2018 Academic Emergency Medicine Consensus Conference: A Workforce Development Research Agenda for Pediatric Care in the Emergency Department

Each year, more than 30 million children visit U.S. emergency departments (EDs). Although the number of pediatric emergency medicine specialists continues to rise, the vast majority of children are cared for in general EDs outside of children's hospitals. The diverse workforce of care providers for children must possess the knowledge, experience, skills, and systemic support necessary to deliver excellent pediatric emergency care. There is a crucial need to understand the factors that drive the professional development and support systems of this diverse workforce. Through the iterative process culminating with the 2018 Academic Emergency Medicine consensus conference, we have identified five key research themes and prioritized a specific research agenda. These themes represent critical gaps in our understanding of the development and maintenance of the pediatric emergency care workforce and allow for a prioritization of future research efforts. Only by more fully understanding the gaps in workforce needs, and the necessary steps to address these gaps, can outcomes be optimized for children in need of emergency care.     

Gender Differences in Emergency Department Patients with Chronic Obstructive Pulmonary Disease Exacerbation

Objectives: Although more men are diagnosed as having chronic obstructive pulmonary disease (COPD), its prevalence is increasing among women. Little is known about gender differences in exacerbations of COPD. The objective of this study was to determine if acute presentation, management, and outcomes differ among men and women seeking care in the emergency department (ED) for exacerbation of COPD. Methods: This was a secondary analysis of a prospective cohort study of ED patients aged 55 years or older who presented with an exacerbation of COPD. Subjects underwent structured interviews in the ED and two weeks later. Results: The cohort consisted of 397 subjects with COPD, of whom 52% were women. Self-report of COPD only tended to be more common among men (61% of men vs. 52% of women), while mixed COPD/asthma tended to be more common among women (39% vs. 48%; p = 0.10). Despite reporting similar chronic symptom severity, women were less likely than men to use anticholinergic agents before their ED visit (59% vs. 69%; p = 0.04). During the exacerbation, women initiated less home therapy and were less likely to seek emergency care within the first 24 hours of symptom onset (25% vs. 36%; p = 0.01). Although ED care and disposition were similar, post-ED outcomes differed. At two-week follow-up, men were more likely to report an ongoing exacerbation (42% vs. 31%; p = 0.03). Conclusions: Men and women who present to the ED for treatment of an exacerbation of COPD have substantial differences in long-term medication use, self-treatment during exacerbation, delay in emergency care, and post-ED outcomes. Further studies are warranted to confirm and explain these gender-related differences.     

Gender Disparity in Analgesic Treatment of Emergency Department Patients with Acute Abdominal Pain

Objectives:  Oligoanalgesia for acute abdominal pain historically has been attributed to the provider's fear of masking serious underlying pathology. The authors assessed whether a gender disparity exists in the administration of analgesia for acute abdominal pain.
Methods:  This was a prospective cohort study of consecutive nonpregnant adults with acute nontraumatic abdominal pain of less than 72 hours' duration who presented to an urban emergency department (ED) from April 5, 2004, to January 4, 2005. The main outcome measures were analgesia administration and time to analgesic treatment. Standard comparative statistics were used.
Results:  Of the 981 patients enrolled (mean age ± standard deviation [SD] 41 ± 17 years; 65% female), 62% received any analgesic treatment. Men and women had similar mean pain scores, but women were less likely to receive any analgesia (60% vs. 67%, difference 7%, 95% confidence interval [CI] = 1.1% to 13.6%) and less likely to receive opiates (45% vs. 56%, difference 11%, 95% CI = 4.1% to 17.1%). These differences persisted when gender-specific diagnoses were excluded (47% vs. 56%, difference 9%, 95% CI = 2.5% to 16.2%). After controlling for age, race, triage class, and pain score, women were still 13% to 25% less likely than men to receive opioid analgesia. There was no gender difference in the receipt of nonopioid analgesia. Women waited longer to receive their analgesia (median time 65 minutes vs. 49 minutes, difference 16 minutes, 95% CI = 3.5 to 33 minutes).
Conclusions:  Gender bias is a possible explanation for oligoanalgesia in women who present to the ED with acute abdominal pain. Standardized protocols for analgesic administration may ameliorate this discrepancy.     

Safety Net Research in Emergency Medicine Proceedings of the Academic Emergency Medicine Consensus Conference on "The Unraveling Safety Net"

A primary goal of the Academic Emergency Medicine Consensus Conference, "The Unraveling Safety Net: Research Opportunities and Priorities," was to explore a formal research agenda for safety net research in emergency medicine. This paper represents the thoughts of active health services researchers regarding the structure and direction of such work, including some examples from their own research. The current system for safety net care is described, and the emergency department is conceptualized as a window on safety net patients and systems, uniquely positioned to help study and coordinate integrated processes of care.     

Sex‐ and Gender‐specific Research Priorities for the Emergency Management of Heart Failure and Acute Arrhythmia: Proceedings from the 2014 Academic Emergency Medicine Consensus Conference Cardiovascular Research Workgroup

The emergency department (ED) is the point of first contact for patients with acute heart failure and arrhythmias, with 1 million annual ED visits in the United States. Although the total numbers of men and women living with heart failure are similar, female patients are underrepresented in clinical studies, with current knowledge predominantly based on data from male patients. This has led to an underappreciation of the sex‐specific differences in clinical characteristics and pathophysiology‐based management of heart failure. Similar disparities have been found in management of acute arrhythmias, especially atrial arrhythmias that lead to an increased risk of stroke in women. Additionally, peripartum and postpartum cardiomyopathy represent a diagnostic and treatment dilemma. This article is the result of a breakout session in the cardiovascular and resuscitation work group of the 2014 Academic Emergency Medicine consensus conference “Gender‐Specific Research in Emergency Medicine: Investigate, Understand, and Translate How Gender Affects Patient Outcomes.” A nominal group technique was used to identify and prioritize themes and research questions using electronic mail, monthly conference calls, in‐person meetings, and Web‐based surveys between June 2013 and May 2014. Consensus was achieved through three rounds of nomination followed by the meeting on May 13, 2014, and resulted in seven priority themes that are essential to the common complex clinical syndrome of heart failure for both men and women and include the areas of pathophysiology; presentation and symptomatology; and diagnostic strategies using biomarkers, treatment, and mortality, with special consideration to arrhythmia management and pregnancy.     

Funding Mechanisms for Gender‐specific Research: Proceedings from a Panel Discussion at the 2014 Academic Emergency Medicine Consensus Conference

As part of the 2014 Academic Emergency Medicine (AEM) consensus conference “Gender‐Specific Research in Emergency Care: Investigate, Understand, and Translate How Gender Affects Patient Outcomes,” we assembled a diverse panel of representatives from federal and nonfederal funding agencies to discuss future opportunities for sex‐ and gender‐specific research. The discussion revolved around the mission and priorities of each organization, as well as its interest in promoting sex‐ and gender‐specific research. The panelists were asked to provide specific examples of funding lines generated or planned for as pertinent to emergency care. Training opportunities for future researchers in this area were also discussed.     

Gender‐specific Research for Emergency Diagnosis and Management of Ischemic Heart Disease: Proceedings from the 2014 Academic Emergency Medicine Consensus Conference Cardiovascular Research Workgroup

Coronary artery disease (CAD) is the most common cause of death for both men and women. However, over the years, emergency physicians, cardiologists, and other health care practitioners have observed varying outcomes in men and women with symptomatic CAD. Women in general are 10 to 15 years older than men when they develop CAD, but suffer worse postinfarction outcomes compared to age‐matched men. This article was developed by the cardiovascular workgroup at the 2014 Academic Emergency Medicine (AEM) consensus conference to identify sex‐ and gender‐specific gaps in the key themes and research questions related to emergency cardiac ischemia care. The workgroup had diverse stakeholder representation from emergency medicine, cardiology, critical care, nursing, emergency medical services, patients, and major policy‐makers in government, academia, and patient care. We implemented the nominal group technique to identify and prioritize themes and research questions using electronic mail, monthly conference calls, in‐person meetings, and Web‐based surveys between June 2013 and May 2014. Through three rounds of nomination and refinement, followed by an in‐person meeting on May 13, 2014, we achieved consensus on five priority themes and 30 research questions. The overarching themes were as follows: 1) the full spectrum of sex‐specific risk as well as presentation of cardiac ischemia may not be captured by our standard definition of CAD and needs to incorporate other forms of ischemic heart disease (IHD); 2) diagnosis is further challenged by sex/gender differences in presentation and variable sensitivity of cardiac biomarkers, imaging, and risk scores; 3) sex‐specific pathophysiology of cardiac ischemia extends beyond conventional obstructive CAD to include other causes such as microvascular dysfunction, takotsubo, and coronary artery dissection, better recognized as IHD; 4) treatment and prognosis are influenced by sex‐specific variations in biology, as well as patient–provider communication; and 5) the changing definitions of pathophysiology call for looking beyond conventionally defined cardiovascular outcomes to patient‐centered outcomes. These emergency care priorities should guide future clinical and basic science research and extramural funding in an area that greatly influences patient outcomes.     

The Role of Graduate Medical Education in Global Health: Proceedings From the 2013 Academic Emergency Medicine Consensus Conference

The past 40 years have seen expanded development of emergency medicine (EM) postgraduate residency training programs worldwide. An important part of this educational experience is the ability of resident trainees to participate in experiences abroad. However, little is known about how these experiences shape trainees and the populations they serve. During the 2013 Academic Emergency Medicine consensus conference, a group of educators met to define and outline current trends in graduate medical education (GME) emergency care research. The authors discuss future research questions bridging the gap of GME and global health.     

Chairperson and Faculty Gender in Academic Emergency Medicine Departments

Objectives: Despite the influx of female physicians in academic medicine departments, there are a small number of women in faculty and departmental leadership positions in emergency medicine (EM). The objective of this study was to determine if the gender of the chairperson of an academic EM department is associated with the gender of the residency program director (RPD) and gender proportion of its faculty.
Methods: This was a retrospective analysis of 133 academic EM departments using the Society for Academic Emergency Medicine online residency catalog, program Web site, or e-mail. Main outcome measures were proportion of female EM faculty and gender of the RPD.
Results: Data were available for 133 academic departments. Women chaired 7.5% ( n = 10) of departments and comprised 22.3% of all faculty and 15.0% ( n = 20) of RPD positions. EM departments that were chaired by women had a significantly higher percentage of female faculty compared with those led by men (31% vs. 22%; p = 0.01). Similarly, departments that were chaired by women had a significantly higher proportion of female RPDs compared with those chaired by men (50% vs. 12%; p < 0.01). Compared with departments chaired by men, the RPD was 5.0 times (95% confidence interval = 1.9 to 27.8; p < 0.01) more likely to be a woman if the chairperson was also a woman.
Conclusions: An academic EM department was more likely to have a higher proportion of female faculty and a female RPD when the department chairperson was female.     

Untying the Gordian Knot: What We Do and Don't Know About Gender‐specific Medicine—Keynote Address for the 2014 Academic Emergency Medicine Consensus Conference

Over the past two decades, a burgeoning interest in women's health, the direct consequence of the feminist movement, has inspired a worldwide interest in the differences between the normal function of men and women and their unique experiences of the same illnesses. The scope and significance of what we have discovered and continue to find has fundamentally changed the way we prevent, diagnose, and treat diseases. Important questions remain, however, and deserve specific investigation and analysis.