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‘Choosing Wisely’ Protocols Can Reduce Testing While Improving Care

Posted on Wed, Feb 17, 2016
‘Choosing Wisely’ Protocols Can Reduce Testing While Improving Care

Michael Silverman, MD, FACEP
 
The Choosing Wisely initiative was initiated by the American Board of Internal Medicine’s (ABIM) Foundation to help providers and patients engage in conversations aimed at reducing the use of tests and procedures. The initiative also supports patients in their efforts to make smart and effective care choices.
 
The American College of Emergency Physicians (ACEP) has partnered with ABIM to support good clinician and patient decisions. ACEP has supported 10 recommendations that physicians and patients should question.
 
Why “Choosing Wisely” Is So Important
 

  • Approximately 1.5-2.0 percent of all cancers in the U.S. may be attributed to radiation from CT examinations. (Baumann BM, et al 2011)
  • In the United States, more than 2 million infections occur with resistant bacteria.
  • Avoidable costs were noted in a 2010 report by Thomson Reuters, which set the amount at $3.6 trillion.

The flipside to why we order so many tests are noted in multiple reports. The reasons include:
 
  • Malpractice concerns
  • To avoid missing a diagnosis and making an error
  • Because patients request or insist on tests and we are evaluated by the satisfaction of our patients 

For this post, I’ll focus on five key recommendations.
 
1 - Avoid CT with low pre-test probability of pulmonary embolism with either a negative Pulmonary Embolism Rule-out Criteria (PERC) or a negative D-dimer.
  • Studies overwhelmingly show the benefit of multiple decision rules to decrease risk of pulmonary embolism to below 2 percent.
  • PERC includes eight questions that, if negative in a low-risk patient, requires no further testing to rule out a significant pulmonary embolism.
  • Utilization of previously validated decision rules for PE along with a negative D-dimer reduces the probability to < 2%. 

2 - Avoid ordering head CT in asymptomatic adult patients with syncope, insignificant trauma and a normal neurological evaluation.
 
  • Literature is overwhelming that syncope does not necessitate a head CT except if the following exists before or after syncope:
    • Headache
    • Garbled speech
    • Weakness in one arm or leg or other focal deficit
    • Trouble walking
    • Confusion 

3 - Avoid antibiotics and wound cultures in ED patients with uncomplicated skin or soft tissue abscesses after successful incision and drainage in patients with adequate medical follow-up.
 
  • Choosing Wisely supports only using antibiotics in patients who are immunocompromised.
  • Author Note: Not part of Choosing Wisely, but literature may support also using antibiotics if the patient has systemic toxicity or lymphangitis. 

4 - Avoid placing indwelling urinary catheters in the ED for either urine output monitoring in stable patients who can void, or for patient/staff convenience.
 
  • Indwelling catheters may be appropriate for:
    • Output monitoring for critically ill patients
    • Relief of urinary obstruction
    • At the time of surgery
    • End-of-life care 

5 - Avoid head CT for ED patients with minor head injuries who are at low risk based on validated decision rules.
 
  • Choosing Wisely notes the following indications for ordering a head CT:
    • If loss of consciousness or post-traumatic amnesia and only if:
      • Headache
      • Vomiting
      • Age greater than 60 years
      • Drug or alcohol intoxication
      • Deficits in short-term memory
      • Physical evidence of trauma above the clavicle
      • Post-traumatic seizure
      • Glasgow Coma Scale (GCS) score less than 15
      • Focal neurologic deficit
      • Coagulopathy
  • Order a head CT for patients with no loss of consciousness or post-traumatic amnesia if:
    • Focal neurologic deficit
    • Vomiting
    • Severe headache
    • Age 65 years or greater
    • Physical signs of a basilar skull fracture
    • GCS score less than 15
    • Coagulopathy
    • Dangerous mechanism of injury
      • Injury includes ejection from a motor vehicle
      • Pedestrian struck
      • Fall from a height of more than 3 feet or 5 stairs 

The Choosing Wisely initiative focuses on evidence-based best practices that provide additional guidance in the care of our patients. The use of Choosing Wisely guidelines can foster a discussion with our patients, staff and consultants to improve patient care and avoid unnecessary tests and procedures.
 
As with anything in medicine, this tool is just that - a tool – and should be used along with clinical experience, individual circumstances and your current environment. Your decisions on any individual patient may vary.

Michael Silverman, MD
 
Michael Silverman, MD, FACEP, is the vice chairperson of the Emergency Department at Morristown Medical Center, Morristown, N.J. He is a diplomate of the American Board of Emergency Medicine and a fellow of the American College of Emergency Physicians. He is a member of the New Jersey Chapter of the American College of Emergency Physicians and is the former president of the New Jersey section of the Delaware Valley AAEM chapter. Dr. Silverman is also board-certified in internal medicine and undersea and hyperbaric medicine.

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ACEP15: EmCare Paints Beantown Green!

Posted on Thu, Nov 12, 2015
ACEP15: EmCare Paints Beantown Green!

Another autumn, another ACEP annual meeting in the books! EmCare leaders, physicians and recruiters traveled to Boston Oct. 26-28 for the American College of Emergency Physicians’ annual meeting, ACEP15.

As one of the world’s largest gathering of researchers, teachers and practitioners of emergency medicine, it’s a great opportunity for physicians to earn CME and for recruiters to meet with residents and practicing physicians looking to make a career change.

Congratulations Dr. Parker!

The highlight of ACEP15 was the election of Rebecca Parker, MD, FACEP, as president-elect of ACEP. Dr. Parker will serve as president-elect through October 2016, when she will assume the one-year post of President at the organization’s annual meeting in Las Vegas. Dr. Parker was serving as the Chair of ACEP’s Board of Directors.

“As the next President-elect, I have two visions: to establish emergency medicine as the nucleus of a new acute care continuum and to enhance our diversity,” said Dr. Parker. “Let’s create a new acute care continuum, with the emergency physician leading the charge. And let’s foster generational, racial and gender diversity within our specialty. As the next president, I will create a new Task Force on Diversity with our sister societies. We will take a new approach and make this an opportunity to re-invent our practice.”

Dr. Parker was chair of ACEP’s Board of Directors for the last year, and is an attending emergency physician with Vista Health in Waukegan, Ill. She also serves as senior vice president of Envision Healthcare and president of Team Parker LLC, a consulting group. In addition, she is a clinical assistant professor at the Texas Tech El Paso Department of Emergency Medicine.

Dr. Parker has been active with ACEP for about 20 years. She has been a member of both the Illinois and Texas chapters’ boards of directors and chaired the chapters’ education committees. She has served in a variety of leadership positions on the Illinois ACEP Board, including president-elect, when she was elected to the national ACEP Board of Directors for the first time in 2009.

For national ACEP, Dr. Parker has served as chair of the Coding and Nomenclature Advisory Committee, chair of the Young Physicians Section, board liaison to the Clinical Emergency Medicine Data Registry (CEDR) subcommittee, and chair-elect of the ACEP Foundation.

New Booth, New President

EmCare unveiled a redesigned exhibitor booth this year. With an open floor plan and modern aesthetic, the booth promoted networking and conversation. Several monitors provided information about the company and its many employment opportunities.

Recruiters were armed with iPads to input candidates’ information and provide marketing materials to interested physicians in real time.

And, physicians were invited to the booth to meet EmCare’s new president, Ray Iannaccone, MD, FACEP, FACHE.

“ACEP’s annual meeting is one of our few opportunities to come together as a company and share our passion for emergency medicine with the rest of the world,” said Dr. Iannaccone in an email to the company’s physicians. “This is my first ACEP as President of EmCare, and I am very proud to represent our dynamic, cutting-edge organization. There are so many of our physicians that I haven’t had the opportunity to meet – yet. I’d love to hear your ideas and feedback about how we can continue to make healthcare work better.”

Dr. Iannaccone held “open door” hours to meet with practicing physicians.

EMRA Job Fair

The annual Job Fair sponsored by the Emergency Medicine Residents Association (EMRA) was held Oct. 26 at the Boston Convention & Exhibition Center. A “speed dating” of sorts for emergency medicine residents and recruiters, the event provides an opportunity for job-seekers to meet with recruiters in the locations in which they want to practice.

EmCare recruiters met with residents seeking positions in Central, North Central, Northeast, Southeast and Western locations of the U.S., as well as those looking for openings at academic medical centers and at fellowship programs.

EMRA Party

New this year, EmCare co-sponsored the annual EMRA Party. Held Oct. 27 at Club VENU and ICON, the event was a spectacle of flashing lights, dance music and merriment. The nightclub atmosphere allowed residents to unwind at one of Boston’s premier clubs. In fact, the facility has hosted some of the top EDM and hip hop acts, including The Chainsmokers, Steve Aoki, 50 Cent, Fabolous and Ja Rule.

ACEP15 Closing Party

Despite the rain and wind, EmCare capped off ACEP15 with its signature sponsorship of ACEP’s Closing Party on Oct. 28 at the New England Aquarium. Attendees mingled with their co-workers, and with penguins, sea lions, stingrays, sea turtles and more! The evening included commemorate photos, catered food and musical entertainment, which got the dance floor moving.

The event was so popular that a pop-up overflow party was held at the Westin Boston, complete with a DJ, TVs for watching the World Series, and light refreshments.

Showcasing Medical Research

ACEP15 wasn’t all play. Several EmCare physicians presented research projects, including:
 

  • Stephen H. Anderson, MD, FACEP – “Coordination of Care Through the ED: Influencing Costs, Recidivism and Health Outcomes”
  • Matthew C. Delaney, MD - “Lost in FOAM: Free Open Access Medical Education for the Technologically Challenged” and “Fast Track Success: Avoiding Pitfalls and Getting Up to Speed”
  • Charlotte Derr, MD, RDMS, FACEP – “Musculoskeletal Ultrasound Scanning Lab”
  • Lucas Friedman, MD - “Ultrasound-Guided Regional Anesthesia Lab”
  • Neil A. Gandhi, MD - “Physician Onboarding: Don’t Miss the Boat”
  • William P. Jaquis, MD, FACEP - “Are Your Patient Satisfaction Scores Driving You Mad? The 12-Step Program to Improving Your Patient’s Experience and YOUR Satisfaction”
  • Kirk B. Jensen, MD, MBA, FACEP - “Observation Medicine: Your Inpatient Fast Track” and “Engaging Your Physician Team: You Can’t Lead If People Won’t Follow”
  • Brian D. Johnson, MD - “Procedural Ultrasound Lab”
  • Thomas A. Mayer, MD, FACEP - “EDCAHPS: The New Beast on the Block,” “Not Another Complaint? What Do I Do?” and “Are Your Patient Satisfaction Scores Driving You Mad? The 12-Step Program to Improving Your Patient’s Experience and YOUR Satisfaction”
  • Alfred Sacchetti, MD, FACEP - “Pediatric Pain: Safe Sedation Practices,” “Antibiotic Stewardship in the Peds ED: Evidence-Based Approach to Common Infections in Pediatrics,” “PK-Trauma: Let’s Chat About Pediatric Trauma,” “Masters of Pediatric Emergency Medicine: Manage Common Conditions Like One of the Experts” and “Lessons My Patients Have Taught Me: Humor, Humility and Humanity Learned at the Bedside”
  • Adam B. Sivitz, MD - “Advanced Pediatric Ultrasound Lab: Kids Are Not Just Small Adults…Or Are They?”
  • David A. Talan, MD, FACEP - “It’s a Small World: Update on Outbreaks and Vaccine-Preventable Infections” and “Cruising the Infectious Disease Literature 2015”

We’re looking forward to ACEP16 in Las Vegas! If you’d like to join our team, visit the Careers section of our website to search more than 1,000 jobs.

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It’s Time for ACEP15!

Posted on Thu, Oct 08, 2015
It’s Time for ACEP15!

By Russell H. Harris, MD, MMM, FACEP, CPE

I joined the American College of Emergency Physicians (ACEP) in 1982. I was a new physician seeking career advancement, fellowship and clinical education, and ACEP provided the support that I needed then – and still does now.

With more than 32,000 members, ACEP is the largest and most influential emergency medicine organization in the world. The organization benefits EM clinicians in a variety of ways by providing:
 

  • Resources to help clinicians develop and improve their skills
  • Information and advocacy regarding new governmental regulations and policies
  • Insight into the latest emergency medicine technology
  • Tools and resources for continuing education and leadership development
  • Networking opportunities both locally and nationally

The association also advocates for fair payment for ED services, including assisting members with compliance disputes with private payers that violate settlement terms. The college also gives EM physicians a voice in Washington. In fact, ACEP’s political action committee, NEMPAC, is one of the largest and most influential PACs in organized medicine.

Opportunities for Networking and Research Abound

ACEP’s 33 sections provide opportunities for exploring your specific interests, networking with like-minded clinicians and pursuing research projects. Sections are focused such as air medical transport, women in EM, democratic group practice, emergency medicine informatics, telemedicine, EMA-prehospital care, forensic medicine, geriatric emergency medicine, observation medicine, pediatric emergency medicine, rural emergency medicine, toxicology, undersea and hyperbaric medicine and wilderness medicine.

The organization’s annual meeting, ACEP15, is a great opportunity to meet with your fellow clinicians, earn CME and review the latest research conducted by your peers. During the Research Forum on Oct. 26 and 27, clinicians will present and discuss original research at the world’s largest gathering of researchers, teachers and practitioners of emergency medicine.

Several EmCare clinicians will present research projects at ACEP15, including:
 
  • Stephen H. Anderson, MD, FACEP – “Coordination of Care Through the ED: Influencing Costs, Recidivism and Health Outcomes”
  • Matthew C. Delaney, MD - “Lost in FOAM: Free Open Access Medical Education for the Technologically Challenged” and “Fast Track Success: Avoiding Pitfalls and Getting Up to Speed”
  • Charlotte Derr, MD, RDMS, FACEP – “Musculoskeletal Ultrasound Scanning Lab”
  • Lucas Friedman, MD - “Ultrasound-Guided Regional Anesthesia Lab”
  • Neil A. Gandhi, MD - “Physician Onboarding: Don’t Miss the Boat”
  • William P. Jaquis, MD, FACEP - “Are Your Patient Satisfaction Scores Driving You Mad? The 12-Step Program to Improving Your Patient’s Experience and YOUR Satisfaction”
  • Kirk B. Jensen, MD, MBA, FACEP - “Observation Medicine: Your Inpatient Fast Track” and “Engaging Your Physician Team: You Can’t Lead If People Won’t Follow”
  • Brian D. Johnson, MD - “Procedural Ultrasound Lab”
  • Thomas A. Mayer, MD, FACEP - “EDCAHPS: The New Beast on the Block,” “Not Another Complaint? What Do I Do?” and “Are Your Patient Satisfaction Scores Driving You Mad? The 12-Step Program to Improving Your Patient’s Experience and YOUR Satisfaction”
  • Alfred Sacchetti, MD, FACEP - “Pediatric Pain: Safe Sedation Practices,” “Antibiotic Stewardship in the Peds ED: Evidence-Based Approach to Common Infections in Pediatrics,” “PK-Trauma: Let’s Chat About Pediatric Trauma,” “Masters of Pediatric Emergency Medicine: Manage Common Conditions Like One of the Experts” and “Lessons My Patients Have Taught Me: Humor, Humility and Humanity Learned at the Bedside”
  • Adam B. Sivitz, MD - “Advanced Pediatric Ultrasound Lab: Kids Are Not Just Small Adults…Or Are They?”
  • David A. Talan, MD, FACEP - “It’s a Small World: Update on Outbreaks and Vaccine-Preventable Infections” and “Cruising the Infectious Disease Literature 2015”

ACEP is an important organization for clinicians in our field, and ACEP15 is the culmination of a year’s worth of hard work. If you’re an emergency physician and haven’t registered yet, the clock’s ticking … I look forward to seeing you in Boston at the end of the month!



Russell H. Harris, MD, MMM, FACEP, CPE, is Chief Executive Officer of EmCare’s North Division. Dr. Harris also is the Vice Chief of the Department of Emergency Medicine at Our Lady of Lourdes Medical Center in Camden, N.J., a position he has held for more than 20 years. He serves on the emergency medicine faculty of Thomas Jefferson University and is a frequent lecturer to residency programs. Dr. Harris is a past-president of the New Jersey Chapter of the American College of Emergency Physicians. He also served on ACEP’s EMTALA Task Force, and in 2008 was recognized as a leader in governmental advocacy and Hero of Emergency Medicine. Dr. Harris received his master’s degree in medical management from Tulane University and is active in the American College of Physician Executives. Dr. Harris served a two-year term as the health policy fellow assigned to the New Jersey State Senate Health Committee. He is a retired captain of the U.S. Navy, having received two Navy Achievement Medals. Dr. Harris serves on the Governor of Pennsylvania’s Advisory Health Board. He has published more than 20 articles in medical journals and textbooks.
 

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Top 10 Things You Must Do in Chicago by Someone Who's from There

Posted on Thu, Oct 16, 2014
Top 10 Things You Must Do in Chicago by Someone Who's from There

Chicago. The Windy City. The City with Big Shoulders. Home.

I've been gone from Chicago longer than I lived there, but on some level, it will always feel like home. For the past several years, I've gotten to go back for trade shows on a regular basis, and so I was very excited when I joined EmCare earlier this year and learned that I would be back again this October. Chicago is also a fitting location for an ACEP event-- I wonder how many of this year's attendees first became interested in a career in emergency medicine while watching the show ER, set in a fictional hospital in the Loop?

If you're not from Chicago, you might be wondering how to prioritize your time when you're not in sessions. We've got you covered. Following is my list of things you must do while you're in town.

You are already on track to visit one of the jewels of the city-- The closing event is at the Museum of Science and Industry (and the party is sponsored by EmCare don't miss it!). It's the kind of place it would be easy to get lost in for days. I've been there more than a dozen times and don't think I've seen it all.

  1. Take your picture at The Bean in Millennium Park. The guide books will tell you it's called "Cloud Gate", but everyone from here just calls it The Bean. As a centerpiece in Millennium Park on Michigan Avenue, the Bean (pictured above) draws crowds night and day. The sculpture is a giant mirrored, well, bean, that reflects the city scape in strange and lovely ways.
  2. Grab a hot dog at Portillo's (100 W. Ontario St). Most people associate Chicago with pan pizza, and there are definitely some good pizza places around.  But for real classic Chicago food, you're looking for hot dogs. There are lots of places that sell hot dogs, and lots of opinions about which ones are the best. You really can't go wrong (as long as you're getting Vienna Beef hot dogs, at least). But Portillo's gets the nods from natives as the place to go.
  3. Catch the view from the John Hancock Building. (Pro Tip: go to the restaurant on the 95th floor, not the observatory on the 99th). Some prefer the view from the Sears Tower (that is no longer the correct name for the building, but that's how everyone knows it), but the Hancock gives you a look up and down the Magnificent Mile, the lakefront, the Gold Coast area and into Lincoln Park – a better view, in my opinion.
  4. Make time for the Art Institute. Right along Michigan Avenue, the Art Institute of Chicago is one of the great museums in the world-- Trip Advisor rated it the #1 Museum in the US in 2013.  Featured exhibits: Veiled Architecture; Art of Byzantium; City Lost & Found- New York, Chicago & Los Angeles 1960-1980
  5. Take a skyline cruise along the river. The one thing here that is on my personal bucket list is to take an architectural boat tour up the river. Chicago is the birthplace of the skyscraper, and it remains a hub of innovation for building design.
  6. Red Head Piano Bar (16 W. Ontario). My daughter tells me that if you happen to be a red head, you will be treated like royalty here. But, you'll have a great time here no matter what.
  7. The Picasso statue at Daley Center. Your introduction to Chicago might have been watching the final sequences of the Blues Brothers movie. The chase ends up here, at City Hall. The Picasso statue is a thing of wonder and beauty. And given the time of year, there are Halloween festivities going on in the plaza.
  8. Billy Goat Tavern (430 N. Michigan Ave Lower Level) near Tribune Tower and the Wrigley Building. The original cast of Saturday Night Live featured a lot of actors who learned their craft with the Second City performing group in Chicago. One of the signature sketches from the early days of the show was a burger joint with an outspoken staff-- the sort of place that Seinfeld updated with the Soup Nazi episode in the 90's. The Billy Goat on Lower Michigan is the original article, a hang-out for reporters, columnists, politicians and ne'er-do-wells. Go for the history. Go for the atmosphere. "Go for a Cheezeburger-cheezeburger-cheezeburger- Pepsi, no Coke. Chips, no fries!"
  9. Navy Pier jutting out a mile into Lake Michigan. Navy Pier is destination that has a lot going on-- restaurants, music venues, shops and other attractions. It's a great place from which to view the skyline, and a great place to visit with the family.
  10. Stroll the Miracle Mile. When I polled my Facebook friends and family for recommendations for this list, this last one came up time and time again. Michigan Avenue from the river north to the Water Tower is known as the Magnificent Mile. It is Chicago's version of 5th Avenue in New York-- a place to shop, to browse, to see and be seen. I can't promise you'll find any great bargains, but you will love the walk.
Bonus for sports fans: Chicago is one of the all- time great sports towns in the country, and it's a great place to watch a game, no matter what sport you follow. It's October, so no baseball in Wrigley Field, of course (said the South Sider). That would have been a thing to see. So, instead, make your way to see one of the best teams in hockey. The Chicago Blackhawks play the Ottawa Senators on Sunday, October 26 at 6:00 pm.

Oh, you have to have a pizza? Giordano's. Trust me.

Click here to view photos of Martin's favorite Chicago landmarks!

ABOUT THE AUTHOR
heath-headshot-(1).jpgMartin Heath, FACHE, is EmCare’s marketing director. A native of Chicago, he has worked in hospitals, physician practices and other healthcare settings for more than 30 years. 
 

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