Regional highlights in global emergency medicine development

There are a number of notable trends in the development of EM that have been highlighted at the regional level globally. From the establishment of formal EM training as the standard of care to practice in an ED to the influence of transnational regulatory bodies and financing mechanisms on specialty development and the broad-based issues of health security that affect EM, the specialty continues to grow around the world. As practitioners in each of these regions struggle to respond effectively to the development issues and challenges presented here, they continue to advance EM as one of the more dynamic young specialties in medicine. The regions presented here are as distinctive as the people who practice our specialty; however, in many respects the highlights and challenges are universal. This recognition is perhaps what motivates the appeal for collaboration in international EM development.     

Coping with a crowded ED: an expanded unique role for midlevel providers

Crowding in the emergency department (ED) has multiple causes, including space and staffing in both inpatient areas and the ED. Waiting for inpatient beds is the primary issue in our ED. Waiting inpatients require continuing care and attention from emergency-medicine (EM) physicians. As a managerial response, we developed a unique role for midlevel practitioners (MLPs) in which they could provide "back-end" work for patients awaiting inpatient beds. After initial EM physician evaluation, patients without ready inpatient beds were grouped in the ED and their care was transferred to the transition team (TT). The TT consisted of an MLP (nurse practitioner or physician assistant) and a registered nurse or licensed practical nurse, all reporting to ED supervisors. MLPs were readily available from the local medical professional market. The TT provided all patient care until a patient was seen by the admitting inpatient service or until the patient left for an inpatient unit. The major TT objectives were a reduction of EM physician work in caring for inpatients, and improved patient care. We demonstrated that the TT assumed a significant patient load, an indirect measure of reduced EM physician work, but this did not improve patient satisfaction. The TT clinical role is less desirable to MLPs than are other traditional clinical roles. The TT is a potentially available, incremental staffing resource for a crowded ED.     

Evaluation of an Advanced Nurse Practitioner (Emergency Care)—An Irish Perspective

The purpose of this audit was to provide empirical evidence for the outcomes of care of advanced nurse practitioners (ANPs) within the emergency department (ED). In addition, the audit permitted the comparison of ANPs with other medical clinicians working in the ED setting in relation to results of radiology investigations, analgesia administration, and waiting times. Results show that ANPs have equivalent if not better radiology diagnostic skills, evidence of increased awareness of pain management practices, and a greater impact on reducing patient waiting times compared to other grades of clinician.     

Transition to an All-Digital Echocardiography Laboratory: A Large, Multi-site Private Cardiology Practice Experience

Acquisition, interpretation, and storage of digital echocardiographic images has many advantages over the standard videotape-based method. Archival, transmission, and comparative interpretation are all optimized with digital echocardiography. A study performed at one site can be immediately available for viewing and analysis at another site by means of standard data transfer technology. Echocardiograms can be interpreted in the context of prior studies, which are readily available for side-by-side comparison. The transition to an all-digital laboratory involves the commitment of persons at multiple levels in the cardiology practice, including administrators, information technology specialists, sonographers, and physicians. Quality of patient care, use of physicians' and sonographers' time, and long-term financial benefit are all areas where improvement may be realized with the use of digital echocardiography. We present our experience in the development of an all-digital echocardiography laboratory, and we conclude that digital echo-cardiography is practical and can be implemented readily in a clinical setting. We performed several correlative analyses during this transition to validate the consistency and accuracy of digital interpretation compared with those of analog methods. The transition process from analog (videotape) to digital, including full wide area network exchange, took approximately 8 months. As technology advances, issues surrounding storage, comparison, and acquisition formats will continue to develop. We hope that our experience will help others make the transition to the digital environment and benefit from the ease of image access, the ability to comparatively interpret echocardiograms, and the superior image quality afforded by this advancement.     

In situ simulation in emergency medicine: Moving beyond the simulation lab

In situ simulation (ISS), a point of care training strategy that occurs within the patient care environment involving actual healthcare team members, provides additional benefits to centre‐based simulation. ISS can serve several roles within emergency medicine (EM): improves provider/team performance, identifies and mitigates threats to patient safety and improves systems and infrastructure. The effective use of ISS fosters inter‐professional team training and a culture of safety essential for high performance EM teams and resilient systems. Using a case example, this article addresses the uses of ISS in EM, strategies for implementation and mitigation strategies for ED‐specific challenges.     

Implementing evidence-based practice in clinical situations

Many nurses in a variety of clinical settings are facing the challenges posed by incorporating evidence-based practice in health care. Some of the steps involved in implementing evidence-based care in clinical practice are discussed and a two-step framework to assist practitioners in implementing evidence-based practice is outlined. Factors such as the relevance of specific guidelines or research, generalisability of research findings, the strength of the evidence relative to the risks and benefits of treatment, and patient preferences are discussed in terms of evidence-based decision making.     

Shared Decision‐making in the Emergency Department: Respecting Patient Autonomy When Seconds Count

Shared decision‐making (SDM), a collaborative process in which patients and providers make health care decisions together, taking into account the best scientific evidence available, as well as the patient's values and preferences, is being increasingly advocated as the optimal approach to decision‐making for many health care decisions. The rapidly paced and often chaotic environment of the emergency department (ED), however, is a unique clinical setting that offers many practical and contextual challenges. Despite these challenges, in a recent survey emergency physicians reported there to be more than one reasonable management option for over 50% of their patients and that they take an SDM approach in 58% of such patients. SDM has also been selected as the topic on which to develop a future research agenda at the 2016 Academic Emergency Medicine consensus conference, “Shared Decision‐making in the Emergency Department: Development of a Policy‐relevant Patient‐centered Research Agenda” ( http://www.saem.org/annual-meeting/education/2016-aem-consensus-conference ). In this paper the authors describe the conceptual model of SDM as originally conceived by Charles and Gafni and highlight aspects of the model relevant to the practice of emergency medicine. In addition, through the use of vignettes from the authors' clinical practices, the applicability of SDM to contemporary EM practice is illustrated and the ethical and pragmatic implications of taking an SDM approach are explored. It is hoped that this document will be read in advance of the 2016 Academic Emergency Medicine consensus conference, to facilitate group discussions at the conference.     

Ultrasound in the ED can mean dramatic improvement in care, research shows

The practice of ultrasound in the ED is a quickly growing trend, and experts predict it will soon become the standard of care in the ED. Ultrasound results can provide evidence to specialists that a patient has a life-threatening emergency, such as an abdominal aortic aneurysm. Studies show that ED use of ultrasound can decrease morbidity and mortality, and reduce length of stay. Document gaps in ultrasound service provided by radiology that the ED can fill.     

Climate Change and Emergency Medicine: Impacts and Opportunities

There is scientific consensus that the climate is changing, that human activity plays a major role, and that the changes will continue through this century. Expert consensus holds that significant health effects are very likely. Public health and health care systems must understand these impacts to properly pursue preparedness and prevention activities. All of medicine will very likely be affected, and certain medical specialties are likely to be more significantly burdened based on their clinical activity, ease of public access, public health roles, and energy use profiles. These specialties have been called on to consider the likely impacts on their patients and practice and to prepare their practitioners. Emergency medicine (EM), with its focus on urgent and emergent ambulatory care, role as a safety-net provider, urban concentration, and broad-based clinical mission, will very likely experience a significant rise in demand for its services over and above current annual increases. Clinically, EM will see amplification of weather-related disease patterns and shifts in disease distribution. In EM's prehospital care and disaster response activities, both emergency medical services (EMS) activity and disaster medical assistance team (DMAT) deployment activities will likely increase. EM's public health roles, including disaster preparedness, emergency department (ED)-based surveillance, and safety-net care, are likely to face increasing demands, along with pressures to improve fuel efficiency and reduce greenhouse gas emissions. Finally, EM's roles in ED and hospital management, particularly related to building and purchasing, are likely to be impacted by efforts to reduce greenhouse gas emissions and enhance energy efficiency. Climate change thus presents multiple clinical and public health challenges to EM, but also creates numerous opportunities for research, education, and leadership on an emerging health issue of global scope.     

Hospice and Palliative Medicine: A Novel Subspecialty of Emergency Medicine

Background: Emergency Medicine (EM) is a resuscitative discipline where the major focus in teaching and practice is to rapidly diagnose, stabilize, and initiate curative therapy. Thus, it may seem counterintuitive to have Hospice and Palliative Medicine (HPM), a specialty often perceived as a last resort measure “when no more can be done” for the patient, included as the latest subspecialty of EM. Objective: We discuss the scope of practice and the role of HPM in the emergency department (ED) to clarify some commonly held misconceptions. Discussion: HPM principles are frequently applied in ED patient care. EM clinicians routinely rely on many of the same skills that are refined and advanced by HPM when treating symptoms, facilitating goals of care discussions, communicating bad news, and integrating the treatment of the physical, psychological, and social suffering in patient care. The HPM approach to care is patient-centered as opposed to disease-centered, with a focus on the relief of distressing symptoms to improve the quality of life. This parallels ED care, where priority is given to alleviate distressing symptoms such as acute pain or vomiting, regardless of the underlying disease process. In fact, EM is one specialty in which we may submit a bill purely based on an International Classification of Diseases-9^th Revision symptom code. Conclusion: In this article we explore the background of HPM; outline the principles and core skills of HPM that are applicable to the daily practice of EM; and explore the pathway, now available, towards a subspecialty certification.     

Evaluation of a mentorship programme for specialist practitioners

Health care professionals moving from general care to specialist cancer and palliative care face many challenges during their role transition. Mentorship has been identified as an effective support mechanism during role transition and the Macmillan National Institute of Education devised and piloted a mentorship training programme to enable established specialist practitioners to support new practitioners through their transition into specialist practice. The 12-month programme consisted of a two day workshop and continued support for mentors using action learning groups. The pilot programme was evaluated to identify whether or not it was meeting the needs of mentors and mentees. Using a self-report questionnaire comprising open and closed questions the programme was evaluated from the perspective of mentors, mentees, line managers and Macmillan service development managers. Results demonstrated that there was a shared belief that the presence of a mentor was important during role transition, and that the programme was effective in preparing and supporting mentors for their role. As new practitioners were supported in role transition there were identified benefits for service development. The programme was evaluated positively in respect of both the two day workshop and the action learning groups.     

State of emergency medicine in Spain

Spain has universal public health care coverage. Emergency care provisions are offered to patients in different modalities and levels according to the characteristics of the medical complaint: at primary care centers (PCC), in an extrahospital setting by emergency medical services (EMS) and at hospital emergency departments (ED). We have more than 3,000 PCCs, which are run by family doctors (general practitioners) and pediatricians. On average, there is 1 PCC for every 15,000 to 20,000 inhabitants, and every family doctor is in charge of 1,500 to 2,000 citizens, although less populated zones tend to have lower ratios. Doctors spend part of their duty time in providing emergency care to their own patients. While not fully devoted to emergency medicine (EM) practice, they do manage minor emergencies. However, Spanish EMSs contribute hugely to guarantee population coverage in all situations. These EMS are run by EM technicians (EMT), nurses and doctors, who usually work exclusively in the emergency arena. EDs dealt with more than 25 million consultations in 2008, which implies, on average, that one out of two Spaniards visited an ED during this time. They are usually equipped with a wide range of diagnostic tools, most including ultrasonography and computerized tomography scans. The academic and training background of doctors working in the ED varies: nearly half lack any structured specialty residence training, but many have done specific master or postgraduate studies within the EM field. The demand for emergency care has grown at an annual rate of over 4% during the last decade. This percentage, which was greater than the 2% population increase during the same period, has outpaced the growth in ED capacity. Therefore, Spanish EDs become overcrowded when the system exerts minimal stress. Despite the high EM caseload and the potential severity of the conditions, training in EM is still unregulated in Spain. However, in April 2009 the Spanish Minister of Health announced the imminent approval of an EM specialty, allowing the first EM resident to officially start in 2011. Spanish emergency physicians look forward to the final approval, which will complete the modernization of emergency health care provision in Spain.     

The legal danger of written protocols and standards of practice.

Nurse practitioners have historically developed protocols and standards of practice to guide and improve the quality of their patient care. Written protocols and standards of practice can, however, create a potential malpractice problem. Lawyers who bring malpractice cases on behalf of patients will use the protocols and standards to measure the practitioner's care. The practice standards are often too high to be reasonably met by practitioners at all times and in all settings. As a result, the practitioner's care may breach those standards. Nurse practitioners should develop protocols that are based on a minimum safe level and not the maximum level aimed at ideal care. Standards and protocols should be updated and realistic. Once developed, protocols and standards must be followed precisely to limit potential liability.     

Health care students experience of using digital technology in patient care: A scoping review of the literature

ObjectivesTo explore how undergraduate health care students use digital technology to deliver patient care during their clinical placements.DesignA scoping review of primary research was conducted using the extended PRISMA guidelines.Data sourcesA subject specialist librarian assisted in searching for the academic literature in four electronic databases: CINAHL, PubMed, Scopus and ERIC.Review methodsFour reviewers, working in pairs, independently reviewed a total of 332 potentially relevant articles according to set inclusion and exclusion criteria. Then, all included papers underwent an independent quality review by two reviewers.ResultsSeven studies involving medical or nursing/midwifery students were included in the review. Three studies evaluated the use of mobile learning devices in patient care with four studies evaluating the use of digital systems in practice. Due to the heterogeneity of studies, which used differing digital systems and instruments, the researchers decided the most suitable method of analysis was a narrative review. The results are explained using four key themes: student learning needs when using technology in practice; access to technology in placements; perceptions of using technology in placements; and impact of technology on patient care.ConclusionThe use of digital systems in clinical settings creates challenges and benefits to student learning in delivering patient care. When students are prepared and facilitated to use digital systems, a sense of confidence and belonging to the team is fostered. Lack of availability and access to these systems, however, may impede students’ ability to be involved in all aspects of patient care. Limitations of the current review included the relatively low quality of the educational research being conducted in this field of research. Further quality research is needed to explore how students in the health care professions are supported in digital environments and how higher education institutions are adapting their curricula to meet the digital learning needs of health care students.     

Critical care medicine training and certification for emergency physicians

Demand for critical care services is increasing. Unless the supply of intensivists increases, critically ill patients will not have access to intensivists. Recent critical care society recommendations include increased graduate medical education support and expansion of the J-1 visa waiver program for foreign medical graduates. This article proposes additional recommendations, based on strengthening the relationship between emergency medicine and critical care medicine. Demand for critical care services is increasing. Unless the supply of intensivists increases, critically ill patients will not have access to intensivists. Recent critical care society recommendations include increased graduate medical education support and expansion of the J-1 visa waiver program for foreign medical graduates. This article proposes additional recommendations, based on strengthening the relationship between emergency medicine (EM) and critical care medicine (CCM). Critical care is a continuum that includes prehospital, emergency department (ED), and intensive care unit (ICU) care teams. Both EM and CCM require expertise in treating life-threatening acute illness, with many critically ill patients often presenting first to the ED. Increased patient volumes and acuity have resulted in longer ED lengths of stay and more critical care delivery in the ED. However, the majority of CCM fellowships do not accept EM residents, and those who successfully complete a fellowship do not have access to a U.S. certification exam in CCM. Despite these barriers, interest in CCM training among EM physicians is increasing. Dual EM/CCM-trained physicians not only will help alleviate the intensivist shortage but also will strengthen critical care delivery in the ED and facilitate coordination at the ED-ICU interface. We therefore propose that all accreditation bodies work cooperatively to create a route to CCM certification for emergency physicians who complete a critical care fellowship.     

Transitioning to the Electronic Medical Record: Its Impact on Nursing Care in Interventional Radiology

Electronic medical records (EMRs) are being integrated into the health care industry. It is widely believed that EMRs will improve the overall quality of patient care through the promotion of both patient safety and satisfaction. The introduction of EMRs at Boston Children's Hospital created a multitude of challenges for the nurses in the hospital's interventional radiology (IR) department. Despite the difficulties the new EMR presented, the IR nurses were able to safely transition their documentation to the electronic format.     

Setting the Educational Agenda and Curriculum for Error Prevention in Emergency Medicine

Graduate and postgraduate medical education currently teaches safety in patient care by instilling a deep sense of personal responsibility in student practitioners. To increase safety, medical education will have to begin to introduce new concepts from the "safety sciences," without losing the advantages that the values of commitment and responsibility have gained. There are two related educational goals. First, we in emergency medicine (EM) must develop a group of safety-educated practitioners who can understand and implement safe practice innovations in their clinical settings, and will be instrumental in changing our professional culture. Second, EM must develop a group of teachers and researchers who can begin to deeply understand how safety is maintained in emergency care, develop solutions that will work in emergency department settings, and pass on those insights and innovations. The specifics of what should be taught are outlined briefly. Work is currently ongoing to identify more specifically the core content that should be included in educational programs on patient safety in emergency care. Finally, careful attention will have to be paid to the way in which these principles are taught. It seems unlikely that a series of readings and didactic lectures alone will be effective. The analysis of meaningful cases, perhaps supplemented by high-fidelity simulation, seems to hold promise for more successful education in patient safety.     

A Qualification Course in an International Emergency Medicine Intervention

Background: The Tuscan Emergency Medicine Initiative is a comprehensive training program for physicians designed to create a lasting infrastructure for training in emergency medicine (EM) in a region of Italy. A “Train-the-Trainers” model was utilized to prepare physicians who were working in the emergency department (ED) to become the teachers of EM, and a master's program was created to train the next generation of emergency physicians as well as to put in place a structure into which residency training in EM will be placed. This model has been used in other projects as well; however, the dilemma of what to do with physicians who are already in practice remained an unsolved problem. Objectives: We wished to create a qualification course in EM for this important group of physicians. Methods: Didactic lectures, workshops, simulations, and clinical rotations were utilized to standardize current emergency care delivery in the region's EDs. Results: Between 2005 and 2008, 488 physicians completed the program. Conclusions: We propose this model as a way of training and including the physicians caught in the transition to specialty training in any area developing the specialty of EM.     

Manualized communication interventions to enhance palliative care research and training: rigorous, testable approaches

Palliative care practice requires excellent communication between the patient, family, and clinical team. Experts in the field have proposed a variety of communication interventions that can be used in the palliative care setting. However, these interventions are at a high level of generality: the specifics of each intervention are not well codified; the individual steps in each intervention are not easily reproducible and thus not comparable between practitioners; the methods to measure adherence to these communication protocols have not been established; and there is little detail on how to adapt these general interventions to the individual patient and family. Therefore, we lack good evidence for the efficacy of these recommendations. This paper makes the case for development of structured, testable approaches to communication that will inform clinical practice and communication training. To do so, palliative care communication should be conceived as a formal medical and psychosocial intervention-a potential treatment with risks and benefits to be systematically researched and operationalized in the same manner as medication interventions. As we illustrate, psychotherapy research has faced the same challenges in the past and has utilized manualized treatments to meet its goals. Through such approaches, we can begin to address the most basic intervention questions such as protocol efficacy, dose-response, side effects, and the optimal process and content of communication with the patient and family. The advantages of manualized communication approaches; some concepts underlying manual construction; and challenges to extending manualized communication to the palliative care domain are discussed.