Improving EM in Philly at ACEP Council ‘23
Medmal. Reproductive care for miscarrying patients. Transfer coordination. Metric shaming. Geriatric and pediatric boarding reimbursement.
They were just a few of the issues on the table this month at ACEP Council, held in Philadelphia in advance of the organization’s annual conference this week.
Virginia’s ACEP Councillors and Board members at ACEP Council in Philadelphia.
There, Virginia’s 10 ACEP Councillors and those from 52 other chartered chapters gathered to vote on a series of resolutions under consideration by ACEP. Resolutions focus on issues affecting the practice of emergency medicine, advocacy and regulatory topics, and amendments to things like the College bylaws or rules.
“Some of the themes this year that got attention were very surprising,” says Caroline Cox, MD, a Virginia College of Emergency Physicians Board member and ACEP Councillor. “There were some very clear priorities that had a lot of discussion, because we wanted to make sure we got it right, and that the language we chose wasn't opening us up to legal trouble. As a body, we really got behind some resolutions that were in support of making things better for emergency physicians.”
Among them:
Medical Malpractice Certificate of Merit (Resolution 48)
For a plaintiff to file a medical malpractice lawsuit against a physician requires a signed document, known as an affidavit of merit, by a medical expert who attests to a claim.
Councillors approved a resolution requiring the affidavit be signed by a board-certified emergency physician who is also licensed and practicing in the same state as the emergency physician facing the case.
That doesn’t make the policy legally binding law, which is dependent on each state.
“What the resolution does is directs ACEP to take a stance, and have that as their policy,” Cox says. “As we ask states to follow the policy, or, if it comes up in a lawsuit, lawyers can point to the policy of the specialty group. You can't force states to do anything, but when we have a very clear position and advocacy tools, it makes it easier to put this policy in place in states, and support physicians who are going through those lawsuits.”
Metric Shaming (Resolution 50)
Emergency physicians are often tracked and evaluated based on various metrics — patients seen per hour, door-to-doctor time, or RVU (Relative Value Units), which can affect compensation.
Caroline Cox, MD
“While these metrics are essential for improving patient care, they can sometimes be posted publicly, leading to unfair comparisons,” Cox says. “Often these metrics are used as a business tool to say, ‘You need to make this faster, or better, or used as part of your compensation.’”
While partly fair, Cox notes, the data can be posted online and published in a comparative way. “Which can be uncomfortable or unfair, because these metrics aren’t necessarily pertinent or accurate,” she says.
The outcome of the resolution? ACEP will develop policies and practices to prevent public or external publication of “unblinded” metric-related information about emergency physician performance.
ACEP is still working on the language. “We don’t want to stand in the way of employers using this information, we just don’t want it to harm emergency physicians,” Cox says. “The ACEP Board is going to take a holistic look at the issue and consider how we support our members.”
A similar resolution looked at quality measures and patient satisfaction stores. Council advocated for ACEP to work with stakeholders to decrease or eliminate the role of patient experience surveys in reimbursement decisions.
Inter-Hospital Transfers (Resolution 28)
Passing unanimously was a resolution to facilitate EMTALA inter-hospital transfers by making transfer coordinator information more accessible. The move aims to streamline the transfer process and reduce the burden on physicians.
“Right now we've had situations where physicians are Googling hospitals in their area and cold-calling them trying to find a place to send their patients, especially from rural or small hospitals to a larger one with more services,” Cox explains. “And it's incredibly time-consuming and inefficient. If there was just one number you could call or even had a list of how to get to that transfer coordinator, it would save physicians an enormous amount of stress and time on shift.”
““There are many things about our job that are hard, frustrating, or stand in the way of us taking the best care of our patients. When I go to ACEP Council, I see very clearly that those issues are present across the country. It is really inspiring to see emergency physicians committed to trying to make these problems better. Many physicians feel we can help at the bedside, but it’s harder to change those systems issues. ACEP really gives me the place I can go to talk about it and help try to change and advance things.””
Miscarriage and Early Pregnancy Loss (Resolutions 44 and 45)
Some resolutions sought clarity on emergency physicians’ role in managing miscarriage and early pregnancy loss in the ED, considering the changing landscape of reproductive care with the overturning of Roe v. Wade.
“With the Dobbs decision [the 2022 case that overturned abortion rights], access to many types of early pregnancy care has been restricted,” Cox said. “And as OB-GYNs have left certain states or been less available to help with care, it's really forced emergency physicians to step into that gap.”
ACEP needs a clear policy: What if someone comes in and is actively miscarrying? How do emergency physicians prescribe medicines to help them through the process? How do emergency physicians do it all within scope of practice?
“This is not a typical area for emergency physicians, but it is a growing area where our services are needed,” Cox said. Council referred the resolution to the ACEP Board for further consideration.
Clarification and Taking a position against use of “Excited Delirium Syndrome” (Resolution 47)
In 2009, ACEP published a white paper on “excited delirium,” describing a condition for patients who were out of control and agitated. The Board has since retracted the paper.
However, the term was disproportionately used by medical examiners and others to explain the deaths of Black men in police custody. The paper was used by expert witnesses to buttress claims of deaths from “excited delirium” in civil lawsuits and criminal investigations related to deaths in law enforcement custody.
At Council, ACEP further made its position clear: that the use of “Excited Delirium Syndrome” is outdated and does not align with the College’s position based on the most recent science and better understanding of the issues surrounding hyperactive delirium.
Instead, ACEP recognizes the existence of “hyperactive delirium syndrome” with severe agitation, a potentially life threatening clinical condition characterized by a combination of vital sign abnormalities (e.g., elevated temperature and blood pressure), pronounced agitation, altered mental status, and metabolic derangements.
These patients are at high risk of direct physical trauma, not only unintentional harm from trauma such as falls, but also the metabolic stress that may result from physical restraint that may be required to facilitate the safety of the patient, bystanders, and responding professionals and ensure appropriate patient evaluation by emergency personnel.
“Unsupervised” Practice of Medicine (Resolution 43)
Nationwide and in Virginia, some advanced practice providers such as Nurse Practitioners are seeking to practice without direct physician supervision. NPs refer to it as “independent” practice, which has been adopted in statehouses nationwide, including Virginia (with restrictions).
Council addressed the need to clarify the terminology to “unsupervised” when discussing the practice of medicine by healthcare professionals other than physicians.
“What we are against is the unsupervised practice of medicine, from people who aren't trained in medicine,” Cox says. “The ‘unsupervised’ language is more accurate. Of course we support nurses having independent practice of nursing — they are experts in it and incredibly important to healthcare. But what we don't support is them practicing medicine, because they’re not trained in it unsupervised. Helping change the culture of that language will help more clearly reflect our position.”
Geriatric/Pediatric Mental Health Boarding Reimbursement (Resolutions 40 and 29)
ACEP passed resolutions supporting reimbursement for geriatric ED care and pediatric mental health admissions.
“Right now, this care has incredible value. We all want to do the best we can for a suicidal teenager, or an elderly person who keeps falling,” Cox says. “And when we have psychiatric care in the ED for those pediatric patients, or we have a geriatrician and elderly-friendly space in the emergency department, that really improves our patient outcomes.”
But such care is uncompensated by payers, “which makes it really hard for hospitals to put these enormously impactful things in place,” Cox says. “With ACEP making it a priority to advocate for these to be reimbursed, it could really expand the scope of how we help those vulnerable populations.”
