key: cord-0781821-p5aabag2 authors: nan title: Emergency Physician Involvement, Utilization, and Compensation During a Pandemic date: 2022-04-30 journal: Annals of Emergency Medicine DOI: 10.1016/j.annemergmed.2021.12.011 sha: e6a341033b6cd3efa5c01e04f1a02bd93b519956 doc_id: 781821 cord_uid: p5aabag2 nan Policy statements and clinical policies are the official policies of the American College of Emergency Physicians and, as such, are not subject to the same peer review process as articles appearing in the journal. Policy statements and clinical policies of ACEP do not necessarily reflect the policies and beliefs of Annals of Emergency Medicine and its editors. 0196 Originally approved October 2021 The COVID-19 pandemic revealed critical weaknesses in the practice of medicine. The past three decades have seen a transition from physician-owned hospitals, faithbased facilities, and community-owned specialty centers into multi-state corporate health care entities. Physicians have reduced input and control of their home institutions. Changes in hospital supply chains and focus on staffing precisely to volume while minimizing salary costs undermined facilities' ability to respond during unforeseen crises. Surge planning and staffing models are based on local seasonal conditions, not low frequency high consequence events. ACEP affirms the following as necessary and integral to the health and safety of patients and communities served by emergency physicians during disasters: Emergency physicians must have input into emergency department staffing patterns inclusive of the unexpected surge during a high consequence event of low probability, ensuring the health and safety of patients and the community served. Due to the variable flux of such an event, hospitals and health systems must ensure the identification, acquisition, and maintenance of essential materials in preparation for, as well as the training and maintenance of, a defined health care workforce capable of responding to each phase of a disaster. Partnerships must be developed with hospitals, health systems, and jurisdictional agencies to secure funding streams to sustain this critical workforce. This must occur prior to and during a disaster, thus ensuring community resilience. The behavioral health needs of healthcare workers must be given higher priority. Family needs of healthcare workers must be considered. Liability protections during disasters and Crisis Standards of Care situations must be put into place. Incentive pay needs to be considered if hospitals expect to retain and encourage critical clinical staff to respond during disasters. Originally approved October 2021 The American College of Emergency Physicians (ACEP) is committed to supporting diversity, inclusion, and equity in all aspects of the practice of medicine. Implicit bias refers to attitudes and associations that an individual holds about others that exist outside of their conscious awareness but influence their behavior. ACEP recognizes that implicit bias affects the quality of medical care patients receive and patient outcomes. Implicit bias also creates inequities in opportunities for all members of the healthcare team including within the realms of education, hiring, promotion, leadership, and compensation. These inequities remain pervasive in emergency medicine and impact physicians at all levels of training, from medical students to attending physicians. Improving these inequities is vital to the practice of medicine and necessitates a larger cultural change not only amongst physicians within the field of emergency medicine but inclusive of all members of the healthcare team across all specialties. ACEP strongly recommends inclusion of implicit bias training for emergency physicians at all practice levels and encourages the inclusion of implicit bias training for all members of the healthcare team. To this effect, ACEP recommends implementation of the following strategies: Incorporate effective implicit bias training into the continuing education of all emergency medicine physicians and trainees, including instruction in bias recognition and mitigation techniques. Strive to include a diverse group of representatives in all interviewing, recruiting, hiring, and promotional processes. Implement policies and practices that support transparency in hiring, recruitment, and promotion regarding compensation, benefits, and clinical as well as non-clinical responsibilities. Support expanding opportunities for promotion and career advancement through mentorship, sponsorship, and physician development initiatives. Employ processes to identify implicit bias and mitigate its effects on the assessments of trainees, including shift or rotation evaluations, interview evaluations, and the formation of rank lists. Incorporate methods to address the influence of implicit bias on patient care and patient outcomes as a vital element of continuous quality improvement within the healthcare system. Demonstrate sustained efforts to increase awareness of implicit bias and engage in bias reduction strategies. Originally approved October 2021 The ongoing COVID-19 pandemic unmasked many shortcomings in hospital and healthcare disaster planning and response. More focus needs to be given to disasters that evolve over long periods of time and disrupt multiple facets of society. Many existing plans are based on faulty assumptions and unrealistic expectations. COVID-19 demonstrated the utility of having an emergency medicine presence at regional and state emergency operation centers (EOC). Emergency physicians possess the clinical and operational knowledge and skills necessary to prepare for and respond to disasters. The American College of Emergency Physicians (ACEP) encourages emergency physicians to: Assist their institutions and community to prepare for and respond to disasters at the local, regional, state, and federal level. Serve as subject matter experts on the allocation of scarce healthcare resources. Emergency physicians must be at the Work with hospitals and health systems to protect healthcare workers, their families, and their patients from unnecessary risks. These risks (perceived and real) undermine the effectiveness of disaster response by healthcare providers. The American College of Emergency Physicians (ACEP) recognizes that strangulation, the act of neck compression in any context, can cause serious injuries and significant morbidity and mortality, especially to victims of intimate partner and sexual violence, child and elder abuse, and interpersonal, nonmalicious martial arts, and policing tactics, as well as intentional hanging and self-strangulation. ACEP recommends that: Emergency physicians and emergency departments assess all victims of intimate partner and sexual violence, child and elder maltreatment, and neglect for strangulation injuries. Emergency physicians and emergency departments maintain familiarity with the signs and symptoms of strangulation and have evidence-informed guidelines for the evaluation and management of patients who experience these signs and symptoms in this context. Emergency medical services, medical schools, and emergency medicine residency curricula should include education and training in the recognition, assessment, and interventions for strangulation injuries. Hospitals and emergency departments are encouraged to participate in collaborative interdisciplinary approaches for the assessment, safety planning, and interventions for patients assaulted by strangulation, especially those who are victims of intimate partner and sexual violence, child and elder abuse, and interpersonal violence. These approaches include the development of policies, protocols, and relationships with outside agencies that oversee the management and investigation of these types of violence. Emergency physicians and emergency departments are encouraged to better understand the partially hidden epidemiology of strangulation as well as evidence-based approaches to accurate assessment, appropriate radiographic imaging, and effective intervention for victims. Originally approved October 2021 The COVID-19 pandemic led to a renewal of the discussion and development of Crisis Standards of Care (CSC) protocols throughout the United States. 1 CSCs are implemented when a crisis results in a substantial change in the level of care that can be delivered. 2 As resource scarcity increases, the typical availability of "space, stuff, and staff" becomes limited, necessitating a transition of focus from individual patient-centered care to public health-based obligations to the community. 3 CSC guidelines aim to provide direction for navigating this conflict, typically through a focus on maximizing lives saved and/or life years saved. CSC policies provide concrete guidance for clinicians and institutions facing difficult decisions about who should receive scarce resources. 3 In response to the 2009 H1N1 pandemic, the National Academy of Medicine (formerly the Institute of Medicine) released guidance for establishing CSC protocols for implementation during disaster events. 2 These recommendations are based on the ethical principles of fairness, duty to care, duty to steward resources, transparency, consistency, proportionality, and accountability. 2 In the intervening decade, several states established CSC guidelines, though there is variation in the manner in which these guidelines have been operationalized. 4 During the COVID-19 pandemic, several versions of CSC were developed by states to provide guidelines, with subsequent implementation by healthcare systems. 5, 6 As the frontline in current and future disasters, emergency medicine physicians, particularly those with expertise in disaster medicine, should: Be involved in design, trial, and implementation of CSC guidelines at the federal, state, and local level. CSC design should include standards of equity and transparency. 7 Support state legislatures and Congress, who must provide liability protections and support services (physical and mental) for clinicians who are engaged in implementation of CSC guidelines. 6, 8 Serve as critical advisors to hospitals, health care systems, and governmental agencies, that should track the initiation of CSC and review their implementation to document maximum benefit and equity within an impacted community. Originally approved October 2021 International travel is common among all age groups. However, many patients lack adequate primary care or access to specialized pretravel consultations and may seek pre-travel counseling in the emergency department (ED). This policy statement helps guide emergency physicians in this situation but should not be interpreted as mandating travel screening or making it the standard of care for emergency physicians to provide this care. Only half of all children and minority of children visiting family seek out pre-travel consultation and advice from any source. Children visiting their family are a group that is at the highest risk for contracting travel related diseases because for a variety of epidemiological reasons. As this represents an opportunity to mitigate risks associated with travel and promote the health and safety of vulnerable children, the American College of Emergency Physicians (ACEP) supports the ability, but not the requirement, of emergency physicians to provide targeted pre-travel screening and resources to pediatric patients in the ED. Risk assessment should include a discussion of planned travel-related activities and should take into account agespecific needs. Key areas to consider include infection prevention and prophylaxis, as well as vehicle and water safety. Routine vaccinations should be emphasized in addition to referrals for specialized travel vaccines. Targeted emergency department pre-travel screening should not replace a comprehensive pre-travel evaluation, and families planning high-risk travel should be referred to specialized travel medicine services whenever feasible. Emergency physicians are encouraged to familiarize themselves with local resources for vaccination and prophylaxis and have information about appropriate specialty travel medicine centers for referral when needed. As travel guidelines to specific countries can change, reference to the CDC Yellow Book is encouraged: https://wwwnc.cdc.gov/travel/yellowbook/ 2020/family-travel/traveling-safely-with-infants-andchildren Duty to plan: health care, crisis standards of care, and novel coronavirus SARS-CoV-2 Institute of Medicine (US) Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations Ethical framework for health care institutions responding to novel coronavirus SARS-CoV-2 (COVID-19) guidelines for institutional ethics services responding to COVID-19. The Hastings Center Allocation of scarce resources in a pandemic: a systematic review of US state crisis standards of care documents Addressing challenges associated with operationalizing a crisis standards of care protocol for the Covid-19 pandemic. NEJM Catalyst Innovations in Care Delivery Crisis standards of care and state liability shields Crisis Standards of Care and State Liability Shields