Critical Care Medicine Section Newsletter - September 2011
From the Secretary/Newsletter Editor - Critical Care Medicine Section Newsletter, September 2011
Brian J. Wright, MD, MPH
Department of Emergency Medicine
Hofstra North Shore-LIJ School of Medicine
Greetings Critical Care Medicine (CCM) section members. With the Fall approaching, I look forward to seeing you at this year’s Scientific Assembly in San Francisco, October 15th-18th. San Francisco is a great city, and I’m sure it will be a great conference. Please be sure to block out some time on your schedule to attend the CCM section’s annual meeting to be held on Sunday, October 16th, from 1pm to 5pm, in the Union Square Room at the San Francisco Hilton.
The section meeting will have a different format this year. In addition to the always informative business meeting, the section meeting will lead off with an educational symposium showcasing some of the ACEP CCM section’s best and brightest. This is sure to be an inspiring and enlightening session. Dr. Rivers, as you are already well aware, is the father of early goal directed resuscitation. He is also one of the finest critical care lecturers around. Dr. Rivers has the uncanny ability to take often complex physiological principles and make them simple and practical, and I always am learning something new after hearing one of his talks. The topic panel also promises to be outstanding, featuring some of the leaders of EM/CCM. The panel will be a great opportunity to “talk shop” and learn about and share new techniques in resuscitation, airway and ventilator management. Kudos to our incoming chair, Dr. Shiber, for leading the effort to create this symposium. In addition to highlighting the talent of the CCM section, this year’s symposium will hopefully lead to future larger symposiums, increase the buzz and profile of our section in ACEP, and provide a way to increase our membership. Finally, be sure to stick around after the business meeting for our annual social happy hour. The location will be announced at the business meeting.
The University of Pittsburgh Medical Center (UPMC) is well represented in our current newsletter. Leading off we have our Chair, Dr. Lillian Emlet. Dr. Emlet has served our section for the last six years as newsletter editor, chair elect, councillor, and chair. We are all grateful for her dedication and leadership over that time period, and look forward to her continued support and influence in CCM moving forward. Dr. Emlet’s article, as we have come to expect from our outgoing chair, provides an admirable focus and framework for our section and membership going forward. Both as a section and individually, we should work to continue to advance the care of the critically ill by improving collaboration and research among section members, getting involved locally in hospital performance improvement and administrative leadership, and innovating new and improved ways of educating and mentoring future generations of EM/CCM providers.
Next up we have a good friend of mine, Dr. David Wallace. Dr. Wallace completed a CCM fellowship at UPMC after doing an EM/IM residency at SUNY-Downstate/Kings County Hospital in Brooklyn, NY. He is currently a research fellow and postdoctoral scholar at the CRISMA center at UPMC. In addition to clinical CCM practice, Dr. Wallace’s academic interests are in Health Services Research (HSR). HSR is a field that I didn’t have a lot of exposure to early on in my career. However, with a little more time under my belt in the ED and ICU, I have begun to have increasing respect for the importance that systems processes, personnel, and resource allocation have in the outcome of patients that I am taking care of. One of the tremendous advantages of our section is the breadth and depth of talent in our ranks. Health Services Research, in addition to Health Policy and Management, are areas that are critical to the care of ED and ICU patients, as there are plenty of forces (overcrowding, boarding, CCM physician shortages) that if left unchecked have detrimental impact on the patients that we spend so much time taking care of. Dr. Wallace provides a salient introduction to HSR, and its application to the ED and ICU. Importantly, he also provides information for those of you that would like to get more involved in this vital field.
Dr. Boniface, one of our colleagues from the ACEP Section of Ultrasound, provides an update on the joint collaborative between the sections of CCM and Ultrasound to develop an ultrasound educational program that focuses on CCM applications of ultrasound. This program will be in collaboration with the preexisting ACEP site acep.org/sonoguide. As you are all probably well aware, ultrasound is something that can potentially separate and distinguish us from our non EM trained CCM colleagues. As echoed many times from this newsletter, this is an opportunity for EM/CCM to be leaders and I urge you to get involved with Dr. Boniface and Dr. Mallemat if you have an interest in ultrasound.
Next up, some business issues. This is an election year for the section. We are currently looking to fill the positions of chair elect, secretary/newsletter editor, and website editor. In addition, there is Section Policy Statement that needs to be voted on. If you haven’t already voted, please do so. If you have not received either of the electronic ballots, please contact Margaret Montgomery at firstname.lastname@example.org to ensure that ACEP has your current email address and that your section membership is current. Please keep an eye on the ACEP CCM e-list for information regarding the elections as well as the ACEP council resolutions that are due to come out after this newsletter hits the press.
Finally, this is my last newsletter as secretary and editor. I’d like to thank you for this wonderful opportunity. The last two years have flown by. I’ve taken great joy and satisfaction in collaborating with many of you over the last two years, and I am especially grateful to those of you that have personally contributed to making this a great newsletter. Going forward, I hope this newsletter continues to be a means of promoting collaboration between our section members, and providing the information that is necessary for the section to thrive. As always, if you have any suggestions or comments, e-mail me here.
From the Chair - Critical Care Medicine Section Newsletter, September 2011
Lillian L. Emlet, MD, MS, FACEP
Program Director, Emergency Medicine MCCTP Fellowship
University of Pittsburgh Medical Center
It is time for my last Newsletter as your Section Chair, and I am filled with sadness about becoming your Immediate Past Chair but also am excited for the future: a future of new leaders in EM-CCM, partnerships with colleagues around the country, and a burgeoning network of educators, researchers, and clinicians.
This section has provided me one of the greatest opportunities in my academic career: a chance to improve and advance the discipline of EM-CCM. Yet there is much work that lies ahead, and we are on the cusp of being able to bring something important to the discipline of CCM: the ability to understand and unify both the medical and surgical disciplines. Certification is the first step in partnering with our colleagues in critical care medicine and creating new opportunities for growth of both medical and surgical regionalized critical care.
Clinical Administrative Leadership
Emergency physicians and intensivists, by nature of coordinating complex care, are poised well to serve as hospital administrative leaders. Building teams and working well with a large variety of disciplines is routine for an EM-CCM physician. I urge each of you to push the envelope and become a clinical leader in your local area, and advocate for quality and process improvement for the ED and the ICU, which in turn will lead to healthier and more efficient hospitals. Seeing the bigger picture from a resource management perspective from the prehospital arena to the ICU allows for good clinical operations, with a fundamental focus grounded in patient care. Initiatives to improve patient care include multidisciplinary protocol development and adoption of lean healthcare principles.1-3 Yet, at the root of all teams and quality improvement are the people. By being able to function clinically in a variety of arenas (ie, EMS, ED, ICU, RRT) EM-CCM physicians are able to lead a wide variety of people.
Opportunities become available in unexpected ways. While all junior faculty and new partners have a difficult time saying no to the abundance of projects and committees, this is also where career shaping opportunities abound. Having a clear understanding of expectations, importance to your clinical and academic leadership, and time commitment will help you integrate into the health system and your academic department. These opportunities should be seen as a way to improve clinical efficiency and quality, with the additional benefit of being able to speak regionally, nationally, or publish to disseminate best practices for quality and safety. Advocating for best practices across the board from ED to ICU, including the specific in-hospital issues that cross both specialties of medicine and surgery is something that easily fits the EM-CCM physician.
Moving forward, I intend to focus my energies and time on the mentorship of EM-CCM. I am excited to develop a Virtual Mentor program for students and residents interested in a dual career in EM and CCM. I have had the pleasure to talk with many residents and students interested in a dual career, and hope to see everyone flourish and achieve all of their goals in a fellowship program. Additionally, our small group of program directors has continued to remain in communication quarterly since 2009, and are in the process of forming the Association of EM-CCM Program Directors. Our mission remains to collaborate on best practices for the training and mentorship of dually trained EM-CCM physicians. Our programs range from those embedded in IM-CCM, Surgical Critical Care, Anesthesia Critical Care, and newly formed Multidisciplinary programs. We hope to provide guidance and tips for each phase of the early career of dually trained EM-CCM physicians, both osteopathic and allopathic.4
I am pleased to also encourage collaborative educational efforts, such as the Section Grant co-sponsored by our Section and the Section of Emergency Ultrasound. Our EM residents entering CCM fellowships come prepared with critical care ultrasound skills that surpass many intensivists, and this serves as prime time for EM-CCM physicians to assist, teach, and lead in educational and research initiatives in critical care ultrasound. A plethora of critical care ultrasound courses have been developed by a wide variety of groups, and our Section Grant seeks to provide additional modules for the Section of EUS Sonoguide, a freely available educational module. Led by Keith Boniface and Haney Mallemat, this project anticipates adding several new critical care ultrasound modules to Sonoguide.5
Research remains an important area where EM-CCM needs to forge new paths via leadership of research projects. The EMShock Net continues to expand and incorporate additional centers.6 Many EM-CCM physicians have gone the path of academic research, and we need more people to develop the rigor, discipline, and dedication to research bridging prehospital, ED, and ICU research. Becoming involved in your hospital’s projects and research training opportunities continues to be an important area for EM-CCM. EM research fellowships are becoming great ways to start an academic career with dedicated time to learn methodology, start pilot work, and develop mentorship in order to obtain grant funding. Opportunities to bridge relationships between EM and other Departments (ie, Neurosurgery, Cardiology, Anesthesia, Medicine, Surgery) is a win-win for all, but does take an open-minded, diplomatic, and eager to learn individual. We are lucky in EM that there are many different areas of exploration and partnership for research.
Our future depends upon strengthening the network of collaboration within EM-CCM and disseminating our work in these clinical, educational, and research avenues. I ask that each and every one of this Section’s membership step up to the plate to make a difference in EM-CCM: locally, regionally, and nationally. More importantly, our community needs to share: reach out, tell us what you are doing, become informed in and help each other’s work. Thank you for the opportunity to be your Section Chair. I look forward to many years of helping, growing, and working with all of you.
- Gawande, A. The Checklist Manifesto: How to Get Things Right. Metropolitan Books. 2009.
- American College of Healthcare Executives. http://www.ache.org
- Lean healthcare exchange. http://www.leanhealthcareexchange.com
- ACEP Sonoguide. http://www.acep.org/sonoguide
- EMShockNet. http://emshocknet.com
From the Chair Elect - Critical Care Medicine Section Newsletter, September 2011
Joseph Shiber, MD, FACEP, FACP
Emergency Medicine and Critical Care
University of Florida School of Medicine
ACEP Scientific Assembly 2011: EM-CCM Section Educational Symposium
In keeping with our mission: “The Critical Care Medicine Section of ACEP seeks to provide resources and support for emergency physicians who practice critical care medicine in the emergency department and in the intensive care unit” the EM-CCM Section will be hosting a two-hour educational symposium on Sunday 10/16/2011 at the Hilton San Francisco on the 4th floor of Tower 3 in Union Square 19 at 1pm. The event is open to all of attendees of the ACEP Scientific Assembly.
We are pleased to announce the following topics and speakers for the symposium:
End Points of Resuscitation: A 50 minute didactic lecture with 10 minutes for discussion and questions from the audience. Presented by Emanuel Rivers, MD, MPH, Vice Chair and Director of Research, Department of Emergency Medicine and Critical Care, Henry Ford Hospital.
Challenging Case Panel Discussion: A complex case broken down into three sections: Optimal Airway Management, Mechanical Ventilation Strategies, and Hemodynamic resuscitation and Management. Each topic will be discussed by two presenters who will pick distinct teaching points.
The panel includes:
- Lillian Emlet, MD, MS, FACEP, Program Director Emergency Medicine-Critical Care Medicine Fellowship, Department of Critical Care Medicine, University of Pittsburgh
- James Dargin, MD, Department of Critical Care Medicine, Lahey Clinic - Tufts University School of Medicine
- Jonathan Marinaro, MD, Co-Director Trauma Surgical ICU, Section Chief Surgical Critical Care, University of New Mexico
- Julie Mayglothling, MD, FACEP, Department of Emergency Medicine and Surgical Critical Care, Virginia Commonwealth University
- H. Bryant Nguyen, MD, MS, Vice Chair of Research, Department of Emergency Medicine and Medicine, Loma Linda University
- Scott Weingart, MD, FACEP, Director of ED Critical Care, Department of Emergency Medicine, Mount Sinai School of Medicine
Immediately after this event, the EM-CCM Section will hold its business meeting from 3 – 5pm followed by a Social Happy Hour; the location is still to be determined but will be announced at the meeting. We are looking forward to seeing all our section members for this 1st inaugural event, and please encourage any resident or student ACEP members who may be interested in CCM to attend also.
What is Health Services Research? - Critical Care Medicine Section Newsletter, September 2011
David John Wallace, MD, MPH, RDMS
CRISMA Research Fellow & Postdoctoral Scholar
Department of Critical Care Medicine
University of Pittsburgh Medical Center
- Patients with out of hospital cardiac arrest who are brought to emergency departments with a high volume of such cases survive to discharge significantly more often those who are brought to low volume centers.1
- Boarding critically ill patients in non-ideal intensive care units is associated with increased in-hospital mortality.2
- Septic patients admitted from emergency departments with a high sepsis case volume have lower overall and early in-hospital mortality.3
- Critically ill patients who board in the emergency department for more than six hours have increased in-hospital mortality.4
- Every hour delay in administering effective antibiotics to patients with hypotension from sepsis is associated with a 7.6% increase in mortality.5
These five seemingly disparate studies have a common umbrella: health services research. Health services research examines how people get access to health care, how much care costs and what happens to people as a result of this care. It focuses on organization, financing, policy and resources, and is home to sociologists, epidemiologists, statisticians, economists and physicians. In the broadest of strokes, health services research explores structures, processes and outcomes in medicine: it seeks to evaluate the quality of care.
Health services research questions have a natural home in the emergency department. Length of stay, boarding, throughput, disposition, transfer, timing of care, use of protocols, triage decisions and emergency medical services integration are shared interests of the community physician, the academic clinician and the career health services researcher. Frequently conducted as a component of local quality improvement, but also often done with a broader scope on a health system level, health services research in the emergency department aims to find structural or process opportunities to improve outcomes or efficiency. It asks if there is a better way to do the things we do.
The impact of health policy on the practice of emergency medicine is also a health services question: how well does legislation aimed at improving the quality of health care attain this goal? Last year President Obama signed the Patient Protection and Affordable Care Act, legislation intended in part to expand health care coverage for low-income adults. How would this legislation affect the day-to-day practice of emergency medicine? One expensive means of obtaining medical care for the low-income uninsured are emergency departments. Would expanding coverage reduce total health care spending by eliminating inefficiencies and shift some of the burden off the first floor and out of the ED?
The question itself is certainly not new - but remains unsettled because comparisons of behaviors and cost streams between insured and uninsured patients are not at all straightforward. While it would ordinarily be ethically impossible to address this question with a randomized controlled study, a natural experiment presented itself that was amenable to conducting this type of analysis. With a looming revenue shortfall to fund its Medicaid program, the state of Oregon conducted a lottery for 30,000 remaining Medicaid spots among patients on the state wait-list. Approximately one third of the eligible pool successfully enrolled, creating three study groups: those randomized to no insurance, those randomized to Medicaid and not enrolled, and those randomized to Medicaid and successfully enrolled. Using combinations of these strata the investigators studied the effect of Medicaid eligibility (“intention-to-treat”), regardless of actual enrollment, and the effect of actually being enrolled compared to uninsured (also known as impact evaluation or “treatment on the treated”). With a year of data reported, the group showed that in the short term, increased coverage resulted in increased health care use, lower out-of-pocket medical expenditures, lower medical debt and better self-reported mental and physical health. But there was no clear improvement in mortality. Does this mean that the program is ineffective? It’s too early to say, as one year may not be long enough to accrue the health advantages of routine primary care that result in a measurable mortality signal. As the study timeline extends, more will be known about the health effects of enrollment and the implications for the institutions providing this ongoing care - especially emergency medical services. [The study working paper can be downloaded from the National Bureau of Economic Research (NBER)(www.nber.org).]
In a natural extension of its role as the nation’s largest insurer, the United States government is also interested in health services research. The Agency for Healthcare Research and Quality is one of twelve agencies in the Department of Health and Human Services. Its goal is to examine the quality, safety, efficiency and effectiveness of health care. The agency is a major funding source for health services researchers, and sets a national agenda for future investigations. [More information on AHRQ and its many projects can be found at www.ahrq.gov]
There are several post-graduate training programs dedicated to health services research, the largest being the Robert Wood Johnson Foundation Clinical Scholars Program (www.rwjcsp.unc.edu). The organization offers two-year university-based post-residency training positions at four academic centers. As of April 2010, the Clinical Scholars Program trained forty-one emergency medicine physicians, with graduates going on to prominent positions in academia, public health, industry and research foundations.6 Additionally, the National Information Center on Health Services Research and Health Care Technology (NICHSR) provides a clearinghouse of resources related to fellowship training and funding opportunities in health services research (www.nlm.nih.gov/hsrinfo/grantsites.html).
Health services research is a field defined by the types of questions asked, rather than specific diseases or organ systems. The practice of emergency medicine is well-suited to health services studies, as our care is expensive, complex, high-risk and in increasing demand. Recent national attention on fiscal solvency has elevated the importance of the field, as it is clear that we spend too much and get too little. With a dedicated federal funding mechanism, several private non-profit academic foundations, fellowship training opportunities and interesting research questions still unanswered, emergency medicine physicians interested in ways to better organize and finance health care should consider this field of inquiry. In essence, when presented with the argument, “If some is good, more is better,” ask yourself, why is some good? Is some improving quality and reducing costs? Can we link some to new policy or export some to lower performing hospitals? This is health service research.
“[E]ven under the best conditions, constant monitoring will have to be maintained, for without it medicine cannot see itself, nor know where it is going.” - Donabedian, 1978 Science7
- Shin SD, Suh GJ, Ahn KO, et al. Cardiopulmonary resuscitation outcome of out-of-hospital cardiac arrest in low-volume versus high-volume emergency departments: An observational study and propensity score matching analysis. Resuscitation. 2011. 82(1):32-9.
- Lott JP, Iwashyna TJ, Christie JD, et al. Critical illness outcomes in specialty versus general intensive care units. Am J Respirator Crit Care Med. 2009. 179(8):676-83.
- Powell ES, Khare RK, Courtney DM, et al. Volume of emergency department admissions for sepsis is related to inpatient mortality: results of a nationwide cross-sectional analysis. Crit Care Med. 2010. 38(11):2161-8.
- Chalfin DB, Trzeciak S, Likourezos A, et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007. 35(6):1477-83.
- Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med, 2006. 34(6):1589-96.
- Landman A, Meisel ZF. The Robert Wood Johnson Foundation Clinical Scholars Program and Emergency Medicine. Acad Emerg Med. 2010. 17(4): p. e17-e22.
- Donabedian A. The quality of medical care. Science. 1978. 200(4344):856-64.
Update on ACEP US and CCM sections collaborative project - Critical Care Medicine Section Newsletter, September 2011
Keith S. Boniface, MD, RDMS, RDCS
Chief, Section of Emergency Ultrasound
Associate Professor, Emergency Medicine
George Washington University Medical Center
We are excited to announce a collaborative Section Grant awarded to ACEP’s Sections of Critical Care Medicine (Haney Mallemat, co-PI) and Emergency Ultrasound (Keith Boniface, co-PI), with special assistance from Beatrice Hoffmann, Editor of the ACEP Ultrasound Guide for Emergency Physicians website (Sonoguide). With this grant, we aim to develop open source online modules focusing on critical care ultrasound applications, especially those techniques not necessarily taught as part of emergency medicine ultrasound. The modules will expand the lineup of educational offerings available at acep.org/sonoguide, and will be in the form of web pages and webcasts that will address pulmonary ultrasound, critical care procedure guidance, and quantitative echocardiography. We will also include a section of case discussions that illustrate how ultrasound can help with critical care decision-making at the bedside. Think about the last time that careful application of ultrasound impacted patient care for you - we are looking for submissions, if interested in having your ultrasound exam be part of the clinical cases, contact Keith .
Annual Meeting Agenda - Critical Care Medicine Section Newsletter, September 2011
Critical Care Medicine Section Meeting
Sunday 10/16/2011 1pm-5pm
Hilton Hotel Union Square-San Francisco
Tower 3, 4th Floor
Union Square 19
1-3pm EM-CCM Educational Symposium
1pm “Endpoints of Resuscitation
2pm “Challenging Case: Panel Discussion”:
- Lillian Emlet, MD, MS, FACEP
- James Dargin, MD
- Jonathan Marinaro, MD
- Julie Mayglothling, MD, FACEP
- H. Bryant Nguyen, MD, MS
- Scott Weingart, MD, FACEP
5 pmSocial Happy Hour
Location to be announced at meeting