ACEP President talks Boarding, Workplace Violence, Workforce at VACEP ‘24
Boarding, Workplace Violence, and emergency physician “maldistribution.”
They were the three critical emergency medicine issues addressed last weekend by American College of Emergency Physicians president Aisha T. Terry, MD, MPH, FACEP. Her attendance marks the third straight year that VACEP has brought ACEP’s emergency physician leader directly to Virginia’s emergency medicine community.
ACEP President Aisha Terry, MD with newly installed VACEP board member Ashley Nicholson, MD.
Here’s a recap of her remarks.
On Boarding
ACEP is focused on solving the boarding crisis through the lens of health equity, Terry noted. In other words: when ERs are backed up, people don’t receive quality — or even humane — treatment.
ACEP signed onto a November 2022 letter to The White House urging a fix to the boarding crisis. Though not much came of it, ACEP convened a September 2023 boarding summit at its Washington offices that included representatives from the Centers for Medicare and Medicaid Serivces (CMS), medical societies, state and federal government leaders, hospitals, nursing homes, and patient group representatives.
“It wasn’t just us preaching to the choir,” Terry said. “This is a group of really influential folks who can move the needle if they so choose.”
The group came up with the root causes of the boarding crisis — staffing shortages, transport limitations, and misaligned financial incentives to reduce overcrowding. Here’s a report from the Summit. And as a result of it, in December, Secretary for the Department of Human Services of the United States Xavier Becerra tasked ACEP government agency partner the Agency for Healthcare Research and Quality to convene a roundtable to define actionable next steps to address boarding.
“We do feel the needle is moving, albeit slowly,” said Terry, an associate professor of emergency medicine and health policy at the George Washington University School of Medicine and Milken Institute School of Public Health in Washington, D.C..
Quality Measurement on Boarding
There is no official quality measure around boarding — but one is coming. The Yale University Center for Outcomes Research and CMS partnered to develop the Equity of Emergency Care Capacity and Quality for the Hospital Outpatient Quality Reporting (HOQR) program.
Yale and CMS aim to:
Capture variation in equity of emergency care, and measure capacity and quality of emergency care to support hospital quality improvement.
Reduce patient harm and improve outcomes for patients requiring care in an ED. Emergency care capacity is inclusive of several concepts pertaining to boarding and crowding in an ED.
Align with incentives to promote improved care both in EDs and the broader health system.
Capture established outcome metrics that quantify capacity and access of care in an ED. The target population includes patients of all ages and all visits that occur at an ED. There are two separate cohorts for this measure: one for patients without behavioral health disorders, and one for patients with behavioral health disorders.
On Workplace Violence
Fifty percent of healthcare workers say they have experienced physical assault, according to ACEP. Nurses get it the worst, Terry noted: 100% of emergency nurses reported verbal assault, and 85% reported physical assault in the past year.
And workplace violence directly impacts quality of care — 60% of patients have left an ED due to witnessing violence, without being seen by a doctor. Violence also increases burnout, trauma, and anxiety.
ACEP’s position on workplace violence has been to create protections for healthcare workers and establish penalties for assailants, Terry said. She said there must be a culture shift to understand that violence, even in a place where anything can happen, cannot be tolerated: “Even though we are in a special business to take care of people who may not have capacity, there has to be a way to still take care of patients safely — and also take care ourselves,” she said. “It is not okay to be screamed at in the ED.”
As of 2022, the leading accrediting body The Joint Commission requires all hospitals to meet certain standards to prevent workplace violence, she noted. That helps.
So does getting involved in politics. In addition to policy positions that help the national organization and state chapters guide legislative actions, ACEP has pushed the federal bipartisan "Workplace Violence Prevention for Health Care and Social Service Workers Act,” meant to protect emergency physicians and ED staff. It directs the Occupational Safety and Health Administration to issue a standard requiring healthcare and social service employers to write and implement a workplace violence prevention plan to prevent and protect their employees from violent incidents.
That legislation has passed the House of Representatives.
In addition, the “Safety from Violence for Healthcare Employees Act” (SAVE) to establish federal penalties for violence against healthcare workers, criminalizing intentional assault or intimidation against healthcare workers while ensuring reasonable protections for individuals who may be mentally incapacitated due to illness or substance use.
“In emergency medicine, oftentimes, our patients truly don't have the capacity to make great decisions. This legislation takes that into account,” she said. “The idea is not to put anyone in jail. The idea is to have a deterrent so that [violence] doesn’t happen in the first place.”
The SAVE Act is in progress.
Terry also praised Virginia as one of 11 states that has taken steps to combat workplace violence. Last year, Virginia passed a law requiring every emergency department to have 24/7 trained security.
“We talk about it all the time, how amazing Virginia is,” she said. “Other states are following your lead, and we’re super proud of all the work Virginia has done, and I know there is more to come.”
On Workforce
Terry pressed the need for more emergency physicians in rural areas, as most emergency physicians are working along the coasts and in urban centers. Without emergency physicians in rural areas, they cannot lead care teams, which impacts quality of and access to care, she said.
“The reality is we don’t have a shortage of emergency physicians. What we do have is a maldistribution of emergency physicians,” Terry said. “The issue is where we’re practicing. That’s more what we should be talking about.”
Applications to emergency medicine residencies are climbing, driven by DOs and international medical graduates. Source: Electronic Residency Application Service (ERAS).
A 2021 ACEP report noted emergency medicine is facing a likely oversupply of emergency physicians by 2030, to the tune of nearly 8,000 positions. In response, ACEP built a comprehensive plan to expand opportunities for emergency physicians while addressing rural challenges, residency standards, and the work environment, where burnout is a leading cause of attrition. The attrition rate among emergency physicians remains high compared to prior years and other specialties, Terry noted.
ACEP has committed to five “pillars” to address the issue of oversupply:
Define EM residency standards for the future. ACEP is part of a multi-organization task force to increase residency standards.
Ensure business interests of residency programs do not supersede education of residents or trainees or patient care.
Support emergency physicians in all communities.
Protect the unique role of emergency physicians and ensure care is led by an emergency physician.
Broaden demand of emergency services to meet evolving needs of the community.
Residency and workforce
There are approximately 280 emergency medicine residency programs in the U.S. The two most recent National Resident Matching Program (NRMP) Match cycles saw a high number of initially unfilled emergency medicine residency positions.
Growth in applications to emergency medicine residencies outpace all other specialties. Source: Electronic Residency Application Service (ERAS).
Coming out of the pandemic in 2021 — the same year of ACEP’s workforce oversupply report — there was a record interest in frontline emergency care. There were about 4,300 EM applicants to 265 residency programs. Of the 2,800 positions, essentially none went unfilled.
In 2022, there were 3,600 applicants to 277 emergency medicine programs. Of the 2,900 positions, 7% went unfilled.
In 2023, while applicants dropped again to about 3,200, a record 18% of the 3,000 positions went unfilled.
This year will see a return to 2021’s outlier application levels, with 4,400 applicants. Match Day is March 15.
Despite the interest in EM, Terry noted, “at the end of the day, our residency numbers are growing too fast.”
While experts expected a continued drop in applicants, that pool has rebounded with a growth rate eclipsing all other specialties. “Suffice to say, we are the winner,” Terry said. That growth is driven by osteopathic physicians (DOs) and international medical graduates (IMGs); MD applicants are up only slightly. “I think it behooves us to be aware of that now and prepare accordingly, to make sure that we have the strongest workforce possible,” she said.
Still, burnout-driven attrition remains an issue that impacts access, care, and supply.
“We have to figure out how to fix the burnout, how to fix the environment, how to fix the workplace violence, how to fix boarding so that we can really cure, or certainly ameliorate, the impact of burnout,” she said. “No doubt about it: it is impacting us and our future.”
But things are headed in the right direction, she said: “There is a brighter day ahead, I believe that.”
