Archive for October, 2012

ACEP ‘Chooses’ Differently, Opts for Alternative Approach to Find Cost Savings

[This article will be published in the November issue of ACEP News. See the entire ACEP News libary online at]

After considerable debate, the ACEP Council voted this month to refrain from participation in the national “Choosing Wisely” campaign in large part due to the other efforts being taken by ACEP to achieve the same and even larger goals.

“Choosing Wisely” is part of a multi-year effort of the American Board of Internal Medicine (ABIM) Foundation to help physicians be better stewards of finite health care resources, according to its website. As part of the campaign, specialty organizations identify five tests or procedures commonly used in their field, the necessity of which should be questioned and discussed by patients and physicians.

ACEP had considered joining this campaign three distinct times since its launch in December 2011. Three different workgroups of various ACEP members, committees and Board members looked at the campaign and decided that while the concept is positive, the scope of listing tests, especially for emergency physicians, was too narrow.

Despite this extensive review by ACEP members, a resolution was submitted by the New York Chapter asking the ACEP Council to decide if ACEP should join the “Choosing Wisely” campaign.

As part of the Council process, resolutions are first debated in a reference committee where members of the Council provide background about the resolution, give testimony to its merit or explain reasons why it should not be adopted.  It was standing room only for the debate about this resolution and discussion was spirited. The debate continued the next day with many of the same reasons echoed on the open floor of the Council with mroe than 300 voting members in attendance.

Those in support of ACEP joining the campaign said that 26 medical specialties (except for emergency medicine and anesthesia) have joined or committed to participate. They added that participating could give ACEP more national visibility and bargaining power, and that ACEP could use its participation to educate other specialties about emergency medicine’s particular challenges.

Those opposed to ACEP joining the campaign said that the Choosing Wisely campaign does not involve any negotiation with others in medicine, and that it could lead to unintended consequences, including a lack of liability protection, vulnerability to the False Claims Act and automatic payment denials from insurance companies based on tests that the campaign deems to be “unnecessary.” 

One large concern was that the intent of the campaign had already eroded, with several specialties offering only minimal savings and stepping outside of their field and including tests on their lists that are outside the scope of their practice.

The issue generated strong feeling on both sides and the majority of the Council ultimately decided to refrain from participation.

ACEP already had opted to strive to identify cost savings measures without compromising patient care. Three task forces were established in 2012 to work toward this idea – the Cost Effective Care Task Force, the Delivery System Reform Task Force, and the Transitions of Care Task Force.

ACEP’s Cost Effective Care Task Force is developing recommendations on ways to reduce costs in emergency care. Through member surveys, a Delphi approach, and use of the Emergency Medicine Practice Research Network (EMPRN), this group will not only consider unnecessary tests and procedures but also processes with emergency care that might represent meaningful cost savings while improving patient care. This task force is expected to complete its work and offer its report to ACEP’s Board in February of 2013.

It is hoped that these reports of significant recommendations can fuel a public campaign and support health policy advocacy concerning how emergency physicians are not just making a list of tests to cut, but instead are looking at much larger initiatives, processes and transitions that could result in real health care savings while improving patient care.

The Delivery System Reform Task Force gave its report to the ACEP Board of Directors on Oct. 5. It can be found online at

“The emergency department remains at least one of the reasonable solutions for addressing many of the health care system’s most vexing problems from a delivery system perspective,” the report states. “Emergency physicians are well positioned to provide innovation and leadership across the acute care continuum. Even from the perspective of employers, the patients, and payers, the allegedly high cost of care is incompletely characterized, often misconstrued, and lacks sufficient perspective in the broader context of community economics and the health care delivery system itself. Addressing these dynamics will require significant and intensive efforts to bring data, information, and solutions to a delivery system in rapid evolution.”

In addition to efforts that should be continued, the report also lists several recommendations of efforts that should be started or enhanced, including information sharing to primary care providers (and specialists), care coordination for high-cost users, regionalization of patient care resources (mobile technology, telemedicine), cost effective alternatives to hospital admission and others.

The report also recommends efforts that should be stopped or reduced (because emergency physicians are not trained or resourced for it, or could be more efficiently delivered in an alternative setting), such as longitudinal care for chronic illnesses, primary preventative care, non-value driven convenience care, and treatment of medical conditions that have no incremental benefit to the patient or value to the system.

The Transitions of Care Task Force also developed an information paper that was submitted to the ACEP Board of Directors in draft form on Oct. 5. When it is finalized, it will be announced to ACEP members and posted on ACEP’s website.

The Task Force paper notes that “The emergency department has an important, in fact pivotal, role in transitions of care and can enhance its value to the system by implementing more successful transition programs. As the emphasis and oversight of quality and cost increase, successful coordination of patients’ journeys through the health care system will help advance the triple aim of better population health, better patient experiences, and reduced cost to the system. “

To achieve this goal, the Transitions of Care Task Force made several recommendations, including

  • improve residency training and continuing professional development for emergency physicians on the importance of handoffs in effective transitions of care
  • work with emergency department information system vendors to produce transition support tools
  • identify strategies that make handoffs successful, and use them to establish goals for emergency departments
  • develop a web-based toolkit that includes resources, assessment and support tools, and best practices
  • develop education resources on palliative care in the emergency department to enhance knowledge and increase the number of emergency department-based palliative care programs
  • and more.

ACEP has a strong focus on these issues of improving patient care and providing cost savings. To that end, multiple recommendations continue to be developed and adopted by the College. We are dedicated to ensuring that our specialty brings ideas that truly will improve care for the millions of patients we treat and provide real, substantial savings to the nation’s health care expenses.

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In All My Career…Stories from the ED





Please send your stories to Tracy Napper ( today!

The night after Christmas day was a busy day in the department.  We had already slogged our way through a stream of what seemed like endless patients when Triage alerted the team of a potentially sick patient. “They are coming straight over to the Acute Care side now, and they are turning blue!” With this information, my interest was instantly piqued. 

The patient rolled quickly across the ED into a bed via wheelchair.  I half-jogged to the room to find a young patient, in no apparent distress. A quick glance up at her monitor revealed normal vital signs, normal oxygen saturations on room air.  Hmmm. “What brings you in today?” I started. “My mom told me to come in tonight. She said, I don’t look right and that my face and hands look blue. I feel fine.” It was only then that I was able to see the subtle, but easily recognizable blue hue around her mouth, lips, and her fingertips. 

 My first thought was, this girl is cyanotic. She sure is. And with the involvement of her face and lips, she has central cyanosis. From what? But, she has normal oxygen saturations, heart rate, and blood pressure. A quick listen to her chest revealed no murmur and no extraneous lung sounds. Hmmm. Very interesting.

 I turned my attention to her hands. Closer inspection revealed the subtle blue hue to primarily be located on her fingertips. I squeeze her fingertip to assess her capillary refill, and it was normal. However, when blanched, her fingertip remained slightly blue. 

 “I don’t know why this is happening to me, I feel fine. I’m a little freaked out right now because everybody looked very worried in triage,” she said anxiously. At this point, she looked very nervous, drumming her fingers on her leg, tapping her foot. I looked at her hands again. She was wringing them, tapping her fingers on her leg, rubbing them together, then back again, drumming her jeans. Her dark blue, denim jeans. 

 “Did you get some new jeans for Christmas?” I asked. “Yeah….,” she replied, looking very confused. I took an alcohol swab out of the drawer, ripped open the package, and wiped one of her fingertips. I showed her the results. Her face now turned a beet red. “I’m so embarrassed,” she said putting her hands up to her mouth. “It’s a rare disorder, but a very curable case,” I teased. 

 It’s not every shift you catch a “zebra” like Blue Jean Pseudo-Cyanosis. But when you do, it reminds you why you love this job, even during the holidays.

 Jeremy Webb, PGY3

Wake Forest Baptist Health. Winston Salem, NC




October Annals Audio posted!

The October audio summary/podcast is now posted and available. Highlights include:

-Antidotes for cyanide and organophosphates: routes of administration
-Evidence base on treatment of jellyfish stings
-Synthetic cannabinoids
-Epi or hydroxocobalamin for cyanide arrest
-Adaptive and group sequential analyses in trials
-Trial registry fidelity in EM publications
-Syncope: should we investigate cardiac structural abnormalities?
-Treating and considering potential organ donors in the ED
-Opiate prescriptions in the ED: ACEP Clinical Policy

Enjoy, and email any time at,

David and Ashley

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