Emergency medicine (EM) is an important component of the healthcare safety net in the United States and throughout the world.1 With more than 110 million emergency department (ED) visits each year in the United States, a shrinking physical capacity to care for these patients, and a federal mandate to provide universal emergency medical care, our specialty functions at a critical (and somewhat tenuous) interface between the general health care establishment and public health.2–4
Emergency departments consistently care for the large proportion of our society that is undeserved and disadvantaged. These same people are those most likely to be underinsured (approximately 45 million are currently uninsured), those without access to routine primary care or the ability to easily navigate the medical care system, and those thought to be at highest risk for harboring or acquiring preventable illnesses. They routinely seek care in EDs, and such encounters often represent these patients’ only contact with the medical care establishment and the only potential opportunity to provide varying levels of medical care, including preventive care.
In this issue of Academic Emergency Medicine, two articles highlight ongoing efforts to improve aspects of performing preventive interventions for infectious diseases in EDs.5,6 The first, by Ehrenkranz et al.,5 describes the results of a survey of rapid human immunodeficiency virus (HIV) testing practices among academic EDs, finding that just over half of the 102 sites included in the survey offered rapid HIV testing in some context (mostly in situations involving occupational exposure), but that only 13% of the EDs offered HIV screening as a routine preventive health care measure. In light of the Centers for Disease Control and Prevention’s (CDC) most recent recommendations of performing nontargeted, opt-out, rapid HIV screening in health care settings with prevalences of ≥ 0.1%, this finding may be surprising.7 However, this study represents to our knowledge only the second study to evaluate HIV testing practices in academic EDs. An earlier article by Wilson and colleagues8 did not specifically evaluate routine HIV screening practices, likely because no ED was close to providing such a service in 1996. While the recommendations by the CDC have been met with controversy and it is still uncertain to what extent they will be adopted, primarily because performing widespread HIV screening in a busy, acute-care setting is operationally complex and expensive, these data suggest that a higher current level of HIV screening exists among academic EDs than from a decade ago.9
The second article, by Al-Tayyib et al.,6 describes the results of a study to develop an instrument to improve ED screening for chlamydia and gonorrhea. Recognizing previously reported ED prevalences between 2 and 11% for these infectious sexually transmitted diseases, and that routine, nontargeted screening is common in EM, the authors attempted to develop an algorithm to identify patients at increased risk of harboring these infectious diseases to guide real-time clinical screening decisions. Overall, approximately 10% of all patients included in this single-ED study tested positive for either infection, and for both genders, age under 26 years was the only variable associated with infection. While these results may not be generalizable, they do support the notion of more efficient targeted screening for chlamydia or gonorrhea among ED patients.
These articles highlight the importance of providing secondary preventive care in the ED, and a number of original research and review articles, editorials, and commentaries have previously outlined the growing importance of EM and public health.10–14 EM and public health have been described to interact across the following four general core areas: 1) surveillance of diseases, injury, and health risk; 2) monitoring health care access; 3) delivery of preventive services; and 4) the development of policies to protect and improve the public’s health.10
Emergency medicine plays a central role in providing disease and injury prevention, and we routinely provide secondary disease prevention (i.e., providing early disease detection). In fact, it could easily be argued that this is fundamental to our specialty’s mission, especially as it relates to identifying life-threatening conditions early in their courses (e.g., an expanding abdominal aortic aneurysm or worsening angina). EM, however, also plays an important role in the provision of primary prevention (i.e., preventing disease development) by providing vaccinations for tetanus, and postexposure prophylaxis for diseases such as rabies and hepatitis, and routinely provides tertiary prevention (i.e., reducing the public health impact of already established diseases) by referring patients to primary care providers for ongoing management of existing chronic diseases.
Additionally, the public health community has long been enamored with EDs as sites for surveillance. Consortia such as the Drug Abuse Warning Network (DAWN) and the EmergeIDNet have provided the CDC, local and state public health communities, medical providers, and the general public with invaluable information about emerging trends in substance use and infection, respectively. In recent years, both the Substance Abuse and Mental Health Services Administration (SAMHSA) and the CDC have called on EDs to intervene as well, by instituting screening programs for alcohol use disorders and HIV infection.15 More recently, EM and EDs have taken the lead in several important roles in bioterrorism preparedness, including syndromic surveillance and containment.16
The affection of public health authorities for EDs has not, in general, been reciprocated. For various reasons, including clinical, cultural, and perhaps financial, EDs and emergency physicians have not widely embraced the performance of interventions with a public health focus. However, in the 13 years since Bernstein et al.17 called for a public health approach to emergency medical practice, a sizeable body of literature has defined the epidemiology of preventable illnesses and injury among ED patients; various practice guidelines have called for screening, brief intervention, and referral for treatment (SBIRT) interventions; and a growing base of evidence has documented the efficacy and effectiveness of such interventions.14,18
Emergency medicine is gradually embracing this important aspect of providing front-line medical care. It seems difficult to justify, on ethical grounds, that EDs and emergency care providers are not obligated to address important public health issues, particularly when considering the burden of premature disease and death conferred by patient-specific behaviors or other chronic medical conditions that lead to preventable morbidity and mortality.19 What may be open to reasonable debate is the extent to which interventions should be offered in the ED.
Provision of preventive interventions in EDs depends on a number of factors related to the disease process or behavior involved as well as to the underlying complexities of the ED itself. One may reasonably question whether SBIRT interventions constitute another unfunded mandate for underresourced, underfinanced, crowded EDs. We contend, however, that when done properly, the answer is no. Currently EDs, in addition to managing acute illness and injury, also successfully provide food and shelter for the homeless; arrange safe dispositions for elders and those with substance use or mental illness; provide screening for intimate partner violence, HIV infection, substance abuse, and seatbelt and helmet use; provide vaccinations when appropriate; identify chronic medical conditions; and refer patients to primary care providers for further evaluation and care.
A number of barriers potentially preclude routine preventive care in the ED, however. Arguably, incorporating such activities into a busy acute-care setting is difficult, and physicians and other emergency care providers do not routinely envision these services as a priority, particularly in nonacademic settings. Instead, clinicians are more likely to do what they were primarily trained to do—perform critical resuscitation and diagnose or exclude life-threatening medical conditions. Although important, these activities are just a part of the care EDs provide. Numerous clinical and nonclinical staff and nonpersonnel resources are potentially available to assist physicians in preventive services delivery (Table 1).20 Of course, availability of local resources will strongly dictate local practice, but at a minimum, waiting areas can be stocked with literature addressing risky health behaviors and locally available organizations and clinics that offer treatment. Similarly, discharge instructions can be configured to provide similar information. This may involve working with vendors of electronic health information systems.
|Stage of ED Visit||Intervention||Triage Officer||Nurse||Physician/ Provider||Ancillary Provider*||Supplemental†|
|Waiting area||S, RT||X|
|History and physical examination||S, BI, RT||X|
|Postexamination waiting period||S, BI, RT||X||X||X||X|
SBIRT activities need not be time-consuming for clinicians or other staff. Flocke et al.21 refer to the “opportunistic delivery of preventive health services” as a cost- and time-sensitive means to perform these activities.21 Some examples include: 1) use of computerized, self-administered health profiles accessed through kiosks in the waiting area;22,23 2) engaging the patient in a brief discussion of his or her smoking following auscultation of the lungs and heart or during examination of the abdomen, skin, and extremities; or 3) referring the patient to a smokers’ quit line, while handing the patient a brochure at the point of discharge.
In general, SBIRT activities are not reimbursable. There are CPT codes that address behavioral counseling, including new codes for smoking cessation, but they are not widely used by emergency physicians. For counseling, lack of reimbursement has been generally considered a minor barrier to performance. For HIV screening, or other activities that involve collection of blood or tissue samples, reimbursement is a real barrier that must be addressed.
Another objection raised to physician-initiated SBIRT is the lack of formal training. The core curriculum in EM does not mandate such training at present, although successful curricula in alcohol24 and tobacco25 screening have been tested. The long-term ability of these curricula to affect provider behavior remains to be explored. One may assume that the presence of SBIRT content in the in-training and certification examinations of the American Board of Emergency Medicine would help trigger physicians’ interest in these activities.
Last, it is important to conceptualize ED-based screening and intervention as part of a continuum of care. That continuum includes primary care, out-of-hospital care, and inpatient care, in addition to emergent care. We would not suggest that preventive care in the ED constitutes a successful stand-alone intervention without integrated participation by the medical care establishment as a whole.
Although the principal mission of EM is to care for patients with acute illness and injury, this is not its only mission and it is naïve to believe our role is strictly confined to the former. Since its inception as a recognized medical specialty approximately 30 years ago, emergency practitioners have consistently provided preventive care services, many of which have become standard of care. We are not advocating for making the ED a venue for all forms of preventive screening. In fact, the current EM and general health care environments will not likely tolerate this without dramatic changes. We do, however, strongly advocate for performing preventive interventions that make the most sense in the context of available resources. Such interventions should be demonstrated to be clinically- and cost-effective without affecting the primary mission of EM. Ongoing health services research efforts will likely demonstrate such characteristics and will drive future decisions regarding preventive efforts in EM. Much of this will depend heavily on the nature of the preventive intervention, including its prevalence, the specific clinical setting, and its associated individual-level morbidity and mortality, as well as its broader impact on the public’s health.