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The introduction of Mission: Lifeline significantly increased timely access to percutaneous coronary intervention for patients with ST-segment-elevation myocardial infarction (STEMI). In the years since, morbidity and mortality rates have declined, and research has led to significant developments that have broadened our concept of the STEMI system of care. However, significant barriers and opportunities remain. From community education to 9-1-1 activation and emergency medical services triage and from emergency department and interfacility transfer protocols to postacute care, each critical juncture presents unique challenges for the optimal care of patients with STEMI. This policy statement sets forth recommendations for how the ideal STEMI system of care should be designed and implemented to ensure that patients with STEMI receive the best evidence-based care at each stage in their illness.

The adverse influences of climate change are manifesting as health burdens relevant to clinical practice, affecting the very underpinnings of health and stressing the health care system. Emergency medicine is likely to bear a large burden, with its focus on urgent and emergency care, through its role as a safety-net provider for vulnerable populations and as a leader in disaster medicine. Clinically, climate change is affecting emergency medicine practice through the amplification of climate-related disease patterns and epidemiologic shifts for conditions diagnosed and treated in emergency departments (EDs), especially for vulnerable populations. In addition, climate-driven intensification of extreme weather is disrupting health care delivery in EDs and health care systems. Thus, there are significant opportunities for emergency medicine to lead the medical response to climate change through 7 key areas: clinical practice improvements, building resilient EDs and health care systems, adaptation and public health engagement, disaster preparedness, mitigation, research, and education. In the face of this growing health threat, systemwide preparation rooted in local leadership and responsiveness is necessary to efficiently and effectively care for our vulnerable communities., (Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background: International professional bodies have been quick to disseminate initial guidance documents during the COVID-19 pandemic. In the absence of firm evidence, these have been developed by expert committees, limited in participant number. This study aimed to validate international COVID-19 surgical guidance using a rapid Delphi consensus exercise., Methods: Delphi statements were directly mapped to guidance from surgical professional bodies in the US and Europe (SAGES/EAES), the UK (Joint RCS), and Australasia (RACS), to validate content against international consensus. Agreement from ≥70% participants was determined as consensus agreement., Results: The Delphi exercise was completed by 339 individuals from 41 countries and 52 statements were mapped to the guidance, 47 (90.4%) reaching consensus agreement. Of these, 27 statements were mapped to SAGES/EAES guidance, 21 to the Joint RCS document, and 33 to the RACS document. Within the SAGES/EAES document, 92.9% of items reached consensus agreement (median 89.0%, range 60.5-99.2%), 90.4% within the Joint RCS document (87.6%, 63.4-97.9%), and 90.9% within the RACS document (85.5%, 18.7-98.8%). Statements lacking consensus related to the surgical approach (open vs. laparoscopic), dual consultant operating, separate instrument decontamination, and stoma formation rather than anastomosis., Conclusion: Initial surgical COVID-19 guidance from the US, Europe and Australasia was widely supported by an international expert community, although a small number of contentious areas emerged. These findings should be addressed in future guidance iterations, and should stimulate urgent investigation of non-consensus areas., Competing Interests: Declaration of competing interest The authors report no conflicts of interest., (Copyright © 2020 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

In this randomized trial, the authors compared the instructional quality of instructor candidates trained in instructional methods through an Internet-based versus a traditional classroom-led version of the American Heart Association Core Instructor Course. The self-guided, Internet-based group had significantly higher posttest scores than did the traditional instructor-led group (although not when adjusted for pretest scores). The Internet-based group scores changed from 54% to 67%, exceeding the a priori definition of 8% as a minimally practically significant improvement (instructor-led group scores changed from 49% to 53%). The Internet-based course appeared to be a suitable alternative to the traditional course.

The Portland Veterans Affairs Medical Center (PVAMC) participated in a research-based National Demonstration and Evaluation Study of Hospital at Home Care for Elderly Patients. PVAMC continued hospital at home care in a modified form based on the results of that research phase and feedback from patients, families, and staff. The modified clinical program (referred to as Program @ Home) provided care for the same diagnoses (exacerbation of congestive heart failure, exacerbation of chronic obstructive pulmonary disease, community-acquired pneumonia, cellulitis) but differed from the research-based demonstration project in that it accepted patients of all ages, accepted early-discharge patients from the hospital, and provided a less-intensive physician and nursing model. In the first 42 months, 290 patients were admitted; 23% came from the emergency room, 54% were early hospital discharge, and the remainder came from an outpatient clinic or home care. Average length of stay was 3.2 days, and 37% were younger than 65. The results describe how a home hospital program has been integrated into the clinical care offerings of a managed care health system and how it supports inpatient, primary, emergency, and home care programs.

Objective: To determine the privileges of Private Attending Pediatricians (PAP) in caring for newborns requiring intensive (ITC), intermediate (IMC), or continuing (CC) care in Level III neonatal intensive care units (NICUs) throughout the United States., Design: A two-page mail questionnaire was sent to 429 Level III NICUs to obtain the statement best describing the PAPs' privileges, the number of PAP, and some of the PAPs' functions. Level III NICUs were classified by geographic region as Eastern, Central, or Western United States., Results: Responses were received from 301 NICUs (70%) representing 48 states, the District of Columbia, and > 9000 PAP. Twenty-two institutions had no PAP. In the remaining 279 institutions, 96% (267/279) had restricted the PAPs' privileges partially or completely. In 32% (88/279), the PAP were not allowed to render any type of NICU care. In 18% (51/279) of the institutions, the PAP were allowed to render CC only. In 27% (76/279) of the institutions, the PAP were allowed to render IMC and CC only. Limitation of PAPs' privileges were reported in all geographic areas in the U.S., were more pronounced in the Eastern than the Central or Western sections of the country, and were noted in institutions with small (< or = 10) as well as large (> or = 60) numbers of PAP. Limitation of PAPs' privileges was determined by the PAP him/herself in many institutions. Proficiency in resuscitation was considered to be a needed skill. Communication with parents of an infant under the care of a neonatologist was encouraged., Conclusions: The PAPs' privileges were limited partially or completely in most Level III NICUs. Knowledge of this restricted role impacts significantly on curriculum design for pediatric house officers, number and type of health care providers required for Level III NICUs and future house officer's career choices.