Integration of disaster mental health services with emergency medicine

Despite limited resources, emergency medical settings will be called upon to play many roles in the context of disasters and terrorist attacks that are related to preparedness, surveillance, mental health services delivery, and staff care. Such settings are a central capture site for those individuals likely to be at highest risk for developing mental health and functional problems. Because much of the potential harm to survivors of disaster or terrorism (and their families) will be related to their mental health and role functioning, preparedness requires the active integration of behavioral health into emergency medicine in every component of disaster response. There are many challenges of doing this including: (1) finding ways to integrate activities of the medical care, emergency response, and public health systems; (2) determining whether an incident has actually occurred; (3) making differential diagnoses and managing other aspects of initial medical needs; and (4) coping with the risks associated with system overload and failure. Delivery of direct mental health care must include: (1) survivor and family education; (2) identification and referral of those requiring immediate care and follow-up; (3) group education and support services; and (4) individual counseling. In order for effective response to occur, the integration of psychosocial care into disaster response must occur prior to the disaster itself, and will depend on effective collaboration between medical and mental health care providers. At workplaces, emergency medical care centers must ensure that staff and their families are properly trained and supported with regard to their disaster functions and encouraged to develop personal/family disaster plans.     

Emergency Medicine Public Health Research Funded by Federal Agencies: Progress and Priorities

The emergency department (ED) visit provides an opportunity to impact the health of the public throughout the entire spectrum of care, from prevention to treatment. As the federal government has a vested interest in funding research and providing programmatic opportunities that promote the health of the public, emergency medicine (EM) is prime to develop a research agenda to advance the field. EM researchers need to be aware of federal funding opportunities, which entails an understanding of the organizational structure of the federal agencies that fund medical research, and the rules and regulations governing applications for grants. Additionally, there are numerous funding streams outside of the National Institutes of Health (NIH; the primary federal health research agency). EM researchers should seek funding from agencies according to each agency's mission and aims. Finally, while funds from the Department of Health and Human Services (HHS) are an important source of support for EM research, we need to look beyond traditional sources and appeal to other agencies with a vested interest in promoting public health in EDs. EM requires a broad skill set from a multitude of medical disciplines, and conducting research in the field will require looking for funding opportunities in a variety of traditional and not so traditional places within and without the federal government. The following is the discussion of a moderated session at the 2009 Academic Emergency Medicine consensus conference that included panel discussants from the National Institutes of Mental Health, Drug Abuse, and Alcoholism and Alcohol Abuse and the Centers for Disease Control and Prevention (CDC). Further information is also provided to discuss those agencies and centers not represented.     

Research Directions in Emergency Medicine*

The goal of EM is to improve health while preventing and managing disease and illness in patients seeking emergency medical care. Improvements in emergency medical care and the delivery of this care can be achieved through credible and meaningful research efforts. Improved delivery of emergency medical care through research requires careful planning and the wise use of limited resources. To achieve this goal, EM must provide appropriate training of young investigators and attract support for their work. Promotion of multidisciplinary research teams will help the specialty fulfill its goals. The result will be the improvement of emergency medical care, which will benefit not only the patients whom EPs serve, but also, ultimately, the nation's health.     

Disaster Medicine: Current Assessment and Blueprint for the Future

Emergency services for disaster-affected populations require the application of out-of-hospital planning, curative acute medical skills, and public health principles. SAEM can play an important role in promoting the research and educational agendas for disaster medicine through its network of EM educators at academic health centers. Testing of disaster medicine principles as part of the EM certification process will emphasize the importance of disaster medicine in the overall training of EPs. Postgraduate fellowships in disaster medicine also should be promoted and closely linked to disaster response organizations. Overall professional training must encompass the many facets described in this paper to prepare physicians to meet the challenges of disaster medicine.     

Strategies for Improving Information Management in Emergency Medicine to Meet Clinical, Research, and Administrative Needs

The ED of the future will require the effective integration of information technologies into clinical care. This article proposes strategies for improving information management in emergency medicine to facilitate patient care, public health surveillance, clinical research, medical education, and health care management.     

The role of public health nurses in emergency preparedness and response: a position paper of the Association of State and Territorial Directors of Nursing

ABSTRACT The Association of State and Territorial Directors of Nursing vision for emergency preparedness is that every community, family, and individual will have a comprehensive emergency preparedness plan that minimizes the consequences of disasters and emergencies, and enables communities, families, and individuals to respond and recover. This position paper provides national and state policy guidance during emergencies to all public health nurses in the United States and its Territories. Public health nurses bring critical experience to each phase of a disaster: mitigation, preparedness, response, and recovery. Public health nurses strive to achieve individual competencies so that they may better collaborate with others and contribute to emergency preparedness and response. Twelve Emergency Preparedness Competencies are listed in this position paper that will assist public health nurses with disaster prevention, planning, response, recovery, drills, exercises, and training. This position paper will be useful in clarifying the expertise that public health nurses can contribute to teams that serve to protect the health and safety of communities against disaster threats and realities.     

Public Health in the Emergency Department: Overcoming Barriers to Implementation and Dissemination

This article is the outcome of a consensus building workshop entitled, "Overcoming Barriers to Implementation and Dissemination" convened at the 2009 Academic Emergency Medicine Consensus Conference, 'Public Health in the ED: Surveillance, Screening, and Intervention." The participants were asked to address potential methods for overcoming barriers to the dissemination and implementation in the emergency department (ED) of evidenced-based practices to improve public health. The panel discussed three broad areas of interest including methods for disseminating evidence-based practices, barriers encountered during the process of implementation, and the importance of involvement in activities outside the ED including engagement in policy development and improvement. Four recommendations were discussed in detail and consensus was reached. The recommendations included 1) researchers and advocates should disseminate findings through multiple forums beyond peer-reviewed publications when an ED-based public health intervention has enough evidence to support integration into the routine practice of emergency care; 2) local barriers to implementation of public health interventions should be recognized and well understood from multiple perspectives prior to implementation; 3) innovation must be put into place and adapted based on local institutional context and culture as barriers and the best methods for overcoming them will vary across institutions; and 4) use of legislation, regulation, and incentives outside of the ED should support and strengthen ED-based interventions. For each area of interest, research dimensions to extend the current understanding of methods for effectively and efficiently implementing evidence-based public health interventions in the ED were discussed and consensus was achieved.     

The Development of International Emergency Medicine: A Role for U.S. Emergency Physicians and Organizations

ABSTRACT
There is a rapidly growing interest in emergency medicine (EM) and emergency out-of-hospital care throughout the world. In most countries, the specialty of EM is either nonexistent or in an early stage of development. Many countries have recognized the need for, and value of, establishing a quality emergency health care system and are striving to create the specialty. These systems do not have to be high tech and expense but can focus on providing appropriate emergency training to physicians and other health care workers. Rather than repeatedly "reinventing the wheel" with the start of each new emergency care system, the preexisting knowledge base of EM can be shared with these countries. Since the United States has an advanced emergency health care system and the longest history of recognizing EM as a distinct medical specialty, lessons learned in the United States may benefit other countries. In order to provide appropriate advice to countries in the early phase of emergency health care development, careful assessment of national resources, governmental structure, population demographics, culture, and health care needs is necessary. This paper lists specific recommendations for EM organizations and physicians seeking to assist the development of the specialty of EM internationally.     

A CLIMATE: A Tool for Assessment of Climate-Change–Related Health Consequences in the Emergency Department

Climate change is an urgent public health problem that has looming implications and associated deleterious health consequences. The intersection of climate change and health has broad implications for health professionals in a variety of settings but especially for ED settings. Climate change is already affecting human health and health systems—which includes impacts on ED care. Disaster response and emergency preparedness are critically important public health interventions in our climate-changing world, and the contributions of emergency nurses are essential. Disaster preparedness, environmental emergency response, and health emergency management are important elements of emergency nursing and are explicated in Sheehy’s Emergency Nursing Principles and Practices, 7th Edition. The purpose of this article is to present an overview of a clinical tool and mnemonic, A CLIMATE, developed by the authors with application to a case review. It is imperative that the nursing profession—particularly emergency clinicians—address the intersection of climate and health to engage in the assessment, intervention, management, evaluation, education, and referral of those who present to emergency departments with potential climate-related health impacts.     

Partnering to prepare: An academic/workforce collaboration to develop disaster shelter training for nurses

In California, more frequent, intense, and destructive wildfires have prompted public health departments to enhance disaster response plans as evacuations and shelter needs increase. In addition, individuals utilizing shelters have increasingly complex medical and behavioral health needs and are accessing shelters for longer periods of time. Public health nurses (PHNs) are often called to staff disaster shelters but may have less recent experience in, or comfort with, direct patient care. Many health departments are experiencing challenges developing sustainable training infrastructure that prepares PHNs to deliver direct patient care in disaster shelters. Partnering with academic institutions can address this challenge. This article describes a partnership between a regional collaborative of health jurisdictions and a public university to train public health nurses to work in disaster shelters. The training demonstrates a sustainable way to instruct public health nurses while also highlighting the potential of partnerships between academic institutions and local health departments to address disaster preparedness and response needs in a community. Public health nurses are essential to public health preparedness and providing additional training can augment their ability to respond to disasters.     

The Emergency Medicine Capacity Assessment Study: Anticipated impact of a major increase in intern numbers in Australian ED

Objective: To identify emergency medicine (EM) staff perceptions of EM intern rotation, the capacity of ED to accept an increase in intern numbers of 70%, attitudes of staff towards the increase, and its anticipated impact on management of ED, patient care and learning opportunities. Method: A semistructured telephone interview was conducted with ED Directors, Directors of Emergency Medicine Training (DEMT), advanced trainees and interns in EM from a stratified sample of city, metropolitan and rural/provincial public hospitals in Australia. Results: Ninety‐five interviews were completed with 100% participation from ED Directors. Most participants agreed that the ED rotation should remain compulsory for full medical registration, 67% disagreed that they would like 70% more interns in their ED; most ED Directors and DEMT indicated this could not occur without problems. Most felt it would be difficult for existing numbers of consultants and registrars to supervise 70% more interns, and more interns would not improve patient wait times and ED length of stay. Almost two‐thirds felt the increase in interns would decrease their exposure to procedures; most Directors and DEMT felt that an increase in medical students would affect their ability to take medical elective students (78%) and Australian Medical Council observers (70%). Conclusion: The increase in interns peaking in 2012 represents a significant change to the health system that will challenge the capacity of ED. Although ED internship is perceived as an indispensable learning opportunity, maintaining the ED experience with a rapid influx of interns will not occur without problems.     

Emergency Medical Preparedness and Response to a Singapore Airliner Crash

A Singapore airline crash in 2000 was the first documented mass casualty incident (MCI) caused by an aircraft disaster in Taiwan. This report reviews the emergency medical preparedness of the airport and examines its effects on the medical response during this incident. The anticipated benefits from the new MCI plan and prior medical preparedness were not achieved during this disaster. Poor compliance with the new MCI plan by the airport authority was noted. Victims were not triaged and did not receive adequate field medical care. Structural problems with the MCI plan were also noted. Site medical teams responding from hospitals could not function as the plan had been designed. This article discusses factors causing the poor compliance, various problems, and related issues in medical response to the incident. As learned from this experience, a properly and practically designed MCI plan, good compliance of responders, and a strong support system of responding agencies are the most important factors for successful emergency response to any MCI.     

Public health nursing competencies for public health surge events

OBJECTIVE: To develop consensus regarding public health nursing competencies in the event of a public health surge event related to disaster. DESIGN AND METHODS: Using a 3-round Delphi approach, public health nurses (PHNs) and directors of nursing from local health departments, state nursing leaders, and national nursing preparedness experts reviewed and commented on 49 draft competencies derived from existing documents. RESULTS: The final 25 competencies were categorized into Preparedness (n=9), Response (n=8), and Recovery (n=7). The Preparedness competencies focus on personal preparedness; comprehending disaster preparedness terms, concepts, and roles; becoming familiar with the health department's disaster plan, communication equipment suitable for disaster situations; and the role of the PHN in a surge event. Conducting a rapid needs assessment, outbreak investigation and surveillance, public health triage, risk communication, and technical skills such as mass dispensing are Response phase competencies. Recovery competencies include participating in the debriefing process, contributing to disaster plan modifications, and coordinating efforts to address the psychosocial and public health impact of the event. CONCLUSIONS: Identification of competencies for surge events that are specific to public health nursing is critical to assure that PHNs are able to respond to these events in an effective and efficient manner.     

Emergency Department Digital Radiology: Moving from Photos to Pixels

Emergency department (ED) patient care relies heavily on radiologic imaging. As advances in technologic innovation continue to present opportunities to streamline and simplify the delivery of care, emergency medicine (EM) practitioners face the challenge of transitioning from a system of primarily film-based radiography to one that utilizes digitized images. The move to digital radiology can result in enhanced quality of patient care, reduction of errors, and increased ED efficiency; however, making this transition will necessarily involve changes in EM practice. As the technology evolves, digital radiology will gradually become ingrained into everyday practice because of these and other notable benefits; however, EM practitioners will need to overcome several challenges to make the transition smoothly and consider the potential impacts that this change will have on ED workflow. The authors discuss the benefits, challenges, and other operational considerations involved with the ED implementation of digital radiology and close by presenting guiding principles for current and future users. Despite the unresolved issues, digital radiology will mature as a technology and improve EM practice, making it one of the great information technology advances in EM.     

Mental Health Aspects of Emergency Medical Services for Children Summary of a Consensus Conference

OBJECTIVE: To address the mental health needs of children involved in emergency medical services (EMS). METHODS: A multidisciplinary consensus conference convened to identify mental health needs of children and their families related to pediatric medical emergencies, to examine the impact of psychological aspects of emergencies on recovery and satisfaction with care, and to delineate research questions related to mental health aspects of medical emergencies involving children. RESULTS: The consensus group found that psychological and behavioral factors affect physical as well as emotional recovery after medical emergencies. Children's reactions are critically affected by age and developmental level, characteristics of the emergency medical event, and parent reactions. As frontline health care providers, EMS staff members are in a pivotal position to recognize and effectively manage the mental health needs of patients and their families. CONCLUSIONS: Ecological changes in emergency departments, such as linkages to mental health follow-up services, training of EMS providers and mental health professionals, and focused research that provides an empirical basis for practice, are necessary components for improving current standards of health care.     

Academic Emergency Medicine''s Future

Emergency medicine (EM) will change over the next 20 years more than any other specialty. Its proximity to and interrelationships with the community, nearly all other clinicians (physicians and nonphysicians), and scientific/technologic developments guarantee this. While emergency physicians (EPs) will continue to treat both emergent and nonemergent patients, over the next decades our interventions, methods, and place in the medical care system will probably become unrecognizable from the EM we now practice and deliver. This paper, developed by the Society for Academic Emergency Medicine (SAEM) Task Force on Academic Emergency Medicine's Future, was designed to promote discussions about and actions to optimize our specialty's future. After briefly discussing the importance of futures planning, it suggests "best-case," "worst-case," and most probable future courses for academic EM over the next decades. The authors predict that EPs will practice a much more technologic and accurate form of medicine, with diagnostic, patient, reference, and consultant information rapidly available to them. They will be at the center of an extensive consultation network stemming from major medical centers and the purveyors of a sophisticated home health system, very similar to or even more advanced than what is now delivered on hospital wards. The key to planning for our specialty is for EM organizations, academic centers, and individuals to act now to optimize our possible future.     

On-call Specialists and Higher Level of Care Transfers in California Emergency Departments

Objectives:  To survey California emergency department (ED) medical directors' impressions of on-call specialist availability and higher level of care (HLOC) transfer needs and difficulties and changes since the passage of the Emergency Medicine Treatment and Active Labor Act (EMTALA) final rule in 2003.
Methods:  The authors conducted a survey of all California ED medical directors from February to June 2006 with regard to the composition of the ED on-call panel and need for HLOC transfer. ED demographic data were obtained from the California Office of Statewide Health Planning and Development.
Results:  Overall response rate was 243 of 347 (70%). More than 80% of respondent EDs reported having internal medicine, obstetrics/gynecology (OB/GYN), and pediatrics on call. However, fewer than 60% of EDs reported cardiac surgery, otolaryngology, neurosurgery, plastic surgery, or vascular surgery on call. Specialists were less likely to be on call in rural EDs. On-call coverage was rated worse than 3 years ago for 10 of 16 specialties. Rural EDs were more likely, and trauma centers and teaching hospitals were less likely to transfer at least one patient daily for HLOC. ED medical directors reported that the ability to transfer for HLOC has worsened over the past 3 years for all specialties. Respondents indicated that more than 40% of ear, nose, and throat (ENT), orthopedics, plastic surgery, and mental health HLOC transfers take more than 3 hours.
Conclusions:  This survey of California ED medical directors suggests ED on-call specialist availability and the ability to transfer for HLOC have worsened since the passage of the EMTALA final rule in 2003.     

Meeting the challenge of bioterrorism: lessons learned from West Nile virus and anthrax

Hospital emergency departments (EDs) and ambulatory clinics may be the first to recognize illness related to a bioterrorist event. Every health-care institution must develop a weapons-of-mass- destruction (WMD) preparedness plan as part of its all-hazards disaster planning. As part of an all-hazards disaster plan, WMD preparedness should use the incident-command model to insure the required chain of command for effectively coordinating activities between hospital departments and external agencies. Preparedness for bioterrorism poses unique challenges. In the event of a biological attack, the hospital infection control staff and administration must already have in place the means to communicate with local and state public health agencies, the Centers for Disease Control and Prevention (CDC), local law-enforcement agencies, and the Federal Bureau of Investigation (FBI). Local and regional planners must consider how to coordinate the responses of emergency medical services (EMS), police, and fire departments with healthcare providers and the news media. Most hospitals are ill equipped to deal with a catastrophic event caused by WMD. The burden of responding to such events will fall initially on ED physicians and staff members. The severity of such an incident might be mitigated with careful planning, training and education. The responses of one hospital network to the outbreak of West Nile virus and, more recently, to the threat of anthrax, are presented as guides for bioterrorism preparedness.     

Public Health Considerations in Knowledge Translation in the Emergency Department

Effective preventive and screening interventions have not been widely adopted in emergency departments (EDs). Barriers to knowledge translation of these initiatives include lack of knowledge of current evidence, perceived lack of efficacy, and resource availability. To address this challenge, the Academic Emergency Medicine 2007 Consensus Conference, “Knowledge Translation in Emergency Medicine: Establishing a Research Agenda and Guide Map for Evidence Uptake,” convened a public health focus group. The question this group addressed was “What are the unique contextual elements that need to be addressed to bring proven preventive and other public health initiatives into the ED setting?” Public health experts communicated via the Internet beforehand and at a breakout session during the conference to reach consensus on this topic, using published evidence and expert opinion. Recommendations include 1) to integrate proven public health interventions into the emergency medicine core curriculum, 2) to configure clinical information systems to facilitate public health interventions, and 3) to use ancillary ED personnel to enhance delivery of public health interventions and to obtain successful funding for these initiatives. Because additional research in this area is needed, a research agenda for this important topic was also developed. The ED provides medical care to a unique population, many with increased needs for preventive care. Because these individuals may have limited access to screening and preventive interventions, wider adoption of these initiatives may improve the health of this vulnerable population.     

Ambulance Diversion and Emergency Department Offload Delay: Resource Document for the National Association of EMS Physicians Position Statement

Abstract

The emergency medical services (EMS) system is a component of a larger health care safety net and a key component of an integrated emergency health care system. EMS systems, and their patients, are significantly impacted by emergency department (ED) crowding. While protocols designed to limit ambulance diversion may be effective at limiting time on divert status, without correcting overall hospital throughput these protocols may have a negative effect on ED crowding and the EMS system. Ambulance offload delay, the time it takes to transfer a patient to an ED stretcher and for the ED staff to assume the responsibility of the care of the patient, may have more impact on ambulance turnaround time than ambulance diversion. EMS administrators and medical directors should work with hospital administrators, ED staff, and ED administrators to improve the overall efficiency of the system, focusing on the time it takes to get ambulances back into service, and therefore must monitor and address both ambulance diversions and ambulance offload delay. This paper is the resource document for the National Association of EMS Physicians position statement on ambulance diversion and ED offload time.