Emergency physicians are innate problem solvers. If they see a gap, they work to close it. When they identify a need, they figure out how to fill it. Those natural instincts, combined with a desire to help people, are the fuel for some of the most impactful clinical developments in emergency medicine.
Explore This IssueACEP Now: Vol 38 – No 08 – August 2019
Like most inventions, ACEP’s point-of-care (POC) app was born out of necessity. Expert panels had worked tirelessly to develop valuable bedside tools for emergency physicians related to atrial fibrillation, buprenorphine use, acute pain management, and more, but feedback showed that some were unable to access those web-based tools easily during an ED shift. Sometimes, it was because of a poor internet connection; other times, it was simply having no time to stop at a desktop computer to view the tool.
The usability gap was clear: We needed to improve access by circumventing the variability of the internet and making these POC tools easy to use on the move. Enter emPOC, ACEP’s new native app that takes five of the most-used bedside tools—AFIB (atrial fibrillation and flutter), BUPE (buprenorphine use in the emergency department), ADEPT (agitation in the elderly), MAP (management of acute pain), and iCar2e (suicide assessment)—and puts them in your pocket. Available in Apple’s App Store and Google Play, emPOC is a free app exclusively available to ACEP members.
Christopher Baugh, MD, MBA, FACEP, chair of the ACEP Expert Panel on Atrial Fibrillation, has built a career on plugging gaps. He’s been interested in observational medicine, leadership, and finance from the beginning, earning his MBA while getting his medical degree. As he dug into observational medicine as an intern at Massachusetts General Hospital, he noticed “a problem everyone had,” which was that some patients need more time for treatments and diagnostic testing and end up getting admitted from the emergency department into inpatient services, even though inpatient services isn’t designed for those quick admissions. He felt like it wasn’t the best use of resources.
He started studying the patients who were admitted for short stays, and atrial fibrillation (AFib) jumped out as one of the most frequently encountered conditions. One thing led to another, and Dr. Baugh was soon conducting a pilot at his institution around developing a protocol to discharge AFib patients in a timelier manner. That pilot turned into a paper, and soon Dr. Baugh was tapped to lead ACEP’s Expert Panel on Atrial Fibrillation.
Dr. Baugh was excited to take his local work and try to make a national impact, and he welcomed the challenge of managing a multidisciplinary expert panel. The panel immediately started working toward several different deliverables. First, it set out to develop a pathway, an example protocol for AFib as a starting point for peer physicians that could be modified depending on ED variables, such as the presence of an observation unit or ability to consult. The panel also developed example efficiency and outcome metrics so those who implemented the new AFib protocol would be able to make sure the changes were having the intended effect. Then it did expert consensus statements examining topics such as electrocardioversion, chemical cardioversion, adequate weight control, etc.
Dr. Baugh said the panel envisioned this tool helping the physician who wants to change protocol but needs a resource to help them navigate the process. “The goal of the panel was to give people a road map or toolkit of how to get there so we can be that resource for them.”
Once the paper was developed, the expert panel worked with ACEP staff to build the online AFib POC tool that took the protocol from the paper and broke it down in a simplified, streamlined way that made it easy to reference quickly while on shift. Once the online tool was created and the need for the native app version was identified, the panel consulted on the conversion from the web tool to the app. ACEP members can choose whether to access the AFib tool through the emPOC app or the ACEP website, but the content is the same.
POC Tools You Need When You Need Them
- emPOC is ACEP’s new point-of-care app that puts helpful bedside tools in your pocket for easy access during busy shifts.
- AFIB (atrial fibrillation and flutter)
- BUPE (buprenorphine use in the ED)
- ADEPT (agitation in the elderly)
- MAP (management of acute pain)
- iCar2e (suicide assessment)
emPOC is for ACEP members only and can be downloaded on iTunes and Google Play.
A Protocol for Pain
Alexis LaPietra, DO, FACEP, was an EM resident as the opioid crisis was gaining momentum, and she felt conflicted about how to navigate pain management within the emergency department. “It was a strange place to be in where I’m dispensing or prescribing opioids but also seeing the significant harm associated with opioid prescribing,” Dr. LaPietra said. “I thought, is there a way to do this better? I want to do better, and I don’t want to do harm.”
At the end of her residency, she spoke with her chairman, Mark Rosenberg, DO, MBA, FACEP, about her growing interest in pain management. He suggested a fellowship where she could spend a year learning about pain management by rotating through almost every other specialty at St. Joseph’s Regional Medical Center in Paterson, New Jersey, with the goal of coming back to the emergency department with new processes for pain management.
At the end of her fellowship, she became the medical director in charge of EM pain management at St. Joseph’s, the third largest emergency department in the country, which sees more than 170,000 annual visits from its diverse, urban community. She then collaborated with other leaders in the pain management space to help develop the Alternative to Opioids (ALTO) protocol, which she describes as a “cheat sheet for how to treat pain on a shift in the emergency department.”
“I really wanted [ALTO] to be easy because pain is so complex. Pain is so hard to treat,” Dr. LaPietra said. “You’re in a busy ED, you’re doing CPR on one bed, you’re running a stroke code on the other bed, but a patient with pain deserves that much attention. … I wanted to take the legwork out of it, take the guesswork out of it.”
Once ALTO was up and running in New Jersey, Dr. Rosenberg encouraged Dr. LaPietra to take what she had learned to the national level by petitioning ACEP to start a pain management section. She quickly got the signatures of support she needed and was soon chairing ACEP’s brand-new Pain Management and Addiction Medicine Section. That role led to Dr. LaPietra leading ACEP’s expert panel that recently developed the MAP tool, a collaborative process involving pain management section members from across the country.
When the section agreed it wanted to tackle this project to make it easier to manage pain for the types of conditions physicians see daily in the emergency department, it sent out a call for content. It wanted to know what others were doing on the front lines for pain management. The results indicated key topics that had a lot of buzz and good evidence that formed the basis of the MAP tool—forearm nerve block, intra-articular posterior shoulder injection, ketamine for acute pain, ketamine for chronic non-cancer pain, nitrous oxide, posterior tibial nerve block, sphenopalatine ganglion block, and trigger point injection.
Dr. LaPietra and the rest of the expert panel focused on whittling down the literature into the most relevant information and summarizing it into a bulleted format so that the protocol could be processed very quickly in busy emergency departments.
“You sometimes can’t go to the bathroom during an ED shift, so how are you supposed to stop and look up a journal article?” Dr. LaPietra said. “… We’re on shift, and we just want to get the gist of what’s going on from a trusted source, and that’s where you can use [the MAP tool] in the middle of your crazy shifts while you’re managing 16 patients.”
The content was reviewed multiple times, with all parties weighing in to make sure it would be easy for different practice settings to utilize. The pain management expert panel participated in the beta testing for the online tool and the app, checking for accuracy and functionality.
Now that MAP is available in a native app, Dr. LaPietra is thrilled that all ACEP members can access the tool just like the section leaders originally intended. “This tool was always meant to be used at bedside for the busy doc who feels like they are stuck and just needs to spend 30 seconds figuring out their game plan. … We needed it to be disseminated in a streamlined way in the same way we’re used to practicing, which is jumping on our phone if we need some answers,” Dr. LaPierta said.
For both Dr. LaPietra and Dr. Baugh, being chosen to lead the development of these impactful bedside tools was an honor and privilege—and an education on the art of collaboration and consensus.
“The nice thing is I didn’t do it all by myself,” Dr. LaPietra said. “I had a lot of national contributors. I ran things by other experts when I wasn’t quite sure. It showed me the importance of collaboration, the importance of stepping up and leading when you feel like there’s passion and you have something to say.”
For Dr. Baugh, there was deep satisfaction in helping to build a tool that physicians can use on a daily basis to take better care of patients. “As an academic emergency physician, that’s really what you’re trying to do, right? You’re trying to make a difference in your specialty.”
Dr. LaPietra and Dr. Baugh are able to look back at how their paths led them to this point and how one simple step can chart a new course. Their message to other ACEP members who want to influence clinical practice is simple: Start the conversation.
“There is so much clinical expertise out there in the country that is going untapped,” Dr. Baugh said. “There is an opportunity to contribute, and that’s the bottom line. You have to be willing to have the conversation, to put it out there that you’re interested in making a change. You’d be surprised how much one conversation leads to another.”
Dr. LaPietra thinks one of the best ways to get involved with ACEP’s clinical efforts is by joining the section(s) that align with personal passions. “Through the section structure, you’re able to engage with individuals nationally who have similar interests, and that opens so many doors for projects you didn’t know existed.”
She said the sections also help personalize ACEP and give you a way to plug into a large national organization in a more manageable way. “To define your tribe within our big tribe, you should use the sections. That way, you know you’ve come into a group with common interests where the possibilities are endless because this is where that topic is being mastered.”
One simple way for ACEP members to contribute to ACEP’s clinical efforts right away is simply by providing feedback on the POC tools and the new emPOC app. The app has a section allowing users to submit questions and feedback, and ACEP staff is monitoring the feedback closely as they work to continually refine and improve the tool. More POC tools will be added to the app during phase II, so now is the perfect time to submit feedback or suggestions for the next iteration.
Thank You, Contributors!
ACEP would like to thank the following thought leaders for participating in the expert panels that developed the five bedside tools on the emPOC app. Your expertise and dedication help us move the practice of emergency medicine forward.
Christopher Baugh, MD, MBA (chair); Karen Pate, PhD (moderator); JoAnn Brooks, PhD, RN, FAAN, FCCP; Carol L. Clark, MD, MBA, FACEP; Abraham G. Kocheril, MD, FACC, FACP, FHRS; Dhanunjaya Lakkireddy, MD; Krista Luck, PharmD, CACP, CPP; Troy Myers, MD, FACEP; Brian Patel, MD; Jesse Pines, MD; Charles V. Pollack Jr., MA, MD, FACEP, FAAEM, FAHA, FESC, FCPP; Steven Roumpf, MD; Matthew Shaw, PA-C; Ian Stiell, MD, MSc, FRCPC; Gery Tomassoni, MD, FHRS, FACC; James Williams, MS, DO, FACEP; Jason W. Wilson, MD, MA, FACEP, FAAEM; Fred Wu, MHS, PA-C; GilAnthony Ungab, MD
Charles A. Austin, MD, MSCR; Michael Gerardi, MD, FACEP; Maura Kennedy, MD, MPH; Christina Shenvi, MD, PhD, FACEP; Michael P. Wilson, MD, PhD, FACEP, FAAEM
Christie DeFranco, DO; Herbie Duber, MD, MPH, FACEP; Kate Hawk, MD; Andrew Herring, MD; Eric Ketcham, MD, MBA, FACEP, FASAM, FACHE; Kurt Kleinschmidt, MD; Shawn Ryan, MD, MBA, ABEM, ABAM; Evan Schwarz, MD
Marian E. Betz, MD, MPH; Christine Moutier, MD; Kimberly Nordstrom, MD, JD; Michael Wilson, MD, PhD; Lisa Wolf, PhD, RN
Caleb Canders, MD; Maria Conradt, MD, MS; Andrea Dewing, MD; Daniel Freess, MD, FACEP; John Hipskind, MD, FACEP; Alexis M. LaPietra, DO, FACEP; Maureen McCollough, MD, FACEP; Evan Schwarz, MD, FACEP; Adelaide Viguri, DO
ACEP STAFF SUPPORT
Marta Foster, Riane Gay, MPA, Ram Khatri, Margaret Montgomery, RN, MSN, Steven Morrissey, Jana Nelson, Loren Rives, MNA, Sandy Schneider, MD, FACEP, Travis Schulz, MLIS, Sam Shahid, MBBS, MPH, Cynthia Singh, MS, Lori Vega
Ms. Grantham is ACEP’s communications manager.