American College Of Emergency Physicians Research Articles

SCAI SHOCK Stage Classification Expert Consensus Update: A Review and Incorporation of Validation Studies: This statement was endorsed by the American College of Cardiology (ACC), American College of Emergency Physicians (ACEP), American Heart Association (AHA), European Society of Cardiology (ESC) Association for Acute Cardiovascular Care (ACVC), International Society for Heart and Lung Transplantation (ISHLT), Society of Critical Care Medicine (SCCM),

SCAI SHOCK Stage Classification Expert Consensus Update: A Review and Incorporation of Validation Studies: This statement was endorsed by the American College of Cardiology (ACC), American College of Emergency Physicians (ACEP), American Heart Association (AHA), European Society of Cardiology (ESC) Association for Acute Cardiovascular Care (ACVC), International Society for Heart and Lung Transplantation (ISHLT), Society of Critical Care Medicine (SCCM),

A Warm Welcome to The First Issue of JSCAI

A Warm Welcome to The First Issue of JSCAI

Systematic review of methodology and reporting quality of global guidelines on fever in children

Objective:This study aimed to evaluate the global clinical practice guidelines on fever in children. We also aimed to select a guideline with good methodology and reporting quality to provide scientific reference for diagnosis and treatment of fever in children.Methods:The Chinese and English databases Embase, PubMed, Cochrane library, China National Knowledge Infrastructure, Wanfang database, clinical guides, and the website of the Department of Public Health Administration were retrieved up to January 2020. The clinical practice guidelines on fever in children were included. The AGREE II instrument and Reporting Items for Practice Guidelines in Healthcare statement were used to evaluate the methodology and reporting quality of the guidelines.Results:Eight clinical guidelines for fever in children were included. Methodological quality assessment showed that the recommendation level of ISP, South Africa, National Institute for Health and Care Excellence, China, and American College of Emergency Physicians were grade B (recommended with modification), while that of American Academy of Pediatrics, New South Wales, and South Australia was grade C recommendation (not recommended). No grade A recommendation guideline was found. The reporting quality from higher to lower was National Institute for Health and Care Excellence, the Chinese guideline, American College of Emergency Physicians, ISP, South Africa, New South Wales, South Australia, and American Academy of Pediatrics. The guideline recommendations were similar in various countries, but they were slightly different in various aspects, including body temperature measurement and the timing of drug administration.Conclusion:There are limitations in the methodology and reporting quality of all eight global guidelines on fever in children. For future development of these guidelines, attention should be paid to improving applicability of the guidelines in terms of methodology. Additionally, the principles and explanations for formation of recommendations should be described, as well as the limitations of the reporting guideline in detail in terms of the reporting quality. Treatments of fever in children are similar in different countries, but there are still differences that require further research.

A clinical decision framework to guide the outpatient treatment of emergency department patients diagnosed with acute pulmonary embolism or deep vein thrombosis: Results from a multidisciplinary consensus panel.

The outpatient treatment of select emergency department patients with acute pulmonary embolism (PE) or deep vein thrombosis (DVT) has been shown to be safe, cost effective and associated with high patient satisfaction. Despite this, outpatient PE and DVT treatment remains uncommon. To address this, the American College of Emergency Physicians assembled a multidisciplinary team of content experts to provide evidence‐based recommendations and practical advice to help clinicians safely treat patients with low‐risk PE and DVT without hospitalization. The emergency clinician must stratify the patient's risk of clinical decompensation due to their PE or DVT as well as their risk of bleeding due to anticoagulation. The clinician must also select and start an anticoagulant and ensure that the patient has access to the medication in a timely manner. Reliable follow‐up is critical, and the patient must also be educated about signs or symptoms that should prompt a return to the emergency department. To facilitate access to these recommendations, the consensus panel also created 2 web‐based “point‐of‐care tools.”

Building a virtual community of practice for medical students: The Global Emergency Medicine Student Leadership Program.

Virtual communities of practice (VCoPs) facilitate distance learning and mentorship by engaging members around shared knowledge and experiences related to a central interest. The American College of Emergency Physicians and Emergency Medicine Residents’ Association's Global Emergency Medicine Student Leadership Program (GEM‐SLP) provides a valuable model for building a VCoP for GEM and other niche areas of interest. This VCoP facilitates opportunities for experts and mentees affiliated with these national organizations to convene regularly despite barriers attributed to physical distance. The GEM‐SLP VCoP is built around multiple forms of mentorship, monthly mentee‐driven didactics, academic projects, and continued engagement of program graduates in VCoP leadership. GEM‐SLP fosters relationships through (1) themed mentoring calls (career paths, work/life balance, etc); (2) functional mentorship through didactics and academic projects; and (3) near‐peer mentoring, provided by mentors near the mentees’ stage of education and experience. Monthly mentee‐driven didactics focus on introducing essential GEM principles while (1) critically analyzing literature based on a journal article; (2) building a core knowledge base from a foundational textbook; (3) applying knowledge and research to a project proposal; and (4) gaining exposure to training and career opportunities via mentor career presentations. Group academic projects provide a true GEM apprenticeship as mentees and mentors work collaboratively. GEM‐SLP mentees found the VCoP beneficial in building fundamental GEM skills and knowledge and forming relationships with mentors and like‐minded peers. GEM‐SLP provides a framework for developing mentorship programs and VCoPs in emergency medicine, especially when niche interests or geographic distance necessitate a virtual format.

Overcoming barriers to promotion for women and underrepresented in medicine faculty in academic emergency medicine.

Equity in the promotion of women and underrepresented minorities (URiM) is essential for the advancement of academic emergency medicine and the specialty as a whole. Forward‐thinking healthcare organizations can best position themselves to optimally care for an increasingly diverse patient population and mentor trainees by championing increased diversity in senior faculty ranks, leadership, and governance roles. This article explores several potential solutions to addressing inequities that hinder the advancement of women and URiM faculty. It is intended to complement the recently approved American College of Emergency Physicians (ACEP) policy statement aimed at overcoming barriers to promotion of women and URiM faculty in academic emergency medicine. This policy statement was jointly released and supported by the Society for Academic Emergency Medicine (SAEM), American Academy of Emergency Medicine (AAEM), and the Association of Academic Chairs of Emergency Medicine (AACEM).

Emergency department active shooter training: A survey of current practices in 2020.

Shooting events in hospitals are increasing in frequency, with the emergency department (ED) being the most common site of such events. EDs must be prepared for shooting events, but current practices surrounding active shooter preparation are unknown. To determine what active shooter training emergency medicine physicians are receiving. A survey was developed to assess current practices around active shooter preparation in EDs. The survey was distributed to members of the American College of Emergency Physicians' Emergency Medicine Practice Research Network. All members of the Emergency Medicine Practice Research Network are currently practicing emergency medicine physicians. There were 194 respondents. The most common form of training received was online (76/194), followed by lecture (50/194). Only 39 respondents had participated in an active shooter drill. Sixty-five respondents (33 percent) reported having never received any formal active shooter training. There is a wide array of active shooter training that emergency medicine physicians are receiving, with nearly one-third receiving no training at all.

Tricuspid Regurgitant Jet Velocity Point-of-Care Ultrasound Curriculum Development and Validation.

The American College of Emergency Physicians (ACEP) recommends that Emergency Medicine physicians with advanced training can evaluate right ventricular (RV) pressures via point-of-care ultrasound (POCUS) by measuring a tricuspid regurgitant jet (TRJ). We were unable to find a published curriculum to deliver education for this at any skill level. Therefore, we developed, delivered, and evaluated a curriculum for the assessment of TRJ for novice physician sonographers. We designed an educational intervention for novice physician sonographers. The curriculum was created using a modified Delphi methodology. All novice sonographers participated in the educational intervention which consisted of a didactic lecture followed by hands-on-deliberate practice on healthy medical student volunteers with expert feedback in a simulated setting. Sonographer's knowledge was assessed at 3 time points: pre-intervention, immediately post-intervention, and 3 months post-intervention (retention assessment) by multiple choice exam. Nine novice physician sonographers participated in the intervention. Mean exam performance increased from 55.6% [standard deviation (SD) 11.3%] on the pre-intervention exam to 94.4% (SD 7.3%) on the post-intervention exam and 92.9% (SD 12.5%) on the retention exam. The mean improvement between the pre- and post- exam was +38.9% (95% CI 31.8 - 46.0), and between the pre-exam and retention exam +37.1% (95% CI 22.3 - 52.0). Sonographer knowledge of TRJ assessment improved following a brief educational intervention as measured by exam performance. Given the expanding role of POCUS it is increasingly important to provide effective resources for teaching these skills. This work establishes the basis for further study and implementation of our TRJ curriculum.

Emergency Medicine Physicians Would Prefer Using Cannabis Over Opioids for First-Line Treatment of a Medical Condition if Provided With Medical Evidence: A National Survey.

Objective: To determine emergency medicine (EM) physicians’ preferences for using medical cannabis versus opioids if medical cannabis was legalized.Methods: We surveyed US physicians at the largest national EM conference (American College of Emergency Physicians’ Annual Conference) held in San Diego, CA from October 1 to 4, 2018. Of the thousands of conference participants approached, 539 US physicians completed the anonymous written survey, which represented 15.2% of the US physicians attending the conference.Results: The mean age of the participants was 39.6 ± 10.9 years, men composed 57.5% of the participants, and whites made up 72.8% of the respondents. Participants practicing in medically legal (54.8%) and medically plus adult-use legal cannabis states (23.1%) totaled 77.9%. A majority (70.7%) of the participants believed that cannabis has medical value. EM physicians preferred cannabis over opioids as a first-line treatment addressing a medical condition provided that medical studies found that cannabis was equally effective (p < 0.001, X2 = 36.8 [95% CI 2, 415]), and overwhelmingly preferred cannabis over opioids if it were more effective (p < 0.001, X2 = 90.8 [95% CI 2, 415]). Physicians appeared to prefer opioids over cannabis if medical studies found that cannabis was less effective though it was not significant (p > 0.05). Subgroup analyses showed that belief in the medical value of cannabis significantly increased the odds ratio of choosing cannabis over opioids if cannabis was equally or more effective than opioids.Conclusion: Our study shows that EM physicians believe cannabis has medical value and would prefer using cannabis over opioids if provided with equivalent findings. We believe our findings reflect EM physicians’ experience of the opioid epidemic and suggest the need for further study of this potential therapeutic.

197 Emergency Medicine Development Around the World: An Analysis of 2019 American College of Emergency Physicians International Ambassador Country Reports

Emergency medicine (EM) is in different stages of development around the world, with many countries not yet formally recognizing the specialty. The American College of Emergency Physicians (ACEP) International Ambassador Program is composed of emergency physicians who represent ACEP and connect with local EM societies and EM pioneers, practitioners, and educators in 78 countries to promote emergency medicine development. Our objective was to describe the current state of EM around the world by analyzing 63 Country Report survey responses submitted by the ACEP Ambassadors in 2019. The 2019 Country Report survey was developed by ACEP Ambassador Program leadership with input from the ACEP Ambassadors. The survey consisted of 40 questions about EM as a specialty, the history of EM, EM residencies, out-of-hospital care, EM academic activities, and challenges and opportunities for growth in EM. ACEP Ambassadors answered questions based on their experience working in their respective countries with assistance from local partners. Maps of the world were created to display categorical variables. Qualitative data was analyzed for themes. Percentages were calculated and variables were categorized by World Bank regions and income categories. Chi-square was used to look for association between country income and recognition of EM as a specialty. The populations of the 63 countries in this study totaled 5.19 billion or about 67% of the world’s population. The sample included countries in each of the World Health Organization Regions. Of the countries represented, 7.9% are low income, 24% lower middle income, 33.3% upper middle income and 35% high income. Country income was not associated with recognition of EM as a specialty (p = 0.29). The number of residency-trained emergency physicians per 100,000 people was >5 in 6 countries (9.5%), 2 to 5 in 12 countries (19%), and <2 in 37 countries (59%). Nine countries (14.5%) do not recognize EM as a specialty (3 high, 1 high middle and 5 low middle-income). Six countries (9.5%) do not have a out-of-hospital system. Eleven countries (17.5%) do not have an emergency phone number (eg, 911). A majority of countries had fewer than 10 EM residency programs (55%), and 16% had none. Thirty countries (48%) have EM board exams. Eighteen countries (29%) have an EM-specific peer-reviewed journal. Common challenges reported in EM development included: lack of resources and/or funding (53%), lack of EM recognition or resistance to the specialty (47%), the need for more educational and faculty organization (29%), and physician shortages (23% ). Within the constraints of a survey study, the ACEP Ambassador Country Report survey provides unique information about the state of EM development around the world. Most countries in the sample have recognized EM or have EM residencies. However, EM is still in the early stages of development in many countries, with few emergency physicians per 100,000 population and few having board exams or EM peer-reviewed journals. Future research can track the growth of EM over time and help promote collaborations across countries.

CAN PATIENTS PRESENTING TO THE ED WITH CHEST PAIN WHO HAVE INTERMEDIATE-RISK HEART SCORES BE MANAGED AS OUTPATIENTS? A RETROSPECTIVE REVIEW OF TWO RAPID ACCESS CHEST PAIN CLINICS

CAN PATIENTS PRESENTING TO THE ED WITH CHEST PAIN WHO HAVE INTERMEDIATE-RISK HEART SCORES BE MANAGED AS OUTPATIENTS? A RETROSPECTIVE REVIEW OF TWO RAPID ACCESS CHEST PAIN CLINICS

167 The PEAGE Study: Patient Experience After Geriatric Evaluation

Based on United States (US) Census data, by 2030 the geriatric population (adults aged 65 and older) is expected to be 20% of the population. Currently there are 46 million older adults in the US, and this is projected to reach 90 million by 2050. As the population of the US ages, the population of patients evaluated in the emergency department (ED) will increase as well. In 2018, the American College of Emergency Physicians (ACEP) began a formal accreditation process for Geriatric Emergency Departments (GED).

322 Novel Quality Assessment Methodology in Focused Cardiac Ultrasound

Focused cardiac ultrasound is regularly utilized in the emergency department to evaluate and manage a variety of patient complaints. Quality assessment should be routinely performed, to ensure correct patient care and allow for feedback to performing providers. The current grading scale used during quality assessment promoted by the American College of Emergency Physicians (ACEP) is not organ-specific and has not been rigorously tested. The goal of this study was to determine if a similar, yet organ-specific grading scale would be more precise, with better inter-observer agreement.

ACEP Emergency Department COVID-19 Management Tool: A Review of the Updated Guidelines.

This review examines the American College of Emergency Physicians' (ACEP) Emergency Department COVID-19 Management Tool (2021). The authors and contributors developed a tool to provide a framework to assist with severity classification, risk assessment, diagnostic workup, disposition, and treatment of patients with suspected or confirmed COVID-19 in the emergency department. By utilizing the tool from this study, the emergency nurse practitioner can confidently treat COVID-19 and reduce patient risks from unnecessary treatments or unneeded admissions.

28 Geriatric Emergency Department Accreditation Accelerates Integration of Geriatric Care at the Veterans Health Administration

Geriatric emergency department (GED) accreditation (GEDA) through the American College of Emergency Physicians requires developing a strategic plan for education, equipment, policies, environment, staffing, and quality improvement. To support Veterans Affairs (VA) EDs in achieving accreditation, an interdisciplinary group of leaders in the VA National Offices of Emergency Medicine and Geriatrics and Extended Care and subject matter experts created a council that hosted a bootcamp, mentored support, created a Web site housing sample policies, staffing descriptions, workflows, and order sets. Additional individualized support was provided to assist with implementation of GED processes during the COVID-19 crisis. We sought to identify feedback on the accreditation process to inform onboarding of future cohorts. This was a dissemination plan for GED implementation at 20 VA EDs. VA medical centers were invited to submit an application for GEDA mentored support and fee waiver. An in-person kickoff bootcamp was held February 2020 for 10 VA EDs applying for Level 1 or Level 2 GEDA. As part of the planned quality review and to prepare for future VA GEDA, we performed follow-up surveys on the accreditation process, new interdisciplinary services relationships established, outcomes, and feedback on the process. A total of 26/110 VA facilities with EDs applied for VA GEDA support; 10 were accepted for the in person bootcamp and virtual support and 10 additional for virtual support only. Nineteen supported sites have applied for accreditation and 14 have received accreditation: one level 1, four level 2, and nine level 3. Mean ED visit volume in 2019 for accredited sites was 25, 475 (range 8, 212-42, 589 visits/year) with 47% of visits made by veterans 65 years or older (range 33-60%). Sixteen sites responded to the survey. Ninety-four percent (15/16) described new interdisciplinary services (figure 1). When asked what accomplishment associated with the accreditation process they were proud of, 6 reported ED outcome improvements, 12/16 reported connecting patients to VA services, and 13/16 reported improved patient care team engagement. Feedback on the process suggested the need for standardization of data collection, workflow, and documentation, which has led to the development of a central dashboard and patient care note with standardized geriatric screens and assessments. A central supported system allowed 14 VA EDs to achieve geriatric ED accreditation despite the COVID pandemic. Almost all facilities reported they formed new associations with interdisciplinary services as a result of the accreditation process. More than half reported improved patient care team engagement and connection to VA services as additional accomplishments. Feedback has led to increased standardization of geriatric emergency care assessments across the healthcare system.

Hyperkalemia management in the emergency department: An expert panel consensus.

Hyperkalemia is a common electrolyte abnormality identified in the emergency department (ED) and potentially fatal. However, there is no consensus over the potassium threshold that warrants intervention or its treatment algorithm. Commonly used medications are at best temporizing measures, and the roles of binders are unclear in the emergent setting. As the prevalence of comorbid conditions altering potassium homeostasis rises, hyperkalemia becomes more common, and hence there is a need to standardize management. A panel was assembled to synthesize the available evidence and identify gaps in knowledge in hyperkalemia treatment in the ED. The panel was composed of 7 medical practitioners, including 5 physicians, a nurse, and a clinical pharmacist with collective expertise in the areas of emergency medicine, nephrology, and hospital medicine. This panel was sponsored by the American College of Emergency Physicians with a goal to create a consensus document for managing acute hyperkalemia. The panel evaluated the evidence on calcium for myocyte stabilization and potassium shifting and excretion. This article summarizes information on available therapies for hyperkalemia and proposes a hyperkalemia treatment algorithm for the ED practitioner based on the currently available literature and highlights diagnostic pitfalls and evidence gaps.

Emergency medicine research: 2030 strategic goals.

All academic medical specialties have the obligation to continuously create new knowledge that will improve patient care and outcomes. Emergency medicine (EM) is no exception. Since its origins over 50years ago, EM has struggled to fulfill its research mission. EM ranks last among clinical specialties in the percentage of medical school faculty who are National Institutes of Health (NIH)-funded principal investigators (PIs; 1.7%) and the percentage of medical school departments with NIH-funded PIs (33%). Although there has been a steady increase in the number of NIH-funded projects and total NIH dollars, the slowing growth in the number of NIH-funded PIs and lack of growth in the number of EM departments with NIH-funded PIs is cause for concern. In response, the Association of Academic Chairs of Emergency Medicine (AACEM) Research Task Force proposes a set of 2030strategic goals for the EM research enterprise that are based on sustaining historic growth rates in NIH funding. These goals have been endorsed by the AACEM Executive Committee and the boards of Society for Academic Emergency Medicine (SAEM), American College of Emergency Physicians (ACEP), and American Academy of Emergency Medicine (AAEM). The 2030strategic goals include 200NIH-funded projects led by 150 EM PIs in at least 50 EM departments with over $100M in annual funding resulting in over 3% of EM faculty being NIH-funded PIs. Achieving these goals will require a targeted series of focused strategies to increase the number of EM faculty who are competitive for NIH funding. This requires a coordinated, intentional effort with investments at the national, departmental, and individual levels. These efforts are ideally led by medical school department chairs, who can create the culture and provide the resources needed to be successful. The specialty of EM has the obligation to improve the health of the public and to fulfill its research mission.

Reach and Adoption of a Geriatric Emergency Department Accreditation Program in the United States

The objectives of this study were to describe the reach and adoption of Geriatric Emergency Department Accreditation (GEDA) program and care processes instituted at accredited geriatric emergency departments (EDs). We analyzed a cross-section of a cohort of US EDs that received GEDA from May 2018 to March 2021. We obtained data from the American College of Emergency Physicians and publicly available sources. Data included GEDA level, geographic location, urban/rural designation, and care processes instituted. Frequencies and proportions and median and interquartile ranges were used to summarize categorical and continuous data, respectively. Over the study period, 225 US geriatric ED accreditations were issued and included in our analysis-14 Level 1, 21 Level 2, and 190 Level 3 geriatric EDs; 5 geriatric EDs reapplied and received higher-level accreditation after initial accreditation at a lower level. Only 9 geriatric EDs were in rural regions. There was significant heterogeneity in protocols enacted at geriatric EDs; minimizing urinary catheter use and fall prevention were the most common. There has been rapid growth in geriatric EDs, driven by Level 3 accreditation. Most geriatric EDs are in urban areas, indicating the potential need for expansion beyond these areas. Future research evaluating the impact of GEDA on health care utilization and patient-oriented outcomes is needed.

Using the 4M Model to Screen Geriatric Patients in the Emergency Department

Several models of specialized geriatric care in the Emergency Department (ED) have been developed since the American College of Emergency Physicians (ACEP) began accrediting geriatric EDs in 2018. There is considerable variability in terms of both design and efficacy in regard to screening older patients in the ED and determining proper interventions The John A. Hartford Foundation and Institute for Healthcare Improvement (IHI) have developed the 4M Model for Creating Age-Friendly Health Systems which aims to provide high quality care to older patients by addressing four critical elements: Mentation, Mobility, Medication, What Matters. This article describes a screening tool for older patients based on the 4M model that has been developed and implemented by a Level 1 geriatric ED, as accredited by the ACEP. The purpose of this article is to highlight how this screening tool has helped facilitate care and follow up for older patients presenting to the ED and to discuss the possible implementation of this screening tool in other geriatric ED sites.

The age-old question: Thematic analysis of focus groups on physician experiences of aging in emergency medicine.

ObjectivesEmergency medicine has a demanding work environment. Characteristics influencing longevity among older physicians in emergency medicine have been the subject of ongoing discussion. The American College of Emergency Physicians (ACEP) released a policy statement in 2009 suggesting accommodating emergency physicians in preretirement years. We engaged emergency physicians to determine awareness of the ACEP policy and issues faced in preretirement years.MethodsWe conducted a series of online focus group discussions with a purposive sample of emergency physicians, age ≥ 50 years. The discussion guide was developed from the ACEP policy statement and relevant literature. Groups were audio recorded, transcribed, and analyzed with a thematic coding system developed iteratively by the 4‐person team. Emerging themes were identified, organized, and presented with illustrative quotations.ResultsA total of 28 emergency physicians participated in 4 focus groups, with between 6 and 9 participants in each group. These physicians had between 17 and 35 years of clinical experience (median = 27), 6 were female (21%), and the majority (n = 26, 93%) worked in academic emergency medicine. Only 1 emergency physician was fully aware of the ACEP policy. Three principal content areas were identified: workload demands that change as physicians age, wellness and physician social equity, and senior emergency physician value. Interwoven across all of these was the focus on leadership and solutions to issues. Issues facing emergency physicians in their preretirement years were identified; commitment from emergency medicine site and national leadership and buy‐in from junior colleagues was emphasized. Generational conflicts in recognizing the contribution and needs of preretirement emergency physicians was a major barrier to solutions.ConclusionsWorkload demands, wellness and physician social equity, and concerns about value as a senior physician are major themes confronting preretirement emergency physicians. Generational divides, deficits in local and national leadership, and the health detriments of rotating schedules and night shifts are barriers to longevity in emergency medicine. Further research on the value of senior physicians and the impact of hospital and departmental financial models on adopting accommodations for senior emergency physicians is needed.