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First of all, I’d like to thank ACEP members for allowing me to serve as your President since October. It has been a joy to do my part in advancing the specialty and continuing our efforts to improve your lives and the care of our patients. Each quarter, we’re going to offer a report about what we’ve been working on lately and some of the events that shaped emergency medicine. As you will read below, we have done a lot already in 2015, but a lot of important work is still to come over the next few months, particularly with legislation that directly impacts us and with our Clinical Emergency Data Registry. I look forward to visiting with many of you in Washington, D.C. in May.
SGR Repeal, EMTALA Legislation Top Advocacy List in Early 2015
Two major pieces of legislation kicked off the first quarter of 2015, beginning with the EMTALA Services Medical Liability Reform Bill in early February and continuing with an attempt to repeal the Sustainable Growth Rate in late March.
On Feb. 10, ACEP leaders joined Representative Charlie Dent (R-PA) at a news conference in Washington, D.C., to announce the introduction of the Health Care Safety Net Enhancement Act of 2015 — to improve emergency care for patients. H.R. 836 will encourage physicians and on-call specialists to continue their lifesaving work and ensure emergency medical care will be available for your constituents when and where it is needed. Specifically, the legislation addresses the growing crisis in access to emergency care by providing emergency and on-call physicians who provide EMTALA-related services with temporary protections under the Federal Tort Claims Act.
The Bill was referred to the House Energy and Commerce Committee. As of today, it has 32 co-sponsors, but we can use your help growing that number. Please click here to learn more, and please contact your Member of Congress and ask for support.
On March 26, the House approved a bill that proposed significant changes to the Medicare system’s reimbursement model. It signals what could repeal the Sustainable Growth Rate Formula. The New York Times called it the “most significant bipartisan policy legislation to pass through that chamber since the Republicans regained a majority in 2011.” If successfully passed, the bill would put an end to the recurring threat of payment cuts to physicians. The measure would also increase premiums for some higher income Medicare beneficiaries and extend the Children’s Health Insurance Program for two years.
Unfortunately, the Senate failed to consider the legislation on March 27 before adjourning for two weeks. Senate Democrats wanted a chance to consider several amendments to the House-approved bill, but Majority Leader Mitch McConnell (R-KY) did not agree to that request, instead stating he would work with Minority Leader Harry Reid (D-NV) during the recess to settle on a pathway forward as soon as the Senate returns on April 13, 2015. The Centers for Medicare & Medicaid Services has indicated that it will hold claims through April 14 to give Congress time to act.
We are disappointed the Senate failed to act before leaving town. We remain optimistic that, after fighting this battle for more than 12 years, we will finally rid ourselves of the flawed SGR permanently. We are calling for the Senate to act expeditiously as soon as they return and seize this opportunity to enact real, meaningful change in the Medicare program. Visit the ACEP Grassroots Advocacy Center to send a message to your Senators today.
Supreme Court Rules on Medicaid Rate Challenges
On March 31, 2015 the Supreme Court of the United States issued a ruling on the case of Armstrong vs. Exceptional Child Center. At issue was whether medical providers could sue over low Medicaid rates as a way to enforce federal payment requirements to assure that payments are consistent with efficiency, economy and quality of care sufficient enough to enlist providers so as to maintain adequate provider networks.
The opposing view was that such a ruling would result in endless litigation for higher pay and that Congress had not authorized such suits. The court was divided 5 to 4, ruling that providers do not have a federal cause of action to challenge low Medicaid rates. Instead providers with complaints must appeal to the federal government for enforcement.
ACEP has successfully used legal action in various states such as Louisiana, New York and Washington when the Medicaid plan offered unreasonably low payment, limited the number of ED visits for Medicaid patients, or restricted the approved diagnosis list so as to be unreasonable. Going forward, we will have to look to Congress or HHS regulatory staff to enforce Medicaid provisions, making strong relationships with your elected leaders important.
The ACEP Reimbursement Committee is considering whether a “white paper” should be developed to guide ACEP members and stakeholders regarding whether the Armstrong case could be distinguishable for emergency medicine. The issue is whether the “prudent layperson” provisions of the Balanced Budget Act of 1997 that apply to Medicaid HMOs and the ACA provisions barring prior authorization provide legal rights and/or remedies to emergency medicine that are unique and different from the legal basis presented by the plaintiffs in the Armstrong case.
American Hospital Association (AHA)
Publication Promotes Value of Emergency Care
In late March, the AHA issued a publication that highlighted emergency care’s value and role in the health care system. The report “explores the standby role and its critical importance to our nation’s health care system. It outlines the pressures hospitals face and frames critical economic and policy questions that must be addressed to ensure future hospital standby capacity can meet the growing health and public safety challenges.”
ACEP and the AHA worked together to issue a joint letter about the report, which was entitled “Always There, Ready to Care.” It was made available to all members. We encouraged ACEP members to share this report with key leaders and policy makers in your community and state and promote through social media. If you haven’t received a copy, click here.
ACEP Responds to Measles Crisis
On the heels of the Ebola crisis last fall, ACEP leaders and staff responded quickly to another epidemic when the United States experienced a record number of measles cases in early 2015.
This virus represents a challenge to Emergency Medicine because it is highly infectious and has been rarely seen in emergency departments in the recent past. ACEP developed a Fact Sheet about this disease for a review of its presentation, clinical course and implications for the ED. Emergency physicians and other health care professionals can visit acep.org/measles for more information and for new resources, which will be added as needed.
- Comment Period on tPA Clinical Policy Closed March 13: Early in 2015, ACEP opened a 60-day comment period on the draft clinical guideline: “Clinical Policy: Use of Intravenous tPA for the Management of Acute Ischemic Stroke in the Emergency Department.” The next step is for the Clinical Policy Committee to review comments and draft a revision as appropriate to submit for ACEP Board approval.
- Mental Health, Substance Abuse Patient Care Resources Added to ACEP’s Website: In early January, ACEP combined numerous mental health and substance abuse resources at www.acep.org, anchored by the Emergency Medicine Practice Committee’s information paper on “Care of the Psychiatric Patient in the ED: A Review of the Literature.” Included on this new resource page was also information about sobering centers, ACEP Policy Statements, Patient Resources and more. See these resources here.
- ACEP Releases New Publication, Cardiovascular Emergencies: More than 6 million people present to EDs each year with chest pain and forms of cardiac disease—arrhythmias, infections and cardiovascular complications from other conditions. ACEP’s newest publication, Cardiovascular Emergencies, provides information to help you deliver efficient and cutting-edge care to patients who present with acute cardiovascular conditions. Learn more.
- EMRA Launches Updated PressorDex App: Newly revised and updated for 2015, PressorDex is a comprehensive therapeutic guide to the myriad of pressors, vasoactive drugs, continuous infusions, and other medications needed to treat the critically ill patient. Written by emergency medicine physicians for emergency medicine physicians, this app gives you concise tools for choosing the right medication and dosing regimen every time, even during the busiest of shifts. Find it and other useful EMRA apps here.
- Qualified Clinical Data Registry Work Continues: ACEP announced last year that it would begin work on a Qualified Clinical Data Registry (QCDR). This is a very complex project, but it will position emergency medicine to develop quality measures that will resonate with members and, we believe, improve quality. We can develop measures that apply to patients beyond the Medicare population. As Executive Director Dean Wilkerson, JD, MBA, CAE, wrote in the December issue of ACEP Now, “If we have our own QCDR, we can control the playing field and develop measures we believe are appropriate without having to submit them to the National Quality Forum for other groups to approve. Rather than having measures imposed on us, we will drive the measures ourselves.” Quality measure reporting and quality improvements are of increasing importance for physician reimbursement. ACEP’s QCDR will allow our members to avoid cuts to their reimbursement and obtain incentive payments. The initial testing and QCDR approval phase began in February 2015 with the participation of five emergency departments. The pilot phase is expected to begin in May of 2015. Through the aggregation and organization of data on clinical effectiveness, patient safety, care coordination, patient experience, efficiency and system effectiveness, ACEP’s Clinical Emergency Data Registry will provide clinicians with a definitive resource for informing and advancing the highest quality of emergency care. ACEP expects final approval of its Quality Measures and our QCDR later this month. Learn more about CEDR.
- End of Life/Advance Care Planning: A task force led by Vidor Friedman, MD, FACEP, Mark Rosenberg, DO, MBA, FACEP, FACOEP-D, and Sandy Schneider, MD, FACEP, has been assembled to prepare a white paper within the next few months to make recommendations to the Board on our next steps to promote a national discussion on EOL/AC issues.
- Psychiatric Emergency Care Initiative: We have already had our first summit of stakeholder organizations and have created COPE – “Coalition on Psychiatric Emergencies.” ACEP is a leader on the Steering Committee, and subcommittees have been created to: address education of the public and caregivers, study the latest advances in diagnosis and treatment, develop a research agenda, and configure an advocacy approach for true parity of care for psychiatric emergencies. In addition, we are working on a public relations release in the next few weeks announcing our mission and the stakeholders. Sandy Schneider, MD, FACEP, along with Barbara Tomar and Cynthia Singh of our staff are leading this effort.
- Sepsis Task Force: We have a task force led by Board Member John Rogers, MD, FACEP, Task Force Chair Don Yearly, MD, and Sandy Schneider, MD, FACEP, to review all of the current literature and summarize it for our members to use. We will also have an educational campaign for our members and other organizations highlighting our role in diagnosing and initiating treatment of sepsis to a point that we, Emergency Medicine, will “own sepsis.” We want to simplify sepsis management and also develop quality measures to be used by EP’s.
Join us in Washington, D.C. this May
The Legislative Advocacy Conference and Leadership Summit is coming up May 3-6 in Washington, D.C., and has been revamped for 2015. Don’t worry. The same excellent education will be available, but the schedule has been changed slightly to emphasize the unique opportunities available at this event. Sunday’s Leadership Essentials, presented by EMRA and the Young Physicians Section, is particularly appealing to those just getting started in advocacy and developing leadership skills. Monday is packed with the latest information about policy, payment models, innovation and much more.
Tuesday is Capitol Hill Day, when more than 500 emergency physicians head to the House and Senate office buildings to advocate for pending legislation and the need for reforms to strengthen emergency medicine and improve access to better patient care. Wednesday is a full day of leadership training and includes valuable CME courses. Please don’t miss this conference. I love our annual meeting in the fall, but this conference offers a chance to spend some time with people in a much more intimate setting while doing some excellent and crucial work for our specialty.
I’ll see you in Washington. Click here for more information.
Dr. Steven Stack to Take Over as AMA President
By the time our next quarterly update comes around, Steven Stack, MD, FACEP, will be the AMA’s 170th President. Dr. Stack takes over in June at the AMA annual meeting. He is the first emergency physician to ever hold that position, and when he assumes office, he will be the youngest president in the past century.
Dr. Stack currently practices in Lexington and surrounding central Kentucky. He has served as medical director of multiple emergency departments, including St. Joseph East (Lexington), St. Joseph Mt. Sterling (rural eastern Kentucky) and Baptist Memorial Hospital (Memphis, Tenn.). Born and raised in Cleveland, Dr. Stack graduated magna cum laude from the College of the Holy Cross in Worcester, Mass., where he was a Henry Bean Scholar for classical studies. He then returned to Ohio, where he completed his medical school and emergency medicine residency training at the Ohio State University before moving to Memphis to begin his clinical practice.
An expert in health information technology, Dr. Stack speaks on behalf of ACEP and emergency medicine at numerous events and conferences throughout the year and delivered the Rorrie Lecture last year at our annual conference.
We appreciate his efforts and congratulate Dr. Stack for his important new position.
New Headquarters Groundbreaking Set for April 16
I’m excited to announce that we will break ground on a new headquarters on April 16 on a six-acre tract of land near the Dallas-Fort Worth International Airport.
The new building will be three stories with approximately 57,000 square feet. This building will have all the things we do not have in our current building, including many member amenities, work areas, top-notch A/V capabilities and video conferencing, a small media room for filming and interviews, history recognition throughout the building and celebration of our specialty.
We have outgrown our space and comparison studies of other professional societies underscored what we expected – our outstanding staff is working under less than desirable conditions, especially as we grow in membership and management responsibilities (SEMPA, EMRA, CORD, EMF). A new building is also symbolic or our coming of age as a recognized and MAJOR specialty. We need advances in our headquarters for our staff and volunteers to serve our members and our patients.
This new building’s location is also nestled between two major hotels, allowing us to offer better service to our chapters and groups that use the national office for meetings and training, such as the Emergency Medicine Basic Research Skills (EMBRS) courses and the Emergency Medicine Foundation grant projects. The Texas chapter also uses our building for meetings, and this will assist in their efforts. There are other educational meetings ACEP may hold in this new building.
We have been in our current building for more than 30 years, and it has served us well. Our specialty is much different now, and this new headquarters is necessary for future growth.
Thanks for allowing me to update you on recent projects and offer a little about what’s coming around the corner. If you need anything, please don’t hesitate to contact me.
Dr. Michael Gerardi
By Nell Harrison
Scott Weingart labeled smacc the “Best conference ever” but is it really worthy of all the hype?
In the past two decades we have seen the Information, Technology and Communication revolution. In 2015 we can access the internet almost anywhere on our smart phones and tablets to connect with each other. The way we communicate and share information is changing. Social media platforms like “YouTube” and “Twitter” enhance the dissemination of learning material but more importantly they provide the opportunity for a two conversation between the teacher and student. We should ask ourselves then how can this new era of communication facilitate learning, particularly at critical care and emergency medicine conferences?
Smacc (Social media and Critical Care) so named because it is powered by a collaboration of FOAM (Free Open Access Meducation) websites from around the world, is truly different. It is a high power critical care conference but more importantly it is inspirational, informative and innovative. The collective experience gained growing these websites has guided the program formation.
There is energy at smacc that not only augments the learning atmosphere but it recharges our commitment to critical care. In the words of one delegate from #smaccGOLD 2014: “This was the first conference where I not only learnt plenty, but I came away proud to be a professional in critical care. I feel excited about taking all this back to work!”
Here are 10 reasons you should consider smacc Chicago in June 23-26 2015.
1: Speakers – The speakers are hand picked from both the FOAM world and the conventional conference circuit because they are inspirational leaders in their fields. http://www.smacc.net.au/speakers/
2: Topics – The sessions are delicately pieced together to cover issues from hard core medical science and research to education and end of life care, but more critically they embrace controversy. http://www.smacc.net.au/program/
3: Format – The style has an informal open feel that encourages a two-way conversation, which is further enhanced by the integration of social media into the sessions.
4: Community – smacc brings together all the critical care community together from Pre-Hospital/Emergency/Critical Care and Anaesthesia.
5: Excitement – The energy at smacc powers a vibrant atmosphere
6: Networking – All breaks and lunches are catered free to provide a relaxed atmosphere for delegates to come together
7: Social – All social functions are included in the registration to bring all delegates together as part of one critical care community
8: Workshops – Over 30 pre-conference workshops cater for every need from communication and debriefing to Airway and Ultrasound http://www.smacc.net.au/program/workshops/
9: Post-conference – All sessions at smacc are podcast and released FREE in a serial fashion over 6 months post conference as part of FOAM http://www.smacc.net.au/the-talks/
10: Not for Profit – smacc is administered by a charitable trust and no individual benefits financially
The theme for smacc Chicago is smaccFEST, because it is more than a conference, it is a festival. Smacc is a celebration of medical science, knowledge, education, ideas, community and innovation united by a love of practicing critical care. There are already over 1,300 delegates and many pre-conference workshops have sold out. Get more information here.
The Clinical Policies Committee of ACEP has completed a draft clinical guideline: “Clinical Policy: Use of Intravenous tPA for the Management of Acute Ischemic Stroke in the Emergency Department.” Since the 2012 clinical policy on IV tPA, there have been changes to the clinical policies development process, the grading forms used to rate published research have continued to evolve, and some newer research articles have been published.
The draft is now open for comments until March 13, 2015.
To view the draft policy and comment form, Click Below:
Clinical Policy Comment Form – Intravenous-tPA
For questions, please contact Rhonda Whitson at email@example.com.
As relieved as we are that the Ebola outbreak appears to be limited and less of a daily concern in our emergency departments, we do still remain on alert for the outbreak of other infectious diseases. It’s been very gratifying to see several ACEP members who are subject matter experts in infectious disease step up and help us create the resources we’ve posted on ACEP.org for the entire emergency medicine community. Among those experts are Kristi Koenig and Carl Schultz from the University of California at Irvine. They’re working on a new edition of their book on disaster medicine and realized that the chapter on emerging infectious diseases would be very useful to us all right now. As they said,
“The emergency health care system must be prepared for an evolving public health event of international significance such as this. Emergency physicians are on the front lines and should be knowledgeable, up-to-date, and ready to effectively manage infectious disease threats. It doesn’t matter whether such threats arise from Ebola virus disease, Enterovirus D-68, MERS-CoV, SARS, the 2009 H1N1 pandemic, or the next big event, as yet unnamed. We should be leaders in our hospitals, EMS systems, and communities, advocating for protection of the public health, our patients, and colleagues.”
Kristi and Carl have donated a preliminary electronic draft of that chapter to the College – to all of you, really – as a resource to help you and your team prepare to screen for and treat the wide range of infectious diseases any of us could see any day of the week.
Just follow this link to download the chapter now.
Best wishes to you all, and be well. We hope to see you next week in Chicago for ACEP14.
Alex M. Rosenau, DO, CEP, FACEP
Micahael J. Gerardi, MD, FAAP, FACEP
With so much information and speculation being circulated about Ebola presentations in the United States, I want you – our members – to know what your College is doing on this issue.
The landscape about treatment and containment of this infectious disease is changing minute by minute. ACEP has been working in many ways to filter the information and provide you with a trusted source of updates. We also have many initiatives planned for next week, next month and beyond as we continue to help you in these challenging times and be a supportive advocate for our specialty and our patients. Advocating for your safety and making sure you have everything you need are our most important goals.
Here are some of the things we are doing:
- Immediately convene a panel of 8 emergency care infectious disease experts.
- Review materials pertinent to emergency care for dissemination to members.
- Respond to questions posted by members via an easily accessible form on the www.acep.org/ebola resource page.
- Develop repository of best practices for managing the patient with suspected and confirmed Ebola and work with CDC, WHO, and other federal, state and local agencies to develop protocols that can be implemented in hospitals with limited resources. Update the content regularly.
Resources on ACEP Website
- Consolidation of pertinent resources, including those from the Expert Panel, on www.acep.org/ebola with frequent updates.
- Continue to promote availability of resources through social media, e-newsletters and other communication vehicles.
Identify short and long-term legislative initiatives designed to assist our members and other health care providers to enhance their disaster preparedness:
- Advocate for regionalization protocols
- Enactment of trauma systems/emergency regionalization legislation
- Funding of a national grid of bio-containment hospital annexes,
- Increase funding for disaster preparedness
- Increase supplies of PPEs
- Additional resources for training and retention of first responders
- Good Samaritan liability protection for first responders in a national emergency
Communications with Members
- EM Today curates the media daily for a round-up of the most pertinent articles and editorials.
- Immediate dissemination of important information through social media, e-newsletters and stand-alone messages.
- Section listservs include the latest updates and guidelines from CDC to some of the most impacted sections – Air Medical Transport, Disaster Medicine, EMS-Prehospital Care, and Tactical Emergency Medicine.
- EMS Committee review of CDC guidelines to consider operational ‘suggestions’ on meeting the requirements or model practices.
Communication with the Public and the News Media
- Linking reporters with ACEP experts in infectious disease and disaster preparedness. ACEP is managing 10 to 20 calls a day from reporters on this issue. (a round-up of ACEP spokesperson in the news can be found at http://www.acep.org/Content.aspx?id=80956)
- Coordinated editorial about Ebola response for ACEP President Dr. Alex Rosenau published in USA Today.
- Developed talking points for use by ACEP spokespersons to conduct press interviews.
- Using responses from ACEP infectious disease and preparedness experts to craft public messages.
- New course on Ebola infection and emergency department response added to ACEP14 — “Ebola: Hemorrhagic Fever and the U.S. Experience” will be presented Tuesday, October 28, during ACEP14, the world’s largest meeting of emergency physicians.
- ACEP14 Ebola Courses – Three presentations from ACEP14, October 27-30, will be captured live and presented as free courses in ACEP eCME, the College’s online and mobile education platform to members and other EM colleagues. Each of the three courses will have a pretest, an audio and slide presentation of the lecture as it was delivered live in Chicago, and a post-test. Each of the courses also is approved for AMA PRA Category 1 Credit.™The courses are:
- Inside the Hot Zone: Highly Infectious Pathogens in the ED / David C. Pigott, MD, RDMS, FACEP, will identify those pathogens—including Ebola and anthrax—that are most likely to be encountered in the ED as well as those that present the greatest risk for health care providers and other personnel. This case-based review will include a discussion of appropriate barrier precautions, including personal protective equipment, as well as departmental and hospital-based infectious disease transmission precautions.
- Ebola: Hemorrhagic Fever and the U.S. Experience / David C. Pigott, MD, RDMS, FACEP; and Alexander P. Isakov, MD, FACEP will discuss the risk factors for exposure to the Ebola virus, the clinical features associated with, and considerations for, evaluation and management of patients with suspected or confirmed Ebola virus disease (EVD). They will highlight the most recent recommendations for infection control and prevention applicable for healthcare workers in both the out-of-hospital (EMS) and emergency department setting. Participants will be provided a framework that permits the delivery of optimal care to this special patient population while minimizing risk to members of the healthcare team.
- Infections From Abroad: Unwanted Souvenirs / Ever heard about “airport malaria?” Should you be worried about that “funny rash” on the Ugandan businessman? What medical advice do you give your sister who is planning a trip to Vietnam? Swaminatha Mahadevan, MD, FACEP, will identify infectious hotspots around the world and highlight “must-know facts” about travelers and visitors from these areas. In addition, find out what precautions travelers should consider as they plan their next great adventure abroad.
- “Emerging Infectious Diseases: Concepts in Preparing for and Responding to the Next Microbial Threat” – Two of the nation’s experts in disaster medicine, Kristi Koenig, MD, FACEP, and Carl Schultz, MD, FACEP, along with Cambridge University Press, have donated the “rough cut” of this chapter from the second edition of their book, Koenig and Schultz’s Disaster Medicine: Comprehensive Principles and Practice to help emergency physicians care for patients with a wide variety of emerging and re-emerging infectious diseases. It will be posted on the ACEP Ebola Resources page (www.acep.org/ebola) by Oct. 24, 2014. The chapter covers many diseases and a variety of issues such as resource allocation, preparedness training exercises, personnel, communications, and much more.
- “Innovations in Patient Safety Presented by ACEP, Urgent Matters, and the Emergency Medicine Patient Safety Foundation” is a 5-hour conference scheduled for Sunday, Oct. 26, in Chicago. It will be captured live, and the portions addressing error prevention in the care of infectious diseases such as Ebola will be made available as another free educational resource.
- “ACEP Advanced EMS Practitioners’ Forum and Workshop” is another education event scheduled for Oct. 26, in conjunction with ACEP14. It, too, will be recorded so that information related to prehospital response and precautions in infectious disease can be disseminated to a larger audience. There will be three presentations on Ebola and the Dallas experience.
- “Fighting Ebola by Design” is a 10-minute EDTalk in the innovatED space presented by HKS/MI2. These companies were involved in Project ER One, which was federally funded to develop design features for ED’s to address terrorism, disaster and epidemics of emerging diseases. Innovative design features developed for ER One will be presented, as well as how one can mitigate the risk of infection transfer. Key features of design and new technology will be discussed. This talk will be videotaped and made available to the public as soon as possible after the conference.
- Ebola response survey being developed for dissemination through our Emergency Medicine Patient Safety Network (EMPRN) to gather data on preparedness for Ebola, EV-D68 and other infectious diseases. Members will be asked about their need for education/resources/assistance from ACEP and/or government sources to effectively respond to an Ebola case in their hospital.
- Surveyed the Disaster Medicine Section, EMS Committee and Section and ACEP infectious disease experts about response needs and preparedness
Work with Other Organizations
- Meet with high-level officials at the CDC.
- Convene a meeting(s) with the American Hospital Association, Emergency Nurses Association, National Association of EMS Physicians, Emergency Medicine Residents’ Association, and other key stakeholders for information/resource sharing.
- Work with additional federal agencies, such as National Institutes of Health, Assistant Secretary for Preparedness and Response, Emergency Care Coordination Center, Department of Homeland Security, and National Highway Traffic Safety Administration, to develop resources for infectious disease response.
- Share information with top officers of the American Medical Association and other groups.
Regionalization will be a key discussion point in all conversations.
Alex M. Rosenau, DO, CPE, FACEP
Click here to get the shiny new October issue of the audio/podcast for Annals of EM.
-Patient satisfaction: is it a marker of quality care? NOPE
-Pediatric appendicitis: can EPs accurately use bedside sono?
-Navigating online EM resources: 5 tips
-Steroids for bronchiolitis: yes or no
Enjoy the ACEP 2014 SA in Chicago, find us and say ‘hello’. Also, email firstname.lastname@example.org any time.
ps We forgot to post it on Central Line, but Sept is up as well — download and listen, it’s a good one.
Emergency physicians from top organizations representing emergency medicine traveled to Washington, DC, this week to meet with Ben Harder, managing editor and director of health care analysis at US News & World Report and Dr. Nate Gross, co-founder of Doximity, an online social networking service for U.S. physicians that conducts surveys for US News.
The purpose of these meetings was to convey the concerns of nine emergency medicine organizations about the results of a Doximity survey, which was promoted by US News & World Report, identifying the nation’s top emergency medicine residency programs.
Prior to the meeting, emergency physicians from the nine organizations held a conference call and developed a joint letter to US News and Doximity challenging the sampling method and the implications of providing misleading information to medical students and the public.
Four physicians represented the group at these meetings:
- Hans R. House, MD, FACEP, ACEP board member
- Jeffrey N. Love, MD, MSC, president, Council of Emergency Medicine Residency Directors
- Jordan Celeste, MD, president, Emergency Medicine Residents’ Association
- Mark Mitchell, DO, FACOEP, president, American College of Osteopathic Emergency Physicians
During the meetings, the physicians conveyed that the results:
- Are misleading to medical students because they are not based on objective criteria.
- Are not useful to medical students because residency choices are made for many reasons, including geography, which are not factors in the Doximity survey.
- Are not an accurate portrayal of residency programs because they are based solely upon opinions expressed by physicians who have no first-hand knowledge of any residency training programs other than the ones they attended.
- Do not reflect the unique nature of emergency medicine.
- Send a dangerous public health message to patients having medical emergencies.
The physicians conveyed there is potential value in a secure data service for communicating HIPAA-compliant messages among emergency physicians. Also, a resource that provides detailed information on residency programs and their alumni could help medical students in making decisions about their applications to specialty training. However, the collective organizations that represent all of emergency medicine could not support the data as long as the rankings were included. Both US News and Doximity agreed there were significant limitations of the data and discussed the challenges of developing objective measures for emergency medicine, because it is a unique medical specialty. Both also agreed that these data would not be promoted to the general public.
The editor at US News described the new organiza
tion’s publications that rank hospitals and medical specialties as “consumer decision support,” which are intended to help members of the general public make decisions about where to seek care for complex medical problems. Emergency medicine has never been included in these rankings in the past, and there are no plans to begin doing so. The editor conveyed that US News recognizes that, in a medical emergency, the best place to get care is the nearest emergency department.
The physicians asked to provide a companion piece to the US News article about the results. The editor agreed to review and publish, if acceptable. The co-founder of Doximity offered to discuss these issues with leaders in his organization and suggested further discussion at ACEP 14 in Chicago.
The following organizations are participating in this effort:
- American College of Emergency Physicians
- American Academy of Emergency Medicine
- American Academy of Emergency Medicine Resident and Student Association
- American Board of Emergency Medicine
- American College of Osteopathic Emergency Physicians
- Association of Academic Chairs of Emergency Medicine
- Council of Emergency Medicine Residency Directors
- Emergency Medicine Residents’ Association
- Society for Academic Emergency Medicine
ACEP and the leaders of other medical specialties representing emergency medicine, have taken issue with a recent survey of emergency medicine residency programs, by US News & World Report and Doximity. Below is a letter from Dr. Rosenau to US News & World Report.
September 12, 2014
Mr. Ben Harder
Managing Editor and Director
Health Care Analysis
US News & World Report
105 Thomas Jefferson Street, NW
Washington, DC 20007
Dear Mr. Harder:
As leaders of the top organizations representing emergency medicine, we have been contacted by scores of emergency physicians from around the country about a survey being conducted by Doximity and publicized by US News and World Report. We appreciate your recognition of emergency medicine as an academic medical specialty with a unique core of knowledge and robust research agenda.
However, we are concerned about the sampling method chosen for this survey, because we believe it will fail to achieve your objective for this survey — to identify America’s top emergency medicine training programs. Asking only physicians enrolled in a social media website to nominate their five most preferred residencies will result in egregious sample bias and is not capable of resulting in a scientifically valid result. The results will be based solely upon opinions expressed by physicians who have no first-hand knowledge of any residency training programs other than the ones they attended themselves.
While not a formal ranking of residency programs, the results would convey that some programs provide better training than others. However, given the limitations, this would not be an accurate portrayal — to medical students or to the public. It also would not be useful to many medical students, because research shows that more than 75 percent of emergency physician residents report the number one reason for selecting a residency program is geography.
More concerning, the results could send a dangerous public health message to people with medical emergencies. It implies they should consider bypassing hospital emergency departments with residency programs that fared poorly in the survey. In a medical emergency, people should seek emergency care at the nearest emergency department, not one that scored better on a highly subjective opinion survey.
Patients need confidence in their physicians in times of crisis, especially since comparison shopping among doctors is not an option when someone is having a medical emergency. Emergency medicine residency programs train physicians in the emergent and acute conditions of just about every medical specialty in health care. As a result, emergency physicians are uniquely qualified to handle a full range of adult and pediatric emergencies. In addition, they see every kind of human drama imaginable, often treating multiple patients at a time.
The overall quality of medical care delivered in emergency departments in the United States is excellent, thanks to the uniformly high standards that govern the accreditation of residency programs in emergency medicine. Emergency medicine residencies collaborate openly with shared curricular tools built around a core model of clinical practice, an approach that is fairly unique in medical education. Ranking training programs above others is contrary to the principles of our specialty, although we recognize that certain programs are best suited for certain trainees.
Many factors contribute to a successful residency program, not all of which can be measured or compared. If your target audience is medical students contemplating a career in our field, we would be happy to work with you to identify objective, measurable factors to help students find the best program for their individual needs.
Unfortunately, our organizations, which represent more than 40,000 emergency physicians, could not recommend or encourage participation in the current survey by emergency physicians. We would, however, be happy to meet with you and help to identify the parameters that might better accomplish that purpose. If you are interested, please contact Marjorie Geist at 800-798-1822, ext. 3290.
Alex M. Rosenau, DO, CPE, FACEP
President, American College of
Meaghan Mercer, MD
President, American Academy of Emergency
Medicine Resident and Student Association
Mark Mitchell, DO, FACOEP
President, American College of Osteopathic
Jeffrey N. Love, MD, MSc
President, Council of Emergency Medicine
Jordan Celeste, MD
President, Emergency Medicine Residents’
cc: Avery Comarow, Health Rankings Editor
By Andrew E. Sama, MD, FACEP
With nearly two-thirds of all admitted septic patients presenting to the ED, and with the clear time sensitivity that exists between recognition, treatment, and outcomes, our members are on the front lines to save lives from this frequently fatal disease. In the CY 2015 IPPS rule, in which CMS cited the fact that “that patients admitted through the ED had a 17% lower likelihood of dying from sepsis than when directly admitted,” CMS finalized NQF #0500: Early Management Bundle for Severe Sepsis and Septic Shock, which mandated the invasive monitoring of CVP and ScVO2 via the placement of a central line in the ED. However, late on Friday, CMS notified hospitals, that it will suspend data collection for the Severe Sepsis and Septic Shock: Management Bundle measure (NQF #0500) until further notice.
Emanuel Rivers, MD, MPH, and his team improved mortality and raised the awareness of the EM community about sepsis through their Early Gold Directed Therapy (EGDT) study in the early 2000s. A few years later, the measure was initially endorsed by the NQF in 2008 without the requirement for a central line for the emergency department. While it is certain that early intervention does reduce mortality, not all elements of the sepsis composite bundle were equally evidence-based. Many studies over the years have demonstrated dramatic improvements in sepsis-related mortality after the implementation of early interventions for septic patients, which included early antibiotic administration, source control, and aggressive fluid resuscitation without invasive monitoring of CVP and ScVO2. One study addressing this, authored by Dr. Alan Jones and colleagues, was conducted at three EDs in the US, and compared two protocols that both included central venous pressure measurement; however, one used lactate clearance and the other used central venous oxygenation monitoring as a way to guide resuscitation. Dr. Jones’ 2010 study found no differences in mortality, suggesting that using central venous oxygenation to guide resuscitation may not be necessary.
In 2012 the measure underwent routine NQF maintenance review for re-endorsement in 2012-2013. During those proceedings, under the leadership of David Seaberg, MD, FACEP and myself ACEP commented that central venous pressure (CVP) was not the only reliable measure of intravascular volume. Several members of ACEP’s Quality and Performance Committee (QPC) including chair Jeremiah D. Schuur, MD, MHS, FACEP, Michael Phelan, MD, RDMS, FACEP, Todd Slessinger, MD, FACEP, FCCM, FCCP, Christopher Fee, MD, FACEP, and others testified on conference calls and at in-person meetings, that there were equally effective and less invasive methods for monitoring septic patients. Nonetheless, the NQF endorsed the requirement for the central line, noting that they would re-consider if additional evidence warranted it.
Within a few months the Protocolized Care for Early Septic Shock (ProCESS) trial was published on March 18, 2014 and under Dr. Alexander Rosenau’s leadership ACEP immediately requested that NQF #0500 undergo an ad hoc review given the impact that this new data would have on this quality measure. After reviewing the data from the ProCESS trial, NQF questioned whether NQF #0500’s item ‘F’, which measures central venous pressure and central venous oxygen saturation, should be retained or removed from the measure. During the review, one of the PIs, Donald Yealy, MD, FACEP engaged in a scientific debate noting that the ProCESS trial enrolled 1,341 patients, with a power to detect a 6-7 percent absolute difference, yet demonstrated no difference in mortality 60-day mortality 90-day mortality, one year mortality, or the need for organ support. The ProCESS also noted no benefit in any outcome when using CVC- guided care and the simpler approaches that stressed early and ongoing care produced the same good outcomes.
CMS, NQF, and others are now also convinced that honing the sepsis bundle is a move forward for our septic patients, with or without invasive monitoring depending on the progression of their disease, their unique circumstances, and the resources available at the ED where they are being treated. As it is ACEP’s mission, we will continue to advocate on behalf of our patients presenting with a diagnosis of sepsis to ensure that they receive the highest quality of emergency care. We look forward to continuing to work with the measure developer to ensure that all septic patients receive the timely, effective care they need, and to continue to save lives from this deadly disease.
Dr. Sama is ACEP’s Immediate Past President and Chair of the Board of Directors
In a recent newsletter, the American Hospital Association informed its members of a change by CMS as it relates to data collection for severe sepsis and sepsis shock. Below is the CMS announcement.
The Centers for Medicare & Medicaid Services (CMS) is notifying hospitals participating in the Hospital Inpatient Quality Reporting (IQR) Program that it will suspend data collection for the Severe Sepsis and Septic Shock: Management Bundle measure (NQF #0500) until further notice. This measure was adopted for the FY 2017 payment determination in the CY 2015 IPPS final rule.
CMS continues to believe that this is an important area for measurement given mortality rates that range from 16-49% and that sepsis is one of the top 10 most common principle causes for hospitalizations. Further, through surveillance of early effective treatment of severe sepsis or septic shock, hospitals will not only know where in the sequence of steps to treat severe sepsis and septic shock patients, but also begin to decrease mortality related to sepsis and the costs associated with inefficient care of severe sepsis and septic shock patients. With this measure CMS will gauge if care of severe sepsis and septic shock patients is improving.
This measure was initially endorsed by the NQF in 2008 for the hospital/acute care facility setting and underwent routine NQF maintenance review for re-endorsement in 2013. During the 2013 NQF endorsement proceedings it was noted that should new data be published related to the measure, that the measure would undergo an ad hoc review. With publication of the Protocolized Care for Early Septic Shock (ProCESS) trial in early 2014, NQF #0500 underwent an ad hoc review to discern if the new data would impact the measure as currently designed. After reviewing the data from the ProCESS trial, NQF questioned whether NQF #0500’s item ‘F’, which measures central venous pressure and central venous oxygen saturation, should be retained or removed from the measure. During the review two other trials were identified that might also impact NQF #0500, those trials are the Australian Resuscitation in Sepsis Evaluation Randomized Controlled Trial (ARISE) and The Protocolised Management in Sepsis Trial (ProMISe). After much discussion of the results of the ProCESS trial, the potential impact the ARISE and ProMISe trials may have on the measure, and the recommendations to remove item ‘F’ from the measure, NQF recommended that measure stewards collaborate with other stakeholders to reach a compromise on NQF #0500’s item F. NQF recommended that measure developers collaborate with other stakeholders to reach a compromise on this specific element of NQF #0500 measure.
Given forthcoming research and NQF’s recommendations, with potential changes to the measure, CMS will delay data collection for the measure until further notice. The duration of this suspension pending further information from the measure developer has not yet been determined. This delay does not affect the data collection period for any other Hospital IQR Program measures.