Most medical practices have policies about no-show patients, but does your practice have a clear protocol for patients who show up late to appointments? How about the chronically late patients for whom tardiness has come to be expected?
A tardy patient can easily derail a practice’s whole schedule. Especially in small practices where there is less coverage, one late patient can affect the amount of time all patients receive that day. Do you accommodate the patient? Turn him away? What are the effects of either option?
There can be major liability issues with refusing to see a late patient outright. “It can be downright unethical,” states Torrieri. It is recommended to discuss this with your malpractice carrier. Unfortunately, if a medical emergency were to occur as your late patient is asked to leave your office, you can be held responsible.
The right thing to do is try to accommodate the patient. First, be sure that your practice is running on time before penalizing a patient for being late. "If you're five minutes late, everyone is five minutes late," cites the article. If another clinician is available, fit the patient into her schedule instead. If there is no available coverage, let the patient know the approximate length of time until he can be seen.
For chronic lateness, you may decide to dismiss the patient from your care if the behavior is addressed and does not change. Here is an example from the article on an escalating tardiness policy:
At Performance Pediatrics in Plymouth, Mass., late patients — those who are more than five minutes late — are treated the same as no-show patients. On the first and second offenses, they're sent a warning letter. On the third offense, they're told they will be dismissed if the problem continues. And on the fourth offense, they are asked to find another provider.
IM Boards start on August 6, 2013. Have you done everything you can to prepare?
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2013 American Academy of Otolaryngology - Head and Neck Surgery Annual Meeting
What should your patients know about anaphylaxis?
Anaphylaxis is the rapid onset of a severe and potentially lethal allergic reaction. Unpredictable in nature, the key identifiers for this condition are variable. While most people who experience an anaphylactic reaction have a pre-existing and known allergy to a trigger substance, a smaller fraction of those afflicted are not even aware that they have an allergy. Although the lifetime prevalence is estimated at 0.05-2%, the rate of occurrence is on the rise and even the first episode of anaphylaxis can result in fatality.
Symptom onset commonly occurs within 2 minutes to 1 hour of exposure to a specific trigger.
It is uncommon, but it is possible that symptoms do not develop for several hours.
80- 90% of anaphylactic reactions include hives (urticarial) and swelling of the skin (angioedema).
Approximately 70% of reactions cause respiratory symptoms, which are more common in individuals with chronic respiratory diseases.
Severe anaphylaxis causes sudden collapse without other symptoms; this form occurs most commonly after a person is given a medication intravenously or is stung by an insect.
EYES: Tearing, redness, itching and swelling
SKIN: Flushing, hives (urticaria), or swelling (angioedema)
HEART: Weakness, dizziness, fainting, rapid or irregular heartbeat, and low blood pressure
NERVOUS SYSTEM: Confusion and anxiety
DIGESTIVE SYSTEM: Vomiting, abdominal cramps, nausea and diarrhea
NOSE & MOUTH: Runny nose, sneezing, nasal congestion, swelling of the tongue and metallic taste
LUNG & THROAT: Difficulty breathing, excessive coughing, chest tightness, wheezing or other sounds of labored breathing, increased mucus production, throat swelling or itching, hoarseness, change in voice and choking sensation
Who is at risk?
Some people are more likely than others to experience anaphylaxis, for example, those who have one or more of the following:
Previously experienced a sudden severe allergic reaction involving the whole body
Those diagnosed with asthma
Those with other types of diagnoses
People with chronic lung disease, especially older adults with chronic obstructive pulmonary disease (COPD) or emphysema, are at increased risk of complications during an anaphylactic reaction. People with coronary artery disease and other heart diseases are also at greater risk of developing complications.
How to prevent/treat?
If patient has had an anaphylactic reaction or has suspected triggers:
See an allergist for evaluation and for specific training and diagnosis.
Seek out testing to determine the trigger; an allergist should perform skin testing at least 3-4 weeks after an anaphylactic reaction b because if done too soon after the event, such tests may give false negative results.
Avoid triggers! When a trigger has been identified, the individual should be urged to stay away from the substance.
Always wear medical identification and carry epinephrine!
During an anaphylactic episode:
Call for emergency help immediately. Episodes are often times life-threatening-- it should be treated as a medical emergency.
Treat the person with epinephrine, those with a history of anaphylaxis should always carry an injector.
Place the person on their back or in a semi–reclining position with the lower extremities raised
During the episode, if needed, give high flow supplemental oxygen, establish intravenous access to provide high volume fluids, and perform cardiopulmonary resuscitation.
Go to the hospital, after injecting epinephrine; it is important to be evaluated in a hospital emergency department. There is no reliableway to predict whether or not a late-phase reaction will occur, but up to 20% of people with anaphylaxis have a late-phase reaction and might require additional treatment.
All HCPs are encouraged to talk with their patients who have a history of these types of reactions to develop an Anaphylaxis Action Plan. Many people find having a treatment plan to respond to future reactions reassuring.
Are you killing yourself? Think Before You Indulge...
We’ve all heard it before- just one cigarette can shave 3 minutes off your life. Well, what if this formula could be applied to all of your guilty pleasures? A study published by the British Medical Journal has linked life expectancy to activities such as having a couple of drinks and even watching TV; activities that to most Americans come as second nature. Did the beers you consumed during Sunday’s Super Bowl shorten your lifespan?
University of Cambridge statistician Professor David Spiegelhalter sought to find a way to communicate the impact of human behavior on our lifespan in a simple and effective formula. In this analysis, Spiegelhalter further expands on the concept of aging slower/ faster, first introduced through the study of cigarettes on life expectancy more than a decade ago. He explicitly expresses the effect of our daily lifestyle habits as half hours of life expectancy or “microlives.” Through the use of population studies he was able to deduce that on average over a lifetime habit of behavior, that smoking two cigarettes or being 10 pounds overweight, or even watching two hours of TV, equates to the loss of a “microlife.” The idea that watching the Ravens win the Super Bowl could have cost you thirty minutes of your life is alarming to most, considering the inherent concern most humans have with their own mortality.
However, Spiegelhalter’s “microlife” formula isn’t just a penalty system for life’s indulgences. In contrast, Spiegelhalter says, each day of positive behavior such as exercising or sticking to just one alcoholic beverage will help you gain “microlives” at an even faster rate. He cites that this positive behavior can add up to two hours to your life.
But before you start tracking your behavior and counting “microlives” as if they were calories, read Spiegelhalter’s entire explanation of the concept. He explains that this formula for life expectancy is not definitive but based on a number of assumptions, and should be treated as an approximation. The crux of his article supports the old adage, “Everything in moderation.”
In Spiegelhalter’s words: "Of course, evaluation studies would be needed to quantify any effect on behavior, but one does not need a study to conclude that people do not generally like the idea of getting older faster."