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Tough Negotiations Avert B.C. Hospitalist AN OFFICIAL PUBLICATION OF THE SOCIETY OF HOSPITAL MEDICINE Volume 10 Number 8 August 2006 Features PALLIATIVE CARE/END OF LIFE Pantilat Receives Endowed Chair . .14 A first for hospital medicine Uncertain Prognosis . .32 Considerations for high-risk patients at end of life CMS proposes double-digit increases for work RVUs for services performed by hospitalists Hospice Heart . .40 A hospitalist fulfills her dream: n June the Centers for Medicare and Medicaid Services (CMS) issued a notice directing an inpatient hospice unit proposing changes to the Medicare Physician Fee Schedule (MPFS) that, if en- Iacted, would significantly increase Medicare payments to hospitalists for many CLINICAL services routinely performed. Because many private health plans use the Medicare- approved RVUs for their own fee schedules, it is anticipated that hospitalists will The Yuk Factor . .16 likely see payment increases for their non-Medicare services as well. Maggot debridement therapy The changes, which will take effect in January 2007 if enacted, reflect the rec- makes a comeback ommendations of the Relative Value Update Committee (RUC) of the American Medical Association, along with input from SHM. At this point, however, they are To Tube or Not to Tube? . .24 only proposed changes that CMS could modify based on input from affected groups Implications of PEG tube use in SHM encourages and Congress. SHM will continue to urge CMS to implement the proposed changes hospitalized older adults hospitalists and others and we encourage all hospitalists and other interested individuals to send a letter to to send a letter to CMS indicating support for the proposed changes. (See “How to Show Your Sup- CMS indicating OPERATIONAL support for the port,” p. 15.) CMS is accepting comments on the rule until August 21, with the COLOR DAY PRODUCTION/GETTYIMAGES COLOR DAY proposed changes. final ruling expected in November. Team Rapid . .22 Up close with an L.A. hospital’s rapid response team Tough Negotiations While Residents Rest . .42 Hospitalists fill in as residents’ duty Avert B.C. hours are reduced Hospitalist RESEARCH Take Research Initiative . .28 ❚❘ By Gretchen Henkel Avenues to increase hospital Walkout medicine research wo weeks of intense talks between hospitalists and government offi- Tcials resulted in an 11th-hour compromise on June 29th in British Co- Columns & Departments PAID lumbia, one day before hospitalists’ contracts were set to expire. Through- Prsrt Std Permit # 7 U.S. Postage Letters . 3 Easton,PA 18042 Easton,PA out the month of June, the B.C. hospitalists had threatened to move back to community practice if the Ministry of Health (MOH) did not offer a SHM Point of View . 4 contract that recognized the value of their work. The hospitalists con- tended that low payment schedules and staffing levels were seriously un- ✸New Department! dermining staff retention and recruiting—as well as patient safety. Dur- CDC Situation Room . 5 ing the dispute, MOH officials had been equally adamant about their position. The province’s Minister of Health, George Abbott, said that the Society Pages: SHM News . 6 salaries were fair, and that the government would not be “held for ransom Career Development . 9 on this issue.” Hospitalists believed that failure to reach agreement would have left What’s Your Diagnosis? . 10 many hospitals scrambling to provide coverage for hospitalized patients. Flashback . 21 Wayne DeMott, MD, is a hospitalist at Royal Jubilee Hospital in Victoria, B.C., and chief negotiator for the British Columbia Medical As- Classified Connection . 49 sociation’s Section of Hospitalist Medicine. CONTINUED ON PAGE 11 Progress Notes . 74 The Hospitalist John Wiley & Sons 111 River Street Hoboken, NJ 07030 Society of Hospital Medicine Maggot debridement therapy: the ancient treatment for chronic wounds makes a comeback ❚❘ By Pascal Steenvoorde, MD, MSc, Louk van Doorn, MSc, Cathrien E. Jacobi, PhD, and Jacques Oskam, MD, PhD espite modern wound treatment and sociated with rotting and decay. The image Dbroad-spectrum antibiotic treatment, is of filthy, low-life creatures that are ugly patients with chronic wounds still exist. and disgusting. Although a nice recent ex- The appearance of antibiotic resistant bac- ample for the general public is the scene in teria, such as methicillin-resistant Staphy- the movie Gladiator. The main character lococcus aureus (MRSA) in the 1980s and (played by Russell Crow) is advised to leave ’90s, gave rise to a search for other reme- the maggots that spontaneously infested a dies. One of the remedies that has been re- wound on his shoulder in place so that the discovered and subsequently successfully wound would heal. He leaves them in place reintroduced is maggot debridement ther- and the wound heals without any problem, apy (MDT).1 The fact that more than 100 enabling Crow’s character to fight many articles were published on the subject in the battles. MAGGOT DEBRIDEMENT THERAPY DEBRIDEMENT MAGGOT past two decades indicates that the use of In contrast, in an oral presentation we maggots is making a strong comeback in held recently at a Dutch scientific surgical medicine.2 In January 2004, the U.S. Food meeting, a surgical professor in the audience and Drug Administration (FDA) issued said, “I will never allow those creatures in 510(k)#33391, allowing production and my ward.”8 This remark shows that wide- marketing of maggots as a medical device. spread use and acceptance of MDT has not In this article, we discuss the use of MDT Figure 1: This patient had a malignant tumor of the yet been reached. It seems there is still much in patients with a chronic wound. leg removed and underwent post-operative radio- work to do before MDT is generally ac- therapy. The wound contains necrosis and slough. An earlier sharp debridement and split skin graft cepted as a therapeutic method. A LONG HISTORY OF MAGGOT produced no effect. Fortunately, the negative image that THERAPY seems to exist among nurses and physicians MDT has been used in many cultures and does not seem to bother patients.9 We have has been known for centuries.3 Ambroise treated more than 100 patients in our clin- Parè is credited as the father of modern ic with MDT. All patients to whom we pro- MDT. Unfortunately, no evidence can be posed MDT agreed to the therapy. All were found of Parè using maggots as a means to allowed to discontinue the therapy whenev- clean or heal wounds. The only reference er they wanted; none did. In a survey of the is the often-cited case that occurred in first 38 MDT-treated patients, 89% agreed 1557 at the battle of St. Quentin, when to another session of MDT if the surgeon Parè observed soldiers whose wounds were believed it would be beneficial, and 94% of covered by maggots. He mainly described the patients said that they would recom- the negative effects of the maggots, and, mend it to others. This is despite the fact above all, believed they were spontaneous- that the therapy was not successful in all pa- ly produced by the wound itself, not by the tients (there was a below-knee of above the eggs of fly.4 knee amputation-rate of 19% among pa- Baron Larey (1766-1842) a famous tients who underwent MDT).10 surgeon in the army of Napoleon Bona- parte, wrote about soldiers who had larvae- INDICATIONS AND EVIDENCE infested wounds, but was frustrated that it Indications and contra-indications for mag- was difficult to persuade his patients to Figure 2: The full-grown maggots are removed got therapy are not well defined. Some state leave the maggots in place, believing that after three days of treatment. There is no necrosis that all kind of wounds that contain necro- “they promoted healing without leaving left. The wound was treated with four applications sis or slough can be good candidates for any damage.”5 with a total of 145 maggots. The wound was subse- MDT. In our own study of 101 patients The first surgeon to use MDT in pa- quently treated with vacuum-assisted closure therapy with 116 wounds treated with maggots, we and secondarily closed. tients in the hospital was the orthopedic had an overall success rate of 67%. (Seven- surgeon William Baer. In the 1920s he was ty-eight out of 116 wounds had a beneficial faced with a group of untreatable patients outcome.) However, in 13 patients with with severe osteomyelitis (antibiotics had septic arthritis, all wounds failed. Success not yet been discovered). He successfully rates where significantly reduced in cases of treated many patients with maggots, and chronic limb ischemia, visible tendon or because of his success the therapy became bone, and in cases of duration longer than regularly used in the United States.6 three months before the start of MDT.11 By 1934 more than 1,000 surgeons Most physicians who start MDT use it were using maggot therapy. Surgical Mag- mainly for worst-case scenarios. From our gots were available commercially from Led- previous studies, it is clear that success rates erle Corporation.7 But with the introduc- in those patients are low. After witnessing a tion of antibiotics in the 1940s, the use of few failures, the physician is naturally reluc- maggots dropped off. In the following tant to use it again. years, case reports were published only oc- What about evidence? Large random- casionally. ized studies are lacking, although one con- taining 600 venous ulcer patients was initi- THE NEGATIVE IMAGE OF MAGGOTS Figure 3: A patient with a necrotizing fasciitis of the ated in 2004.12 There have been three A large problem of MDT is the difficulty left upper leg is treated with the contained technique.
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