Public Health in the Emergency Department: Academic Emergency Medicine Consensus Conference Executive Summary
The consensus conference was supported by Grant R13HS018606 from the Agency for Healthcare Research and Quality and the National Institute on Drug Abuse of the National Institutes of Health. The views expressed in this issue of Academic Emergency Medicine do not necessarily reflect the official policies of the Department of Health and Human Services, nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. government.
Additional funding for the conference was provided by secondary support from the following: National Institute of Mental Health, National Institute on Alcohol Abuse and Alcoholism, Substance Abuse and Mental Health Services Administration, Join Together–Boston University School of Public Health, Boston University Department of Emergency Medicine, Brown University Department of Emergency Medicine, George Washington University Department of Emergency Medicine, University of Maryland Department of Emergency Medicine, Yale University Department of Emergency Medicine, Emory University Department of Emergency Medicine, Johns Hopkins University Department of Emergency Medicine, and University of Michigan Department of Emergency Medicine.
Fifty years ago, C. P. Snow wrote of the intellectual divide between the humanities and the sciences in his essay, Two Cultures.1 The book sparked an intellectual debate that continues to this day. In health care, a similar intellectual and clinical rift has arisen over the decades—between clinicians who treat individual patients and practitioners of public health, population health, and prevention. Numerous educational and clinical efforts have been made to bridge these diverging paradigms of care as early as half a century ago,2 and as recently as the present agreement between the Centers for Disease Control and Prevention (CDC) and the Association of American Medical Colleges.3
In emergency medicine (EM), a specialty dedicated to “the identification and stabilization of patients threatened with loss of life or limb,”4 the paradigm of public health practice may seem foreign: “what we as a society do collectively to assure the conditions in which people can be healthy.”5 One addresses the treatment of individuals with acute problems; the other addresses the prevention of threats to the health of a community.
How might one link these two paradigms? Several authors have offered a public health–relevant model of emergency medical practice. 6–10 These approaches center around the insight that many of the acute illnesses and injuries suffered by emergency department (ED) patients result from preventable or modifiable health risks, such as substance use, interpersonal violence, mental health disorders, and unsafe sexual behavior. Redesigning systems of care so that these individuals can be identified, and receive brief interventions and referrals to appropriate follow-up care, may alleviate some of the substantial burden of illness and injury caused by these health risks.
Consensus conference background
With this intellectual framework in mind, on May 13, 2009, a group of 163 emergency physicians, researchers, administrators, and others gathered in New Orleans for the 10th annual Academic Emergency Medicine (AEM) consensus conference. The topic this year, developed by the Public Health Interest Group of the Society for Academic Emergency Medicine (SAEM), was “Public Health in the Emergency Department: Surveillance, Screening, and Intervention.” Joining members of the academic EM community were a number of federal partners representing several NIH institutes, including the National Institute on Mental Health, National Institute on Alcohol Abuse and Alcoholism, and National Institute on Drug Abuse, along with the CDC, and the Substance Abuse and Mental Health Services Administration (SAMHSA).
The mission of the conference was to stimulate the development of a research agenda and a coordinated initiative within our specialty to explore public health–relevant domains in surveillance, screening, and intervention for risky heath behaviors. This issue of the journal reports on the consensus conference proceedings. As with the prior special issues dedicated to these annual conferences, the entire issue is available free of charge online at the journal’s Web site, http://www.aemj.org.
The first half of this issue, guest-edited by Lowell Gerson, PhD, contains the proceedings of the conference, reporting on the four consensus-building workshops, five breakout presentations, two panel discussions, and two plenary presentations. The topics and moderators of the nine breakout groups are summarized below; session findings and content are discussed in substantially more detail in the proceedings papers that follow.
The second half of this issue of the journal, guest-edited by Mark Hauswald, MD, is a compilation of original research contributions on topics relevant to the consensus conference theme. The breadth of topics addressed is reassuring, in that it demonstrates the work that our specialty is already doing in this area, but it is the goal of this conference to stimulate further work to populate the pages of this and other journals in the future.
Common themes linking the consensus recommendations
The nine breakout and consensus sessions, despite their broad range of topics and tasks, reached consensus around several recommendations, including these:
1. Continue to define the nature and scope of effective ED-initiated interventions for risky health behaviors. Many studies of risky health behaviors and behavioral health have focused on defining the prevalence and epidemiology of these conditions in ED populations. For at least one health risk, hazardous and harmful use of alcohol, there is now a fairly well-defined body of knowledge. Evidence of efficacy exists, particularly in primary care settings. But the efficacy and effectiveness of ED-based interventions for alcohol remains unclear, because of the heterogeneity of results from randomized clinical trials. Nonetheless, the brief interventions known as SBIRT (screening, brief intervention, and referral to treatment) have been endorsed by several groups, including Substance Abuse and Mental Health Services Administration (SAMHSA).11 For other risky behaviors, such as smoking, use of illicit substances, or interpersonal injury such as intimate partner violence, the evidence is sparse. Additional work is needed in all these areas to define the efficacy, effectiveness, and cost-effectiveness of brief interventions.
2. Develop a multicenter network to conduct rigorous trials of brief interventions for risky health behaviors. Most published trials of interventions for risky health behaviors have been conducted in single EDs. An organized, extramurally funded research network composed of academic and nonacademic EDs could conduct trials of interventions for risky health behaviors and other public health–relevant activities. There are several models for this, such as the Neurologic Emergencies Neurological Emergencies Treatment Trials Network and the Pediatric Emergency Care Applied Research Network.
3. Incorporate the principles of public health, population health, and prevention into the core curriculum of EM. Public health and related topics are not well represented in the core content of EM.12 The most recent iteration of the core curriculum has 18 content areas, containing 115 subsections. One content area, psychobehavioral emergencies, covers illicit substance use and alcohol and intimate partner violence. However, there is no mention of the two leading causes of preventable death and illness in the United States, smoking and obesity. Neither is there any mention of the social or behavioral determinants of health or a discussion of the principles of prevention or population health. Revising the curriculum to include these topics would enhance the training of emergency physicians and establish these topics as within the domain of clinical EM.
4. Address the perceived barriers of time, space, funding, and staffing that inhibit ED staff from intervening in patients’ risky health behaviors. EDs are stressed by growing patient volumes, crowding, inability to transfer admitted patients to inpatient units, decreasing reimbursements, and increasing scrutiny by regulatory and accrediting agencies. It is essential that ED-based screening, surveillance, and interventions be evidence-based and sensitive to these clinical, operational, and fiscal constraints. This will be essential to overcome the historic reluctance of ED staff to screen and intervene in patients with preventable health risks. Interventions should not be considered “stand-alone,” that is, confined to the ED, but should incorporate linkages to primary care and treatment settings for substance abuse and mental health. Finally, although some interventions might be performed by physicians and other providers, dissemination and implementation will likely be greater for programs that involve changing systems and processes of care and include the full spectrum of ED personnel.
After a welcome by David C. Cone, MD, Editor-in-Chief of AEM, Conference Co-Chair Steven L. Bernstein, MD, gave a talk discussing the clinical impact of risky health behaviors on the epidemiology of ED visits. This was followed by a keynote address by Arthur L. Kellermann, MD, MPH, Vice Dean for Health Policy at Emory University, addressing the conceptual and practical linkages between EM and public health.
The next plenary session was a panel discussion, moderated by Conference Co-Chair Gail D’Onofrio, MD, MS, on federal agencies’ funding priorities for public health–relevant research in EM. Discussants included Richard Denisco, MD, MPH, from the National Institute on Drug Abuse; Ralph W. Hingson, ScD, MPH, from the National Institute on Alcohol Abuse and Alcoholism; Amy Goldstein, PhD, from the National Institute of Mental Health; and James Heffelfinger, MD, MPH from the CDC. A lunchtime discussion on the clinical efficacy of SBIRT was moderated by Edward Bernstein, MD, and featured Richard Saitz, MD, MPH, from Boston University, and Jack Stein, MSW, PhD, Director of SAMHSA’s Center for Substance Abuse Treatment.
There were five content-specific breakout sessions in the morning and four more thematic consensus sessions in the afternoon. Each of these sessions is represented by a paper elsewhere in this issue of AEM.
The morning breakout sessions were:
1. Alcohol and substance use (Rebecca Cunningham, MD, and Frederick C. Blow, PhD).
2. Injury prevention/intimate partner violence (Debra Houry, MD, MPH, Stephen W. Hargarten, MD, MPH, and Robin M. Ikeda, MD, MPH).
3. Sexually transmitted infections/HIV (Jason Haukoos, MD, MSc, and Richard Rothman, MD, PhD).
4. Health services databases (Jon Mark Hirshon, MD, MPH, and Margaret Warner, PhD).
5. Mental health disorders (Gregory Luke Larkin, MD, MS, MSPH).
The afternoon consensus sessions were:
1. Study designs and evaluation models (Bruce M. Becker, MD, MPH, and Kerry B. Broderick, MD).
2. Conceptual models of health behavior (Edwin D. Boudreaux, PhD, and Rita K. Cydulka, MD, MS).
3. Dissemination and implementation (Mary Pat McKay, MD, MPH, and Karin V. Rhodes, MD, MS).
4. Funding and sustainability (Linda Degutis, DrPH, and Robert Woolard, MD).
On behalf of the conference organizing committee (Table 1) and the journal’s editorial board, we thank the participants, federal partners, and funders for making the day a successful one. We also thank the staff of the journal and SAEM for their administrative and logistic support. We hope that the reader finds the conference proceedings and solicited papers stimulating and informative and that these documents will catalyze research in these important areas. We thank the Society for the opportunity to have held the conference.
Consensus Conference Organizing Committee
|Steven L. Bernstein, MD: Co-Chair|
|Gail D’Onofrio, MD, MS: Co-Chair|
|David C. Cone, MD: Editor-in-Chief|
|Lowell W. Gerson, PhD: Guest Editor|
|Mark Hauswald, MD: Guest Editor|
|Barbara Mulder: SAEM Associate Executive Director|
|Sandra Arjona: Journal Manager|
|Jamie Petrone: Conference Administrator, Yale University|
|Holly Gouin: SAEM Marketing and Membership Manager|
|Rebecca Sullivan: Conference Assistant, Yale University|