CDC Traces MRSA Outbreaks to Improper Injection Practices in Pain Clinics

Is a medication shortage causing you to use single dose vials for more than one patient?

On July 13, the Centers for Disease Control and Prevention (CDC) released a report detailing two life-threatening outbreaks that occurred when healthcare providers used medication from single-dose/single-use vials for multiple patients undergoing treatment for pain. At least 10 patients contracted severe staph or MRSA (methicillin-resistant S. aureus) infections and had to be hospitalized. An additional patient died, and although MRSA was not listed as the cause of death, it could not be ruled out.

needle ready for injection

Repackaging is the way to go.

These breaches of basic infection control practices are a stark reminder that CDC recommendations for injection safety must be followed closely with every patient, even during times of medication shortages. In circumstances when individually packaged and appropriately sized single-dose/single-use vials are unavailable (e.g., during national shortage) contents from unopened vials can be packaged into multiple single-use vehicles, provided that the repackaging is performed in accordance with all standards in United States Pharmacopeia General Chapter <797 >.

The CDC encourages clinicians to double check their practices against CDC’s Injection Safety Recommendations. This is a very handy checklist that you can also use in your practice to train new clinical personnel and to test personnel skills annually.

In addition, CDC offers healthcare providers a toolkit (this is excellent!) featuring a narrated PowerPoint presentation that is ideal for staff meetings, seminars, and other education opportunities.

Is your facility performing injections correctly?

We know that medical practices often do not follow the same safety practices that hospitals do, but now is the time to start. You don’t want your patient to get sick from something done wrong in your facility, and you certainly don’t want the risk exposure, lawsuits, or bad publicity. Nurse leads and managers and practice administrators, make sure your practice is doing it right!


Medicare News for the Week of February 13, 2012: PQRS, eRX and EHR, EHR and EHR

(PQRS) AM News Reports 2012 Last Year for Physicians to Voluntarily Report Quality Data (jump to story)

(PQRS & eRX) National Provider Call: Claims-Based Reporting for the Physician Quality Reporting System & Electronic Prescribing Incentive Program (jump to story)

(Purchasing) National Provider Call:  Hospital Value-Based Purchasing Program (jump to story)

(eRx) Electronic Prescribing (eRx) Incentive Program: Updates for 2012 (jump to story)

(Observation) Some Medicare Beneficiaries Receive Large Bills Over “Observation Care” Status (jump to story)

CMS Gives Consumers Access to More Details about Infection Rates at America’s Hospitals – Data Will Save Lives, Cut Costs (jump to story)

(EHR) CMS Has Updated the EHR Information Center with New Self-Service Options (jump to story)

(EHR) Updated and New FAQs Added to the CMS EHR Website (jump to story)

(EHR) Stay Informed via the CMS EHR Incentive Programs Listserv (jump to story)



AM News Reports 2012 Last Year for Physicians to Voluntarily Report Quality Data

According to coverage in AM News, “…doctors have only this year to report data to the program voluntarily.” …doctors who don’t report data will not only not be eligible for a bonus but may be dinged with a 1.5% penalty on their payments in 2015.”  Read more in AM News.

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National Provider Call:  Claims-Based Reporting for the Physician Quality Reporting System & Electronic Prescribing Incentive Program – Registration Now Open

Tue Feb 21; 1:30-3pm ET

CMS will host a National Provider Call on the Physician Quality Reporting System & Electronic Prescribing (eRx) Incentive Program.  Subject matter experts will provide an overview on claims-based reporting for both programs, followed by a question and answer session.

Target Audience:  All Medicare Fee-For-Service Providers, Medical Coders, Physician Office Staff, Provider Billing Staff, Electronic Health Records Staff, and Vendors


  • Opening Remarks
  • Program Announcements
  • Overview of claims-based reporting for the Physician Quality Reporting System
  • Overview of claims-based reporting for the eRx Incentive Program
  • Question & Answer Session

Registration Information:  In order to receive the call-in information, you must register for the call.  Registration will close at 12pm on the day of the call or when available space has been filled; no exceptions will be made, so please register early.  For more details, including instructions on registering for the call, please visit http://www.eventsvc.com/blhtechnologies.

Presentation:  The presentation for this call will be posted at least one day in advance at http://www.CMS.gov/PQRS/04_CMSSponsoredCalls.asp in the “Downloads” section of the page.

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National Provider Call:  Hospital Value-Based Purchasing Program – Registration Now Open

Tue Feb 28; 1:30-3pm ET

The Centers for Medicare & Medicaid Services (CMS) will be creating hospital-specific performance reports that simulate the FY2013 Hospital Value-Based Purchasing Program for each hospital to review; the simulated reports will employ hospital data from prior years to construct each hospital’s baseline period and performance period scores.  To prepare providers for interpreting the simulated report, this National Provider Call will discuss a sample report that shows what hospitals can expect when they receive their own reports.

Target Audience:  Hospitals, Quality Improvement Organizations, medical coders, physician office staff, provider billing staff, health records staff, vendors, and all Medicare Fee-For-Service providers.


  • Opening Remarks
  • Program Announcements
  • Overview of the Hospital Value-Based Purchasing Program
  • Presentation and Walkthrough of the Hospital-Specific Report
  • Question & Answer Session

Registration Information:  In order to receive the call-in information, you must register for the call.  Registration will close at 12pm on the day of the call or when available space has been filled; no exceptions will be made, so please register early.  For more details, including instructions on registering for the call, please visit http://www.eventsvc.com/blhtechnologies.

Presentation:  The presentation for this call will be posted at least one day in advance at http://www.CMS.gov/Hospital-Value-Based-Purchasing in the “Downloads” section of the page.

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Electronic Prescribing (eRx) Incentive Program: Updates for 2012

The Medicare Electronic Prescribing (eRx) Incentive Program, which began January 1, 2009 and is authorized under the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008, provides incentives for eligible professionals who are successful electronic prescribers. A web page dedicated to providing all the latest news on the eRx Incentive Program is available on the Centers for Medicare & Medicaid Services (CMS) website at http://www.cms.gov/ERxIncentive.

Under section 1848(a)(5)(A) of the Social Security Act, for years 2012 through 2014, a Physician Fee Schedule (PFS) payment adjustment applies to eligible professionals who are not successful electronic prescribers at an increasing rate through 2014. Specifically, if the eligible professional is not a successful electronic prescriber for the respective reporting period for the appropriate program year, the PFS amount for covered professional services during the year shall be a percentage less than the PFS amount that would otherwise apply.

The following are key changes for the 2012 eRx Incentive Program:

Group Practice Reporting Option (GPRO) changes
Group practices (who self-nominated and were selected by CMS to participate in the Group Practice Reporting Option) can qualify to earn an eRx incentive if it is determined that the practice is a successful electronic prescriber. This incentive payment is equal to 1.0 percent of the total estimated Medicare Part B PFS allowed charges under the group practice’s Taxpayer Identification Number (TIN).  The minimum number of times a group must report the eRx measure is 2,500 for large group practices participating in eRx GPRO participants (100 or more individual eligible professionals), 625 for small group practices participating in eRx GPRO (25-99 individual eligible professionals).

Important Changes for the 2013 eRx Payment Adjustment

  • Added a second reporting period to avoid the 2013 eRx payment adjustment (6-month reporting period, January 1-June 30, 2012)
  • Eligible professionals can report on any billable Medicare Part B PFS service to avoid the 2013 payment adjustment.
  • Hardship exemption requests are available for eligible professionals who are unable to report the eRx measure.

Avoiding the 2013 eRx Payment Adjustment

  • In order to avoid the 2013 payment adjustment, eligible professionals are now able to report the eRx Quality-Data Code (QDC) on any billable Medicare Part B PFS service. In previous program years, eRx events could only be reported with specified encounter codes. Please note that reporting denominator- eligible events is still required to earn an incentive payment for 2012.
  •  Additional information on how to avoid future eRx payment adjustments can be found in the Electronic Prescribing (eRx) Incentive Program – Future Payment Adjustments document located on the CMS eRx website at http://www.cms.gov/ERxIncentive.asp, under the “Educational Resources” section.

2012 Hardship Exemption Requests to Avoid the 2013 Payment Adjustment

  • Individual eligible professionals requesting hardship exemptions from the 2013 eRx payment adjustment will be able to submit their request using the CMS Quality Reporting Communication Support Page located at https://www.qualitynet.org/portal/server.pt/community/communications_support_system/234.
  • CMS will announce when the Quality Reporting Communication Support Page becomes available for requesting a hardship exemption for the 2013 eRx payment adjustment.
  • For more information on the 2012 eRx hardship exemption categories and on the process for requesting an exemption visit the CMS Electronic Prescribing Incentive Program at http://www.cms.gov/ERxIncentive.

Additional Information

  • For more information on the 2012 eRx Incentive Program, go to https://www.cms.gov/ERxIncentive/06_E-Prescribing_Measure.asp
  •  For more information on avoiding future payment adjustments, go to https://www.cms.gov/ERxIncentive/20_Payment_Adjustment_Information.asp

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Some Medicare Beneficiaries Receive Large Bills Over “Observation Care” Status.

CMS, in an effort to reduce spending, requires medical necessity for a patient to be admitted to the hospital. Many times, however, it cannot be determined immediately if patients do require admission to the hospital. In these cases, patients are admitted to observation (today commonly called the CDU, or Clinical Decision Unit) to try to determine if the patient does need to be admitted or can be released. Observation is considered an Outpatient Service (even though the patient is in a hospital bed in the hospital), just as Emergency Room care is considered outpatient service. Patients who have received Observation Care, once they return home and receive a bill,  are stunned to find that they are paying according to Medicare Part B. Part B has a deductible plus a 20% co-insurance for all services they received in the hospital as an outpatient. Read more here:  Wall Street Journal

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CMS Gives Consumers Access to More Details about Infection Rates at America’s Hospitals – Data Will Save Lives, Cut Costs

Central line-associated bloodstream infections (CLABSIs) are among the most serious of all healthcare-associated infections, resulting in thousands of deaths each year and nearly $700 million in added costs to the US healthcare system.  On Tue Feb 7, CMS announced that Hospital Compare will now include data about how often these preventable infections occur in hospital intensive care units across the country.  This step will hold hospitals accountable for bringing down these rates, saving thousands of lives and millions of dollars each year.

The Centers for Disease Control and Prevention estimates that in 2009, there were about 41,000 CLABSIs in US hospitals.  Studies show that up to 25 percent of patients who get a CLABSI will die from the infection.  Caring for a patient with a CLABSI adds about $17,000 to a hospitalization.  These infections prolong hospitalizations and can cause death.

Hospital Compare is one of Medicare’s most popular web tools.  The site receives about 1 million page views each month and is available in English and in Spanish.  More information about Hospital Compare is online at http://www.HospitalCompare.HHS.gov.

To view the CMS video of Nancy Foster, Vice President of Quality and Patient Safety Policy at the American Hospital Association, discussing Hospital Compare, visit the CMS YouTube channel.

The full text of this excerpted CMS press release (issued Tue Feb 7) can be found at http://www.CMS.gov/apps/media/press/release.asp?Counter=4260.

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CMS Has Updated the EHR Information Center with New Self-Service Option

Following months of review and collective input, the Electronic Health Record (EHR) Information Center Interactive Voice Response (IVR) system has been enhanced to provide users with an increased number of options and services to make accessing and reviewing data easier than ever before.

For eligible professionals (EPs), eligible hospitals, or critical access hospitals (CAHs), the revised functionality vastly improves the efficiency in obtaining desired information, while also offering a more varied amount of information and options for callers.  CMS is proud to announce that providers can now obtain information through an extensive IVR Self-Service option.  Included in this option is a reinforced privacy protection module that requires your individual National Provider Identifier (NPI), the last five digits of your Tax Identification Number (TIN), and your EHR registration ID.  Once accepted, this newly enhanced Self-Service tool allows you to:

  • Obtain registration status
  • Acquire attestation status
  • Review payment information
  • Check progress towards meeting the $24,000 threshold amount

Users may access these new options by dialing 888-734-6433, pressing 3 for Self-Service, and entering the authentication elements.  These options will be available on the IVR effective Thu Feb 16.

EHR Information Center Hours of Operation:  7:30am-6:30pm CT, Monday through Friday, except federal holidays.  (Note that General Information and Self-Service options may be reached via IVR 24 hours a day, except during periods of planned system maintenance or upgrades).

Supplementary information on the program may also be viewed by visiting the FAQs section of the EHR Incentive Programs website, where users can search for any questions they have about the Medicare or Medicaid EHR Incentive Programs.

Want more information about the EHR Incentive Programs?  Make sure to visit the EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.

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Updated and New FAQs Added to the CMS EHR Website

CMS wants to help keep you updated with information on the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs, and has recently updated previously-posted FAQs and added new FAQs on several incentive program topics, including reporting periods and incentive payments.  Take a minute and review these FAQs:

  • For the 2011 payment year, how and when will incentive payments for the Medicare EHR Incentive Programs be made?  Read the answer.
  • What are the EHR reporting periods for eligible hospitals participating in both the Medicare and the Medicaid EHR Incentive Programs, as well as the requirements for receiving an EHR incentive payment?  Read the answer.
  • For the Medicare and Medicaid EHR Incentive Programs, how will non-standard (or irregular) cost reporting periods be taken into account in determining the appropriate cost reporting periods to employ during the Medicare and Medicaid EHR Hospital Calculations?  Read the answer.
  • In order to qualify for payment under the Medicaid EHR Incentive Program for having adopted, implemented, or upgraded to (AIU) certified EHR technology, an eligible professional (EP) working at an Indian Health Services (IHS) clinic may be asked to submit to their State Medicaid Agency an official letter containing information about the clinic’s electronic health record from IHS (which is an Operating Division of the United States Department of Health and Human Services).  The information in this letter identifies the EHR vendor, the ONC Certified Heath IT Product List (CHPL) number of the EHR, as well as other information regarding the EHR product version and licensure.  Does this letter meet states’ documentation requirements for AIU?  Read the answer.
  • For the Medicaid EHR Incentive Program, how do we determine Medicaid patient volume for procedures that are billed globally, such as obstetrician (OB) visits or some surgeries?  Such procedures are billed to Medicaid at a global rate where one global rate might cover several visits.  Read the answer.

Want more information about the EHR Incentive Programs?  Make sure to visit the CMS EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.

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Stay Informed via the CMS EHR Incentive Programs Listserv

CMS wants to invite you to join a free email service to receive the latest news on the EHR Incentive Programs.  The CMS EHR Incentive Program listserv provides timely information on program requirements and changes in the EHR Incentive Programs.

By subscribing to this listserv, you will receive early notification of new program developments, the availability of new resources, and the addition of any new Frequently Asked Questions that are published on the CMS EHR Incentive Programs website.  Join the listserv and visit the listserv section of the EHR Incentive Programs website to take a review some of the recent messages we have sent.  We encourage you to let others know about the CMS EHR Incentive Program listserv, and to share its messages.

Want more information about the EHR Incentive Programs?  Make sure to visit the EHR Incentive Programs website for complete information about the CMS Medicare and Medicaid EHR Incentive Programs.

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The Social Media Conversation

As social media matures and more healthcare groups gain experience using it, we understand more about it and the role it will play in the future of healthcare.

Last week, Abraham and I gave a program called “Starting the Conversation: An Introduction to Using Social Media In Healthcare” to a group of healthcare managers. We discussed social media’s potential to influence patient satisfaction, which is expected to influence reimbursement.

You can download our program here.

Resources from the presentation:

AMA Social Media Guidelines
Ohio State Medical Association Social Media Policy
CDC Social Media Toolkit
Dose of Digital Wiki of Healthcare Communities and Websites
Pew Internet and American Life Project
Mayo Clinic Center for Social Media
Manage My Practice Social Media Posts
“Found in Cache” Social Media resources for health care professionals by Ed Bennett
Five Simple Rules for Social Business
Brian Solis Definition of Social Media

Providing and Billing for the Flu Vaccine: Guidance from CMS, the CDC and the Affordable Care Act

Update posted 8-14-2012: For flu shot updates for the 2012-2013 influenza season, click here.


Update posted 9-22-2011: For flu shot updates for the 2011-2012 influenza season, click here.


Update Posted 12-20-2010 – Medicare posted code changes for flu vaccines billed to Medicare after January 1, 2011.  Click here for the changes.

For dates of service on or after September 1, 2010, the corrected Medicare Part B payment allowance for CPT 90655 is $14.858.


It’s that time again, and despite delayed deliveries to some hospitals and practices, the word on the street is that there will be enough flu vaccine (171 million doses) this year for all who want a flu shot.

Model of Influenza Virus from NIH

Image via Wikipedia

The Center for Disease Control (CDC) recommends that everyone 6 months and older get a flu shot.  Each year’s flu vaccine cocktail is unique and this season’s (2010-2011) flu vaccine will protect against three different flu viruses: an H3N2 virus, an influenza B virus and the H1N1 virus that caused so much illness last season.

The Affordable Care Act and the Influenza Vaccine

Just in time for flu season is the Affordable Care Act’s emphasis on preventive care.  The ACA states:

This influenza season, children 6 months through 18 years, certain high-risk adults 19 through 49 years, and adults 50 years and older who are enrolled in new group and individual health plans will be eligible to receive the seasonal flu vaccine without cost-sharing when provided by an in-network provider.  Beginning in the plan year that starts after March 2, 2011, all adults 19-49 years of age will be eligible to receive the seasonal flu vaccine with no cost-sharing requirements when provided by an in-network provider.

This is great news for the patient and for healthcare in general.  You may consider it good news or bad news, depending on your view of the whole flu shot process.  Here’s how it works in many practices:

  1. The vaccine is ordered in the spring, with everyone trying hard to guess correctly how many patients will want flu shots in 6 months.
  2. The vaccine arrives in the fall and the first hurdle is pricing it, as you will have to decide how much to mark it up to cover the cost of the ordering, handling and stocking and possibly a teeny profit.
  3. The administration of the vaccine also has to be priced to cover the cost of supplies (syringe, alcohol swab, sometimes a bandaid, printed Vaccine Administration Sheets) and the cost of labor (assessing the patient to make sure they can get the flu shot, giving the shot, and documenting the lot numbers in case of a recall.)
  4. The next decision is disbursement.  Do you have a flu shot clinic and have people get in line for the flu shot, or do you take flu shot appointments, do you give flu shots during regular appointments, or some combination thereof? What about drive-through flu clinics?  Do people sit in the parking lot for 15 minutes to make sure there are no bad after-effects?  How do you let patients know about your flu shot plans without costly postcards or advertisements?
  5. Then, there is policy setting for patients whose insurance covers the flu shot and for patients whose insurance does not.  Do you collect and refund if necessary, or do you not collect and bill the patient after insurance responds (Jaws theme music here, please.)

Does Medicare pay for flu shots?

Medicare pays 100% of the allowable for influenza vaccine (and pneumococcal vaccines) and the administration of the vaccines without any out-of-pocket costs to the patient.  One flu vaccine is allowable per flu season, but Medicare will pay for a second flu shot if a physician determines and documents the medical necessity.  A physician’s order is not necessary and a physician’s supervision is not necessary – that’s why patients are able to get a flu shot at the drugstore.  A patient can receive a flu shot twice in one calendar year by getting a flu shot late in one season and getting a flu shot early in the next season.

How should a provider that is not enrolled in Medicare bill for the flu vaccine?

CMS typically does not allow non-enrolled providers to treat Medicare beneficiaries, however, CMS is allowing them to give flu shots this year.  Beneficiaries can receive a flu vaccine from any licensed physician or provider. However, the billing procedure will vary depending on whether the physician or provider is enrolled in the Medicare Program.

If you are not a Medicare-enrolled physician or provider who gives a flu vaccine to a Medicare beneficiary, you can ask the beneficiary for payment at the time of service. The beneficiary can then request Medicare reimbursement. Medicare reimbursement will be approximately $18 for each flu vaccine.

Public health poster from Spanish flu era.
Image via Wikipedia

To request reimbursement, the beneficiary will need to obtain and complete form CMS 1490S.  So the beneficiary may receive reimbursement, you will need to provide the beneficiary with a receipt for the flu vaccine that has the following information written or printed on it:
”¢    The doctor’s or provider’s name and address
”¢    Service provided (“flu vaccine”)
”¢    Date flu vaccine received
”¢    Amount paid

What codes are used for flu shots?

For flu vaccine and vaccine administration, the following codes are used.

Effective September 1, 2009, (no 2010 changes have been announced) the Medicare Part B payment allowances for influenza vaccines are as follows:

  • For HCPCS 90655, the payment will be  $15.447:  Influenza virus vaccine, split virus, preservative free, for children 6- 35 months of age, for intramuscular use
  • For HCPCS code 90656, the payment will be  $12.541: Influenza virus vaccine, split virus, preservative free, for use in individuals 3 years and above, for intramuscular use
  • For HCPCS code 90657, the payment will be  $15.684:  Influenza virus vaccine, split virus, for children 6-35 months of age, for intramuscular use;
  • For HCPCS code 90658, the payment will be  $11.368:  Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use
  • HCPCS 90660 (FluMist, a nasal influenza vaccine) may be covered if the local Medicare contractor determines its use is medically reasonable and necessary for the beneficiary. When payment is based on 95 percent of the Average Wholesale Price (AWP), the Medicare Part B payment allowance for CPT 90660 is $22.316 (effective September 1, 2009).

G0008 is the Medicare HCPCS for Administration of influenza virus vaccine, including FluMist.  Other payers usually require use of 90465, 90466, 90467, 90468, 90471, 90472, 90473 or 90474 for administration of the vaccine.

The associated ICD-9 codes for flu shots are:

V04.81    Influenza
V06.6      Pneumococcus and Influenza (both vaccines at one visit)

Other resources:

  • Get your practice and your staff ready for flu season by following the guidelines I write about here.
  • Free downloads from the CDC here.
  • MedLine Plus Articles, Downloads and Resources here
  • Article: Mandating Influenza Vaccine – One Hospital’s Experience (MedScape free account required)
  • National Foundation for Infectious Diseases: Influenza
  • National Influenza Vaccine Summit: Prevent Influenza
  • Vaccine Education Center at Children’s Hospital of Philadelphia (CHOP) -Influenza: What You Should Know (pdf)   EnglishSpanish
  • Medicare Preventive Services Quick Reference Information Chart: Medicare Part B Immunization Billing (Influenza, Pneumococcal, and Hepatitis B) is available here (pdf.)
  • For information on roster billing (billing for many patients at one time) see the Medicare Claims Processing Manual for Preventive and Screening Services (Chapter 18) here (pdf) Section 10-3.

NOTE: Beneficiaries have been advised to contact the Inspector General hotline at 1-800-HHS-TIPS (1-800-447-8477) to file a complaint if they believe their physician or provider charged an unfair amount for a flu vaccine.

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Pandemic Possibilities: Do You Have a Plan for Your Patients and Your Employees?

The HHS and the CDC have developed lots of widgets that you can place on your practice website to give your patients the latest information on the swine flu.  You can get a widget for your practice website from HHS here or from CDC here. These sites also provide podcasts and other resources that you can use to develop your practice protocols and education materials for staff and patients globally for a pandemic illness, or specifically for the A(H1N1) swine influenza illness.

This article will provide resources for three areas:

  1. Protocol for your practice for potential pandemic illness (swine flu or other)
  2. Plan to provide information to your patients about swine flu
  3. Plan for your practice to function during the swine flu or a pandemic illness episode

The good news about the swine flu is that it is a wake-up call for all practices to have a protocol in place going forward.  Most practices have their hands full with Red Flags Rules, Medicare enrollment rules, PQRI, e-Prescribing , etc.but none of this will matter if a practice cannot manage its sick and scared patients, or if there are no staff to run the practice.

The first distinction between protocols should be whether your practice is primary-care based or not.  In almost all cases, a primary care practice will do the heavy lifting for outpatients during an illness outbreak, whether pandemic or not.  The fluWiki says this about a pandemic illness:

Practical definitions of a pandemic vary. “Pan” suggests everywhere, but the World Health Organization (WHO) Level 6 requirement for a pandemic indicates that there are serious outbreaks in communities two or more different WHO regions.

According to the WHO, a pandemic can start when three conditions have been met:

  • Emergence of a disease new to a population.
  • Agents infect humans, causing serious illness.
  • Agents spread easily and sustainably among humans.

A disease or condition is not a pandemic merely because it is widespread or kills many people; it must also be infectious. For instance, cancer is responsible for many deaths but is not considered a pandemic, because the disease is not infectious or contagious.

If you are not a primary care practice, most experts advise not risking the spread of illness by treating patients experiencing symptoms that may or may not be the swine flu.

What follows is an excellent discussion of the question surrounding just how seriously the swine flu should be taken.  It is written by a physician whose blog I read regularly, Dr. Rob:

Is this worth getting panicked about?  Is it worth all the press coverage?

I have to say, I find myself wondering this myself.  But my experience as a doctor teaches me that it is far better to overreact to something than to not take it seriously enough.  If we get all worked-up about the flu and it ends up being something that is not serious, I will be very happy.  The world will be spared a big tragedy.  But if we take this threat lightly and it ends up being a virus as deadly as some previous pandemic viruses, a lot of life will be lost because of our fear of overreaction.

But is the flu worth worrying about?  There haven’t been many deaths due to it so far – at least in the US.  So why should we get worked up about it?  Here is the rationalle for a strong reaction:

  • This is a virus against which nobody is immunized.
  • The fact that it was a pig virus that mutated means that it is significantly different from other flu viruses our bodies have been exposed to in the past.  This is the reason pandemics are so deadly – the body takes longer to build up defenses and fight off the virus because it is basically new to the person.
  • The type of influenza – Influenza A, is a more virulent strain in general than Influenza B.
  • Even if this virus is an “average” or a “mild” influenza virus, the death tolls could still be quite high without aggressive action.  Each year there are over 40,000 deaths in the US attributable to influenza  – and this is in a population that has a significant percentage of immunized people.
  • The H1N1 strain of this virus is the same strain found in the 1918 Spanish flu virus that cause the worst pandemic on record.  20 to 100 million people died of that pandemic – a large proportion of which were younger, more healthy individuals, not the people who typically succumb to flu each year.

No, it doesn’t seem that this virus is as virulant as the 1918 strain, but early indications in Mexico was that the death rate was quite high.  The decision to exercise caution and act as if this would be similar to the Spanish flu virus is wise.  Delay could result in the unnecessary deaths of thousands, even millions of people.

Key Elements of a Pandemic Illness Protocol

  1. Review and reinforce basic infection control guidelines with all staff.  Confirm the importance of Standard and Droplet Precautions when caring for patients with acute, febrile, respiratory illness.  Standard Precautions are basic precautions designed to minimize direct unprotected exposure to potentially infected blood, body fluids or secretions.   Droplet Precautions require healthcare workers to wear a medical mask if working within 3 feet of the patient suspected of having A(H1N1).
  2. Review and reinforce respiratory hygiene and cough etiquette with all staff: cover mouth and nose with a tissue when coughing, discard the used tissue without touching the waste container and perform hand hygiene afterwards. There are great stations that you can purchase that have a poster illustrating cough etiquette and a place for respiratory masks, tissues, a trash can and hand sanitizer.  These stations educate patients and family members while in the practice.  Simple stations can be devised by mounting dispensers on the wall with a relevant poster.
  3. Place hand sanitizer at all workstations and in all patient and staff rooms.
  4. Confirm triage policy.  Answer the question “Do we see patients suspected of having A(H1N1) influenza?”  If no, prepare script for staff to advise patients where to go for care.  If yes, prepare script to consider A(H1N1) swine influenza infection in patients with acute, febrile, respiratory illness who have been in an affected region within the one week prior to symptom onset and/or who have had exposure to an A(H1N1) swine influenza infected patient or animal.  Script should include education on symptoms that necessitate an office visit and those that do not.
  5. Change schedules of physicians and staff as needed to accommodate volume of sick patients.
  6. Place suspected A(H1N1) patients in adequately-ventilated exam rooms.  If one or more rooms can be dedicated just to suspected A(H1N1) patients, containment can be more successful.  Limit the number of staff serving patients in these room.  Dedicate separate equipment to A(H1N1) swine influenza patients. If not possible,
    clean and disinfect equipment before reuse in another patient.
  7. Review and reinforce the use of Standard and Droplet Precautions for specimen collection and for specimen transport to the laboratory.
  8. For patient transport within health-care facilities, suspected or confirmed A(H1N1) swine influenza patients should wear a medical/surgical mask. All patients couging should be offered a medical/surgical mask at the time they enter the practice.
  9. Monitor health of health-care workers exposed to A(H1N1) swine influenza patients.  Antiviral prophylaxis should follow local policy.  Staff with with symptoms should stay at home.
  10. Treat any waste that could be contaminated with A(H1N1) swine influenza virus as infectious clinical waste and dispose of properly.
  11. Clean soiled and/or frequently touched surfaces regularly with a disinfectant. e.g. door handles.
  12. Wash all linen and laundry with routine procedures, water and detergent; avoid shaking linen/laundry during handling before washing. Use non-sterile rubber gloves.

Providing Information to Your Patients During a Pandemic Illness

  1. Provide information on your website about:
    • Information about swine flu symptoms and possible contagion
    • Whether or not your practice will be seeing patients with these symptoms
    • Where patients you cannot see should go for care
    • Information on healthy habits to stay well during the swine flu episode
    • Podcasts, printable information and links to CDC or HHS about the swine flu
    • Information on any changes to your hours, or any any special clinic hours for urgent-care style care
  2. If you use a Message on Hold product, duplicate the information above and point listeners to your website for more information.  If you are adding hours or “no-appointment” clinic to your practice for patients with swine flu, emphasize this information.
  3. Develop patient handouts with information in an easily readable Question & Answer style.  Remember that it is recommended that patient education material be written at an 8th grade level.
  4. If you have a system to mass email your patients, use it to send information to all your patients, pointing them to the resources on your website.

Staff Management During a Pandemic Illness

Now is the ideal time to improve your staffing protocols for being short-staffed.  Staff who are sick should stay home. If staff come to work exhibiting signs of influenza, they should be examined by a practice physician, and advised by that physician whether or not they are approved for work.

Short-staffing will bring into play the cross-training you’ve hopefully already achieved, and reassignment from staff in secondary task positions to primary task positions.  Answer the question “what needs to be done today to make the practice run” which are primary tasks, versus “what can slide for awhile until we get back on our feet?” which are secondary tasks.

Although many physicians reject the idea that employees can be productive at home, an illness episode like the swine flu is the ideal time to have employees work at home.  If you are not in need of employees physically in the clinic, they are well enough to work at home, and you have set up their home computer to VPN into the office server, this is a win/win situation for everyone.

If schools and daycares close duing an illness episode and many staff are unable to come to work due to no childcare, you may need to consider consolidating daycare at the home of one or more employees (fully funded by the practice, of course) or even bringing a temporary daycare onsite if you can turn an area into a safe and comfortable area for children, and assign employees to the daycare.

After the episode is over, you will probably have a number of employees concerned about losing so much time from work.  You may need to review your time-off policy with your physicians and decide if you want to make a single exception due to the length and severity of the episode and grant all staff additional paid time off.  Consider it carefully, however, as any single change has the potential of potentially setting a precedent.  You may want to discuss this with you HR attorney if you are unsure.

Again, make sure your staff have been thoroughly reviewed on Standard Precautions, Droplet Precautions and correct hand hygieneMasks should be available to any staff who request them.

Links for more resources:

CDC Swine Flu Public Service Announcements

CDC Guidance on Specimen Collection for Patients with Suspected Swine Flu

CDC Antiviral Recommendations for Patients with Confirmed or Suspected Swine Flu

CDC Guidance for Infection Control for Care of Patients with Confirmed or Suspected Swine Flu

Pandemic Flu Preparedness Guides for Families, Businesses, Medical Providers, and Community Groups Released by Trust for America’s Health

Knowledgeable, frequently-updated reports and discussion by a collective of public health scientists and practitioners

Sample Q & A for Patients

(Adapted from Thomas E. Gaiter, M.D. and chief medical officer, Community and Family Medicine at Howard University Hospital, online discussion Thursday, April 30. Full articlehere.

Q: Can H1N1 be spread in the swimming pool?

A: Thomas E. Gaiter: At this time, there are no reports that swine flu can be transmitted through the use of swimming pools. It is commonly believed that chlorine is effective in killing the virus. As with any situation in which individuals congregate, all precautions should be adhered to so as to prevent the spread of infection between individuals.

Q: Is it true that instant hand sanitizers offer no protection against catching this virus?

A: Hand hygiene is very important in decreasing the spread of this virus from human-to-human. This includes appropriate handwashing and the use of alcohol-based hand sanitizers which are effective. Hand sanitizers along with other measures of avoidance are recommended.

Q: Do  you recommend avoiding domestic flying at this time?

A: The Center for Disease Control (CDC) has not issued restrictions for domestic travel. However, if you are planning to travel, the following recommendations will help you to reduce your risk of infection: monitor the national international situation, prepare for your trip before you leave by visiting CDC’s website which discusses disease risks and health recommendations, practice healthy habits to help prevent the spread of infection, seek medical care if you feel sick and upon your return, monitor yourself for flu-like symptoms. Contact your physician as necessary.

Q: What immediate steps should a person take who suspects that he/she has contracted the virus?

A: If you suspect that you have been exposed to the virus and you have respiratory or flu-like symptoms, contact your physician who will assess your health condition. Identify your travel history and exposure to individuals who have symptoms of the flu which will assist your physician in making a diagnosis.

Q:  There are still people here at the office coming in with ‘colds.’ We can’t open any windows here — as the building is completely sealed. Doesn’t matter if company policy tells you to STAY HOME if you’re sick…individuals STILL come in to spread the germs around. Not much you can do!

A: I must reiterate that those individuals who may be exhibiting flu-like symptoms should stay home and avoid close contact with others. This will assist in limiting the spread of any virus. It is important from an infectious disease standpoint that contact be limited by individuals manifesting respiratory symptoms until they are cleared by their physician.

Q: I’ve heard that face masks are not useful in preventing the spread of or catching the virus. Is that true? If so, why are people wearing it?

A: Face masks alone are not 100% effective in preventing the spread of infection. However, when used correctly, the mask functions as a barrier to minimizing the transmission of respiratory droplets amongst individuals.

Q: If, in fact, a pandemic occurs, what plans have been made for distribution of available medicines? Will the drugs be distributed only to hospitals, or to pharmacies as well?

A: The Department of Homeland Security has released 25% of its stockpile of Tamiflu and Relenza (antivirals to treat flu)to various states. Tamiflu is available by prescription at pharmacies and hospitals. The Department of Health in the various states and jurisdictions will identify their need and distribute these antivirals appropriately if necessary.

Q: I got a flut shot and a pneumonia shot too. Am I still safe?

A: I applaud your efforts in getting pneumococcal and influenza vaccines. These vaccines however are of little to no effect in fighting this virus. Currently no vaccine is available for swine flu.

Q: If you got the flu, how can you tell if its Swine Flu or just plain old regular flu? Is there a blood test or something?  If you go to the hospital, your waiting rooms are going to be unbelievably busy. What better place to catch it then the emergency room?

A: Some individuals have commented that we are fortunate from the standpoint of being at the end of the seasonal flu period. The signs and symptoms of swine flu are very similar to seasonal flu and only your physician can properly diagnose flu type. The swine flu is diagnosed via swab testing of the throat and nasal cavities. If testing is positive, specimens are generally sent for additional testing to the appropriate health department and/or CDC for confirmation.

Q:: As what point should people stop gathering in large groups? I know of a daily gathering of 435 people, and I am beginning to wonder if maybe we should ask the group to stop meeting for awhile until this threat is over.

A: Currently no recommendation is in place to completely avoid gathering of groups when there is no evidence of illness. Keep in mind that precautions must be adhered to inclusive of hand hygiene efforts. If individuals are ill, they should absolutely avoid large crowds or settings where close contact is required. Some jurisdictions have closed schools and public areas due to suspected cases of swine flu in an effort to minimize or decrease the spread of infection. It is important to continue to monitor the day-to-day developments of this health concern.

Q: How long until this has run its course?

A: The short answer is that we don’t know at this time. Recreational activities such as walking, biking, jogging, etc., still help us to maintain good health. Sunshine is also helpful so continue to enjoy.

Q: A lot of the people coming in with “colds” probably have allergies!

A: The pollen count has been reportedly high in a number of states. Reactions to such may indeed mimic some of the symptoms of the flu. Knowledge of the virus and the specific symptoms such as fever, fatigue, body aches, diarrhea, and vomiting should contrast allergies from flu syndromes.

Q: Why is swine flu different?:

A: Swine flu affects pigs and is not commonly found in humans. It is suspected that a mutation has taken place with this virus. We are therefore seeing infections passed from human-to-human contact. The other difference is that we are able to anticipate the strain of the seasonal flu in which vaccines are available for use. However, there is no vaccine available for swine flu virus (H1N1). The various health departments across the country are extremely concerned because of the ease of transmission. Although there has only been one reported death, as this virus moves across the country, the expectation is that we may begin to see more deaths associated with this virus. As you mentioned, there are thousands of deaths associated with seasonal flu and this is with a vaccine on board, so therefore, without a vaccine, this health concern raises a question as to the expected mortality rate associated with this virus.

Q: . We are roughly a month (or less) from: high school graduations, college graduations, college reunions and June weddings.  What is your take on this? Do you think a lot of these either will or should be canceled by the end of May? Is it just too soon to tell? I was looking forward to a really major college reunion but of course it’s not worth risking lives. What to do?

A: There is currently no CDC recommendation to cancel ceremonies. As always, one should assess the day-to-day situation because frankly, we are unable to indicate with a degree of certainty the duration of this health concern. Individuals who suspect that they are sick should avoid participating in large gatherings to prevent the spread of infection. I wish I could be more definitive, however, this is the information as we know it today.

Q: How long does the virus remain on objects? I’ve been wondering since I got a package from out of state recently. Is it possible for an infected person to cough/sneeze on something, mail it to a friend far away, and leave a trail of infection in his wake?

A: Droplets main remain viable on objects for a period of two or more hours. A package going through the mail system would have little to no viable droplets as you have described.


Q: I can’t help but believe that all this hype about swine flue is way out of proportion to the risk involved. Why is there so much concern about swine flu when many more people are going to die from other causes (traffic accidents, heart desease, AIDS, drug wars) than from swine flue? Do we have our priorities straight?

A: In fact, we are aware from a previous pandemic that millions of people can become infected by viruses. It is prudent to address this health concern quickly to limit the spread nationally. You are correct in stating that other disease entities will in fact contribute to mortality rates in the U.S. with the number one killer being heart disease.

One Physician Recommends Five of the Best Health Information Sites on the Web





When your patients ask what internet sites your doctors recommend for reliable health information, do you have an answer?  Many practices have embedded health information on their websites, or link to sites sponsored by their professional society (American College of Obstetricians and Gynecologists, American Association of Orthopedic Surgeons) or national non-profits (American Cancer Society, American Diabetes Association.)  Here’s a great article written by physician Patricia M. Hale, PhD, MD, listing her “top 5 safe web sites containing the best tools and resources for health-related information.”

Dr. Hale introduces her list and notes that:

” There are many other useful health resources on the web but it is very important to be sure they are run by reputable medical authorities and contain accurate and safe information.”

Her top five are:

  1.  Medline Plus
  2. Mayo Clinic
  3. Center for Disease Control (CDC)
  4. Merck Source
  5. U.S. Dept. of State Tips for Traveling Abroad
Dr. Hale also advises:
One of the best ways you can be further reassured that the web site you are exploring is safe is to look for the Health on The Net Foundation (HON) seal of approval. HON has strict criteria for approval of health related web sites and checks regularly to be sure their rules are followed.


What sites do you recommend and feature on your website?