Initial Validity Evidence for the American Board of Emergency Medicine Emergency Medical Services Certification Examination.

OBJECTIVES: The American Board of Emergency Medicine (ABEM) Emergency Medical Services Medicine (EMS) subspecialty was approved by the American Board of Medical Specialties on September 23, 2010. Subspecialty certification in EMS was contingent on two key elements-completing Accreditation Council for Graduate Medical Education (ACGME)-accredited EMS training and passing the subspecialty certification examination developed by ABEM. The first EMS certification examination was offered in October 2013. Meaningful certification requires rigorous assessment. In this instance, the EMS certification examination sought to embrace the tenets of validity, reliability, and fairness. For the purposes of this report, the sources of validity evidence were anchored on the EMS core content, the examination development process, and the association between fellowship training and passing the certification examination. METHODS: We chose to use validity evidence that included: 1) content validity (based on the EMS core content); 2) response processes (test items required intended cognitive processes); 3) internal structure supported by the internal relationships among items; 4) relations to other variables, specifically the association between examination performance and ACGME-accredited fellowship training; and 5) the consequences of testing. RESULTS: There is strong content validity evidence for the EMS examination based on the core content and its detailed development process. The core content and supporting job-task analysis was also used to define the examination blueprint. Internal structure support was evidenced by Cronbach's coefficient alpha, which ranged from 0.82 to 0.92. Physicians who completed ACGME-accredited EMS fellowship training were more likely to pass the EMS certification examination (chi square, p < 0.0001; Cramér's, V = 0.24). Finally, there were two sources of consequential validity evidence-use of test results to determine certification and use of the resulting certificate. CONCLUSIONS: There is substantial and varied validity evidence to support the use of the EMS certifying examination in making summative decisions to award certification in EMS. Of note, there was a statistically significant association between ACGME-accredited fellowship training and passing the examination.

Factors associated with door-in-door-out times in large vessel occlusion stroke patients undergoing endovascular therapy.

INTRODUCTION: In the management of large vessel occlusion stroke (LVOS), patients are frequently evaluated first at a non-endovascular stroke center and later transferred to an endovascular stroke center (ESC) for endovascular treatment (EVT). The door-in-door-out time (DIDO) is frequently used as a benchmark for transferring hospitals though there is no universally accepted nor evidenced-based DIDO time. The goal of this study was to identify factors affecting DIDO times in LVOS patients who ultimately underwent EVT. METHODS: The Optimizing Prehospital Use of Stroke Systems of Care-Reacting to Changing Paradigms (OPUS-REACH) registry is comprised of all LVOS patients who underwent EVT at one of nine endovascular centers in the Northeast United States between 2015 and 2020. We queried the registry for all patients who were transferred from a non-ESC to one of the nine ESCs for EVT. Univariate analysis was performed using t-tests to obtain a p value. A priori, we defined a p value of <0.05 as significant. Multiple logistic regression was conducted to determine the association of variables to estimate an odds ratio. RESULTS: 511 patients were included in the final analysis. The mean DIDO times for all patients was 137.8 min. Vascular imaging and treatment at a non-certified stroke center were associated with longer DIDO times by 23 and 14 min, respectively. On multivariate analyses, the acquisition of vascular imaging was associated with 16 additional minutes spent at the non-ESC while presentation to a non-stroke certified hospital was associated with 20 additional minutes spent at the transferring hospital. The administration of intravenous thrombolysis (IVT) was associated with 15 min less spent at the non-ESC. DISCUSSION: Vascular imaging and non-stroke certified stroke centers were associated with longer DIDO times. Non-ESCs should integrate vascular imaging into their workflow as feasible to reduce DIDO times. Further work examining other details regarding the transfer process such as transfer via ground or air, could help further identify opportunities to improve DIDO times.

Evolution of endovascular stroke centers and disparities in access to stroke care in four Northeastern states: 2015-2019.

OBJECTIVES: Disparities exist throughout our healthcare system, especially related to access to care. Advanced stroke care for strokes is only available at selected endovascular centers (ESCs) in the United States. Although the number of ESCs increase each year, this does not necessarily reflect increased access to care. Here, we look at the evolution of ESC in four states and disparities in access to advanced stroke care. MATERIALS AND METHODS: This is a descriptive study of access to ESCs in four Northeastern states between 2015-2019. Using data from the United States Census Bureau and spatial analysis, we examined the proportion of the population with drive times of less than 60 minutes stratified by income, race/ethnicity, population density, and insurance. We also calculated the mean drive time for each of these socioeconomic groups from their census tracts to the nearest ESC. RESULTS: Between 2015 and 2019, the number of ESCs increased from 15 to 48. The proportion of patients within a 60-minute drive of an ESC increased from 77% to 88%. However, only 66% of the least densely populated quartile lived within 60 min of an ESC. By income, access to ESCs in the wealthiest quartile was 96.6% compared to 83.7% in the lowest quartile. Hispanics and non-Hispanic Blacks had the largest proportions of populations within 60 minutes of an ESC while Non-Hispanic Whites had the smallest. CONCLUSIONS: This study underscores the need to evaluate the placement of new ESCs to assure that these hospitals decrease disparities and increase access to advanced stroke care.

Optimizing Prehospital Stroke Systems of Care-Reacting to Changing Paradigms (OPUS-REACH): a pragmatic registry of large vessel occlusion stroke patients to create evidence-based stroke systems of care and eliminate disparities in access to stroke care.

BACKGROUND: Large vessel occlusion (LVO) strokes are best treated with rapid endovascular therapy (EVT). There are two routes that LVO stroke patients can take to EVT therapy when transported by EMS: primary transport (ambulance transports directly to an endovascular stroke center (ESC) or secondary transport (EMS transports to a non-ESC then transfers for EVT). There is no clear evidence which path to care results in better functional outcomes for LVO stroke patients. To find this answer, an analysis of a large, real-world population of LVO stroke patients must be performed. METHODS: A pragmatic registry of LVO stroke patients from nine health systems across the United States. The nine health systems span urban and rural populations as well as the spectrum of socioeconomic statuses. We will use univariate and multivariate analysis to explore the relationships between type of EMS transport, socioeconomic factors, and LVO stroke outcomes. We will use geographic information systems and spatial analysis to examine the complex movements of patients in time and space. To detect an 8% difference between groups, with a 3:1 patient ratio of primary to secondary transports, 95% confidence and 80% power, we will need approximately 1600 patients. The primary outcome is the patients with modified Rankin Scale (mRS) ≤ 2 at 90 days. Subgroup analyses include patients who receive intravenous thrombolysis and duration of stroke systems. Secondary analyses include socioeconomic factors associated with poor outcomes after LVO stroke. DISCUSSION: Using the data obtained from the OPUS-REACH registry, we will develop evidence based algorithms for prehospital transport of LVO stroke patients. Unlike prior research, the OPUS-REACH registry contains patient-level data spanning from EMS dispatch to ninety day functional outcomes. We expect that we will find modifiable factors and socioeconomic disparities associated with poor outcomes in LVO stroke. OPUS-REACH with its breadth of locations, detailed patient records, and multidisciplinary researchers will design the optimal prehospital stroke system of care for LVO stroke patients.

Igniting Inquiry: Development and Implementation of a Novel Journal Club Curriculum in an Emergency Medicine Residency.

BACKGROUND: The journal club is a long-standing pillar of medical education and medical practice, although its components and format are quite variable. In addition, selecting literature for discussion must strike a delicate balance between reviewing seminal and durable articles with that of emerging evidence, all while complementing a residency curriculum. Although the critical appraisal of literature is a fundamental skill of the practicing physician, a universal curriculum has not yet been optimized to facilitate journal club. OBJECTIVE: We sought to design and implement a comprehensive, complementary, and evidence-based journal club curriculum that was modular in design, reproducible, and effective at generating participation. METHODS: Our novel curricular design incorporates many evidence-based components, including optimizing the learning environment, providing ease of access to resources, and using educational methodology that immerses learners in the experience in a structured manner. In addition, the curriculum complements, but does not duplicate, the core residency curriculum. In 2020, we analyzed our data, using descriptive and comparative statistical methods. RESULTS: We demonstrated significant improvement in common metrics used to analyze the efficacy of the journal club, including attendance and participation. Significant improvements were seen in both resident and attending participation. CONCLUSIONS: Our design methods used resources easily available to our residency program and commonly available to others, with minimal time and resource cost. Further study is required to measure long-term educational outcomes.

Should Emergency Department Patients with End-of-Life Directives be Admitted to the ICU?

BACKGROUND: Whether emergency physicians should utilize critical care resources for patients with advance care planning directives is a complex question. Because the cost of intensive care unit (ICU)-level care, in terms of human suffering and financial burden, can be considerable, ICU-level care ought to be provided only to those patients who would consent and who would benefit from it. OBJECTIVES: In this article, we discuss the interplay between clinical indications, patient preferences, and advance care directives, and make recommendations about what the emergency physician must consider when deciding whether a patient with an advance care planning document should be admitted to the ICU. DISCUSSION: Although some patients may wish to avoid certain aggressive or invasive measures available in an ICU, there may be a tendency, reinforced by recent Society of Critical Care Medicine guidelines, to presume that such patients will not benefit as much as other patients from the specialized care of the ICU. The ICU still may be the most appropriate setting for hospitalization to access care outside of the limitations set forward in those end-of-life care directives. On the other hand, ICU beds are a scarce and expensive resource that may offer aggressive treatments that can inflict suffering onto patients unlikely to benefit from them. Goals-of-care discussions are critical to align patient end-of-life care preferences with hospital resources, and therefore, the appropriateness of ICU disposition. CONCLUSIONS: End-of-life care directives should not automatically exclude patients from the ICU. Rather, ICU admission should be based upon the alignment of uniquely beneficial treatment offered by the ICU and patients' values and stated goals of care.

"Futile Care"-An Emergency Medicine Approach: Ethical and Legal Considerations.

Futility often serves as a proposed reason for withholding or withdrawing medical treatment, even in the face of patient and family requests. Although there is substantial literature describing the meaning and use of futility, little of it is specific to emergency medicine. Furthermore, the literature does not provide a widely accepted definition of futility, and thus is difficult if not impossible to apply. Some argue that even a clear concept of futility would be inappropriate to use. This article will review the origins of and meanings suggested for futility, specific challenges such cases create in the emergency department (ED), and the relevant legal background. It will then propose an approach to cases of perceived futility that is applicable in the ED and does not rely on unilateral decisions to withhold treatment, but rather on avoiding and resolving the conflicts that lead to physicians' believing that patients are asking them to provide "futile" care.

Refusal of Emergency Medical Treatment: Case Studies and Ethical Foundations.

Informed consent is an important component of emergency medical treatment. Most emergency department patients can provide informed consent for treatment upon arrival. Informed consent should also be obtained for emergency medical interventions that may entail significant risk. A related concept to informed consent is informed refusal of treatment. Patients may refuse emergency medical treatment during their evaluation and treatment. This article addresses important considerations for patients who refuse treatment, including case studies and discussion of definitions, epidemiology, assessment of decisional capacity, information delivery, medicolegal considerations, and alternative care plans.

Lyme Disease: Emergency Department Considerations.

BACKGROUND: Lyme disease (LD) is the most common vector-borne illness in North America. Reported cases of LD have increased from approximately 10,000 cases annually in 1991 to >25,000 cases in 2014. Greater recognition, enhanced surveillance, and public education have contributed to the increased prevalence, as have geographic expansion and the number of infected ticks. Cases are reported primarily in the Northeastern United States, Wisconsin, and Minnesota, with children having the highest incidence of LD among all age groups. The increased incidence and prevalence of LD in the United States makes it increasingly more common for patients to present to the emergency department (ED) for tick bites and LD-related chief complaints, such as the characteristic erythema migrans skin manifestation. OBJECTIVE: We sought to review the etiology of LD, describe its clinical presentations and sequela, and provide a practical classification and approach to ED management of patients with LD-related presentations. DISCUSSION: In this review, ED considerations for LD are presented and clinical presentations and management of the disease at different stages is discussed. Delayed sequelae that have significant morbidity, including Lyme carditis and Lyme neuroborreliosis, are discussed. Diagnostic tests and management are described in detail. CONCLUSION: The increasing prevalence and growing geographic reach of Lyme disease makes it critically important for emergency physicians to consider the diagnosis in patients presenting with symptoms suggestive of LD and to initiate appropriate treatment to minimize the potential of delayed sequelae. Special consideration should be made for the epidemiology of LD and a high clinical suspicion should be present for patients in endemic areas or with known exposures to ticks. Emergency physicians can play a critical role in the recognition, diagnosis, and treatment of LD.

Shared decision making in the ED: ethical considerations.

The process of shared decision making (SDM) is an ethical imperative in the physician-patient relationship, especially in the emergency department (ED), where SDM can present unique challenges because patients and emergency physicians often have no established relationship and decisions about diagnosis, treatment, and disposition are time dependent. SDM should be guided by the ethical principles of autonomy, beneficence, nonmaleficence, and justice and the related principle of stewardship of finite resources. The objective of this article is to outline the ethical considerations of SDM in the ED in the context of diagnostic evaluations, therapeutic interventions, disposition decisions, and conflict resolution and to explore strategies for reaching decision consensus. Several cases are presented to highlight the ethical principles in SDM in the ED. SDM is an important approach to diagnostic testing in the ED. Achieving agreement regarding diagnostic evaluations requires a balance of respect for patient autonomy and stewardship of resources. SDM regarding ED therapeutic interventions is an important component of the balance of respect for patient autonomy and beneficence. While respecting patient autonomy, emergency physicians also recognize the importance of the application of professional judgment to achieve the best possible outcome for patients. SDM as an ethical imperative in the context of ED disposition is especially important because of the frequent ambiguity of equipoise in these situations. Unique clinical situations such as pediatric patients or patients who lack decisional capacity merit special consideration.

Evaluation of hidden HIV infections in an urban ED with a rapid HIV screening program.

BACKGROUND: To investigate the prevalence of undiagnosed HIV infections in an emergency department (ED) with an established screening program. METHODS: Evaluation of the prevalence and risk factors for HIV from an 8-week (June 24, 2007-August 18, 2007) identity-unlinked HIV serosurvey, conducted at the same time as an ongoing opt-in rapid oral-fluid HIV screening program. Testing facilitators offering 24/7 bedside rapid testing to patients aged 18 to 64 years, with concordant collection of excess sera collected as part of routine clinical procedures. Known HIV positivity was determined by (1) medical record review or self-report from the screening program and/or (2) presence of antiretrovirals in serum specimens. RESULTS: Among 3207 patients, 1165 (36.3%) patients were offered an HIV test. Among those offered, 567 (48.7%) consented to testing. Concordance identity-unlinked study revealed that the prevalence of undiagnosed infections was as follows: 2.3% in all patients, 1.0% in those offered testing vs 3.0% in those not offered testing (P < .001); and 1.3% in those who declined testing compared with 0.4% in those who were tested (P = .077). Higher median viral loads were observed in those not offered testing (14255 copies/mL; interquartile range, 1147-64354) vs those offered testing (1865 copies/mL; interquartile range, undetectable-21786), but the difference was not statistically significant. CONCLUSIONS: High undiagnosed HIV prevalence was observed in ED patients who were not offered HIV testing and those who declined testing, compared with those who were tested. This indicates that even with an intensive facilitator-based rapid HIV screening model, significant missed opportunities remain with regard to identifying undiagnosed infections in the ED.

HIV Care Continuum for HIV-Infected Emergency Department Patients in an Inner-City Academic Emergency Department.

STUDY OBJECTIVE: The recently released HIV Care Continuum Initiative is a cornerstone of the National AIDS Strategy and a model for improving care for those living with HIV. To our knowledge, there are no studies exploring the entirety of the HIV Care Continuum for patients in the emergency department (ED). We determine gaps in the HIV Care Continuum to identify potential opportunities for improved care for HIV-infected ED patients. METHODS: A mixed-methods approach was used in 1 inner-city ED in 2007. Data elements were derived from an identity-unlinked HIV seroprevalence study, an ongoing nontargeted HIV screening program, and a structured survey of known HIV-positive ED patients. RESULTS: Identity-unlinked testing of 3,417 unique ED patients found that 265 (7.8%) were HIV positive. Of patients testing HIV positive, 73% had received a previous diagnosis (based on self-report, chart review, or presence of antiretrovirals in serum), but only 61% were recognized by the clinician as being HIV infected (based on self-report or chart review). Of patients testing positive, 43% were linked to care, 39% were retained in care, 27% were receiving antiretrovirals, 26% were aware of their receiving antiretroviral treatment, 22% were virally suppressed, and only 9% were self-aware of their viral suppression. CONCLUSION: To our knowledge, this study is the first to quantify gaps in HIV care for an ED patient population, with the HIV Care Continuum as a framework. Our findings identified distinct phases (ie, testing, provider awareness of HIV diagnosis, and linkage to care) in which the greatest opportunities for intervention exist, if appropriate resources were allocated. This schema could serve as a model for other indolent treatable diseases frequently observed in EDs, where continuity of care is critical.

Gender differences in perceptions and self-reported driving behaviors among teenagers.

BACKGROUND: The Centers for Disease Control reports that motor vehicle crashes (MVCs) are the leading cause of injury and death among U.S. teenagers, and disproportionately affect males. Among preventable causes of MVCs involving teenage drivers, distracted driving continues to be a serious public health problem. OBJECTIVES: To describe gender differences in teenage drivers' self-perceptions of safe driving behaviors, and self-reported risk behaviors and distractions while driving. METHODS: We prospectively surveyed teenage drivers from four high schools in Pennsylvania and New Jersey. Gender comparisons were made between self-reported perceptions and self-reported driving behaviors. Descriptive statistics and chi-squared testing were used in data analyses; significance was set at p < 0.05. RESULTS: Seven hundred fifty-six high school teenage drivers completed surveys. Males (52%) and females (48%) were equally distributed; 32% of males reported that they were extremely safe drivers, whereas only 18% of females reported that they were extremely safe drivers (p < 0.001). Significantly more females (91%) compared to males (77%) reported always wearing their seatbelts (p < 0.001). Female drivers were more likely than male drivers to self-report that they always make their passengers wear a seat belt (76% vs. 63%, p < 0.001). A higher proportion of males reported using their cell phones while driving, compared to females (68% vs. 56%, p = 0.004), and 42% of males reported texting while driving, compared to 34% of females (p = 0.037). CONCLUSION: Teenage male drivers perceive themselves to be safe drivers, but report engaging in more distracted driving and risky behaviors compared to females. These results suggest that there is an opportunity for gender-specific educational and injury prevention programs for teen drivers.

Traumatic dislocation of the first carpometacarpal joint.

We present a case report and review of the literature of traumatic dislocation of the carpometacarpal joint of the left thumb without associated fracture. The injury was sustained while skiing, and after emergency department diagnosis, the dislocation was reduced and the joint stabilized with a splint. The patient was discharged with close follow-up with a hand surgeon for definitive surgical fixation. Carpometacarpal joint dislocations of the thumb are exceedingly rare injuries and require appropriate diagnosis and treatment to minimize the morbidity and loss of function that can occur with these injuries.

Association between the American Board of Emergency Medicine Oral Certifying Examination and Future State Medical Board Disciplinary Actions.

Objectives: The American Board of Emergency Medicine (ABEM) requires a written examination (the Qualifying Examination) followed by the Oral Certifying Examination (OCE) to obtain ABEM certification. Maintaining ABEM certification is associated with fewer state medical board (SMB) disciplinary actions. We sought to determine the association between poor initial performance on the OCE and subsequent severe SMB disciplinary action. Methods: We included physicians who completed US categorical emergency medicine residencies in 2016 and earlier. We classified OCE performance as good (passed on first attempt) and poor (never passed or required > 1 attempt to pass). We obtained data on physician SMB disciplinary actions from the National Practitioner Data Bank that were limited to actions that denied licensure or altered the status of a medical license (eg, suspension). We determined the association between poor OCE performance and subsequent severe SMB disciplinary action. Results: Of 34,871, 93.5% passed the OCE on the first attempt, 6.1% required multiple attempts, and 0.3% never passed. Of the physicians (93.5%) with good OCE performance, 1.0% received a severe SMB action. Among physicians with poor OCE performance, 2.3% received a severe action; and of those who never passed, 1.7% received a severe action (Table 1). Poor OCE performance was associated with an increased odds of severe SMB disciplinary action (OR 2.21, 95% CI: 1.57-3.12). Conclusion: Physicians with poor OCE performance exhibited higher odds of experiencing a subsequent severe SMB disciplinary action. The OCE may have utility as a predictor of future professionalism or clinical performance.

Cellular host response sepsis test for risk stratification of patients in the emergency department: A pooled analysis.

OBJECTIVES: Sepsis is one of the most common, costly, and misdiagnosed conditions in U.S. emergency departments (EDs). ED providers often treat on nonspecific signs, subjective suspicion, or presumption of infection, resulting in over- and undertreatment. An increased understanding of host response has opened a new direction for sepsis diagnostics. The IntelliSep test is a U.S. Food and Drug Administration-cleared cellular host response diagnostic that could help distinguish sepsis in ED settings. Our objective was to evaluate the potential of the cellular host response test to expedite appropriate care for patients who present with signs of infection. METHODS: We performed a pooled analysis of five adult (≥18 years) cohorts enrolled at seven geographically diverse U.S. sites in separate studies. Structured blinded adjudication was used to classify presence or absence of sepsis, and only patients with high confidence in the adjudicated label were included (n = 1002), defined as patients for whom there was consensus in the determination of sepsis per the Sepsis-3 and severe sepsis per the Sepsis-2 definitions between both the independent adjudication panel and the site-level physician. RESULTS: Among patients with signs or suspicion of infection, the test achieved similar or better performance compared to other indicators in identifying patients at high risk for sepsis (specificity > 83%) and significantly superior performance in identifying those at low risk (sensitivity > 92%; 0% sepsis-associated mortality). The test also stratified severity of illness, as shown by 30-day in-hospital mortality (p < 0.001), hospital length of stay (p < 0.01), and use of hospital resources (p < 0.001). CONCLUSIONS: Our data suggest that the cellular host response test provides clinically actionable results for patients at both high and low risk for sepsis and provides a rapid, objective means for risk stratification of patients with signs of infection. If integrated into standard of care, the test may help improve outcomes and reduce unnecessary antibiotic use.

Not all roses are sweet-Pediatric ependymoma.

Ependymomas are rare malignant neoplasms that originate from radial glial cells within the central nervous system. Within pediatric central nervous tumors, ependymomas constitute the third most common entity with the majority occurring within the posterior fossa. Over the past decade, there have been monumental strides in classifying and grading central nervous tumors, specifically ependymomas. Revised classifications now identify ependymomas by anatomic location, histopathological and genetic subgroups with varying levels of symptom presentation and disease progression. Standard care of therapy remains surgical resection with post- operative radiotherapy.

Emergency physician professionalism versus wellness: A conceptual model.

Striking the balance between professional duties, obligations, and responsibility with protecting one's wellness as a physician and as an individual have been brought into sharper focus during COVID-19. The objective of this paper is to describe ethical principles in the balance between emergency physician wellness and professional responsibility to patients and the public. We propose a schematic that helps us as emergency physicians visualize continuously striving to be both well and professional.

Is Medical Cannabis Evidence-Based Medicine? Concerns Based on Qualifying Conditions and the National Academy of Sciences Report.

This study aims to examine the coherence of state-level qualifying conditions (QCs) for medical cannabis (MC) with the evidence-based conclusions of the 2017 National Academies of Sciences (NAS) report. Data was collected for the QCs from 38 states where MC was legal in 2023 and compared to the QC data from 31 states where MC was legal in 2017. Each condition was divided into a NAS-established category based on the level of evidence supporting their effectiveness. The findings revealed wide variation in the number of QCs between states, with only an average of 8.4% of QCs in each state generally satisfying the substantial evidence category. Over three fourths of states included QCs with limited evidence of ineffectiveness (78.9%) or no/insufficient evidence (76.3%). Additionally, four fifths (81.6%) of states included QCs not covered in the NAS report. Only a few states appeared to have updated their QCs after the NAS report was released. This investigation highlights a large discrepancy between the state-level recommendations for MC and the supporting data.