What Is Incident-to Billing & Why You Should Avoid It?

Posted on April 30, 2013 by

One of the most challenging issues for NPs comes down to billing for services. After having performed a thorough history and physical, prescribing a culturally competent and evidence-based treatment, proper documentation is essential for the success of a practice.  For NPs billing Medicare, they will receive 85% of the physician payment schedule (there is really no rhyme or reason as to how they arrived at this number). Private insurers vary on their reimbursement rates from 100% to something less.

Using electronic health records (EHRs) has somewhat eased the billing mystery by ensuring that certain documentation is completed and justified before submitting the claim. But before we get into billing, every NP will need to get a National Provider Identifier (NPI). The NPI replaces any and all previous identifiers. The National Provider Identifier initiative was mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and requires that NPIs be used by health plans, health care clearinghouses, and health care providers that process claims, handle claim status inquiries/responses and eligibility inquiries/responses, as well as other transactions. The NPI is a 10-digit number and it is a good idea to memorize this number or keep it handy since it is now often asked for when phoning in a prescription to the pharmacy instead of giving your DEA number. Nurse practitioners can apply for an NPI by going to www.cms.hhs.gov/nationalProvIdentstand

Incident-to Billing

Many NPs working for physicians bill Medicare using “incident-to.” Incident-to billing is only applicable for Medicare and is not recognized with other carriers or even with Medicaid. The implication is that the service is being billed “incident-to” the physician by the NP. One can try to make sense of the Medicare Carrier Manual on Incident-to billing that can be found here though it is certainly not as easy read. In a nutshell, incident-to billing can only be used for office visits and not in institutional settings. Incident-to billing assumes that an established patient has already been physically seen by a physician who established the diagnosis and treatment plan. The NP technically can follow-up with this patient and bill the service as incident-to (which would be 100% of the physician payment schedule), However, if the NP was seeing a patient with an established diagnosis of diabetes and on a  follow-up visit, has a “new” problem such as knee pain, the NP can NOT bill this new diagnosis as incident-to unless the physician physically examined the patient. As far as documentation is concerned, both the physician and the NP would have to write their own substantive notes on the new diagnosis in order to collect 100% otherwise the NP can see the patient with the new diagnosis of knee pain, establish a treatment plan but then bill at 85%

Finally, even for established diagnoses, incident-to billing assumes that the physician is physically present in the office at all times when the NP is seeing the patients – there is very little flexibility in the language with this and something as simple as the physician stepping out of the office for lunch, would preclude the NP billing under incident-to.

What To Do

Obviously, incident-to billing has many stipulations which are not readily understood. I believe that all NPs should be billing using their own NPI numbers regardless of physician presence. Not only is this proper billing, it gives NPs visibility and data collection capabilities that may otherwise have been unnoticed. While this may be difficult to explain to a physician employer who assumes that the NP can bill at 100%, the strict language of incident-to and the possibility of a Medicare audit with fines for any violations should make this easier to understand.

Please be sure to consult with a billing expert if there are any specific questions on this oft confusing topic.

 

 

 

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Prescribing Controlled Substances – What you Need to Know

Posted on February 28, 2013 by

In a widely circulated national news article, the  FDA recently voted to change hydrocodone along with some other controlled substances to the more restrictive Schedule II classification. There was much confusion among nurse practitioners when some of the news articles erroneously reported that this change would prevent all nurse practitioners and physician assistants from prescribing the medication. While there are a few states that do not allow NPs to prescribe schedule II medications, the majority of states do allow the prescribing of this medication. The American Association of Nurse Practitioners is working at the national level to assist those states where NPs would be affected.

One thing to particularly note is the (incorrect) assumption that NPs (and PAs) are somehow responsible for some patients  out of control addictions to opiod  controlled substances. This is simply not true.

Here is a link to the FDAs presentation on the issue.

Did you know? The difference between a Schedule II medication and Schedule III – V**?

(**Please note that  states can set their own standards that can supersede the Federal regulations – the information below is from Federal regulations).

Schedule II

  • Schedule II prescriptions require written prescriptions signed by the prescriber
  • No refills are permitted for Schedule II medications
  • While some states and many insurance carriers limit the quantity of a controlled substance dispensed for a 30-day supply, there are no specific federal limits to quantities of drugs dispensed via prescription.

 Schedule III-V

  • Schedule III – V medications may be communicated either orally, in writing, or by facsimile
  • May be refilled if so authorized on the prescription or by call in
  • Schedule III and IV controlled substances may be refilled if authorized on the prescription. However, the prescription may only be refilled up to five times within six months after the date on which the prescription was issued. After five refills or after six months, whichever occurs first, a new prescription is required.

(adapted from: http://www.deadiversion.usdoj.gov/pubs/manuals/pract/section5.htm)

New York is among a handful of states that is also addressing prescription narcotic abuse. The I-STOP law will go into effect on August 27, 2013. I-STOP stands for Internet System for Tracking Over-Prescribing.

The I-STOP law does the following:

  • requires the Department of Health to establish and maintain an on-line, real-time controlled substance reporting system to track the prescription and dispensing of controlled substances;
  • requires practitioners to review a patient’s controlled substance prescription history on the system prior to prescribing;
  • requires practitioners or their agents to report a prescription for such controlled substances to the system at the time of issuance;
  • requires pharmacists to review the system to confirm the person presenting such a prescription possesses a legitimate prescription prior to dispensing such substance;
  • requires pharmacists or their agents to report dispensation of such prescriptions at the time the drug is dispensed.

We can expect many other states to soon follow suit to address these issues.

It is so important to be familiar with your state’s prescribing laws and I highly encourage you to check with your state’s NP association for the latest information for narcotic prescribing.

 

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What Every Hospital Employee Will Need to Do in 2013

Posted on January 30, 2013 by

If you haven’t had enough of influenza-related news over the last few weeks, for those of you working in the acute care hospital setting, there is more to come.

Beginning the 2012-13 influenza season, the CDCs, National Healthcare Safety Network (NHSN), is requiring all employees, students/volunteers, licensed independent providers, and contractors to answer questions  about their influenza vaccination status. There have been recent news reports of various hospital employees being terminated for refusing influenza vaccine.  While the new NHSN requirement does not mandate the vaccination, it does require hospitals to report their staffs vaccination rates.

Among the criteria that will be asked is as follows:

  • Did the Health Care Worker (HCW) physically work in the building where care is rendered for 30 days or more from the period of October 1, 2012 – March 31, 2013?
    • HCWs refer to all hospital personnel.  
    • If one merely walked through the area where patients are, they would be need to be surveyed. This is regardless of one’s job description, responsibility, or patient contact.
  • Did the HCW receive the 2012-13 Influenza Vaccine?
  • If yes, was the vaccine received on-site at the facility or at another location?
  • When was the vaccine received?
  • Does the HCW have a medical contraindication to the influenza vaccine?
    • For consistency across healthcare facilities, contraindications only include a severe allergy to eggs or a component in the vaccination or history of Guillian-Barré Syndrome within 6 weeks following a previous influenza vaccination.   
    • All other contraindications will be classified as declined to receive the influenza vaccine.
  • Everyone else who did not answer will be considered unknown status. 
  • The data will not be at the individual level but will be reported at the institutional level.
  • The data must be reported by May 15, 2013.

As you can imagine, many hospitals are scrambling now to get everything in order to comply with the new reporting requirements. The task gets very difficult when tracking not just the employees of the hospital, but the expectation is for students/volunteers, and licensed independent providers (i.e. attending physicians, nurse practitioners, physician assistants, etc) to be counted as well. One can imagine the challenges that larger institutions will face given this criteria. Also, if healthcare workers are employed by different institutions, they have to be counted at each institution.

The employee influenza vaccination data will not be made public this year but it widely expected that it will be for the 2013-2014 influenza season. The public will have access to the data and may decide to choose one hospital over the other based on their staff’s vaccination rates. It wouldn’t be surprising at all to eventually see reimbursement rates affected based on the immunization data.

Therefore, those working in hospital settings (or even those walking through them for 30 days or more from October 1st – March 31) can expect to be asked questions on their influenza vaccination status in the foreseeable future. And with that, we can also anticipate increased scrutiny on health care worker immunization rates.

For more information on this topic, be sure to check out the CDCs Influenza Vaccine Summary Protocol.

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It’s National Nurse Practitioner Week 2012!

Posted on November 12, 2012 by

This week, November 11 -17, 2012, represents National Nurse Practitioner Week! The American Academy of Nurse Practitioners selected the theme, “Your Partner in Health..The Nurse Practitioner. ” I believe the idea of partnering with patients is extremely important and is in fact one of the tenets of my philosophy of practice.

Many nurse practitioner organizations/associations have secured proclamations from their governor to celebrate the contributions of nurse practitioners within their own state. There will also be heightened awareness of nurse practitioner partnered care on various media outlets throughout the week – so be sure to be on the look out.

I had the very distinct privilege of meeting and listening to Dr. Loretta Ford speak last month. For those unaware of  Dr. Ford, she is considered to be the “mother of nurse practitioning” – the very first person to create the profession along with Dr. Henry Silver. Dr. Ford has won various national and international awards for her role in the creation of the profession of nurse practitioners and is still going strong, now in her 90′s!

What particularly struck me while listening to Dr. Ford were the struggles she encountered while blazing the trail of a new practice model. She faced opposition from her nurse colleagues, from her physician colleagues and everyone else in between. Yet, she did not let that stop her. Dr. Ford and her were beyond committed to the model and had a vision for the role. Fortunately for any current nurse practitioner or nurse practitioner student, they persevered.

One may now think nurse practitioners enjoy acceptance into their provider roles. By far and large, many do. Yet, there are still barriers to practice that do not allow nurse practitioners to practice at the full extent of our education and training. We can look at the patchwork of various state practice acts and find full nurse practitioner autonomy to supervisory and collaborative requirements with physicians.

Evidence is consistently suggesting that nurse practitioners practice in autonomous roles. A recent health policy brief in Health Affairs, “Nurse Practitioners and Primary Care” does just that.  Nurse practitioner leaders are quick to point out that no provider is truly “independent” and we all rely on trans-disciplinary support in fully caring for our patients.

One particular challenge facing nurse practitioners today and their patients today is the inability to order home care services for home-bound patients. Legislation was introduced called the Home Health Care Planning Improvement Act.

What is the Home Health Care Planning Improvement Act of 2011?

Currently, nurse practitioners are not able to certify Medicare beneficiaries’ eligibility for home health care services despite the fact that physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives are recognized Medicare providers. H.R. 2267/S. 227, the Home Health Care Planning Improvement Act of 2011, as introduced by Representatives Greg Walden and Allyson Schwartz in the House of Representatives and Senators Susan Collins and Kent Conrad in the Senate, recognizes and authorizes nurse practitioners as eligible health care professionals who can certify home health services under Medicare, ensuring that Medicare patients requiring these services receive optimal continuity of care.

This is a prime example of something that doesn’t make sense. Nurse practitioners are recognized providers of health services by Medicare but aren’t recognized when it comes to ordering home health care – care that is largely nursing in nature! (Please contact your legislator and ask for their co-sponsorship and support of this Bill).

It is essential for current and future nurse practitioners to continue providing the high-quality, culturally competent, and evidence-based care that we do everyday. It is also vital to for us to take on the challenges of the profession and contribute positively to our nation’s health care. I’m certain Dr. Ford would like to see it this way!

Enjoy this  short clip of Dr. Ford wishing NPs in New York a Happy Nurse Practitioner Week!

 

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Different States, Different Rules

Posted on September 21, 2012 by

One of the biggest areas of frustration for students, stakeholders, and nurse practitioners are the seemingly lack of consistency among state regulations regarding NP practice. The rules in one state may not necessarily apply in the next (and even neighboring state). I have known NPs that lived near state borders, licensed in both states, yet had completely different sets of rules regarding what they can/can’t do, requirements for collaboration versus autonomy and prescribing ability.

Barton Associates created this free interactive tool that lets you visually compare all 50 states’ (plus DC) NP scope of practice. It is ultra handy and can help one decide whether to practice in one state that is very prohibitive compared to one that offers autonomy.

There is also a push for the APRN Consensus Model whose aim is to have consistency among the states when it comes to regulations.  

If moving out of the state isn’t feasible, well, the alternative is to become involved, active, and supportive of  a national and local  nurse practitioner organization (it is helpful to be supportive whether your state is autonomous or not since there are constant threats to your practice!)

An example of the advocacy that membership affords was evidenced this past week. The American Academy of Family Physicians (AAFP) put out their white paper, “Primary Care for the 21st Century.” I looked forward to reading this report based on the title and hoped that I would find innovation and new ways of enhancing care for our patients based on the primary care model. To my surprise (and dismay), I found myself reading the executive summary and seeing terms like “nurse practitioners are not doctors”   and “the ideal practice ratio of nurse practitioners to physicians is 4:1″ and on. Huh? “How is this a report about primary care?” I thought.

Then I realized that it wasn’t, it was an attack on a profession by another wrapped in a pretty looking monograph with old data. It might as well have been called “Lets Denigrate the NPs Under the Auspices of Solving the Ills of the Health Care System Report.” At least I would have known what to expect.

To be completely honest, I really couldn’t read it beyond the executive summary (I looked at the Table of Comments and further became ill).

Luckily, one of our national NP organizations (the AANP) did read the whole thing (I am unsure if they became ill or not) and responded. Here is one of the benefits of advocacy for nurse practitioners that benefits all nurse practitioners.

All areas of the health care sector must better work together to achieve outcomes that are truly patient-centric. Do reports like the one referenced above help? I am highly doubtful. We have real issues to deal with and turf wars will continue to distract from them.

 

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A Cure for the Common Cold? — Not Quite

Posted on September 12, 2012 by

With back-to-school and the Fall season upon us, the common cold will once again rear it’s ugly head. The search for curing the common cold is an on-going topic in health care. We have heard all sorts of both traditional and homeopathic remedies including some bizarre treatments to various mega-dosing of vitamins and minerals. In recent months, 2 systematic reviews/meta-analyses have been published that examine the studies completed on the mineral, zinc. (As a reminder, a systematic review/meta-analysis is considered the highest level of evidence on the evidence pyramid by using the data from other studies to form an overall conclusion about the intervention in question).

One of the reviews written by Singh and published in the Cochrane Library of Systematic Reviews is entitled Zinc for the Common Cold. Below is a summary of some of the findings (thanks to my colleague Dr. Robert Burke):

  • There is some evidence to suggest that zinc does work and helps reduce the duration and severity of cold symptoms, with an additional reduced incidence of developing a cold, prescription of antibiotics, and school absence.
  • In general, it is recommended to start zinc within 24 hours of cold symptoms.
  • Zinc supplements range from lozenges (zinc gluconate, zinc acetate) or zinc sulphate tablets or syrup.
  • As for the dosing, the syrup was used at 30mg/day (unclear of divided dose equivalent or frequency) and the lozenge dose ranged from 80-190 mg/day in divided doses.  Conservative dosing would be zinc lozenges of 15-23 mg every 2 hours while awake.

Another systematic review/meta-analysis was written by Science et al. and published in CMAJ is entitled,  Zinc for the treatment of the common cold: a systematic review and meta-analysis of randomized controlled trials. Below is a summary of some of the finding from this analysis:

  • Treatment with zinc compared with placebo significantly reduced the duration of cold symptoms (quality of evidence =moderate).
  • Zinc reduced the duration of cold symptoms in adults but not in children.
  • The reduction in the duration of cold symptoms was greater with high doses of ionic zinc than with lower doses.
  • These authors concluded that until larger and better methodological studies are conducted, there is weak rationale for recommending zinc to patients for cold symptoms.

Some additional Zinc facts:

  • As for adverse effects of lozenges, the two most common ones were nausea and bad taste in the mouth.
  • There are several other available zinc preparations
  • Drug-supplement interactions: It is important to separate administration of zinc + quinolone antibiotics (eg, the ‘floxacins) because zinc will affect the absorption of these medicines and the amount of antibiotic absorbed will be reduced.
  • Supplement-supplement interactions: It is important to separate administration of zinc + iron by 2 hours because zinc will affect the absorption of iron and the amount of iron absorbed will be reduced.

Certainly, we don’t have overwhelming evidence to make the case for zinc being the cure for the common cold. My personal experience with zinc has been that it has been effective for me by cutting down the symptom duration when I have used it at the very onset of symptoms (I have used liquid ionic zinc with a dose of 50 mg mixed with a little orange juice). I must warn you that the taste is beyond horrible and you must take it on an empty stomach to lessen the nausea side effects.

Hopefully, this information will help patients and providers make informed decisions by using the best validated evidence (and for those holding important information on new treatment modalities, if the evidence can support it, then it may be worth considering).

 

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Part II: What You Need to Know About 2012-2013 Flu Vaccine

Posted on August 31, 2012 by

In one of my recent posts, I discussed some important facts about the upcoming 2012-2013 influenza season. Today, I’d like to review some of the formulations of influenza vaccine available that is imperative for clinicians to know.

The economic impact of seasonal influenza on the United States economy is staggering. According to Molinari et al., direct medical costs of influenza account for an estimated $10.4 billion dollars, $16.3 billion dollars in loss of projected earnings and a total of $87.1 billion in projected statistical life values. The Centers for Disease Control (CDC) estimates approximately 200,000 people are annually hospitalized from influenza-related complications and about 36,000 people die from influenza-related causes. Therefore, it is essential to try and prevent this very costly and deadly seasonal virus via vaccination.

This flu season, we will widely see new formulations of the vaccine along with the traditional variety. All forms of influenza vaccine are still egg protein-based so severe allergic reactions to eggs are a contraindication to vaccination. **The information below is for informational purposes only. Every effort was used to ensure accuracy though all providers should verify package information prior to administration.** 

All varieties of the 2012-13 trivalent (containing three strains) vaccine has the following strains:

  • an A/California/7/2009 (H1N1)pdm09-like virus;
  • an A/Victoria/361/2011 (H3N2)-like virus;
  • a B/Wisconsin/1/2010-like virus (from the B/Yamagata lineage of viruses).

Inactivated Influenza Vaccine

  • Intradermal Flu Vaccine: First introduced in the 2011-12 flu vaccine season. Available as Fluzone Intradermal, this vaccine is indicated for those 18-64 years of age and uses a needle that is 90% smaller than the traditional needle. The dose is 0.1 mL. One downside is that there are more localized reactions with this method (i.e. redness and swelling at the injection site). I was recently shown how to use this device and it comes fully assembled and ready to use (no need to add a needle) with a built-in safety feature. It takes some practice using it as it differs from a traditional intramuscular injection. Another downside that it costs more than traditional flu vaccine so some insurers may cover it while others may not. This vaccine is latex and preservative free though costs more than traditional vaccine. Here is a short video on the micro-needle delivery system.
  • High-Dose Fluzone: Is indicated for patients 65 years and older. This is a traditional intramuscular vaccine and is both latex and preservative free that has been FDA approved in 2009. The dose is 0.5 mL. This formulation is made with 4 times the antigen content of traditional vaccine and has shown an increased immune response for those individuals receiving it. Therefore, for those older adults with immunocompromised immune systems, this vaccine has shown to provide greater immunity than the standard dose.
  • Pediatric Flu Vaccine: Indicated for children 6 months – 35 months of age. This is also preservative free and the dose is 0.25 mL administered intramuscularly. *Providers should follow the graphic below to determine if children (aged 6 months to 8 years of age) should receive 1 or 2 doses of vaccine (separated by at least 4 weeks apart).
  • Standard Flu Vaccine: Indicated for those 36 months of age and up. The dose is 0.5 mL and administered intramuscularly. The pre-filled syringes are preservative free whereas the multi-dose vial does contain preservative.
An area on frequent confusion is pediatric dosing. The algorithm below was designed by the ACIP as a guide for determining how many doses a child aged 6 months to 8 years should receive.

 

The figure shows influenza vaccine dosing algorithm for aged children 6 months through 8 years in the United States, during the 2012-13 influenza season. Children are recommended to receive 2 doses this season, even if 2 doses of seasonal influ¬enza vaccine were received before the 2010-11 season. This is illustrated in two approaches for determining the number of doses required for children aged 6 months through 8 years, both of which are acceptable.

The figure above shows influenza vaccine dosing algorithm for aged children 6 months through 8 years in the United States, during the 2012-13 influenza season. Children are recommended to receive 2 doses this season, even if 2 doses of seasonal influenza vaccine were received before the 2010-11 season. This is illustrated in two approaches for determining the number of doses required for children aged 6 months through 8 years, both of which are acceptable.

Live Influenza Vaccine

FluMist: is an attenuated live flu virus vaccine that was first approved by the FDA in 2003. FluMist is indicated for patients from 2 years of age to 49 years of age only. This live flu vaccine is administered intranasally (the dose is divided evenly into both nostrils) and is preservative free. Here is a demo of intranasal administration.

FluMist should not be administered to patients with a history of asthma and/or patients who are immunocompromised or those living with immunocomprised household contacts since the virus is live.

One particular note about FluMist is that in a large study of children by Belshe et. al, (2007), FluMist as live vaccine was more effective than traditional inactive vaccine for preventing influenza. One theory that has been postulated is that since the nasal anatomy is smaller in children, the vaccine was better absorbed and thus had a better immune response.

The 2012-13 flu vaccine will have NINE different flu products:

It is vital for providers to become familiar with these options since there are so many and it can be quite confusing. It is actually a great thing for patients needing/wanting the vaccine since there is redundancy with vaccine manufacturers  to help ensure adequate supply (versus 2004 when the manufacturer Chiron, who was supposed to supply half of US supply of flu vaccine had contaminated vaccine causing a severe shortage).  Keeping track of all of them is the real challenge!

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Prescription: Exercise

Posted on August 25, 2012 by

Diet and exercise. Those two words are used so often when prescribing an intervention for patients with chronic health conditions (such as diabetes/obesity, etc) and in the maintenance of wellness. It is important for clinicians to specify and give some parameters to patients regarding the exercise component. It is unrealistic (and unnecessary) to expect patients to join a gym and become a workout freak. However, specific instructions such as a brisk 10 minute walk 2-3 times a day is much more feasible and attainable. In fact, evidence suggests that three 10 minute bursts of exercise is as good for you as a prolonged 30 minute workout.  Oftentimes, these interventions are essentially lifestyle and behavior modifications which take a considerable amount of counseling and guidance – if it were that easy to do, there we be virtually no obesity and obesity-related conditions.

I recently discovered the website and organization, Exercise is Medicine.  Their goal is to help both health care professionals and patients focus on prescribing exercise as routine interventions for the treatment of many conditions. They provide resources for clinicians to help incorporate specific regimens into their plans of care.

So how much physical activity should an adult aged 18-64 years of age get each week? According to the World Health Organization (WHO), it would take 150 minutes of moderate intensity activity each week to get the maximum benefits of exercise. This physical activity (exercise) includes things like: brisk walks, gardening, dancing, household chores and cycling for example. Exercise need not mean joining a gym and feeling intimidated with the whole gym atmosphere. It can merely mean doing activities that you or your patients like to and ensuring that the right amount of intensity is attained.

Take dancing for example. Many people love to dance and it is a wonderful workout. Dance and exercise are the keys to the widely popular Zumba regimen. My institution offers Zumba classes to employees for a deeply discounted rate and many are taking advantage of this fun and lively workout.

I propose that clinicians start prescribing RWE – Recommended Weekly Exercise. Many are familiar with the Recommended Dietary Allowance (RDA) when it comes to nutrition. (Though it is oftentimes incorrectly referred to as Recommended Daily Allowance). The RDAs are found on virtually all food and supplement labels. The RWE can be used by clinicians and patients as a tangible guideline when it comes to prescribing exercise. If one stops exercising after a steady regimen, the health effects start to fade away – just as it would be if someone chose to stop consuming healthy and nutritious foods.

Are the importance of these interventions easy to incorporate into a 15 minute typical office visit? No, but it will take repeated counseling and coaching to encourage our patients to make behavioral changes to improve health outcomes. That’s a prescription that is easy to write.

** Conference Opportunity **

Check out the Sixth Annual Southern Gulf Coast Nurse Practitioner Educational Conference in Fort Myers, Florida on September 28th & 29th, 2012. It looks like a great agenda put together by my new NP friends in Florida!

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What You Need to Know About the 2012-13 Flu Season: This Little Piggy

Posted on August 17, 2012 by

Within the next few weeks we can expect our first allotment of influenza vaccine to arrive in our offices (if it hasn’t arrived already). Yes, flu vaccination season is upon us.

It is no time to be complacent after an unusually and extremely quiet 2012 flu season. In fact, the CDC is monitoring several recent variant swine strains of Influenza variant known as H3N2v. As of this August 2012, there have been about 154 cases of this variant identified (see CDC Table below).

Table. Case Count: Detected U.S. Human Infections with H3N2v by State since August 2011

States Reporting H3N2v Cases Cases in
2011		 Cases in
2012
Hawaii 1
Indiana 2 120
Illinois 1
Iowa 3
Maine 2
Ohio 31
Pennsylvania 3
Utah 1*
West Virginia 2
Total 12 154

The 2012-2013 is a trivalent (containing three strains) vaccine. The strains contained within the vaccine were determined this past February 2012 by the World Health Organization and include:

  • an A/California/7/2009 (H1N1)pdm09-like virus;
  • an A/Victoria/361/2011 (H3N2)-like virus;
  • a B/Wisconsin/1/2010-like virus (from the B/Yamagata lineage of viruses).

According to the CDC, “…while the H1N1 virus used to make the 2012-2013 flu vaccine is the same virus that was included in the 2011-2012 vaccine, the recommended influenza H3N2 and B vaccine viruses are different from those in the 2011-2012 influenza vaccine for the Northern Hemisphere.” 

A constant area of confusion within the healthcare community is when should people receive the vaccine. The CDC addressed this in their last FAQ:

CDC recommends that influenza vaccination begin as soon as vaccine becomes available in the community and continue throughout the flu season. It takes about two weeks after vaccination for antibodies to develop in the body and provide protection against influenza, and influenza seasons can begin as early as October. Therefore, CDC recommends that vaccination begin as soon as vaccine becomes available to ensure that as many people as possible are protected before flu season begins.

The CDC has also offered guidance to those planning fairs with live animals and has wonderful free health care provider resources available.

Interestingly, this year the FDA approved the first quadrivalent flu vaccine which will include 2 strains of Influenza A and 2 strains of Influenza B. However, this won’t be available until the next flu season in 2013-2014. The vaccine will be in the form of the FluMist nasal vaccine, which will still be available this year as the trivalent vaccine with the above identified strains.

Both the CDC and WHO have robust reporting and surveillance data dedicated to influenza and should be regular web destinations for clinicians this flu season. Also check out the CDC’s Influenza Twitter feed @CDCFlu for pertinent updates. Finally, a cool tool is Google’s Flu Trends which has been shown to correlate with influenza activity based on people’s search inquiries based upon their location.

Of course, every influenza season is unpredictable. Prevention and preparation at all levels of public health are paramount to minimize the deadly complications from this respiratory virus. There should be adequate supplies of flu vaccine to go around this year, unlike the shortage of 2004. Clinicians and public health providers must be prepared for worst while stressing primary prevention strategies including vaccination.

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3 Essential Tips for NP/DNP Students

Posted on August 15, 2012 by

Where has the time gone? We find ourselves in the middle of August as the summer is quickly winding down where thousands of nurse practitioner students will either start or return to their coursework in addition to existing nurse practitioners returning for their doctorate degrees in either nursing practice (DNP), education, (EdD), or philosophy (PhD).  Today, I offer some tips on preparation for returning to school.

1. Books – Let’s face the fact that textbooks are expensive. I would always try to find a used “very good” version to purchase (with Amazon being my go to source.)  I would never purchase a book that had sections already highlighted or answers circled in already. Therefore, it is wise to pay attention to the seller’s description of the book. I’m still not totally comfortable with e-textbooks on an e-reader device because I like to either make notes or highlight sections. These are possible on the e-versions but for me, the retention of material is best from traditional textbooks. Plus, the e-versions are usually very similar price-wise to the traditional version and I felt if I’m going to spend the money, I might as well get the “real” thing. The used inventory is always changing so be sure to check early and often.

2. Schedule – There are many formats for higher education today including on-line, traditional in-person, and blended formats of the two. I cannot stress how important it is to stick to a schedule of completing coursework – especially when the work is asynchronous. Many people chose to also work while returning for their Master’s and Doctorate degrees (maybe it’s not so much a choice, but necessary!) A well-thought out and planned schedule is essential.

3. On-line Posting – The biggest learning curve for me was with our required DNP weekly on-line postings in the blended format. When I first thought “post,” I figured 150-200 words of my beliefs on a topic. Boy was I wrong! The posts were essentially mini-research papers. The posts needed to be scholarly and include references. Reflecting back on this now, it makes complete sense for both masters and doctoral programs to require this amount of work. These posts are graded and oftentimes make up a significant portion of your grade.

Another consideration is that everyone doesn’t post at the same time. There will be students posting early and there will be last minute posters and then everything else in between. A requirement of many online courses is to respond to 2 or 3 or your classmates postings. Again, the responses need to be scholarly and referenced, where appropriate. You can not simply post something like, “I agree with you” or “great post!” That doesn’t cut it at this level. While no one wants to cause trouble and trash someone else’s post, a unbiased and evidence-based approach is usually the best way to go. Again, posting early and often should be your goal. It gets you into a good routine of reading one another’s posts and responding meaningfully.

* Bonus Tip: This is from my colleague @NurseSallie on Twitter: Keep up with the required readings. A great tip since there is a lot of reading and it’s very easy to fall behind.

I wish you much luck and success in the upcoming semester!

 

 

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