To survey academic departments of emergency medicine (ADEMs) concerning the effects of managed care on their operation and practice.A 38-question survey was mailed to the chairs of all 52 ADEMs in the United States requesting information concerning managed care activity and its effects on ADEMs in academic years 1994-1995 and 1995-1996.Forty-seven ADEMs (90.3%) responded. When comparing the 1995-1996 and 1994-1995 academic years, the following changes were noted: decreased overall growth in ED patient volume (38.3% vs 51.1%), larger percentage of respondents reporting an actual decrease in ED patient volume (38% vs 27.6%), less growth in ED gross revenue (43.7% vs 52.1%), larger percentage of ADEMs reporting actual decreased gross revenues (25% vs 12.5%), increase in ED patient acuity (76.6% vs 59.6%), and relative stability in the number of EM faculty (40.4% vs 44.7% reporting no change in faculty number). Two-thirds of ADEMs used mid-level providers (i.e., physician assistants, nurse practitioners), most commonly in a fast-track setting (41%). Thirty percent of ADEMs reported that other academic departments actively directed patients away from the ED, with pediatrics, family medicine, and internal medicine the most active. Ninety-eight percent of ADEMs reported ongoing negotiations between their institution or hospital and managed care organizations (MCOs); only 54.3% of ADEMs were involved in these negotiations. Twenty-eight percent of ADEMs reported MCOs have had an effect on their emergency medical services system, with 37% indicating HMOs routinely discouraged their enrollees from using 9-1-1 services and 16% reporting HMOs provided 9-1-1 services to take patients only to participating hospital EDs.ADEMs have experienced significant changes in nearly every aspect of their practice over the two academic years under study, much of which is due to managed care. ADEMs must take a leadership role in dealing with MCOs.
On March 13, 2019 the EMS Examination Committee of the American Board of Emergency Medicine (ABEM) approved modifications to the Core Content of EMS Medicine. The Core Content is used to define the subspecialty of EMS Medicine, provides the basis for questions to be used during written examinations, and leads to development of a certification examination blueprint. The Core Content defines the universe of knowledge for the treatment of prehospital patients that is necessary to practice EMS Medicine. It informs fellowship directors and candidates for certification of the full range of content that might appear on certification examinations.
This is a revision of the previous joint Policy Statement titled “Guidelines for Care of Children in the Emergency Department.” Children have unique physical and psychosocial needs that are heightened in the setting of serious or life-threatening emergencies. The majority of children who are ill and injured are brought to community hospital emergency departments (EDs) by virtue of proximity. It is therefore imperative that all EDs have the appropriate resources (medications, equipment, policies, and education) and capable staff to provide effective emergency care for children. In this Policy Statement, we outline the resources necessary for EDs to stand ready to care for children of all ages. These recommendations are consistent with the recommendations of the Institute of Medicine (now called the National Academy of Medicine) in its report “The Future of Emergency Care in the US Health System.” Although resources within emergency and trauma care systems vary locally, regionally, and nationally, it is essential that ED staff, administrators, and medical directors seek to meet or exceed these recommendations to ensure that high-quality emergency care is available for all children. These updated recommendations are intended to serve as a resource for clinical and administrative leadership in EDs as they strive to improve their readiness for children of all ages.
Background:The use of telemedicine in the diagnosis and treatment of acute stroke, or telestroke, is a well-accepted method of practice improving geographic disparities in timely access to neurological expertise. We propose that mobile telestroke assessment during ambulance transport is feasible using low-cost, widely available technology.Materials and Methods:We designed a platform including a tablet-based end point, high-speed modem with commercial wireless access, external antennae, and portable mounting apparatus. Mobile connectivity testing was performed along six primary ambulance routes in a rural network. Audiovisual (AV) quality was assessed simultaneously by both an in-vehicle and an in-hospital rater using a standardized 6-point rating scale (≥4 indicating feasibility). We sought to achieve 9 min of continuous AV connectivity presumed sufficient to perform mobile telestroke assessments.Results:Thirty test runs were completed: 93% achieved a minimum of 9 min of continuous video transmission with a mean mobile connectivity time of 18 min. Mean video and audio quality ratings were 4.51 (4.54 vehicle; 4.48 hospital) and 5.00 (5.13 in-vehicle; 4.87 hospital), respectively. Total initial cost of the system was $1,650 per ambulance.Conclusions:In this small, single-centered study we maintained high-quality continuous video transmission along primary ambulance corridors using a low-cost mobile telemedicine platform. The system is designed to be portable and adaptable, with generalizability for rapid assessment of emergency conditions in which direct observational exam may improve prehospital diagnosis and treatment. Thus mobile telestroke assessment is feasible using low-cost components and commercial wireless connectivity. More research is needed to demonstrate clinical reliability and efficacy in a live-patient setting.
Abstract. Objective: To determine whether changes in graduate medical education (GME) funding have had an impact on emergency medicine (EM) residency training programs. Methods: A 34‐question survey was mailed to the program directors (PDs) of all 115 Accreditation Council for Graduate Medical Education (ACGME)‐accredited EM residency programs in the United States in the fall of 1998, requesting information concerning the impact of changes in GME funding on various aspects of the EM training. The results were then compared with a similar unpublished survey conducted in the fall of 1996. Results: One hundred one completed surveys were returned (88% response rate). Seventy‐one (70%) of the responding EM residency programs were PGY‐I through PGY‐III, compared with 55 (61%) of the responding programs in 1996. The number of PGY‐II through PGY‐IV programs decreased from 25 (28%) of responding programs in 1996 to 17 (16%). The number of PGY‐I through PGY‐IV programs increased slightly (13 vs 10); the number of EM residency positions remained relatively stable. Fifteen programs projected an increase in their number of training positions in the next two years, while only three predicted a decrease. Of the respondents, 56 programs reported reductions in non‐EM residency positions and 35 programs reported elimination of fellowship positions at their institutions. Only four of these were EM fellowships. Forty‐six respondents reported a reduction in the number of non‐EM residents rotating through their EDs, and of these, 11 programs reported this had a moderate to significant effect on their ability to adequately staff the ED with resident physicians. Sixteen programs limited resident recruitment to only those eligible for the full three years of GME funding. Eighty‐seven EM programs reported no change in faculty size due to funding issues. Sixty‐two programs reported no change in the total number of hours of faculty coverage in the ED, while 34 programs reported an increase. Three EM programs reported recommendations being made to close their residency programs in the near future. Conclusions: Changes in GME funding have not caused a decrease in the number of existing EM residency and fellowship training positions, but may have had an impact in other areas, including: an increase in the number of EM programs structured in a PGY‐I through PGY‐III format (with a corresponding decrease in the number of PGY‐II through PGY‐IV programs); a decrease in the number of non‐EM residents rotating through the ED; restriction of resident applicants who are ineligible for full GME funding from consideration by some EM training programs; and an increase in the total number of faculty clinical hours without an increase in faculty size.
Introduction: The American Heart Association-American Stroke Association (AHA-ASA) Target:Stroke iniative calls for innovative approaches to prehospital stroke care. We hypothesize that mobile telestroke from a hospital-based neurologist to an ambulance-based provider, using tablet devices and commercially available broadband, will facilitate earlier stroke diagnosis and more accurate prenotification to reduce stroke onset-to-treatment times. Methods: We assessed the technical feasibility of mobile teleconferencing along the six common rural emergency medical service (EMS) routes into the University of Virginia Medical Center, allowing a minimum travel time of 15 minutes and continuous connectivity of 5 minutes. Our mobile telestroke platform included Apple iPad with retina display, high-speed 4G LTE modem, Cisco Jabber secure video conferencing application, and magnetic-mount external antennae. Continuous mobile connectivity was facilitated through the commercial Verizon Wireless network. Continuous transmission audiovisual (AV) quality along each route was rated by independent raters from both hospital and vehicle using a standardized six-point scale (≥4 indicating technical feasibility). Results: Of 31 test runs, two had extraneous technical issues and one failed to meet the minimum duration for continuous connectivity. The mean transmission video quality rating was 4.51 (4.54 vehicle; 4.48 hospital) and overall audio quality 5.00 (5.13 vehicle; 4.87 hospital). Both raters deemed AV quality as "good" or "excellent" (rating ≥4) for 78.5% of test runs. Five out of six EMS routes consistently demonstrated feasible connectivity, with 87.5% of runs achieving "good" or "excellent" bidirectional AV quality for these five routes. Conclusion: Our pilot data suggest technical feasibility for mobile teleconferencing between transporting ambulance and hospital-based provider using low-cost, off-the-shelf technology and commercial networks. These results support our hypothesis that mobile telestroke in a rural EMS setting can be implemented. Further troubleshooting along routes with limited connectivity, and prospective testing of the impact on stroke diagnosis and time-to-treatment is planned.
