ACEP NowACEP Now http://www.acepnow.com Fri, 20 Apr 2018 21:28:20 +0000 en-US hourly 1 https://wordpress.org/?v=4.9.5 Opinion: Did Obamacare Reduce ER Use? http://www.acepnow.com/article/opinion-did-obamacare-reduce-er-use/ http://www.acepnow.com/article/opinion-did-obamacare-reduce-er-use/#respond Tue, 17 Apr 2018 18:11:07 +0000 http://www.acepnow.com/?post_type=article&p=18800 Will increasing access to health insurance decrease ED utilization by increasing access to primary care providers (PCPs)?...

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ILLUSTRATION: Chris Whissen & shutterstock.com

Will increasing access to health insurance decrease ED utilization by increasing access to primary care providers (PCPs)? On the other hand, does having health insurance make people more likely to visit the emergency department? These questions have important implications for ED capacity, quality of care, and future funding models.

When the Affordable Care Act (ACA) became law, differing opinions emerged about how it might affect ED utilization. Some argued that more insured patients would lead to better access to outpatient care, reducing the need for emergency care, as was seen in Massachusetts following the pre-ACA rollout of their own state’s health insurance expansion (Romneycare).1 Others contended that more access to care would mean more usage of all types of care, resulting in increased ED visits, as 75 percent of emergency physicians believe.2

ED Usage in Illinois

A recent study, an analysis of ED use before and after Affordable Care Act (ACA) implementation in Illinois, provides evidence against the assumption that ED use would decrease as newly-insured patients received care from PCPs instead of the emergency department, leading to more efficient and less costly health care.3 The authors analyzed ED visits across Illinois from 2011 to 2015, comprising 36 months prior to and 24 months following ACA implementation. Although the number of ED visits by uninsured patients dropped, visits by Medicaid and private insurance patients increased more substantially, leading overall to a 5.7 percent increase in ED usage. Meanwhile, visit acuity appeared to remain constant, as the number of hospitalizations through the emergency department was essentially unchanged throughout the study period.

This study indicates that increasing access to insurance alone does not lead to a decrease in ED visits, and similar results have been found in Massachusetts, Oregon, Kentucky, and Colorado.4-6 A program in Virginia offers an interesting alternative where, in addition to receiving health care, patients were assigned to PCPs.7 Although these PCPs were paid at rates higher than those offered by Medicaid, cost per patient had decreased significantly after three years of the program.

These potentially counterintuitive results highlight the complexity of health care reform. While providing health insurance may lead to fewer ED visits for some patients (ie, young adults), that effect does not hold universally. Of course, this immediate increase in ED use may be an anomaly in a long-term trend toward less ED use, though studies from Oregon have shown this effect to be long lasting.8 Additionally, there may be benefits to health insurance (ie, financial security, increased PCP visits, or potentially improved overall health) that are not captured in this study. However, while removing financial barriers to receiving care is likely an important part of reforming our health care system, this study indicates that health insurance expansion alone is unlikely to lead to more efficient health care delivery through reduced ED usage.

ED Utilization Trends

Another study investigated changes in ED utilization rates at a national level based on the hypothesis that increases in Medicaid-covered populations would result in proportional increases in ED visits.9 They also predicted a change in the payer mix that would result in fewer uninsured visits and more Medicaid-covered visits. States that opted not to expand Medicare coverage under the ACA served as the control group.

Overall, the authors estimated 10 additional ED visits per 1,000 people. As predicted, Medicaid expansion resulted in more visits by patients with Medicaid. The proportion of visits covered by Medicaid increased from 35 percent pre-ACA to 48 percent during the study. The authors argue that some of this increase may be temporarily caused by pent-up demand from patients who needed health care but could not afford it prior to the ACA. A reciprocal decrease in the proportion of uninsured visits was noted (from 23 percent down to 11 percent).

Further analyzing the data provides interesting insights into the chief complaints that became more common for patients with Medicaid. The largest increases were for dental and mental health visits, which aligns with the disproportionate number of Medicaid-eligible patients who report less than excellent mental health.10

Naturally, increased visits raise questions about the effects on emergency departments. Without an increase in capacity, more visits may mean overcrowding, decreased quality of care, and worse patient outcomes. Changes in payer mix affect the hospital’s bottom line, since Medicaid generally reimburses less than private insurance. However, Medicaid reimbursement is higher than that from self-pay patients. Furthermore, recognizing that there are fewer uninsured patients, the ACA reduces payments for hospitals serving a disproportionately high level of uninsured patients.11 The balance of these clinical and financial forces should continue to be explored.


Dr. Dark is assistant professor of emergency medicine at Baylor College of Medicine in Houston and executive editor of Policy Prescriptions.

Dr. Maughan is an emergency medicine resident at Maine Medical Center in Portland, Maine.

Dr. Sontag is an emergency medicine resident at UT Health San Antonio.

References

  1. Miller S. The effect of insurance on emergency room visits: an analysis of the 2006 Massachusetts health reform. J Public Econ. 2012;96:893-908.
  2. ACEP. ER visits continue to rise since implementation of Affordable Care Act. ACEP website. Accessed March 23, 2018.
  3. Dresden SM, Powell ES, Kang R, et al. Increased emergency department use in Illinois after implementation of the Patient Protection and Affordable Care Act. Ann Emerg Med. 2017;69(2):172-180.
  4. Taubman SL, Allen HL, Wright BJ, et al. Medicaid increases emergency-department use: evidence from Oregon’s health insurance experiment. Science. 2014;343(6168):263-268.
  5. Chalmers N, Grover J, Compton R. After Medicaid expansion in Kentucky, use of hospital emergency departments for dental conditions increased. Health Aff (Millwood). 2016;35(12):2268-2276.
  6. Colorado Hospital Association Center for Health Information and Data Analytics. Impact of Medicaid expansion on hospitals: updated for second-quarter 2014. C Colorado Hospital Association website. Accessed March 23, 2018.
  7. Bradley CJ, Gandhi SO, Neumark D, et al. Lessons for coverage expansion: a Virginia primary care program for the uninsured reduced utilization and cut costs. Health Aff (Millwood). 2012;31(2):350-359.
  8. Finkelstein AN, Taubman SL, Allen HL, et al. Effect of Medicaid coverage on ED use – further evidence from Oregon‘s experiment. N Engl J Med. 2016;375(16):1505-1507.
  9. Nikpay S, Freedman S, Levy H, et al. Effect of the Affordable Care Act Medicaid expansion on emergency department visits: evidence from state-level emergency department datases. Ann Emerg Med. 2017;70(2):215-225.
  10. Newport F. Strong relationship between income and mental health. Gallup web site. Accessed March 23, 2018.
  11. Medicaid and CHIP Payment and Access Commission. Report to Congress on Medicaid disproportionate share hospital payments. MACPAC website. Accessed March 23, 2018.

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ACOEP Appoints Board President, New President Elect http://www.acepnow.com/article/acoep-appoints-board-president-new-president-elect/ http://www.acepnow.com/article/acoep-appoints-board-president-new-president-elect/#respond Tue, 17 Apr 2018 18:07:05 +0000 http://www.acepnow.com/?post_type=article&p=18866 The American College of Osteopathic Emergency Physicians (ACOEP) elected its 21st President and a new President-Elect during...

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The American College of Osteopathic Emergency Physicians (ACOEP) elected its 21st President and a new President-Elect during its Nov. 5, 2017, meeting. Christine Giesa, DO, FACOEP-D, became the new President, and Robert Suter, DO, MHA, FACOEP-D, FAAEM, FACEP, FIFEM, became the new President-Elect.

Dr. Giesa currently works in the emergency department at Delaware County Memorial Hospital in Drexel Hill, Pennsylvania, where she is the residency program director. She has been a member of ACOEP for 23 years, during which time she has served as the Chair of the Continuing Medical Education Committee and Chair of the Spring Seminar. She is the second woman President of ACOEP and the first mother.

Dr. Suter is a colonel in the United States Army Reserve and recently returned from a Middle East deployment where he served as commander of the medical and health care forces in the 13-nation CENTCOM region. He is a third-term member of the ACOEP Board of Directors, during which time he has mentored osteopathic students, residents, and physicians across the country. He was the first osteopathic physician to serve in an officer position for ACEP, serving as Secretary, Treasurer, and finally President in 2004–2005. While in the United States, he practices emergency medicine in a variety of settings, from small rural hospitals to major academic medical centers as a professor of emergency medicine.

In addition to the appointments of a new President and President-Elect, the ACOEP Board elections also saw Timothy Cheslock, DO, FACOEP-D, appointed Treasurer and Gregory “Joe” Bierne, FACOEP-D, as Secretary. Brandon Lewis, DO, MBA, FACOEP, FACEP; John W. Graneto, DO, M.Ed, FACOEP-D; and Justin Grill, DO, FACOEP, were also elected to the Board.

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Do Hallway and Other Non-Private Exams Negatively Affect Patient Encounters? http://www.acepnow.com/article/do-hallway-and-other-non-private-exams-negatively-affect-patient-encounters/ http://www.acepnow.com/article/do-hallway-and-other-non-private-exams-negatively-affect-patient-encounters/#respond Tue, 17 Apr 2018 18:00:01 +0000 http://www.acepnow.com/?post_type=article&p=18862 Emergency physicians often find themselves treating patients in settings that don’t provide sufficient privacy or confidentiality. These...

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Emergency physicians often find themselves treating patients in settings that don’t provide sufficient privacy or confidentiality. These non-private settings can negatively affect the patient encounter, according to a recent study published in Emergency Medicine Journal.1

The researchers found that settings in hallways and those where a companion of the patient is present can render patients reluctant to provide sensitive information. Furthermore, physicians may not perform all the routine examinations they would in a private encounter.

As a result, emergency physicians’ ability to provide the appropriate care for conditions related to human trafficking and other medical, social, and psychiatric conditions can be compromised.

Methods

The study applied a cross-sectional convenience sample survey on the emergency physicians present at ACEP15 in Boston. Only practicing emergency physicians were surveyed. A total of 409 completed the survey.

Results

Of the emergency physicians surveyed, 90 percent indicated that they changed their history-taking practices and 56 percent indicated that they changed their physical examination of patients when other people were present during the examination.

Physicians who changed their history-taking processes indicated the two main reasons for doing so were the patient’s location in the hallway or the presence of a family member, friend, or acquaintance.

Regarding deviations from ordinary physical examinations, 90 percent of the emergency physicians surveyed indicated that they altered their patient exam at least “sometimes” based on a patient’s presence in the hallway, while 77 percent did so at least “sometimes” when a companion was present with the patient.

Of the physicians who indicated alterations to history-taking and physical exams either due to hallway encounters or the patient having a companion present, 35 percent and 41 percent, respectively, reported experiencing delays or failures in their diagnoses stemming from those alterations.

This study found that patient-physician encounters in non-private settings caused delays or failures in identifying human trafficking, partner violence, child abuse, substance abuse, and elder abuse.

Implications for Practice

For patients who have previous or current trauma related to abuse, including human trafficking, hallway consultations with emergency physicians may prevent the identification of the abuse and the necessary intervention.

The study calls for informed guidelines for the universal separation of ED patients during their encounters with emergency physicians. Such a mandated separation would allow for private encounters, where incidences of abuse, including human trafficking, may be identified more easily.

Reference

  1. Stoklosa H, Scannell M, Ma Z, et al. Do EPs change their clinical behaviour in the hallway or when a companion is present? A cross-sectional survey. [Published online ahead of print February 3, 2018] .Emerg Med J.

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How to Spot and Help Human Trafficking Victims in the Emergency Department http://www.acepnow.com/article/how-to-spot-and-help-human-trafficking-victims-in-the-emergency-department/ http://www.acepnow.com/article/how-to-spot-and-help-human-trafficking-victims-in-the-emergency-department/#respond Sat, 14 Apr 2018 00:35:39 +0000 http://www.acepnow.com/?post_type=article&p=18858 Human trafficking is an incredibly challenging problem to solve because it hides in the shadows. Not only...

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Human trafficking is an incredibly challenging problem to solve because it hides in the shadows. Not only are traffickers motivated to keep their activities under the radar of law enforcement, but often victims are, too. Is that young woman with the broken arm who was brought to your emergency department by a male “friend” a trafficking victim? What about the shy young man with the black eye and sexually transmitted infection? And if they are, what can you do about it?

Cynthia M. Deitle, JD

Cynthia M. Deitle, JD, spent two decades with the FBI’s civil rights program, which includes a program to combat human trafficking. Her experience ranged from working on individual trafficking cases to being chief of the civil rights unit, giving her a broad understanding of the trafficking problem in the United States and the bureau’s efforts to combat it. She recently sat down with ACEP Now Medical Editor-in-Chief Kevin Klauer, DO, EJD, FACEP, to talk about some of the challenges she faced while trying to help trafficking victims, and what emergency department staff can use to try to help suspected victims. Here is Part 2 of that conversation; Part 1 appeared in the March issue.

KK: I heard you tell a story not long ago that really illustrated how victims are able to hide in communities, oftentimes intentionally, because they’re not ready to leave or feel like they can’t. Can you tell us about that?

CD: Sure. We love for victims to somehow get to an ER. Please understand I’m not happy they’re injured, but we’re grateful that now they’re in a place that is safe. Also, there are many people the victim has to talk to, and hopefully one of them can crack through and encourage her and persuade her to tell the truth about why she is there to begin with.

So what we see, especially when it comes to ERs, is most of the time she’s not going to walk in there by herself. She’s going to an ER because her pimp can’t use her because she’s pregnant, she has an ovarian cyst that is painful, she needs an appendectomy, she’s been beaten so badly that she’s no use to him, etc. For him to keep earning money from her, she has to get cured, she has to be healed. He needs her back on her feet, so he will take her to get medical attention.

He’s never going to let her go by herself, because then she’s out of his control. He will take her, and it will be apparent right from the ER waiting area that there’s something odd about these two people. It will be a boy and a girl, and there will be obvious signs of control over the girl from the boy. She’s not going up to the desk by herself. He’s standing with her, and she clearly is giving a story that doesn’t seem all that credible. “You fell down the stairs is why you’re here?” Perhaps she is afraid she is pregnant and has vaginal bleeding. “Is this your husband? Is this your boyfriend?” He’ll still be standing there and not looking very caring or loving. He’ll often look quite menacing. He just wants to get her in and get her out. He won’t have health insurance, and she won’t either. Chances are, he will want to pay cash.

I’ve spoken with other ER personnel before, and the best thing you can do is get her alone. He will want to go everywhere with her. He will say, “I’m her husband, I’m the father of the baby,” whatever it takes, and she will say, “I want him right here with me.” Get a female to talk to her, if possible, and keep her there as long as you can.

Now, I know you and I are both sensitive and very aware of HIPAA violations and HIPAA protection, and when that question comes up, I always tell medical personnel I respect HIPAA the same way you do. I don’t want to get in trouble with HIPAA, but there are things you can do to bring attention to this girl who is in your care and in your control, because as physicians you can help her in a variety of ways without violating HIPAA.

She needs law enforcement. Whomever can break away, call the local police department and say, “I’m not going to violate HIPAA, and I’m not going to talk about who I have in the ER, but there is a gentleman who is standing in the emergency department wearing jeans and a red baseball hat and you might want to talk to him.” He’s not your patient. You’re not violating HIPAA by calling the police department. Chances are, if you develop a relationship with law enforcement and it’s a familiar name who makes the call to a certain officer, the person on the other end of the phone will understand what you are conveying.

KK: Once we have the possible victim alone, should we be very direct or a bit more tangential with our questions?

CD: This will be one of those answers every lawyer and doctor hates: It depends. It depends on the person asking the questions. If you have one of your nurses in the ER who has been there for 20 years, and she is phenomenal at getting victims of domestic violence and human trafficking to talk to her due to a slow, methodical and caring approach, then you let her do it her way. Or you may have other people just come right out and say, “Honey, who is that guy in the waiting room, he’s not your husband. What is going on?” And that might work. It’s very personally driven, and it’s very situation specific. Go with your strength.

As an FBI agent, I’ve been in ERs and I know that intake questioning list can be fine-tuned to get at the trafficking situation. “So, are you safe in your home?” She will lie to you and say, “Yes.” If you just keep drilling into her domestic situation, you might be able to get at it. “So who lives in your home with you?” Well, right away, Kevin, that presumes she has a home. These domestic trafficking victims don’t have a home. They go from hotel to hotel to hotel. “Are you safe in your home? Where do you live? How long have you lived there? Do you rent?” Really try to delve into tripping her up in the answers and getting her to admit what’s going on. That’s really the key, along with asking her who else you should call. “Is there a grandmother, an aunt, a teacher? Is there somebody else I can call who can come down and be with you? You don’t have to stay with him.”

KK: That’s a great approach. Thank you very much for your time, Cynthia.

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Communication Tips for Reaching Your Opioid-Addicted Patients http://www.acepnow.com/article/communication-tips-for-reaching-your-opioid-addicted-patients/ http://www.acepnow.com/article/communication-tips-for-reaching-your-opioid-addicted-patients/#respond Sat, 14 Apr 2018 00:23:00 +0000 http://www.acepnow.com/?post_type=article&p=18856 Editor’s Note: This is the second part of an ongoing series on what emergency physicians can do...

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Editor’s Note: This is the second part of an ongoing series on what emergency physicians can do to combat the opioid epidemic. The series will continue in the June issue.

You’re in the midst of a busy shift trying to balance multiple patients when a nurse suddenly grabs you for an unconscious 30-year-old male pulled from a car with agonal respirations. You begin to bag him while ordering a dose of intramuscular naloxone. Within minutes, the patient starts to breathe, sits up confused, and tries to get off the gurney. Before you can blink, someone tells him, “Lay back down, and by the way, you’re welcome for saving your life.” The situation deteriorates, and both you and the patient leave the encounter dissatisfied, to put it mildly. Later you wonder if things could have played out differently.

It’s probably fair to say we’ve all experienced a similar encounter. Instead of receiving an appreciative “thank you” and plugging the patient into treatment, it ends with yelling and the patient suddenly walking out while you wonder if it’s safe for them to do so. There are many reasons these encounters go poorly. The patient may be scared or embarrassed, be afraid from previous encounters in which he felt disrespected, be in withdrawal from the naloxone, or have a poorly controlled mental illness. We might make incorrect assumptions about the patient’s ability to hear what we are telling them. Sometimes we think we are helping but may be making things worse. Of course, some people are just difficult, but this is true of patients with and without a substance-use disorder.

Are They Motivated?

It’s easy to assume a near-death encounter would motivate patients to change. But if overcoming addiction were this “easy,” no one would ever need a second dose of naloxone. How many times have you thought, after something bad occurs, that it’s time to make a change? Maybe after a bad traffic accident or near miss, you tell yourself you will never speed again, but then you do speed again.

As it turns out, there are several change stages, including pre-contemplation, contemplation, preparation, action, and maintenance. People move back and forth among these stages during their lifetime and don’t always progress in a linear fashion. Unfortunately, nearly dying does not always move someone with an opioid-use disorder to the action phase no matter how much we’d like it to.

As such, we must meet the person where they are. If they are ready to change, great! If there are resources available for treatment, hand them over and encourage them to follow up. But if they aren’t, us pushing remains unlikely to move them, and a change of approach may prove necessary. Otherwise, you’ll be pounding a square peg into a round hole.

Roll with It

In addition to the message, consider how you deliver it. In our emergency department, most of the time we’re overworked, overtired, and overstressed. As such, we try to be concise and to the point. We doubt we’re the only ones who have told a patient, “You will get HIV and die if you don’t stop using,” and then sometimes become upset or annoyed when they blankly stare at us. This used to be how addiction specialists would speak with them also, until they figured out this approach doesn’t work.

Addiction specialists now use motivational interviewing. This involves a lot of reflective listening with the goal of developing discrepancies between the patient’s goals and their behavior. By evoking an individual’s reasons to change, it allows the patient to conclude that continued use will lead to them not obtaining their goals, such as keeping custody of their children, holding a job, not contracting HIV, etc. This is opposed to us telling them what their goals or outcomes should be.

Should we expect everyone to enroll in courses and become an expert at such conversations? Absolutely not. Also, we can’t expect everyone to routinely stop in the middle of a busy shift to spend 15 minutes trying to motivate patients to change, although we do this for other less deadly conditions such as low-risk chest pain.

This approach avoids confrontation. It emphasizes adjusting to or rolling with resistance, and not clashing against it with brute force. In short, don’t overtly blame the patient, don’t threaten them with a Foley or restraints, and don’t escalate an already difficult situation. If they seem really concerned that they almost died, empathize, listen, and support them in coming to the conclusion that they could die next time instead of just bluntly telling them they will die and coming across adversarially.

Keep in mind the circumstances when you try to have this conversation. If the patient is in acute withdrawal, we recommend getting them feeling better before having this discussion. Also, words are important. Refrain from using the term “addict” or calling them addicted to improve the chances they will hear you. Specialists currently recommend using the term “opioid-use disorder.” Yes, it may seem a little silly, but that’s OK.

Harm Reduction

Of course, if the patient isn’t ready to hear our message and quit using, maybe changing our approach to a harm-reduction strategy is a better use of our limited time. It would be great if everyone was ready to quit, but that’s just not realistic.

In future columns, we’ll explain harm reduction in detail, but to put it briefly, the idea is to keep the patient alive and as safe as possible until they’re ready to quit. We’re not advocating for encouraging drug use, just understanding that if the patient is going to use, we should attempt to prevent them from acquiring HIV or dying from an overdose.

Even the best of us will have encounters that don’t end well for reasons beyond our control. However, emergency physicians are very skilled at de-escalating and communicating. Hopefully with a few additional tools, you’ll more successfully relate to this population and make your life easier. And if you do, there’s a bonus: Leading by example can make a massive difference in your department.


Dr. Waller is a fellow at the National Center for Complex Health and Social Needs and managing partner at Complex Care Consulting LLC. Dr. Schwarz is assistant professor of emergency medicine and medical toxicology section chief at Washington University School of Medicine in St. Louis.

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Opinion: Stanford’s New Stroke Protocol Expands the Treatment Window http://www.acepnow.com/article/opinion-stanfords-new-stroke-protocol-expands-the-treatment-window/ http://www.acepnow.com/article/opinion-stanfords-new-stroke-protocol-expands-the-treatment-window/#respond Fri, 13 Apr 2018 21:19:37 +0000 http://www.acepnow.com/?post_type=article&p=18784 Until now, the window to treat acute stroke with tissue plasminogen activator (tPA) or endovascular thrombectomy was...

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Until now, the window to treat acute stroke with tissue plasminogen activator (tPA) or endovascular thrombectomy was six hours, maximum. Many centers wouldn’t administer tPA after four hours.

Although many emergency physicians can attest to the professional satisfaction of successfully administering treatment to a patient who otherwise would have had a lifelong, debilitating neurologic deficit, most can also point to the intense frustration felt when a patient presented with a stroke that fell outside the treatment window. The treatment time limit cruelly limited the number of patients who could regain the ability to move or speak.

Progress has been made in the implementation of operational efficiencies to facilitate the early, prehospital identification of stroke symptoms; rapid EMS stroke diagnosis; rapid CT imaging; and, if appropriate, the timely administration of tPA and thrombectomy. However, the six hour problem remained—endovascular thrombectomy was previously recommended only if performed within six hours of symptom onset.

But we have good news: With the recent publications of the DAWN and DEFUSE3 trials, there’s new hope.

The DAWN trial demonstrated that select patients with acute ischemic stroke presenting from 6–24 hours of symptom onset have improved 90-day outcomes after mechanical thrombectomy compared to medical therapy alone.1

The DEFUSE3 trial showed similar results of improved outcomes with endovascular thrombectomy for ischemic stroke patients 6–16 hours after they were last known to be well.2 The patients best served featured proximal middle-cerebral-artery or internal-carotid-artery occlusion, and a region of tissue that was ischemic but not yet infarcted.

This evolving treatment paradigm, while groundbreaking, requires new emergency department and collaborative workflows to identify appropriate stroke patients and activate the correct treatment pathway.

A New Stroke Protocol

Stanford University’s department of emergency medicine collaborated closely with other departments to develop a novel Stroke Code Extended protocol that expedites evaluation and treatment of patients with large-vessel

debilitating strokes that, prior to the protocol, would have limited treatment options. The protocol was crafted by a multidisciplinary team of stakeholders from the departments of neurology, emergency medicine, nursing, radiology, and hospital staff. We designed and implemented the new stroke code process using quality improvement principles, such as adherence to standard work, pre-existing protocol preservation, planned outcome measures, and widespread education. Mock code simulations provided iterative feedback before we launched the process.

The team created the protocol for patients presenting with stroke symptoms at 8–24 hours without changing the pre-existing code process for patients presenting before 8 hours (see Figure 1). Emergency physicians rapidly triage and activate all stroke codes if the patient presents as greater than or equal to 6 on the National Institutes of Health Stroke Scale (NIHSS). However, the new protocol excludes a bedside pharmacy evaluation and moves directly to alerting the stroke team to come to the patient’s bedside in the emergency department.

Stanford University’s Stroke Code Extended protocol.

Stanford University’s Stroke Code Extended protocol.(Click for larger image.)
Source: Alexei Wagner

Other unique protocol elements include expedited CT angiogram and perfusion imaging, and mobilization of the interventional neuroradiology team for thrombectomy. The CT angiogram and perfusion imaging is critical in determining the amount of brain tissue at risk of infarct, and therefore whether thrombectomy would be indicated. To determine patients appropriate for thrombectomy with adequate salvageable tissue, the team looks at the ratio of ischemic tissue to the initial infarct volume (ischemic core), and an absolute volume of potentially reversible ischemia (penumbra).

The Stroke Code Extended also requires the emergency department attending to perform and document a NIHSS score on all suspected stroke patients. Although this is a core emergency medicine skill, Stanford instituted an educational initiative to certify our entire faculty and residency in performing the assessment. This was accomplished through online training modules and traditional lecture-style didactics.

In addition, immediately upon arrival at the bedside, the neurology resident now performs an NIHSS stroke scale assessment. Our goal is to study the inter-rater reliability between neurology- and emergency medicine-completed NIHSS stroke scales.

Beyond the New Protocol

Parallel to our initiative to identify and treat extended strokes, Stanford’s neurology department has performed significant educational outreach to referral hospitals to facilitate the rapid transport of stroke patients to Stanford Hospital even if they’re outside the tPA window but still likely to benefit from thrombectomy. In addition, the Stanford School of Medicine has found that collaboration between the emergency medicine and neurology departments is instrumental in improving the treatment of acute stroke.

Looking ahead, we will evaluate the implementation of this protocol by collecting stroke quality metrics, measuring NIHSS inter-rater reliability, and monitoring the stroke mimic rate. We look forward to sharing further insights about our protocol and results.

Speak Out on Stroke

Have comments on extending the time window for thrombectomy? We want to hear from you! Send your comments to dantolin@wiley.com. We may publish them in a future issue.


Dr. WagnerDr. Wagner is assistant director of Adult Emergency Medicine at the Stanford University School of Medicine in Palo Alto, Calif.

Dr. ShenDr. Shen is the interim chair of the Department of Emergency Medicine at the Stanford University School of Medicine in Palo Alto, Calif.

References

  1. Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2018;378(1):11-21.
  2. Albers GW, Marks MP, Kemp S, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med. 2018;378(8):708-718.

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How Is ACEP Directly Affecting Your Practice? http://www.acepnow.com/article/how-is-acep-directly-affecting-your-practice/ http://www.acepnow.com/article/how-is-acep-directly-affecting-your-practice/#respond Fri, 13 Apr 2018 20:42:45 +0000 http://www.acepnow.com/?post_type=article&p=18790 ACEP leadership and staff works every day to make change at the highest levels that will affect...

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Dr. Mark Rosenberg (left) and Dr. Alexis LaPietra developed the Alternatives to Opioids protocol at St. Joseph‘s Regional Medical Center. Hansi Lo Wang/NPR

ACEP leadership and staff works every day to make change at the highest levels that will affect all levels of your practice. Catch up on what leadership has done for you lately in the Leadership Report.

ACEP Board of Directors member Mark S. Rosenberg, DO, MBA, FACEP, has been appointed to the Department of Health and Human Services (HHS) Pain Management Best Practices Inter-Agency Task Force (PTMF). The PTMF was created to determine whether there are gaps or inconsistencies in pain management best practices among federal agencies and propose recommendations for addressing identified gaps and/or inconsistencies.

ACEP and the Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) met on March 1 to discuss quality measures policy, process, and the future vision for CMS’ approach to meaningful measures. The meeting was very productive and provided insight to the ACEP team in preparation for developing the next generation of quality measures, validating existing measures, and assessing their applicability to ACEP’s Quality Clinical Data Registry, known as Clinical Emergency Data Registry (CEDR).

Laura Wooster, ACEP’s associate executive director of public affairs, represented ACEP in a day-long meeting in Washington, D.C., held by HHS’ Assistant Secretary for Preparedness and Response, Robert Kadlec, MD, to gain stakeholder input on how to implement his vision for a national medical disaster system. Dr. Kadlec will be sharing more on this vision when he joins ACEP‘s Public Policy Town Hall during the Leadership and Advocacy Conference on May 21.

Dr. Jon Mark Hirshon, a member of ACEP’s Board of Directors, speaking at the House Ways and Means Health Subcommittee.

Dr. Jon Mark Hirshon, a member of ACEP’s Board of Directors, speaking at the House Ways and Means Health Subcommittee.
ACEP

ACEP Board member Jon Mark Hirshon MD, PhD, MPH, FACEP, participated in a roundtable held by the House Ways & Means Health Subcommittee on its “Red Tape Initiative” to reduce provider administrative burdens. Dr. Hirshon talked about administrative burdens in the Medicare program that impact emergency physicians and provided recommendations for addressing them.

ACEP joined with the American Hospital Association and the American College of Radiology in a joint letter to Anthem Chief Clinical Officer Craig Sammit, MD, to state concerns with the insurer’s policy retroactively denying coverage for emergency visits it deems as non-emergent. ACEP also has worked closely on the Anthem issue with Senators Ben Cardin of Maryland and Claire McCaskill of Missouri, who wrote a joint letter to HHS Secretary Alex Azar and Department of Labor Secretary Alexander Acosta expressing concerns about the Anthem policy and seeking information on whether it violates federal laws or regulations.

Two emergency medicine opioid bills that ACEP was heavily involved in developing were recently introduced in Congress. The “Alternatives to Opioids (ALTO) in the Emergency Department Act” would provide $30 million (over three years) to establish a demonstration program to nationally test the ALTO protocol developed at St. Joseph’s Regional Medical in Paterson, New Jersey, by Dr. Rosenberg and Alexis M. LaPietra, DO, medical director of emergency medicine pain management at St. Joseph’s. The program uses alternative pain management protocols to limit the use of opioids in the emergency department. Additionally, the “Preventing Overdoses While in Emergency Rooms (POWER) Act” would provide $50 million (over five years) in grants to establish policies and procedures for administering medication-assisted treatment (MAT) in the emergency department to opioid overdose patients with subsequent referral to community providers.

ACEP President, Paul Kivela, MD, MBA, FACEP, was formally invited by the National Academy of Sciences (NAS) to participate in a panel to discuss “Leading Changes at the Ground Level” of clinical medicine/healthcare administration at the workshop titled, “Engaging the Private Sector Health Care System in Building Capacity to Respond to Threats to the Public’s Health and National Security.” Dr. Kivela worked with ACEP‘s EMS and Disaster Sections for his discussions.

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Highlights from the ACEP17 Research Forum http://www.acepnow.com/article/highlights-from-the-acep17-research-forum/ http://www.acepnow.com/article/highlights-from-the-acep17-research-forum/#respond Fri, 13 Apr 2018 20:22:07 +0000 http://www.acepnow.com/?post_type=article&p=18825 The ACEP Research Forum, held at our annual scientific meeting, focuses on cutting edge research. In 2017,...

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The ACEP Research Forum, held at our annual scientific meeting, focuses on cutting edge research. In 2017, the forum included outstanding expert state-of-the-art talks on how research is incorporated into clinical practice guidelines and how landmark articles come into being. There was also a session including legislators and researchers discussing the opioid crisis. This article highlights just a few of the research abstracts that may help your practice.

You can find all the abstracts presented at the ACEP17 Research Forum in Annals of Emergency Medicine’s October 2017 supplement.

Multicenter Trial of Rivaroxaban for Early Discharge of Pulmonary Embolism From the Emergency Department (MERCURY-PE)

Peacock W, Diercks D, Francis S, et al

Presenters at the ACEP17 Research Forum.

Presenters at the ACEP17 Research Forum.
Photos: Paul Kim and ACEP

This multicenter, prospective, open label, randomized clinical trial sought to determine what happens to low risk pulmonary embolism (PE) patients who are discharged home straight from the emergency department with rivaroxaban compared to standard care (SC; observation unit stay or inpatient admission). Not surprisingly, mean total hospital days (for any reason) at 90 days after randomization were significantly less for rivaroxaban than SC; 0.8 versus 1.8 days. The composite safety endpoint was similar in both groups. This industry-funded study suggests that carefully selected patients with PE can be managed as outpatients from the emergency department.

Trends in Site of Care for Low-Acuity Conditions Among Those with Commercial Insurance, 2008–2015

Poon SJ, Schuur JD, Mehrotra A

This study examined an insurance database for visits related to three low-acuity complaints. They found not only that emergency departments were seeing a decreasing proportion of these types of visits, but also that this decrease was due to an increase in “new” visits to urgent care and retail clinics (additive visits, not substitution). Thus, these clinics did not “steal” visits from the emergency department, but “created” visits through supply-induced demand.

Association of State Gun Laws with Pediatric Mortality from Firearms

Patel SJ, Badolato G, Parikh K, et al

Presenters at the ACEP17 Research Forum.<br>Photos: Paul Kim and ACEP

Photos: Paul Kim and ACEP

In this politically timely abstract, the authors analyzed Centers for Disease Control and Prevention (CDC) data for firearm-related mortality in children 0–21 years of age and measured whether there was a relationship to state-specific Brady Campaign Gun Law Scores for 2015. The CDC noted that 4,528 children died from firearm-related injuries in 2015. Higher pediatric mortality rates were associated with lower (less strict) state-specific gun law scores. More specifically, median mortality rates were lower among the 12 states requiring universal background checks for firearm purchase (3.8 versus 5.7 per 100,000 children) and ammunition (2.3 versus 5.6 per 100,000 children). Although observational, these data provide the best available evidence to guide policy development.

Effect of SEP-1 Core Measure Compliance on Mortality and Hospital Length of Stay

E.A. Gross, G. McGlynn

Fluid Resuscitation of Septic Patients at Risk for Fluid Overload

M. Akhter, M. Hallare, A. Roontiva, et al

We’ve all seen this patient: past medical history of congestive heart failure (CHF) and creatinine of 5.6 who presents in septic shock. The much-discussed SEP-1 quality metric mandates an intravenous fluid bolus (30 ml/kg), but clinicians fear causing pulmonary edema, leading to a need for intubation. These two abstracts look at institutional databases and found that even in patients with CHF and end-stage renal disease (ESRD), following SEP-1 decreased mortality. Furthermore, there was no increase in intubation in septic patients with CHF and ESRD when clinicians followed SEP-1.

While noting, once again, the caveat of observational data and likely inclusion bias, this still provides some reassurance to providers caring for septic patients with CHF or ESRD.

Figure 1: Visit rates to acute care venues for all conditions, 2008–2015. ED=emergency department; UC=urgent care; RC=retail clinics; Tele=telehealth.

Figure 1: Visit rates to acute care venues for all conditions, 2008–2015. ED=emergency department; UC=urgent care; RC=retail clinics; Tele=telehealth.
Ann Emerg Med. 2017;70(4 suppl):S69.

A Randomized Study of Naproxen Plus Placebo, Orphenadrine, or Methocarbamol for Acute Low Back Pain

Friedman BW, Irizarry, E, Solorzano, C, et al

Back pain continues to be a common reason for ED visits, and Dr. Friedman and colleagues continue to search for effective treatments. This double-blind trial randomized patients to receive naproxen plus a one-week supply of either orphenadrine (Norflex) 100mg, methocarbamol (Robaxin) 750mg, or placebo. Unfortunately, 34 percent of naproxen+placebo patients reported moderate or severe low back pain versus 33 percent of naproxen+orphenadrine and 39 percent of naproxen+ methocarbamol patients. This study reinforces an approach that emphasizes nonsteroidal anti-inflammatory drugs and education for patients with musculoskeletal back pain.

Do Intranasal Vasoconstrictors Increase Blood Pressure?

Bellew SD, Johnson KL, Kummer T

This study calls to mind another common ED scenario: the epistaxis patient with severe hypertension. In this elegant randomized, double-blinded, placebo-controlled trial, a convenience sample of patients was assigned to one of four arms: phenylephrine 0.25%, oxymetazoline 0.05%, lidocaine 1% with epinephrine 1:100,000, or bacteriostatic 0.9% sodium chloride in cotton soaked nasal pledgets. They did not find any changes in blood pressure over the 30 minutes after drug administration between any of the arms. This suggests that vasoconstrictors cause minimal acute blood pressure changes when applied nasally via soaked pledgets.

High Sensitivity Troponin T (hsTnT) Identifies Patients at Very Low Risk of Adverse Events

Peacock WF, Baumann B.M, Bruton D, et al

There has been much literature published on the utility of high-sensitivity troponin assays. This study reports on their use in an American cohort. This Roche-funded study examined a three-hour protocol in 1,264 ED patients suspected of having acute coronary syndrome, finding that in the 974 (77.1 percent) patients with both a zero- and three-hour hsTnT<19 ng/L a 30-day adverse cardiac event occurred in seven patients for a negative predictive value of 99.3 percent (95 percent CI, 99.05–99.55).

Telehealth for Low-acuity EMS: One Fire-based System Experience with 10,000 Patients

Gonzalez MG, Persse DE, Gleisberg GR, et al

Telemedicine in the Emergency Department: A Novel, Academic Approach to Optimizing Operational Metrics and Patient Experience

Sharma R, Clark S, Torres-Lavoro J, et al

Finally, we would be remiss if we did not highlight the latest cutting-edge work from our first ever session of abstracts devoted to telemedicine. Both of these abstracts demonstrated the ability of emergency physicians to care for patients via remote communication, the first in the pre-hospital environment, and the second in a fast track scenario. Both abstracts demonstrated that patients could be cared for efficiently and safely while reducing ED visits or time in the emergency department.

Awards

Congratulations are also in order to award winners Brett Schuchardt and Rebecca Kowalski, who were awarded Best Medical Student abstract for “The Ability of Heparin-Binding Protein to Identify Delayed Shock in Emergency Department Sepsis Patients is Impacted by Age and Source of Infection,” and Sumit Patel, MD, who was awarded Best Resident Abstract for “A Comparison of Three Sobering Center Screens Using a Prospective Cohort of Intoxicated Emergency Department Patients,” at the first–ever live award finalists presentation. Congratulations also to Best Young Investigator Naveen Poonai, MD, for “Intranasal Ketamine for Procedural Sedation in Children: A Randomized Controlled Pilot Study” and to Michael Gonzalez, MD, for Best Overall Abstract on his telehealth EMS abstract above.

Find out what’s next for emergency medicine this October at the ACEP18 Research Forum in San Diego!


Dr. Limkakeng is director of the ACEP Research Forum and associate professor and director of acute care research in the division of emergency medicine at Duke University School of Medicine in Durham, North Carolina.

Dr. Piktel is assistant professor of emergency medicine at Case Western Reserve University School of Medicine in Cleveland, Ohio.

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Tips to Improve Airway Management http://www.acepnow.com/article/tips-to-improve-airway-management/ http://www.acepnow.com/article/tips-to-improve-airway-management/#respond Fri, 13 Apr 2018 20:15:51 +0000 http://www.acepnow.com/?post_type=article&p=18833 Procedural sedation and emergency airway management are recognized risks to patient safety. Sedation, induction agents, and muscle...

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Figure 1: Pulse oximeter reading.

Procedural sedation and emergency airway management are recognized risks to patient safety. Sedation, induction agents, and muscle relaxants can quickly impact oxygen saturation, and desaturation is often precipitous.

What contributes to the sorcery that seems to surround airway management and procedural sedation, and how can we avoid bad outcomes?

Gas Monitoring

First, recognize that with pulse oximetry, we use an imperfect monitor. It lags what’s happening in your patient by 30–90 seconds. Moreover, it does not give you an estimation of safe apnea time, even with high values (ie, 94–100 percent), because the asymptotic shape of the pulse oximeter curve displays saturation, not the amount of oxygen in the blood (ie, the partial pressure of O2 [PaO2] in a blood gas). A pulse oximeter reading of 95 percent may represent a PaO2 of 80, while a pulse oximeter reading of 100 percent can represent a PaO2 of anywhere from 95–600 (see Figure 1).

The argument for CO2 monitoring is that it monitors ventilation and therefore is immediate as well as forward looking. The problem: Most commonly used end-tidal CO2 detection methods (ie, small bore nasal cannulas) can’t provide higher flows (ie, >6 lpm) without popping off the oxygen source. Even if you rig a cannula or other mechanism to place the CO2 detector into or under a mask, high-flow oxygen given simultaneously affects CO2 detection.

Figure 2 (left): A standard nasal cannula, shown here, can be paired with a with a low-flow cannula with end-tidal CO2 detection to avoid affecting CO2 detection when higher flows are needed.

Figure 2: A standard nasal cannula, shown here, can be paired with a with a low-flow cannula with end-tidal CO2 detection to avoid affecting CO2 detection when higher flows are needed.
PHOTO: Richard Levitan

Perhaps the easiest way around this is to use two cannulas—that is, start with a low-flow cannula with end-tidal CO2 detection, and if you need higher flows, run oxygen through a standard nasal cannula previously placed on the patient (see Figure 2). Coming off the wall, a standard nasal cannula can deliver flows well above 50 lpm (even though the manometer only goes to 15 lpm) and as high as 70 lpm. “O’s up the nose” at these high flows can dramatically improve oxygenation, assuming the airway remains patent.

Divide the Airway

After more than twenty years of being airway obsessed, I recently began to gain a different perspective of the anatomy and clinical challenges of airway management. I believe it is useful to divide the airway into three sections to improve our anatomic understanding, and more importantly, to guide therapeutic intervention (see Figure 3):

  1. The upper airway includes the nasopharynx, mouth, and the hypopharynx down to the larynx. The upper airway is the most common site of airway obstruction due to the soft tissue structures of the palate, tongue, and epiglottis.
  2. The middle airway runs from the laryngeal cartilages (larynx) to the bronchi. It is normally patent, stented open by the rigidity of the thyroid and cricoid cartilage, and the tracheal rings.
  3. The lower airway includes the lungs and alveoli, where gas absorption occurs across the alveolar-capillary membrane.

To decipher the sorcery of the airway, we must appreciate how sedation, positioning, and our therapeutic interventions and techniques affect the airway at all three levels. Gravity is the enemy of both upper and lower airway patency when the patient is in a supine position. Supine positioning (coupled with poor muscular tone) causes the tongue to fall backwards against the soft palate and contact the posterior pharynx. Oral airways and/or nasopharyngeal airways are often needed to keep the soft palate and tongue from obstructing the airway. This is problematic because some patients may have respiratory depression or poor tone, but an oral airway may still trigger a gag response and vomiting, risking aspiration. Although mask ventilation techniques emphasize jaw thrust, struggling to maintain upper airway patency in a supine position is intrinsically self-defeating. It is also ergonomically difficult and frequently a multi-person task, especially in large patients.

Figure 3: Think of the airway in these three sections.

Figure 3: Think of the airway in these three sections.
PHOTO: Richard Levitan

Supine positioning runs counter to lower airway (alveolar) patency. In the supine position, the lung’s upper areas compress the dependent alveoli, and abdominal contents push the diaphragm up, significantly reducing lung volume. Changing position from upright to supine reduces functional residual capacity (FRC) by as much as one liter. Because estimated FRC in adults measures approximately 2,400 ml, a reduction of 1,000 ml reduces FRC by 42 percent. Loss of tone (as occurs with anesthetic induction) or over-sedation further reduces FRC by 400 ml.

Collectively, then, FRC reduction from standing to supine plus loss of tone results in a reduction of roughly 52 percent! This reduction’s impact on alveolar gas absorption is dramatic, especially in patients who already have compromised lung function.

Sit Them Up

The first and most important technique for boosting oxygen absorption is to apply high oxygen concentration with high flow as a means of augmenting the patient’s negative inspiratory efforts. But beyond the application of 100 percent oxygen, and shy of extracorporeal membrane oxygenation or using hyperbaric oxygenation, clinicians have only two methods of further improving oxygenation across the alveoli: 1) positioning, and 2), positive end-expiratory pressure (PEEP).

The immediate and easiest positioning fix to open the lower airway? Sit the patient up. This causes the abdominal contents to move caudad, the diaphragm to drop, and lung volume to rapidly expand. The area for gas absorption across the alveioli dramatically increases with proper positioning.

Middle airway obstruction is an infrequent clinical problem because the three-dimensional shape of laryngeal cartilages and the cartilaginous rings of the trachea maintain patency regardless of positioning or muscular tone. An orally placed tracheal tube traverses the upper airway and reaches the mid-trachea level. When the middle airway obstructs due to intrinsic laryngeal-tracheal pathology (eg, tumors, angioedema about the larynx, blood clots, etc.) or trauma (eg, laryngeal fracture, direct tracheal injury, etc.), patients can die precipitously.

With an awareness of gravity and positioning, and an understanding of the three airway components, engineering airway interventions that augment patency and gas absorption makes sense. Here’s my stepwise approach to hypoxia with procedural sedation or in an initial emergency department presentation:

  1. Sit the patient up, allowing the diaphragm to drop and the alveoli volume to expand, and pull on the mandible. This opens the upper airway.
  2. Send O’s up the nose—blast open the soft palate and shoot oxygen into the trachea up to and beyond 15 lpm.
  3. Add PEEP with a bag valve mask (BVM) and a PEEP valve, or a continuous positive airway pressure system. PEEP is absolutely necessary when high-flow oxygen (with cannula plus mask) does not achieve high oxygen saturations (ie, >98 percent).

To desaturate after the tracheal tube has been placed, first examine the system to ensure the tube is at right depth, the oxygen is connected, and the cuff is up. Suction through the tube to remove mucous plugs, clots, etc. If high-pressure alarms go off or bagging difficulty persists (that is not consistent with the patient’s pathology, ie, COPD, asthma, etc.), pull the tracheal tube. It is quite common to experience ball-valve obstructions from mucous plugs or clots that suctioning alone doesn’t resolve.

Plan to maximize oxygenation in every instance of procedural sedation. Use gravity to reduce the risk of aspiration, and always ask, “Do you need the patient flat?” We rarely do, and head elevation adds tremendously to patient safety.

The highest-risk patients may be those sedated for hip reduction because they need to be lying flat. Even a slight amount of head elevation (ie, 10 degrees) tilts the pannus down and improves lung function tremendously. Once the hip reduction is complete, bring the head higher and pull on the mandible with the nasal cannula on. Often the most dangerous part of sedation occurs after the reduction because pain input drops but the drugs haven’t worn off.

If positioning, pulling on the mandible, and nasal oxygen at high flow does not resolve hypoxia, add PEEP by using a BVM with a PEEP valve. Install PEEP valves on every BVM in your department so when PEEP is needed, you don’t need to locate one.

Be mindful of patients at high risk of desaturation due to alveolar disease (ie, heart failure, acute respiratory distress syndrome, multi-lobar pneumonia, aspiration, etc.). The sickest of the sick may require combining both upright positioning and PEEP for pre-oxygenation, and also during the onset phase of muscle relaxation when performing rapid sequence intubation. Even after successful intubation, these patients can prove difficult to oxygenate. Increase the fraction of inspired O2, increase PEEP, lower tidal volumes, and increase the ventilator rate in these challenging cases.

Finally, consider prone positioning if upright positioning doesn’t allow for sufficient oxygenation.

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Today’s ACEP Board Is Its Most Diverse Ever http://www.acepnow.com/article/todays-acep-board-is-its-most-diverse-ever/ http://www.acepnow.com/article/todays-acep-board-is-its-most-diverse-ever/#respond Fri, 13 Apr 2018 20:15:51 +0000 http://www.acepnow.com/?post_type=article&p=18816 For the first time in ACEP‘s history, our Board of Directors truly reflects the diverse membership of...

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For the first time in ACEP‘s history, our Board of Directors truly reflects the diverse membership of the College.

There are 15 members of the Board of Directors and five of them are female. This is the most female physicians ACEP has ever had on its Board at one time. There are Board members with a variety of racial, ethnic, and religious backgrounds.

One Board member is under 40, and five are 60 or older. Nearly all geographic areas of the country are represented.

In addition to being attending physicians, there are seven Board members who hold academic physician positions. Some are emergency department directors or EMS directors. Others hold various emergency medicine administration positions in addition to their practice.

They come from a variety of practice settings, including small independent groups, large emergency physician groups, community hospitals, urban trauma centers, university academic institutions, military hospitals, freestanding emergency departments, and even one rural setting. Members of our Board understand the practice environments of our members.

With this unprecedented diversity and inclusiveness of our ACEP Board, we are able to be more responsive to the diverse needs and perspectives of our members.

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