This clinical policy from the American College of Emergency Physicians is a revision of the 2015 clinical policy: critical issues in the evaluation and management of adult patients with suspected acute nontraumatic thoracic aortic dissection. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical question: "In adult patients presenting to the emergency department with suspected acute nontraumatic thoracic aortic dissection, can a clinical decision rule plus additional laboratory testing or imaging (plain film or point-of-care ultrasound) identify a group of patients at very low risk for the diagnosis of thoracic aortic dissection?" Evidence was graded, and recommendations were made based on the strength of the available data.

This clinical policy from the American College of Emergency Physicians addresses key issues in the evaluation and management of adult emergency department patients presenting with asymptomatic elevated blood pressure. A writing committee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical question: In adult emergency department patients being discharged with asymptomatic elevated blood pressure, is initiation of outpatient antihypertensive medications from the emergency department safe and effective? Evidence was graded and recommendations were made based on the strength of the available data.

This clinical policy from the American College of Emergency Physicians (ACEP) is the revision of a clinical policy approved in 2015 addressing a critical question regarding the use of thrombolytics for the management of acute ischemic stroke. A writing committee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical question: In adult stroke patients who are a candidate for mechanical thrombectomy, is the use of intravenous thrombolysis prior to mechanical thrombectomy (Bridge therapy) beneficial and safe versus mechanical thrombectomy alone? Evidence was graded, and recommendations were made based on the strength of the available data.

OBJECTIVES:Procedural competency is an essential prerequisite for the independent practice of emergency medicine. Multiple studies demonstrate that simulation-based procedural training (SBPT) is an effective method for acquiring and maintaining procedural competency and preferred over traditional paradigms ("see one, do one, teach one"). Although newer paradigms informing SBPT have emerged, educators often face circumstances that challenge and undermine their implementation. The goal of this paper is to identify and report on best practices and theory-supported solutions to some of these challenges as derived using a process of expert consensus building and reviews of the existing literature on SBPT. METHODS:The Society for Academic Emergency Medicine (SAEM) Simulation Academy SBPT Workgroup convened approximately 8 months prior to the 2019 SAEM Annual Meeting to perform a review of the literature and participate in a consensus-building process to identify solutions (in the form of best practices and educational theory) to these challenges faced by educators engaging in SBPT. RESULTS AND ANALYSIS:Thirteen distinct educational challenges to SBPT emerged from the expert group's primary literature reviews and consensus-building processes. Three domains emerged upon further analysis of the 13 challenges: learner, educator, and curriculum. Six challenges within the "learner" domain were selected for comprehensive discussion in this paper, as they were deemed representative of the most common and most significant threats to ideal SBPT. Each of the six challenges aligns with one of the following themes: 1) maximizing active learning, 2) maintaining learner engagement, 3) embracing learner diversity, 4) optimizing cognitive load, 5) promoting mindfulness and reflection, and 6) emphasizing deliberate practice for mastery learning. Over 20 "special treatments" for mitigating the impact of the 13 challenges were derived from the secondary literature search and consensus-building process prior to and during the preconference workshop; 11 of these that best address the six learner-centered challenges are explored, including implications for educators involved in SBPT. CONCLUSIONS/IMPLICATIONS FOR EDUCATORS:We propose multiple consensus-generated solutions (in the form of best practices and applied educational theory) that we believe are suitable and well aligned to overcome commonly encountered learner-centered challenges and threats to optimal SBPT.

Introduction The goal of this study was to characterize current practices in the transition of care between the emergency department and primary care setting, with an emphasis on the use of the electronic medical record (EMR). Methods Using literature review and modified Delphi technique, we created and tested a pilot survey to evaluate for face and content validity. The final survey was then administered face-to-face at eight different clinical sites across the country. A total of 52 emergency physicians (EP) and 49 primary care physicians (PCP) were surveyed and analyzed. We performed quantitative analysis using chi-square test. Two independent coders performed a qualitative analysis, classifying answers by pre-defined themes (inter-rater reliability > 80%). Participants’ answers could cross several pre-defined themes within a given question. Results EPs were more likely to prefer telephone communication compared with PCPs (30/52 [57.7%] vs. 3/49 [6.1%] P < 0.0001), whereas PCPs were more likely to prefer using the EMR for discharge communication compared with EPs (33/49 [67.4%] vs. 13/52 [25%] p < 0.0001). EPs were more likely to report not needing to communicate with a PCP when a patient had a benign condition (23/52 [44.2%] vs. 2/49 [4.1%] p < 0.0001), but were more likely to communicate if the patient required urgent follow-up prior to discharge from the ED (33/52 [63.5%] vs. 20/49 [40.8%] p = 0.029). When discussing barriers to effective communication, 51/98 (52%) stated communication logistics, followed by 49/98 (50%) who reported setting/environmental constraints and 32/98 (32%) who stated EMR access was a significant barrier. Conclusion Significant differences exist between EPs and PCPs in the transition of care process. EPs preferred telephone contact synchronous to the encounter whereas PCPs preferred using the EMR asynchronous to the encounter. Providers believe EP-to-PCP contact is important for improving patient care, but report varied expectations and multiple barriers to effective communication. This study highlights the need to optimize technology for an effective transition of care from the ED to the outpatient setting.

Due to a miscommunication during the process of transferring this manuscript from our editorial team to Production, the Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) were not properly indexed in PubMed. This has now been corrected online. The publisher would like to apologize for any inconvenience caused.

Ischemic heart disease is the leading cause of death in the world. More than half a million patients present to emergency departments across the United States each year with ST-segment elevation myocardial infarctions(1). Timely reperfusion is critical to saving myocardium at risk. Multiple studies have been conducted that demonstrate that improved care processes are linked to improved survival in patients having an acute myocardial infarction. This clinical policy from the American College of Emergency Physicians addresses key issues in reperfusion for patients with acute ST-segment elevation myocardial infarction. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In adult patients having an ST-segment elevation myocardial infarction, are there patients for whom treatment with fibrinolytic therapy decreases the incidence of major adverse cardiac events when percutaneous coronary intervention is delayed? (2) In adult patients having an ST-segment elevation myocardial infarction, does transfer to a percutaneous coronary intervention center decrease the incidence of major adverse cardiac events? (3) In adult patients undergoing reperfusion therapy, should opioids be avoided to prevent adverse outcomes? Evidence was graded and recommendations were made based on the strength of the available data.

This 2012 Academic Emergency Medicine consensus conference breakout session was devoted to the task of identifying the history and current state of faculty development in education research in emergency medicine (EM). The participants set a future agenda for successful faculty development in education research. A number of education research and content experts collaborated during the session. This article summarizes existing academic and medical literature, expert opinions, and audience consensus to report our agreement and findings related to the promotion of faculty development.

Introduction: The objective of this study is to identify (1) the current role of simulation in medical student emergency medicine (EM) education; (2) the challenges to initiating and sustaining simulationbased programs; and (3) educational advances to meet these challenges. Methods: We solicited members of the Clerkship Directors in Emergency Medicine (CDEM) e-mail list to complete a Web-based survey addressing the use of simulation in both EM clerkships and preclinical EM curricula. Survey elements addressed the nature of the undergraduate EM clerkship and utilization of simulation, types of technology, and barriers to increased use in each setting. Results: CDEM members representing 60 EM programs on the list (80%) responded. Sixty-seven percent of EM clerkships are in the fourth year of medical school only and 45% are required. Fewer than 25% of clerkship core curriculum hours incorporate simulation. The simulation modalities used most frequently were high-fidelity models (79%), task trainers (55%), and low-fidelity models (30%). Respondents identified limited faculty time (88.7%) and clerkship hours (47.2%) as the main barriers to implementing simulation training in EM clerkships. Financial resources, faculty time, and the volume of students were the main barriers to additional simulation in preclinical years. Conclusion: A focused, stepwise application of simulation to medical student EM curricula can help optimize the ratio of student benefit to faculty time. Limited time in the curriculum can be addressed by replacing existing material with simulation-based modules for those subjects better suited to simulation. Faculty can use hybrid approaches in the preclinical years to combine simulation with classroom settings for either small or large groups to more actively engage learners while minimizing identified barriers.

Objectives: The objective of this study was to determine whether a 5-module self-paced computerized educational program improves residents' skills in assessing and managing youth presenting to the emergency department in acute psychiatric distress. Methods: The evaluation used a quasi-experimental posttest-only design assessing both knowledge of the educational context of the program and self-rated pretest knowledge of program content with 32 residents recruited from 1 medical center in Cleveland, Ohio. Results: About half of the respondents were female (48%); almost two thirds were white (65%), and few were trained in psychiatric assessment of children/adolescents. On average, residents had significantly higher scores on the posttest compared with the self-rated pretest (6.4 ± 1.1 vs 3.8 ± 2.3; P < 0.001), an effect size of 1.32. Residents responded positively to the modules and rated them highly on educational content (4.2 ± 0.5 on a 5-point scale) and satisfaction with clinical applicability (8.2 ± 1.2 on a 10-point scale) and found the program easy to navigate (8.5 ± 1.9 on a 10-point scale). Conclusions: A brief, self-administered, Web-based training program shows promise for improving residents' knowledge about suicidal behaviors in youth.

Aim: The aim of this thesis was to describe the service use, clinical outcomes and prescribing change associated with the implementation of a complex intervention designed to improve care for people with depression in a primary care setting. Background: Health systems have limited capacity to provide appropriate psychological and pharmacological treatments for people with depression. Although guidance on the treatment of depression in primary care in the UK was clarified by the National Institute for Clinical Excellence (NICE) in 2004, it is generally acknowledged that the current diagnostic classification of depression is not satisfactory. Antidepressant prescriptions have continued to rise in Scotland since the mid-1990s, even though there is no indication that the incidence or prevalence of depression is increasing. There is limited access to psychological therapies. Health services have not implemented consistent packages or systems of care in order to provide adequately for patient needs. Although the welfare of staff is critical to their therapeutic engagement with patients, this is rarely an explicit focus of health systems design. Method: This thesis describes an observational study examining the implementation of a complex intervention to improve depression care called “Doing Well”. The intervention was based in 14 General Practices in Renfrewshire, a mixed urban-rural area in Scotland. The catchment population for the study was 76,000 people. A small team of clinicians implemented a programme for people with low mood, depression and adjustment disorder, based in primary care. This programme incorporated a number of changes to standard mental health care, including the following: no “severity threshold” for referral to secondary care; the routine use of an objective measure of depression severity with continuous outcome monitoring; a paperless clinical record; prompt access to guided self-help; prompt “step-up” care to more formal psychological therapy or medical care if indicated; and careful attention to staff training and satisfaction. Findings: 1501 out of 1584 people referred to the programme met inclusion criteria and were included in the study. Three hundred and thirty-two people (22%) did not attend any appointment; 320 (21%) dropped out of treatment after at least one contact. One hundred and ninety-five people (13%) subsequently had their care transferred to other services (of which 43% were to secondary care mental health services), and 654 (44%) of patients completed treatment per protocol. There was good fidelity to the intended model of care, with patients in the “treatment complete” group receiving “brief interventions” of an average of five contacts. These contacts totalled 151 minutes over an average of 103 days of treatment. Referrals from GPs continued at a high and stable level throughout the period of the evaluation. Median waiting times of 15 days were satisfactory. The mean reduction in PHQ for patients completing treatment was 10.6 points, representing a reduction from baseline of 62%. Seventy-two percent of the treatment complete group showed a PHQ drop greater or equal than 50%, compared with seven percent in the “disengaged” and ten percent in the “transfer of care” groups. Doing Well received a lower than expected proportion of referrals from deprived areas, and there was a small negative association between clinical outcome and living in a more deprived area. Defined daily doses of antidepressants in the practices that had access to the Doing Well clinical intervention increased less rapidly (5.3% between the 12 months to June 2004 and the 12 months to June 2008) than in neighbouring areas or Scotland as a whole (15.8% over the same period). Gross ingredient costs of antidepressants in the Doing Well practices fell more substantially over this period (to 56% of baseline) than in Scotland as a whole (to 65% of baseline). Formulary compliance increased more rapidly in the Renfrewshire area than in a neighbouring area which used the same formulary, but had no contact with Doing Well. Conclusions: It was feasible to implement and sustain a system of care for depression that was consistent with NICE guidance, including the provision of some form of psychological therapy (including guided self help) for all who needed it. Access to the service was acceptable, and retention within the service compares favourably with equivalent studies in other parts of the UK. Clinical outcomes were satisfactory, but it was not possible to compare with outcomes in usual care in this observational study. Doing Well practices showed a reduction in the rate of rise of antidepressant use, although did not stop the rise altogether. The implications of this form of “stepped care” for depression for service development are discussed.

In 2006, the latest version of a national curriculum for the fourth-year emergency medicine (EM) clerkship was published. Over the past several years, that curriculum has been implemented across multiple clerkships. The previous curriculum was found to be too long and detailed to cover in 4 weeks. As well, updates to the Liaison Committee on Medical Education (LCME)'s form and function document, which guides the structure of a clerkship, have occurred. Combining experience, updated guidelines, and the collective wisdom of members of the national organization of the Clerkship Directors in Emergency Medicine (CDEM), an update and revision of the fourth-year EM clerkship educational syllabi has been developed.

OBJECTIVES The authors sought to design an integrated theme-based hybrid simulation experience to educate and evaluate emergency medicine (EM) residents, to measure the Accreditation Council for Graduate Medical Education (ACGME) competencies using this simulation model, to measure the impact of the simulation experience on resident performance on written tests, and to measure resident satisfaction with this simulation experience. METHODS A theme-based hybrid simulation model that takes advantage of multiple simulation modalities in a concentrated session was developed and executed to both educate and evaluate EM residents. Simulation days took place at an integrated simulation center and replaced one 5-hour didactic block per quarter. Modified competency checklists were used to evaluate residents based on ACGME competencies. Written tests were administered before, during, and after simulation days. Residents were given the opportunity to evaluate the simulation days using standard residency program evaluation tools. RESULTS The model was proven feasible. Core competencies were measured using the model, which was executed on four occasions in 2007. Most residents met expectations based on objective checklist criteria and subjective assessment by an observing faculty member. Data from the written tests showed no overall difference in scores measured before, during, or after the simulation days. The simulation model was rated highly useful by the residents. CONCLUSIONS With the use of a highly developed simulation center and an organized, theme-based, hybrid simulation model that takes advantage of multiple simulation modalities, the authors were able to successfully develop an educational model to both train and evaluate EM residents with a high degree of resident satisfaction.

Study objectives: We determine the effect of screening examinations for mental status impairment on the care of elderly patients in the emergency department and prospectively assess recognition of mental status impairment by emergency physicians. Methods: We performed a prospective cross-sectional study. Patients were 70 years of age or older and presented to an urban teaching hospital ED over a 17-month period. Mental status impairment screening comprised the Orientation Memory Concentration examination for cognitive impairment and the Confusion Assessment Method for delirium. Emergency physicians who were blinded to the patient's screening results were interviewed to assess recognition of mental status impairment, dispositions, and referrals. Results of mental status impairment screens were then given to emergency physicians, and emergency physicians were reinterviewed regarding any change in care. Results: Two hundred seventy-one of the 327 eligible patients were enrolled. Seventy-four (27%; 95% confidence interval [CI] 22% to 33%) patients had impaired mental status. Nineteen (7%; 95% CI 4% to 11%) had delirium, and 55 (20%; 95% CI 16% to 25%) had cognitive impairment without delirium. Mental status impairment was recognized in only 28 (38%; 95% CI 27% to 50%) of 74 patients: 3 (16%; 95% CI 3% to 40%) of 19 with delirium and 25 (46%; 95% CI 32% to 59%) of 55 with cognitive impairment without delirium. Emergency physicians altered management in none of the study patients on the basis of survey results. Five (26%; 95% CI 9% to 51%) of the 19 patients with delirium were discharged to home. Of these 5 patients discharged to home with unrecognized delirium, 1 presented with fall, 2 returned 3 days later and required hospitalization, and 1 with a history of colon cancer was given a new diagnosis of metastatic disease 4 days after the initial ED visit. Conclusion: Mental status impairment is highly prevalent in older ED patients. There is a lack of recognition by emergency physicians of mental status impairment in this group. Screening tools for mental status impairment in the ED did not substantially alter the care of elderly patients with mental status impairment. [Ann Emerg Med. 2003;41:678-684.]