CMDA



January 7, 2020 CMDA Monthly Meeting Noon – 1:30 PM Colorado Department of Public Health and Environment, Building A, Sabin-Cleere Room 4300 Cherry Creek S. Dr. Denver, CO 80246Minutes1. Introductions. Present in person: Eric Wood, Pharm D; Deanna Curry; Ann Kokish; Jodie Walker; Roderic Gottula MD; Jo Tansey, Sheldon Goldberg, MD; Courtney Ruan; Travis Neill, PA-C; Greg Gahm, MD; Stanley Kerstein, MD; Alexander Jacobs, MD; Sing Palat, MD; Leslie Eber, MD2. CDPHE update: Jo Tansey. Gearing up for spring! Doing a few less recertification surveys but still meeting requirements. Some routine surveys happening later because of investigating FRI (Facility Reported Incidents, or occurrence investigations). No new announcements about FRI from CMS, no new guidances on how to survey. May see investigations broken into 3-4 surveys per reinforcement cycle rather than all at once. Kokish: will this affect the Red Hand? Tansey: Certain citations will result in a Red Hand flag. Eber: Will even unsubstantiated allegations require a survey? Tansey: Yes. Eber: Will FRI change the annual survey? Tansey: No. This is a new process for occurrence reports and survey. Surveyors are still learning. One of the things we are asking facilities to do: get your plan of corrections in place. It may shorten the enforcement period and eliminate the need for a surveyor to re-visit. 2.5. CHCA update: Ann Kokish.- Next meeting will tear apart the requirements described above. How to avoid a re-visit. Meeting is next Tuesday. Gearing up for CMDA conference, getting Vendor information. If you let Ann Kokish know, she can reach out to potential vendors. 3. Management of osteomyelitis. Clayton Foster, MD - PPX slides in attachment in this email- Airborne ID - Telemedicine consult service since Sept 2019. Does consults at PAM Specialty Hospital in Denver.- History of osteomyelitis. In pre-antibiotic era, people died of secondary amyloidosis related to chronic osteomyelitis. Acute vs. Chronic definitions. “subacute” not clear clinically. - Bacteria, mycobacteria, fungi, and viruses can cause OM.- Positive bone culture is gold standard, but negative biopsy does not rule out osteomyelitis. MRI is most sensitive imaging modality for OM. “Exposed bone is infected bone” ie. if probe to bone, sinus tract. Suspect OM in non-healing wounds, especially if diabetic foot wound over 2 sq cm. Don’t overly rely on the other, non-specific symptoms (fever, drainage). Inflammatory markers tend to trend with acute OM, with exception of procalcitonin. (Procalcitonin best used for pneumonia). - Slide for Examples of when to be suspicious of OM that are often missed clinically. - Start treatment with surgical debridement to remove hardware and necrotic bone. Open surgical biopsy better than needle biopsy. - Treat to normalization of CRP and wound closure. Watch the trend, or a plateau. - If no sepsis or overt wound infection, hold off on antibiotics until cultures can be obtained.- Chronic OM - no difference in outcomes between IV and oral antibiotics. It is still common practice to start treating Gm positive organisms w/ IV antibiotics for first few weeks. Pick antibiotics with adequate bone penetration. Neill: What if you can’t get a bone culture? Foster: Better to have sub-optimal culture than no culture, if proper surgical bone culture is not available. Sometimes will culture wounds.- Adjunctive treatment. Rifampin is not for monotherapy. Hyperbaric O2: limited data. Local antibiotic delivery (PMMA beads impregnated with antimicrobials) used by surgeons with little standardization, can cause systemic toxicity- Hardware: Big problem is formation of biofilm. Leads to use of prolonged antibiotics, ie 3 months. For longer duration antibiotics, duration must be individualized. - Worry when wounds/ fractures won’t heal, or if CRP won’t normalize or increases. - Dr Foster answered questions from the audience.4 . Monitoring opioid use in residents in chronic, non-malignant pain – Eric Woods PharmD- Important to track morphine milli-equivalance MME. Closely monitor anyone above 50 MME/ day. This is the maximum the CDC recommends- Pharmacy usually has program that automatically converts to MME. Omnicare is now providing monthly list to medical directors. - Kerstein: Use the CDC Opioid Calculator, easy to use. - Gahm: Don’t have to monitor the following people: on hospice, metastatic cancer, or seeing a pain specialist. Otherwise, must have an explicit plan to reduce the MME to below 50. Monitor for worsening pain with high doses of opiates. - Wood: Consider also monitoring hospice patients on high MME. - Goldberg: Sometimes bone mets don’t respond well to high dose opiates. - Eber: Some providers have lost their licenses for prescribing high dose opiates without a plan to address or taper- Gahm: Family can sue you for not having a plan. 6. Flu Update: Greg Gahm MD- CDC thinks this will be the worst year ever. New strains of flu not covered by vaccine. 2100 pediatric deaths in the US this year already. Usually 2 week lag between peak in community to nursing homes. - Start early. Right now, make sure everyone is vaccinated. Anybody who is coughing – stop them at the front door. Bring patient out to the family by the door rather than letting sick family member visit. - If high fever, non-prod cough, assume it is flu. Get the Tamiflu first! Check the rapid test if index case. If you have known flu in the building, don’t swab. - Eber: can’t you have flu without fever? Gahm: yes. The time you’re most infectious is the 24 hr before the onset of symptoms. - Goldberg: What about the new meds? (baloxavir?) Gahm: expensive. New. - Foster: watch for GI symptoms as signs of influenza too. especiall Influenza B5. AMDA delegates – opportunity to be part of national meeting. Anyone interested should contact Dr. Eber. ................
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