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Brush up on UTI's
UTI’s or urinary tract infections are one of the most commonly seen problems in my practice. I work in Urology and this is the bread and butter of our field. Most of our patients are referred from someone else for recurrent UTI’s and I would like to brush up on this common presenting problem as we all will encounter these at some point.
Common presenting symptoms range from dysuria, urinary frequency, urgency of urination, low pelvic pain, hematuria and low back pain. Some patients may present with a fever. Elderly patients may have no symptoms at all. In fact, they may present with a change of mental status. Odor to the urine or cloudy urine are not necessarily diagnostic of an infection. Anyone of these patients who present with these symptoms should have a UA done. If there is suggestion of contamination, a catheterized specimen may be necessary. For patients with a chronic indwelling catheter, the specimen should be obtained from the catheter, preferably upon a catheter change versus from the foley bag. In the presence of a UA suggestive of infection, a C&S should always be done. This is especially helpful when you are treating the patient with antibiotics. This will help you treat your patient appropriately. Most commonly patients who don’t get better with a course of antibiotics, is because of improperly treating a patient with the wrong antibiotic. This could have been prevented by checking a culture.
Most uncomplicated UTI’s will resolve with 3-7 days of antibiotics. Complicated UTI’s will require referral to urology. Especially with recurrence. The most common organism seen with uncomplicated UTI’s is E.coli. Other organisms seen are Proteus, Klebsiella, and Enterococcus. Some of these organisms can be associated with kidney stones and if they are seen, an upper tract study should be considered. Cultures positive for multiple organisms suggest contamination and if the patient continues to be symptomatic, a repeat urine should be obtained. If the patient is asymptomatic, follow up UAs are not indicated. Especially if your patient responded to treatment.
To summarize, UTI’s are a common problem amongst our patients. A UA should always be obtained when making the diagnosis and a C&S if indicated. This will help you properly treat your patient. And hopefully have a happy patient!
Submitted by Kim Brown, PA-C
Rules and Regs Update
The PA Practice Bill that was signed into law on May 22, 2009 has been in the process of being translated into regulations over the last 3 years. This has been a long process but NAPA has been informed that the proposed regulations are now moving on to the next step. The proposed regulations have been approved by the Department of Health and Human Service’s legal division. A public hearing has been set for March 21st. The hearing is scheduled for 9:30 AM in the Lower Level Conference Room A of the State Office Building at 301 Centennial Mall South in Lincoln.
Free Online CME through UNMC
Interventions in Type 2 Diabetes and Infections Diseases
This teleheatlh series consistes of 11 seesions that will provide an interactive learning opportunity for health care professionals to engage UNMC faculty in enhancing knowlege, maximizing performance, and improving patient care. Each session is scheduled on a Monday from 12:15-1:15p. Participate in person, at a group viewing site (through Nebraska Statewide Telehealth Network), via video stream, or view the archived video online. Each presentation counts for 1 AMA PRA Category 1 Credit.
Visit their website at http://unmc.edu/cce/outreach to enroll (under online activities).
CSI - A Student's View
As a first year PA student, feeling overwhelmed is just a fact of life. It’s an everyday occurrence that makes you feel like you just can’t keep your head above water. Despite this, UNMC’s implementation of a program called “Clinical Skills Integration (CSI)” has helped to lighten the weight of the didactic year for many students.
CSI is a program that introduces students to the clinical year. On Fridays and occasional Mondays, students can develop and apply history and physical exam As a first year PA student, feeling overwhelmed is just a fact of life. It's an everyday occurrence that makes you feel like you just can't keep your head above water. Despite this, UNMC's implementation of a program called "Clinical Skills Integration (CSI)" has helped to lighten the weight of the didactic year for many students.
CSI is a program that introduces students to the clinical year. On Fridays and occasional Mondays, students can develop and apply history and physical exam skills to patients in a clinical setting. This process allows students to get a feel for how a clinic runs through the use of a supervising PA.
Although I have little experience with CSI thus far, it is easy to see how beneficial it is to developing our ever-growing knowledge base. A huge advantage of the process is the one-on-one supervision from the preceptor. These CSI encounters will continue throughout the duration of our didactic year, in hopes that we will eventually be seeing and treating patients on our own. When we begin clinicals in October, these visits should allow us to feel more comfortable in the presence of our patients.
Among the many positives of this program, one that stands out is the growing network of excellent PAs who are excited to take on students for this endeavor. This truly speaks volumes about their character and willingness to invest time into developing future health care providers. Without a doubt, choosing to pursue a career as a PA was the best decision I've ever made.
Submitted by Ashley Miller, UNMC PA Student
NAPA is looking for volunteers to serve on the following committees:
PPR (Professional and Public Relations)
Dr. Somers Retires from UNMC
Dr. James Somers officially retired as Program Director of the University of Nebraska Medical Center's Physician Assistant Program on April 30, 2012. This ended the twenty-year tenure as Director, although he spent several years at the UNMC PA Program in other capacities. He has overseen the development and national reputation of the UNMC program. During his tenure, the Program has always met or exceeded the national average on PANCE scores. He has touched the lives of every PA graduate from the UNMC Program for nearly 30 years. He was honored by the Nebraska Academy of Physician Assistants and presented with NAPA's Lifetime Achievement Award in April. NAPA and its members wish Dr. Somers all the best during his retirement. For more on this story, visit the July edition of the newsletter found on the website.
PA Week Proclamation Week Signing
Nebraska Governor Dave Heineman recognized October 6-12 as Physician Assistant Week in Nebraska and presented an official proclamation to representatives of the Nebraska Academy of Physician Assistants. A large group of Physician Assistants and PA students gathered at the State Capitol in Lincoln to accept the proclamation. Past President Jodi Chewakin addressed the crowd and thanked the Governor for his support.
Thank you to all the dedicated Physician Assistants across the state for providing excellent care to the citizens of Nebraska.
Patient Centered Medical Home
The Patient Centered Medical Home is becoming the “new normal” for health care. A medical home provides coordinated and integrated care that is patient and family centered, culturally appropriate, committed to quality and safety, cost-effective, affordable and provided by a health care team led by a physician or PA (AAPA).
This new medical care format may have a positive impact on your practice. It should not change the working relationship between you and your supervising physician. It should not change the provider relationship between you and your patients. What it should do is clarify the PA/patient administrative relationship. It will allow for more appropriate reimbursement to your practice and will diversify the patients for your practice.
The Department of Health and Human Services, Division of Medicaid and Long-Term Care(MLTC) made a program change to allow the assignment of enrolled Pas as PCPs. Beginning June, 2012 clients who enroll in a Physical Health Managed Care plan (health plan) will be able to select as their PCP a PA whose specialty is Family Practice, General Practice, Pediatrics, Internal Medicine, and Ob/GYN. PAs must be enrolled as providers in a group practice before they can be selected as the client’s PCP.
Submitted by Jodi Chewakin, NAPA Past President
Certifying? Look at what is new...
New Certification Maintenance Process Beginning in 2014 (10-year Certification Maintenance Cycle and New CME Requirements)
Beginning in 2014, certified physician assistants will transition to a 10-year certification maintenance cycle, a change from the current six-year certification maintenance and retesting requirement that has been in effect since recertification was first introduced in 1981.
That change is accompanied by the institution of new, more specific continuing medical education (CME) requirements: 20 of the 50 Category I CME credits certified PAs are already required to obtain every two years must be earned through self-assessment CME or performance improvement CME (PI-CME).
PAs who earn initial certification or who regain certification by passing an exam in 2014 will begin a 10-year cycle.
PAs whose current six-year certification maintenance cycle (recertification cycle) ends in 2014 will be the first currently certified PAs to move to the new certification maintenance process; those are PAs who must pass PANRE in their fifth year (2013) or their sixth year (2014). They will be able to begin earning and logging CME credits under the new process on May 1, 2014.
Others will transition to the new 10-year cycle over the following five years as they complete their final six-year certification maintenance cycle.
Sign in to your Personal Certification Record for a message regarding the timing of your transition to the new certification maintenance cycle. You can do this on the NCCPA website... www.nccpa.net
These changes are the result of discussions that spanned eight years, as NCCPA leaders worked first to define the set of competencies critical for effective PA practice and then to determine how to effectively integrate appropriate competencies into the certification maintenance process. That effort included multiple discussions with leaders of the American Academy of Physician Assistants (AAPA) and the Physician Assistant Education Association (PAEA), a public comment period during which all certified PAs were invited to respond to potential changes, and a pilot study.
"We know that the majority of medical boards have now implemented similar changes that licensing authorities feel will serve both the public and the medical profession. The NCCPA initiative is consistent with the medical community's movement toward this practice," said AAPA President Robert L. Wooten, PA-C. "I appreciate that NCCPA's leaders have taken their time with these discussions and have sought input from AAPA and others throughout their consideration of changes to the certification maintenance process."
Later this spring, NCCPA will launch a new information-gathering system that will help measure the impact of these changes. Certified PAs will receive more information about the new "PA Professional Profile" in the coming weeks and will be prompted to complete it within the next couple of months to establish the baseline for later impact studies. Then they will be prompted to update it at least once during every two-year CME cycle.
More on Self-Assessment CME
Unlike traditional lecture-learner CME sessions in which the PA is a passive participant, self-assessment CME activities involve a more active process of conducting a systematic review of one's performance, knowledge base or skill set. Most board-certified physicians are now completing this type of activity as part of their own maintenance of certification process, and many of the self-assessment programs offered by their certification boards are also available to PAs. The
- American College of Physicians Medical Knowledge Self-Assessment Program (MKSAP), now in its 15th edition, is one well-established example.
There are also self-assessment activities already offered by PA organizations (like the Society of Dermatology Physician Assistants Distance Learning Initiative), and AAPA is actively working on the identification and development of others.
More on PI- CME
PI-CME is active learning and the application of learning to improve your practice. This can be done in partnership with your supervising physician and others in your practice; everyone can work on and get credit for PI-CME together. PI-CME involves a three-step process:
• Compare some aspect of practice to national benchmarks, performance guidelines or other established evidence-based metric or standard.
• Based on the comparison, develop and implement a plan for improvement in that area.
• Evaluate the impact of the improvement effort by comparing the results of the original comparison with the new results or outcomes.
Like self-assessment activities, many physician organizations are already offering this type of CME. The American Academy of Pediatrics' EQIPP program is one such example. It offers PI-CME on topics including diagnosing and managing asthma, immunization, and differentiating between and managing GER and GERD; EQIPP modules are free to PAs who are members of the American Academy of Pediatrics. The American Academy of Family Physicians' METRIC program includes modules on asthma, chronic obstructive pulmonary disease, coronary artery disease, depression, diabetes, geriatrics, hypertension and immunizations for high-risk adults. PAs can participate in a METRIC module (in partnership with a supervising physician, if desired) and fulfill the 20-credit requirement for just $25.
In anticipation of the approval of these changes to the certification maintenance process, AAPA staff members have been working for months to ensure that more physician self-assessment programs will be available to PAs. They also have agreed to integrate the identification of an activity as self-assessment CME or PI-CME as part of the Category I CME approval process.
AAPA is also working with NCCPA and others to identify viable options for certified PAs who are not practicing clinically.
"Throughout discussions about these new requirements, NCCPA leaders have been very cognizant that our process would need to make appropriate allowances for PAs who aren't practicing clinically," said Mark Christiansen, PhD, PA-C, NCCPA chair elect and director of the University of California – Davis PA Program. "We've discussed a number of approaches to this and appreciate that AAPA agreed to spearhead discussions about the most effective ways to include non-clinicians in the new certification maintenance process."
The outcome of those discussions is expected later this year and will be announced in a future NCCPA News article.
More Specifics on the New Process
The new CME requirements – 20 credits directed toward self-assessment activities or PI-CME – affect the first four CME cycles in every 10-year certification maintenance cycle. During the fifth and final CME cycle, PAs are free to fulfill the 100-credit CME requirement any way they choose, giving PAs preparing for PANRE maximum flexibility.
In addition, to make sure all PAs are benefitting from both self-assessment activities and PI-CME, during every 10-year certification maintenance cycle, PAs must complete at least two of each type of these activities. Certified PAs will finish their current six-year certification maintenance cycle before transitioning to the new process beginning in 2014. (Sign in to your personal certification record at www.nccpa.net to check on your transition timeline.)
Beyond the certification maintenance fee structure changes going into effect with the 2012-2014 CME cycle, no other fee changes are anticipated for the foreseeable future.
Read more in our FAQ section of the NCCPA Web site, and read future NCCPA News messages for additional details as they become available.