As emergency physicians, we are skilled in responding to disasters and treating every kind of medical condition as part of our daily routines. We also are critical to America health care response to infectious diseases. This is because patients often show up first in emergency departments, as we saw during the anthrax attacks after 9/11 and in Dallas, Texas, yesterday when the first case of Ebola was confirmed in the United States. Clearly this disease deserves our attention and emphasis from health care providers across the country.
Ebola is a serious communicable disease. Heightened vigilance for case presentations and strict adherence by health care personnel to CDC advice, public education and a pre-planned medical response is necessary. Hospital physicians and entire health care teams have planned for these types of medical threats. Like SARS, MERS, and Hantavirus, newly identified serious population health threats continue to occur.
Even if this Ebola case is isolated, it is incumbent upon emergency physicians and other health care providers to properly screen and manage potential Ebola presentations. The CDC, the Emergency Care Coordination Center and the Assistant Secretary for Preparedness and Response, have provided materials that are excellent resources for emergency physicians and other staff in the ED to have readily available for dissemination.
These resources are available on ACEP’s website at www.acep.org/ebola.
The CDC recommends two initial steps in screening for Ebola Virus Disease:
- The symptoms are likely to be fever, headache, joint and muscle aches, weakness, fatigue, diarrhea, vomiting, stomach pain and lack of appetite, and in some cases bleeding.
- Travel to West Africa or other countries where EVD transmission has been reported by the World Health Organization within 21 days of symptom onset.
If both of these criteria are met, the patient should be moved to a private room, and standard-contact and droplet isolation precautions followed during further assessment.
We see dozens of patients each week, and particularly at this time of year, many will have a common cold or influenza. All health care professionals in the emergency department should know the protocols and what to ask so we can do everything possible to ensure that this Ebola case in Dallas remains isolated.
Emergency physicians from top organizations representing emergency medicine traveled to Washington, DC, this week to meet with Ben Harder, managing editor and director of health care analysis at US News & World Report and Dr. Nate Gross, co-founder of Doximity, an online social networking service for U.S. physicians that conducts surveys for US News.
The purpose of these meetings was to convey the concerns of nine emergency medicine organizations about the results of a Doximity survey, which was promoted by US News & World Report, identifying the nation’s top emergency medicine residency programs.
Prior to the meeting, emergency physicians from the nine organizations held a conference call and developed a joint letter to US News and Doximity challenging the sampling method and the implications of providing misleading information to medical students and the public.
Four physicians represented the group at these meetings:
- Hans R. House, MD, FACEP, ACEP board member
- Jeffrey N. Love, MD, MSC, president, Council of Emergency Medicine Residency Directors
- Jordan Celeste, MD, president, Emergency Medicine Residents’ Association
- Mark Mitchell, DO, FACOEP, president, American College of Osteopathic Emergency Physicians
During the meetings, the physicians conveyed that the results:
- Are misleading to medical students because they are not based on objective criteria.
- Are not useful to medical students because residency choices are made for many reasons, including geography, which are not factors in the Doximity survey.
- Are not an accurate portrayal of residency programs because they are based solely upon opinions expressed by physicians who have no first-hand knowledge of any residency training programs other than the ones they attended.
- Do not reflect the unique nature of emergency medicine.
- Send a dangerous public health message to patients having medical emergencies.
The physicians conveyed there is potential value in a secure data service for communicating HIPAA-compliant messages among emergency physicians. Also, a resource that provides detailed information on residency programs and their alumni could help medical students in making decisions about their applications to specialty training. However, the collective organizations that represent all of emergency medicine could not support the data as long as the rankings were included. Both US News and Doximity agreed there were significant limitations of the data and discussed the challenges of developing objective measures for emergency medicine, because it is a unique medical specialty. Both also agreed that these data would not be promoted to the general public.
The editor at US News described the new organiza
tion’s publications that rank hospitals and medical specialties as “consumer decision support,” which are intended to help members of the general public make decisions about where to seek care for complex medical problems. Emergency medicine has never been included in these rankings in the past, and there are no plans to begin doing so. The editor conveyed that US News recognizes that, in a medical emergency, the best place to get care is the nearest emergency department.
The physicians asked to provide a companion piece to the US News article about the results. The editor agreed to review and publish, if acceptable. The co-founder of Doximity offered to discuss these issues with leaders in his organization and suggested further discussion at ACEP 14 in Chicago.
The following organizations are participating in this effort:
- American College of Emergency Physicians
- American Academy of Emergency Medicine
- American Academy of Emergency Medicine Resident and Student Association
- American Board of Emergency Medicine
- American College of Osteopathic Emergency Physicians
- Association of Academic Chairs of Emergency Medicine
- Council of Emergency Medicine Residency Directors
- Emergency Medicine Residents’ Association
- Society for Academic Emergency Medicine
ACEP and the leaders of other medical specialties representing emergency medicine, have taken issue with a recent survey of emergency medicine residency programs, by US News & World Report and Doximity. Below is a letter from Dr. Rosenau to US News & World Report.
September 12, 2014
Mr. Ben Harder
Managing Editor and Director
Health Care Analysis
US News & World Report
105 Thomas Jefferson Street, NW
Washington, DC 20007
Dear Mr. Harder:
As leaders of the top organizations representing emergency medicine, we have been contacted by scores of emergency physicians from around the country about a survey being conducted by Doximity and publicized by US News and World Report. We appreciate your recognition of emergency medicine as an academic medical specialty with a unique core of knowledge and robust research agenda.
However, we are concerned about the sampling method chosen for this survey, because we believe it will fail to achieve your objective for this survey — to identify America’s top emergency medicine training programs. Asking only physicians enrolled in a social media website to nominate their five most preferred residencies will result in egregious sample bias and is not capable of resulting in a scientifically valid result. The results will be based solely upon opinions expressed by physicians who have no first-hand knowledge of any residency training programs other than the ones they attended themselves.
While not a formal ranking of residency programs, the results would convey that some programs provide better training than others. However, given the limitations, this would not be an accurate portrayal — to medical students or to the public. It also would not be useful to many medical students, because research shows that more than 75 percent of emergency physician residents report the number one reason for selecting a residency program is geography.
More concerning, the results could send a dangerous public health message to people with medical emergencies. It implies they should consider bypassing hospital emergency departments with residency programs that fared poorly in the survey. In a medical emergency, people should seek emergency care at the nearest emergency department, not one that scored better on a highly subjective opinion survey.
Patients need confidence in their physicians in times of crisis, especially since comparison shopping among doctors is not an option when someone is having a medical emergency. Emergency medicine residency programs train physicians in the emergent and acute conditions of just about every medical specialty in health care. As a result, emergency physicians are uniquely qualified to handle a full range of adult and pediatric emergencies. In addition, they see every kind of human drama imaginable, often treating multiple patients at a time.
The overall quality of medical care delivered in emergency departments in the United States is excellent, thanks to the uniformly high standards that govern the accreditation of residency programs in emergency medicine. Emergency medicine residencies collaborate openly with shared curricular tools built around a core model of clinical practice, an approach that is fairly unique in medical education. Ranking training programs above others is contrary to the principles of our specialty, although we recognize that certain programs are best suited for certain trainees.
Many factors contribute to a successful residency program, not all of which can be measured or compared. If your target audience is medical students contemplating a career in our field, we would be happy to work with you to identify objective, measurable factors to help students find the best program for their individual needs.
Unfortunately, our organizations, which represent more than 40,000 emergency physicians, could not recommend or encourage participation in the current survey by emergency physicians. We would, however, be happy to meet with you and help to identify the parameters that might better accomplish that purpose. If you are interested, please contact Marjorie Geist at 800-798-1822, ext. 3290.
Alex M. Rosenau, DO, CPE, FACEP
President, American College of
Meaghan Mercer, MD
President, American Academy of Emergency
Medicine Resident and Student Association
Mark Mitchell, DO, FACOEP
President, American College of Osteopathic
Jeffrey N. Love, MD, MSc
President, Council of Emergency Medicine
Jordan Celeste, MD
President, Emergency Medicine Residents’
cc: Avery Comarow, Health Rankings Editor
By Andrew E. Sama, MD, FACEP
With nearly two-thirds of all admitted septic patients presenting to the ED, and with the clear time sensitivity that exists between recognition, treatment, and outcomes, our members are on the front lines to save lives from this frequently fatal disease. In the CY 2015 IPPS rule, in which CMS cited the fact that “that patients admitted through the ED had a 17% lower likelihood of dying from sepsis than when directly admitted,” CMS finalized NQF #0500: Early Management Bundle for Severe Sepsis and Septic Shock, which mandated the invasive monitoring of CVP and ScVO2 via the placement of a central line in the ED. However, late on Friday, CMS notified hospitals, that it will suspend data collection for the Severe Sepsis and Septic Shock: Management Bundle measure (NQF #0500) until further notice.
Emanuel Rivers, MD, MPH, and his team improved mortality and raised the awareness of the EM community about sepsis through their Early Gold Directed Therapy (EGDT) study in the early 2000s. A few years later, the measure was initially endorsed by the NQF in 2008 without the requirement for a central line for the emergency department. While it is certain that early intervention does reduce mortality, not all elements of the sepsis composite bundle were equally evidence-based. Many studies over the years have demonstrated dramatic improvements in sepsis-related mortality after the implementation of early interventions for septic patients, which included early antibiotic administration, source control, and aggressive fluid resuscitation without invasive monitoring of CVP and ScVO2. One study addressing this, authored by Dr. Alan Jones and colleagues, was conducted at three EDs in the US, and compared two protocols that both included central venous pressure measurement; however, one used lactate clearance and the other used central venous oxygenation monitoring as a way to guide resuscitation. Dr. Jones’ 2010 study found no differences in mortality, suggesting that using central venous oxygenation to guide resuscitation may not be necessary.
In 2012 the measure underwent routine NQF maintenance review for re-endorsement in 2012-2013. During those proceedings, under the leadership of David Seaberg, MD, FACEP and myself ACEP commented that central venous pressure (CVP) was not the only reliable measure of intravascular volume. Several members of ACEP’s Quality and Performance Committee (QPC) including chair Jeremiah D. Schuur, MD, MHS, FACEP, Michael Phelan, MD, RDMS, FACEP, Todd Slessinger, MD, FACEP, FCCM, FCCP, Christopher Fee, MD, FACEP, and others testified on conference calls and at in-person meetings, that there were equally effective and less invasive methods for monitoring septic patients. Nonetheless, the NQF endorsed the requirement for the central line, noting that they would re-consider if additional evidence warranted it.
Within a few months the Protocolized Care for Early Septic Shock (ProCESS) trial was published on March 18, 2014 and under Dr. Alexander Rosenau’s leadership ACEP immediately requested that NQF #0500 undergo an ad hoc review given the impact that this new data would have on this quality measure. After reviewing the data from the ProCESS trial, NQF questioned whether NQF #0500’s item ‘F’, which measures central venous pressure and central venous oxygen saturation, should be retained or removed from the measure. During the review, one of the PIs, Donald Yealy, MD, FACEP engaged in a scientific debate noting that the ProCESS trial enrolled 1,341 patients, with a power to detect a 6-7 percent absolute difference, yet demonstrated no difference in mortality 60-day mortality 90-day mortality, one year mortality, or the need for organ support. The ProCESS also noted no benefit in any outcome when using CVC- guided care and the simpler approaches that stressed early and ongoing care produced the same good outcomes.
CMS, NQF, and others are now also convinced that honing the sepsis bundle is a move forward for our septic patients, with or without invasive monitoring depending on the progression of their disease, their unique circumstances, and the resources available at the ED where they are being treated. As it is ACEP’s mission, we will continue to advocate on behalf of our patients presenting with a diagnosis of sepsis to ensure that they receive the highest quality of emergency care. We look forward to continuing to work with the measure developer to ensure that all septic patients receive the timely, effective care they need, and to continue to save lives from this deadly disease.
Dr. Sama is ACEP’s Immediate Past President and Chair of the Board of Directors
In a recent newsletter, the American Hospital Association informed its members of a change by CMS as it relates to data collection for severe sepsis and sepsis shock. Below is the CMS announcement.
The Centers for Medicare & Medicaid Services (CMS) is notifying hospitals participating in the Hospital Inpatient Quality Reporting (IQR) Program that it will suspend data collection for the Severe Sepsis and Septic Shock: Management Bundle measure (NQF #0500) until further notice. This measure was adopted for the FY 2017 payment determination in the CY 2015 IPPS final rule.
CMS continues to believe that this is an important area for measurement given mortality rates that range from 16-49% and that sepsis is one of the top 10 most common principle causes for hospitalizations. Further, through surveillance of early effective treatment of severe sepsis or septic shock, hospitals will not only know where in the sequence of steps to treat severe sepsis and septic shock patients, but also begin to decrease mortality related to sepsis and the costs associated with inefficient care of severe sepsis and septic shock patients. With this measure CMS will gauge if care of severe sepsis and septic shock patients is improving.
This measure was initially endorsed by the NQF in 2008 for the hospital/acute care facility setting and underwent routine NQF maintenance review for re-endorsement in 2013. During the 2013 NQF endorsement proceedings it was noted that should new data be published related to the measure, that the measure would undergo an ad hoc review. With publication of the Protocolized Care for Early Septic Shock (ProCESS) trial in early 2014, NQF #0500 underwent an ad hoc review to discern if the new data would impact the measure as currently designed. After reviewing the data from the ProCESS trial, NQF questioned whether NQF #0500’s item ‘F’, which measures central venous pressure and central venous oxygen saturation, should be retained or removed from the measure. During the review two other trials were identified that might also impact NQF #0500, those trials are the Australian Resuscitation in Sepsis Evaluation Randomized Controlled Trial (ARISE) and The Protocolised Management in Sepsis Trial (ProMISe). After much discussion of the results of the ProCESS trial, the potential impact the ARISE and ProMISe trials may have on the measure, and the recommendations to remove item ‘F’ from the measure, NQF recommended that measure stewards collaborate with other stakeholders to reach a compromise on NQF #0500’s item F. NQF recommended that measure developers collaborate with other stakeholders to reach a compromise on this specific element of NQF #0500 measure.
Given forthcoming research and NQF’s recommendations, with potential changes to the measure, CMS will delay data collection for the measure until further notice. The duration of this suspension pending further information from the measure developer has not yet been determined. This delay does not affect the data collection period for any other Hospital IQR Program measures.
By Dennis Beck, MD, FACEP
ACEP is working with a leading registry vendor who currently provides PQRS registry reporting for more than 40 medical societies. The penalty for failure to satisfy the 2014 PQRS requirements equals up to 4% of Medicare payments, approximately $2,500 per provider.
As a member benefit, ACEP is providing ACEP, EMRA & SEMPA members with $100 off the $299 per provider fee. We have negotiated a deeper discount of 10% off ($179) for groups of 10 or more and 15% ($169) for groups of 20 or more. For more information on reporting requirement, go to www.acep.org/qualityregistry. And be sure to return in early September to take advantage of this member benefit.
In 2014 a group of 10 or more eligible professionals may avoid the 2% PQRS penalty as well as the 2% VBM penalty (both applied to 2016 payments) if at least 50% or more of the individual eligible professionals in the group satisfy PQRS reporting requirements in 2014. Even just one Medicare Fee-For-Service claim for the calendar year qualifies a provider (physician or midlevel) as an eligible professional in a group for purposes of the “50% threshold.” However, please note that those eligible professionals in the group, who do not submit PQRS measures, will still be subject to the PQRS payment adjustment of 2%. To avoid the VBM penalty, at least 50% of individual EPs in a group must meet the minimum PQRS reporting requirements (for more information on these requirements visit www.acep.org/quality. So the choice of whether to report as individuals or to report as a group is a decision that is up to your group.
If your group decides to participate in the 2014 PQRS group practice reporting option (GPRO), the group is required to register through the Physician Value-Physician Quality Reporting System (PV-PQRS) Registration System by September 30, 2014. This registration process can take up to two weeks, so start now! Groups will need an Individuals Authorized Access to the CMS Computer Services (IACS) account to access the PV-PQRS Registration System. Registration lets CMS know which groups want to be analyzed at the group level (or TIN-level analysis).
Complete information about IACS and 2014 PQRS GPRO registration is available on the CMS website. Click here for that information.
During registration, the group practice will need to indicate the size of their group at the time they register. For GPRO Group size is based on the number of eligible professionals including PAs and NPs billing under the TIN. Be sure that your group’s Medicare Provider Enrollment, Chain, and Ownership System (PECOS) information is updated for before you begin registration.
Whatever your decision, to report as a group via GPRO registry or to report as individuals, the ACEP PQRS Wizard registry option will be available for you. Although you can upload quality data codes from your practice management, coding, or billing software to the portal through February of 2015, if you want to participate via GPRO your group must complete the PV-PQRS registration process by September 30, 2014. If you plan to report as individuals you can sign up through Dec. 31, 2014.
Dr. Beck is President and CEO of Beacon Medical Services in Aurora, Colorado. He is past chair and current member of the ACEP Reimbursement, Quality and Performance Committees. Dr. Beck is also a member of the ACEP Coding and Nomenclature Committee and chair of the Colorado ACEP Finance Network.
Check out the August audio here. New format! More clinician-focused than ever. Highlights include:
-ED visits and healthcare reform in Massachusetts: what happens when more people become insured?
-Chest pain risk tolerance: does anyone know what they’re talking about?
-Pediatric minor head injury: we found the rule you should be using….
-MOLST/POLST: get to know it — this changes everything.
Pleeeease give us your feedback, at email@example.com
July’s audio/podcast for Annals of EM is now posted here. Highlights:
-Early vs late rhythm analysis in OOHCA
-Ground based EMS transports and complications
-When do sepsis patients become septic? Usually NOT on arrival. Time to change the metric?
-Diethylene glycol outbreak
-Much, much more!
The ACEP Board Directors accepted a recommendation last week from its Clinical Policies Committee to begin working on a tPA policy exclusive to ACEP instead of a joint project with the American Academy of Neurology.
The 2013 Council had asked that ACEP reconsider its current “Clinical Policy: Use of Intravenous tPA for the Management of Acute Ischemic Stroke in the Emergency Department,” which had been developed with the AAN and published in February 2013.
After an open 60-day comment period in early 2014 and a subcommittee review of the comments and literature findings, the Clinical Policies Committee recommended to pursue an independent policy, which will include updated evidence and grading criteria. The Board unanimously approved this recommendation.
Once the draft is developed, it will be available for members to review and comment for 60 days prior to the Committee’s presentation to the Board. An estimated timeline was not available.
Additionally, the Board confirmed its commitment to the clinical policy development process and agreed to add three methodologists to the committee, additional meetings, and another staff person to ensure a robust review process.
By James M. Cusick, MD, FACEP
Chair, Candidate Forum Subcommittee of the ACEP Council
ACEP is a member-driven organization with a representative body of our peers – the ACEP Council – chosen through component bodies, including our chapters (1 representative per 100 members), our Sections of Membership, and other aligned organizations.
Each year, this body democratically votes to establish ACEP policy and elect leadership positions. Candidates present themselves to the Council through written statements, scheduled speeches, and unrehearsed Question and Answer sessions during the Candidate Forum, which is open to all members. Elections must be fair, follow guidelines applicable to all, and be free of undue influence or pressure on candidates.
The ACEP Council’s Candidate Forum Subcommittee recently performed its annual review of the campaign rules to ensure a fair campaign and elections process for all Board of Directors and President-elect candidates. The changes were approved by the Council Steering Committee.
This year, restrictions on the use of social media were substantially relaxed to allow forms of communication most of us use on a daily basis.
In addition, protections were incorporated into the rules to keep candidate interviews in ACEP publications. Our goal is to avoid candidates being put in the position of commenting on College policy without adequate preparation and to ensure that the campaign process is fair and equal for all candidates.
Certain candidates may unfairly benefit from coverage in non-ACEP publications, while some may be disadvantaged. In order to ensure a fair election, campaign questions and the vetting of candidates is the responsibility of ACEP, its Council and its Council Committees.
If there are specific questions you would like asked of the candidates prior to the election, please send them to firstname.lastname@example.org. The Candidate Forum Subcommittee will consider them, the selected questions will be posed to candidates and their responses will be made public.
Elections will occur during the Council meeting on Oct. 26 in Chicago. The Nominating Committee has selected the final slate of candidates for 2014:
Jay Kaplan, MD, FACEP
Robert O’Connor, MD, FACEP
Rebecca Parker, MD, FACEP
Board of Directors Candidates (4 positions to be filled)
Stephen Anderson, MD, FACEP (WA)
Jon Mark Hirshon, MD, FACEP (MD)
Hans House, MD, FACEP (incumbent – IA)
Mark Mackey, MD, FACEP (incumbent – IL)
John Rogers, MD, FACEP (incumbent – GA)
Mark Rosenberg, DO, FACEP (NJ)