National Survey of Preventive Health Services in US Emergency Departments

doi:10.1016/j.annemergmed.2010.07.015

Annals of Emergency Medicine

Volume 57, Issue 2, February 2011, Pages 104-108.e2

Presented at the Research Forum, California Chapter of the American College of Emergency Physicians, June 2009, Palm Springs, CA; and as a poster at the Research Forum, Scientific Assembly, American College of Emergency Physicians, October 2009, Boston, MA.

https://doi.org/10.1016/j.annemergmed.2010.07.015 Get rights and content

Study objective

We describe the availability of preventive health services in US emergency departments (EDs), as well as ED directors' preferred service and perceptions of barriers to offering preventive services.

Methods

Using the 2007 National Emergency Department Inventory (NEDI)–USA, we randomly sampled 350 (7%) of 4,874 EDs. We surveyed directors of these EDs to determine the availability of (1) screening and referral programs for alcohol, tobacco, geriatric falls, intimate partner violence, HIV, diabetes, and hypertension; (2) vaccination programs for influenza and pneumococcus; and (3) linkage programs to primary care and health insurance. ED directors were asked to select the service they would most like to implement and to rate 5 potential barriers to offering preventive services.

Results

Two hundred seventy-seven EDs (80%) responded across 46 states. Availability of services ranged from 66% for intimate partner violence screening to 19% for HIV screening. ED directors wanted to implement primary care linkage most (17%) and HIV screening least (2%). ED directors “agreed/strongly agreed” that the following are barriers to ED preventive care: cost (74%), increased patient length of stay (64%), lack of follow-up (60%), resource shifting leading to worse patient outcomes (53%), and philosophical opposition (27%).

Conclusion

Most US EDs offer preventive services, but availability and ED director preference for type of service vary greatly. The majority of EDs do not routinely offer Centers for Disease Control and Prevention–recommended HIV screening. Most ED directors are not philosophically opposed to offering preventive services but are concerned with added costs, effects on ED operations, and potential lack of follow-up.

Introduction

Many emergency departments (EDs) treat a high proportion of patients with unmet primary care needs or with illnesses related to unhealthy behaviors.¹ Accordingly, there has been increasing interest in complementing acute care in the ED with some elements of preventive care.1, 2, 3 During the last 3 decades, more than 40 types of ED preventive services have been reported in the peer-reviewed literature.⁴ However, given that most reports on ED preventive services come from academic centers (which account for only 6% of US EDs), nationwide data on the availability of ED preventive services are sparse.³ This is of particular importance since the release of the 2006 Centers for Disease Control and Prevention (CDC) guidelines calling for HIV screening in all EDs.

Characterization of the availability of preventive services in US EDs would provide a frame of reference for the ongoing debate about the appropriate role of these services in ED operations among many other competing priorities for ED resources. Because ED directors generally determine which services are actually implemented, describing ED directors' preferences for preventive services and perceived barriers to implementation would be informative for policymakers and investigators.

The objectives of this study were to determine (1) the availability of 11 different preventive health services in US EDs, and (2) the services that ED directors' would prefer to implement and their perception of barriers to offering preventive services in the ED.

Section snippets

Study Design

The current study was a survey of ED directors from a nationally representative sample of US EDs. Surveys were mailed to ED directors up to 3 times from September 2008 to February 2009. Nonresponders were contacted through April 2009 by telephone and either faxed or e-mailed copies of the survey. The institutional review board at Stanford University School of Medicine approved this study, with a waiver of written informed consent.

Selection of Participants

The sampling frame was the 2007 National Emergency Department

Results

Among the 348 EDs surveyed, 277 responded from 46 states, representing an 80% response rate. Overall, EDs that responded were similar to EDs nationally (Table). The only differences among nonresponders were that there were fewer teaching hospitals (1%) and trauma centers (4%) represented compared with the responders (data not shown).

Figure 1 displays the current availability of ED preventive services. Intimate partner violence screening and referral was the most available among the 11 services

Limitations

Although the results of this survey may be generalizable to US EDs as a whole, they may not be generalizable to high-volume urban EDs, which treat the highest proportion of patients at risk. In addition, the small sample size precluded subgroup analyses by different hospital characteristics.

The study is limited because the survey questions and terminology on availability of ED preventive services have not been validated in previous research. The research participants may have different

Discussion

To our knowledge, this study is the first to provide a snapshot of the scope of preventive care offered in US EDs beyond high-volume, urban academic centers. Most (90%) EDs offered preventive services, although there was large variability in which services were offered. It is also the first to define ED director priorities for preventive services, as well as perceived barriers to implementation.

HIV screening was the least prevalent of the 11 selected services, available in only 19% of EDs

References (10)

K.V. Rhodes et al.
Society for Academic Emergency Medicine Public Health and Education Task Force Preventive Services Work GroupPreventive care in the emergency department, part I: clinical preventive services—are they relevant to emergency medicine?
Acad Emerg Med
(2000)
C.B. Irvin et al.
Society for Academic Emergency Medicine Public Health and Education Task Force Preventive Services Work GroupPreventive care in the emergency department, part II: clinical preventive services—an emergency medicine evidence-based review
Acad Emerg Med
(2000)
S.L. Bernstein et al.
Public health in the emergency department: Academic Emergency Medicine consensus conference executive summary
Acad Emerg Med
(2009)
G.D. Kelen
Public health initiatives in the emergency department: not so good for the public health?
Acad Emerg Med
(2008)
D.E. Trautman et al.
Intimate partner violence and emergency department screening: computerized screening versus usual care
Ann Emerg Med
(2007)

There are more references available in the full text version of this article.

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Emergency department (ED) based influenza vaccine (IV) programs have been successful in adults; however, little is known about pediatric ED IV programs in terms of prevalence, feasibility, or successful implementation.
To describe the reach and effectiveness of IV practices in pediatric EDs, and identify IV facilitators and barriers.
We assessed, via cross-sectional survey of pediatric ED physicians, number of EDs offering IV to children, vaccines administered annually, and perceived facilitators/barriers to vaccination. The proportion of EDs offering IV is reported. Chi-square tests compared facilitators and barriers among high performers (≥50 IV/year), low performers (<50 IV/yr), and non-vaccinators. We calculated an area of missed effect for the number of children who could be vaccinated if non-vaccinating EDs offered IV.
Among 492 physicians from 166 EDs, 142 responded (representing 61 (37.3 %) EDs). Most EDs were in large, urban, academic, freestanding children’s hospitals (Table 1). Only twenty-six EDs (44.3 %) offer ≥ 1 IV/yr. Seventeen (65.4 %) were low performers, five (19.2 %) high performers, and four (15.4 %) were model programs. High/model performers used establish workflows more commonly than lower performers (78 % vs. 33 %), although this was not statistically significant (p = 0.077). Common facilitators included: strong provider and administration buy-in, electronic health record facilitation, storage/accessibility, and having a leadership team/champion (Fig. 1). Non-vaccinators commonly perceived lack of these factors as barriers. Many (24/61, 39.3 %) EDs expressed interested in establishing or growing IV programs. Up to 18,250 unvaccinated children could receive IV annually if non-vaccinating EDs offered IV during influenza season.
Over half of EDs participating in the Pediatric Emergency Medicine Collaborative Research Committee do not currently offer pediatric IV. Addressing identified barriers/facilitators to develop IV programs in EDs has potential to improve vaccination rates, especially among minority and underserved children.
“They're Doing Their Job”: Women's Acceptance of Emergency Department Contraception Counseling
2020, Annals of Emergency Medicine
We explore reproductive-aged women’s acceptance of contraception counseling in the emergency department (ED).
This study is phase 1 of an exploratory sequential mixed methods study. We purposively interviewed 31 participants with the following criteria: black, white, or Latina race/ethnicity; nonpregnant; aged 15 to 44 years; receiving nonemergency care; not using highly effective contraception; and did not intend to become pregnant. We conducted semistructured interviews with a piloted interview guide until reaching thematic saturation. We coded transcripts with an iteratively developed codebook, maintaining intercoder agreement greater than 80%. Qualitative acceptance of ED contraception counseling was grouped into 3 categories: acceptable, unacceptable, and equivocal. We conducted a thematic text analysis to assess themes expressing support and concern for ED contraception counseling. Qualitative findings were stratified by age, race, and frequency of ED use. Using components of grounded theory, we developed a conceptual model.
Most participants (81%) accepted ED contraception counseling. Themes expressing support and concern for ED contraception counseling included opportunity to address women’s unmet contraception needs, contraception is within the scope of ED practice, the ED is a convenient setting with competent providers, contraception is a sensitive topic, and the ED may be an inappropriate setting for some women. Latina participants had lower acceptance of ED contraception counseling. Dominant subthemes varied slightly by race, age, and frequency of ED use.
Diverse women had high acceptance of contraception counseling in the ED. Perspectives expressing both support and concern in regard to ED contraception counseling were explored in detail.
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To evaluate emergency department (ED) pediatric mortality by patient neighborhood income.
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There were 64 893 ED deaths during the study period (incidence 17.3 per 100 000 person-years). The incidence of ED mortality increased with decreasing neighborhood income: compared with the wealthiest income quartile, the poorest, second, and third quartiles had adjusted incidence rate ratios (aIRRs) of 1.79 (95% CI 1.63-1.96), 1.42 (95% CI 1.29-1.55), and 1.23 (95% CI 1.12-1.36), respectively. The incidence of ED mortality was greater among uninsured children (aIRR 4.96, 95% CI 4.55-5.41) and publicly insured children (aIRR 2.69, 95% CI 2.51-2.88) compared with privately insured children. The interaction term showed no consistent relationship between neighborhood income and insurance with ED mortality.
Children from poorer neighborhoods have greater ED mortality rates than children from greater-income neighborhoods. Improved access to health insurance in the US may lead to reduced pediatric mortality, as ED mortality was greatest in uninsured children. Development of interventions to improve upstream determinants of health that contribute to ED mortality are needed.
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This pilot study demonstrates feasibility and preliminary efficacy of a behavioral intervention to increase uptake of CC screening among ED patients.
Acute HIV Infection in a Patient with Repeat HIV Antibody/Antigen Negative Results Presenting at an Urban Emergency Department: A Case Report
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It is not uncommon for patients with human immunodeficiency virus (HIV) infections to visit the emergency department (ED) during seroconversion. However, patients with newly acquired HIV may not have a reactive screening result. We report a case of a patient who initially screened reactive on a fourth generation HIV test and subsequently nonreactive twice, but ultimately had positive viral load tests.
A 41-year-old woman experiencing symptoms of a sore throat, odynophagia, and back and flank pain for 5 days presented to the ED. The patient had a reactive HIV screen but negative confirmatory antibody test. The ED provider ordered a HIV viral load, informed the patient, and discharged with oral antibacterial agent. The patient returned the next day and after review of Visit 1 results, the ED provider ordered a second HIV screen, which had a nonreactive result. Another HIV viral load order was placed. The patient was discharged and returned a third time, 4 days after initial presentation. On this visit she was admitted, and the initial HIV viral load result returned positive.
We report a case of a patient who initially screened reactive on a fourth generation HIV screening and then twice nonreactive on the same screening test, ultimately having positive viral loads. The most probable explanation for her series of atypical HIV results is that the patient presented during the p24 seroconversion window, which is graphically conveyed in Figure 1. If her first screening had been performed during the window, no further test would have been performed to rule out HIV, contributing to misdiagnosis. ED providers need to be aware that, at some time points during seroconversion from “negative” to “positive”, patients recently infected with HIV and manifesting prodromal symptoms may nonetheless have a negative screening result.
Stroke Prevention for High-Risk Atrial Fibrillation in the Emergency Setting: The Emergency Physician Perspective
2018, Canadian Journal of Cardiology
Citation Excerpt :
Patients waiting to be seen might seize from their toxicological exposure, rupture their appendices, develop tension pneumothoraxes, widen their QRS into a sine wave, tort their ovary, and more, to name just a few anecdotal cases. So although emergency physicians could spend time on preventative medicine, discussing the risks and benefits of a blood thinner with the patient, perhaps engaging the patient with a patient-oriented decision tool, as with everything in medicine there is a cost, and it would be myopic to consider the benefit of preventative ED care for AF patients in isolation.18-20 Rather, one must place that benefit into the context of one's whole practice (all ED patients), and indeed the health care system.
Atrial fibrillation is a frequent reason for presentation to an emergency department (ED), and the number of these visits are increasing. This creates an opportunity to improve the suboptimal rate of oral anticoagulation (OAC) use in patients with atrial fibrillation who are at high risk of stroke. However, there are very few data on whether OAC initiation in the ED, compared with referral to the longitudinal health care provider to initiate it, results in better long-term use. Moreover, for ethical and medicolegal reasons, physicians who initiate a chronic medication are obliged to reassess the patient at a later date, to check for medication side effects and the need for dose adjustment. More research is needed to determine whether OAC should be prescribed in the ED, by a physician who will never see the patient again. Patients who are cardioverted in the ED might be an exception, secondary to the increased risk of stroke after cardioversion. If ED OAC prescribing is associated with better outcomes, these results must be placed into context with the care and outcomes of the other patients in the ED. If there is a net benefit, the findings should be disseminated to practicing emergency physicians, preferably via emergency physician opinion leaders. An implementation science-based approach, which addresses the barriers to ED OAC prescribing (eg, the competing demands of running an ED and lack of guaranteed follow-up care after discharge from an ED), should be used to support prescribing of OAC in the ED. Potential solutions are described.
La fibrillation auriculaire qui constitue un motif de consultation fréquent au service des urgences (SU) suscite des visites de plus en plus nombreuses. Cette situation se prête à l’amélioration du taux d’utilisation sous-optimale de l’anticoagulation orale (ACO) chez les patients atteints de fibrillation auriculaire qui sont exposés à un risque élevé d’accident vasculaire cérébral (AVC). Toutefois, on ne possède que peu données qui démontrent si la mise en place de l’ACO au SU entraîne une meilleure utilisation à long terme par rapport à l’orientation du patient vers un prestataire de soins de santé longitudinaux pour la mettre en place. De plus, pour des raisons éthiques et médicolégales, les médecins qui prescrivent une médication à long terme sont obligés de réévaluer ultérieurement le patient pour vérifier l’apparition d’effets secondaires de la médication et la nécessité d’ajuster les doses. Davantage de recherches sont nécessaires pour déterminer si l’ACO devrait être prescrite au SU par un médecin qui ne reverra jamais le patient. Les patients qui subissent une cardioversion au SU constitueraient une exception en raison du risque accru d'AVC après la cardioversion. Si l’ordonnance d’une ACO au SU est associée à de meilleurs résultats cliniques, ces résultats doivent s’inscrire dans le contexte des soins et des résultats cliniques des autres patients du SU. S’il existe des avantages nets, l’on devrait étendre ces conclusions à la pratique de la médecine d’urgence, de préférence par l’intermédiaire des leaders d’opinion parmi les médecins d’urgence. La mise en œuvre d’une approche scientifique, qui surmonte les obstacles liés à l’ordonnance de l’ACO au SU (par exemple les exigences concurrentes de gestion d’un SU et l’absence de soins de suivi après le congé d’un SU), devrait servir à favoriser l’ordonnance de l’ACO au SU. Nous décrivons ci-après les solutions potentielles.

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: A podcast for this article is available at www.annemergmed.com.

: Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. This research was supported by Agency for Health Care Research and Quality training grant T32HS00028 to the Center for Primary Care and Outcomes Research, Stanford University (Dr. Delgado), the Stanford-Kaiser Emergency Medicine Residency (Dr. Delgado), and National Institutes of Health grant 1K23HD051595-01A2 (Dr. Wang).

: Supervising editors: Melissa L. McCarthy, ScD; Donald M. Yealy, MD

: Author contributions: MKD, AAG, and CAC conceived and designed the study. MKD, NEW, and MCS supervised the conduct of data collection. MKD, CDA, and YSK collected and managed the data, including quality control. MKD and CDA analyzed the data. MKD drafted the article, and all authors contributed substantially to its revision. MKD takes responsibility for the paper as a whole.

: Publication dates:Available online October 2, 2010.

: Please see page 105 for the Editor's Capsule Summary of this article.

: Reprints not available from the authors.

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Clinical practice of emergency medicine/brief research reportNational Survey of Preventive Health Services in US Emergency Departments

Study objective

Methods

Results

Conclusion

Introduction

Section snippets

Study Design

Selection of Participants

Results

Limitations

Discussion

Society for Academic Emergency Medicine Public Health and Education Task Force Preventive Services Work GroupPreventive care in the emergency department, part I: clinical preventive services—are they relevant to emergency medicine?

Acad Emerg Med

Society for Academic Emergency Medicine Public Health and Education Task Force Preventive Services Work GroupPreventive care in the emergency department, part II: clinical preventive services—an emergency medicine evidence-based review

Acad Emerg Med

Public health in the emergency department: Academic Emergency Medicine consensus conference executive summary

Acad Emerg Med

Public health initiatives in the emergency department: not so good for the public health?

Acad Emerg Med

Intimate partner violence and emergency department screening: computerized screening versus usual care

Ann Emerg Med

Clinical practice of emergency medicine/brief research report
National Survey of Preventive Health Services in US Emergency Departments