2014 EM Report Card Released

Jon Mark Hirshon, MD, MPH, PhD, FACEP

By Jon Mark Hirshon, MD, MPH, PhD, FACEP
Report Card Task Force Chair

With the release of the 2014 ACEP Report Card on Emergency Medicine, the nation learns how well each state supports emergency medicine and your emergency department.

The nation received an overall grade of D+.

ACEP has produced Report Cards in 2006 and 2009 to evaluate the overall emergency care environment both nationally and on a state by state basis. This is not a report on the emergency care delivered in any specific hospital or by any individual physician, but rather an evaluation of how well the country supports emergency care.

The 2014 Report Card is based on 136 objective measures in five areas:

  • Access to Emergency Care (30%)
  • Quality & Patient Safety (20%)
  • Medical Liability (20%)
  • Public Health & Injury Prevention (15%)
  • Disaster Preparedness (15%)

It reflects the most recent data available from high-quality sources such as the Centers for Disease Control and Prevention, the National Highway Traffic Safety Administration, the Centers for Medicare & Medicaid Services, and the American Medical Association. Additionally, two surveys were sent to state health officials to gather data for which no reliable, comparable state-by-state sources were available. These data elements were then combined to create the components of the Report Card.

Since 2006, ACEP chapters have used the Report Cards to help with the establishment of new emergency medicine residency programs, support the funding of a statewide trauma system, to help with the enactment of liability protection for federally mandated EMTALA related care, and to increase awareness of emergency medicine issues among state and national lawmakers. We plan to use the 2014 Report Card to educate policymakers and the public about the pivotal role of emergency medicine, help change the conversation from preventing “expensive” emergency visits to protecting access to emergency care, and use communications tools to achieve the national and state recommendations of the Report Card in order to improve the emergency care environment.

To access the most current state by state information, including state and national grades, and to be able to compare the 2014 Report Card with the previous Report Card, please visit: http://www.emreportcard.org/

-Jon Mark Hirshon, MD, MPH, PhD, FACEP
Report Card Task Force Chair
Dr. Hirshon is Board Certified in both Emergency Medicine and Preventive Medicine and has authored approximately 75 articles and chapters on various topics, including the development of public health surveillance systems in emergency departments and placing emergency care on the global health agenda. He has a doctorate in epidemiology and is a federally funded researcher and teacher with specific interest in improving access to acute care and in developing emergency departments as sites for surveillance and hypothesis driven research in public health.


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Annals Q&A With Dr. Jeremy Brown, Director of the Office of Emergency Care Research

Dr. Jeremy Brown

Dr. Jeremy Brown is the director of the newly created Office of Emergency Care Research (OECR) at the National Institutes of Health (NIH). He trained as an emergency physician in Boston, and prior to joining the NIH he worked in the Department of Emergency Medicine at the George Washington University (GW) in Washington, DC. While at GW, he founded the emergency department (ED) HIV screening program and was the recipient of 3 NIH grants that focused on a new therapy for renal colic. He continues to teach at GW on the practice of clinical research, as well as teaching a course on science and religion. He is the author of more than 30 peer-reviewed articles and 3 books, including 2 textbooks of emergency medicine, all published by Oxford University Press. Annals News & Perspective editor Truman J. “TJ” Milling Jr., MD, interviewed Dr. Brown in his Bethesda, MD, office, on the importance of the OECR and how he plans to use his new position to coordinate and grow emergency research within the NIH. His comments have been edited for clarity.
Read the Q and A here

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ABEM Loses Power, Extends MOC Deadlines

Editor’s Note: Power distributions from an ice storm have impacted business at the American Board of Emergency Medicine, and they have asked ACEP to help spread the word about their special circumstances.

A significant ice storm on Dec. 22 caused power and communication outages with the ABEM headquarters. These disruptions are continuing while the utility companies actively work on restoring dependable service. Please be advised that intermittent disruptions are possible during the next several days. ABEM apologizes for any inconveniences physicians may have encountered in trying to reach its office or website services.

All December 31, 2013, deadlines for completing MOC activities and PQRS MOC Additional Incentive Payment requirements have been extended to January 10, 2014, 11:59 p.m., EST.

Holiday Hours
The ABEM office will be closed from Dec. 25, 2013, through Jan. 1, 2014.

However, contingent upon the restoration of the power and communication outages the ABEM office is currently experiencing due to the ice storm, staff will be available on December 26, 27, 30, and 31 from 8:30 a.m. to 4:30 p.m. EST to provide assistance with ABEM MOC requirements.

Questions about your ABEM MOC requirements can be sent to MOC@abem.org, or you can call 517.332.4800 for assistance during the times noted.


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ACEP Member Dr. Donna Carden of Florida Awarded PCORI Research Funding

The University of Florida’s Dr. Donna Carden has been approved for PCORI funding for her research, “An Emergency Department-to-Home Intervention to Improve Quality of Life and Reduce Hospital Use.” Dr. Carden will lead one of 82 research projects approved for PCORI funding to help answer the question: “How can clinicians and the care delivery systems they work in help patients make the best decisions about their health and healthcare.”

Dr. Carden: “The transition from the emergency department (ED) to home can create patient confusion and anxiety and lead to a cycle of repeated, costly and preventable ED visits and hospital admissions, especially for older patients with chronic health problems. There is an urgent need, therefore, for more patient-centered management of patients discharged from the ED. Our research team (patients, caregivers, Area Agency on Aging staff, physicians, health-system managers, researchers) proposed the following question: Compared to usual, post-ED care, can an intervention deployed after an ED visit that links chronically ill patients with community-based social- and medical-support improve quality of life and reduce the need for additional ED visits and unnecessary hospital admissions? We expect the proposed community-based intervention to have a positive impact on patient-reported quality of life and to reduce the likelihood of return ED visits and hospital admissions. The knowledge gained from this work has the potential to contribute to a broader understanding of how post-ED transition interventions can be tailored to reduce healthcare disparities for vulnerable populations, improve healthcare quality and reduce healthcare costs.”

By providing support and funding to pilot-test the proposed, community-based intervention, Dr. Carden said that ACEP and EMF contributed substantially to the success of this PCORI application.

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Bat In The Sack


By Constance Doyle, MD, FACEP

She came in with a chief complaint of “needs rabies shot”

Her story: She said she was placing clothes in the washer when something bit her on the hand.  She looked to see if her cat was in the washer and seeing that she was not, slammed the lid and ran the wash twice to be sure that whatever animal it was dead.

Then carefully looking through the clothes while putting the clothes in the dryer, she found a limp and dead bat which she fished out with kitchen dishwashing gloves.  At that point, she pulled a paper sack out of her handbag and set it on the counter.  We went on with the physical and discussion of rabies testing and vaccine, when I noticed the bag was slowly moving in and out like something was breathing and the sack was rattling.  I had visions of the creature getting out and flying all over the ER, being a nightmare to catch, exposing both staff and other patients as well as becoming a liability for the hospital.  The normal bat containers, empty paint cans were in storage, and I knew that someone would have to go to the locker and get one taking at least 15 minutes.   I needed a container now.  I ran next door to the trauma room and grabbed a large suction canister and lid and put the sack in it.  Now to humanely be sure that the bat was not a threat, we found a bottle of alcohol and poured it in through the suction hose connection.  At least it could die in an alcohol stupor.  The bag stopped moving and the paint canister arrived and the whole canister fit inside without opening it and off to the health department.

You just can’t make this stuff up!

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December Annals Audio posted

The December audio issue of Annals of EM is now posted and available. Highlights include:

-New onset atrial fibrillation — should we anticoagulate in the ED?
-Atrial fibrillation in the ED: trends in Canada
-Review: High sensitivity troponins
-Capnography to diagnose PE: meta-analysis
-Observation is associated with less imaging for pediatric minor head injury
-Pediatric magnet ingestions
-Review: reversing warfarin in the ED

Email us at annalsaudio@acep.org, any time.


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How I Found My Voice in Health Care Reform as a Fourth-Year Medical Student

My name is Sara Paradise. I’m a fourth-year medical student at the George Washington School of Medicine in Washington, D.C., and a very soon-to-be emergency physician. Like 99 percent of you docs and future docs out there, I am 100 percent passionate about my chosen specialty and future patients, but have zero understanding of how government and health policy really works.

Which is why, after nearly four years of living only blocks from the White House and the epicenter of political drama, I was pumped to have the honor and privilege of doing an internship with the American College of Emergency Physicians. These are the premier group of people responsible for representing the policies, education, advocacy, and regulatory interests of emergency physicians.

Fast-forward five days, and I feel like I’ve gone from a toddler to a tween in my knowledge of health policy, being taken under the wings of the brilliant people working at ACEP in D.C. to amass a much deeper understanding of emergency medicine and our role in health policy.

So, let’s talk about how things work.

Much of my week has been devoted to meeting with members of Congress, who hold almost daily meetings to educate themselves on issues related to health care reform. The people in attendance tend to be lobbyists, or individuals hired to represent major medical specialty organizations such as ACEP. I was instantly struck by the important role that the medical lobbyists hold in these meetings compared to other public and private groups, often seated next to the Congressperson and directing the conversation. Lobbyists are not only experts in the nitty-gritty details of the Affordable Care Act and how it affects their specialty, but have an unparalleled adeptness in navigating Washington, D.C. politics to convey doctors concerns in a passionate, yet appropriate manner.

The Congresspeople who represent issues that your particular medical specialty cares about are the ones you meet with most frequently.  In our case, that means anyone who champions funding poison centers, drunk driving prevention, and SGR reform (that is, ensuring that we as physicians are not fiscally-penalized for seeing Medicare patients).  These legislators admit they are not experts, and fight for our doctors despite being stuck in a muddy Congress.

So other than rub elbows with political figures, what else do health policy people do? Apparently, they attend a lot of special panels and webinars that discuss details of healthcare-related legislation. They use their strong voices to bridge the gap between those creating health care-related laws, often non-clinicians, and America’s doctors. One such panel discussed the “Two Midnight Rule.” This rule, I learned, states that any Medicare patient who is marked as “Observation Status” – regardless of whether physically in the ER or an inpatient bed – does not automatically qualify to have their skilled nursing facility (SNF) stay covered, even if they are observed for the required three days and it is medically indicated; an unintended loophole, if you will [read more here].  The panelists were policy makers set on changing the laws for the better, with our local and national community’s input.

One of the highlights of my week was most definitely attending the release of the December issue of Health Affairs at the National Press Club on “The Future State of Emergency Care.”

My personal favorite was a talk by Dr. Maria Raven on the urban myth that Emergency Department “frequent fliers” guzzle our health care dollars faster than a non-hybrid SUV consumes gas.  She and Dr. Billings’ research found that those patients utilizing the ED on a “frequent” basis (about 10 times per year) visited their Primary Care MORE frequently than the average ED patient. Perhaps they just have more complicated, and many comorbid conditions! Another talk, by Dr. Jeremiah Schuur, was on changing our emergency medicine infrastructure.  Why not bring the right resources to the patient via tools such as Telemedicine, rather than dragging patient to the resource (which is often time-consuming, costly, and ineffective)?  In the era of Facetime and Medicare reimbursement for Telemedicine consultation, makes sense to me.

One really informative meeting was with ACEP’s Quality & Health I.T. Manager. Even though I have an extensive background in Electronic Health Records, I felt as though she was speaking a foreign language.  HL7? CCDA-1?? MU2? I nodded my head, thinking “What do these codes mean?!” Jumping on the Internet, I discovered the how we are standardizing the language of Electronic Health Records in hopes that Health Information Exchange can become a reality, outside of utilizing the same brand of system.

The moment I felt my voice really matter was when I had informal discussion with my new colleagues about what I had experienced as a third-year medical student.  Fresh off the wards of OB-Gyn, Medicine, and Psych, I had some solid opinions about how the Emergency Department interacts with each of these specialties and ways we could improve our health care system.  I was shocked that they not only took my input seriously, but wanted to know more, leading to a number of meetings with different specialists on their calendars.

Reflecting on my first week, I now feel a much stronger responsibility to “represent” each and every G.W. medical student, future Emergency Physician, and maybe even late 20-something woman starting her career.  I also want to emphasize: You, too, can set a meeting with these tremendous people and discuss your observations and ideas. You, too, can become an advocate and leader in your field.  It takes a simple e-mail to your respective governing body, and a will to fight for something you believe in.

I’m already looking forward to what lies ahead…affter a quick detour to L.A. for a residency interview, I’ll be back for more next week!

Want to get in touch with ACEP regarding an issue you read about above?  http://www.acep.org/contactus/
Have questions for the author? E-mail: sparadise@acep.org
Follow me on Twitter: @saraparamd

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November audio summary is up

The November audio issue is posted! Highlights include:

-Do elderly patients wait longer?
-A delirium screening tool
-Do people who can’t afford their medicines come back to the ED more?
-Standoff: Canada and US — who does more CTs?
-The cost of emergency medicine, it’s not what you’ve heard
-NAC v IV fluids to prevent contrast nephropathy
-Unused IV lines
-UTI in renal colic patients – predictors and urinalysis utility

Check it out and email any time at annalsaudio@acep.org

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Will You Still Love Me?

“Do you still love it?”
I was sitting in the atrium at the Chihuly Garden and Glass Museum in Seattle during the ACEP Scientific Assembly a couple of weeks ago enjoying a glass of wine and some fine appetizers, so it took me a moment to think about what my colleague was asking me.  And, to be honest, I wasn’t sure if I could answer her question.
I joked back, “Love is such a strong word…”  But, her question really put me in a pensive mood.  Did I still love it?  At a time when more patients are going to the emergency department because they can’t find a primary doctor, or don’t have insurance or have just gotten insurance and have put off having any routine medical care until today, and at a time when government fund cutbacks mean stricter measures for payment of fees (i.e., if you don’t get good patient satisfaction scores, we’re not going to pay you) it’s hard to be an ED doc and not develop a certain level of cynicism.
I’ve already written about my decision to return to Emergency Medicine after having trained in Surgery in prior posts.  I wanted variety, continued challenges, the ability to go home at the end of my shift knowing I wouldn’t get called back into the hospital just as I was getting settled in for the night.  And, for the most part, I do enjoy my job.  But there are those days when I wonder if I wouldn’t be happier as a cashier… or a waitress… or….?  I think about what my application would look like… Prior Work Experience:  dealing daily with irrational people having unrealistic expectations and demanding all their problems get solved promptly.  I guess maybe they’d tell me I was over qualified.
Then I think about those moments of pure chaos, when you weren’t sure if you were making the right decision at the time, and you relied solely on pure guts and instinct with whisperings of medical knowledge;  when both you and the patient came out slightly bruised and beaten on the other side but alive to fight another day.  Those are the moments when you truly feel you have made a difference; that those 10 years of  post-graduate education weren’t a waste of time.
Those are the days when I do love my job.  And, they’re the ones that keep me going…
Find a job you enjoy, and you will never have to work a day in your life.
- Confucius

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George Podgorny, MD – Advocate and Architect of Emergency Medicine

Dr. George Podgorny

Editor’s Note: In lieu of flowers, please consider a memorial donation to the Emergency Medicine Foundation. The family will be notified of any gifts received in his memory.

By Brian J. Zink, MD
Author, “Anyone, Anything, Anytime: A History of Emergency Medicine”

November 5, 2013

Life has sweet and sad moments, sometimes too closely juxtaposed. At the October 2013 ACEP Scientific Assembly meeting in Seattle, emergency physicians, residents, medical students, and long-time colleagues were pleased and intrigued to watch Dr. George Podgorny in the premiere of the EMRA Legacy Initiative 24/7/365 documentary, and then to hear him interviewed later that evening and in a panel discussion the following day. Many learned about the key role that Dr. Podgorny played in establishing emergency medicine (EM) as a legitimate US medical specialty through the creation of the American Board of Emergency Medicine (ABEM). At the time of the approval of ABEM by the American Board of Medical Specialties in 1979, Dr. Podgorny was clearly in the mix – serving as both President of ACEP and President of ABEM that year. He was integrally involved in the negotiations that created the approved “modified conjoint” ABEM board after the original ABEM proposal had been roundly defeated in an American Board of Medical Specialties (ABMS) House of Delegates vote in 1977. After ABEM was approved, Podgorny was the Chief Examiner for the first ABEM exam. He also became the head of the newly created Residency Review Committee and served in that capacity for 6 years. He tirelessly surveyed and approved residencies, helping to ensure the quality of new emergency medicine residency programs.

Unfortunately, after gracing us with his encyclopedic memory, wit, and insights at ACEP, Dr. Podgorny fell ill after his trip to Seattle and died in Winston Salem, North Carolina on November 5th, 2013.

George Podgorny was born in Iran, but his heritage was Czech and Armenian. His father taught physical education to the children of the Shah of Iran, and his mother wrote children’s books. It was decided that George would come to the United States after high school because the family felt that a US university education would be superior. Podgorny left his family and came alone to Maryville College in Tennessee and decided to go in to medicine. He became enamored with Wake Forest University School of Medicine (then the Bowman Gray Medical School) and its Baptist Hospital, was accepted there for medical school and never left the region. Podgorny excelled as a medical student and was accepted in to the general surgery residency. As a surgery resident he spent a great deal of time in the emergency department, and was struck by the fact that the sickest patients were cared for by the least trained residents who were rarely supervised. He worked diligently to improve care in the ED even as a resident. Podgorny then completed vascular surgery training and was in a cardiothoracic surgery training fellowship when he began to learn more about physicians who were practicing full time in emergency departments (EDs). He attended the 1970 ACEP meeting and met many of the early leaders. After this, he joined with a couple friends to work in the ED of Forsyth Hospital in Winston-Salem. He loved this work, and the possibility of being involved in a new specialty of medicine, and did not return to surgery.

As someone who was academically-oriented and had 7 years of residency training, Podgorny linked with the early ACEP leaders and began to push for formation and approval of a specialty board in EM. His background and connections in the surgical world helped to lend some credibility to the early group, and allowed him to battle the opposition that came from surgical fields. He came across as a unique individual, always sporting a handlebar mustache, with an exotic sounding accent and an eloquent but raspy voice. People paid attention when he spoke.

One of his most important roles came at the “Workshop Conference on Education of the Physician in Emergency Medicine” in Chicago in 1973. Podgorny was an important, persuasive figure in a comprehensive gathering of medical leaders from government, the other medical specialties, and academia. The fate of EM going forward hinged on the early EM leaders convincing others that the field was credible and that residency training and specialists in EM were just as important as in other medical fields. The outcome of the meeting was favorable and Podgorny and other early leaders in EM then made a concerted push, against considerable odds, to get ABEM established over the next 6 years. Podgorny was a key negotiator in the process, particularly in the final compromise that allowed ABEM to be approved in 1979.

George Podgorny continued to practice emergency medicine for many years in Greensboro, North Carolina after his direct leadership in ACEP and ABEM ended. However, he was a constant presence at the annual Scientific Assembly and offered advice and counsel to the new leaders in EM. On a personal level, George loved his Persian heritage, and his home was lavishly decorated with Persian art and furniture. He was a widely read intellectual, and an astute scholar of the history of medicine. He also loved his adopted home state of North Carolina, and was a regular at the local barbeque restaurants.

Dr. Podgorny is one a handful of people who can be considered to have been truly essential to the formation of emergency medicine. Without his forceful, scholarly, and gracious diplomacy, some of the early deliberations of the future of EM could have gone the other way. His loss leaves us greatly saddened, but we can also warmly reflect on how his determination, skill in negotiation, and perseverance made EM become a reality in the US. This is his tremendous legacy. We are grateful to have had the pleasure of seeing and hearing this senior icon of emergency medicine one last time at the ACEP Scientific Assembly 2013.

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