Advanced practice providers in academic emergency medicine: A national survey of chairs and program directors.

BACKGROUND: The Society for Academic Emergency Medicine Board of Directors convened a task force to elucidate the current state of workforce, operational, and educational issues being faced by academic medical centers related to advanced practice providers (APPs). The task force surveyed academic emergency department (ED) chairs and residency program directors (PDs). METHODS: The survey was distributed to the Association of Academic Chairs of Emergency Medicine (AACEM)-member chairs and their respective residency PDs in 2021. We surveyed 125 chairs with their self-identified PDs. The survey sampled hiring, state-independent practice laws, scope of practice, teaching and supervision, training opportunities, delegation of procedures between physician learners and APPs, and perceptions of the impact on resident and medical student education. RESULTS: Of the AACEM-member chairs identified, 73% responded and 47% of PDs responded. Most (98%) employ either physician assistants or nurse practitioners. Among responding departments, 86% report APPs working in fast-track settings, 80% work in the main ED, and 54% work in the waiting room. In 44% of departments, APPs and residents evaluate patients concurrently, and 2% of respondents reported that APPs manage high-acuity patients without attending involvement. Two-thirds of chairs believe that APPs contribute positively to the quality of patient care, while 44% believe that APPs contribute to the academic environment. One-third of PDs believe that the presence of APPs interferes with resident education. Although 75% of PDs believe that residents require training to work effectively with APPs in the ED, almost half (49%) report zero hours of training around APP supervision or collaborative skills. CONCLUSIONS: APPs are ubiquitous across academic EDs. Future research is required for academic ED leaders to balance physician and APP deployment across the academic ED within the context of patient care, resident education, institutional resources, professional development opportunities for APP staff, and standardization of APP EM training.

Prehospital Trauma Scene and Transport Times for Pediatric and Adult Patients.

INTRODUCTION: Increased out-of-hospital time is associated with worse outcomes in trauma. Sparse literature exists comparing prehospital scene and transport time management intervals between adult and pediatric trauma patients. National Emergency Medical Services guidelines recommend that trauma scene time be less than 10 minutes. The objective of this study was to examine prehospital time intervals in adult and pediatric trauma patients. METHODS: We performed a retrospective cohort study of blunt and penetrating trauma patients in a five-county region in North Carolina using prehospital records. We included patients who were transported emergency traffic directly from the scene by ground ambulance to a Level I or Level II trauma center between 2013-2018. We defined pediatric patients as those less than 16 years old. Urbanicity was controlled for using the Centers for Medicare and Medicaid's Ambulance Fee Schedule. We performed descriptive statistics and linear mixed-effects regression modeling. RESULTS: A total of 2179 records met the study criteria, of which 2077 were used in the analysis. Mean scene time was 14.2 minutes (95% confidence interval [CI], 13.9-14.5) and 35.3% (n = 733) of encounters had a scene time of 10 minutes or less. Mean transport time was 17.5 minutes (95% CI, 17.0-17.9). Linear mixed-effects regression revealed that scene times were shorter for pediatric patients (p<0.0001), males (p=0.0016), penetrating injury (p<0.0001), and patients with blunt trauma in rural settings (p=0.005), and that transport times were shorter for males (p = 0.02), non-White patients (p<0.0001), and patients in urban areas (p<0.0001). CONCLUSION: This study population largely missed the 10-minute scene time goal. Demographic and patient factors were associated with scene and transport times. Shorter scene times occurred with pediatric patients, males, and among those with penetrating trauma. Additionally, suffering blunt trauma while in a rural environment was associated with shorter scene time. Males, non-White patients, and patients in urban environments tended to have shorter transport times. Future studies with outcomes data are needed to identify factors that prolong out-of-hospital time and to assess the impact of out-of-hospital time on patient outcomes.

Direct Air Versus Ground Transport Predictors for Rural Pediatric Trauma.

OBJECTIVE: Traumatic injury is the leading cause of mortality in children and the most common cause of emergency medical services transport in pediatric populations. We aimed to identify what factors are currently associated with selection for helicopter transport (HEMS) over ground ambulance (GEMS) in a primarily rural state. METHODS: We performed a retrospective case-control study of trauma patients younger than 18 years old reported to the Oklahoma State Trauma Registry between 2005 and 2014 who received direct transport from the scene of injury to a tertiary trauma center within the state. Factors associated with HEMS transport over GEMS were identified by multivariate regression analysis. RESULTS: Of the 1,700 patients in the study group, 50.8% were transported by HEMS. Increased distance (odds ratio [OR] = 6.1-18.6), lower Glasgow Coma Scale (OR = 2.5), multisystem injury (OR = 1.5), intubation (OR = 2.7), motor vehicle collision-related injuries (OR = 2.1), and elevated heart rate (OR = 1.8) were all associated with increased odds of HEMS transport, with distance being the strongest factor. CONCLUSION: This study found that the principal determinants of triage to HEMS transport in the case of pediatric trauma in a rural state were primarily distance to a major trauma center and clinical factors relating to the type and severity of injury.

Using the Association of American Medical Colleges Standardized Video Interview in a Holistic Residency Application Review.

Each year, residency programs work diligently to identify the best applicants for their respective programs, given the increasing volume of applications. Interview offers are often based on a mix of subjective and objective measures, with different programs relying more or less on each. A holistic application review involves a flexible and individualized way of assessing an applicant's capabilities through a balanced consideration of experiences, attributes, and academic metrics. When considered collectively, these attributes may define how an individual may perform as a physician. One particular tool developed by the American Association of Medical Colleges (AAMC), the Standardized Video Interview (SVI), provides an objective measure of an applicant's professional behavior and interpersonal communication skills. The SVI may provide applicants with a chance to showcase the intangibles about themselves that are neither entered on their application nor reflected by their standardized examination scores.

The ubiquitin-conjugating enzyme, UbcM2, is restricted to monoubiquitylation by a two-fold mechanism that involves backside residues of E2 and Lys48 of ubiquitin.

Proteins can be modified on lysines (K) with a single ubiquitin (Ub) or with polymers of Ub (polyUb). These different configurations and their respective topologies are primary factors for determining whether substrates are targeted to the proteasome for degradation or directed to nonproteolytic outcomes. We report here on the intrinsic ubiquitylation properties of UbcM2 (UBE2E3/UbcH9), a conserved Ub-conjugating enzyme linked to cell proliferation, development, and the cellular antioxidant defense system. Using a fully recombinant ubiquitylation assay, we show that UbcM2 is severely limited in its ability to synthesize polyUb chains with wild-type Ub. Restriction to monoubiquitylation is governed by multiple residues on the backside of the enzyme, far removed from its active site, and by lysine 48 of Ub. UbcM2 with mutated backside residues can synthesize K63-linked polyUb chains and to a lesser extent K6- and K48-linked chains. Additionally, we identified a single residue on the backside of the enzyme that promotes monoubiquitylation. Together, these findings reveal that a combination of noncatalytic residues within the Ubc catalytic core domain of UbcM2 as well as a lysine(s) within Ub can relegate a Ub-conjugating enzyme to monoubiquitylate its cognate targets despite having the latent capacity to construct polyUb chains. The two-fold mechanism for restricting activity to monoubiquitylation provides added insurance that UbcM2 will not build polyUb chains on its substrates, even under conditions of high local Ub concentrations.