Clinical use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in civilian trauma systems in the USA, 2019: a joint statement from the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, the National Association of Emergency Medical Services Physicians and the National Association of Emergency Medical Technicians

This is a joint statement from the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, the National Association of Emergency Medical Services Physicians and the National Association of Emergency Medical Technicians regarding the clinical use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in civilian trauma systems in the USA. This statement addresses the system of care needed to manage trauma patients requiring the use of REBOA, in light of the current evidence available in this patient population. This statement was developed by an expert panel following a comprehensive review of the literature with representation from all sponsoring organizations and the US Military. This is an update to the previous statement published in 2018. It has been formally endorsed by the four sponsoring organizations.

The 2019 Core Content of Emergency Medical Services Medicine

On March 13, 2019 the EMS Examination Committee of the American Board of Emergency Medicine (ABEM) approved modifications to the Core Content of EMS Medicine. The Core Content is used to define the subspecialty of EMS Medicine, provides the basis for questions to be used during written examinations, and leads to development of a certification examination blueprint. The Core Content defines the universe of knowledge for the treatment of prehospital patients that is necessary to practice EMS Medicine. It informs fellowship directors and candidates for certification of the full range of content that might appear on certification examinations.

Spinal Motion Restriction in the Trauma Patient - A Joint Position Statement

The American College of Surgeons Committee on Trauma (ACS-COT), American College of Emergency Physicians (ACEP), and the National Association of EMS Physicians (NAEMSP) have previously offered varied guidance on the role of backboards and spinal immobilization in out-of-hospital situations. This updated consensus statement on spinal motion restriction in the trauma patient represents the collective positions of the ACS-COT, ACEP and NAEMSP. It has further been formally endorsed by a number of national stakeholder organizations. This updated uniform guidance is intended for use by emergency medical services (EMS) personnel, EMS medical directors, emergency physicians, trauma surgeons, and nurses as they strive to improve the care of trauma victims within their respective domains.

Abstract TP246: Emergency Medical Services Survey of a Low-cost, Ambulance-based System for Mobile Neurological Assessment: The iTREAT Study

Introduction: Modern advances in acute stroke care place an added emphasis on accurate prehospital diagnosis and triage. As part of the Improving Treatment with Rapid Evaluation of Acute Stroke via mobile Telemedicine (iTREAT) study, we assessed the EMS provider experience with a novel system for mobile telestroke assessment.

Methods: We developed a 12-question survey with input from local participants in an EMS Council serving rural counties in central Virginia. Providers rated the iTREAT system on feasibility for acute stroke triage, potential effectiveness in prehospital neurological assessment, and interactions with prehospital care. All survey responses were voluntary and anonymous.

Results: Since initiation of live patient enrollment, we have completed 34 ambulance-based telestroke encounters with the iTREAT system. Among 7 participating agencies, 19 EMS providers have served as tele-presenters during the telestroke assessment, and 17 EMS providers completed the voluntary survey. Of the respondents, 71% were certified EMS providers for over 5 years. Regarding technical feasibility, 69% experienced issues related to maintaining a video connection, 41% with logging in to the videoconferencing application, and 18% powering on the tablet. Of technical challenges, 41% of providers resolved the issue on their own, 18% with guidance from study staff, and 24% could not resolve the issue. Concerning patient care, 23% felt the system interfered, 35% were neutral, and 41% felt there was no interference. The majority of respondents (71%) agreed that the iTREAT system is feasible for acute stroke triage, and an effective tool (59%) for prehospital neurological assessment. In commentary, EMS participants emphasized the system’s utility in rural areas.

Conclusion: This survey of the EMS experience with a low-cost, ambulance-based system for prehospital telestroke assessment reveals both technical challenges and clinical promise. Importantly, technical issues are mostly solvable in real time and correctable for further system refinement. As a novel tool for prehospital neurological assessment and acute stroke triage, the initial EMS evaluation supports further investigation of clinical efficacy, particularly in rural and underserved areas.

A low-cost, tablet-based option for prehospital neurologic assessment: The iTREAT Study

OBJECTIVES

In this 2-center study, we assessed the technical feasibility and reliability of a low cost, tablet-based mobile telestroke option for ambulance transport and hypothesized that the NIH Stroke Scale (NIHSS) could be performed with similar reliability between remote and bedside examinations.

METHODS

We piloted our mobile telemedicine system in 2 geographic regions, central Virginia and the San Francisco Bay Area, utilizing commercial cellular networks for videoconferencing transmission. Standardized patients portrayed scripted stroke scenarios during ambulance transport and were evaluated by independent raters comparing bedside to remote mobile telestroke assessments. We used a mixed-effects regression model to determine intraclass correlation of the NIHSS between bedside and remote examinations (95% confidence interval).

RESULTS

We conducted 27 ambulance runs at both sites and successfully completed the NIHSS for all prehospital assessments without prohibitive technical interruption. The mean difference between bedside (face-to-face) and remote (video) NIHSS scores was 0.25 (1.00 to -0.50). Overall, correlation of the NIHSS between bedside and mobile telestroke assessments was 0.96 (0.92-0.98). In the mixed-effects regression model, there were no statistically significant differences accounting for method of evaluation or differences between sites.

CONCLUSIONS

Utilizing a low-cost, tablet-based platform and commercial cellular networks, we can reliably perform prehospital neurologic assessments in both rural and urban settings. Further research is needed to establish the reliability and validity of prehospital mobile telestroke assessment in live patients presenting with acute neurologic symptoms.

The prehospital and hospital costs of emergency care for frequent ED patients

INTRODUCTION

Frequent emergency department (ED) use has been identified as a cause of ED overcrowding and increasing health care costs. Studies have examined the expense of frequent patients (FPs) to hospitals but have not added the cost Emergency Medical Services (EMS) to estimate the total cost of this pattern of care.

METHODS

Data on 2012 ED visits to a rural Level I Trauma Center and public safety net hospital were collected through a deidentified patient database. Transport data and 2012 Medicare Reimbursement Schedules were used to estimate the cost of EMS transport. Health information, outcomes, and costs were compared to find differences between the FP and non-FP group.

RESULTS

This study identified 1242 FPs who visited the ED 5 or more times in 2012. Frequent patients comprised 3.25% of ED patients but accounted for 17% of ED visits and 13.7% of hospital costs. Frequent patients had higher rates of chronic disease, severity scores, and mortality. Frequent patients arrived more often via ambulance and accounted for 32% of total transports at an estimated cost of $2.5-$3.2 million. Hospital costs attributable to FPs were $29.1 million, bringing the total cost of emergency care to $31.6-$32.3 million, approximately $25,000 per patient.

CONCLUSIONS

This study demonstrates that the inclusion of a prehospital cost estimate adds approximately 10% to the cost of care for the FP population. In addition to improving care for a sick population of patients, programs that reduce frequent EMS and ED use have the potential to produce a favorable cost benefit to communities and health systems.

Mobile Telestroke During Ambulance Transport Is Feasible in a Rural EMS Setting: The iTREAT Study

BACKGROUND

The use of telemedicine in the diagnosis and treatment of acute stroke, or telestroke, is a well-accepted method of practice improving geographic disparities in timely access to neurological expertise. We propose that mobile telestroke assessment during ambulance transport is feasible using low-cost, widely available technology.

MATERIALS AND METHODS

We designed a platform including a tablet-based end point, high-speed modem with commercial wireless access, external antennae, and portable mounting apparatus. Mobile connectivity testing was performed along six primary ambulance routes in a rural network. Audiovisual (AV) quality was assessed simultaneously by both an in-vehicle and an in-hospital rater using a standardized 6-point rating scale (≥4 indicating feasibility). We sought to achieve 9 min of continuous AV connectivity presumed sufficient to perform mobile telestroke assessments.

RESULTS

Thirty test runs were completed: 93% achieved a minimum of 9 min of continuous video transmission with a mean mobile connectivity time of 18 min. Mean video and audio quality ratings were 4.51 (4.54 vehicle; 4.48 hospital) and 5.00 (5.13 in-vehicle; 4.87 hospital), respectively. Total initial cost of the system was $1,650 per ambulance.

CONCLUSIONS

In this small, single-centered study we maintained high-quality continuous video transmission along primary ambulance corridors using a low-cost mobile telemedicine platform. The system is designed to be portable and adaptable, with generalizability for rapid assessment of emergency conditions in which direct observational exam may improve prehospital diagnosis and treatment. Thus mobile telestroke assessment is feasible using low-cost components and commercial wireless connectivity. More research is needed to demonstrate clinical reliability and efficacy in a live-patient setting.

Abstract 90: NIH Stroke Scale Assessment via iPad-based Mobile Telestroke During Ambulance Transport is Feasible - Pilot data from the Improving Treatment with Rapid Evaluation of Acute Stroke via Mobile Telemedecine (iTREAT) Study

Introduction: The AHA-ASA Target:Stroke Program calls for innovative approaches to prehospital stroke care. We previously showed that mobile videoconferencing during ambulance transport is technically feasible in a rural EMS setting using an iPad-based telemedicine system. We now hypothesize that this mobile telestroke system is clinically feasible as measured by agreement of the NIH Stroke Scale (NIHSS) between face-to-face (FTF) and remote ambulance-based assessments (iTREAT).

Methods: The iTREAT system comprises an Apple iPad® with retina display, high-speed 4G LTE modem, Cisco Jabber secure video conferencing application, mounting apparatus, and magnetic external antenna. We developed 4 unique stroke and 2 unique stroke-mimic scenarios to simulate prehospital stroke alerts. We recruited 3 standardized patients each assigned two scenarios, and randomly assigned each scenario to one of 6 major ambulance routes triaging to UVA Medical Center. To eliminate bias, we alternated the order of FTF and iTREAT evaluations. Statistical measures were inter- and intra-rater correlation coefficient for the NIHSS and audio/visual(AV) quality ratings on a 6-point scale (>4 indicating “good” or “excellent” connectivity).

Results: For the 12 iTREAT and 10 FTF evaluations (two FTF missing data), intra-rater correlation of NIHSS scores was consistently >0.91 (mean=0.96). Inter-rater correlation for FTF evaluations was >0.89 (mean 0.96), and inter-rater correlation for iTREAT evaluations was >0.84 (mean=0.94). AV quality ratings during all iTREAT evaluations were deemed “good” or “excellent” (audio mean=5.3, median=5.5; video mean=4.67, median=4.5). Both NIHSS correlation and AV quality rating increased over the study period.

Conclusion: In this pilot feasibility study, NIHSS scores obtained via ambulance using our iPad-based mobile telestroke system correlated well with in person assessments. These results support further research to determine feasibility and efficacy of this low-cost mobile telestroke system in prehospital stroke care.

Abstract 103: Mobile Telestroke During Ambulance Transport is Feasible in a Rural EMS setting - pilot data from the Improving Treatment with Rapid Evaluation of Acute stroke via mobile Telemedicine (iTREAT) study

Introduction: The American Heart Association-American Stroke Association (AHA-ASA) Target:Stroke iniative calls for innovative approaches to prehospital stroke care. We hypothesize that mobile telestroke from a hospital-based neurologist to an ambulance-based provider, using tablet devices and commercially available broadband, will facilitate earlier stroke diagnosis and more accurate prenotification to reduce stroke onset-to-treatment times.

Methods: We assessed the technical feasibility of mobile teleconferencing along the six common rural emergency medical service (EMS) routes into the University of Virginia Medical Center, allowing a minimum travel time of 15 minutes and continuous connectivity of 5 minutes. Our mobile telestroke platform included Apple iPad with retina display, high-speed 4G LTE modem, Cisco Jabber secure video conferencing application, and magnetic-mount external antennae. Continuous mobile connectivity was facilitated through the commercial Verizon Wireless network. Continuous transmission audiovisual (AV) quality along each route was rated by independent raters from both hospital and vehicle using a standardized six-point scale (≥4 indicating technical feasibility).

Results: Of 31 test runs, two had extraneous technical issues and one failed to meet the minimum duration for continuous connectivity. The mean transmission video quality rating was 4.51 (4.54 vehicle; 4.48 hospital) and overall audio quality 5.00 (5.13 vehicle; 4.87 hospital). Both raters deemed AV quality as "good" or "excellent" (rating ≥4) for 78.5% of test runs. Five out of six EMS routes consistently demonstrated feasible connectivity, with 87.5% of runs achieving "good" or "excellent" bidirectional AV quality for these five routes.

Conclusion: Our pilot data suggest technical feasibility for mobile teleconferencing between transporting ambulance and hospital-based provider using low-cost, off-the-shelf technology and commercial networks. These results support our hypothesis that mobile telestroke in a rural EMS setting can be implemented. Further troubleshooting along routes with limited connectivity, and prospective testing of the impact on stroke diagnosis and time-to-treatment is planned.

Development of an EMS curriculum

Emergency medical services (EMS) became an American Board of Medical Specialties (ABMS) approved subspecialty of emergency medicine in September 2010. Achieving specialty or subspecialty recognition in an area of medical practice requires a unique body of knowledge, a scientific basis for the practice, a significant number of physicians who dedicate a portion of their practice to the area, and a sufficient number of fellowship programs. To prepare EMS fellows for successful completion of fellowship training, a lifetime of subspecialty practice, and certification examination, a formalized structured fellowship curriculum is necessary. A functional curriculum is one that takes the entire body of knowledge necessary to appropriately practice in the identified area and codifies it into a training blueprint to ensure that all of the items are covered over the prescribed training period. A curriculum can be as detailed as desired but typically all major headings and subheadings of the core content are identified and addressed. Common curricular components, specific to each area of the core content, include goals and objectives, implementation methods, evaluation, and outcomes assessment methods. Implementation methods can include simulation, observations, didactics, and experiential elements. Evaluation and outcomes assessment methods can include direct observation of patient assessment and treatment skills, structured patient simulations, 360° feedback, written and oral testing, and retrospective chart reviews. This paper describes a curriculum that is congruent with the current EMS core content, as well as providing a 12-month format to deploy the curriculum in an EMS fellowship program. Key words: curriculum; education; emergency medical services; fellowships and scholarships.

The 2011 model of the clinical practice of emergency medicine

The 2011 Model of the Clinical Practice of Emergency Medicine.

The core content of emergency medical services medicine

On September 23, 2010, the American Board of Medical Specialties (ABMS) approved emergency medical services (EMS) as a subspecialty of emergency medicine. As a result, the American Board of Emergency Medicine (ABEM) is planning to award the first certificates in EMS medicine in the fall of 2013. The purpose of subspecialty certification in EMS, as defined by ABEM, is to standardize physician training and qualifications for EMS practice, to improve patient safety and enhance the quality of emergency medical care provided to patients in the prehospital environment, and to facilitate integration of prehospital patient treatment into the continuum of patient care. In February 2011, ABEM established the EMS Examination Task Force to develop the Core Content of EMS Medicine (Core Content) that would be used to define the subspecialty and from which questions would be written for the examinations, to develop a blueprint for the examinations, and to develop a bank of test questions for use on the examinations. The Core Content defines the training parameters, resources, and knowledge of the treatment of prehospital patients necessary to practice EMS medicine. Additionally, it is intended to inform fellowship directors and candidates for certification of the full range of content that might appear on the examinations. This article describes the development of the Core Content and presents the Core Content in its entirety.

Report of the Task Force on Residency Training Information (2006-2007), American Board of Emergency Medicine

The American Board of Emergency Medicine (ABEM) gathers extensive background information on emergency medicine residency training programs and the residents training in those programs. We present the tenth annual report on the status of US emergency medicine residency programs.

Report of the Task Force on Residency Training Information (2005-2006), American Board of Emergency Medicine

The American Board of Emergency Medicine gathers extensive background information on emergency medicine residency training programs and the residents training in those programs. We present the ninth annual report on the status of US emergency medicine residency programs.

Report of the Task Force on Residency Training Information (2004-2005), American Board of Emergency Medicine

The American Board of Emergency Medicine gathers extensive background information on emergency medicine residency training programs and the residents training in those programs. We present the eighth annual report on the status of US emergency medicine residency programs.

Integrating the Accreditation Council for Graduate Medical Education Core competencies into the model of the clinical practice of emergency medicine

In response to public pressure for greater accountability from the medical profession, a transformation is occurring in the approach to medical education and assessment of physician competency. Over the past 5 years, the Accreditation Council for Graduate Medical Education (ACGME) has implemented the Outcomes and General Competencies projects to better ensure that physicians are appropriately trained in the knowledge and skills of their specialties. Concurrently, the American Board of Medical Specialties, including the American Board of Emergency Medicine (ABEM), has embraced the competency concept. The core competencies have been integral in ABEM's development of Emergency Medicine Continuous Certification and the development of the Model of Clinical Practice of Emergency Medicine (Model). ABEM has used the Model as a significant part of its blueprint for the written and oral certification examinations in emergency medicine and is fully supportive of the effort to more fully define and integrate the ACGME core competencies into training emergency medicine specialists. To incorporate these competencies into our specialty, an Emergency Medicine Competency Taskforce (Taskforce) was formed by the Residency Review Committee-Emergency Medicine to determine how these general competencies fit in the Model. This article represents a consensus of the Taskforce with the input of multiple organizations in emergency medicine. It provides a framework for organizations such as the Council of Emergency Medicine Residency Directors (CORD) and the Society for Academic Emergency Medicine to develop a curriculum in emergency medicine and program requirement revisions by the Residency Review Committee-Emergency Medicine. In this report, we describe the approach taken by the Taskforce to integrate the ACGME core competencies into the Model. Ultimately, as competency-based assessment is implemented in emergency medicine training, program directors, governing bodies such as the ACGME, and individual patients can be assured that physicians are competent in emergency medicine.

Electrocardiogram interpretation training and competency assessment in emergency medicine residency programs

OBJECTIVES

To determine the type of electrocardiogram (ECG) interpretation instruction in emergency medicine (EM) residency programs, the use and perceived value of teaching modalities and resources, and the methods used to assess competency of ECG interpretation.

METHODS

An interactive survey instrument was posted on the Internet using SurveySuite, Inc., software and e-mailed to program directors (PDs) of all 125 Accreditation Council for Graduate Medical Education-approved U.S. EM residency programs. Responses are reported in total numbers and percentages.

RESULTS

Ninety-nine of 125 PDs completed the online survey (response rate, 79.2%). Emergency department instruction (99%), case-based lectures (98%), and didactic lectures (98%) were most commonly used to teach interpretation of ECGs, followed by computer-based instruction (34%) and ECG laboratory (12%). The majority of programs (53%) spent more than eight hours on formal ECG lectures per year, while 11% spent less than three hours. Observation during clinical time (99%), lecture time (76%), and hypothetical cases (57%) were the most common ways to determine competency in reading ECGs, while clinical observation and hypothetical cases were perceived as the most valuable. The most commonly used resource was personal or departmental ECG files (91%), and this had the highest perceived value. The majority of PDs were comfortable with residents' abilities to read ECGs by the third year (96%) and fourth year (91%) of residency.

CONCLUSIONS

These data suggest that EM PDs believe that EM residency is adequately preparing graduates to interpret ECGs. This goal is achieved through a variety of methods.

Report of the task force on residency training information (2003-2004), American Board of Emergency Medicine

The American Board of Emergency Medicine gathers extensive background information on emergency medicine residents and the programs in which they train. We present the seventh annual report on the status of US emergency medicine residency programs.

Noncardiogenic pulmonary edema

Pulmonary edema is differentiated into two categories--cardiogenic and noncardiogenic. Noncardiogenic pulmonary edema is due to changes in permeability of the pulmonary capillary membrane as a result of either a direct or an indirect pathologic process. It is a spectrum of illness ranging from the less severe form of ALI to the severe ARDS. The mainstay of treatment is mechanical ventilation with maximization of ventilation and oxygenation through the judicious use of PEEP. Newer ventilation techniques, such as high-frequency oscillatory ventilation and partial fluid ventilation, are promising but are in the early stages of clinical testing. Mortality rates remain high despite increasing intensive care unit care.

The status of bedside ultrasonography training in emergency medicine residency programs

Bedside ultrasonography (BU) is rapidly being incorporated into emergency medicine (EM) training programs and clinical practice. In the past decade, several organizations in EM have issued position statements on the use of this technology. Program training content is currently driven by the recently published "Model of the Clinical Practice of Emergency Medicine," which includes BU as a necessary skill.

OBJECTIVE

The authors sought to determine the current status of BU training in EM residency programs.

METHODS

A survey was mailed in early 2001 to all 122 Accreditation Council for Graduate Medical Education (ACGME)-accredited EM residency programs. The survey instrument asked whether BU was currently being taught, how much didactic and hands-on training time was incorporated into the curriculum, and what specialty representation was present in the faculty instructors. In addition, questions concerning the type of tests performed, the number considered necessary for competency, the role of BU in clinical decision making, and the type of quality assurance program were included in the survey.

RESULTS

A total of 96 out of 122 surveys were completed (response rate of 79%). Ninety-one EM programs (95% of respondents) reported they teach BU, either clinically and/or didactically, as part of their formal residency curriculum. Eighty-one (89%) respondents reported their residency program or primary hospital emergency department (ED) had a dedicated ultrasound machine. BU was performed most commonly for the following: the FAST scan (focused abdominal sonography for trauma, 79/87%); cardiac examination (for tamponade, pulseless electrical activity, etc., 65/71%); transabdominal (for intrauterine pregnancy, ectopic pregnancy, etc., 58/64%); and transvaginal (for intrauterine pregnancy, ectopic pregnancy, etc., 45/49%). One to ten hours of lecture on BU was provided in 43%, and one to ten hours of hands-on clinical instruction was provided in 48% of the EM programs. Emergency physicians were identified as the faculty most commonly involved in teaching BU to EM residents (86/95%). Sixty-one (69%) programs reported that EM faculty and/or residents made clinical decisions and patient dispositions based on the ED BU interpretation alone. Fourteen (19%) programs reported that no formal quality assurance program was in place.

CONCLUSIONS

The majority of ACGME-accredited EM residency programs currently incorporate BU training as part of their curriculum. The majority of BU instruction is done by EM faculty. The most commonly performed BU study is the FAST scan. The didactic component and clinical time devoted to BU instruction are variable between programs. Further standardization of training requirements between programs may promote increasing standardization of BU in future EM practice.

A study of the workforce in emergency medicine: 1999

STUDY OBJECTIVE

We estimate the total number of physicians practicing clinical emergency medicine during a specified period, describe certain characteristics of those individuals to estimate the total number of full-time equivalents (FTEs) and the total number of individuals needed to staff those FTEs, and compare the data collected with those data collected in 1997.

METHODS

Data were gathered from a survey of a random sample of 2,153 hospitals drawn from a population of 5,329 hospitals reported by the American Hospital Association as having, or potentially having, an emergency department. The survey instrument addressed items such as descriptive data on the institution, enumeration of physicians in the ED, and the total number of physicians working during the period from June 6 to June 9, 1999. Demographic data on the individuals were also collected.

RESULTS

A total of 940 hospitals responded (a 44% return rate). These hospitals reported that a total of 6,719 physicians were working during the specified period, or an average of 7.85 persons scheduled per institution. The physicians were scheduled for a total of 347,702 hours. The average standard for FTE was 40 clinical hours per week. This equates to 4,346 FTEs or 5.29 FTEs per institution. The ratio of persons to FTEs was 1.48:1. With regard to demographics, 83% of the physicians were men, and 82% were white. Their average age was 42.6 years. As for professional credentials, 42% were emergency medicine residency trained, and 58% were board certified in emergency medicine; 50% were certified by the American Board of Emergency Medicine.

CONCLUSION

Given that there are 5,064 hospitals with EDs and given that the data indicate that there are 5.35 FTEs per ED, the total number of FTEs is projected to be 27,067 (SE=500). Given further that the data indicate a physician/FTE ratio of 1.47:1, we conclude that there are 39,746 persons (SE=806) needed to staff those FTEs. When adjusted for persons working at more than one ED, that number is reduced to 31,797. When the 1999 data are compared with those collected in 1997, we note a statistically significant decline in the number of hospital EDs, from 5,126 in 1997 to 5,064 in 1999 (P =.02). The total number of emergency physicians remained the same over the 2-year period, whereas the number of FTEs per institution increased from 5.11 to 5.35. The physician/FTE ratio remained unchanged.

A survey of academic departments of emergency medicine regarding operation and clinical practice

STUDY OBJECTIVE

To survey academic departments of emergency medicine concerning their operation and clinical practice.

METHODS

A survey was mailed to the chairs of all 56 academic departments of emergency medicine in the United States requesting information concerning operations and clinical activity in budget year 1997-1998 compared with 1995-1996. These results were then compared with a similar survey conducted in the fall of 1996, examining the 1995-1996 academic year compared with the 1994-1995 academic year.

RESULTS

Forty-one (73%) academic departments of emergency medicine responded. For 1997-1998, compared with 1995-1996, 24 (59%) academic departments of emergency medicine reported an increase in emergency department patient volume; 10 (24%) reported a decrease. Twenty-four (51%) academic departments of emergency medicine reported an increase in ED patient severity, whereas 7 (15%) reported a decrease. Twenty-five (61%) academic departments of emergency medicine reported an increase in net clinical revenue for emergency medicine services, and 9 (22%) reported a decrease. Only 9 (22%) academic departments of emergency medicine reported other academic departments within their university/medical center aggressively directing patients away from the ED compared with 14 (30%) in the previous study. The percentage of academic departments of emergency medicine using midlevel providers remained essentially the same over time (68% versus 66%). In both studies, midlevel providers were used most commonly in a fast-track setting. Only 37% of academic departments of emergency medicine reported having an observation unit; staffing in all cases was by emergency physicians. Since the last survey, 38 (93%) academic departments of emergency medicine reported their medical center or hospital negotiating with managed care organizations to provide services. Unfortunately, only 41% of chairs were involved in these discussions. Between January 1, 1997, and the 1998 fall survey, 29% of academic departments of emergency medicine reported their university merging with another university system, and 19% reported such mergers being discussed. Similarly, between January 1, 1997, and fall 1998, 22% of academic departments of emergency medicine reported their institution merging with a private entity, whereas 16% reported ongoing discussions.

CONCLUSION

Academic departments of emergency medicine have experienced some encouraging trends: an increase in ED patient volume, patient severity, and net clinical revenue during the study period. Midlevel providers continue to be used primarily in fast-track areas of EDs. An area of potential growth for academic departments of emergency medicine is observation medicine, because only one third of academic departments of emergency medicine have such a unit. Academic medical centers have experienced a significant increase in merger activity during the study period.

Academic departments of emergency medicine: the effects of managed care

OBJECTIVE

To survey academic departments of emergency medicine (ADEMs) concerning the effects of managed care on their operation and practice.

METHODS

A 38-question survey was mailed to the chairs of all 52 ADEMs in the United States requesting information concerning managed care activity and its effects on ADEMs in academic years 1994-1995 and 1995-1996.

RESULTS

Forty-seven ADEMs (90.3%) responded. When comparing the 1995-1996 and 1994-1995 academic years, the following changes were noted: decreased overall growth in ED patient volume (38.3% vs 51.1%), larger percentage of respondents reporting an actual decrease in ED patient volume (38% vs 27.6%), less growth in ED gross revenue (43.7% vs 52.1%), larger percentage of ADEMs reporting actual decreased gross revenues (25% vs 12.5%), increase in ED patient acuity (76.6% vs 59.6%), and relative stability in the number of EM faculty (40.4% vs 44.7% reporting no change in faculty number). Two-thirds of ADEMs used mid-level providers (i.e., physician assistants, nurse practitioners), most commonly in a fast-track setting (41%). Thirty percent of ADEMs reported that other academic departments actively directed patients away from the ED, with pediatrics, family medicine, and internal medicine the most active. Ninety-eight percent of ADEMs reported ongoing negotiations between their institution or hospital and managed care organizations (MCOs); only 54.3% of ADEMs were involved in these negotiations. Twenty-eight percent of ADEMs reported MCOs have had an effect on their emergency medical services system, with 37% indicating HMOs routinely discouraged their enrollees from using 9-1-1 services and 16% reporting HMOs provided 9-1-1 services to take patients only to participating hospital EDs.

CONCLUSION

ADEMs have experienced significant changes in nearly every aspect of their practice over the two academic years under study, much of which is due to managed care. ADEMs must take a leadership role in dealing with MCOs.

Resident perspectives of EMS as a subspecialty

OBJECTIVE

Emergency medical services (EMS) is frequently considered to be a subspecialty of emergency medicine (EM) despite the unavailability of subspecialty certification. An assessment of future interest in EMS subspecialization and the perceived educational needs of potential EMS physicians was performed in order to provide data to leaders responsible for development of this subspecialty area.

METHODS

A survey concerning EMS subspecialization issues was distributed to 2,464 members of the Emergency Medicine Residents Association (EMRA). Questions addressed demographic information, interest in EMS, educational issues, and desired credentials. The response rate was 30% (n = 737). All surveys were analyzed by the Pearson chi-square probability and Mantel-Haenszel tests for linear association.

RESULTS

A moderate to very high interest in EMS medical direction was expressed by 84% of the respondents, with 14% interested in full-time EMS positions. This interest increased with years of training (p < 0.0001). Almost 89% believed that EMS physicians should have special preparations prior to practice beyond EM residency training. Fewer than half (44%) thought that an EM residency provided sufficient preparation for a significant role in EMS, and this perception increased in intensity with years of training (p < 0.0052). Interest in EMS fellowships (24%) would increase to 36% if subspecialty certification were available (p < 0.0001). Thirty-nine percent believed subcertification should be required of all EMS medical directors if available.

CONCLUSIONS

Many EM residents have an interest in active participation in EMS on either a part-time or a full-time basis. Most respondents think EMS is a unique area requiring focused education beyond an EM residency. Interest in EMS fellowships would greatly increase if subspecialty certification were available.

Propafenone ingestion

Propafenone is a type 1c antiarrhythmic drug that recently has become available for clinical trials within the United States. We present the case of a 2-year-old child who accidentally ingested 1,800 mg (133 mg/kg) of propafenone. The patient subsequently developed cardiac conduction abnormalities and generalized seizures. Following the administration of IV phenytoin, cardiopulmonary collapse occurred. The patient had a successful outcome with aggressive cardiopulmonary life support.