ACEP NowACEP Now https://www.acepnow.com Mon, 22 Jul 2019 14:21:19 +0000 en-US hourly 1 https://wordpress.org/?v=5.2.2 Tips for Managing Urinary Tract Infections in 2- to 24-Month Old Kids https://www.acepnow.com/article/tips-for-managing-urinary-tract-infections-in-2-to-24-month-old-kids/ https://www.acepnow.com/article/tips-for-managing-urinary-tract-infections-in-2-to-24-month-old-kids/#respond Wed, 17 Jul 2019 14:48:58 +0000 https://www.acepnow.com/?post_type=article&p=21573 Pediatric patients between the ages of 2 and 24 months who present with fever without a known...

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Pediatric patients between the ages of 2 and 24 months who present with fever without a known source present a particular challenge because of the exceedingly nonspecific clinical presentation.1 Asymptomatic bacteriuria and true urinary tract infections (UTIs) are often difficult to distinguish, which has led to overtesting, overdiagnosis, and overtreatment in otherwise healthy children.2 In this column, I’d like to dispel some common myths and misperceptions about pediatric UTI that will better arm you to tackle this challenging problem. I’ll outline a standardized approach to pediatric UTI so that you know who to screen, how to screen, and what to do with the screen results, thereby reducing the risk of harm caused by excessive antibiotic use.

While observational data reveal that 7 percent of children 2 to 24 months of age presenting to the emergency department with isolated fever without an obvious source have a UTI, the prevalence of urosepsis in otherwise healthy, immunocompetent children has been estimated to be only 1 in 25,000.3,4

The most important clinical predictors of UTI in the 2– to 24-month age group include temperature >40°C, fever >24 hours, suprapubic tenderness, jaundice, and, in males, lack of circumcision.1 While “history of prior UTI” was shown to be predictive of UTI, it is important to recognize that prior false positives can be misleading, as earlier diagnoses may have been made speculatively without cultures or the culture results themselves may have been false positives. Placing patients in a high-risk category for UTI when they present with fever without a source based on a “history of UTI” is therefore a common pitfall that leads to overdiagnosis and overtreatment.

Negative predictors of pediatric UTI include an alternate obvious source of infection. A question that frequently arises is, does a febrile bronchiolitis presentation rule out UTI? A recent meta-analysis found the incidence of UTI in patients with bronchiolitis to be 0.8 percent, far lower than in previous studies suggesting testing for UTI in febrile bronchiolitis patients.5 It appears that most positive urine cultures in infants >2 months of age with bronchiolitis result from contamination or asymptomatic bacteriuria.

Urine specimen interpretation can lead to misdiagnosis. No single element of a urinalysis is sensitive enough to rule a UTI in or out; while nitrites are highly specific but not sensitive, leukocyte esterase is sensitive but not very specific.1

UTI Calculator

A risk-stratification decision tool (https://uticalc.pitt.edu) has been developed to help physicians decide which infants 2–24 months of age require testing for UTI and which of those patients require treatment with antibiotics while cultures are pending.6 It involves a two-step process. In the first step, five questions are asked:

  1. Age <12 months?
  2. Maximum temperature ≥39°C (102.2°F)?
  3. Self-described race as black (fully or partially)?
  4. Female or uncircumcised male?
  5. Other fever source identified?

If the calculator generates a score corresponding to a <2 percent risk for UTI, it indicates that no urine testing is required. When the generated score indicates higher risks, providers then must move to a second step, which assesses the subsequent urinalysis results. Based on the combination of the presence or absence of nitrites, leukocyte esterase, bacteria on Gram’s stain, and the white blood cell/mm3 concentration, the calculator generates a probability of UTI. When the calculated probability is <5 percent, no empiric antibiotics are required.

Sometimes, the decision hinges on the eventual culture results. Whether delayed treatment causes renal impairment and hypertension later in life is controversial. American Academy of Pediatrics (AAP) guidelines suggest that delays in appropriate treatment could increase the risk of renal damage.3 Some studies suggest that early antibiotic therapy within 72 hours is necessary to prevent renal scarring. However, these studies didn’t assess patient-oriented outcomes or long-term complications like chronic renal failure and hypertension. We simply do not know whether treating pediatric UTI prevents clinically relevant renal disease.

In higher-risk patients (>2 percent risk on step 1 of the UTI calculator) or in those who appear toxically ill, it may be appropriate to treat with antibiotics empirically. Always discuss the need to have the culture results reviewed to make the definitive diagnoses (and either continue therapy or stop it based on the culture results) with the family. If the patient is at lower risk (either <2 percent via step 1 of the calculator or <5 percent via step 2) and appears well, a watchful waiting approach whereby empiric antibiotics are not administered is reasonable.

How to Test the Urine

Once you’ve decided to order a urinalysis, the question is how best to obtain the sample. In the 2– to 24-month age group, the AAP guidelines suggest two options: obtain urine either through catheterization or suprapubic aspiration for culture and urinalysis or through the most convenient means to perform a urinalysis.3 If the urinalysis suggests a UTI (leukocyte esterase or nitrite test positive, or microscopic analysis results for leukocytes or bacteria), then a second urine specimen should be obtained through catheterization or suprapubic aspiration and cultured. Specimens obtained via urine bag have been shown to be effective to exclude UTI diagnosis; however, urine bags should not be sent for culture due to high risk of contamination.7 All positive urine bag dipsticks/urinalyses must be confirmed with a catheterized or midstream specimen before sending for culture.

As we all know, infants do not produce urine on command in the emergency department. To help speed up the clean catch process (while obtaining a sample less prone to contamination), two effective methods have been described. The Quick-Wee Method involves gentle suprapubic cutaneous stimulation (circular movement) using gauze soaked in cold fluid (for infants ages 1–12 months) until the clean catch urine is obtained.7

The Bladder Tap Technique involves three providers.8 The patient is fed 25 minutes prior. One provider gently taps the suprapubic area, at a rate of 100 taps per minute, for 30 seconds. The other provider then massages the lumbar paravertebral area in the lower back for 30 seconds. Both maneuvers are repeated until the third provider collects a clean catch urine sample.

There is little, if any, role for imaging in the emergency department for pediatric UTI. The latest AAP guideline no longer recommends voiding cystourethrograms after a single UTI. AAP and Canadian Paediatric Society guidelines both recommend children <2 years of age should be investigated with a renal bladder ultrasound after their first febrile UTI to identify any significant renal abnormalities (albeit a level C recommendation).2,9 There is no convincing evidence suggesting that ultrasound improves patient-oriented outcomes, and ultrasound imaging may lead to further invasive testing that can cause harm.

My hope is that if we all think carefully about the predictive value of the clinical features of pediatric UTI, less unnecessary testing will occur. Consider using the UTI calculator and treating appropriately with antibiotics only when truly indicated and without imaging. By doing this, we can collectively reduce the harms that we are currently causing by overtesting, overdiagnosing, and overtreating pediatric UTI.

Special thanks to Dr. Michelle Science and Dr. Olivia Ostrow for their contributions to the EM Cases podcast that inspired this article. 

References

  1. Shaikh N, Morone NE, Lopez J, et al. Does this child have a urinary tract infection? JAMA. 2007;298(24):2895-2904.
  2. Alghounaim M, Ostrow O, Timberlake K, et al. Antibiotic prescription practice for pediatric urinary tract infection in a tertiary center [published online ahead of print Feb. 28, 2019]. Pediatr Emerg Care.
  3. American Academy of Pediatrics, Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management, Roberts KB. Urinary tract infection: clinical practice guideline for diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011;128(3):595-610.
  4. Morgenstern J. Articles of the month special edition: pediatric UTI. First10EM website. Feb 2, 2016. Accessed June 11, 2019.
  5. McDaniel CE, Ralston S, Lucas B, et al. Association of diagnostic criteria with urinary tract infection prevalence in bronchiolitis: a systematic review and meta-analysis center [published online ahead of print Jan. 28, 2019]. JAMA Pediatr.
  6. Shaikh N, Hoberman A, Hum SW, et al. Development and validation of a calculator for estimating the probability of urinary tract infection in young febrile children. JAMA Pediatr. 2018;172(6):550-556.
  7. Kaufman J, Fitzpatrick P, Tosif S, et al. Faster clean catch urine collection (Quick-Wee method) from infants: randomised controlled trial. BMJ. 2017;357:j1341.
  8. Tran A, Fortier C, Giovannini-Chami L, et al. Evaluation of the bladder stimulation technique to collect midstream urine in infants in a pediatric emergency department. PLoS One. 2016;11(3):e0152598.
  9. Robinson J, Finlay J, Lang, M, et al. Urinary tract infections in infants and children: diagnosis and management. Paediatr Child Health. 2014;19(6):315-319.

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ACEP Task Force Examining Collaboration with Advanced Practice Providers https://www.acepnow.com/article/acep-task-force-examining-collaboration-with-advanced-practice-providers/ https://www.acepnow.com/article/acep-task-force-examining-collaboration-with-advanced-practice-providers/#respond Wed, 17 Jul 2019 14:48:58 +0000 https://www.acepnow.com/?post_type=article&p=21568 One of the most discussed and debated issues in emergency medicine over the past few years has...

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One of the most discussed and debated issues in emergency medicine over the past few years has been our workforce and how we interact with physician assistants (PAs) and advanced practice registered nurses (APRNs), including nurse practitioners (NPs). While some see advanced practice providers (APPs) as valued team members who enhance our ability to streamline patient flow and better match patient acuity to clinical resources, others raise concerns that independent practice by APPs threatens quality patient care and physician job security. Similarly, ACEP has heard concerns that some emergency physicians are required to sign charts of patients seen independently by PAs/NPs, which some feel to be both unethical and a possible medicolegal risk.

For decades, ACEP has had guidelines and policies providing guidance on these issues, including policies on unsupervised care (https://bit.ly/2VTVTHt) and the role of PAs and APRNs in the emergency department (https://bit.ly/2vcYBMx). While these policies have provided valued consistency over time, many feel they need to be updated, revised, and strengthened to better reflect current industry trends and expectations for emergency care.

In response to the needs of the specialty and our membership, ACEP has formed a task force to gather data and provide guidance on the best practices for collaboration with APPs in everyday emergency medicine. This task force initially met this past October at ACEP18 and will complete its work at ACEP19 this coming October. While there have been a few papers and guidelines published by emergency physicians on this topic over the past few years, ACEP felt that the most comprehensive information and meaningful recommendations would come from a collaborative approach where all parties are able to provide their unique perspectives. As emergency medicine is rooted in team-based care, multiple stakeholder organizations were invited to actively participate in the task force. These include the American Academy of Emergency Nurse Practitioners (AAENP), American Academy of Emergency Medicine (AAEM), AAEM Resident and Student Association (RSA), American College of Osteopathic Emergency Physicians (ACOEP), Association of Academic Chairs of Emergency Medicine (AACEM), Council of Emergency Medicine Residency Directors (CORD), Emergency Medicine Residents’ Association (EMRA), Emergency Nurses Association, Society for Academic Emergency Medicine (SAEM), SAEM Residents and Medical Students (RAMS), and Society of Emergency Medicine Physician Assistants (SEMPA).

Over the past few months, we have been hard at work reviewing anything and everything related to APPs in the emergency medicine workforce, including how they are trained, what unique emergency medicine training and certifications are offered, laws about supervision and collaboration, variations in how APPs are currently supervised, current physician-to-APP ratios, billing issues and requirements related to APPs, and the regional distribution of both emergency physicians and APPs in the current workforce. Though some physicians have asked the committee to provide “preliminary guidelines” and quick updates to existing ACEP policy, due to the comprehensive nature of our review and the desire for the finished product to be thorough and comprehensive, we have elected to avoid such “quick releases” until our work is complete and we are able to provide our final recommendations.

With that said, a few interesting facts and misconceptions that have been noted relate to current APP independent practice. Despite the publicized experiences of a few, the vast majority of APPs are, in fact, directly supervised for patients with Emergency Severity Index levels 1–3. Similarly, both SEMPA and AAENP advocate for supervised and real-time collaborative practice with emergency physicians rather than independent practice. Finally, though it is not uncommon for physicians to be “required” to sign off on APP charts for patients they did not personally have direct or indirect involvement with, there is rarely any billing or legal requirement for this signature (although many states do require a degree of physician supervision for APPs). If you do find yourself in this situation and it makes you uncomfortable, take a moment to sit down with your director or administrator to discuss whether the practice is, in fact, required or simply an electronic medical record or hospital “checkbox” that could potentially be removed with no change in billing or patient care.

APPs serve an integral role in emergency care that can only be improved with better communication, guidelines, and education. As such, we look forward to being able to present the various works and recommendations of our task force with ACEP’s general membership and the medical community as a whole over the next few months. In the interim, feel free to reach out to me, your local ACEP chapter, or national ACEP with your concerns, opinions, and experiences working with APPs. The more voices that are heard and that we can represent, the stronger our work and recommendations will be. 


Dr. Freess is assistant professor of emergency medicine at the University of Connecticut and clinical attending at Hartford Hospital in Hartford, Connecticut. He is Chair of the ACEP Task Force on the Utilization of PAs/NPs in Emergency Care.

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Insurance Companies Force Emergency Departments Out of Network, Shift Costs to Patients https://www.acepnow.com/article/insurance-companies-force-emergency-departments-out-of-network-shift-costs-to-patients/ https://www.acepnow.com/article/insurance-companies-force-emergency-departments-out-of-network-shift-costs-to-patients/#respond Wed, 17 Jul 2019 14:48:58 +0000 https://www.acepnow.com/?post_type=article&p=21558 The cost of out-of-network care has come under scrutiny and grabbed media attention as physicians, insurance companies,...

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The cost of out-of-network care has come under scrutiny and grabbed media attention as physicians, insurance companies, and legislators grapple with the issue of “surprise billing.” Emergency physicians have cited narrow networks and skimpy insurance coverage as the major reasons costs have been shifted to patients. Insurance companies, meanwhile, have promoted the narrative that emergency physicians intentionally stay out of network in order to charge higher prices.

The insurance industry has been particularly critical of independent freestanding emergency departments (FSEDs), which have been a disruptor to the market in Texas. Some FSEDs exist as hybrid models, combining an emergency department with an urgent care facility to try to improve price transparency and reduce costs for lower-acuity visits. There are studies suggesting that FSEDs may decrease admissions, which may also reduce costs.1 It was presumed that insurance companies would want to contract with these facilities to save money. However, many owners were unable to get a contract (or even a return phone call) from most of the major health plans. This begs the question of whether physicians were really intentionally trying to stay out of network or whether the health plans simply refused to negotiate in good faith.

We administered a survey in 2017 to investigate the percentage of independent FSEDs that were in-network with insurance companies and identify barriers to securing contracts. The survey was sent by email to all independent FSEDs in Texas, and data were collected about in-network status for facility and physician fees, affiliated urgent care or hybrid model design, number of attempts to contract, and barriers to successful negotiations. The survey found that:

  • 25 of 38 physician groups responded to the survey (66 percent), representing 102 different independent FSEDs in Texas.
  • 80 percent of independent FSEDs were not in-network for either physician or facility fees.
  • 64 percent of FSEDs said they had not been contacted by an insurance company or had been unable to get an insurance company to return phone calls about contracting.

Failure to obtain in-network status occurred most frequently because rates were unreasonably low (45 percent), the insurance company refused to offer the FSED any contract (27 percent), and the insurance company did not want to contract with any FSEDs (41 percent). Physician groups did not want to contract with insurers only 5 percent of the time (see Figure 1).

Thus, despite a demonstrated desire of FSEDs to provide in-network care, only 20 percent were able to secure a contract with insurance companies.

The most common reason FSEDs were not in-network is that insurance companies did not offer to contract with them, ignored repeated attempts by physicians to negotiate, or offered unreasonably low rates and were unwilling to negotiate.

Although this study looked specifically at independent FSEDs in Texas, the concern is that insurance companies are using similar tactics nationwide. This is particularly challenging for small groups that have less leverage to negotiate, rural hospitals, and disproportionate share hospitals (ie, hospitals that see a high number of low-income patients and receive payments from the Centers for Medicaid and Medicare Services to cover the costs for uninsured patients), which have slimmer margins.

The health plans have a perverse incentive to avoid fair contracting because they know emergency departments are beholden to EMTALA and will take care of any patient, regardless of their ability to pay. Knowing that patients will be cared for regardless, insurance companies have little incentive to offer fair reimbursement rates.

Health plans need to be held accountable for offering reasonable in-network rates and providing adequate networks of care. Failure to do so results in decreased access and cost shifting to patients. Placing the blame on emergency providers only dirties the wound.

Reference

  1. Simon EL, Dark C, Kovacs M, et al. Variation in hospital admission rates between a tertiary care and two freestanding emergency departments. Am J Emerg Med. 2018;36(6):967-971.

Dr. SimonDr. Simon is associate professor at the Northeast Ohio Medical University in Rootstown, research director for Cleveland Clinic Akron General emergency department in Akron, Ohio, and Medical Director of the Cleveland Clinic Bath emergency department.

Dr. de MoorDr. de Moor is CEO of Code 3 Emergency Partners in Frisco, Texas, and chair and founder of Code 3 Emergency Physicians.

Dr. DaytonDr. Dayton is adjunct assistant professor at the University of Utah in Salt Lake City, FSED Alpha Team for US Acute Care Solutions, and chair of ACEP’s Freestanding Emergency Centers Section.

Dr. SchmitzDr. Schmitz is associate professor at the F. Edward Hébert School of Medicine at the Uniformed Services University of the Health Sciences at San Antonio Military Medical Center.

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Submit Your Council Resolutions for ACEP19 https://www.acepnow.com/article/submit-your-council-resolutions-for-acep19/ https://www.acepnow.com/article/submit-your-council-resolutions-for-acep19/#respond Wed, 17 Jul 2019 14:26:49 +0000 https://www.acepnow.com/?post_type=article&p=21554 Did you know you can influence the ACEP agenda? It only takes two members to submit a...

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Did you know you can influence the ACEP agenda? It only takes two members to submit a Council resolution as part of ACEP’s democratic decision-making process. Submit your resolution by July 27, 2019, and the Council will vote on it during its annual two-day meeting in conjunction with ACEP’s Scientific Assembly. The Board of Directors will also vote on the resolutions. Learn more about the process and submit your resolution at www.acep.org/council.

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New ACEP Now Medical Editor in Chief Announced https://www.acepnow.com/article/new-acep-now-medical-editor-in-chief-announced/ https://www.acepnow.com/article/new-acep-now-medical-editor-in-chief-announced/#respond Wed, 17 Jul 2019 14:25:16 +0000 https://www.acepnow.com/?post_type=article&p=21552 Jeremy Samuel Faust, MD, MS, MA, has been named the new medical editor in chief of ACEP...

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Jeremy Samuel Faust, MD, MS, MAJeremy Samuel Faust, MD, MS, MA, has been named the new medical editor in chief of ACEP Now. Dr. Faust, who is an instructor at Harvard Medical School and an attending physician in the department of emergency medicine at Brigham and Women’s Hospital in Boston, has been a member of ACEP Now’s editorial board since 2014 and writes the “FOAMcast” and “The Feed” columns. He has been an ACEP member since 2012.

Dr. Faust succeeds Kevin Klauer, DO, EJD, FACEP, who stepped down as medical editor in chief to take on the role of chief executive officer of the American Osteopathic Association.

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ACEP Emergency Physician Workforce Task Force Study Is Under Way https://www.acepnow.com/article/acep-emergency-physician-workforce-task-force-study-is-under-way/ https://www.acepnow.com/article/acep-emergency-physician-workforce-task-force-study-is-under-way/#respond Wed, 17 Jul 2019 14:24:45 +0000 https://www.acepnow.com/?post_type=article&p=21571 ACEP’s fourth and most comprehensive workforce study is under way. This two-year study aims to describe the...

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ACEP’s fourth and most comprehensive workforce study is under way. This two-year study aims to describe the current and future workforce in emergency medicine as well as projections of the workforce supply and demands.

ACEP’s previous workforce studies were published in 1998, 2002, and 2009. Although these studies demonstrated a significant shortage of the workforce, much has changed since the last study. We practice in an environment of ever-increasing numbers of annual emergency department visits. The Centers for Disease Control and Prevention (CDC) recently reported a record high of 145.6 million annual ED visits in the United States in 2016.1 To help train the workforce needed to treat these patients, there are currently 240 emergency medicine residency programs, more than at any time in the history of our specialty.

ACEP’s Workforce Task Force includes experts from AAENP, American Board of Emergency Medicine, ACEP, ACOEP, American Osteopathic Board of Emergency Medicine, CORD, EMRA, SAEM, and SEMPA. The following organizations were also invited to participate but declined: AAEM, AAEM/RSA, AACEM, SAEM/RAMS. ACEP has contracted with George Washington University’s Health Workforce Institute to perform a study. The task force plans a multifaceted approach to the study, including analysis of CDC ambulatory visit data, Medicare claims data, American Medical Association data, focus groups, surveys of practicing emergency physicians and emergency medicine residents and program directors, and other sources of data.

The final report is expected to be released in 2021. 

Reference

  1. National Hospital Ambulatory Medical Care Survey: 2016 Emergency Department Summary Tables. CDC website. Accessed April 22, 2019.

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Helen DeVos Children’s Hospital’s Emergency Department Has Data-Driven Efficiency https://www.acepnow.com/article/helen-devos-childrens-hospitals-emergency-department-has-data-driven-efficiency/ https://www.acepnow.com/article/helen-devos-childrens-hospitals-emergency-department-has-data-driven-efficiency/#respond Wed, 17 Jul 2019 14:22:27 +0000 https://www.acepnow.com/?post_type=article&p=21576 Helen DeVos Children’s Hospital (HDV) is a 173–licensed bed private hospital and level I trauma center in...

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Helen DeVos Children’s Hospital (HDV) is a 173–licensed bed private hospital and level I trauma center in Grand Rapids, Michigan. The emergency department sees more than 54,000 pediatric visits anually in its 27-bed facility, which has the ability to flex both space and staff during times of surge. It is operationally one of the most efficient (perhaps the most efficient) emergency department in the pediatric academic category. Table 1 compares its benchmarks with the Emergency Department Benchmarking Alliance (EDBA) and Academy of Administrators in Academic Emergency Medicine (AAAEM) data surveys of pediatric emergency departments.

HDV is a busy pediatric emergency department, seeing almost 150 patients per day. Astonishingly, it is able to put more than 1,900 patients through each treatment space per year (the typical pediatric emergency department moves about 1,500). Door-to-doctor times are a mere 11 minutes, and overall length of stay (LOS) averages are 95 minutes. This displays an efficiency that is unheard of across the country.

Table 1: Pediatric Emergency Department Benchmark Metrics Helen DeVos 2018 EDBA Pediatrics 2017

(click for larger image) Table 1: Pediatric Emergency Department Benchmark Metrics

What are some of the secrets to its extraordinary efficiency? The physicians are members of Emergency Care Specialists, which staffs both adult and pediatric emergency departments, and the hospital is a Spectrum Health facility. Both organizations are known for innovation and operational efficiency. I spoke with one of the medical directors at HDV, Jackson Lanphear, MD. He practices both adult and pediatric emergency medicine and often brings innovative ideas from the adult emergency department to HDV. He, his co-director, Erica Michiels, MD, and their nursing leaders, Stephanie Flohr and Drew Peklo, run one of the most data-driven emergency departments in the country. Dr. Lanphear notes, “It is all about the data.”

Data-Driven Flow

First, after recognizing they deliver a lot of urgent care to the children and families in their community, they developed a flow model based on the patient population they serve (see Table 2). Note the lower-acuity breakdown.

Table 2: Acuity Breakdown of Helen DeVos Versus Pediatric ED Averages

(click for larger image) Table 2: Acuity Breakdown of Helen DeVos
Versus Pediatric ED Averages

HDV sees more Emergency Severity Index (ESI) 4 and 5 patients and fewer ESI 3. (It also admits fewer patients than average.) For comparison, an EDBA pediatric cohort with 75 emergency departments admitted 10 percent. Using this information, HDV created acuity-based zones. While ESI has been a good place to start in the streaming of patients, most ED stakeholders have found it is not a good LOS predictor. Therefore, the leaders developed a flow model (see Figure 1) that placed only 40 percent of patients in a traditional ED room and bed. This area, called Mod I, consists of 12 beds. Ambulances arrive there directly. Patients who can be treated and discharged in under one hour are streamed to Mod II, the Rapid Assessment Zone (RAZ).

There are two triage rooms where nurses do an abbreviated intake and then stream patients to one of the Mods. Providers in Mod II/RAZ start patients in a six-bed area. However, if the child will need more than 30 minutes of care, the child is moved to another area of seven beds designated as the “Extended Care” area. If a treatment bed is not needed, the patient may move to an internal waiting space. This fluidity in the lower-acuity zone is essential to efficiency and something most emergency departments should consider. In lower-acuity zones, the patient should not own the bed. Rather, movement in and out of beds to imaging or internal waiting rooms should be the norm. A patient bed in a low-acuity zone should only be occupied by patients needing diagnosis (a physical exam) or treatment (a procedure) in the bed.

Planning for Higher Volumes

When the department exceeds capacity (which is not a daily occurrence), there is a mechanism to open a third eight-bed area, called Mod III. Interestingly, the Mod III area was originally conceived as an observation unit, but in practice, they were unable to consistently populate it with patients. This is turning out to be a common situation in pediatric emergency departments nationwide. As productive and useful as ED-based adult observation units have proven to be, pediatric observation units have not proven as successful a concept in practice. Dr. Lanphear points out that, unlike adult emergency medicine, pediatric emergency medicine does not have many conditions that easily populate an observation unit year-round (like chest pain, mild congestive heart failure, and chronic obstructive pulmonary disease). Many observation-appropriate conditions (pediatric respiratory illnesses and dehydration) can run in seasonal patterns following viral transmission. This makes it hard to populate such a unit year-round. In addition, many pediatric emergency physicians have noted the difficulty in predicting which patients could be successfully turned around in the observation unit, creating myriad regulatory and compliance concerns.

Figure 1: Helen DeVos ED Flow Model

(click for larger image) Figure 1: Helen DeVos ED Flow Model

The HDV emergency department also created a model of flexibility in scheduling. Shifts match the patient arrivals, not physician or nursing preference. There are daily shifts called “at-risk shifts.” Providers come in for a four-hour shift but know they may stay four to six hours longer depending on the situation and conditions in the department. Physicians and nurses huddle to decide the strategy for opening and closing areas and sending providers home in real time. They have well-articulated processes for most contingencies.

All decisions about zone size, opening and closing areas, and staffing are based on data. HDV is one of the most data-driven departments I have encountered. Decisions are based on what is best for the patients and their parents, not on provider preference. Look at the success that this overarching theme has brought. 

Helen DeVos leadership team

The Helen DeVos leadership team (from left): Stephanie Flohr, Drew Peklo, Erica Michiels, MD, and Jackson Lanphear, MD.
Credit: HDV

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Call for Applications: JACEP Open Editorial Board https://www.acepnow.com/article/call-for-applications-jacep-open-editorial-board/ https://www.acepnow.com/article/call-for-applications-jacep-open-editorial-board/#respond Wed, 10 Jul 2019 15:06:35 +0000 https://www.acepnow.com/?post_type=article&p=21538 A call to join the Editorial Board for what is to be the leading new Open Access...

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A call to join the Editorial Board for what is to be the leading new Open Access journal in the field

ACEP’s new Open Access journal, Journal of the American College of Emergency Physicians Open (JACEP Open), seeks individuals with experience in peer review and editing to join our exciting new venture as decision editors. Editors will be fully involved in the peer review process, including the review of submitted manuscript, soliciting comments from expert peer reviewers, and helping the Editor in Chief to choose the best articles to feature in the journal.

JACEP Open will start accepting papers this fall, post papers online in January 2020, and publish its first issue in February 2020.

We seek:

    • to bring together a broad range of experts in emergency care from around the world
    • individuals who will further the mission of the journal, including encouraging submissions from peers internationally
    • people who will be energetic and invested in the success of the journal

Please join our Editor in Chief, Dr. Henry Wang, in blazing this exciting trail. Send your CV and a letter of interest to Martha Villagomez, no later than August 1st, 2019.

About Dr. Wang

Henry E. Wang, MD, MS, is professor and vice chair for research of the department of emergency medicine at the University of Texas Health Science Center at Houston. He is one of the world’s most prolific emergency medicine scientists and is internationally recognized for his scientific work in out-of-hospital airway management, resuscitation, and sepsis epidemiology. Dr. Wang was a deputy editor for Annals of Emergency Medicine and has served on the editorial boards of Academic Emergency MedicinePeerJ and Prehospital Emergency Care.

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2019 Midyear Report from ACEP President Dr. Vidor Friedman https://www.acepnow.com/article/2019-midyear-report-from-acep-president-dr-vidor-friedman/ https://www.acepnow.com/article/2019-midyear-report-from-acep-president-dr-vidor-friedman/#respond Thu, 20 Jun 2019 14:30:59 +0000 https://www.acepnow.com/?post_type=article&p=21459 Leading an organization as large and diverse as ACEP requires a focus on both the urgent problems...

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Leading an organization as large and diverse as ACEP requires a focus on both the urgent problems of the moment and the long-term health of the organization and its members. For ACEP President Vidor E. Friedman, MD, FACEP, centering his efforts on improving life for emergency physicians and advocating for shared areas of concern have allowed him to tackle both current issues and long-term strategy initiatives.

From a leadership perspective, Dr. Friedman has accomplished much in a short time. Instead of spending the usual year as ACEP President-Elect, he only spent three months in the role before assuming the presidency in September 2018. He was elected by the ACEP Board of Directors in June 2018 to serve as President-Elect following the resignation of former ACEP President-Elect, John Rogers, MD, FACEP.

Dr. Friedman recently sat down with ACEP Now Medical Editor in Chief Kevin Klauer, DO, EJD, FACEP, to discuss his goals as ACEP President. Here are some highlights from their conversation.

KK: Let’s talk about your initial goals as ACEP President. What did you really want to try to accomplish in this year?

VF: Well, these were interesting times. The reality is that most president-elects have a year to prepare. I only had three months to prepare, following John Rogers’ transition out of the role. I didn’t have as much time to think about what my personal goals were for the presidency. I wanted to do what I could in this year to improve life for emergency physicians and particularly for future emergency physicians. I think most presidents go into it thinking of the things that they would like to accomplish. However, the crises of the moment that we have to deal with have a tendency to hijack the agenda to a certain extent.

There were internal things that I wanted to try to accomplish this year. My goal was to help the Board be more strategic in its operations. What I mean by that is over the last 10 years, the Board has become very operational. I’m glad that our annual Board retreat went well and that we were able to focus on how to help the Board become more strategic in its functioning.

In terms of what’s happened since I’ve assumed office, I knew going into it that the issues around out-of-network billing were going to be important this year. There’s a tremendous bipartisan desire to do something in that arena. In fact, it’s including the White House and the Secretary of Health and Human Services. They’ve decided that [surprise] billing is something they’re going to focus on.

I’ve been advocating for our profession and our College in Washington, D.C., at least once or twice a month since the annual meeting. That doesn’t include multiple phone calls trying to bring all the parties to the table internally around this issue, which we have struggled with as a profession. I think we’ve made some good progress. Having said that, I think we have to be realistic that the forces against us are pretty significant. But we’ll continue to fight for our right to take care of patients in the way we want to care for them, for our profession, and for our right to be fairly compensated. That’s really been the central focus so far in my presidency.

KK: I’m certain you had imagined “the day in the life” of your presidency. How has that changed for you?

VF: I think the biggest difference is that I didn’t anticipate the amount of time that would be required during this presidency for our lobbying efforts in D.C. Our D.C. office is doing a tremendous job, and I don’t intend to take anything away from their efforts. However, as president, I’m the spokesperson for our College, and I need to be there articulating things from the physician’s perspective that are best delivered by the president. I knew this would be a piece of what I did this year but didn’t realize it was going to be such a big piece. Like you said, the issues of the day really help define the presidency.

I’ll try to highlight some of the things that I would like to see the College do. One area that I would encourage the College to be engaged in is firearm injury prevention and firearm safety. I recently met with the American College of Surgeons (ACS) last month. They put together a meeting of 49 medical specialties and societies to discuss this issue. I really have to give the ACS kudos that they internally did a deep dive and were able to come to some consensus on the things they did agree on around firearm safety. That helped their leadership be more focused and more proactive. I want our College to do that as well. Are we going to agree 100 percent on everything? No. But instead of focusing on the issues that split us apart, I’d like us to be clear about the things that we do agree on so that we can advocate for those together. We can advocate better if we have a clear understanding of where our membership stands on the issues.

KK: How do you meet the needs of the membership on such a polarizing topic without disenfranchising a component of the membership?

VF: Well, you’re never going to meet everyone’s needs 100 percent of the time. That’s a fool’s errand. However, we can ask them where they stand on particular aspects of this issue and try to get a clear understanding of where the majority, hopefully the vast majority, does agree. That’s a reasonable place to start, which may be accomplished by doing a survey of our Council, the representative body of our College. [Editor’s note: At its April meeting, the ACEP Board of Directors voted to survey the Council for a representative viewpoint on firearm-associated research, safety, and policy.]

I don’t think anyone wants our patients to continue to suffer from firearm injuries. It’s just a question of what we see as reasonable solutions. Frankly, we know that there’s a paucity of research in this area. I think that there’s broad consensus that supporting research into firearm injury prevention is worth doing. That’s one example of a place where I believe there to be consensus.

KK: You’re so right. You can provide the greatest benefit, perhaps, by tackling some of the most challenging topics, so I’m glad you’ve taken it on. Moving to another topic, are there any successes that you’d like to share with the membership?

VF: Well, I can’t really take credit for it, but it happened on my watch. The conversations that we had with The Joint Commission about the ability to eat in the emergency department on your shift may be the thing that I’m most remembered for as president. That’s a huge success.

KK: Well, I personally will thank you and our staff for that one, Vidor.

VF: You’re very welcome, Kevin. I had little to do with it. But since I get to take all the credit for the things that go wrong, I might as well take a little credit for some of the stuff that goes well.

KK: That’s fair enough.

VF: I think we have continued to improve and deepen our collaborative efforts with other specialties and with the American Medical Association (AMA). I think that we have worked very diligently to position ourselves well within the AMA over the last decade. Our AMA delegation continues to grow and be very impactful.

Another area I feel strongly about is emergency physician well-being. Physician suicide is the endpoint of a predictable continuum. Depressed physicians have a difficult time accessing appropriate resources to deal with that depression. One of the things that I’m pushing us to do is to help our chapters advocate to state medical boards to refine their questionnaires for licensure. Similar efforts should be taken with the hospital credentialing procedures.

Many, if not most, processes ask, “Have you ever been treated for mental illness?” An affirmative response is often interpreted as a red flag for patient safety. Being treated for medical or mental illness is no one’s business unless it will prevent you from doing your job safely.

I’d like us to work with the AMA to expand the offerings that physicians have, improving access to resources when they’re in trouble. Burnout is a big issue in emergency medicine, with depression being a key component.

KK: What do you hope to accomplish with the remaining time you have, Vidor?

VF: I’ve been working with our staff to develop end-of-life care initiatives. There’s a tremendous need to decrease health care costs in this country, and we, as emergency physicians, have a better understanding of where some of that excess cost exists. Most people don’t have end-of-life care orders. This is partly because up until two years ago, physicians in the United States were not reimbursed for conducting advanced care planning discussions. That’s changing, but slowly. I think it would behoove us, and our membership, to accelerate the adoption of conducting those important conversations while patients are still in a position to do so. This is an area that I’d like to work on.

I also want to continue to work on physician wellness, not just around resiliency, but to work on the environmental causes that lead to burnout. I think our BalancED conference was a really good start, and I hope we’ll be able to continue that effort in the coming years.

KK: Those are all wonderful goals. If anyone can accomplish that much in the second half of a presidential term, it’s Vidor Friedman. Thanks for the time, Vidor, and thank you for your service and excellent leadership. 

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Congrats to ACEP’s Outstanding Medical Students https://www.acepnow.com/article/congrats-to-aceps-outstanding-medical-students/ https://www.acepnow.com/article/congrats-to-aceps-outstanding-medical-students/#respond Thu, 20 Jun 2019 14:30:59 +0000 https://www.acepnow.com/?post_type=article&p=21463 The winners of our 2019 Outstanding Medical Student Awards have been announced! This honor recognizes students who...

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The winners of our 2019 Outstanding Medical Student Awards have been announced! This honor recognizes students who excel in compassionate care of patients, professional behavior, and service to the community and/or specialty. Winners receive a year of free ACEP membership and free registration to the Scientific Assembly. This year’s winners are:

  • Arthur Broadstock, The Ohio State University College of Medicine
  • Alexandria Gregory, Saint Louis University School of Medicine
  • Jonathan Lee, University of California, Irvine
  • Andrea Quiñones-Rivera, University of California, San Francisco
  • Stephanie Winslow, University of Florida College of Medicine

The following students received honorable mentions: Adrienne Caiado (Penn State College of Medicine), Reed Macy (University of Texas Southwestern), and Dylan Lukato (University of Wisconsin School of Medicine and Public Health).

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