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Aim: The “2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease” provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). Methods: A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

In the United States, acute low back pain, with or without radiculopathy, is the leading cause of years lived with disability and the third ranking cause of disability-adjusted life-years. Uncomplicated acute low back pain and/or radiculopathy is a benign, self-limited condition that does not warrant any imaging studies. Imaging is considered in those patients who have had up to 6 weeks of medical management and physical therapy that resulted in little or no improvement in their back pain. It is also considered for those patients presenting with red flags, raising suspicion for a serious underlying condition, such as cauda equina syndrome, malignancy, fracture, or infection. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Vaginal bleeding can occur throughout pregnancy with varied etiologies. Although history and physical examination can identify many etiologies, imaging, in particular ultrasound (US), is the backbone of current medical practice. US pregnant uterus transabdominal, US pregnant uterus transvaginal, and US duplex Doppler velocimetry are usually appropriate for the evaluation of women with painless vaginal bleeding, those with painful vaginal bleeding, and also for those with second or third trimester vaginal bleeding with suspicion of or known placenta previa, low-lying placenta, or vasa previa. US cervix transperineal may be appropriate for those with painless or painful vaginal bleeding but is usually not appropriate for second or third trimester vaginal bleeding with suspicion of or known placenta previa, low-lying placenta, or vasa previa. Because the outcome of pregnancies is unequivocally related to the specific etiology of the vaginal bleeding, knowledge of imaging results directly informs patient management to optimize the outcome for mother and fetus. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

This clinical policy from the American College of Emergency Physicians addresses key issues in opioid management in adult patients presenting to the emergency department. 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 experiencing opioid withdrawal, is emergency department-administered buprenorphine as effective for the management of opioid withdrawal compared with alternative management strategies? (2) In adult patients experiencing an acute painful condition, do the benefits of prescribing a short course of opioids on discharge from the emergency department outweigh the potential harms? (3) In adult patients with an acute exacerbation of noncancer chronic pain, do the benefits of prescribing a short course of opioids on discharge from the emergency department outweigh the potential harms? (4) In adult patients with an acute episode of pain being discharged from the emergency department, do the harms of a short concomitant course of opioids and muscle relaxants/sedative-hypnotics outweigh the benefits? 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 addressed key issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In the adult emergency department patient presenting with acute headache, are there risk-stratification strategies that reliably identify the need for emergent neuroimaging? (2) In the adult emergency department patient treated for acute primary headache, are nonopioids preferred to opioid medications? (3) In the adult emergency department patient presenting with acute headache, does a normal noncontrast head computed tomography scan performed within 6 hours of headache onset preclude the need for further diagnostic workup for subarachnoid hemorrhage? (4) In the adult emergency department patient who is still considered to be at risk for subarachnoid hemorrhage after a negative noncontrast head computed tomography, is computed tomography angiography of the head as effective as lumbar puncture to safely rule out subarachnoid hemorrhage? 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 is a revision of the 2009 "Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia." A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In the adult emergency department patient diagnosed with community-acquired pneumonia, what clinical decision aids can inform the determination of patient disposition? (2) In the adult emergency department patient with community-acquired pneumonia, what biomarkers can be used to direct initial antimicrobial therapy? (3) In the adult emergency department patient diagnosed with community-acquired pneumonia, does a single dose of parenteral antibiotics in the emergency department followed by oral treatment versus oral treatment alone improve outcomes? Evidence was graded and recommendations were made based on the strength of the available data.

Objectives The objectives were 1) to design systems ethnography roles for first-year medical students that could enhance student learning with regard to healthcare systems, ethnography, and systems thinking and 2) to describe strategies for other education programs seeking to implement systems ethnography roles in clinical settings. Methods Fourteen medical students were educated about ethnography and systems thinking and linked with patients in the emergency department (ED) for 12 to 15 hours to observe patient experiences and clinical processes. Students submitted written assignments, participated in a debriefing exercise with ED and medical education leadership, and completed an electronic survey regarding educational benefits and perceived clinical value conferred to the ED using 5-point Likert-scale questions. Qualitative methods were used to analyze both students’ assignments and notes taken during the debriefing session, including small-group report-outs and discussions, and to identify vulnerabilities in the patient experience. Results Students identified one overarching theme of the patient experience—prolonged waiting in close proximity to the fast-paced, hectic “world” of the ED. Four key categories of systems vulnerabilities were identified through student observations: 1) patient experience; 2) communication and collaboration; 3) processes, physical space, and resources; and 4) professionalism. Students reported improved appreciation for challenges experienced by patients (3.92/5), importance of communication between providers and patients (3.92/5), and improved understanding of the patient experience while receiving care (3.77/5). Conclusions These results demonstrate how innovative systems ethnography experiences for medical students can provide unique educational opportunities while at the same time adding value by highlighting shortcomings in the care environment that can be used for system improvement.

From the American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department: Thomas W. Lukens, MD, PhD, (Chair) Stephen J. Wolf, MD Jonathan A. Edlow, MD Samina Shahabuddin, MD Michael H. Allen, MD, (American Association for Emergency Psychiatry) Glenn W. Currier, MD, MPH, (American Association for Emergency Psychiatry) Andy S. Jagoda, MD, (Chair, Clinical Policies Committee)

Author(s): Hart, Danielle; Franzen, Douglas; Beeson, Michael; Bhat, Rahul; Kulkarni, Miriam; Thibodeau, Lorraine; Weizberg, Moshe; Promes, Susan | Abstract: Introduction: Medical education is moving toward a competency-based framework with a focus on assessment using the Accreditation Council for Graduate Medical Education Milestones. Assessment of individual competencies through milestones can be challenging. While competencies describe characteristics of the person, the entrustable professional activities (EPAs) concept refers to work-related activities. EPAs would not replace the milestones but would be linked to them, integrating these frameworks. Many core specialties have already defined EPAs for resident trainees, but EPAs have not yet been created for emergency medicine (EM). This paper describes the development of milestone-linked EPAs for EM. Methods: Ten EM educators from across North America formed a consensus working group to draft EM EPAs, using a modified Glaser state-of-the-art approach. A reactor panel with EPA experts from the United States, Canada and the Netherlands was created, and an iterative process with multiple revisions was performed based on reactor panel input. Following this, the EPAs were sent to the Council of Residency Directors for EM (CORD-EM) listserv for additional feedback.Results: The product was 11 core EPAs that every trainee from every EM program should be able to perform independently by the time of graduation. Each EPA has associated knowledge, skills, attitudes and behaviors (KSAB), which are either milestones themselves or KSABs linked to individual milestones. We recognize that individual programs may have additional focus areas or work-based activities they want their trainees to achieve by graduation; therefore, programs are also encouraged to create additional program-specific EPAs. Conclusion: This set of 11 core, EM-resident EPAs can be used as an assessment tool by EM residency programs, allowing supervising physicians to document the multiple entrustment decisions they are already making during clinical shifts with trainees. The KSAB list within each EPA could assist supervisors in giving specific, actionable feedback to trainees and allow trainees to use this list as an assessment-for-learning tool. Linking each KSAB to individual EM milestones allows EPAs to directly inform milestone assessment for clinical competency committees. These EPAs serve as another option for workplace-based assessment, and are linked to the milestones to create an integrated framework.

Introduction: Emergency medicine (EM) milestones are used to assess residents’ progress. While some milestone validity evidence exists, there is a lack of standardized tools available to reliably assess residents. Inherent to this is a concern that we may not be truly measuring what we intend to assess. The purpose of this study was to design a direct observation milestone assessment instrument supported by validity and reliability evidence. In addition, such a tool would further lend validity evidence to the EM milestones by demonstrating their accurate measurement. Methods: This was a multi-center, prospective, observational validity study conducted at eight institutions. The Critical Care Direct Observation Tool (CDOT) was created to assess EM residents during resuscitations. This tool was designed using a modified Delphi method focused on content, response process, and internal structure validity. Paying special attention to content validity, the CDOT was developed by an expert panel, maintaining the use of the EM milestone wording. We built response process and internal consistency by piloting and revising the instrument. Raters were faculty who routinely assess residents on the milestones. A brief training video on utilization of the instrument was completed by all. Raters used the CDOT to assess simulated videos of three residents at different stages of training in a critical care scenario. We measured reliability using Fleiss’ kappa and interclass correlations. Results: Two versions of the CDOT were used: one used the milestone levels as global rating scales with anchors, and the second reflected a current trend of a checklist response system. Although the raters who used the CDOT routinely rate residents in their practice, they did not score the residents’ performances in the videos comparably, which led to poor reliability. The Fleiss’ kappa of each of the items measured on both versions of the CDOT was near zero. Conclusion: The validity and reliability of the current EM milestone assessment tools have yet to be determined. This study is a rigorous attempt to collect validity evidence in the development of a direct observation assessment instrument. However, despite strict attention to validity evidence, inter-rater reliability was low. The potential sources of reducible variance include rater- and instrument-based error. Based on this study, there may be concerns for the reliability of other EM milestone assessment tools that are currently in use.

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.

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.

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.

This clinical policy focuses on critical issues concerning the management of adult patients presenting to the emergency department (ED) with acute symptomatic carbon monoxide (CO) poisoning. The subcommittee reviewed the medical literature relevant to the questions posed. The critical questions are: Should hyperbaric oxygen (HBO2) therapy be used for the treatment of patients with acute CO poisoning; and Can clinical or laboratory criteria identify CO-poisoned patients who are most or least likely to benefit from this therapy. Recommendations are provided on the basis of the strength of evidence of the literature. Level A recommendations represent patient management principles that reflect a high degree of clinical certainty; Level B recommendations represent patient management principles that reflect moderate clinical certainty; and Level C recommendations represent other patient management strategies that are based on preliminary, inconclusive, or conflicting evidence, or based on committee consensus. This clinical policy is intended for physicians working in hospital-based EDs.

Michael S. Beeson, MD, MBA, is Residency Program Director in the Department of Emergency Medicine, Akron General Medical Center; Wallace A. Carter, MD, is Residency Program Director in the Department of Emergency Medicine, New York Presbyterian Hospital; Theodore A. Christopher, MD, is Professor and Chairman of the Department of Emergency Medicine, Thomas Jefferson University and Hospitals; Jonathan W. Heidt, MD, is Clinical Instructor in the Division of Emergency Medicine, Washington University School of Medicine in St Louis; James H. Jones, MD, is Professor of Clinical Emergency Medicine in the Department of Emergency Medicine, Indiana University School of Medicine; Lynne E. Meyer, PhD, MPH, is Executive Director of the Review Committee for Emergency Medicine, Accreditation Council for Graduate Medical Education; Susan B. Promes, MD, is Professor and Vice Chair for Education in the Department of Emergency Medicine, University of California, San Francisco; Kevin G. Rodgers, MD, is Professor in the Department of Emergency Medicine, Indiana University School of Medicine; Philip H. Shayne, MD, is Professor and is Program Director and Vice Chair for Education in the Department of Emergency Medicine, Emory University School of Medicine; Mary Jo Wagner, MD, is Residency Program Director and Chief in the Department of Emergency Medicine, Central Michigan University College of Medicine; and Susan R. Swing, PhD, is Vice President of Outcome Assessment at the Accreditation Council for Graduate Medical Education.

Background Women in medicine continue to experience disparities in earnings, promotion, and leadership roles. There are few guidelines in place defining organization-level factors that promote a supportive workplace environment beneficial to women in emergency medicine (EM). We assembled a working group with the goal of developing specific and feasible recommendations to support women's professional development in both community and academic EM settings. Methods We formed a working group from the leadership of two EM women's organizations, the Academy of Women in Academic Emergency Medicine (AWAEM) and the American Association of Women Emergency Physicians (AAWEP). Through a literature search and discussion, working group members identified four domains where organizational policies and practices supportive of women were needed: 1) global approaches to supporting the recruitment, retention, and advancement of women in EM; 2) recruitment, hiring, and compensation of women emergency physicians; 3) supporting development and advancement of women in EM; and 4) physician health and wellness (in the context of pregnancy, childbirth, and maternity leave). Within each of these domains, the working group created an initial set of specific recommendations. The working group then recruited a stakeholder group of EM physician leaders across the country, selecting for diversity in practice setting, geographic location, age, race, and gender. Stakeholders were asked to score and provide feedback on each of the recommendations. Specific recommendations were retained by the working group if they achieved high rates of approval from the stakeholder group for importance and perceived feasibility. Those with >80% agreement on importance and >50% agreement on feasibility were retained. Finally, recommendations were posted in an open online forum (blog) and invited public commentary. Results An initial set of 29 potential recommendations was created by the working group. After stakeholder voting and feedback, 16 final recommendations were retained. Recommendations were refined through qualitative comments from stakeholders and blog respondents. Conclusions Using a consensus building process that included male and female stakeholders from both academic and community EM settings, we developed recommendations for organizations to implement to create a workplace environment supportive of women in EM that were perceived as acceptable and feasible. This process may serve as a model for other medical specialties to establish clear, discrete organization-level practices aimed at supporting women physicians.

ACADEMIC EMERGENCY MEDICINE 2012; 19:852–860 © 2012 by the Society for Academic Emergency Medicine Abstract Objectives: The objective was to report the results of a survey conducted jointly by the Society for Academic Emergency Medicine (SAEM) and the Association of Academic Chairs in Emergency Medicine (AACEM) of faculty salaries, benefits, work hours, and department demographics for institutions sponsoring residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee for Emergency Medicine (RRC-EM). Methods: Data represent information collected for the 2009–2010 academic year through an electronic survey developed by SAEM and AACEM and distributed by the Office for Survey Research at the University of Michigan to all emergency department (ED) chairs and chiefs at institutions sponsoring accredited residency programs. Information was collected regarding faculty salaries and benefits; clinical and nonclinical work hours; sources of department income and department expenses; and selected demographic information regarding faculty, EDs, and hospitals. Salary data were sorted by program geographic region and faculty characteristics such as training and board certification, academic rank, department title, and sex. Demographic data were analyzed with regard to numerous criteria, including ED staffing levels, patient volumes and length of stay, income sources, salary incentive components, research funding, and specific type and value of fringe benefits offered. Data were compared with previous SAEM studies and the most recent faculty salary survey conducted by the Association of American Medical Colleges (AAMC). Results: Ninety-four of 155 programs (61%) responded, yielding salary data on 1,644 faculty, of whom 1,515 (92%) worked full-time. The mean salary for all faculty nationwide was $237,884, with the mean ranging from $232,819 to $246,853 depending on geographic region. The mean salary for first-year faculty nationwide was $204,833. Benefits had an estimated mean value of $48,915 for all faculty, with the mean ranging from $37,813 to $55,346 depending on geographic region. The following factors are associated with higher salaries: emergency medicine (EM) residency training and board certification, fellowship training in toxicology and hyperbaric medicine, higher academic rank, male sex, and living in the western and southern regions. Full-time EM faculty work an average of 20 to 23 clinical hours and 16 to 19 nonclinical hours per week. Conclusions: The salaries for full-time EM faculty reported in this survey were higher than those found in the AAMC survey for the same time period in the majority of categories for both academic rank and geographic region. On average, female faculty are paid 10% to 13% less than their male counterparts. Full-time EM faculty work an average of 20 to 23 clinical hours and 16 to 19 nonclinical hours per week, which is similar to the work hours reported in previous SAEM surveys.

Objective Emergency Department (ED) crowding is a major public health problem and one that has not been well studied for its effects on education. The objective of this article was to identify best-practice, consensus recommendations to help emergency medicine (EM) residency programs and faculty maintain educational excellence in an era of ED crowding. Methods A geographically diverse group of 37 clinician-educator leaders in EM convened at the 2010 Council of Emergency Medicine Residency Directors Academic Assembly. The participants discussed innovative ideas and solutions to address the many educational challenges that ED crowding poses. Results To cope with crowding, the consensus group identified 3 educational domains, focusing on the educator, the learner, and the institutional system. Core subthemes included optimizing teaching opportunities, providing alternative teaching approaches, and redefining what faculty and learners traditionally think of as teaching. An ED rotation provides ample opportunities for teaching not only about patient care and medical knowledge but also other Accreditation Council for Graduate Medical Education competencies, such as interpersonal and communication skills, professionalism, and system-based practice. Conclusions Crowding in EDs poses educational challenges, but with some creativity, flexibility, and desire to make the most of a challenging situation, educational excellence is an achievable goal.

Strategies for approaching generational issues that affect teaching and learning, mentoring, and technology in emergency medicine (EM) have been reported. Tactics to address generational influences involving the structure and function of the academic emergency department (ED), organizational culture, and EM schedule have not been published. Through a review of the literature and consensus by modified Delphi methodology of the Society for Academic Emergency Medicine Aging and Generational Issues Task Force, the authors have developed this two-part series to address generational issues present in academic EM. Understanding generational characteristics and mitigating strategies can address some common issues encountered in academic EM. By understanding the differences and strengths of each of the cohorts in academic EM departments and considering simple mitigating strategies, faculty leaders can maximize their cooperative effectiveness and face the challenges of a new millennium.

ACADEMIC EMERGENCY MEDICINE 2011; 18:190–199 © 2011 by the Society for Academic Emergency Medicine Abstract For the first time in history, four generations are working together—traditionalists, baby boomers, generation Xers (Gen Xers), and millennials. Members of each generation carry with them a unique perspective of the world and interact differently with those around them. Through a review of the literature and consensus by modified Delphi methodology of the Society for Academic Emergency Medicine Aging and Generational Issues Task Force, the authors have developed this two-part series to address generational issues present in academic emergency medicine (EM). Understanding generational characteristics and mitigating strategies can help address some common issues encountered in academic EM. Through recognition of the unique characteristics of each of the generations with respect to teaching and learning, mentoring, and technology, academicians have the opportunity to strategically optimize interactions with one another.

Background Representatives of emergency medicine (EM) were asked to develop a consensus report that provided a review of the past and potential future effects of duty hour requirements for EM residency training. In addition to the restrictions made in 2003 by the Accreditation Council for Graduate Medical Education, the potential effects of the 2008 Institute of Medicine (IOM) report on resident duty hours were postulated. Discussion The elements highlighted include patient safety, resident wellness, and the resident training experience. Many of the changes and recommendations did not affect EM as significantly as other specialties. Current training standards in EM have already emphasized patient safety by requiring continuous onsite supervision of residents. Resident fatigue has been addressed with restrictions of shift lengths and limitation of consecutive days worked. Conclusion One recommendation from the IOM was a required 5-h rest period for residents on call. Emergency department (ED) patient safety becomes an important concern with the decrease in the availability and in the patient load of a resident consultant that may result from this recommendation. Of greater concern is the already observed slower throughput time for admitted patients waiting for resident care, which will increase ED crowding and decrease patient safety in academic institutions. A balance between being overly prescriptive with duty hour restrictions and trying to improve resident wellness was recommended. Discussion is included regarding the appropriate length of EM training programs if clinical experiences were limited by new duty hour regulations. Finally, this report presents a review of the financing issues associated with any changes.

Objectives: The goal of undergraduate medical education is to prepare medical students for residency training. Active learning approaches remain important elements of the curriculum. Active learning of technical procedures in medical schools is particularly important, because residency training time is increasingly at a premium because of changes in the Accreditation Council for Graduate Medical Education duty hour rules. Better preparation in medical school could result in higher levels of confidence in conducting procedures earlier in graduate medical education training. The hypothesis of this study was that more procedural training opportunities in medical school are associated with higher first-year resident self-reported competency with common medical procedures at the beginning of residency training. Methods: A survey was developed to assess self-reported experience and competency with common medical procedures. The survey was administered to incoming first-year residents at three U.S. training sites. Data regarding experience, competency, and methods of medical school procedure training were collected. Overall satisfaction and confidence with procedural education were also assessed. Results: There were 256 respondents to the procedures survey. Forty-four percent self-reported that they were marginally or not adequately prepared to perform common procedures. Incoming first-year residents reported the most procedural experience with suturing, Foley catheter placement, venipuncture, and vaginal delivery. The least experience was reported with thoracentesis, central venous access, and splinting. Most first-year residents had not provided basic life support, and more than one-third had not performed cardiopulmonary resuscitation (CPR). Participation in a targeted procedures course during medical school and increasing the number of procedures performed as a medical student were significantly associated with self-assessed competency at the beginning of residency training. Conclusions: Recent medical school graduates report lack of self-confidence in their ability to perform common procedures upon entering residency training. Implementation of a medical school procedure course to increase exposure to procedures may address this challenge.

Goal-directed pelvic sonography in pregnant women is one of the primary indications for emergency department ultrasound. It can be used to confirm the presence of an intrauterine pregnancy (IUP) in a woman with a positive BHCG who presents with abdominal pain or vaginal bleeding, thus making the diagnosis of ectopic pregnancy extremely unlikely in most cases. After an IUP has been confirmed, fetal age may be estimated. IN the absence of IUP visualization of free fluid in the pelvis, and/or an adnexal mass may aid in the diagnosis of ectopic pregnancy. Bedside ultrasound may also be used in the initial evaluation of the fetus and placenta in the pregnant trauma patient to look for an abruption and signs of fetal cardiac activity and fetal movement. Fetal movement and cardiac activity can easily be visualized and occasionally an abruption may be identified.

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.

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.

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. This has now been corrected online. The publisher would like to apologize for any inconvenience caused.

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.

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.

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.

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.

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.

This clinical policy from the American College of Emergency Physicians is the revision of the 2003 Clinical Policy: Critical Issues in the Initial Evaluation and Management of Patients Presenting to the Emergency Department in Early Pregnancy.(1) A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1) Should the emergency physician obtain a pelvic ultrasound in a clinically stable pregnant patient who presents to the emergency department (ED) with abdominal pain and/or vaginal bleeding and a beta human chorionic gonadotropin (β-hCG) level below a discriminatory threshold? (2) In patients who have an indeterminate transvaginal ultrasound, what is the diagnostic utility of β-hCG for predicting possible ectopic pregnancy? (3) In patients receiving methotrexate for confirmed or suspected ectopic pregnancy, what are the implications for ED management? Evidence was graded and recommendations were developed based on the strength of the available data in the medical literature. A literature search was also performed for a critical question from the 2003 clinical policy.(1) Is the administration of anti-D immunoglobulin indicated among Rh-negative women during the first trimester of pregnancy with threatened abortion, complete abortion, ectopic pregnancy, or minor abdominal trauma? Because no new, high-quality articles were found, the management recommendations from the previous policy are discussed in the introduction.

In 2001, "The Model of the Clinical Practice of Emergency Medicine" was first published. This document, the first of its kind, was the result of an extensive practice analysis of emergency department (ED) visits and several expert panels, overseen by representatives from six collaborating professional organizations (the American Board of Emergency Medicine, the American College of Emergency Physicians, the Society for Academic Emergency Medicine, the Residency Review Committee for Emergency Medicine, the Council of Emergency Medicine Residency Directors, and the Emergency Medicine Residents' Association). Every 2 years, the document is reviewed by these organizations to identify practice changes, incorporate new evidence, and identify perceived deficiencies. For this revision, a seventh organization was included, the American Academy of Emergency Medicine.

Study Objective: We determine whether paramedics, using written guidelines, can accurately triage patients in the field. Methods: This prospective, descriptive study was conducted at an urban county emergency medical services (EMS) system and county hospital. Paramedics triaged patients, for study purposes only, according to 4 categories: (1) needing to come to the emergency department by advanced life support (ALS) transport, (2) needing to come to the ED by any transport, (3) needing to see a physician within 24 hours, or (4) not needing any further physician evaluation. Medical records that provided patient treatment information to the point of ED disposition were subsequently reviewed (blinded to the paramedic rating) to determine which of the categories was appropriate. The protocol of the EMS system of the study site dictates that all patients should be transported except for those who refuse care and leave against medical advice. Only transported patients were included in the present study. Fifty-four paramedics triaged 1,180 patients. Results: Mean patient age was 43.4±17 years; 62.0% were male. Paramedics rated 1,000 (84.7%) of the patients as needing to come to the ED and 180 (15.3%) as not needing to come to the ED. Ratings according to triage category were as follows: 804 (68.1%) category 1, 196 (16.6%) category 2, 148 (12.5%) category 3, and 32 (2.7%) category 4. Seven hundred thirty-six (62.4%) patients were discharged, 298 (25.3%) were admitted, 90 (7.6%) were transferred, 36 (3.1%) left against medical advice, and 20 (1.7%) died. The review panel determined that 113 (9.6%) patients were undertriaged; 55 (48.7%) of these patients were misclassified because the paramedics misused the guidelines. Ninety-nine patients (8.4% of the total sample) were incorrectly classified as not needing to come to the ED. This represented 55% of the patients (99/180) categorized as 3 or 4 by the paramedics. Fourteen patients (1.2% of total) were incorrectly classified as category 4 instead of 3. Of the 113 undertriaged patients, 22 (19.6%) were admitted, 86 (76.1%) were discharged, and 4 (3.5%) were transferred. Conclusion: Paramedics using written guidelines fall short of an acceptable level of triage accuracy to determine disposition of patients in the field. [Pointer JE, Levitt MA, Young JC, Promes SB, Messana BJ, Ader MEJ. Can paramedics using guidelines accurately triage patients? Ann Emerg Med. September 2001;38:268-277.]