Discussion of how we in the ED lie at the intersection of acute care and population health

1. Public Health and the ED
Pon-Hsiu Yeh
April 2016

2. Outline
• Why Public health in the ED?
• History
• Improving access
• Surveillance of diseases
• Preventative Services
• Policy relevant research
• Innovative partnerships

3. Why is the ED and public health a
perfect match?
• ED is intersection of individual and population
health, between the hospital and the community
• Serves as a first point of presentation for urgent
problems
• Presents a unique cross section of the
community with 24 hour access
• Interfaces between primary care, specialty care,
unmet health needs of population
• Collects data on important health metrics
• Identifies social issues

4. History
• pre1970’s: Pts seeking emergency care
seen at “charity hospitals” staffed by
physicians from various specialties
• 1970s: EM specialty started to improve
patient needs to access care specifically
with respect to vulnerable populations
• 1980s: EMTALA passed to prevent
“patient dumping” of uninsured patients

5. Health care access
• Historically, ED a place for vulnerable patient
populations to seek care
• Studies have found that “Attempts to restrict ED
use would disproportionately burden minorities
and the poor (Tyrance, 1996)
• ED is “safety net” for millions of uninsured
• Medicaid recipients may have fewer options to
seek care outside of the ED (NEJM, 1994)
• Today struggles between keeping cost down in
ED vs providing quality care

6. Access: Future research
• Improve patient flow and care outside of
ED
• Research best methods to provide care
for vulnerable populations
• Assess barriers to seeking care

7. Surveillance
• ED based surveillance began in 1990s in response to
infectious disease and violence
• ED front line position to identify/treat/control epidemics
– Important for early detection/response
– Important for rapid reporting
• Relevant with new emerging infectious diseases and
bioterrorism
• ED also provides surveillance for domestic violence,
firearms, child abuse
• ED databases provide information for injury surveillance

8. Surveillance: future
• Extend surveillance to include more public
health conditions
• Use of electronic tools to speed up
detection
• Collaboration between hospitals,
government, public health agencies to
influence policy, increase impact

9. Preventative services
• Primary/secondary/tertiary prevention for chronic diseases, injury
causing behavior
• ED for screening and plugging patients into long term outpatient
care
• US Preventive Services Task Force (USPSTF) recs provision of
preventive services through acute care
• Comprehensive preventive services difficult in resource poor ED
• 1998: SAEM Public Health Task Force recs five preventative
services in ED
– Alcohol screening/intervention
– HIV screening/referral
– Htn screening and referral
– Pneumococal vaccinations (age > 65)
– Smoking cessation

10. Prevention: future
• Expand research on impacts of prevention
• Identify ED discharge materials/methods
that influence outcomes
• Test how impactful ED recommendations
are in setting of “teachable moments”
• Identify the restraints that preventative
care places on ED physician time and
resources

11. Emerging topics
• ED crowding
• Health care disparities based on race,
age, sexual orientation, gender
• Opiod epidemic
• Mental health care
• Vulnerable populations: homeless,
domestic/sexual abuse, elder abuse, child
abuse
• Injury/trauma

12. How to get involved
• Apply public health principles to clinical
practice
• Public education, community involvement,
public policy advocacy
• Development of med school and residenty
public health curricula
• Increase research opportunities and
surveillance

13. References
• Rhodes KV and DA Pollack. The Future of
Emergency Medicine Public Health
Research. Upenn Repository. 2006.
• Bernstein E, et al. A public health
approach to emergency medicine:
preparing for the twenty-first century.
Acad Emerg Med. 1994 May-
Jun;1(3):277-86.