trauma," he stressed, as a patient’s accident may have been precipitated by a stroke or myocardial infarction that can be overlooked in the rush to treat their injuries.

Geriatric trauma patients are potential candidates for being discharged home if they had minor closed head trauma and are not on anticoagulation, they had a simple fall and do not have ambulatory difficulties, or they have isolated extremity fractures, provided they have adequate mobility and home support. "I would say pretty much consider admissions for most if not all others," he said.

A final consideration to be aware of is end-of-life issues in patients with little potential for recovery, Dr. Levy noted. Risk stratification tools can help physicians and families make treatment decisions in this context, he said. For example, the combination of age, base deficit, and head injury severity assessed on arrival in the emergency department can help predict if care is likely to ultimately be futile in geriatric trauma patients (J. Trauma 2004;57:37-41).

"We can consider that within the context of everything else: Are they demented, living in a nursing home, on a feeding tube? Or are they a fully functional individual in the community?" Dr. Levy said. "Certainly, these are all factors in the equation to consider when you are making that decision."

LAS VEGAS – Geriatric patients – with their age-related changes, frequent comorbidities, and some unique patterns of injury – "are clearly at risk for poor outcomes with trauma," Dr. Phillip D. Levy said.

Injury severity scores among trauma patients are generally similar across age ranges (J. Trauma 2010;69:88-92). "However, at every injury severity score, the percent mortality for geriatric patients ... is much worse," he said.

Aging leads to a host of anatomical and physiological changes – including reduced cardiac and pulmonary function, altered brain anatomy, and decreased musculoskeletal mass – that play a role in the setting of serious injury, said Dr. Levy, associate director of clinical research in the department of emergency medicine at Wayne State University in Detroit.

"The net effect is that there is a diminished physiological response, and some of these things may also lead to a delayed onset of overt consequences," he said, which may initially mask the extent of injury.

The EAST (Eastern Association for the Surgery of Trauma) guidelines for trauma care in older adults highlight several key concepts, he noted, such as the risk of undertriage and the adverse impact of pre-existing conditions and postinjury complications on outcomes (J. Trauma 2003;54:391-416).

Pre-existing conditions are present in 40% of patients aged 65-74 years, 65% of those aged 75-84 years, and 90% of patients aged 85 years and older, and these patients are often taking medications. For example, trauma patients with heart failure have more than double the risk of death, compared with those without heart failure, and the elevation of risk is even greater for those who are also taking beta-blockers or warfarin (J. Trauma 2010;69:645-52).

Because of these factors, the initial evaluation, secondary survey, and management of geriatric trauma patients have some unique aspects, according to Dr. Levy.

Initial Evaluation

Although the standard ATLS (Advanced Trauma Life Support) protocols still apply in older adults with trauma, "there are some caveats with it," Dr. Levy said.

One caveat is that this population is highly vulnerable to respiratory compromise with chest trauma. "Even one or two rib fractures in an elderly patient has dramatic impact," he noted.

Age-related issues such as nasopharyngeal fragility, the presence of arthritis in the temporomandibular joint, and dentures affect airway management in geriatric patients.

"Probably the most important thing when considering the airway, though, is recognizing that there are pharmacokinetic responses that are different," Dr. Levy said. Because older adults have increased responsiveness to sedatives, the dose should be reduced by 20%-40% to avoid complications.

Hypoperfusion is often occult in the elderly. "You facilitate the search by looking at serum markers of [tissue] oxygen deficit: base deficit and lactic acid," he said. These measures predict mortality in older normotensive adults who have sustained blunt trauma (J. Trauma 2009;66:1040-4). In particular, a base deficit of –6 or less or a venous lactic acid level greater than 4.0 mmol/L is associated with a mortality rate of nearly 40%, independent of injury severity.

He cautioned that specificity is much greater than sensitivity with these markers; hence, "if it’s positive, it’s positive. If it’s negative, well, it may not really be negative; you may be just early in the phase."

Use of pulmonary artery catheters (PACs) may seem an extreme approach for hemodynamic monitoring in geriatric trauma patients, Dr. Levy acknowledged. But "it enables direct measurement of cardiac function and it does improve outcomes if you use a targeted therapeutic approach, either targeting improving cardiac index or improving oxygen consumption."

For instance, therapy using PACs has been associated with a nearly 70% reduction in the risk of death for patients aged 61-90 years with severe injuries (Crit. Care Med. 2006;34:1597-601). "You optimize the patient’s hemodynamic status and their perfusion status, and you may not have even known that it was not optimized before," he said.

Secondary Survey

In blunt head trauma, patients older than 65 years are more likely to sustain traumatic brain injury than are their younger peers, according to one study (Acad. Emerg. Med. 2006;13:302-7).

"What was really interesting was that they found that 26%, about a quarter, of all elderly patients who had an injury had an occult presentation, no symptoms," he noted.

Outward clues, such as decreased alertness, prolonged loss of consciousness, and an abnormal Glasgow Coma Scale score were all less common in the older group, meaning that physical exam findings can’t be relied on to predict whether an older patient has a head injury, he said.

On CT imaging, likely because of different mechanisms of injury, geriatric patients are less likely to have linear skull fractures and epidural hemorrhages, but more likely to have subdural hematomas and subarachnoid hemorrhages.

Cervical spine injuries are also more common in older vs. younger trauma patients, and patterns of injury differ (Ann. Emerg. Med. 2002;40:287-93), again likely reflecting differences in the mechanism, according to Dr. Levy.

"The geriatric patients were at much greater risk for C1 fractures and any fracture at C2 – most specifically, an odontoid fracture," he noted.

And importantly, "you always have to consider central cord syndrome in your elderly patients due to that [hyperextension] type of mechanism. You might have osteophytes that squeeze off the cord."

CT is indicated as the primary imaging modality in cervical spine injuries among adults older than 65 years (J. Emerg. Med. 2009;36:64-71).

"The most likely [cervical spine] area for an elderly individual to have an injury is at C2 and, coincidentally, the most likely area to be missed on plain films is C2," Dr. Levy explained. "Additionally, the elderly are at a tremendous risk of false-positive findings [on plain films]. They have a lot of arthritis."

As for chest injuries, half of all older adults who sustain rib fractures do so during simple falls from a standing position (J. Trauma 2003;54:478-85), likely from hitting something on the way down. Hence, the index of suspicion should be high even after seemingly minor spills.

"As the number of rib fractures increases, mortality increases in both elderly and nonelderly, but it increases disproportionately in the elderly," he observed.

The take-home message is early airway management: "When you see a patient with three or four rib fractures, they are not taking good deep breaths in, their saturations are hovering around 90% or 92% – that’s a patient you are probably going to want to consider intubating very early on."

Geriatric patients can get an injury unique to this age group: the sacral insufficiency fracture. "Suspect it if somebody has persistent hip pain, persistent back pain, [and] they can’t get up and walk," he advised. "The elderly person who fell, there is nothing on x-ray, you don’t see much on the CT scan, you may need to go ahead if the index of suspicion is high and make this diagnosis." In addition, relative to their younger counterparts, older adults are less likely to get open-book pelvic fractures and more likely to get acetabular and pubic rami fractures, according to Dr. Levy.

Management

Fluid resuscitation is often challenging in geriatric trauma patients because of underlying cardiac dysfunction and concerns about precipitating heart failure, Dr. Levy observed.

"You can facilitate this by using central venous pressure [CVP] guidance," he said. "If you can see what their CVP is, you can titrate their fluids to their CVP, recognizing that that might not be the best marker of preload in an elderly individual and it might not be the best marker of fluid response, but it may help."

Early consideration of blood products is important in geriatric trauma patients with hemodynamic instability, and their use has the advantages of administration of a smaller fluid volume (compared with saline) and a colloid effect.

"Rapid reversal of anticoagulation is not something a lot of us do routinely, but you should consider it in every elderly patient who comes in, especially those with traumatic head injuries. [Use] vitamin K and fresh frozen plasma," he recommended.

In a study of geriatric patients with head trauma taking warfarin, mortality was 48% in historical controls who developed intracranial hemorrhage but just 10% with use of a rapid imaging and, when indicated, reversal protocol including vitamin K and fresh frozen plasma (J. Trauma 2005;59:1131-7).

Proactive management for patients with chest trauma should include both pain control and early ventilatory support, Dr. Levy said.

"Pain control is huge," he commented. "If they are more comfortable, they are more apt to take big deep breaths in and less likely to suffer from the adverse consequences of their chest trauma."

Although strategies for ventilatory support may include intubation, "in some of these older folks with COPD [or] heart failure, when you intubate them, you may never extubate them. That’s always a concern," so a trial of bilevel pulmonary airway pressure is probably warranted if started early, he said.

Additional Considerations

Dr. Levy cautioned physicians not to forget to remove cervical collars once geriatric trauma patients have been medically cleared. "The longer they stay in that collar, the longer they stay on their back, the greater the risk they have of decubiti," he explained.

Prompt orthopedic consultation for patients with hip fracture is also key, as the time to intervention influences outcomes after this injury.

Be alert for rhabdomyolysis, especially in patients who have been immobile for a prolonged period, he said. In this setting, creatine kinase is more sensitive than urine myoglobin.

If "somebody comes in and they have multiple long bone fractures, multiple upper extremity fractures, a lot of bruising," consider the possibility of elder abuse or neglect, Dr. Levy further advised.

"And always, always, always look for medical causes in trauma," he stressed, as a patient’s accident may have been precipitated by a stroke or myocardial infarction that can be overlooked in the rush to treat their injuries.

Geriatric trauma patients are potential candidates for being discharged home if they had minor closed head trauma and are not on anticoagulation, they had a simple fall and do not have ambulatory difficulties, or they have isolated extremity fractures, provided they have adequate mobility and home support. "I would say pretty much consider admissions for most if not all others," he said.

A final consideration to be aware of is end-of-life issues in patients with little potential for recovery, Dr. Levy noted. Risk stratification tools can help physicians and families make treatment decisions in this context, he said. For example, the combination of age, base deficit, and head injury severity assessed on arrival in the emergency department can help predict if care is likely to ultimately be futile in geriatric trauma patients (J. Trauma 2004;57:37-41).

"We can consider that within the context of everything else: Are they demented, living in a nursing home, on a feeding tube? Or are they a fully functional individual in the community?" Dr. Levy said. "Certainly, these are all factors in the equation to consider when you are making that decision."

LAS VEGAS – Geriatric patients – with their age-related changes, frequent comorbidities, and some unique patterns of injury – "are clearly at risk for poor outcomes with trauma," Dr. Phillip D. Levy said.

Injury severity scores among trauma patients are generally similar across age ranges (J. Trauma 2010;69:88-92). "However, at every injury severity score, the percent mortality for geriatric patients ... is much worse," he said.

Aging leads to a host of anatomical and physiological changes – including reduced cardiac and pulmonary function, altered brain anatomy, and decreased musculoskeletal mass – that play a role in the setting of serious injury, said Dr. Levy, associate director of clinical research in the department of emergency medicine at Wayne State University in Detroit.

"The net effect is that there is a diminished physiological response, and some of these things may also lead to a delayed onset of overt consequences," he said, which may initially mask the extent of injury.

The EAST (Eastern Association for the Surgery of Trauma) guidelines for trauma care in older adults highlight several key concepts, he noted, such as the risk of undertriage and the adverse impact of pre-existing conditions and postinjury complications on outcomes (J. Trauma 2003;54:391-416).

Pre-existing conditions are present in 40% of patients aged 65-74 years, 65% of those aged 75-84 years, and 90% of patients aged 85 years and older, and these patients are often taking medications. For example, trauma patients with heart failure have more than double the risk of death, compared with those without heart failure, and the elevation of risk is even greater for those who are also taking beta-blockers or warfarin (J. Trauma 2010;69:645-52).

Because of these factors, the initial evaluation, secondary survey, and management of geriatric trauma patients have some unique aspects, according to Dr. Levy.

Initial Evaluation

Although the standard ATLS (Advanced Trauma Life Support) protocols still apply in older adults with trauma, "there are some caveats with it," Dr. Levy said.

One caveat is that this population is highly vulnerable to respiratory compromise with chest trauma. "Even one or two rib fractures in an elderly patient has dramatic impact," he noted.

Age-related issues such as nasopharyngeal fragility, the presence of arthritis in the temporomandibular joint, and dentures affect airway management in geriatric patients.

"Probably the most important thing when considering the airway, though, is recognizing that there are pharmacokinetic responses that are different," Dr. Levy said. Because older adults have increased responsiveness to sedatives, the dose should be reduced by 20%-40% to avoid complications.

Hypoperfusion is often occult in the elderly. "You facilitate the search by looking at serum markers of [tissue] oxygen deficit: base deficit and lactic acid," he said. These measures predict mortality in older normotensive adults who have sustained blunt trauma (J. Trauma 2009;66:1040-4). In particular, a base deficit of –6 or less or a venous lactic acid level greater than 4.0 mmol/L is associated with a mortality rate of nearly 40%, independent of injury severity.

He cautioned that specificity is much greater than sensitivity with these markers; hence, "if it’s positive, it’s positive. If it’s negative, well, it may not really be negative; you may be just early in the phase."

Use of pulmonary artery catheters (PACs) may seem an extreme approach for hemodynamic monitoring in geriatric trauma patients, Dr. Levy acknowledged. But "it enables direct measurement of cardiac function and it does improve outcomes if you use a targeted therapeutic approach, either targeting improving cardiac index or improving oxygen consumption."

For instance, therapy using PACs has been associated with a nearly 70% reduction in the risk of death for patients aged 61-90 years with severe injuries (Crit. Care Med. 2006;34:1597-601). "You optimize the patient’s hemodynamic status and their perfusion status, and you may not have even known that it was not optimized before," he said.

Secondary Survey

In blunt head trauma, patients older than 65 years are more likely to sustain traumatic brain injury than are their younger peers, according to one study (Acad. Emerg. Med. 2006;13:302-7).

"What was really interesting was that they found that 26%, about a quarter, of all elderly patients who had an injury had an occult presentation, no symptoms," he noted.

Outward clues, such as decreased alertness, prolonged loss of consciousness, and an abnormal Glasgow Coma Scale score were all less common in the older group, meaning that physical exam findings can’t be relied on to predict whether an older patient has a head injury, he said.

On CT imaging, likely because of different mechanisms of injury, geriatric patients are less likely to have linear skull fractures and epidural hemorrhages, but more likely to have subdural hematomas and subarachnoid hemorrhages.

Cervical spine injuries are also more common in older vs. younger trauma patients, and patterns of injury differ (Ann. Emerg. Med. 2002;40:287-93), again likely reflecting differences in the mechanism, according to Dr. Levy.

"The geriatric patients were at much greater risk for C1 fractures and any fracture at C2 – most specifically, an odontoid fracture," he noted.

And importantly, "you always have to consider central cord syndrome in your elderly patients due to that [hyperextension] type of mechanism. You might have osteophytes that squeeze off the cord."

CT is indicated as the primary imaging modality in cervical spine injuries among adults older than 65 years (J. Emerg. Med. 2009;36:64-71).

"The most likely [cervical spine] area for an elderly individual to have an injury is at C2 and, coincidentally, the most likely area to be missed on plain films is C2," Dr. Levy explained. "Additionally, the elderly are at a tremendous risk of false-positive findings [on plain films]. They have a lot of arthritis."

As for chest injuries, half of all older adults who sustain rib fractures do so during simple falls from a standing position (J. Trauma 2003;54:478-85), likely from hitting something on the way down. Hence, the index of suspicion should be high even after seemingly minor spills.

"As the number of rib fractures increases, mortality increases in both elderly and nonelderly, but it increases disproportionately in the elderly," he observed.

The take-home message is early airway management: "When you see a patient with three or four rib fractures, they are not taking good deep breaths in, their saturations are hovering around 90% or 92% – that’s a patient you are probably going to want to consider intubating very early on."

Geriatric patients can get an injury unique to this age group: the sacral insufficiency fracture. "Suspect it if somebody has persistent hip pain, persistent back pain, [and] they can’t get up and walk," he advised. "The elderly person who fell, there is nothing on x-ray, you don’t see much on the CT scan, you may need to go ahead if the index of suspicion is high and make this diagnosis." In addition, relative to their younger counterparts, older adults are less likely to get open-book pelvic fractures and more likely to get acetabular and pubic rami fractures, according to Dr. Levy.

Management

Fluid resuscitation is often challenging in geriatric trauma patients because of underlying cardiac dysfunction and concerns about precipitating heart failure, Dr. Levy observed.

"You can facilitate this by using central venous pressure [CVP] guidance," he said. "If you can see what their CVP is, you can titrate their fluids to their CVP, recognizing that that might not be the best marker of preload in an elderly individual and it might not be the best marker of fluid response, but it may help."

Early consideration of blood products is important in geriatric trauma patients with hemodynamic instability, and their use has the advantages of administration of a smaller fluid volume (compared with saline) and a colloid effect.

"Rapid reversal of anticoagulation is not something a lot of us do routinely, but you should consider it in every elderly patient who comes in, especially those with traumatic head injuries. [Use] vitamin K and fresh frozen plasma," he recommended.

In a study of geriatric patients with head trauma taking warfarin, mortality was 48% in historical controls who developed intracranial hemorrhage but just 10% with use of a rapid imaging and, when indicated, reversal protocol including vitamin K and fresh frozen plasma (J. Trauma 2005;59:1131-7).

Proactive management for patients with chest trauma should include both pain control and early ventilatory support, Dr. Levy said.

"Pain control is huge," he commented. "If they are more comfortable, they are more apt to take big deep breaths in and less likely to suffer from the adverse consequences of their chest trauma."

Although strategies for ventilatory support may include intubation, "in some of these older folks with COPD [or] heart failure, when you intubate them, you may never extubate them. That’s always a concern," so a trial of bilevel pulmonary airway pressure is probably warranted if started early, he said.

Additional Considerations

Dr. Levy cautioned physicians not to forget to remove cervical collars once geriatric trauma patients have been medically cleared. "The longer they stay in that collar, the longer they stay on their back, the greater the risk they have of decubiti," he explained.

Prompt orthopedic consultation for patients with hip fracture is also key, as the time to intervention influences outcomes after this injury.

Be alert for rhabdomyolysis, especially in patients who have been immobile for a prolonged period, he said. In this setting, creatine kinase is more sensitive than urine myoglobin.

If "somebody comes in and they have multiple long bone fractures, multiple upper extremity fractures, a lot of bruising," consider the possibility of elder abuse or neglect, Dr. Levy further advised.

"And always, always, always look for medical causes in trauma," he stressed, as a patient’s accident may have been precipitated by a stroke or myocardial infarction that can be overlooked in the rush to treat their injuries.

Geriatric trauma patients are potential candidates for being discharged home if they had minor closed head trauma and are not on anticoagulation, they had a simple fall and do not have ambulatory difficulties, or they have isolated extremity fractures, provided they have adequate mobility and home support. "I would say pretty much consider admissions for most if not all others," he said.

A final consideration to be aware of is end-of-life issues in patients with little potential for recovery, Dr. Levy noted. Risk stratification tools can help physicians and families make treatment decisions in this context, he said. For example, the combination of age, base deficit, and head injury severity assessed on arrival in the emergency department can help predict if care is likely to ultimately be futile in geriatric trauma patients (J. Trauma 2004;57:37-41).

"We can consider that within the context of everything else: Are they demented, living in a nursing home, on a feeding tube? Or are they a fully functional individual in the community?" Dr. Levy said. "Certainly, these are all factors in the equation to consider when you are making that decision."

LAS VEGAS – Geriatric patients – with their age-related changes, frequent comorbidities, and some unique patterns of injury – "are clearly at risk for poor outcomes with trauma," Dr. Phillip D. Levy said.

Injury severity scores among trauma patients are generally similar across age ranges (J. Trauma 2010;69:88-92). "However, at every injury severity score, the percent mortality for geriatric patients ... is much worse," he said.

Aging leads to a host of anatomical and physiological changes – including reduced cardiac and pulmonary function, altered brain anatomy, and decreased musculoskeletal mass – that play a role in the setting of serious injury, said Dr. Levy, associate director of clinical research in the department of emergency medicine at Wayne State University in Detroit.

"The net effect is that there is a diminished physiological response, and some of these things may also lead to a delayed onset of overt consequences," he said, which may initially mask the extent of injury.

The EAST (Eastern Association for the Surgery of Trauma) guidelines for trauma care in older adults highlight several key concepts, he noted, such as the risk of undertriage and the adverse impact of pre-existing conditions and postinjury complications on outcomes (J. Trauma 2003;54:391-416).

Pre-existing conditions are present in 40% of patients aged 65-74 years, 65% of those aged 75-84 years, and 90% of patients aged 85 years and older, and these patients are often taking medications. For example, trauma patients with heart failure have more than double the risk of death, compared with those without heart failure, and the elevation of risk is even greater for those who are also taking beta-blockers or warfarin (J. Trauma 2010;69:645-52).

Because of these factors, the initial evaluation, secondary survey, and management of geriatric trauma patients have some unique aspects, according to Dr. Levy.

Initial Evaluation

Although the standard ATLS (Advanced Trauma Life Support) protocols still apply in older adults with trauma, "there are some caveats with it," Dr. Levy said.

One caveat is that this population is highly vulnerable to respiratory compromise with chest trauma. "Even one or two rib fractures in an elderly patient has dramatic impact," he noted.

Age-related issues such as nasopharyngeal fragility, the presence of arthritis in the temporomandibular joint, and dentures affect airway management in geriatric patients.

"Probably the most important thing when considering the airway, though, is recognizing that there are pharmacokinetic responses that are different," Dr. Levy said. Because older adults have increased responsiveness to sedatives, the dose should be reduced by 20%-40% to avoid complications.

Hypoperfusion is often occult in the elderly. "You facilitate the search by looking at serum markers of [tissue] oxygen deficit: base deficit and lactic acid," he said. These measures predict mortality in older normotensive adults who have sustained blunt trauma (J. Trauma 2009;66:1040-4). In particular, a base deficit of –6 or less or a venous lactic acid level greater than 4.0 mmol/L is associated with a mortality rate of nearly 40%, independent of injury severity.

He cautioned that specificity is much greater than sensitivity with these markers; hence, "if it’s positive, it’s positive. If it’s negative, well, it may not really be negative; you may be just early in the phase."

Use of pulmonary artery catheters (PACs) may seem an extreme approach for hemodynamic monitoring in geriatric trauma patients, Dr. Levy acknowledged. But "it enables direct measurement of cardiac function and it does improve outcomes if you use a targeted therapeutic approach, either targeting improving cardiac index or improving oxygen consumption."

For instance, therapy using PACs has been associated with a nearly 70% reduction in the risk of death for patients aged 61-90 years with severe injuries (Crit. Care Med. 2006;34:1597-601). "You optimize the patient’s hemodynamic status and their perfusion status, and you may not have even known that it was not optimized before," he said.

Secondary Survey

In blunt head trauma, patients older than 65 years are more likely to sustain traumatic brain injury than are their younger peers, according to one study (Acad. Emerg. Med. 2006;13:302-7).

"What was really interesting was that they found that 26%, about a quarter, of all elderly patients who had an injury had an occult presentation, no symptoms," he noted.

Outward clues, such as decreased alertness, prolonged loss of consciousness, and an abnormal Glasgow Coma Scale score were all less common in the older group, meaning that physical exam findings can’t be relied on to predict whether an older patient has a head injury, he said.

On CT imaging, likely because of different mechanisms of injury, geriatric patients are less likely to have linear skull fractures and epidural hemorrhages, but more likely to have subdural hematomas and subarachnoid hemorrhages.

Cervical spine injuries are also more common in older vs. younger trauma patients, and patterns of injury differ (Ann. Emerg. Med. 2002;40:287-93), again likely reflecting differences in the mechanism, according to Dr. Levy.

"The geriatric patients were at much greater risk for C1 fractures and any fracture at C2 – most specifically, an odontoid fracture," he noted.

And importantly, "you always have to consider central cord syndrome in your elderly patients due to that [hyperextension] type of mechanism. You might have osteophytes that squeeze off the cord."

CT is indicated as the primary imaging modality in cervical spine injuries among adults older than 65 years (J. Emerg. Med. 2009;36:64-71).

"The most likely [cervical spine] area for an elderly individual to have an injury is at C2 and, coincidentally, the most likely area to be missed on plain films is C2," Dr. Levy explained. "Additionally, the elderly are at a tremendous risk of false-positive findings [on plain films]. They have a lot of arthritis."

As for chest injuries, half of all older adults who sustain rib fractures do so during simple falls from a standing position (J. Trauma 2003;54:478-85), likely from hitting something on the way down. Hence, the index of suspicion should be high even after seemingly minor spills.

"As the number of rib fractures increases, mortality increases in both elderly and nonelderly, but it increases disproportionately in the elderly," he observed.

The take-home message is early airway management: "When you see a patient with three or four rib fractures, they are not taking good deep breaths in, their saturations are hovering around 90% or 92% – that’s a patient you are probably going to want to consider intubating very early on."

Geriatric patients can get an injury unique to this age group: the sacral insufficiency fracture. "Suspect it if somebody has persistent hip pain, persistent back pain, [and] they can’t get up and walk," he advised. "The elderly person who fell, there is nothing on x-ray, you don’t see much on the CT scan, you may need to go ahead if the index of suspicion is high and make this diagnosis." In addition, relative to their younger counterparts, older adults are less likely to get open-book pelvic fractures and more likely to get acetabular and pubic rami fractures, according to Dr. Levy.

Management

Fluid resuscitation is often challenging in geriatric trauma patients because of underlying cardiac dysfunction and concerns about precipitating heart failure, Dr. Levy observed.

"You can facilitate this by using central venous pressure [CVP] guidance," he said. "If you can see what their CVP is, you can titrate their fluids to their CVP, recognizing that that might not be the best marker of preload in an elderly individual and it might not be the best marker of fluid response, but it may help."

Early consideration of blood products is important in geriatric trauma patients with hemodynamic instability, and their use has the advantages of administration of a smaller fluid volume (compared with saline) and a colloid effect.

"Rapid reversal of anticoagulation is not something a lot of us do routinely, but you should consider it in every elderly patient who comes in, especially those with traumatic head injuries. [Use] vitamin K and fresh frozen plasma," he recommended.

In a study of geriatric patients with head trauma taking warfarin, mortality was 48% in historical controls who developed intracranial hemorrhage but just 10% with use of a rapid imaging and, when indicated, reversal protocol including vitamin K and fresh frozen plasma (J. Trauma 2005;59:1131-7).

Proactive management for patients with chest trauma should include both pain control and early ventilatory support, Dr. Levy said.

"Pain control is huge," he commented. "If they are more comfortable, they are more apt to take big deep breaths in and less likely to suffer from the adverse consequences of their chest trauma."

Although strategies for ventilatory support may include intubation, "in some of these older folks with COPD [or] heart failure, when you intubate them, you may never extubate them. That’s always a concern," so a trial of bilevel pulmonary airway pressure is probably warranted if started early, he said.

Additional Considerations

Dr. Levy cautioned physicians not to forget to remove cervical collars once geriatric trauma patients have been medically cleared. "The longer they stay in that collar, the longer they stay on their back, the greater the risk they have of decubiti," he explained.

Prompt orthopedic consultation for patients with hip fracture is also key, as the time to intervention influences outcomes after this injury.

Be alert for rhabdomyolysis, especially in patients who have been immobile for a prolonged period, he said. In this setting, creatine kinase is more sensitive than urine myoglobin.

If "somebody comes in and they have multiple long bone fractures, multiple upper extremity fractures, a lot of bruising," consider the possibility of elder abuse or neglect, Dr. Levy further advised.

"And always, always, always look for medical causes in trauma," he stressed, as a patient’s accident may have been precipitated by a stroke or myocardial infarction that can be overlooked in the rush to treat their injuries.

Geriatric trauma patients are potential candidates for being discharged home if they had minor closed head trauma and are not on anticoagulation, they had a simple fall and do not have ambulatory difficulties, or they have isolated extremity fractures, provided they have adequate mobility and home support. "I would say pretty much consider admissions for most if not all others," he said.

A final consideration to be aware of is end-of-life issues in patients with little potential for recovery, Dr. Levy noted. Risk stratification tools can help physicians and families make treatment decisions in this context, he said. For example, the combination of age, base deficit, and head injury severity assessed on arrival in the emergency department can help predict if care is likely to ultimately be futile in geriatric trauma patients (J. Trauma 2004;57:37-41).

"We can consider that within the context of everything else: Are they demented, living in a nursing home, on a feeding tube? Or are they a fully functional individual in the community?" Dr. Levy said. "Certainly, these are all factors in the equation to consider when you are making that decision."