After an extensive look at ways to provide cost effective care to emergency department patients, the American College of Emergency Physicians believes there is room to improve the use of specific tests or procedures in emergency medicine to participate in the national “Choosing Wisely” campaign.
“Choosing Wisely” is part of a multi-year effort of the American Board of Internal Medicine (ABIM) Foundation to help physicians be better stewards of finite health care resources. The campaign encourages medical specialty organizations to identify five tests or procedures commonly used in their field, the necessity of which should be questioned and discussed by patients and physicians.
ACEP had previously declined participation in the “Choosing Wisely” campaign because of the challenges of this approach with the unique nature of emergency medicine, liability concerns, and a potential harm to physician reimbursement.
The College meanwhile remained steadfast in its commitment to cost-effective care and a high-value health care system, and last year, Immediate Past President Dr. David Seaberg appointed a Cost Effective Care Task Force, chaired by Dr. David Ross. The Task Force was charged with considering tests, processes and procedures with little or no value to emergency care that might represent meaningful cost savings if eliminated.
In a report to the ACEP Board of Directors this month, Task Force member Dr. Jay Schuur said that their Delphi panel and ongoing member surveys have suggested that a number of tests will meet the criteria of the “Choosing Wisely” campaign. They also determined that these tests would not increase the physician’s liability, and would not negatively impact payments for emergency physicians.
After being reviewed by experts, emergency medicine leaders, and the ACEP Board, the report’s data indicates that it would be appropriate for emergency medicine to participate in the campaign. A letter of ACEP’s intention to participate was sent to the ABIM Foundation today.
The list of recommendations should be established by June. ACEP’s Task Force is finalizing the evidence base for these recommendations, in part though the Emergency Medicine Practice Research Network (EMPRN). Attaching estimates of potential real-dollar savings to the recommendations is also being completed. Members of the Task Force and the ACEP Board believe this responsible approach will validate the substance of our recommendations, and provide assurance that there will be a real savings to the health care system while not impacting patient care.
But joining this national campaign is not the only approach ACEP is using its in journey to identify cost savings measures without compromising patient care.
In order for there to be a serious reduction in unnecessary tests and costs of defensive medicine over time, meaningful liability reform and safe harbors are vital. ACEP is encouraging ABIM and its campaign partners to lend their voices to the need for medical liability reform. This remains a top priority in ACEP’s advocacy agenda.
Additionally, the College is working on other significant and impactful efforts, including proposing an elimination of the 3-day-stay rule and better management of transitions of care.
A variety of recommendations that strive to improve patient care and provide meaningful cost savings continue to be initiated, developed, and adopted by ACEP. We are dedicated to ensuring that our specialty can be leaders in health care system efficiency while maintaining a high quality of emergency care and patient safety.
ACEP has arranged for its members to receive a 20% discount on the FH Fee Estimator, a new source of independent charge data from private insurance claims. Participants can access emergency medicine charge data for 491 geographic areas nationwide. This tool gives physicians and management a better understanding of the marketplace and allows instant compare charge data to Medicare fees.
The FH Fee Estimator website, www.feeestimator.org, is easy to use for small data requests. But if you need a more sophisticated data set, contact FAIR Health for custom analytics. To get the ACEP 20% discount, enter the promotion code 20ACEP13 at the checkout screen.
FH Fee Estimator is brought to you by the not-for-profit corporation FAIR Health, whose mission is to bring transparency to healthcare costs through comprehensive data products and consumer resources. Created in 2009 to provide an objective source of data, FAIR Health owns and maintains a database of billions of billed medical and dental services. This database serves as the foundation for benchmark products that reflect the prices charged for healthcare services in specific geographic markets across the country.
This database is a great resource for emergency physicians groups to inform development of fee schedules and other practice decision making, says David McKenzie, CAE, ACEP’s director of physician reimbursement. The data is available based on an aggregation of zip codes and can be tailored for the geographic area you serve. Because it is drawn from actual claims data, it is a wonderful source of information on fees charged in your area, he adds.
February is up and ready for ears, highlights include:
-Introducing computerized charts and information in the ED: impressions
-Point of Care metabolic panels associated with shorter length of stay
-EMS on-scene times and trauma outcomes
-EMS-hospital relations in high performing cardiac care
-Peripheral ultrasound-guided IVs reduce central lines
-ED pharmacists affect discharge prescribing
…and more. Enjoy, and email any time at firstname.lastname@example.org.
Please send your stories to Tracy Napper (email@example.com) today!
An Orderly Shoot-out
Back in the 70’s I was moonlighting at a hospital in Florida and was partly through my shift when an “orderly” appeared asking if he would mind if he followed me around because he had an interest in emergency medicine. He seemed to be a reasonable fellow, dressed appropriately and so I said “sure.” After a few patients a charge nurse appeared and began to accost him for apparently leaving his post and coming down to the emergency department. A shouting match ensued and security was called as the orderly became more and more belligerent and she (the nurse) continued to push all the wrong buttons. The next thing I knew a quintessential southern sheriff with his wide brim hat and his silver .44 magnum was in the department with the gun aimed at the orderly and the orderly opening fire with one liter glass IV bottles which landed at the feet of the sheriff. Utilizing all my superior interventional skills, I bolted for the parking lot and awaited the sound of gunfire. Hearing none in about 15 minutes, I came back to the emergency department and found thankfully that the situation had been resolved with the orderly being carted off somewhere, the sheriff leaving the department and the charge nurse leaving me to my own devices. It was an interesting introduction into why one should not continue to escalate a tense situation with a patient who in retrospect was probably schizophrenic.
Bruce Janiak, MD
January 2013 audio is up and available!
-Accuracy of weight estimations for kids
-U/S for elbow fractures in children
-Added value of decubitus or expliratory chest xrays for foreign bodies in children
-Shocker: resp rate estimation at triage is not accurate
-Multicenter study: performance of the Canadian triage system for children
-Is tPA cost-effective at 3-4.5 hours? Wait… is it effective?
-Does MRI with DWI in TIA predict short term stroke?
Email any time, firstname.lastname@example.org.
Send your story to Tracy Napper (email@example.com) today!
I met my wife in the hospital during my internship and she gamely followed me for a number of years on this peripatetic journey. I went through a number of hospital EDs in Missouri and Ohio, always moving to a better job. After being married for only several years, we found ourselves in northwestern Ohio, just the two of us, no children, no family, no friends in the area. I was working in a regional referral center and my wife had given up working in hospitals.
This was when I discovered that the all-too-familiar to me was sometimes a bit alien and bizarre to the family. I pulled into a local gas station to fill up with my wife in the passenger seat when I was accosted by a well-dressed young African American man. He seemed genuinely delighted to see me. “Hey doc, remember me?” When his warm greeting was met by my blank unknowing stare, he broke into a broad grin and started pointing enthusiastically and unabashedly at his groin. He was creating quite a scene at the gas station. My wife, trying to look very small, remained in the car. Sudden recognition, smiles all around, bear hugs and guffaws. And my wife? Perhaps wondering just how the marriage was going.
It took me awhile to explain to my wife that I had seen this young man just a few days before in the department with his genitals severely entrained in a zipper – a hazard to males of not wearing underwear. After freeing him, like pulling a thorn from the lion’s paw, I had a friend for life. Ironically, that very night, I received another zipper entrainment when two young boys walked in with one boy’s head very close to the other’s chest. The one’s eyelid had become entrained in the jacket zipper of the other and they arrived walking very, very carefully in sync. The apparent horror was mitigated by the very calm acquiescence by the children of their predicament. Nothing unusual here, my eye’s stuck in your zipper. Do you mind?
Both zipper entrainments were handled successfully (“Something About Mary” notwithstanding, without any blood loss) and I was becoming adept at zippers. So how does one handle human flesh stuck in a zipper? There are several tricks passed down from ED doctor to ED doctor, such as cutting the median bar, but regardless of technique, what most do first is call the hospital maintenance man to access his tool belt. There is nothing like a pair of vise grips or wire cutters.
*Reprinted by permission of EPMG.
Charles Grassie, MD, JD
I think we’ve all experienced what I like to call “case envy.” Or even sometimes, “shift envy.” You come on and your colleague immediately starts telling you about the interesting case, or the polytrauma, or the fantastic save/diagnosis/procedure that they just completed.
“Hey, bud, I just performed an open thoracotomy, cross-clamped the aorta and threw in a central line just after performing a cric while I was watching this guy’s aorta rupture during my ultrasound of his belly during which we lost pulses. Sorry about the rest of the mess here in the ED, but those three pelvics and a disempaction might yield something interesting… Enjoy your shift!”
I sometimes hear the story and wonder what I might have done. Would I have handled things the same way? Is that the diagnostic approach I would have followed? Would I even have considered things the same way? Why don’t I ever get the cool cases…?
In residency, we had one colleague who was the perpetual “Black Cloud.” Now, they got to see a lot of cool stuff. However, you didn’t want to follow them because you knew it was going to be chaos in the ED when you arrived. And, if you came before them, you knew the last part of your shift was going to start going to pot about an hour before the end of it.
So maybe it’s not so bad being a bit of a white cloud… but still… I think we all like to have a little something that gets the juices flowing, the mind working, a bit of “yeah for me” moment… After all, that’s why we got into Emergency Medicine… at least for me… how about you?
ACEP Calls for Increased Investment in Mental Health Resources and a Ban on the Sale of Assault Weapons
The American College of Emergency Physicians (ACEP) today expressed deepest sympathy to all those affected by the senseless tragedy in Connecticut and called on government at every level to increase investments in mental health resources and to ban the sale of assault weapons and high-capacity magazines.
Emergency physicians see the tragic consequences of gun violence every day. Our hearts go out to the families of the victims and to everyone affected by this terrible event in Newtown. We deplore the improper use of firearms and support legislative action to decrease the threat to public safety resulting from the widespread availability of assault weapons. We also are urging policymakers to restore dedicated funding for firearms injury prevention research.
ACEP’s policy on firearm injury prevention endorses limiting the availability of firearms to those “whose ability to responsibly handle a weapon is assured.” It also calls for aggressive action to enforce current laws against illegal possession, purchase, sale or use of firearms.
The nation’s emergency physicians call for increased funding for the development, evaluation and implementation of evidence-based programs and policies to reduce firearm related injury and death. We will fully support legislation that supports the principles of ACEP’s policy on firearms injury prevention.
The lack of mental health resources in the United States has contributed to a significant increase in visits to the emergency department. Psychiatric emergencies grew by 131 percent between 2000 and 2007, according to a recent study in Annals of Emergency Medicine. This is symptomatic of the lack of resources for these patients.
Check out the December Annals of EM audio summary, now available. Highlights:
-ED occupancy and crowding on the rise: it’s not just boarding — it’s us
-Measuring ED utilization: encounters or patients?
-The UK 4-hour rule: gone now, but did it change care?
-The ED is now farther away… is mortality different?
-Endotracheal intubation: video versus direct
-Endotracheal intubation: should EMS do it for head injuries?
-Isolated A Fib, outcomes after ED discharge (real, real good)
-Modifying the criteria for diagnosing MI in patients with LBBB
-Ethnic differences in ACS symptom presentation
Please send your story to Tracy Napper (firstname.lastname@example.org) today!
An example of lack of communication with the patient:
As usual the ER was full. The bed closest to my desk was undergoing thrombolysis for an acute MI. His nurse calls out V-tach! I run over to the bed and adminstered a good hard chest thump which converts him to sinus rhythm, ordered lidocaine and told the nurse to get him to the ICU immediately before he developed any more problems.
As he was going out the door, he asked the nurse “Why did the doctor hit me?”
James Meade, MD, FACEP