AEP.org :: Policy and Position Statements
Policy and Position Statements

Contents:


Vision Statement - top
The vision of the Association of Emergency Physicians (AEP) is to represent all practitioners of Emergency Medicine independent of economics, politics, geographic location or training background.

AEP will always be focused on the issues of fairness, equity and quality patient care. AEP will always be a democratic organization responsive to "the hands that touch the patients." AEP will strive to expand the horizons of Emergency Care.

Mission Statements - top
The Association of Emergency Physicians (AEP) represents All Emergency Physicians from across the United States and internationally who are interested in continually improving the quality of emergency care for their patients, with a special emphasis on rural and underserved communities.

The Goals of AEP are:

  1. To promote the general welfare of Emergency Medicine and to improve the quality of emergency patient care.
  2. To promote freedom from unjust, unfair, or unlawful discrimination in the practice of emergency medicine.
  3. To represent and address the issues and concerns of the membership.
  4. To be the most cost-effective organization offering educational and professional development programs in our specialty.
  5. To collect information and provide a forum for open, uncensored, and meaningful communication concerning the quality of Emergency Medicine.

Emergency Medicine Definition - top
Emergency Medicine is the practice of medicine involving the diagnosis and treatment of any patient requiring unscheduled, episodic care or with acute injury or illness. The mandate of Emergency Medicine is to limit morbidity and mortality in these patients. The practice of Emergency Medicine spans from prehospital care to in-patient care in disciplines closely related to Emergency Medicine.

Emergency Medicine practice requires adequate knowledge and recognition of acute injury and illness, immediate treatment, stabilization and appropriate consultation or disposition for the patient.

Emergency Physician Definition - top
Emergency Physicians practice Emergency Medicine. An Emergency Physician has the education, training, experience and character necessary to practice emergency medicine effectively. A licensed physician with broad based education, training and clinical experience that is dedicated to Emergency Medicine practice is therefore an Emergency Physician.

Emergency Physicians practice in rural, suburban and urban environments. Emergency Physicians practice privately, practice in groups, are employed by a hospital or similar facility, are employed by governments and are employed by medical schools.
Emergency Physician practice ranges from free standing urgent care centers to the community hospital setting to the tertiary care, major medical center and academic setting.

Emergency Physicians are united by a common commitment to accept responsibility for providing unscheduled health care to this nation 24 hours a day.

Emergency Physician Qualifications - top
AEP believes that there is confusion concerning the following concepts; qualification, credentials, certification and competence.

A physician is qualified to practice medicine by virtue of meeting licensing requirements. A physician is qualified to practice a certain medical discipline based on a combination of education, training and clinical experience in that discipline or a closely related one. It is therefore mandatory that a physician be qualified.

A physician becomes credentialed to practice a discipline by meeting individual facility requirements for clinical practice privileges. Credentialing a physician is the exclusive right of the individual facility. Guidelines for acceptable credentials for the purpose of granting clinical privileges in any discipline vary from facility to facility. It is therefore mandatory for a physician to be credentialed.

A physician may become certified to practice a specialty. Certification in a specialty is a proprietary function of the individual certifying body. Certification is not currently a mandatory requirement. Certification in a specialty does not guarantee competence to practice that specialty. Certification is therefore voluntary.

A physician is deemed competent to practice a discipline based on qualification, credentials and, most importantly, satisfactory peer review, satisfactory department director evaluation and satisfactory evaluation of the quality of patient care rendered. It is therefore mandatory that a physician be competent.

An Emergency Physician therefore possesses the following;

  • qualifications: a license to practice medicine and a combination of education, training and clinical experience required to practice Emergency Medicine. (see EM definition policy).
  • credentials: the facility deems that the background, education, training, experience and character of a physician are appropriate to permit satisfactory practice of Emergency Medicine.
  • competence: based on the evaluations of peers and department directors, combined with clinically pertinent competency based assessment, this physician consistently practices emergency medicine at or above acceptable standards of emergency care with acceptable patient outcome.
  • dedication: an Emergency Physician is dedicated to Emergency Medicine practice and high quality emergency patient care.

Certification in Emergency Medicine - top
AEP believes that Emergency Medicine is best practiced by competent, caring and experienced Emergency Physicians. AEP supports the efforts of all practicing emergency physicians to demonstrate their qualification and competence through a combination of education, training, experience, certification examination, practice assessment and the peer review process.

AEP believes that specialty board examinations serve as a useful, but not exclusive, part of the credentialing process for physicians.

AEP believes that evaluations by directors of service during residency training and serial measurement of clinical practice outcomes are the most reliable indicators of the clinical competence and quality of a physician.

AEP believes that many Emergency Physicians that are excluded from participating in EM specialty board examinations practice excellent, high quality emergency medicine.

AEP believes that the lack of board certification alone is not a reasonable criteria for excluding an otherwise competent physician from any position or promotion in private, public or academic medicine.

AEP believes that courses such as CPR, ACLS, ATLS, APLS, PALS, BTLS, etc., serve as an excellent source for review and update for Emergency Physicians. Participation in these courses should not be mandatory for otherwise qualified, practicing emergency physicians. AEP believes that due to complex historical factors, the public perception of the importance of board certification in determining competence to practice EM has been distorted. Because this perception is actively fostered by certain organizations, board certification is generally accepted as the most desirable measure of competence. Due to inappropriate reliance on board certification alone to determine competence, many otherwise qualified EPs have been discriminated against in practice and promotion opportunity. While AEP will work toward changing public perception and deception on this issue, we also recognize that board certification through formal examination is currently regarded by the public as the most reliable measure of competence. AEP will continue to work toward access to standard EM board examination for our members and non-member EPs we represent.

Emergency Physician Supply - top
AEP acknowledges that the current supply of EM residency graduates per year is less than the rate of attrition plus the growth of demand for qualified Emergency Physicians. AEP believes this trend will continue significantly into the next century.

AEP believes that there is no gross shortage of qualified Emergency Physicians. Most of the currently practicing Emergency Physicians have trained in disciplines other than EM and are qualified, competent and dedicated. They will continue to fill the Emergency Physician demands of this nation.

An evaluation system must be implemented to allow all practicing Emergency Physicians to demonstrate their EM competence. This evaluation system should be based on a combination of education, residency training, clinical experience, clinical practice assessment and specialty board exam testing. When practicing EPs demonstrate clinical competence, they may then compete on an equal level with all Emergency Physicians.

AEP believes that Physicians trained in disciplines other than EM will continue to supply a significant share of this nation's future Emergency Physician needs. Due to this reality, those physicians that are dedicated to Emergency Medicine should be offered ways to demonstrate their qualification to begin EM practice.

Emergency Care Definition - top
AEP believes that the definitions of a medical emergency and emergency care must be based on what the public at large believes to be an emergency. If the public at large perceives that a medical process might cause morbidity or mortality, then the condition is an emergency that requires immediate medical attention. These public beliefs may include but are not limited to: severe or acute pain relief, obvious external or suspected internal bleeding, acute changes in mental status, acute weakness, acute or severe shortness of breath, chest pain, acute or severe headache, acute or severe abdominal pain, acute or severe fever, loss of consciousness, acute traumatic injuries, disturbance of adequate circulation, changes in motor function, acute behavioral changes, acute disturbance of sensory function, evaluation and treatment of abuse or neglect, abnormal gynecological function, labor, acute bowel or bladder dysfunction, treatment of disorders that relate to the health of the general public, acute infections, infestations, inflammations, acute allergic reactions, acute mental health crisis, newborn care, substance abuse related disorders.

Access to Emergency Care - top
AEP believes that all Americans should have access to emergency, preventative, primary, specialty and chronic medical care.

AEP believes that emergency care must be available to all patients in need of such care. Emergency care must be rendered regardless of the patients ability to pay for such care.

AEP believes that all medical care providers should be adequately, fairly and equitably compensated for providing medical care.

AEP believes that a mechanism of reimbursement for uncompensated emergency care is needed so that emergency providers and facilities may remain fiscally sound to provide such care. This should include a compensation mechanism for the underinsured, uninsured, non-resident aliens and international visitors.

AEP believes that all patients must receive appropriate medication, medical device or service needed for appropriate recovery from any acute illness or injury treated on an emergency basis.

Advanced Directives/Living Wills - top
AEP believes that the decision to allow any medical treatment, including resuscitation, is the exclusive right of the patient. The patient or legal guardian in consultation with their primary care physician must document these decisions prior to a potentially terminal event. Guidance from family members if requested by the patient, or requested by the primary physician if the patient is not competent, is desirable.

Living wills or advanced directives must be addressed by the primary care physician at such a time when the patient is competent to participate and before any condition arises that may require resuscitation. AEP believes that it is usually impractical and frequently inappropriate to address such an important issue during a crisis or emergent situation.

AEP believes that the patient or legal guardian has the right to refuse resuscitation or any individual component involved in resuscitation.

AEP believes that if a patient in extremis presents for emergency care, appropriate care must be given as is indicated by the clinical situation. If the patient is competent and refuses care, or if there is a legal document produced explicitly refusing care executed by the patient or legal guardian, then efforts may be aborted.

In the absence of advanced directives or living wills the Emergency Physician needs to make clinical decisions concerning the futility of resuscitation efforts. The Emergency Physician should attempt to consult the primary care physician and family members during the decision process.

911 Systems - top
Early access to emergency care is the key to desirable outcome. AEP believes that all communities should be served by a 911 system. Enhanced 911 should be a primary goal for communities to achieve. 911 provides early access to the EMS system so that unnecessary delays in emergency treatment may be avoided. A pre-arrival instruction system should be implemented in all EMS systems regardless of 911 availability.

Cardio-Pulmonary Resuscitation (CPR) - top
CPR initiated promptly in appropriate patients has been proven to reduce morbidity and mortality. Due to the short period of time from onset of arrest to irreversible multi-system injury or death, it is desirable to promote CPR as a citizen initiated treatment for cardio-pulmonary arrest. AEP believes that community emphasis should be directed toward learning CPR and to understand the lifesaving potential of early 911 with pre-arrival instructions - early CPR - early defibrillation - early ALS - early definitive cardiac care. All persons involved in EMS, fire service, police or public safety activities should be required to learn CPR. Due to the possibility of infectious contamination of rescuers from or to victims, AEP recommends that devices capable of preventing infectious contamination be made widely available.

Pre-Hospital Defibrillation and AED Use by Non-ALS Personnel - top
AEP believes that all first responder and EMT level providers should be trained to use an AED device. Early defibrillation is a therapy that is potentially life saving if implemented early in the course of presumed ventricular fibrillation. Under the supervision of a responsible EMS Physician Medical Director an effective program can be implemented. This program should include:

  • appropriate cardiac physiology,
  • appropriate electrocardiography,
  • thorough understanding of the purpose of defibrillation,
  • thorough understanding of clinical applications of AEDs,
  • standing orders review,
  • contraindications/scene safety/AED maintenance
  • CME requirements with both didactic and practical review,
  • Importance of the general life saving potential of early 911 with pre-arrival instructions - early CPR - early defibrillation - early ALS -early definitive cardiac care. An early defibrillation program should be a priority for communities to achieve. AEDs should be made widely available in each EMS jurisdiction and placed on vehicles that routinely respond to presumed cardiac arrest calls. This may include first responder, paramedic, fire apparatus and police vehicles so that the time to potentially life saving defibrillation is as short as possible.

Training of Pre-Hospital Care Providers - top
All pre-hospital medical care providers should be trained and certified to function in the pre-hospital setting. This includes, but is not limited to, first responder, EMT, EMT-IP, EMT-P, Pre-hospital RN, Pre-hospital PA. An appropriate state level agency should be responsible for certification of individuals and approval of training programs.

Pre-Hospital Care Providers Classifications - top
AEP supports the concept of various levels of pre-hospital training with corresponding levels of patient care duties. Logistics, local demand and adequacy of patient care should determine the need for various pre-hospital care levels. Generally, pre-hospital care can be divided into basic/non- invasive and advanced/invasive care. To limit confusion over interstate qualifications, AEP believes that there should be a national standard minimum qualification for basic/non-invasive and advanced/invasive providers. The local EMS agency under the auspices of EMS Physician Medical Directors can then build on the national standard minimum to satisfy local needs. The local optional care can then be added and certified through the appropriate state agency. AEP believes that a basic level provider course should include AED, MAST and adjunct airway training as minimal standard. Advanced level providers should have endotracheal intubation, needle tracheostomy, transthoracic pacer, and interosseous infusion as a minimal standard.

Pre-Hospital Thrombolytic Therapy - top
Thrombolytics when used in appropriate clinical situations in appropriate patients have proven clinical benefits. Due to unresolved pre-hospital risk/benefits issues and the potential for catastrophic events, AEP feels that more pre-hospital research is needed before thrombolytics are used routinely by non-physician personnel in the pre-hospital setting. However, AEP supports the concept of early prehospital identification and preparation of patients in which thrombolytics may be of benefit. Early identification and preparation may include initial history and physical exam, multiple peripheral I/V access sites, 12 lead EKG, blood drawing, pulse oximetry and appropriate medical treatment of the chest pain patient.

Good Samaritan Status - top
AEP believes that any person, regardless of prior medical background, that provides emergency medical assistance in good faith to another person be protected from liability resulting from that assistance.

Off-Line Medical Director - top
An EMS Physician responsible for the overall administration of EMS in a specified area.

On-Line Medical Director - top
A Physician responsible for immediate medical consultation to field providers via communications devises.

In-Field Medical Director - top
An EMS Physician that is a bona fide member of a local EMS agency with field response capability.

Transportation Emergencies in Isolated Surroundings - top
AEP believes that Airline and Cruise Ship crews should be trained at a minimum to the first aid/CPR level. There should be basic first aid equipment available on board including ventilation devices capable of preventing infectious contamination. Advanced medical equipment for use by "good samaritan" medical practitioners should be available including airway management equipment, basic ALS medications and a defibrillation device.

Disaster Emergency Services - top
AEP believes that Emergency Physicians should take a primary role in the development of Disaster Plans on the local, state, regional, national and international levels. Emergency Physicians should assist in developing, improving and implementing such plans. Emergency Physicians should participate in drills and train to participate in field medical operations.

Pre-Hospital Do Not Resuscitate Orders - top
AEP believes that the edict of EMS is to attenuate the morbidity and mortality of victims of acute illness or injury. Unless a valid and legal document expressing DNR status is available, EMS systems must assume the role of patient advocate and treat the patient except when death is obvious, ie, decapitation, rigor mortis, etc. AEP believes that it is unethical and impractical to expect EMS units to address a decision as important as a DNR status during a medical emergency. This type of personal medical decision is best addressed by a competent patient and their personal physician prior to a potentially terminal medical event. The involvement of legal guardians, families, lawyers, legislators, EMS agencies and medical personnel is necessary to place in effect a comprehensive program to address this issue in each community. AEP does not support resuscitation of any patient against their wishes or in patients in which such efforts are medically futile.

Hazardous Materials - top
AEP believes that all persons that may come into contact with hazardous materials have a right to all information about the material. This includes information concerning the following; avoiding exposure, limiting exposure, treating exposure, known health risks of exposure, decontamination procedures, first aid specific for the material and follow up information. All EMS personnel, and those public safety personnel expected to respond to a HAZ-MAT emergency "cold zone" should have the equivalent of a HAZ-MAT first responder course at a minimum. Those personnel with responsibilities for rescue, treatment and decontamination in the "hot zone" require specialized training to avoid personal contamination, treat the victim appropriately, limit extension of the event and avoid contamination of the remainder of the chain of survival and the public at large. Emergency department personnel should have adequate training and facilities to treat a contaminated patient.

Pre-Hospital Care by Licensed Practitioners Other Than Physicians - top
AEP believes that licensed practitioners, ie, Physicians Assistants and Registered Nurses, rendering pre-hospital care as an individual citizen (good samaritan), at the scene of an emergency should function to the level of competence of their license using available emergency equipment. Upon arrival of EMS units operating under supervision of an EMS Physician Medical Director a doctor/patient relationship occurs between the Medical Director and the patient. At this time the care of the patient should be transferred from the individual practitioner to the EMS providers. A formal "sign out" of pertinent information concerning the patient's care should be done to allow for continuity of care.

AEP believes that Physician Assistants and Registered Nurses formally responding to pre-hospital emergencies as part of an EMS system, volunteer or paid, must be appropriately trained in pre-hospital care. AEP believes that by using the individuals base licensure, ie, PA-C or RN, and adding an appropriate, abbreviated pre-hospital curriculum, these practitioners can be certified to function safely and beneficially in the pre-hospital setting. This additional curriculum should receive the sponsorship of the P.A. or R.N. licensing agencies with significant input and approval from the State EMS Authority and the State EMS Physician Medical Director. These pre-hospital practitioners should maintain their base licensure via standard means. The pre-hospital certification component should be maintained separately with fixed expiration, requirements for EMS specific CME and recertification mechanism. The certification should not permit function above the State maximum ALS level authorized by the State EMS Physician Medical Director. The certification should require adherence to pre-hospital medical protocols. The individual licensing agency should issue a separate certification card identifying the individual as a pre-hospital provider, ie, Certified Pre-hospital RN, EMS-RN, Pre-hospital PA or EMS-PA or equivalent.

Medical Control on Scene - top
Pre-hospital care by physicians other than authorized EMS Physicians.
AEP believes that any person, including a physician, that offers pre-hospital assistance in an emergency be encouraged to do so. A physician should use whatever means and equipment available to stabilize the patient pending EMS system intervention. Once EMS units are on scene, under authority of an EMS Physician Medical Director, the physician should "sign out" the patient to the EMS providers. If the physician believes their care is still required, and evidence of medical licensure and identification is produced, the EMS providers should take direction from this physician to the level of their certified ability. Once the patient is stable and an appropriate level of pre-hospital provider is available, the physician may be released from the scene. If the physician performed any procedure or administered any medication above the level permitted in the EMS system, this physician should accompany the patient to a physician staffed medical facility.

Medical Direction of Emergency Medical Services - top
Pre-hospital medical care is the practice of medicine outside a certified medical facility.

Medical Direction of EMS Systems is a medical specialty best practiced by qualified EMS Physicians, (see AEP Policy Statement "EMS Physician Qualifications").

All pre-hospital/EMS activities must be directed by accountable EMS Physicians on both the state and local level. This includes, administration, system design, unit staffing, training, legislation, communications, QA/CQI and direct patient care.

Individual local jurisdictions, ie, town, city or county level, must have dedicated, accessible In- Field Medical Directors as key members of the local EMS agency in addition to Off-Line Medical Directors. This will; insure continuity and appropriateness of medical care locally; add expert local medical support and response capability; allow for local QA/CQI medical audit; improve relations between the EMS agency, the public and other medical professionals; enrich in-field teaching and foster better working relationships between EMS Physicians and pre-hospital providers.

Physicians should be certified or credentialed as EMS Physicians by the appropriate state medical licensing board. Appropriate pre-hospital identification should be issued, ie, EMS-Physician, EMS- MD, EMS-DO or equivalent.

EMS Physician Qualifications - top
Medical Direction of EMS Systems is a medical specialty requiring education, training and experience specific to pre-hospital care. The following are broad recommendations for credentialing or certifying a physician as an EMS Physician capable of functioning as Off-Line, On-Line or In-Field Medical Director.

  • Residency training or board certification or significant clinical practice in a broad based specialty, ie, EM, IM, FP, GS, PED.
  • License to practice medicine and appropriate prescription drug registrations.
  • Completion of the non-medical components of a DOT/EMT program, ie, sections 1, 17, 22, 25,26, 27, 29, 30, 31, or equivalent.
  • Four or more of the following: 1) experience in EMS teaching; 2) experience in direct prehospital care; 3) experience in EMS administration/management; 4) certification or experience as an on-line medical director; 5) significant CME hours in EMS specific areas; 6) fellowship or formal training in EMS.
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