The 2022 Model of the Clinical Practice of Emergency Medicine

Emergency medicine has a scientifically derived and commonly accepted description of the domain of its clinical practice. That document, The Model of the Clinical Practice of Emergency Medicine (EM Model), was developed through the collaboration of the following six organizations: American Board of Emergency Medicine (ABEM), which is the administrative organization for the project; American College of Emergency Physicians (ACEP); Council of Emergency Medicine Residency Directors (CORD); Emergency Medicine Residents' Association (EMRA); Residency Review Committee for Emergency Medicine (RC-EM); and Society for Academic Emergency Medicine (SAEM). Development of the EM Model was based on an extensive practice analysis of the specialty. The practice analysis relied on both empirical data gathered from actual emergency department visits and several expert panels (1Hockberger RS LaDuca A Orr NA et al.Creating the model of a clinical practice: the case of emergency medicine.Acad Emerg Med. 2003; 10: 161-168Crossref PubMed Scopus (0) Google Scholar). The resulting product was first published in 2001 and has served successfully as the common source document for all emergency medicine organizations (2Core Content Task Force IIThe Model of the Clinical Practice of Emergency Medicine.Ann Emerg Med. 2001; 37: 745-770Abstract Full Text Full Text PDF PubMed Scopus (164) Google Scholar,3Core Content Task Force IIThe Model of the Clinical Practice of Emergency Medicine.Acad Emerg Med. 2001; 8: 660-681Crossref PubMed Scopus (39) Google Scholar). One of its strengths is incorporating the reality that emergency medicine is a specialty driven by symptoms, not diagnoses, that require simultaneous therapeutic and diagnostic interventions. The task force that developed the EM Model recommended that a new task force, composed of representatives from all six organizations, be formed every 2 years to assess the success of the document in accomplishing its objective of supporting the ongoing development of the specialty of emergency medicine; to consider alterations to the EM Model suggested by the collaborating organizations; and to recommend changes to the six sponsoring organizations. The initial 2-year review occurred in 2003, with representatives from each of the six organizations suggesting changes and reporting how their respective organizations had used the document. The initial 2-year update was published in Annals of Emergency Medicine and Academic Emergency Medicine in 2005 (4Hockberger RS Binder LS Chisholm CD et al.The Model of the Clinical Practice of Emergency Medicine: a 2-year update.Ann Emerg Med. 2005; 45: 659-674Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar,5Hockberger RS Binder LS Chisholm CD et al.The Model of the Clinical Practice of Emergency Medicine: a 2-year update.Acad Emerg Med. 2005; 12: 543-558Crossref Google Scholar). Subsequently, a task force met every 2 years to review the EM Model and recommend changes (6Thomas HA Binder LS Chapman DM et al.2005 EM Model Review Task ForceThe 2003 Model of the Clinical Practice of Emergency Medicine: the 2005 update.Ann Emerg Med. 2006; 48: e1-17Abstract Full Text Full Text PDF PubMed Scopus (18) , 7Thomas HA Binder LS Chapman DM et al.The 2003 Model of the Clinical Practice of Emergency Medicine: the 2005 update.Acad Emerg Med. 2006; 13: 1070-1073Crossref PubMed Scopus (23) Google Scholar, 8Thomas HA Beeson MS Binder LS et al.The 2005 Model of the Clinical Practice of Emergency Medicine: the 2007 update.Acad Emerg Med. 2008; 15: 776-779Crossref PubMed Scopus (29) Google Scholar, 9Thomas HA Beeson MS Binder LS et al.2007 EM Model Review Task ForceThe 2005 Model of the Clinical Practice of Emergency Medicine: the 2007 update.Ann Emerg Med. 2008; 52: e1-17Abstract Full Text Full Text PDF PubMed Scopus (23) , 10Perina DG Beeson MS Char DM et al.The 2007 Model of the Clinical Practice of Emergency Medicine: the 2009 update.Acad Emerg Med. 2011; 18: e8-26Crossref PubMed Scopus (20) , 11Perina DG Beeson MS Char DM et al.The 2007 Model of the Clinical Practice of Emergency Medicine: the 2009 update.Ann Emerg Med. 2011; 57: e1-15Abstract Full Text Full Text PDF PubMed Scopus (21) , 12Perina DG Brunett CP Caro DA et al.2011 EM Model Review Task ForceThe 2011 Model of the Clinical Practice of Emergency Medicine.Acad Emerg Med. 2012; 19: e19-e40Crossref PubMed Scopus (39) , 13Counselman FL Borenstein MA Chisholm CD et al.The 2013 Model of the Clinical Practice of Emergency Medicine.Acad Emerg Med. 2014; 21: 574-598Crossref PubMed Scopus (47) Google Scholar). In 2013, a seventh organization, the American Academy of Emergency Medicine (AAEM), was added as a collaborating organization. In 2014, the collaborating organizations made the decision to review the EM Model on a 3-year review cycle, beginning in 2016. The 2016 update was published in the Journal of Emergency Medicine in 2017 (14Counselman FL Babu K Edens MA et al.The 2016 Model of the Clinical Practice of Emergency Medicine.J Emerg Med. 2017; 52: 846-849Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar). In 2019, the American Academy of Emergency Medicine Resident and Student Association (AAEM/RSA) was added as an eighth collaborating organization. The 2019 update was published in the Journal of Emergency Medicine in 2020 (15Beeson MS Ankel F Bhat R et al.The 2019 Model of the Clinical Practice of Emergency Medicine.J Emerg Med. 2020; 59: 96-120Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar). On the recommendation of the 2019 EM Model Review Task Force, three working groups were formed in 2021 to focus on ultrasound, cutaneous disorders, and evolving trends in health care. The product of these working groups, along with the results of a job analysis conducted in 2022, helped inform decisions made by the 2022 EM Model Review Task Force related to these areas. Numerous changes occurred with the 2022 review, including expansion of the ultrasound section of Category 19, Procedures and Skills Integral to the Practice of Emergency Medicine. Category 20, Other Core Competencies of the Practice of Emergency Medicine, was significantly revised to provide more clarity regarding patient-centered care. In addition, the task force recommended that a work group be convened to review and recommend updates to the acuity definitions prior to the 2025 EM Model review. This article provides a brief review of the original EM Model, along with the changes to the EM Model recommended by the 2022 EM Model Review Task Force. A summary of all 2022 changes and an update on current uses of the EM Model by the eight collaborating EM organizations are also included in this article. The EM Model is a three-dimensional description of EM clinical practice. The three dimensions are patient acuity; physician tasks; and a listing of medical knowledge, patient care, and procedural skills. All of these dimensions are interrelated and used concurrently by a physician when providing patient care. The emergency physician's initial approach is determined by the acuity of the patient's presentation. When assessing the patient, the physician completes a series of tasks in collecting information. Through this process, the physician is able to select the possible etiologies of the patient's problem from the listing of medical knowledge, patient care, and procedural skills. Through simultaneous application of all three components, the physician is able to determine the most probable diagnosis and implement a treatment plan for the patient. The three dimensions, as revised in 2022, are included in Table 1, Table 2, Table 3, Table 4.Table 1Matrix of Physician Tasks by Patient AcuityPatient AcuityPhysician TasksCriticalEmergentLower AcuityPrehospital careEmergency stabilizationPerformance of focused history and physical examinationModifying factorsProfessional issuesLegal issuesDiagnostic studiesDiagnosisTherapeutic interventionsPharmacotherapyObservation and reassessmentConsultationTransitions of carePrevention and educationDocumentationTask switching/Multiple patient carePhysician-led team leadership and managementMass casualty/Disaster managementInterpersonal and patient-centered communication skillsPrognosis Open table in a new tab Table 2Patient Acuity DefinitionsCriticalEmergentLower AcuityPatient presents with symptoms of a life-threatening illness or injury with a high probability of mortality if immediate intervention is not begun to prevent further airway, respiratory, hemodynamic, and/or neurologic instabilityPatient presents with symptoms of an illness or injury that may progress in severity or result in complications with a high probability for morbidity if treatment is not begun quicklyPatient presents with symptoms of an illness or injury that have a low probability of progression to more serious disease or development of complications Open table in a new tab Table 3Physician Task DefinitionsPrehospital careParticipate actively in prehospital care; provide direct patient care or on-line or off-line medical direction or interact with prehospital medical providers; assimilate information from prehospital care into the assessment and management of the patient.Emergency stabilizationConduct primary assessment and take appropriate steps to stabilize and treat patients.Performance of focused history and physical examinationEffectively interpret and evaluate the patient's symptoms and history; identify pertinent risk factors in the patient's history; provide a focused evaluation; interpret the patient's appearance, vital signs, and condition; recognize pertinent physical findings; perform techniques required for conducting the examination.Modifying factorsRecognize age, gender, race, ethnicity, barriers to communication, socioeconomic status, underlying disease, gender identity, sexual orientation, and other factors that may affect patient management.Professional issuesUnderstand and apply principles of professionalism and ethics pertinent to patient management.Legal issuesUnderstand and apply legal concepts pertinent to the practice of emergency medicine.Diagnostic studiesSelect and perform the most appropriate diagnostic studies and interpret the results, e.g., electrocardiogram, emergency ultrasound, radiographic, and laboratory tests.DiagnosisDevelop a differential diagnosis and establish the most likely diagnoses in light of the history, physical, interventions, and test results.Therapeutic interventionsPerform procedures and nonpharmacologic therapies, and counsel.PharmacotherapySelect, prescribe, and be aware of adverse effects of appropriate pharmaceutical agents based on relevant considerations, such as intended effect, financial considerations, possible adverse effects, patient preferences, institutional policies, and clinical guidelines; and monitor and intervene in the event of adverse effects in the emergency department.Observation and reassessmentEvaluate and re-evaluate the effectiveness of a patient's treatment or therapy, including addressing complications and potential errors; monitor, observe, manage, and maintain the stability of one or more patients who are at different stages in their workups.ConsultationCollaborate with physicians and other professionals to help guide optimal management of patients.Transitions of careArrange for patient admission, discharge (including follow-up plan), observation, or transfer and transitions of care as appropriate, and communicate these arrangements effectively with patients, family, and involved health care team members.Prevention and educationApply epidemiologic information to patients at risk; conduct patient education; select appropriate disease and injury prevention, and harm reduction techniques.DocumentationCommunicate patient care information in a concise and appropriate manner that facilitates quality care. This includes documentation and medical decision-making variables related to billing, coding, and reimbursement for patient care.Task switching/Multiple patient carePrioritize and implement the evaluation and management of multiple patients in the emergency department, including handling interruptions and task switching, in order to provide optimal patient care.Physician-led team leadership and managementFunction as team leaders in support of physician-led teams. Provide appropriate supervision of nurse practitioners and physician assistants in team-based care. Coordinate, educate, or supervise members of the patient management team and utilize appropriate hospital resources.Mass casualty/Disaster managementUnderstand and apply the principles of disaster and mass casualty management, including preparedness, triage, mitigation, response, and recovery.Interpersonal and patient-centered communication skillsEstablish rapport with and demonstrate empathy toward patients and their families; listen effectively and build trust with patients and their families. Identify situations that require individualized communication or shared decision making, such as goals of care, end-of-life care, and palliative options.PrognosisForecast the likely outcome of a medical disease or traumatic condition. Open table in a new tab Table 4Medical Knowledge, Patient Care, and Procedural SkillsCriticalEmergentLower Acuity1.0 SIGNS, SYMPTOMS, AND PRESENTATIONS 1.1 Abnormal Vital Signs 1.1.1 HypothermiaXXX 1.1.2 FeverXXX 1.1.3 BradycardiaXXX 1.1.4 TachycardiaXX 1.1.5 Bradypnea/ApneaXX 1.1.6 TachypneaXX 1.1.7 HypoxiaXX 1.1.8 HypotensionXX 1.1.9 HypertensionXXX 1.1.10 HyperthermiaXXX 1.2 Pain 1.2.1 Pain (unspecified)XXX 1.2.2 Headache (See 12.3)XXX 1.2.3 Eye painXX 1.2.4 Chest painXXX 1.2.5 Abdominal painXXX 1.2.6 Pelvic and genital painXXX 1.2.7 Back painXXX 1.2.8 Chronic painX 1.2.9 Extremity painXXX 1.2.10 Neck painXXX 1.3 General 1.3.1 Altered mental statusXXX 1.3.2 Anuria/OliguriaX 1.3.3 AscitesXX 1.3.4 AtaxiaXX 1.3.5 Auditory disturbancesX 1.3.6 BleedingXXX 1.3.7 Congestion/RhinorrheaX 1.3.8 Constipation/ObstipationXX 1.3.9 CoughXX 1.3.10 Crying/FussinessXX 1.3.11 CyanosisX 1.3.12 DehydrationXX 1.3.13 DiarrheaXX 1.3.14 DysmenorrheaX 1.3.15 DysphagiaXX 1.3.16 DysuriaX 1.3.17 EdemaXX 1.3.18 Failure to thriveXX 1.3.19 Fatigue/MalaiseXX 1.3.20 Feeding problemsX 1.3.21 HematemesisXX 1.3.22 HematuriaXX 1.3.23 HemoptysisXX 1.3.24 HiccupX 1.3.25 JaundiceX 1.3.26 Joint swellingXX 1.3.27 LightheadednessXX 1.3.28 LimpXX 1.3.29 LymphadenopathyX 1.3.30 Mechanical and indwelling devices, complicationsXXX 1.3.31 Nausea/VomitingXX 1.3.32 Occupational exposureXX 1.3.33 PalpitationsXXX 1.3.34 ParalysisXX 1.3.35 Paresthesia/DysesthesiaXX 1.3.36 PoisoningXXX 1.3.37 PruritusXX 1.3.38 RashXXX 1.3.39 Rectal bleedingXXX 1.3.40 ShockX 1.3.41 Shortness of breathXX 1.3.42 Sore throatXX 1.3.43 StridorXX 1.3.44 Syncope/Near syncopeXXX 1.3.45 TinnitusX 1.3.46 TremorXX 1.3.47 Urinary incontinenceX 1.3.48 Urinary retentionX 1.3.49 Vaginal bleedingXXX 1.3.50 Vaginal dischargeX 1.3.51 Visual disturbancesXX 1.3.52 WeaknessXX 1.3.53 WheezingXX 1.3.54 ToxidromesXXX 1.3.55 Sudden unexpected infant death (SUID)X 1.3.56 Suicidal ideationXXX 1.3.57 Brief resolved unexplained events (BRUE)XXX 1.3.58 Intoxication syndromesXXX 1.3.59 Postsurgical complicationsXXX 1.3.60 AgitationXXX 1.3.61 Hypo/HyperglycemiaXXX2.0 ABDOMINAL AND GASTROINTESTINAL DISORDERS 2.1 Abdominal Wall 2.1.1 HerniasXX 2.1.2 HematomaX 2.2 Esophagus 2.2.1 Infectious disorders 2.2.1.1 Candida (See 4.4.2.1, 7.4.6)XX 2.2.2 Inflammatory disorders 2.2.2.1 EsophagitisXX 2.2.2.2 Gastroesophageal reflux (GERD)X 2.2.2.3 Toxic effects of caustic agents (See 17.1.16.1) 2.2.2.3.1 AcidXX 2.2.2.3.2 AlkaliXX 2.2.3 Motor abnormalities 2.2.4 Structural disorders 2.2.4.1 Boerhaave's syndromeXX 2.2.4.2 DiverticulaXX 2.2.4.3 Foreign bodyX 2.2.4.4 HerniasXX 2.2.4.5 Mallory-Weiss syndromeXX 2.2.4.6 Stricture and stenosisXX 2.2.4.7 Tracheoesophageal fistulaXX 2.2.4.8 VaricesXX 2.2.5 TumorsXX 2.3 Liver 2.3.1 Noninfectious hepatitis/CirrhosisXX 2.3.1.1 AlcoholicXX 2.3.1.2 Biliary obstructiveX 2.3.1.3 Drug-inducedXX 2.3.1.4 Infectious TumorsXX and Biliary TumorsXX TumorsXX Abdominal syndromeXX Infectious Inflammatory disorders Structural disorders Foreign TumorsXX (See Infectious Inflammatory disorders Motor abnormalities Structural disorders TumorsXX Infectious disorders Inflammatory disorders Motor abnormalities Structural disorders TumorsXX and Infectious disorders and Inflammatory disorders Structural disorders fistulaXX Foreign Rectal TumorsXX complicationsXXX DISORDERS of the of of (See of of the of the (See HypertensionXXX TumorsXX (See DISORDERS of the Candida (See (See (See (See with and symptoms or syndromeXX syndromeXX Toxic RashXXX Drug-inducedXX AND DISORDERS or syndromeXX and in of DISORDERS and (See (See syndromeXX (See related DISORDERS Foreign (See Eye to (See (See of Foreign of the (See (See and (See Foreign of the and of the Foreign (See complicationsXXX (See AND DISORDERS (See of (See syndromeXX syndromeXX complicationsXXX DISORDERS (See (See related (See Inflammatory in DISORDERS Other (See Toxic syndromeXX A Other and illness Infectious (See (See DISORDERS TumorsXX of the (See stenosisXX painXXX 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