American College Of Emergency Physicians Research Articles

Development of a Curriculum for Emergency Physicians to Teach Transesophageal Echocardiography for Cardiac Arrests: A Kern Six-Step Model

BACKGROUND: The Kern model facilitates the development, implementation, and evaluation of successful educational systems in medicine. It involves six steps that link curricular content to health care needs. One such need is the design of a curriculum to teach emergency physicians practical use of focused transesophageal echocardiography employing a limited number of views for management of out-of-hospital cardiac arrests. The objective of this analysis was to describe the components of such a curriculum based on a Kern model that could be employed to train emergency department providers in this diagnostic modality. METHODS: We predicated our analysis on the American College of Emergency Physicians’ recommendations and goals for use of transesophageal echocardiography to guide emergency department cardiac arrest resuscitation. We then detailed an asynchronous pre-didactic learning experience followed by a synchronous didactic and simulation-based curriculum to teach emergency physicians how to acquire and interpret images for this purpose based upon steps set forth by a Kern model. RESULTS: The component steps in designing a curriculum constructed to teach focused transesophageal echocardiography for out-of-hospital cardiac arrests to emergency physicians are rigorously outlined. These components based on a Kern model include problem identification and a general needs assessment, a targeted needs assessment, defining goals and objectives, choosing educational strategies, curricular implementation, and program evaluation. CONCLUSIONS: Use of a six-step Kern model as a template can facilitate the development and dissemination of a curriculum to teach emergency physicians successfully to employ focused transesophageal echocardiography in the treatment of cardiac arrests. In order to promote its widest dissemination, this model should be pursued in a “train-the-trainer” fashion. In so doing, appropriate education of emergency physicians and their use of transesophageal echocardiography to manage cardiac arrests likely can be rapid and impactful, especially among providers with training and experience in transthoracic echocardiography.

Emergency department responses to nursing shortages

BackgroundThe COVID-19 pandemic exacerbated the nursing shortage, which is predicted to continue to worsen with significant numbers of nurses planning to retire within the next 5 years. There remains a lack of published information regarding recommended interventions for emergency departments (EDs) facing a sudden nursing shortage.MethodsWe queried emergency department leaders from the American College of Emergency Physicians to examine the impact of nursing shortages on EDs and to gather real-world interventions employed to mitigate the effects of the shortage.ResultsMost respondents (98.5%) reported nursing shortages, with 83.3% describing prolonged shortages lasting more than 12 months, with negative impacts such as misses/near-misses (93.9%) and increasing left without being seen rates (90.9%). ED leaders reported a range of interventions, including operational flow changes, utilizing alternative staff to fill nurse roles, recruitment of new nurses, and retention strategies for existing nurses. They employed temporary and permanent pay increases as well as efforts to improve the ED work environment and techniques to hire new nurses from atypical pipelines.ConclusionWe report a patchwork of solutions ED leaders utilized which may have variable efficacy among different EDs; personalization is essential when selecting interventions during a sudden nursing shortage.

Individual Attributes and Environmental Conditions of Registered Nurses Working in Freestanding Emergency Departments in the United States: A Descriptive Exploratory Study

IntroductionFreestanding emergency departments (FSEDs) are emergency facilities not connected to inpatient services. The percentage of FSEDs of all EDs grew from 1% in 2001 to 12% in 2017, making FSEDs a substantial subset of US emergency care. The purpose of this study was to describe the individual attributes and environmental conditions of registered nurses working in FSEDs in the US. MethodsA quantitative descriptive exploratory design with cross-sectional survey methodology. ResultsA total of 364 emergency nurses responded to the survey. Most reported their FSED was open 24 hours/day (99.5%), with board-certified emergency physicians onsite (91.5%) and a mean of 3.6 RNs working per shift. Resources immediately available in more than 50% of FSEDs included laboratory and imaging services, and in fewer than 30% of FSEDs included behavioral health care, MRI, obstetric care, orthopedic care, neurologic care, and surgical consult care. Respiratory therapy was reported by 39.6% of respondents as being immediately available. A significant minority of respondents expressed concerns about adequacy of resources and training and the effect on patient care in both survey (30% of respondents) and open-ended questions (42.5% of respondents). DiscussionThe practice environment of emergency nurses in FSEDs was reported as having positive elements; however, a substantial subpopulation reported serious concerns. FSEDs adhere to some of the standards put forward by the American College of Emergency Physicians, with notable exceptions in the areas of staffing RNs, staffing ancillary staff, and availability of some resources.

Novel Scoring Scale for Quality Assessment of Lung Ultrasound in the Emergency Department.

The use of a reliable scoring system for quality assessment (QA) is imperative to limit inconsistencies in measuring ultrasound acquisition skills. The current grading scale used for QA endorsed by the American College of Emergency Physicians (ACEP) is non-specific, applies irrespective of the type of study performed, and has not been rigorously validated. Our goal in this study was to determine whether a succinct, organ-specific grading scale designed for lung-specific QA would be more precise with better interobserver agreement. This was a prospective validation study of an objective QA scale for lung ultrasound (LUS) in the emergency department. We identified the first 100 LUS performed in normal clinical practice in the year 2020. Four reviewers at an urban academic center who were either emergency ultrasound fellowship-trained or current fellows with at least six months of QA experience scored each study, resulting in a total of 400. The primary outcome was the level of agreement between the reviewers. Our secondary outcome was the variability of the scores given to the studies. For the agreement between reviewers, we computed the intraclass correlation coefficient (ICC) based on a two-way random-effect model with a single rater for each grading scale. We generated 10,000 bootstrapped ICCs to construct 95% confidence intervals (CI) for both grading systems. A two-sided one-sample t-test was used to determine whether there were differences in the bootstrapped ICCs between the two grading systems. The ICC between reviewers was 0.552 (95% CI 0.40-0.68) for the ACEP grading scale and 0.703 (95% CI 0.59-0.79) for the novel grading scale (P < 0.001), indicating significantly more interobserver agreement using the novel scale compared to the ACEP scale. The variance of scores was similar (0.93 and 0.92 for the novel and ACEP scales, respectively). We found an increased interobserver agreement between reviewers when using the novel, organ-specific scale when compared with the ACEP grading scale. Increased consistency in feedback based on objective criteria directed to the specific, targeted organ provides an opportunity to enhance learner education and satisfaction with their ultrasound education.

Use of Topical Anesthetics in the Management of Patients With Simple Corneal Abrasions: Consensus Guidelines From the American College of Emergency Physicians

The management of corneal abrasions has largely excluded dispensing topical local anesthetics for home use due to concern for corneal toxicity. We have reviewed and critically appraised the available literature evidence regarding the use of topical anesthetics in patients with simple corneal abrasions. Using sequential Delphi review, we have developed these clinical guidelines. Herein are evidentiary summaries and consensus recommendations for 8 specific relevant questions. Our key observation is that for only simple corneal abrasions, as diagnosed and treated in accordance with the full protocol described herein, it appears safe to prescribe or otherwise provide a commercial topical anesthetic (ie, proparacaine, tetracaine, oxybuprocaine) for use up to every 30 minutes as needed during the first 24 hours after presentation, as long as no more than 1.5 to 2 mL total (an expected 24-hour supply) is dispensed and any remainder is discarded after 24 hours. Importantly, although published findings suggest absent harm for short courses, more rigorous studies with a greater cumulative sample size and ophthalmologic follow-up are needed.

Results from Multisite Implementation of Electronic Health Record Tools for Clinical Pre-Test Probability of Pulmonary Embolism in the Emergency Department

Introduction: Use of validated risk stratification tools for work up of suspected pulmonary embolism (PE) is an endorsed recommendation of the American Society of Hematology and the American College of Emergency Physicians. Due to variations in clinical practice, electronic health record (EHR) systems, and medical provider trainings, the use, documentation, and implementation of these tools vary widely. Current processes do not allow for electronic capture and quality reporting at most institutions. Methods: We sought to design and implement clinical pre-test probability (PTP) tools at three large healthcare institutions for use in emergency departments (ED). At each site, a hematologist partnered with ED physician leadership and local information technology experts to design and implement PTP tools in clinical workflows. Overall, 38 EDs (high volume tertiary EDs and smaller regional EDs) located in the United States along the East Coast and Midwest regions were involved. A major goal of implementation was integration into clinical workflow and automatic documentation. After design and implementation, awareness and education of the new EHR tool was distributed electronically to ED providers. After implementation, use of PTP tools was analyzed between September 12, 2022 and January 11, 2023. PTP use was examined as percent of visits for which patients underwent CT pulmonary angiography (CTPA). Results: Each institution chose the 3 tier Wells' Score for implementation while one site designed an integrated Wells'/PERC or YEARS score calculator. Two sites implemented the tool as an optional flowsheet and one site implemented the tool as mandatory parameters within the orders for PE imaging studies. The mandatory tool could be bypassed with prespecified selections or if a D-dimer existed within 48 hours . Complete details of the site-specific implementation are shown in Table 1. Over the 4-month evaluation timeframe, there was a total of 270,214 ED encounters. Uptake and utilization of the PTP tools are shown in Table 2. Use of PTP was highest at the site with forced PTP documentation which ranged from 49-53% of ordered CTPAs, compared to Site 2 where use was 2-3%, and Site 1 where use ranged from 1-3%. At Site 1, use of PTP increased slightly over the study period with signs that PE yield on imaging was increasing as well (3.4% to 5.9%). At Site 2, PE yield on imaging was overall high (9-10%), and remained similar with similar use of PTP tools over the study period. Use of PTP and PE yield (6-8%) on imaging also remained similar throughout the study at Site 3. Conclusion: Forced use of PTP within the orders for CTPA led to the highest use of PTP (Site 3) but this did not result in meaningfully higher PE yield on CTPA compared to the other sites. PE yield at each site was at or above the 5% yield for PE on CTPA which has been previously reported. Given that PTP uptake was relatively stable over the measurement period at Site 2 and 3, this indicates the process had mostly stabilized and that other strategies are needed to improve uptake of PTP, reduce utilization of CTPA, and further increase yield on CTPA. Increasing PTP use and rising PE yield at Site 1 demonstrated ongoing potential for improvements past this study timeframe.

The 2023 Model Core Content of Disaster Medicine.

Disaster Medicine (DM) is the clinical specialty whose expertise includes the care and management of patients and populations outside conventional care protocols. While traditional standards of care assume the availability of adequate resources, DM practitioners operate in situations where resources are not adequate, necessitating a modification in practice. While prior academic efforts have succeeded in developing a list of core disaster competencies for emergency medicine residency programs, international fellowships, and affiliated health care providers, no official standardized curriculum or consensus has yet been published to date for DM fellowship programs based in the United States. The objective of this work is to define the core curriculum for DM physician fellowships in the United States, drawing consensus among existing DM fellowship directors. A panel of DM experts was created from the members of the Council of Disaster Medicine Fellowship Directors. This council is an independent group of DM fellowship directors in the United States that have met annually at the American College of Emergency Physicians (ACEP)'s Scientific Assembly for the last eight years with meeting support from the Disaster Preparedness and Response Committee. Using a modified Delphi technique, the panel members revised and expanded on the existing Society of Academic Emergency Medicine (SAEM) DM fellowship curriculum, with the final draft being ratified by an anonymous vote. Multiple publications were reviewed during the process to ensure all potential topics were identified. The results of this effort produced the foundational curriculum, the 2023 Model Core Content of Disaster Medicine. Members from the Council of Disaster Medicine Fellowship Directors have developed the 2023 Model Core Content for Disaster Medicine in the United States. This living document defines the foundational curriculum for DM fellowships, providing the basis of a standardized experience, contributing to the development of a board-certified subspecialty, and informing fellowship directors and DM practitioners of content and topics that may appear on future certification examinations.

Leveraging a Learning Collaborative Model to Develop and Pilot Quality Measures to Improve Opioid Prescribing in the Emergency Department

The American College of Emergency Physicians (ACEP) Emergency Medicine Quality Network (E-QUAL) Opioid Initiative was launched in 2018 to advance the dissemination of evidence-based resources to promote the care of emergency department (ED) patients with opioid use disorder. This virtual platform-based national learning collaborative includes a low-burden, structured quality improvement project, data benchmarking, tailored educational content, and resources designed to support a nationwide network of EDs with limited administrative and research infrastructure. As a part of this collaboration, we convened a group of experts to identify and design a set of measures to improve opioid prescribing practices to provide safe analgesia while reducing opioid-related harms. We present those measures here, alongside initial performance data on those measures from a sample of 370 nationwide community EDs participating in the 2019 E-QUAL collaborative. Measures include proportion of opioid administration in the ED, proportion of alternatives to opioids as first-line treatment, proportion of opioid prescription, opioid pill count per prescription, and patient medication safety education among ED visits for atraumatic back pain, dental pain, or headache. The proportion of benzodiazepine and opioid coprescribing for ED visits for atraumatic back pain was also evaluated. This project developed and effectively implemented a collection of 6 potential measures to evaluate opioid analgesic prescribing across a national sample of community EDs, representing the first feasibility assessment of opioid prescribing-related measures from rural and community EDs.

Beyond the Four Walls: The American College of Emergency Physicians 2022 New Practice Models Task Force Report

Emergency physicians are highly trained to deliver acute unscheduled care. The emergency physician core skillset gained during emergency medicine residency can be applied to many other roles that benefit patients and extend and diversify emergency physician careers. In 2022, the American College of Emergency Physicians (ACEP) convened the New Practice Models Task Force to describe new care models and emergency physician opportunities outside the 4 walls of the emergency department. The Task Force consisted of 21 emergency physicians with broad experience and 2 ACEP staff. Fifty-nine emergency physician roles were identified (21 established clinical roles, 16 emerging clinical roles, 9 established nonclinical roles, and 13 emerging nonclinical roles). A strength-weakness-opportunity-threat (SWOT) analysis was performed for each role. Using the analysis, the Task Force made recommendations for guiding ACEP internal actions, advocacy, education, and research opportunities. Emphasis was placed on urgent care, rural medicine, telehealth/virtual care, mobile integrated health care, home-based services, emergency psychiatry, pain medicine, addiction medicine, and palliative care as roles with high or rising demand that draw on the emergency physician skillset. Advocacy recommendations focused on removing state and federal regulatory and legislative barriers to the expansion of new and emerging roles. Educational recommendations focused on aggregating available resources, developing a centralized resource for career guidance, and new educational content for emerging roles. The Task Force also recommended promoting research on potential advantages (eg, improved outcomes, lower cost) of emergency physicians in certain roles and new care models (eg, emergency physician remote supervision in rural settings).

Working in fours: generational communication in the emergency department

BackgroundThis study examined the conflicts between different generations working in US emergency departments (ED). We sought to record generational differences involving communication preferences, perceived areas of conflict, work motivations, and attitudes regarding work-life balance.MethodsWe developed a survey to assess the physician perspective on generational conflict in the ED. The survey was distributed to members of the American College of Emergency Physicians, a professional organization comprising emergency medicine physicians in the USA.ResultsWe received 696 completed responses. Men represented 60% of respondents and the largest proportion of respondents were emergency physicians working in community settings (53%); 11% were residents. Generation representation was smallest for Traditionalist (2%) and largest for Gen X (43%). Seventy percent reported observing conflict due to generational communication with the largest frequency being once a week (26%). In the associated open-ended questions, 247 (33%) provided 316 anecdotal descriptions of observed conflict. Responses clustered into seven themes (ordered by frequency): Work Ethic, Treatment Approach, Technology Application, Entitlement, Professionalism, Work Life/Balance, and Communication Style. Comparing Work Ethic responses, 52–70-year-olds reported that younger providers are less interested in “accomplishing anything” while 26–34-year-olds resented that attitude. Respondents completing the open-ended questions regarding preventing and responding to conflict provided some insight into helpful strategies including actions supportive of clear communication and standardized policies and expectations. Only 5% of respondents reported that they had discussed generational communication in department meetings with the odds of a woman reporting conflict being less than males (p = .01).ConclusionConflicts in the ED in the USA can be attributed to how an individual views the values of someone from another generation. Understanding the frequency and areas of generational conflict in the ED can help medical leaders find strategies to mitigate negative workplace interactions.

An Outcome Comparison Between Geriatric and Nongeriatric Emergency Departments

We sought to describe diagnosis rates and compare common process outcomes between geriatric emergency departments (EDs) and nongeriatric EDs participating in the American College of Emergency Physicians Clinical Emergency Data Registry (CEDR). We conducted an observational study of ED visits in calendar year 2021 within the CEDR by older adults. The analytic sample included 6,444,110 visits at 38 geriatric EDs and 152 matched nongeriatric EDs, with the geriatric ED status determined based on linkage to the American College of Emergency Physicians' Geriatric ED Accreditation program. Stratified by age, we assessed diagnosis rates (X/1000) for 4 common geriatric syndrome conditions and a set of common process outcomes including the ED length of stay, discharge rates, and 72-hour revisit rates. Across all age categories, geriatric EDs had higher diagnosis rates than nongeriatric EDs for 3 of the 4 following geriatric syndrome conditions of interest: urinary tract infection, dementia, and delirium/altered mental status. The median ED site-level length of stay for older adults was lower at geriatric EDs compared with that at nongeriatric EDs, whereas 72-hour revisit rates were similar across all age categories. Geriatric EDs exhibited a median discharge rate of 67.5% for adults aged 65 to 74 years, 60.8% for adults aged 75 to 84 years, and 55.6% for adults aged >85 years. Comparatively, the median discharge rate at nongeriatric ED sites was 69.0% for adults aged 65 to 74 years, 64.2% for adults aged 75 to 84 years, and 61.3% for adults aged >85 years. Geriatric EDs had higher geriatric syndrome diagnosis rates, lower ED lengths of stay, and similar discharge and 72-hour revisit rates when compared with nongeriatric EDs in the CEDR. These findings provide the first benchmarks for emergency care process outcomes in geriatric EDs compared with nongeriatric EDs.

First-Time Seizure Patients have High Rate of Abnormalities on Emergency Department Performed Brain Computed Tomography: A Prospective Study

BackgroundFirst-time seizures comprise 15% to 35% of all seizure-related complaints in the emergency department (ED). Emergent neuroimaging of first-time seizure patients is recommended by both the American Academy of Neurology and American College of Emergency Physicians. However, most of these studies are over 10 years old and included both adults and children. ObjectivesThe goal of this investigation is to determine the rate of abnormal neuroimaging in adults with first-time seizures presenting to the ED during the current era. MethodsThis was a prospective observational study of patients presenting to three urban EDs with a chief complaint of seizure over 18 months. Abnormal neuroimaging findings were defined a priori and were dichotomized into acute and subacute/chronic categories. ResultsOf the 2505 patients who presented with a seizure, 242 patients (9.7%) presented with a first-time seizure. The most common etiologies for first-time seizures were drug intoxication and drug withdrawal. Of those 242 patients, 29 (11.9%) patients had abnormal findings on brain computed tomography (CT). Brain CT demonstrated an acute finding in 13 (45%) patients and a subacute/chronic finding in 16 (55%) patients. The most common abnormality overall and the most common chronic finding was ischemic changes. The most common acute findings were traumatic intracranial hemorrhage and intracranial metastases. ConclusionsThis study demonstrated that 11.9% of first-time seizure patients presenting to the ED had abnormal findings on neuroimaging. Our findings support current recommendations to obtain emergent neuroimaging for adult patients with first-time seizures.

Interpretation of Cardiac Standstill in Children Using Point-of-Care Ultrasound

This study aimed to determine the level of agreement among pediatric emergency medicine (PEM) physicians in whether various point-of-care ultrasound (POCUS) video clips represent cardiac standstill in children and to highlight the factors that may be associated with the lack of agreement. A single, online, cross-sectional, convenience sample survey was administered to PEM attendings and fellows with variable ultrasound experience. PEM attendings with an experience of 25 cardiac POCUS scans or more were the primary subgroup based on ultrasound proficiency set by the American College of Emergency Physicians. The survey contained 11 unique, 6-second video clips of cardiac POCUS performed during pulseless arrest in pediatric patients and asked the respondent if the video clip represented a cardiac standstill. The level of interobserver agreement was determined using the Krippendorff's α (Kα) coefficient across the subgroups. A total of 263 PEM attendings and fellows completed the survey (9.9% response rate). Of the 263 total responses, 110 responses were from the primary subgroup of experienced PEM attendings with at least 25 previously seen cardiac POCUS scans. Across all video clips, PEM attendings with 25 scans or more had an acceptable agreement (Kα=0.740; 95% CI 0.735 to 0.745). The agreement was the highest for video clips wherein the wall motion corresponded to the valve motion. However, the agreement fell to unacceptable levels (Kα=0.304; 95% CI 0.287 to 0.321) across video clips wherein the wall motion occurred without the valve motion. There is an overall acceptable interobserver agreement when interpreting cardiac standstill among PEM attendings with an experience of at least 25 previously reported cardiac POCUS scans. However, factors that may influence the lack of agreement include discordances between the wall and valve motion, suboptimal views, and the lack of a formal reference standard. More specific consensus reference standards of pediatric cardiac standstill may help to improve interobserver agreement moving forward and should include more specific details regarding the wall and valve motion.

Comparison of Commonly Carried Liquids Against Commercial Ultrasound Gel for Use in the Backcountry Setting.

Point-of-care ultrasound (POCUS) is utilized in austere environments because it is lightweight, durable, battery powered, and portable. In austere settings, weight and space constraints are limitations to carrying dedicated ultrasound gel. Few studies have assessed commonly carried liquids as gel alternatives. The study objective was to assess the suitability of common food and personal care products as ultrasound coupling agents compared with that of commercial gel. A noninferiority study compared 9 products to commercial gel. Each substance was independently tested on 2 subjects by 2 sonographers covering 8 standardized ultrasound windows. Clips were recorded, blinded, and independently graded by 2 ultrasound fellowship-trained physicians on the ability to make clinical decisions and technical details, including contrast, resolution, and artifact. A 20% noninferiority margin was set, which correlates to levels considered to be of reliably sufficient quality by American College of Emergency Physicians' guidelines. The substances included water, soap, shampoo, olive oil, energy gel, maple syrup, hand sanitizer, sunscreen, and lotion. A total of 300 of 318 (94%) clips met the primary endpoint of adequacy to make a clinical decision. All media, except sunscreen, were noninferior to commercial gel in the ability to make a clinical decision (α=0.05). In terms of secondary outcomes, resolution, artifact, and contrast, all substances were noninferior to commercial gel (α=0.05). The sonographers concluded that all gel alternatives' usability performed similarly to commercial gel, with the exception of energy gel. Of the 9 substances tested, 8 were noninferior to commercial gels for clinical decisions. Our study indicates that several POCUS gel substitutes are serviceable to produce clinically adequate images.

Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Appendicitis: Approved by ACEP Board of Directors February 1, 2023.

This clinical policy from the American College of Emergency Physicians is a revision of the 2010 “Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Appendicitis.” A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: 1) in ED patients with possible acute appendicitis, can a clinical prediction rule be used to identify patients for whom no advanced imaging is required? 2) in ED patients with suspected acute appendicitis, is the diagnostic accuracy of ultrasound comparable with computed tomography or magnetic resonance imaging for the diagnosis of acute appendicitis? 3) in ED patients who are undergoing computed tomography of the abdomen and pelvis for suspected acute appendicitis, does the addition of contrast improve diagnostic accuracy? Evidence was graded, and recommendations were made based on the strength of the available data.

Adoption of emergency department crowding interventions among US hospitals between 2007 and 2020

BackgroundTo deal with emergency department (ED) crowding, the American College of Emergency Physicians (ACEP) established a task force to develop a list of low-cost, high-impact solutions. In this study, we report on the trend in the adoption rate of ACEP-recommended ED crowding interventions by US hospitals. MethodsWe analyzed the National Hospital Ambulatory Medical Care Survey data from 2007 to 2020 (N = 3874 hospitals). The primary outcome was whether a hospital adopted each of the ACEP-recommended interventions, which were grouped into three overlapping categories: technology-based, flow modifications, and physical-based (e.g., changing ED layout). ResultsOn average, the most frequently adopted intervention was bedside registration (85.1%) and the least frequently adopted intervention was kiosk check-in (8.3%). The adoption of ED crowding interventions increased significantly between 2007 and 2020, except for expanding ED treatment space which declined by 45.0% from 30.3% in 2007 to 15.7% in 2020. The largest adoption rate increase occurred in having a separate operating room for ED cases with a 188.5% increase in adoption rate followed by radio-frequency identification (RFID) tracking (151.2%), and kiosk check-in (144.2%). ConclusionsThe adoption rate of ED crowding interventions by hospitals has risen, however most effective ED crowding interventions are still underutilized. The trends for each intervention did not always increase linearly, with certain periods showing greater fluctuations in adoption rate. Hospitals tend to implement technology-based interventions, compared to physical-based interventions and flow modification interventions.

Healing Words

Healing Words

ACEP-SAEM response to the National Institutes of Health (NIH) proposal to simplify the review framework for research project grant applications.

The Society for Academic Emergency Medicine (SAEM) and American College of Emergency Physicians (ACEP) are responding jointly to this request for information. SAEM and ACEP promote innovative and imaginative strategy development that will transform prehospital and emergent patient care. The National Institutes of Health (NIH) proposal to modify the current grant scoring system to prioritize these principles is a welcome change and we are supportive of these efforts. Focusing on research importance, feasibility, and scientific rigor will make it easier to interpret reviewer critiques and provide investigators with clearer information on score driving factors related to the science itself. While investigator and environment are important factors for successfully conducting research, reducing their overall importance may help with reducing bias and expanding the pool of meritorious applications. We also support combining significance and innovation into a single “importance” score, as the current format gives equal weight to innovation even though related sections tend to be brief. Furthermore, the existing significance section focuses largely on perceived need and scientific rationale with lesser consideration of the true magnitude of impact. Our societies are hopeful that by broadening the concept of overall importance, this new section can better weight funding decisions toward injuries and illnesses where improved outcomes would benefit the greatest number of people. We also agree that the current scoring system overly emphasizes an investigator's prior grant success and institutional reputation in determining an application's merit. Reliance on these factors detracts from the proposal's true “importance” and may perpetuate existing and ongoing challenges with the development and retention of junior investigators, including investigators from historically underrepresented groups. The proposed changes in this area will allow for increased emphasis on the development of highly novel or paradigm-shifting approaches to problems. Nonetheless, consideration of the capacity to execute the proposed work remains a critically important factor. The proposed method of scoring using a descriptive range of “fully capable” to “additional resources needed” deemphasizes quantitative scoring and we believe accomplishes the stated goals. However, we recommend specific clarification that the proposed scale reflects the entirety of the investigatory team (with due consideration of experience with prior collaboration). An important component of the current scoring system not addressed in the proposed changes is the handling of grant resubmissions. It is not clear why resubmissions have a written narrative that is score-driving and subject to bias. We recommend amending this process for each additional criteria to be marked yes or no as to “all major/moderate concerns appropriately addressed.” Reviewers could also have the option of describing “any new major/moderate concerns identified” in the resubmission process. Finally, while we recognize that these scoring revisions are important, we suggest that the NIH consider a more direct acknowledgment of our nation's need to fund a diverse pool of grant applicants. We believe the approach of the three-factor scoring system that emphasizes capability to perform the work is well aligned with this goal, but we would encourage the NIH to consider an explicit acknowledgment of ongoing disparities in our nation's health research programs addressed by these changes.

Factors associated with emergency physician income.

Income fairness is important, but there are limited data that describe income equity among emergency physicians. Understanding the magnitude of and factors associated with income differences may be helpful in eliminating disparities. This study analyzed the associations of demographic factors, training, practice setting, and board certification with emergency physician income. We distributed a survey to professional members of the American College of Emergency Physicians. The survey included questions on annual income, educational background, practice characteristics, gender, age, race, ethnicity, international medical graduate status, type of medical degree (MD vs DO), completion of a subspecialty fellowship, job characteristics, and board certification. Respondents also reported annual income. We used linear regression to determine the respondent characteristics associated with reported annual income. From 45,961 members we received 3407 responses (7.4%); 2350 contained complete data for regression analysis. The mean reported annual income was $315,306 (95% confidence interval [CI], $310,649 to $319,964). The mean age of the respondents was 47.4 years, 37.4% were women, 3.2% were races underrepresented in medicine (Black, American Indian, or Alaskan Native), and 4.8% were Hispanic or Latino. On linear regression, female gender was associated with lower reported annual income; difference -$43,565, 95% CI, -$52,217 to -$34,913. Physician age, degree (MD vs DO), underrepresented racial minority status, and underrepresented ethnic minority status were not associated with annual income. Fellowship training was associated with lower income; Accreditation Council for Graduate Medical Education (ACGME) program difference -$30,048; 95% CI, -$48,183 to -$11,912, non-ACGME-program difference -$27,640, 95% CI, -$40,970 to -$14,257. Working at a for-profit institution was associated with higher income; difference $12,290, 95% CI, $3693 to $20,888. Board certification was associated with higher income; difference, $43,267, 95% CI, $30,767 to $55,767. This study identified income disparities associated with gender, practice setting, fellowship completion, and American Board of Emergency Medicine or American Osteopathic Board of Emergency Medicine certification.

Prehospital Hemorrhage Control and Treatment by Clinicians: A Joint Position Statement

Exsanguination remains the leading cause of preventable death among victims of trauma. For adult and pediatric trauma patients in the prehospital phase of care, methods to control hemorrhage and hemostatic resuscitation are described in this joint consensus opinion by the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, and the National Association of EMS Physicians.