Public Health Initiatives in the Emergency Department: Not So Good for the Public Health?

Abstract

Academic Emergency MedicineVolume 15, Issue 2 p. 194-197 Free Access Public Health Initiatives in the Emergency Department: Not So Good for the Public Health? G. D. Kelen MD, G. D. Kelen MD (gkelen@jhmi.edu) Department of Emergency Medicine The Johns Hopkins University Baltimore, MDSearch for more papers by this author G. D. Kelen MD, G. D. Kelen MD (gkelen@jhmi.edu) Department of Emergency Medicine The Johns Hopkins University Baltimore, MDSearch for more papers by this author First published: 07 February 2008 https://doi.org/10.1111/j.1553-2712.2008.00068.xCitations: 33AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Keep your shoulder to the wheel, your ear to the ground, and your nose to the grindstone. Now try to work in that position. In its formative years, emergency medicine (EM) was meant to have a clear simple mission: manage and stabilize acute illness and decompensated chronic conditions. Definitive, ongoing, and preventive care was meant to occur in traditional well-established primary care settings. During the past three decades, EM has taken on the basic role of being the health care safety net.1 Even President Bush declared emergency care available to all regardless of ability to pay.2 The Emergency Medicine Treatment and Labor Act (EMTALA), an unfunded mandate, borne nearly exclusively by emergency departments (EDs), guarantees access, at least to evaluate whether an emergency exists.3 For multiple reasons, ED visits have long outstripped ED capacity,1, 4 leading to severe overcrowding in many EDs. However, given that approximately one-third of the entire U.S. population present to EDs any given year,1, 5 there have been numerous suggestions and studies advocating for various population-based public health initiatives not necessarily related to ED visits (Table 1). Table 1. Emergency department (ED)-Based Public Health Initiatives Advocated in the Peer-Review Literature Abdominal aortic aneurism screening Alcohol abuse and intervention Breast cancer screening Carbon monoxide screening (in patients with headaches) Cervical cancer screening Child restraint practice assessment Child abuse Contraception knowledge screening Depression and suicide screening Diabetes screening ED surveillance programs Elders’ abuse screening vigilance Elders’ impairment assessment Elders’ community needs assessment Geriatric risk to falls assessment Health promotion screening HIV screening, counseling and referral* Home fire safety assessment and intervention* Home safety risk assessment† Hypertension screening and referral Influenza vaccine administration Injury prone behavior assessment Intimate partner violence screening‡* Lipid screening Motorcycle helmet use Occult psychiatric illness screening Pediatric immunizations Pneumococcal immunization (elders) Preventive health knowledge screening Primary care referral program (children) PTSD risk screening in injured children Sickle cell anemia Smoking cessation counseling STD screening Syphilis HIV Chlamydia Gonorrhea Substance abuse Suicide screening§ Parenteral risk counseling Unsafe sex practice counseling Youth violence counseling HIV = human immunodeficiency virus; PTSD = posttraumatic stress disorder; STD = sexually transmitted disease. *American College of Emergency Physicians supported in certain situations. †The Joint Commission. ‡Mandated by The Joint Commission. §The Joint Commission requirement (National Patient Safety Goal 15) for patients with behavioral issues. The public health, preventive measures, and screening programs in Table 1 are all described in the literature and were found during a PubMed and Google Scholar search in preparation of this commentary. Two more articles advocating for previously called for measures are featured in this month’s edition of Academic Emergency Medicine.6, 7 One suggests that all adults be screened for Chlamydia trachomatis and Neisseria gonorrhea based on age alone;6 the other surveys U.S. EDs regarding human immunodeficiency virus (HIV) testing practices and essentially advocates for ED-based HIV testing and screening programs.7 This is in keeping with most articles examining ED-based public health initiatives. Advocacy groups or study investigator(s) project their largely favorable findings from a specific perspective. They tend to conclude that screening leading to early detection or intervention for an otherwise occult condition in the ED is feasible and worthwhile. While there is evidence that a few ED-based public health initiatives save lives and are cost-effective,8 most have yet to show clear benefit. The Society for Academic Emergency Medicine had formally explored the issue of offering preventive care services in the ED through its Public Health and Education Committee8, 9 and judged only 6 of 17 explored initiatives as having sufficient evidence to be of benefit. Regardless, the impact of the suggested individual programs on the broader practice of EM is virtually never considered. The debate regarding public health screening initiatives is usually framed in terms of one of two philosophical views of EM. There are those advocating for the purity of the original EM concept enunciated above, and those who believe that EM should take on a wider public health role for the general good of the population.8, 10 The latter argument notes that EM should take advantage of the presence of a relatively captive patient population and that many in the EDs do not have, or do not take advantage of, access to primary care or preventive measures. Regardless of the espoused view, all agree that the primary mission is to provide acute care,8 and most agree that advocacy for ED-based preventive measures is a result of a failed health system.1, 8 Today, the issue is considerably more complex than the simple dichotomy previously debated. The fundamental issue at heart is appropriate resource allocation for patient benefit and safety. Thus, the question needs to be reframed: Does the potential benefit of exercising family practice–like public health and preventive care measures in the ED outweigh the burden and the potential unrecognized harm to other ED patients? There are two possible ways to offer public health–related programs in an ED. One is to incorporate activities into routine practice. The other is to set up a parallel program separately resourced, meant not to interfere with standard routine practice. The former method requires redistribution of existing resources and is best illustrated by the well-known parallel concept of “cost shifting.” While a small proportion of uncompensated cost is likely absorbed by emergency practitioners, most cost of uncompensated and undercompensated care is shifted to those with insurance or ability to pay. The commodity rate (i.e., the price charged) for a given medical service is adjusted to account for the expected losses from nonpayment. Market forces ensure this. While the reality of cost shifting is not perfectly analogous to “resource shifting,” incorporating any public health initiative into emergency practice must be associated with resources shifted from other activities. Peter is being robbed to pay Paul. It should be noted that broad-based public health initiatives have no reimbursement from insurers and other third-party payers, unless the screening or test in question was medically indicated by the patient’s condition in the first place. In fact, billing for measures not otherwise indicated by patient condition could be considered fraud. Broad-based screening, not based on individual patient condition, generally would not qualify as a justifiable reimbursable ED medical service. When incorporating a preventive or screening program, provider or other health care worker (HCW) time as well as ED resources, by necessity, are diverted from established indicated patient needs. Few EDs, if any, can afford to staff HCWs such that significant idle or down time exists to undertake other nonessential tasks. The profit motive is simply too strong, and hospital margins too thin. In fact, most ED-based HCWs are so overextended that frequently, they must forgo any breaks just to keep their practice safe. Some of the screening initiatives noted in Table 1 appear to be innocuous or requiring little time. However, even a few minutes per patient represents thousands of hours of diverted patient care. For example, a mere 5 minutes a patient, for say 50 thousand screened patients per year in one facility, represents 4,167 hours a year diverted from other potentially more pressing and important activities. Given the breadth of the possible initiatives, a conservative estimate might be that at least half of all patients visiting a U.S. ED could benefit from at least one preventive or screening measure. At a minimum of 5 minutes per patient, this would encompass about 5 million hours of expended effort nationally. Even if one of the additional burdens is diverted to ancillary services such as the laboratory that runs tests in bulk, each test must still be logged into the computer, reagents and tubes used, and results viewed and discussed with the patient; referrals made and tracked; interactions documented; quality measures evaluated, etc. Generally, the 5 minutes given in the example would be a severe underestimate of the time required by the least burdensome of the public health initiatives, when all the added steps are accounted for. Thus, early detection of disease in the ED or preventive counseling may benefit patients with the targeted condition, but the effect of resource diversion on patient safety is not known. Given already highly constrained ED resources, it is not difficult to postulate that the effect on patient outcomes is real. Evidence is beginning to emerge that patient care may be compromised during times of resource constraint.11-14 Those who have any doubt simply need to review their patient walkout rates among those triaged as highly acute (Level 1 or 2). If there are any at all, then diversion of resources constitutes a real potential danger to patient care in the ED. The broad argument that incorporating public health measures into routine ED practice will result in potentially dangerous resource shifting in a busy ED is easily established. However, there is a growing call to establish parallel, separately resourced, programs that do not interfere with normal ED practice. To achieve this, separately funded programs are embedded part or full time in the ED. For example, consensus among recently convened HIV testing experts is that ED-based HIV screening, whether broad-based or targeted, is best achieved through a parallel independent program (findings of the First Annual Conference of HIV Testing, held in Baltimore, MD, Nov 11–12, 2007, proceedings publications pending). If funding is made available for such programs, most EDs would happily accept it. However, the issue is not really whether the parallel programs are solutions, but whether the infused resources for such programs would be put to better use in overtaxed EDs. It would be interesting to canvass ED directors and hospital CEOs in regard to funding allocations for these special programs. It is readily hypothesized that should the same resources be made available generally to improve ED patient health and safety, none of the initiatives listed in Table 1 would fall near the top of the list for funding priorities, even if compelling data on the health benefits to the general (or targeted) patient population is shown. It is easy to postulate that almost everyone surveyed would believe there are more pressing immediate needs for other ED-based initiatives to ensure safety and quality of care in their EDs. EM has been forcibly established as the nation’s health care safety net,1, 2 without consult or consent, although over time many have embraced its opportunities and responsibilities. In fact, over the past several decades many providers, doctors, and allied personnel have been drawn to the field at least partly to serve the medically disenfranchised and undeserved and by the field’s strong alliance with public health. This pluralism contributes to EM taking on aspects of health care and public health practice abrogated by other allied health disciplines. It is also inappropriate for EM to shoulder such a huge share of the public health burden. By taking on preventive and public measures, EM may inadvertently be hurting the public good and delaying action on real access and real health care reform. The recent Institute of Medicine report made clear the dire circumstances of ED care in this country.1EM should not take on any noncore initiatives until ED care itself is adequately resourced and all can enjoy a safe practice environment. So long as EDs remain crowded, any resources diverted from solving this huge patient safety issue for whatever well-intentioned public health purpose is inappropriate. The only possible counterargument to this position would be if certain specific preventive and screening measures offered in the ED could be shown to: 1) improve the nations’ health to a greater extent than harm caused to ED patients by resource shifting, or lost opportunity by misallocating new resources, or 2) actually free up currently expended resources (reversing resource shifting) to address other pressing ED patient safety needs. For those who remain skeptical, there remains one last ethical dilemma. There are so many worthy causes listed in Table 1, how is an ED to choose? As noted, a few have been shown to have at least targeted benefit. Most EDs offer those programs that promote a “pet” area of research. Those EDs that feel an overwhelming need to offer preventive programs need to evaluate which would be most worthy for society, at least in their locale, rather than what is easy or driven by research interests of faculty. This issue will remain with us for some time, as true outcomes studies are few.9 Research can help resolve whether offering such programs in the ED are appropriate and beneficial. The following broad questions should be addressed: 1) Which, if any, of the initiatives can be shown to have a lasting beneficial effect on the public health? 2) If a given initiative is incorporated into routine ED practice, what is the broad effect on patient safety? 3) If a given initiative is supported by incremental resources, would those same resources expended elsewhere in the ED have a higher benefit for all ED patients? References 1 Committee on the Future of Emergency Care in the United States Health System. Future of Emergency Care Series: Hospital-based Emergency Care at the Breaking Point. Washington, DC: The National Academies Press, 2006. Google Scholar 2 Editorial. World’s Best Medical Care? New York Times, August 12, 2007. Available at: http://www.nytimes.com/2007/08/12/opinion/12sun1.html?_r=1&oref=slogin. Accessed Feb 12, 2007. Google Scholar 3 Emergency Medical Treatment and Active Labor Act. 42 USCA, 1395dd (1992). Google Scholar 4 Kelen GD, Scheulen JS. Emergency department crowding as an ethical issue. Acad Emerg Med. 2007; 14: 750– 1. CrossrefPubMedWeb of Science®Google Scholar 5 Nawar EW, Niska RW, Xu J. National Hospital Ambulatory Medical Care Survey: 2005 Emergency Department Summary. Advanced Data from Vital and Health Statistics. Centers for Disease Control and Prevention. 2007; 386: 1– 32. Google Scholar 6 Al-Tayyib AA, Miller WC, Rogers SM, et al. Evaluation of risk score algorithms for detection of chlamydial and gonococcal infections in an emergency department setting. Acad Emerg Med. 2008; 15: 126– 35. Wiley Online LibraryPubMedWeb of Science®Google Scholar 7 Ehrenkranz PD, Ahn CJ, Metlay JP, Camargo CA Jr, Holmes WC, Rothman R. Availability of rapid human immunodeficiency virus testing in academic emergency departments. Acad Emerg Med. 2008; 15: 144– 50. Wiley Online LibraryPubMedWeb of Science®Google Scholar 8 Rhodes KV, Gordon JA, Lowe R. Preventive care in the emergency department. I. Clinical preventive services--are they relevant to emergency medicine. Acad Emerg Med. 2000; 7: 1036– 41. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 9 Babcock Irvin C, Wyer PC, Gerson LW. Preventive care in the emergency department. II. Clinical preventive services--an emergency medicine evidence-based review. Society for Academic Emergency Medicine Public Health and Education Task Force Preventive Services Work Group. Acad Emerg Med. 2000; 7: 1042– 54. PubMedGoogle Scholar 10 Schneider SM, Hamilton GC, Moyer P, Stapczynski JS. Definition of emergency medicine. Acad Emerg Med. 1998; 5: 348– 51. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 11 Pine JM, Hollander JE, Localio R, Metlay JP. The association between emergency department crowding and hospital performance on antibiotic timing for pneumonia and percutaneous myocardial infarction. Acad Emerg Med. 2006; 13: 873– 78. CrossrefPubMedWeb of Science®Google Scholar 12 Schull MJ, Vermeulen MJ, Stukel TA. The risk of missed diagnosis of acute myocardial infarction associated with emergency department volume. Ann Emerg Med. 2006; 48: 647– 55. CrossrefPubMedWeb of Science®Google Scholar 13 Schull MJ, Vermeulen MJ, Slaughter G, Morrison L, Daily P. Emergency department crowding and thrombolysis delays in acute myocardial infarction. Ann Emerg Med. 2004; 44: 577– 85. CrossrefPubMedWeb of Science®Google Scholar 14 Pines JM, Hollander JE. Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med. 2008; 51: 1– 5. CrossrefPubMedWeb of Science®Google Scholar Citing Literature Volume15, Issue2February 2008Pages 194-197 ReferencesRelatedInformation