SERUM MYOGLOBIN AS A MARKER FOR ACUTE MYOCARDIAL INFARCTION

Acute myocardial infarction (AMI) is one of the major causes of death in the United States. Every year approximately 4 million people are admitted to hospitals for evaluation of AMI. Of those, 1.3 million are diagnosed. The World Health Organization identifies three indicators for the diagnosis of AMI: clinical history, ECG changes and temporal changes in cardiac markers. Diagnosis is based on the presence of two of the three indicators. The ideal marker would: be found in high concentrations in the heart; not be found in other tissues; have a low molecular weight; and remain elevated for several hours after damage. No one marker is ideal. Currently a panel including CK-MB, Troponin I and myoglobin appears to be the best approach.

Myoglobin is an oxygen carrying protein present in skeletal and cardiac muscle. It may be found in the blood prior to other markers of ischemic injury. Myoglobin’s low molecular weight causes it to be released into the peripheral circulation earlier than other markers. Myoglobin levels begin to rise within 2 hours of cardiac injury. Levels peak 8-12 hours after injury and return to normal in 24-36 hours. Myoglobin can detect cardiac cell damage 2-10 hours sooner than ECG, Troponin and CK-MB in approximately 50% of patients. Doubling of myoglobin over 2 hours has a positive predictive value of >90%. In patients with AMI myoglobin levels could rise approximately 10 times above the normal range. Myoglobin in ideal marker would: be found in high concentrations in the heart; not be found in other tissues; have a low molecular weight; and remain elevated for several hours after damage. No one marker is ideal. Kidney function tests can detect the presence or absence of kidney disease.

CLIENT SERVICES STARS

Sandi Johnson

Sandi has been employed by Avera Queen of Peace for 10 years as a Medical Lab

Technologist. She received her Associate degree for MLT from Dakota Wesleyn University in Mitchell.

Sandi and her husband, Monty, have three children, Angie, 20; Jacob, 11; Danielle, 9,

and one grandchild, Kylie, 7 months.

Sandi’s hobbies include reading, gardening and sporting activities.

Sandi’s favorite aspect of her job is getting to know the new people she visits with on the phone.

FROM THE EDITOR...

How quickly the seasons change, and we find ourselves bundling up and preparing for the inevitable “white stuff” that will soon fly. How quickly summer vacations come to a close and we are back to the normal hustle and bustle of daily life. Work is busy, home is busy, and life in general is busy. Take a break. Relax and spend a few minutes reading this issue. There is bound to be something in here to be of interest to you.

We apologize for not getting the article on Needle Safety devices into this issue. That article will be in our next newsletter. Also in the next issue, an article on transporting hazardous materials, and an update on Influenza, along with other features and current issues.

Enjoy the colors and wonder of autumn!

Lori Murray

DIAGNOSIS CODE REFERENCE ALERT FOR MEDICARE PART B

The August 2000 issue of the Medicare B News highlights a billing requirement taking effect on October 1, 2000. For each CPT code (each test ordered) a single primary diagnosis code documenting the reason for testing must be submitted on the HCFA 1500 form. Only one diagnosis code may be linked to each CPT. Any claims not in compliance with this will be denied.

For clients of reference laboratories that bill Medicare B, ordering physicians and/or authorized individuals must document in the patient record the primary diagnosis for a specific test being ordered. This applies to the states of Alaska, Arizona, Colorado, Hawaii, Iowa, Nevada, North Dakota, Oregon, South Dakota, Washington and Wyoming.

“Have Lab Will Travel!”

Saturday, August 5, 2000, is a day no one at Avera Queen of Peace or in the town of Mitchell will soon forget! About 2:00 a.m. two converging storms met over Mitchell causing a “microburst” that produced winds exceeding 120 mph and 5-6 inches of rain in less than one hour. Many homes and businesses in Mitchell were severely damaged or lost due to wind damage. Although the hospital did not sustain any wind damage, the leaves and branches blown off trees in the area plugged storm drains, preventing the

excessive rainfall from draining away from the building in a timely manner. The knee-deep water poured into the hospital through many doors, flooding the entire ground floor and subsequently draining down to the lower level where our lab is located.

Our night tech did an outstanding job recognizing what was happening and grabbed a housekeeper and a box of garbage bags. They worked together to unplug all the equipment and covered each instrument and piece of equipment with plastic garbage bags. Shortly after this, our internal disaster plan was activated and key personnel were called in.

After staff arrived and we realized the extent of the damage we knew lab operations could not continue in the lower level and so we decided to move all necessary portable equipment up to a higher floor. Many challenges awaited us since we were on generator power only at the time, which meant there were no elevators, no telephones, and no omputers. Since lower level and ground floor were both flooded, we knew we had to go up at least two flights to avoid more water problems. Ceiling tiles were becoming saturated and falling, water was several inches deep and still running down the stairwells, so we did not want to try to carry anything heavy up the steps. We used the hospital’s tunnel system that allows access from lower level to the far end of the ground floor. Plant Operations was able to get one elevator operational in that area, since there was no lower level under that part of the building and therefore, a limited amount of water had accumulated.

We moved our back up hematology, ABG, coagulation and chemistry systems up via the tunnel and elevator. These systems were chosen since they were smaller and more easily transported than the main systems. We also moved up the slide staining equipment, a microscope, and urine dipsticks. When these were operational we brought up a small back-up immunochemistry system so we were able to perform CK-MB and beta HCG if necessary. Luckily, our microbiology and blood bank departments are in separate rooms of the lab and did not receive as much flood damage as the central lab and histology areas. Our goal was to have all critical care systems available as soon as possible.

Emergency generator outlets were located in a hallway of the Maternal Care Unit, located on the second floor, and we decided to make that our temporary lab location. Desks and tables were moved out into the hallway and we began setting up our lab. Within two hours of being called in, we had our temporary lab set up and operational. By utilizing our computer downtime protocol and forms, we were able to report tests in a timely manner. Our entire morning run was reported out on schedule. All staff did a wonderful job adapting to these difficult conditions.

Lab procedures were performed from this temporary location until 4:00 p.m. on the day after the storm. We spent all day Sunday cleaning and were able to move back “home” after being gone only about 36 hours. It felt good being “home” and having everything at our fingertips again. We certainly learned to appreciate elevators after having to run several flights of steps every time we needed to get to patient care areas, or to get something from the lab.

While the problems in the lab were being addressed, similar efforts were taking place in other parts of the hospital. The Emergency Services Department (ER) was relocated to a physicians’ clinic on the north part of town. ER and Radiology Staff were reassigned there as well, so storm victims and other emergency cases could be seen and triaged

accordingly. The clinic lab manager came in and opened the clinic lab as well. We kept a hospital lab tech at the clinic to assist during the entire 12 hours that ER was operated at that site.

Now the clean-up! It’s worse than the flood...almost. Ceilings, walls, cabinets, cupboards, and insulation have to be removed, repaired or replaced, and reinstalled. Phone, computer, and dictation outlets that worked once we returned to the lab are slowly dying due to corrosion from being exposed to water. It is and will continue to be a long haul to total recovery, but we are getting there. The specialists who were brought in to assist in the flood recovery continue to be very helpful, and the construction crews are beginning to feel like

a part of our staff!

All in all, we only lost two printers and two computer terminals. Thanks to the quick thinking staff who got everything covered and unplugged, major losses were prevented. Hopefully this truly was the “100 year flood” and we won’t have to experience anything like this again!

Vicki J. Lehrman

Laboratory Manager

Avera Queen of Peace Hospital

BASIC MEDICARE INFORMATION FOR YOUR CLIENTS

The information in this article is designed to help you as a health care professional to answer basic Medicare questions that your clients may have but do not know where to find the information.

Medicare is a Federal health insurance program for people 65 years or older, with certain disabilities, or people with permanent kidney failure treated with dialysis or a kidney transplant. Medicare has two parts—Part A which is hospital insurance, and Part B which is medical insurance. If you are receiving Social Security or Railroad Retirement or disability benefits, you are automatically enrolled in Medicare Part A and Part B. About three months prior to your 65th birthday or 24th month of disability, you will be sent an Initial Enrollment Package that will contain certain information about Medicare, a questionnaire, and your red, white, and blue Medicare card. If you want both Medicare Part A and Part B, just sign your Medicare card and keep it in your wallet. If you do not want Part B (medical) coverage, you must put an X in the refusal box on the back of the Medicare form; sign it and return it with your card to Social Security Administration at the address shown. You will then be sent a new Medicare card showing that you only have Part A (hospital) coverage.

To find out if you have Medicare coverage, call the Social Security Administration at 1-800-772-1213, or contact your local Social Security office to verify your Medicare coverage. This information can also be found on your Medicare card. To get a replacement card, in case the original is lost or damaged, call 1-800-772-1213 or on-line at the Social Security Administration web site. Make sure you have your Medicare number ready when you call. (It is usually your or your spouses’ Social Security number.) You should receive your new card in about four weeks.

Some people are not automatically enrolled in Medicare. You need to file an application if you are:

a) eligible for Social Security or Railroad

Retirement benefits, but have not signed up

for them;

b) have permanent kidney failure treated with

dialysis or a transplant;

c) are not eligible for Premium Free Part A; or

d) are a government employee who is not

eligible for Social Security or Railroad

Retirement benefits.

You can call the Social Security Administration

1-800-772-1213 to set up an appointment or go to your local Social Security office. They will take your application, determine if you are eligible for Medicare and send you a Medicare card. (Most people do not have to pay a monthly premium for Part A (hospital) because they or a spouse paid Medicare taxes while they were working.)

Medicare Part A (hospital insurance) helps pay for care in hospitals skilled nursing facilities, hospice, and some home health services.

Medicare Part B (medical insurance) helps pay for medically necessary doctors services, outpatient hospital care, blood, medical equipment, and some home health services. It also pays for other medical services such as lab tests, and physical and occupational therapy. Some preventative services are also covered such as mammograms, and flu shots. Medicare Part B does not cover routine physical exams; eye glasses; custodial care; dental care; dentures; routine foot care; hearing aids; orthopedic shoes; or cosmetic surgery. It also does not cover most prescription drugs or health care received outside the United States (except under limited circumstances).

Supplement insurance policies are sometimes called Medigap plans. Medigap plans are private health insurance policies that cover some of the costs of the original Medicare Plan does not such as prescription drugs. Medigap has 10 standard plans called Plan “A” through Plan “J”. Each plan has a different set of benefits. Your State Insurance

Department can answer questions about the Medigap policies sold in your area.

For more information on Medicare, call 1-800-772-1213 or on-line www.medicare.gov . The website even has tips for detection and prevention of fraud and abuse of Medicare, and how to choose a nursing home.

case study

Drug Induced Hepatitis

Case Study: A 31-year-old female presented to the local hospital with flu-like symptoms, including nausea, vomiting, chills and fever. Laboratory tests for assessment of Liver Function were ordered and review of the Laboratory Data showed greatly elevated liver enzymes, slightly elevated Bilirubin, and abnormally prolonged

Prothrombin Time.

Discussion

The patient was admitted and the following day a more thorough Patient history revealed that the patient drank alcohol on a daily basis and had been taking large amounts of Acetaminophen for the past several days because she was not feeling well. An acetaminophen level was ordered. The acetaminophen level, however, was not in the toxic range, because more than 24 hrs had elapsed since the last ingestion of acetaminophen.

An acetaminophen overdose can cause liver hepatotoxicity similar to viral hepatitis or cholestatic liver injury.

The acetaminophen is metabolized to its active metabolite, which is rapidly conjugated with glutathione.

When acetaminophen is ingested in toxic doses glutathione is depleted and the elimination mechanism is overwhelmed. The resulting toxic metabolite accumulates and causes necrosis of the liver. Clinical symptoms include nausea, vomiting, jaundice and hepatic tenderness. The deterioration of liver function is very rapid and early diagnosis is imperative. Therapy with N-acetylcysteine can prevent or minimize liver damage

if it is initiated within 12-16 hrs of the drug overdose.

Recommendations

A careful patient history is essential. The combination of chronic alcohol consumption and over the counter medications, in this case acetaminophen, can be a deadly combination. Acetaminophen’s half-life is normally 2-3 hours. To determine the half-life, peak levels should be drawn at least 4 hrs after poisoning. Values greater than 50ug/ml twelve hours after ingestion result in significant liver damage.

This patient succumbed to acute liver failure within a few months of this episode.

Tests Results Reference Ranges

ALT 13,640 IU/L 10-60 IU/L

AST 19,240 IU/L 10-60 IU/L

Bilirubin, Total 1.8 mg/dl 0.2-1.0 mg/dl

Prothrombin Time 26.8 seconds 11.0-14.5 sec

“Doctor, I have an earache”

2000 B.C. “Here, eat this root

1000 B.C. “That root is heathen, say this prayer”

1850 A.D. “That prayer is superstition, drink this potion”

1940 A.D. “That potion is snake oil, swallow this pill”

1985 A.D. “That pill is ineffective, take this antibiotic”

2000 A.D. “That antibiotic is artificial, Here, eat this root”

ADVANCED BENEFICIARY NOTICES (ABN’s) update

HCFA PROGRAM MEMORANDUM A-00-43)

HCFA has recently published Program Memorandum (A-00-43) which is meant to clearly define proper use of the Advanced Beneficiary Notice (ABN) in hospitals billing the Fiscal Intermediary for Part B Medicare (Outpatient or Outreach laboratory testing). The

purpose is to clarify issues related to the ongoing confusion between use of the Advanced Beneficiary Notice and the Hospital Notice of Non-coverage.

Highlights of memorandum A-00-43 include:

• “Do not give an ABN to a beneficiary in an

emergency room who has not been

stabilized. ABN’s given to an individual who is in

a medical emergency or otherwise under great

duress cannot be considered to be proper

notice.”

• Basic requirements for ABN’s include: it must be

a specific written notice given to the beneficiary

before Part B services are furnished, whenever

you believe that Medicare will not pay for some

or all of the service provided on the basis that

they are not reasonable and necessary

according to published Medical Review

guidelines. The ABN must state the test(s) and

the specific reason why you believe Medicare will

deny the service.

• The ABN should be in the OMB recommended

format (Form No. HCFA-R-131), the body of the

text should be at least 12 point font. Italics or

any typeface that is difficult to read should not

be used. The name of the facility that will bill the

patient should be clear and obvious to the

beneficiary.

• The ABN should be given to patient’s prior to

testing and delivered far enough in advance of

receiving a medical service so that the patient

can make a rational, informed consumer

decision. The general Medicare rules for who

may sign for a beneficiary apply to signing

notices, including the ABN.

• When you have received a properly executed

and signed ABN and Medicare denies payment,

you may bill and collect from the beneficiary for

that service.

• Demand Bills, “occurrence” and “condition”

code usage, when submitting claims with a

signed ABN, are also included in this

memorandum.

Based on the new instructions in this memorandum, we have contacted the Fiscal Intermediary for clarification on how to properly submit claims with a signed ABN and the correct use of modifiers and/or occurrences codes. No clear direction has as yet been received from the Fiscal Intermediary.

A copy of this memorandum A-00-43 is available on the Web by visiting www.hcfa.gov/pubforms/transmit/transmittals. Click on “2000 Program Memos.”

TIDBITS

MEDICARE DEFINITIONS OF FRAUD AND ABUSE.

Fraud: Intentional deception or misrepresentation that an individual or organization makes such as a false statement/claim to Medicare.

Abuse: Incidents or practices which are inconsistent with accepted business or fiscal practices and directly or indirectly create unnecessary costs to the Medicare program.

Be sure to indicate who the ordering physician is on all requisitions, as well as provide complete patient and specimen information, such as, insurance information, date and time of collection, and date of birth.

Remember to spell patient names correctly, and verify that the name on the tube and the name on the requisition are spelled the same.

When submitting specimens for Blood Bank testing, you must label the tube and the requisition with the Social Security number. Specimens without this information will not be processed. The Social Security number is mandatory for Blood Bank testing and is highly recommended on all requisition to assure positive patient identification. We encourage clients to use Social Security numbers at all times when submitting requests to us.