Historical Parallel Evolution of Injury Prevention and Control Science and Emergency Medicine
Injury care is a core part of daily emergency medicine (EM) clinical practice, accounting for over one-third of emergency department (ED) visits every year.1 It also remains a formidable burden to the public’s health in the United States. The Centers for Disease Control and Prevention (CDC) reports that in 2006, 179,065 Americans died as a result of injury,2 and in 2007, 29,756,586 suffered nonfatal injuries.3
Historically, the development of the science of injury prevention and control has paralleled the evolution of the specialty of EM. This was initially nested within the context of emergency medical services (EMS) and trauma systems development. In the 1966 landmark publication, Accidental Death and Disability: The Neglected Disease of Modern Society, the National Academy of Sciences and the National Research Council detailed the first examination of the country’s burden of injury morbidity and mortality. The report outlined specific recommendations calling for EMS development and meaningful federal agency guidance and oversight.4
Along with the first federal funding to establish EMS in the late 1960s and early 1970s came the establishment of the National Highway Safety Bureau (later known as the National Highway Traffic Safety Administration [NHTSA]). This emphasis on EMS contributed to the development and organization of EDs and specialty training of emergency physicians (EPs).
As the specialty of EM began to grow in the 1970s, the public’s awareness of the continued high injury-related morbidity and mortality statistics raised the urgency for policy-makers to address the nation’s injury burden. As a result, state and federal health officials and researchers began to focus their efforts on population health to accurately describe and formulate plans to address the injury burden and its impact on U.S. communities. In 1985, the first of the landmark “red books,”Injury in America: A Continuing Public Health Problem, was published.5 This report outlined the magnitude of the national injury burden, and the gaps in addressing this burden comprehensively, and provided descriptions of opportunities for medical specialties to participate in reducing this burden. Subsequent national reports6 continued to reveal the cost of injury and the challenges in addressing this public health burden. Simultaneously, EM as a specialty began to build its intentional and positive influence in the future development of injury prevention and control activities and science. Over the past two and a half decades, EM’s efforts to address injury as a public health burden have led many EPs to engage in injury prevention and control activities through participation and leadership in surveillance and research, education, and advocacy. These collective efforts have fostered growth in the body of knowledge of injury science and have helped to lessen the burden on society.
Surveillance and research
As the clinical specialty treating the entire spectrum of injury occurring in children and adults, EM is uniquely positioned to contribute to the science of injury prevention and control. At a population level, EM is able to provide understanding of types of injury patterns occurring, the risk factors for their occurrence, and the outcome of the injury. In creating epidemiologic profiles of injury patterns, interventions at both the individual and the population level can be developed and examined. Within states, EM contributes to injury surveillance with external cause coding (E-codes) in the hospital ED data system. Although these data are used primarily for administrative and billing purposes, they provide important state-level external cause of injury data for measuring the impact of nonfatal injury in that state, allowing policy-makers to make data-driven decisions regarding injury prevention.7 Several large national databases that utilize ED data on injured patients are frequently accessed and used by researchers both within and outside of EM to describe a specific injury problem and discuss mechanisms for prevention and control. One database that relies solely on ED data is the National Electronic Injury Surveillance System–All Injury Program (NEISS-AIP), which is a collaborative effort between the US Consumer Product Safety Commission and the CDC’s National Center for Injury Prevention and Control.8 Data on injury-related visits are obtained by NEISS-AIP from a national stratified probability sample of hospitals in the United States and its territories with a minimum of six beds and a 24-hour ED. NEISS-AIP collects data on initial visits for all categories of injuries treated in U.S. EDs and provides data on nearly 500,000 injury-related ED visits annually. Not only does EM contribute to the database through its clinical work, but researchers within the specialty have been consumers of the data and utilize it to further describe injury patterns.9–11 Another injury surveillance database that EM contributes to is the Crash Outcome Data Evaluation System (CODES) database that is maintained by NHTSA.12 It is a statewide population-based probabilistic linkage of police reports on motor vehicle crash (MVC), EMS, and hospital/ED data. EM researchers have used this database in describing transportation injury problems.13,14
Emergency physicians now lead many regional poison control centers. These centers provide important toxicologic expertise for patient care, as well as a large amount of data on the occurrence and outcomes of poisonings that is utilized by EM and non-EM researchers.15,16 The Drug Abuse Warning Network (DAWN)17 is a public health surveillance system that monitors drug-related visits to EDs and helps communities identify emerging problems that are risk factors for intentional and unintentional injuries.
EM-based injury prevention research has also had a substantive role with both interventional and translational research at the patient care level and advancing clinical preventive services. One example is EM-based randomized clinical trials in the area of screening, brief intervention, and referral to treatment (SBIRT) for alcohol use disorders that have demonstrated decreased alcohol use,18 injury,19 or risky behaviors for injury occurrence.20 This has led to type II translational research21 (bedside to community) on how to best integrate SBIRT into routine EM care.22
The ED is frequently a treatment site for victims of interpersonal violence. This has allowed EM-based researchers to contribute to the knowledge development of this problem, as well as expand research to better screen for and intervene with victims.23–25
Motor vehicle crashes are the leading cause of injury death in the first three decades of life. Caring for the entire spectrum of MVC trauma victims allows EM to develop research foci in this area of testing and interventions to decrease future injury risk26 and contributing to the clinical research of care of the injured trauma patient to prevent secondary injury. It has also allowed EM to contribute to the science involving the biomechanics of crash injury27,28 and an appropriate EMS response to reduce the occurrence of secondary injury.29,30
As a result of growing interest and leadership in injury prevention and control, several departments of EM began to organize their efforts and form injury prevention centers. These centers have had a research focus, but also have efforts directed at injury prevention education and community programs. The growing number of EM-led centers reflects the increased leadership that the specialty brings to the field of injury prevention and control. These centers31–35 have a track record of state and federal research funding for injury prevention and control research, as well as incorporating missions for education and community outreach. Several offer fellowship training in injury prevention and control for EM trainees.
Undergraduate/graduate medical education
Instruction to EM residents on injury prevention was first addressed in 1990,36 with a short course with the goal to “provide information on motor vehicle crashes in a public health framework.” As others in EM began to publish and lecture on this topic, efforts to increase health care professional training in injury prevention increased.37 The Institute of Medicine (IOM) report “Who Will Keep the Public Healthy” noted the importance of injury prevention and control education for the well-being of the population and called for health care professional training programs to make injury prevention training a higher priority.38 EPs in training shared the same belief as the IOM and wanted more injury prevention and control education in their training. In one study, 97% of EM residents in California surveyed between 1992 and 1993 felt that injury prevention was a critical aspect of their work, and 70% felt that it was a necessary focus in their training.39 Many articles and efforts from national organizations, such as the Association of American Medical Colleges, have called for an incorporation of injury prevention and control into medical school curricula40,41 and further advancement into medical training programs, including EM.
The integration of injury prevention and control and EM practice and training has continued to grow. Injury prevention and control is now recognized as integral to EM residency training, although it still needs more emphasis in the core curriculum. Medical schools are increasingly recognizing the opportunity injury has in integrating basic science, clinical care, and population health sciences for their students. There are EM-based injury control and prevention fellowships, complementing the traditional trauma surgery fellowships that exist at many academic health centers in the United States.
It is important to emphasize the opportunity that EM has to advance the science of injury prevention and control and bring the various injury control stakeholders together. A good example of this can be found in the context of toxicology and poisonings. Acute injury from chemical agents continues to be a growing and significant cause of mortality and morbidity. It is now the leading cause of injury death in Americans age 35–44 years.2 EM already plays a significant national leadership role in toxicology and poison center activities. According to the American College of Emergency Physicians, there are currently more than 20 fellowships in EM toxicology.
Emergency medicine leaders in disaster preparedness and response from all physical agents including chemical are also in a strong position to reduce fragmented responses and further improve our overall disaster preparedness by unifying response principles and integrating the science of injury prevention and control. The acute care research agenda of the CDC’s National Center for Injury Prevention and Control calls for case studies that further inform our abilities to address mass casualties from physical agents.42
Among the central goals of training future EM leaders, and in unison with Accreditation Council for Graduate Medical Education (ACGME) principles that guide our resident training43 is the development of professionalism and duty to society in EM trainees.44 Consistent with this, EPs have moved to purposely teach and lead by example as advocates for primary injury prevention and control programs and policies. EM leaders have also organized to educate the community and conduct important policy-relevant injury research expertise. Today, state and federal government agencies continue to seek support from EPs to provide important insights and expertise into injury-related issues that are affecting the nation. EM leaders have made and continue to make substantial contributions within these federal agencies including the CDC, the NHTSA, the Department of Health and Human Services, and the Health Resources and Services Administration.
Future opportunities and directions
While there has been significant growth in both injury prevention and control science and EM over the past several decades, the current challenges to EM outlined in recent IOM reports45–47 appear to be daunting and potential indicators of a downturn. However, some of these same challenges reveal tangible opportunities for continued parallel growth in injury prevention and control science and EM. One of the most notable areas where such opportunity exists is within the National Institutes of Health’s creation of the Clinical and Translational Science Awards (CTSA). Understanding that each CTSA will have to be understood in its respective institutional culture and context, opportunities for collaboration and EM investigator–initiated training and research in injury prevention and control should exist. Training EPs in translational sciences has the potential to significantly enhance the capacity for future EM researcher and specialty success while advancing the science of injury prevention and control.
The development and growth of injury prevention and control science and EM as a medical specialty have had paralleled success. The spectrum of leadership of EPs in injury prevention began at the bedside with the desire of EPs to deliver the very best care to injured patients. Many EPs and departments have gone beyond the doors of the ED and have been instrumental in influencing important systems of surveillance, clinical care, and health policy so that primary and secondary prevention efforts are effectively developed and implemented. Still other EPs have gone further to champion injury prevention and control in a variety of prominent leadership positions at state and federal levels. Injury research centers, with primary and collaborative EM leadership, continue to flourish nationally, with EPs partnering with colleagues in surgery, pediatrics, psychiatry, epidemiology, and other disciplines on injury research, advocacy, and policy. The future of EM leadership and growth in injury prevention and control science remains promising, with opportunities for the development and execution of robust research that will influence the public’s health in meaningful and measurable ways.