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Study Objective: We examine the concordance between end-tidal partial pressure of CO2 (PetCO2) measured by capnography and arterial partial pressure of carbon dioxide (PaCO2) obtained by arterial blood gas in acute asthmatic patients presenting to the emergency department., Methods: This was a prospective observational cohort study of acutely ill adult asthmatic patients undergoing an arterial blood gas measurement as part of their evaluation. PetCO2 was recorded during exhalation into a capnograph while arterial blood was pulsing in the arterial blood gas tubing. Concordance between PetCO2 and PaCO2 was displayed as a Bland-Altman matrix, using prespecified limits of agreement of +/-5 mm Hg difference between PetCO2 and PaCO2 in each patient., Results: The mean difference between the PetCO2 and PaCO2 levels was 1.0 mm Hg (95% confidence interval -0.1 to 2.0 mm Hg), with a median of 0 mm Hg. Of the 39 patients enrolled, 37 (95%) fell within the a priori limits of agreement., Conclusion: In adult asthmatic patients with acute exacerbations, concordance between PetCO2 measured by capnography and PaCO2 measured by arterial blood gas was high. These findings must be validated before capnography replacement of arterial blood gas as an accurate means of assessing alveolar ventilation in acute asthma is recommended.

In Williamsburg, VA, April 17 to 20, 1994, the Josiah Macy, Jr. Foundation sponsored a conference entitled "The Role of Emergency Medicine in the Future of American Medical Care," a report on which was published in Annals in 1995. This report promulgated recommendations for the development and enhancement of academic departments of emergency medicine and a conference to develop an agenda for research in emergency medicine. The American College of Emergency Physicians' Research Committee, along with several ad hoc members, presents updates in several of the areas addressed by the Macy Report and subsequent conferences, as a status report for the development of emergency medicine research as a whole, as of late 2002.

Study Objective: One of the principal criticisms of performance assessments, particularly those using an oral format to evaluate physician performance, is the lack of interrater reliability. The objective of this study was to assess interexaminer agreement in the scoring of candidates taking the American Board of Emergency Medicine (ABEM) oral certification examination., Methods: Examiner-observer pairs independently scored individual candidates on each of the 6 simulated cases selected for the October 1999 examination. Simple proportionate agreement for "acceptable" and "unacceptable" scores on critical actions and performance ratings were used to measure interexaminer (examiner-observer) agreement. Further analyses were performed to assess interexaminer agreement at the level of the raw scores of all performance ratings. The candidate's actual score was determined entirely by the examiner administering the case. The study examiner was present only to observe and independently score the candidate. Examiners were blinded to each other's scoring. All examiner-observer, examiner-candidate, and observer-candidate pairings were uniquely randomized and occurred only once during the examination., Results: Of 564 candidates, 186 were randomly selected for scoring by examiner-observer pairs drawn from a pool of 107 trained oral examiners. Interexaminer agreement for 47 critical actions was 97% (95% confidence interval [CI] 96% to 98%), and interexaminer agreement for 68 performance ratings was 95% (95% CI 94% to 96%). Further analyses of raw scores of performance ratings indicated that 94% (95% CI 93% to 95%) of 2,648 pairs of ratings differed by 1 point or less., Conclusion: High interexaminer agreement on the scoring of the ABEM oral certification examination supports the reliability of this final step in the certification process. On the basis of these findings, ABEM has incorporated this methodology into the administration of each oral examination as an ongoing quality control measure.

The American Board of Emergency Medicine gathers extensive background information on emergency medicine residents and the programs in which they train. We present the sixth annual report on the status of US emergency medicine residency programs.

Objective: To test the hypothesis that emergency medicine (EM) has made significant, quantifiable progress within U.S. academic medicine over the past ten years, 1991-2001., Methods: Baseline (7/1/1991) and comparison (7/1/2001) data sets contained all Liaison Committee on Medical Education (LCME)-accredited schools, Association of Academic Chairs of Emergency Medicine (AACEM)-recognized academic departments of EM, Residency Review Committee (RRC)-accredited EM residencies, and Association of American Medical Colleges (AAMC)-designated academic medical centers. The increase over ten years in the two primary variables of academic departmental status, and EM residencies located at academic medical centers, was examined in the aggregate, then stratified by medical schools grouped by academic rank. Differences over time are expressed as simple proportions, bounded by 95% confidence intervals (95% CIs)., Results: Between 1991 and 2001, the proportion of academic departments of EM at medical schools increased from 18% to 48% (95% CI for difference of 30% = 19% to 41%). The proportion of EM residencies at academic medical centers increased from 42% to 66% (95% CI for a difference of 24% = 11% to 36%). The largest increment of 37% (95% CI = 22% to 52%) in academic departments of EM, and of 36% (95% CI = 20% to 52%) in EM residencies located at academic medical centers, occurred within medical schools whose academic rank was above the median., Conclusions: A quantitatively and statistically significant increase in academic departments of EM within medical schools and EM residency programs at academic medical centers has occurred over the past decade. Half of all medical schools now have academic departments of EM, and two-thirds of academic medical centers house EM residency programs. This has taken place largely within institutions whose academic ranking places them among the top half of all U.S. medical schools.

The American Board of Emergency Medicine gathers extensive background information on emergency medicine residents and the programs in which they train. We present the fifth annual report on the status of US emergency medicine residency programs

The American Board of Emergency Medicine gathers extensive background information on emergency medicine residents and the programs in which they train. We present the fourth annual report on the status of US emergency medicine residency programs.

The American Board of Emergency Medicine gathers extensive background information on emergency medicine residents and the programs in which they train. We present the third annual report on the status of US emergency medicine residency programs. [American Board of Emergency Medicine. Report of the Task Force on Residency Training Information (1999-2000), American Board of Emergency Medicine. Ann Emerg Med. May 2000;35:481-498.]

Academic Emergency Medicine is interested in publishing systematic reviews (also known as meta-analyses) containing explicit, quantitative compilations of valid, critically appraised evidence targeted at topics relevant to the science and practice of emergency medicine. This article presents a strategy for the performance and reporting of systematic reviews, based on established recommendations. A well-performed systematic review of the literature may provide clinically relevant information otherwise unobtainable, and has potential to alter patient care. Systematic reviews are logical methodological extensions of evidence-based medicine.

The American Board of Emergency Medicine gathers extensive background information on emergency medicine residents and the programs in which they train. We present the second annual report on the status of US emergency medicine residency programs. [American Board of Emergency Medicine: Report of the Task Force on Residency Training Information (1998-1999), American Board of Emergency Medicine. Ann Emerg Med May 1999;33:529-545.]

Objective: To test the hypothesis that establishment of academic departments of emergency medicine (EM) is associated with improvements in attributes valued by traditional academic medicine., Methods: Cross-sectional, observational analysis of academic departments of EM at all accredited allopathic medical schools, as of July 1, 1996. Nonrespondents were mailed questionnaires three times, followed by phone contact. All variables were examined as before-after comparisons associated with department formation. Findings were reported as absolute differences, bounded by 99% confidence intervals (99% CIs), adjusted for multiple comparisons., Results: Of 50 departments, 49 responded. Department formation was associated with a 25% (99% CI 5% to 46%) increase in accredited EM residencies, a 33% (99% CI 9% to 56%) increase in extramural grant funding, and 46% (99% CI 23% to 69%) and 34% (99% CI 8% to 58%) increases in departmental representation on medical school curriculum and promotions committees, respectively. The mean increase in academic faculty full-time equivalents (FTEs) was 6.7 (99% CI 3.3 to 10.1). There were average increments of 2.1 FTEs (99% CI 1.4 to 2.7) and 0.8 FTEs (99% CI 0.4 to 1.1) attaining senior ranks of associate professor and professor, respectively. With a top possible Likert scale score of 3, departmental status was associated with essentially identical improvements in the quality of faculty [2.6 (99% CI 2.4 to 2.8)], EM residents [2.6 (99% CI 2.4 to 2.8)], student teaching [2.7 (99% CI 2.5 to 2.9)], and overall academic productivity [2.8 (99% CI 2.7 to 3.0)]., Conclusion: Establishment of academic departments of EM at medical schools is associated with quantitatively and statistically significant improvements in many academic attributes that are mutually beneficial for both the institution and the specialty.

The American Board of Emergency Medicine gathers extensive background information on emergency medicine residents and the programs in which they train. Before the compilation of this report, this information has not been widely available.

Study Objective: The Science Citation Index "impact factor" is the only available quantitative estimate of a journal's scientific contributions. However, the derivation of this factor contains an intrinsic bias that underestimates the impact of emergency medicine journals. We wished to test the hypothesis that use of an alternative criterion standard would provide an improved profile of the scientific contributions of emergency medicine journals relative to those of other specialties., Methods: We used an observational, longitudinal, comparative design in which all Index Medicus citations from Advanced Cardiac Life Support (ACLS) publications were aggregated by journal and then stratified by specialty. Proportions and proportionate trends, relative to total citations, were reported by specialty, facilitating comparison of emergency medicine with other disciplines., Results: Among all eight ACLS publications (1974-1994) 4,062 citations met the inclusion criteria. Emergency medicine journals were referenced in 16% of eligible citations (99% confidence interval [CI], 14% to 17%), a figure exceeded only by internal medicine and cardiology journals. Emergency medicine was the only discipline to show a significant proportionate increase in contributions over the 20-year study period (P < .001 by chi 2 for linear trend analysis)., Conclusion: Contrary to the implications of a low impact factor, an analysis of journal citations in ACLS publications over two decades suggests that emergency medicine has made significant contributions to a broad and important area of scientific inquiry.

Study Objective: The "impact factor" published in Science Citation Index (SCI) is widely used in the scientific community to measure the relative importance of a medical journal. In contrast to all other indicators of academic growth in emergency medicine, impact factors for emergency medicine journals have remained low and unchanged since the inception of the specialty. We wished to investigate this incongruity., Methods: We examined the methodology used to derive the SCI's journal impact factor., Results: The impact factor for journals is defined mathematically as the number of times a journal is cited over a period of time (the numerator) divided by the number of articles published by that journal during the same period (the denominator). Citation counts are derived from examination of all references contained in a subset of journals known as "source" journals. No emergency medicine journals are included in this group. The only source of citations for emergency medicine journals is from journals outside of emergency medicine. This produces small numerators with relatively constant denominators, leading to low impact factors., Conclusion: The apparent failure of emergency medicine journals, as measured by the SCI impact factor, to keep pace with other indicators of academic development of the field is at least in part attributable to a methodologic bias inherent in the derivation of this factor.

Objective: An SAEM national task force previously concluded that academic departments and residencies in emergency medicine (EM) had preferentially developed outside of the academic mainstream. This study was designed to determine whether EM has made significant inroads into academic medical centers over the past 5 years., Methods: The baseline data set (7/1/91) contained all 126 Liaison Committee on Medical Education (LCME)-accredited schools, and all 87 Residency Review Committee (RRC)-accredited EM residencies. The comparison data set (7/1/96) contained all 124 LCME-accredited schools, and all 114 RRC-accredited EM residencies. The 1991-96 increments in academic departments and university-hospital residencies was examined in the aggregate, then stratified by medical schools grouped into quartiles and contiguous quartiles, according to academic ranking. A-priori and post-hoc comparisons were expressed with 95% and 99% confidence intervals (CIs), respectively., Results: Over the past 5 years, the proportion of academic departments of EM increased by 23%, from 18% to 41% of all LCME-accredited schools (95% CI 12% to 34%). The largest increase (58%; 99% CI 40% to 77%) occurred among those schools academically ranked above the median. The proportion of EM residencies at university hospitals increased by 17%, from 40% to 57% (95% CI 5% to 30%). Again, the largest increase (25%; 99% CI 3% to 47%) occurred at university hospitals affiliated with schools academically ranked above the median., Conclusion: EM has made substantial inroads into academic medical centers over the past 5 years. This is reflected in quantitatively and statistically significant increases in academic departments and university-hospital residency programs, both occurring largely within institutions whose academic rankings place them among the upper half of all LCME-accredited medical schools.

Objective: To quantify one aspect of emergency medicine (EM) training by determining the proportion of emergency procedures performed by emergency physicians (EPs) in EDs with EM residency programs (EMRPs)., Methods: Cross-sectional descriptive survey of all allopathic EMRPs accredited by the EM Residency Review Committee (RRC-EM) as of July 1, 1993. Using a modified visual analog scale, program directors indicated the proportion of ten index procedures performed in the ED by EPs vs all other physicians., Results: All 98 EMRPs meeting entry criteria responded to the survey. The medians for the percentage of times index procedures were performed in the ED by an EP were as follows (parentheses following percentages enclose 95% CIs): endotracheal intubation, 97% (95%, 100%); reduction of anterior shoulder dislocation, 93% (88%, 97%); thoracostomy, 63% (50%, 75%); transvenous pacer insertion, 60% (50%, 75%); cricothyrotomy, 50% (50%, 75%); thoracotomy, 50% (25%, 50%); diagnostic peritoneal lavage, 50% (25%, 50%); fiberoptic laryngoscopy, 22% (6%, 25%); sigmoidoscopy, 0% (0%, 6%); and pelvic sonography, 0% (0%, 0%)., Conclusion: EPs in EDs of institutions that have EMRPs perform, on average, 50% of all index procedures (95% CI 47%, 52%). This information may assist EM programs experiencing difficulty in ensuring that their residents receive an equitable share of those procedures that are critical to their training.

Study Objective: To characterize the role of emergency medicine residency programs in determining emergency medicine career choice among medical students., Design: Observational, cross-sectional, descriptive study. Information on student career choice was obtained through a targeted query of the National Resident Matching Program data base, simultaneously stratified by specialty and school, and adjusted for class size., Participants: All accredited emergency medicine residency programs and four-year allopathic medical schools., Results: Fifty-two schools (42%) had a closely affiliated emergency medicine residency program, ie, one based primarily at the institution's main teaching hospital(s). This configuration was associated with a 70% increase in the median proportion of students choosing emergency medicine as a career when compared to the 73 schools with no closely affiliated emergency medicine residency (5.1% vs 3.0%, P < .0001). When institutions were stratified by overall commitment to emergency medicine, the median proportion of students choosing emergency medicine as a career was 2.9% for institutions with a minimal commitment to emergency medicine (neither an academic department of emergency medicine nor a closely affiliated emergency medicine residency), 4.1% for institutions with a moderate commitment to emergency medicine (either a department of emergency medicine or an emergency medicine residency, but not both), and 5.7% for institutions with a substantial commitment to emergency medicine (a department of emergency medicine and an emergency medicine residency) (P < .0001). When institutional commitment to emergency medicine was examined in a simple multivariate model, only the presence of an emergency medicine residency was associated independently with student career choice (P < .001)., Conclusion: An emergency medicine residency program that is closely affiliated with a medical school is strongly and independently associated with a quantitatively and statistically significant increase in the proportion of students from that school who choose a career in emergency medicine. These data support the proposition that, if emergency medicine is to meet national manpower shortage needs by attracting students to the specialty, it must establish residency programs within the primary teaching hospital(s) of medical schools. Such a configuration does not currently exist in the majority of schools.

Objective: To characterize the status of emergency medicine within U.S. academic medical centers., Methods: All accredited emergency medicine residency programs and all four-year allopathic medical schools in the United States were identified. Institutions were defined as academic medical centers based upon NIH research grant funding. These institutions were ranked using five measures of academic stature: a survey of medical school deans, a survey of internal medicine residency directors, level of research funding, characteristics of the student body, and an unweighted composite variable reflecting overall academic stature. The relationship between institutional academic stature and an empiric scale of institutional affiliation with emergency medicine was assessed., Results: Sixty-two institutions were designated academic medical centers. These medical schools captured 90% of all NIH grant monies awarded in fiscal year 1990. Twenty-six of 87 emergency medicine residency programs (30%) were closely affiliated with one of these medical schools. Within academic medical centers, the presence of a residency or an academic department of emergency medicine was inversely associated with the medical school deans' ranking (p < 0.005), research rank (p < 0.001), and composite academic rank (p < 0.001)., Conclusion: The majority of emergency medicine residency programs (70%) are not closely affiliated with institutions receiving the bulk (90%) of NIH resources for research. Within the institutions receiving the majority of NIH funding, there is a quantitatively and statistically significant inverse association of institutional emergency medicine affiliation and institutional academic rank.