Spring 2011 Issue

Kentucky Chapter ACEP

Spring 2011

Kentucky Chapter ACEP

Melissa Platt, MD, FACEP
President

Ashlee Melendez, RN, MSPH
Executive Director

Contact us:
ky.chapter@acep.org

Phone: 502-852-7874 begin_of_the_skype_highlighting 502-852-7874 FREE  end_of_the_skype_highlighting
Fax: 502-852-0066

From the President
Melissa Platt, MD, FACEP

And the Winner is…Royce Coleman MD FACEP

It is with great honor that I present to you the 2011 Blue Jay Consulting/EMF Emergency Department Director of the Year. What a proud moment for KACEP and the state of Kentucky to have one of its own presented with such an award.

Dr. Coleman is the University of Louisville Department of Emergency Medicine medical director for the past 16 years. He has navigated the academic department through almost 2 decades of health care advancements, politically hot issues, and economic waves with a style and fortitude unrivaled. Even with his plate full, he remains active at the state and national level of ACEP including being a current Councilor.

The award was specifically created to identify and recognize an individual who has made significant strides in developing collaborative relationships with nursing to implement and improve operational and clinical standards in five specific areas: quality patient care, operational effectiveness, education, community service, and a synergistic approach to leadership within the hospital or hospital system.

According to Anna Smith RN BSN MSN who is the Administrative Director for Emergency and Trauma Services at the University of Louisville Hospital, “Time and again, Dr. Coleman gives of his time and energy in the improvement of our operations. His one goal is to ensure patients receive the best care possible…Dr. Coleman touches hearts in a way that mere words cannot describe.”

With almost 60 nominations from some of the best directors in emergency medicine this distinguished recognition only solidifies what those who have known Royce realized years ago, Dr. Coleman is the best of the best.           Congratulations.

Therapeutic Hypothermia
Devin Faragasso, MD, FACEP                       
Education Chair

Does this affect my practice?
Yes. Because, as Dr. Amal Mattu of the University of Maryland has said, for the patient in cardiac arrest, “there are only three therapies that have been proven to improve survival. These are good compressions, early defibrillation, and post-arrest induced hypothermia.”

Also, the new American Heart Association Guidelines for CPR and Emergency Cardiovascular care includes several changes that affect Emergency Physicians. What follows are a few of the key changes(1):
• A chest compression rate of at least 100/minute
• In the adult, compression of the sternum of at least 5 cm
• Continuous quantitative waveform capnography for the intubated patient
• The discontinuation of the use of atropine for PEA/asystole
• Each institution should develop and utilize a comprehensive, structured, multidisciplinary system of post-cardiac arrest care, including the use of therapeutic hypothermia and percutaneous coronary interventions
So, with the publication of these guidelines, therapeutic hypothermia is beginning to be considered the standard of care.

Who is a candidate for therapeutic hypothermia?
The level I evidence is for any patient with a Glasgow motor score of less than 6, successfully resuscitated from ventricular fibrillation (VF) or ventricular tachycardia (VT). The studies enrolled survivors of VF and VT because these were the arrhythmias most likely to be resuscitated, and hence, the authors could obtain the numbers required to power their investigations. However, the therapy is likely to be useful for survivors of PEA and asystole. This is because hypothermia is directed at ameliorating the effects of a period of ischemia and hypoxia, a condition shared by the survivors of all of these arrhythmias.

The only patients to be excluded from therapeutic hypothermia are those who suffered a traumatic arrest, are awake, or for whom only palliative care is planned.

How good is therapeutic hypothermia?
The number needed to treat is 6. That means that for every 6 patients you induce, one will go home to live a normal life, with normal neurological function. This is quite a remarkable outcome in an area where we have come to expect almost all of our resuscitated patients to either ultimately die of anoxic brain injury, or be discharged from the hospital to nursing home on a ventilator.

How do I implement therapeutic hypothermia?
The goal is to lower the patient’s core temperature as quickly as possible, to between 32° C to 34°C. This temperature is then maintained for 24 hours, and then, the patient is slowly allowed to warm to normal body temperature. There are several commercial devices marketed to help induce and maintain this hypothermia. A hospital, however, does not need to invest in any of these devices for use in the Emergency Department, because, the emergency physician, will ideally only be inducing hypothermia. After induction has begun, the patient should be moved to an ICU or cardiac catheterization laboratory.

Induction is begun with a 2 liter bolus of refrigerated crystalloid fluid. Using pressure bags is recommended. This refrigerator temperature crystalloid (which can be stored in the Emergency Department’s medication refrigerator) will drop the patient’s core temperature about 1°C per liter. Also, ice bags should be packed into the axilla, groin, and around the neck. The patient’s core body temperature must also be continuously monitored. Of the available temperature probes (rectal, bladder, and esophageal), only esophageal gives real-time feedback. The other probes are, however, acceptable alternatives for early induction.

It is noteworthy for those of us who practice at smaller institutions, that in Kentucky, most tertiary care hospitals now accept transfers of patients who have undergone induction of therapeutic hypothermia.

Why does this therapy work?
Experimental evidence demonstrates that mild to moderate hypothermia ameliorates many of the deleterious effects of an ischemia insult. “A complex cascade of processes ensues at the cellular level after a period of ischemia beginning from minutes to hours after injury and continuing for up to 72 h ... [Such] processes are temperature dependent… [and] neurological outcome is established to a substantial degree by mechanisms during the post-injury period…hypothermia affects all of these destructive mechanisms” (Polderman 2008).

What is the evidence?
For years, overwhelming animal evidence has supported a protective role of hypothermia against ischemia and hypoxia in numerous tissues.  Then, between 1997 and 2002, seven small human clinical trials were done, also reporting improved outcomes. In 2002, two larger, multi-centered human trials were published in the New England Journal of Medicine. The larger of these two studies enrolled 273 patients. A favorable neurological outcome was seen in 55% of patients in the hypothermia group compared with 39% of controls (3). In the other study, 77 patients had cooling initiated during ambulance transportation to the hospital. The rate of favorable neurological outcome was 49% in the hypothermia group versus 26% in the controls (4).

What are the side effects?
Hypothermia causes diuresis, so most patients will benefit from the cooled crystalloid volume loading you use to initiate hypothermia. Hypothermia also causes shivering, which can be prophylaxed with buspirone and fentanyl/meperidine. Furthermore, hypothermia causes bradycardia, but this may be one of the cardio protective benefits of treatment. Lastly, despite the concerns of some clinicians, the temperatures used in therapeutic hypothermia is just above that needed to significantly effect the coagulation cascade. Mild hypothermia does, however, probably cause some qualitative platelet dysfunction.  However, these patients are those who have most likely just suffered from a myocardial infarction, and thus, are in need of anti-platelet therapy (5).
Consider speaking to your hospital’s cardiologists and intensivists about developing a hypothermia protocol at your institution. Several university hospitals have already published their therapeutic hypothermia protocols online. More information can be found on their website

References:
1) American Heart Association, website
2) Polderman, K. Induced hypothermia and fever control for prevention and treatment of neurological injuries. Lancet 2008; 371: 1955-69
3) The Hypothermia after Cardiac Arrest Study Group. Mild theraputic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002; 346: 549-56
4) Bernard, S, Gray, TW, Buist, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002; 346: 557-63.
5) Doufas, A.G., Sessler, D.I., Physiology and clinical relevance of induced hypothermia. Neurocritical Care 2004; 1 (4): 489-498

Governmental Affairs
Wes Brewer, MD

WILL LIABILITY REFORM HAPPEN IN YOUR LIFETIME?

Recently there has been an uptick in the level of interest in the possibility of medical liability reform. This is a complex issue so bear with me- following is my take on what might be possible and where the land mines are buried. Let’s clarify that there is discussion at both the federal and state level and also remember that the political divisions are equally intense at both levels. If a conservative has a good idea, liberals are automatically obliged to oppose that idea regardless of the content (vice versa applies as well!). Also remember that the trial lawyers are politically engaged while we as a profession seem content to sit back and wait for good things to happen to us.

In Kentucky, our constitution essentially prohibits any law which potentially impairs one citizen’s right to sue another in court. This in effect precludes any possibility of a cap on damages or the institution of any sort of review panel. Any change would require a constitutional amendment which, quite frankly is not going to happen anytime soon. As it currently functions, our General Assembly cannot even agree that the earth is still flat (unless there happens to be a group of optometrists involved)! In the late eighties Kentucky did find a progressive streak and enacted legislation to change the burden of proof required in malpractice cases but it was promptly overturned in the courts. However there has been recent enthusiasm for revisiting this issue.

Several states have enacted, or are considering special liability provisions specific to care mandated by EMTALA. This would appear to be a win-win situation for emergency physicians and we have had preliminary discussions with key state representatives and while we have no concrete commitments at least we weren't immediately shot out of the water. In states where such reforms have been proposed a major hurdle has been to win the support of the wider medical community. Many physicians are reluctant to support what is viewed by some as being only helpful to a specific "niche" otherwise known as the what's in it for me philosophy. In the next issue I will devote this space to a more in depth examination of EMTALA based reform proposals.

On the federal level, there are currently five bills before the House addressing liability reform. HR 5 is the most comprehensive and most likely to be enacted. It is also strongly supported by ACEP. The concern is that the House has passed reform bills on several previous occasions then they go on the die in the Senate. Senator McConnell has called for liability reform at least 50 times in speeches on the Senate floor, however, he strangely sides with President Obama in the belief that the federal government has no role in this issue and that it should be handled by the individual states. McConnell had not (and according to his office will not) sponsored or endorsed any federal reform legislation.

The Healthcare Reform Act contained 25 million dollars in grant money to the states for demonstration projects for study of health courts and early settlement options ( all of which we cannot take advantage of because of our quirky constitution). The Obama budget proposal for next fiscal year contained 250 million for the same sorts of projects but that was dead before the ink dried on the paper.

Despite the somewhat pessimistic tone of everything above, there are people who believe we have a better chance of meaningful reform than at any time in the past several decades. We'll keep you posted.

Hillbilly Heroin- The Pain Pill Epidemic

So...prescription drug abuse and trafficking is the hot medical media story right now. I think we are all well aware of the problem in our state. A recent article in the Lexington Herald-Leader focused on this topic and quoted some pretty sobering facts.

  • 90% of oxycontin prescriptions are written in the state of Florida. 
  • As of 2002, 25% of oxycontin related deaths took place in eastern Kentucky.
  • 98 of the top 100 prescribing physicians for oxycontin are in Florida. 

Further review of the "White Hose Drug Policy" website noted a survey that showed that 56% of abused pain medications were obtained "free from a friend or relative". They also note that from 1997 to 2007, treatment admission for prescription painkillers increased more than 400%. The internet isn't helping either. In 2007, 187 websites were found that dispensed narcotic pain medications. Of those, only 16% required a prescription with 53% clearly stating "no prescription needed."
 
Prescription drug abuse and drug seeking behavior are an epidemic in this state and I don't have a shift go by that doesn't involve pain seeking behavior. In fact, it almost seems that most of our populations no longer considers tylenol or ibuprofen a pain medicine. Unfortunately, from an ER practitioner standpoint, it is difficult in this era of a huge focus on "customer satisfaction" to confront this issue in our departments. I recently read a correspondence from a Tennessee ER group in which they encouraged liberal usage of narcotic pain medications in an effort to boost their satisfaction scores. Though I am not a zero narcotic prescription physician, I am also not willing to compromise the ethics of our profession to boost a score. These medications play a key roll in the control of acute pain conditions.
 
I think it is our charge as the front line of healthcare to lead this fight against prescription narcotic abuse. I think there are three ways we can start stemming the tide of abuse.
 
1) Evidenced based usage and prescribing of narcotic based medications.
 
2) In ER teaching. We need to educate our patients as to why we will, or will not give narcotic medications. This needs to involve research that shows what has been proven to be the most efficatious therapy (example: tylenol and physical therapy for chronic back pain).
 
3) We must be spokesmen for our profession to the public. Our members need to be active in their area, especially those of you in eastern Kentucky, through the media, legislature, and any other group where we can get the message out.
 
This problem will never be eliminated, but I am happy to see the first steps on the local, state, and national level to reel in one of the public health threats of our generation. It is time for us to stand up and help direct the dialogue as the apparent safety net for the victims of this addiction.
 
Thanks,
Ryan Stanton, MD, FACEP
President Elect, KACEP

L. Barrett Bernard, MD, FACEP
Disaster Preparedness, Medical Reimbursement Committee Chair

A comprehensive clinical report, Sport-Related Concussion in Children and Adolescents, appears in Pediatrics Vol.126 No. 3 Sept. 2010 pp. 597-615

The report serves as a basis for understanding the diagnosis and management of concussion in children and adolescents.

Conclusions and Guidance for Cliniciansb>

  1. Sport-related concussions are common in youth and high school sports. Limited data are available on concussions in grade school athletes, and further research is needed.
  2. Concussion has many signs and symptoms, some of which overlap with other medical conditions. LOC is uncommon, and if it lasts longer than 30 secs., it may indicate more significant intracranial injury.
  3. Results of structural neuroimaging, such as MRI or CT, generally are normal with a concussion.*
  4. Neuropsychological testing can be helpful to provide objective data to athletes and their families after a concussion. Neuropsychological testing is one tool in the complete management of sport-related concussion and alone does not make a diagnosis to determine when return to play is appropriate.
  5. Athletes with concussion should rest, both physically and cognitively, until their symptoms have resolved both at rest and with exertion. Teachers and administrators should work with students to modify workloads to avoid exacerbation of symptoms.
  6. The signs and symptoms of a concussion typically resolve in 7-10 days in the majority of cases. Some athletes however, may take weeks to months to recover.
  7. Any pediatric or adolescent athlete who sustains a concussion should be evaluated by a health care professional, ideally a physician with experience in concussion management, and receive medical clearance before returning to play.
  8. Pediatric and adolescent athletes should never return to play while symptomatic at rest or with exertion. Athletes also should not be returned to play on the same day of the concussion, even if they become asymptomatic. The recovery course is longer for younger athletes than for college and professional athletes, and a more conservative approach to return to play is warranted.
  9. The long-term effects of concussion are still relatively unknown, and further research is needed to offer further guidance to athletes of all ages.
  10. Education about sport-related concussion is integral to helping improve awareness, recognition, and management.
  11. The safety and efficacy or medications in the management of sport-related concussion has not been established.
  12. Retirement from contact or collision sports may be necessary for the athlete with a history of multiple concussions or with long symptomatic courses after his or her concussion.
  13. New evidence-based protocols for the diagnosis and management of concussion should be incorporated into pediatric modules and competencies.
     
    Physical Cognitive Emotional Sleep
    Headache Feeling Mentally "Foggy" Irritabilty Drowsiness
    Nausea Feeling Slowed Down Sadness Sleeping More Than Usual
    Vomiting Difficulty Concentrating More Emotional Sleeping Less Than Usual
    Balance Problems Difficulty Remembering Nervousness Difficulty Falling Asleep
    Visual Problems Forgetful of Recent Events    
    Fatigue Confused about Recent Events    
    Sensitivity to Light Answers Questions Slowly    
    Sensitivity to Noise Repeats Questions    
    Dazed      
    Stunned      

*CT imaging is the test of choice to evaluate any suspicion of an intracranial structural injury in the ER. Clinical suspicion indicating neuroimaging is appropriate includes loss of consciousness or posttraumatic amnesia, severe headache, seizures, focal neurological deficits, repeated emesis, significant drowsiness, slurred speech, disorientation, neck pain, and significant irritability.

The CDC website, has a recent report, Updated Mild Traumatic Brain Injury Guideline for Adults and is recommended by ACEP. Indications for adult neuroimaging is the same as for adolescents except include age > 60, drug or alcohol intoxication, and coagulopathy.

At discharge from the emergency room patients should be:

  1. Alerted to look for post concussive symptoms (physical, cognitive, emotional, and sleep) since onset of symptoms may not occur until days after initial injury.
  2. Instructed on what to expect and when it is important to return to the emergency department.
  3. Emphasize that rest and sleep are important after a concussion as it allows the brain to heal. Referral should be made to a health professional competent to test neurological and physical recovery.

Clinical News

Hospitals Vary Widely in Applying Proven STEMI Treatments
Implementation of evidence-based treatments for patients with acute myocardial infarction saves lives, but hospitals show substantial variation in the extent to which they apply these treatments, according to a study of more than 60,000 patients treated at 72 Swedish hospitals during 1996-2007.

During the period studied, Swedish hospitals increasingly used proven treatments for patients presenting with ST-elevation MIs, including increased use of reperfusion therapies, aspirin, clopidogrel, statins, beta-blockers, and ACE inhibitors or angiotensin receptor blockers. Concurrently with increased use of these interventions, the standardized, 1-year mortality of patients dropped from 19% in 1996 to 11% in 2007, Dr. Tomas Jernberg, a cardiologist at Karolinska University Hospital in Stockholm, and his associates reported in an article published online on April 27 (JAMA 2011;305:1677-84).

But in addition to documenting the efficacy of evidence-based therapies for treating acute STEMI, the findings also revealed a wide variation in the application of these therapies by all 72 Swedish hospitals that provide care for patients with acute cardiac diseases.
Read the entire article online.

Antibiotics Alone May Suffice for Uncomplicated Acute Appendicitis
Uncomplicated acute appendicitis can be safely treated by antibiotics alone, a systematic meta-analysis suggests.

Use of antibiotics may prevent unnecessary appendectomy and reduce overall complication rates, lead author Dr. Katherine J. Liu said at the annual meeting of the Central Surgical Association.

“Appendectomy may be reserved for antibiotic treatment failure and recurrent appendicitis,” she said.

Dr. Liu pointed out that antibiotics have become progressively more powerful in the last 30 years and that spontaneous resolution of acute appendicitis occurs in 24-48 hours without any treatment in up to 20% of patients in large series. A recently published study found that the negative appendectomy rate in the era of computed tomography is 5% with CT and 10% without CT (Ann. Surg. 2008;248:557-63). Also, perforated and nonperforated appendicitis are probably two separate disease entities, based on several very large epidemiologic studies, she said.
Read the entire article online.

Focus On: Variceal Hemorrhage
“Focus On” is an ongoing series of articles that examine common complaints that present to the emergency department or highlight new literature or treatment options. The February 2011 article reviews current therapy for gastroesophageal varices and the importance for emergency physicians to deliver life-saving treatment.

Learning objectives for this article include to assume that patients with a history of cirrhosis who present with upper GI bleeding have esophageal varices until proven otherwise; recognize that patients with esophageal varices have an extremely high mortality rate; always perform a rectal exam and consider nasogastric lavage in the evaluation of esophageal varices; treat esophageal variceal bleeding with octreotide, proton pump inhibitors, antibiotics, intravenous fluids, and early blood product transfusion; and consult GI specialists and interventional radiology early in the evaluation of variceal bleeding.
After reading the article, take the CME quiz online.

Spring Brings New Member Benefits to ACEP

New ACEP member benefits are blooming this spring, with products and savings to make it easier for you to practice emergency medicine and provide the highest quality care for your patients.

  • Free CME Credits for “Focus On”
    You asked, we’ve responded. ACEP Members can now earn free CME by taking the “Focus On” quizzes online. These quizzes are based on ACEP News articles that address new approaches to common presentations or a refresher on topics that might fall into a learning gap. Certificates can be printed instantly after completing the quiz. Sign in and explore this new member benefit. Non-members still pay $10 a quiz. Sorry, no refunds for quizzes already purchased.
     
  • Discounts for National Salary Surveys
     ACEP has partnered with Daniel Stern and Associates to offer their annual national emergency medicine salary surveys to our members at a discounted price. You can now find clinical, academic, regional and even trends reports in the ACEP Bookstore. Whether you are getting your first job or want a snapshot of the current job market, there are a variety of salary survey products that can help you with your practice needs and goals.
     
  • Easier Access to the Health Care Notification Network, More Features
    Get Physicians’ Desk Reference (PDR) drug alerts from the Health Care Notification Network sent right to your inbox with no log-in required. Just sign up for the service on our website. Once registered, you will begin receiving FDA-approved information and alerts on a real-time basis. ACEP members can also access other PDR Network features, including free CME courses and a free copy of mobilePDR, which brings the most widely used drug information resource to your smartphone.
     
  • Enhancements to the Member Renewal Process
    A new Online Member Guide is now being sent to each member after they join or renew. Each guide is personalized and populated with data that is particular to the recipient. And online dues statements now contain the same statement the member received in the mail. These automated member renewal messages contain their statement, which can be downloaded and printed.

ACEP understands the practice challenges you face and we want to help you with the issues that matter most to you and your patients.

Thank you for your continued membership in ACEP, the leading emergency medicine advocate for our specialty and your career.

AAEM, Small Groups Join EM Action Fund

Recognizing the potential threat to the independent practice of emergency medicine, the American Academy of Emergency Medicine (AAEM) and several small to mid-sized groups have joined the Emergency Medicine Action Fund, which is collectively working to impact health care reform's regulatory implementation.

These contributors are looking past the differences of the varied participants in the EM Action Fund and recognizing the need to improve the emergency medicine practice for everyone, said Dr. Wesley Fields, Chairman of the EM Action Fund.

“What I hope AAEM, the other EM organizations vested in the EM Action Fund, and EM groups large and small will do is to change the conversation about the acute care continuum among policy makers and thought leaders regarding the future of health care in the U.S.,” Dr. Fields said.

“There will never be a better time or a more compelling need for emergency physicians to find common cause,” he added. “The macro forces that threaten our specialty and our health care system are far greater than any intramural disputes between EM organizations.”

AAEM will join the American College of Emergency Physicians, the Emergency Medicine Residents’ Association (EMRA), the American College of Osteopathic Emergency Physicians (ACOEP), and the Society of Academic Emergency Medicine (SAEM) on the EM Action Fund Board of Governors. AAEM and SAEM each contributed $25,000 to the Action Fund, and EMRA contributed $100,000 over the next two years. ACOEP contributed $50,000 over the next two years.
 
Invitations to sit on the Board also have been extended to the Association of Academic Chairs of Emergency Medicine (AACEM), and the Emergency Department Practice Management Association (EDPMA) and were still being considered in mid-April.

The reminding 10 Board seats will be allocated to the largest contributors. Several small and mid-sized groups are working together to form coalitions in hopes of attaining a seat on the Board.

As of mid-April, 12 physician groups of various sizes have contributed to the EM Action Fund, along with two companies that work closely with emergency physicians. There have also been dozens of individual contributions.

As an adjunct to ACEP’s Washington, DC staff, the EM Action Fund’s consulting firms have been developing analysis pieces about the recently released draft regulations for Accountable Care Organizations (ACOs) from the Centers for Medicare & Medicaid Services (CMS).

There is a synopsis of the quality reporting requirements for ACOs, a summary of the ACO waivers of various federal laws, and many other useful resources useful for review as a formal response to CMS is being prepared.

The website also has a list of the issues and provisions in the Patient Protection and Affordable Care Act (PPACA) relating to emergency medicine, a timeline of implementation dates of various provisions, and a status update of current legal challenges to PPACA.

“Regardless of one's personal views of the Act, it is obvious to any serious observer that the federal government is likely to continue to have more and more influence over the practice of emergency medicine,” Dr. Fields said. “That is why the Emergency Medicine Action Fund will focus on federal regulatory affairs, which, under IRS guidelines, are not political in nature or in tax law.”

There is still time to contribute to the EM Action Fund, which is expecting to have its Board in place and being regular meetings later this summer.

“Regardless of your mode of practice, EMAF deserves your support and needs your intellectual capital as much as your financial pledge,” Dr. Field said.

Find out more and use the new online contribution form.

Make A Difference: Write That Council Resolution

ACEP is a living entity, which needs new ideas to keep it healthy and viable in the 21st century. Many College members introduce new ideas and current issues to ACEP through Council resolutions. This may sound daunting to our newer members, but the good news is that only takes two ACEP members to submit a resolution for Council consideration. In just a few months the ACEP Council will meet and consider numerous resolutions.

ACEP’s Council, the major governing body for the College, considers resolutions annually in conjunction with Scientific Assembly. During this annual meeting, the Council considers many resolutions, ranging from College regulations to major policy initiatives thus directing fund allocation. For 2011, the Council has 338 Councillors: ACEP members representing chapters, sections, EMRA, AACEM, and CORD.

This Council meeting is your opportunity to make a resounding impact by setting our agenda for the coming years. Topics such as the direct election of the president-elect, or working with the Emergency Nurses’ Association on staffing models, grew directly from member resolutions submitted to the Council. If you have a hot topic that you believe the College should address, now is the time to start writing that resolution.

I’m Ready to Write My Resolution
Resolutions consist of a descriptive Title, a Whereas section, and finally, the Resolved section. The Council only considers the Resolved when it votes, and the Resolved is what the Board of Directors reviews to direct College resources. The Whereas section is the background, and explains the logic of your Resolved. This should be short, focus on the facts, and include any available statistics. The Resolved section should be direct and include recommended action, such as a new policy or action by the College.

There are two types of resolutions: general resolutions and Bylaws resolutions. General resolutions require a simple majority vote to pass, while Bylaws resolutions require a two-thirds majority. When writing Bylaws resolutions, list the Article number, and Section from the Bylaws you wish to alter. Then, in the resolution, you should show the current language, and bold your suggested new language while striking through the suggested edits. See the ACEP Web site article, “Guidelines for Writing Resolutions,” which further details the process and offers tips on writing a resolution.

I Want to Submit My Resolution
It takes at least two members to submit a resolution, or a Chapter, Section, AACEM, CORD, or EMRA may submit a resolution. If the resolution comes from a Chapter or Section, then a letter of support from the President of the Chapter or Chair of the Section is required. The Board of Directors or an ACEP committee can also submit a resolution. The Board of Directors must review any resolution from an ACEP committee, and usually reviews all drafts at their June meeting. Bylaws resolutions pass through the Bylaws committee for review and suggested changes. These changes and suggestions are referred back to the author of the resolution for consideration. One may submit a resolution by mail, fax, or email. Resolutions are due at least 90 days before the Council meeting. This year the deadline is July 16, 2011.

Debating The Resolution
Councillors receive the resolutions prior to the annual meeting along with background information from ACEP staff. Discussion often occurs on the Council electronic list serve prior to the Council meeting. At the discretion of the Speaker, non-Councillor resolution authors may be added to the Council e-list serve upon request.

At the Council meeting, the Speaker and Vice-Speaker divide the resolutions into four reference committees. The reference committees meet and hear testimony on each resolution. You, as the author of your resolution, should attend the reference committee that discusses your resolution. Reference committees allow for open debate and unlimited testimony, and participants often have questions best answered by the author. Afterwards, the reference committee summarizes the debate and makes a recommendation to the Council.

The Council then meets to discuss all the resolutions. Each reference committee presents each resolution, providing a recommendation and summary of the debate to the Council in writing and on the podium, and then the Council debates each resolution. Any ACEP member may sit in the back and listen to the Council debate whether a Councillor or not. If you wish to speak directly to the Council, you may request to do so in writing to the Speaker before the debate. Include your name, organization affiliation, issue to address, and the rationale for speaking to the Council. Alternatively, you may ask your Chapter or Section for alternate Councillor status and permission for Council floor access during debate. Chapters and Sections often have alternate Councillor slots and encourage the extra participation.

The Council’s options are: Adopt the resolution as written; Adopt as Amended by the Council; Refer to the Board, the Council Steering Committee, or the Bylaws Interpretation Committee; Not Adopt (defeat or reject) the resolution; or Postpone.

Hints from Successful Resolution Authors

  • Present your resolution prior to submission to your Chapter or Section for sponsorship on the Council floor. This way, they can give advice and assistance.
  • Consider the practical applications of your resolution. A well-written resolution that speaks to an important issue in a practical way passes through the Council much more easily.
  • Do a little homework before submitting your resolution. The ACEP web site is a great place to start. Does ACEP already have a policy on this topic? Has the Council considered this before? What happened?
  • Find and contact the other stakeholders for your topic. They have valuable insight and expertise. Those stakeholders may co-sponsor your resolution.
  • Attend debate concerning your resolution in both reference committee and before the Council. If you cannot attend, prepare another ACEP member to represent you.

I Need More Resources
Go to ACEP’s Web site, www.acep.org. Click on “About Us,” then “Leadership,” and finally click on “Council.” Scroll down and you will see a link to the “Guidelines for Writing Resolutions” article. All authors should review this article prior to writing their resolution. Additionally, there is information about the Council Standing Rules, Council committees, and Councillor/Alternate Councillor position descriptions. Of special note, there is a link to Actions on Council Resolutions. Under this link are PDF documents dating back to 1998 summarizing each resolution and what has occurred with each of them. You can review past actions, or keep track of what happens once your resolution passes.

Well, Get To It
Writing and submitting Council resolutions keeps our College healthy and vital. A Council resolution is a great way for College members to speak to the leaders of the College and the Board of Directors. Even if your resolution does not pass, the College will debate the topic and consider its ramifications. Additionally, other members may have resources or suggestions to address your issue. I encourage you to take advantage of this opportunity and exercise your rights as part of our Emergency Medicine community. Dare to make a difference by submitting a resolution to the ACEP Council.

ACEP Joins Partnership of Professional Organizations to Improve Care for Patients with Hereditary Angioedema 

ACEP is excited to announce its partnership with the American College of Allergy, Asthma and Immunology (ACAAI), the American Gastroenterological Association (AGA) Institute, and the World Allergy Organization (WAO) in the “HAE: Learn About It, Talk About It” program, an innovative, peer-driven campaign aimed at uniting disparate specialties that see patients with hereditary angioedema (HAE) to help advance the standard of care.

HAE is a rare and potentially fatal genetic disease characterized by sudden, severe, and painful swelling episodes that can affect any part of the body. Because HAE symptoms can mimic other emergencies, including appendicitis, acute abdomen, or an allergic reaction, the average patient can endure 13 years of repeated misdiagnoses before HAE is identified.

As the first line of contact with undiagnosed and diagnosed patients in many cases, emergency physicians and physicians’ assistants can play an important role in improving care for patients by quickly recognizing HAE symptoms, understanding new disease management paradigms, and referring patients to an HAE-treating physician for appropriate management.

With new, targeted therapy options available in the U.S., now is the time for specialists on the front lines of HAE to work together to improve patient care through increased awareness and education, faster diagnosis, and appropriate disease management.

Visit their website to learn more about HAE and its impact in emergency medicine, to be prepared by finding an HAE-treating allergist in your area, and to take advantage of free educational resources, including an HAE Webinar, podcast series, and iPhone app.

“HAE: Learn About It, Talk About It” is supported by ViroPharma Incorporated.

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