Conceptual Models of Health Behavior: Research in the Emergency Care Settings

This article provides recommendations for incorporating conceptual models of health behavior change into research conducted in emergency care settings. The authors drafted a set of preliminary recommendations, which were reviewed and discussed by a panel of experienced investigators attending the 2009 Academic Emergency Medicine consensus conference. The original recommendations were expanded and refined based on their input. This article reports the final recommendations. Three recommendations were made: 1) research conducted in emergency care settings that focuses on health behaviors should be grounded in formal conceptual models, 2) investigators should clearly operationalize their outcomes of interest, and 3) expected relations between theoretical constructs and outcomes should be made explicit prior to initiating a study. A priori hypothesis generation grounded in conceptual models of health behavior, followed by empirical validation of these hypotheses, is needed to improve preventive and public health–related interventions in emergency care settings.     

Violence Prevention in the Emergency Department: Future Research Priorities

The 2009 Academic Emergency Medicine Consensus Conference working group session participants developed recommendations and research questions for violence prevention in the emergency department (ED). A writing group devised a working draft prior to the meeting and presented this to the breakout session at the consensus conference for input and approval. The recommendations include: 1) promote and facilitate the collection of standardized information related to violence victimization and perpetration in ED settings; 2) develop and validate brief practical screening instruments that can identify those at risk for perpetration of violence toward others or toward self; 3) develop and validate brief practical screening instruments that can identify victims at risk for violent reinjury and mental health sequelae; and 4) conduct efficacy, translational, and dissemination research on interventions for violence prevention. The work group emphasized the critical need and role of ED-based research to impact surveillance and prevention of future violence-related injury.     

The Use of Performance Improvement Methods to Enhance Emergency Department Patient Satisfaction in the United States: A Critical Review of the Literature and Suggestions for Future Research

Objectives: The authors reviewed the evidence on performance improvement methods for increasing emergency department (ED) patient satisfaction to provide evidence-based suggestions for clinical practice.
Methods: Data sources consisted of searches through MEDLINE, CINAHL, PSYCHINFO, Cochrane Library, and Emergency Medicine Abstracts and a manual search of references. Articles were included if they reported a performance improvement intervention targeting patient satisfaction in the ED setting. Articles on studies not conducted in the United States or that failed to provide enough details to allow critical evaluation of the study were excluded. Two authors used structured evaluation criteria to independently review each retained study.
Results: Nineteen articles met all selection criteria. Three studies found varying levels of support for multicomponent interventions, predominantly focused on implementation of clinical practice guidelines for specific presenting complaints and process redesign. Sixteen studies evaluated single-component interventions, with the following having at least one supportive study: using alternating patient assignment to provider teams rather than "zone"-based assignment, enhancing provider communication and customer service skills, incorporating information delivery interventions (e.g., pamphlets, video) that target patient expectations, using preformatted charts, and establishing ED-based observation units for specific conditions such as asthma and chest pain.
Conclusions: There is modest evidence supporting a range of performance improvement interventions for improving ED patient satisfaction. Further work is needed before specific, evidence-based recommendations can be made regarding which process changes are most effective. Recommendations are made for improving the quality of performance improvement efforts in the ED setting.     

Novel approaches to facilitate the implementation of guidelines in the ICU

The effective implementation of evidence-based recommendations in routine intensive care unit (ICU) practice is challenging. Barriers related to the proposed recommendations, local contexts and processes can make the adoption of evidence-based practices difficult, contributing to healthcare inefficiency and worse patient and family outcomes. This review discusses the common barriers to guideline implementation in critical care settings, explores how implementation science provides an important framework for guiding implementation interventions, and discusses some specific and proven implementation strategies to improve adherence to evidence-based practices in the ICU.     

Multicenter survey of emergency physician management and referral for hyperglycemia

Background: The Emergency Department (ED), with its high-risk and often disenfranchised patient population, presents a novel opportunity to identify patients as having undiagnosed or uncontrolled diabetes. Objective: To evaluate Emergency Physician opinion on management and referral for incidental hyperglycemia and on ED-based diabetes screening. Methods: We conducted a web-based survey of all attending and resident Emergency Physicians at three academic EDs. We asked for glucose thresholds to treat and refer non-diabetic and diabetic ED patients for hyperglycemia, comparing physicians' ideal and actual practices. We also inquired about interest in and barriers for active ED-based diabetes screening compared to use of blood glucose values obtained during usual ED care. Results: We contacted 185 physicians, and 152 (85%) completed the survey; 75% of respondents reported routine outpatient referral of non-diabetic patients for random glucose values ≥ 200 mg/dL. However, a majority (71%) believed that they should use a lower threshold to refer than they currently use. Nearly all (92%) agreed that Emergency Physicians should inform non-diabetic patients of elevated glucose values; 53% supported and 21% opposed active ED-based screening of asymptomatic patients. The most commonly cited barriers were limited follow-up (69%), insufficient time/resources (51%), and outside scope of practice (36%). Conclusion: Emergency Physicians support improved recognition of and referral for hyperglycemia, based on glucose values collected during usual ED care. We plan to develop tools to interpret random ED glucose values in the context of undiagnosed and uncontrolled diabetes.     

Emergency Provider Attitudes and Barriers to Universal HIV Testing in the Emergency Department

Background: The Centers for Disease Control and Prevention (CDC) recently published recommendations for routine, voluntary human immunodeficiency virus (HIV) testing of adults in all health care settings, including the emergency department (ED). Study Objective: The objective of this study was to examine the willingness of ED providers to offer HIV testing, as well as their perceived barriers to implementation of these guidelines. Methods: Before the establishment of a routine HIV testing program in the ED, a 21-item survey was used to assess ED providers' knowledge, attitudes, and perceived challenges to HIV testing. Six months after program initiation, the identical survey was re-administered to determine whether HIV testing program experience altered providers' perceptions. Results: There were 108 of 146 (74%) providers who completed both the pre- and post-implementation surveys. Although the majority of emergency providers at 6 months were supportive of an ED-based HIV testing program (59/108 [55%]), only 38% (41/108) were willing to offer the HIV test most or all of the time. At 6 months, the most frequently cited barriers to offering a test were: inadequate time (67/108 [62%]), inadequate resources (65/108 [60%]), and concerns regarding provision of follow-up care (64/108 [59%]). Conclusions: After the implementation of a large-scale HIV testing program in an ED, the majority of emergency providers were supportive of routine HIV testing. Nevertheless, 6 months after program initiation, providers were still reluctant to offer the test due to persistent barriers. Further studies are needed to identify feasible implementation strategies that minimize barriers to routine HIV testing in the ED.     

Tobacco control interventions in the emergency department: a joint statement of emergency medicine organizations.

Smoking is the leading cause of preventable death and illness in the United States. National practice guidelines call for all health care providers to "ask" all patients about tobacco use, and to "advise, assess, assist, arrange" when smokers want to quit smoking (the "5 As"). Emergency departments (EDs) have not been an important locus of tobacco control efforts, although ED patients typically smoke at rates exceeding that of the general population, are interested in quitting, and often have limited access to primary care. To address the role of emergency medicine in tobacco control, the American College of Emergency Physicians convened a task force of representatives of major emergency medicine professional organizations. Funded by the Robert Wood Johnson Foundation, the group met in 2004 and 2005. This article represents a summary of the task force's recommendations for tobacco control practice, training, and research. We call on emergency care providers to routinely assess patients' smoking status, offer brief advice to quit, and refer patients to the national smokers' Quitline (800-QUIT-NOW) or a locally available program. Given the global burden of tobacco-related illness, the task force considers it essential for emergency physicians to conduct research into the efficacy of ED-based interventions and to place tobacco control into the training curriculum for emergency medicine residencies. Tobacco control fits within the traditions of other ED-based public health practices, such as injury control. ED-based tobacco control would allow the specialty to help fulfill the Healthy People 2010 mandate to reduce the prevalence of smoking among US citizens.     

Preventive Care in the Emergency Department: Screening for Domestic Violence in the Emergency Department

OBJECTIVES: The most effective methods for identification and management of domestic violence (DV) victims in health care settings are unknown. The objective of this study was to systematically review screening for DV in the emergency department (ED) to identify victims and decrease morbidity and mortality from DV. METHODS: Using the terms "domestic violence" or "partner violence," and "identification" or "screening," and "emergency," the authors searched MEDLINE, the Cochrane Database, and Emergency Medical Abstracts from 1980-2002. They selected articles studying screening tools, interventions, or determining the incidence or prevalence of DV among ED patients. The studies were analyzed using evidence-based methodology. RESULTS: Three hundred thirty-nine articles resulted from the literature search. Based on selection criteria, 45 were reviewed in detail and 17 pertained to the ED. From references of these 17 articles, three additional articles were added. Screening can be conducted using a brief verbal screen and existing ED personnel. A randomized, controlled trial did not demonstrate a difference in screening rates between experimental and control hospitals. No studies assessed the effect of ED screening for DV on morbidity or mortality of domestic violence. An ED-based advocacy program resulted in increased use of shelters and counseling. CONCLUSIONS: Because of the paucity of outcomes research evaluating ED screening and interventions, there is insufficient evidence for or against DV screening in the ED. However, because of the high burden of suffering caused by DV, health care providers should strongly consider routinely inquiring about DV as part of the history, at a minimum for all female adolescent and adult patients.     

Study Designs and Evaluation Models for Emergency Department Public Health Research

Public health research requires sound design and thoughtful consideration of potential biases that may influence the validity of results. It also requires careful implementation of protocols and procedures that are likely to translate from the research environment to actual clinical practice. This article is the product of a breakout session from the 2009 Academic Emergency Medicine consensus conference entitled "Public Health in the ED: Screening, Surveillance, and Intervention" and serves to describe in detail aspects of performing emergency department (ED)-based public health research, while serving as a resource for current and future researchers. In doing so, the authors describe methodologic features of study design, participant selection and retention, and measurements and analyses pertinent to public health research. In addition, a number of recommendations related to research methods and future investigations related to public health work in the ED are provided. Public health investigators are poised to make substantial contributions to this important area of research, but this will only be accomplished by employing sound research methodology in the context of rigorous program evaluation.     

Design and Implementation of a Controlled Clinical Trial to Evaluate the Effectiveness and Efficiency of Routine Opt-out Rapid Human Immunodeficiency Virus Screening in the Emergency Department

In 2006, the Centers for Disease Control and Prevention (CDC) released revised recommendations for performing human immunodeficiency virus (HIV) testing in health care settings, including implementing routine rapid HIV screening, the use of an integrated opt-out consent, and limited prevention counseling. Emergency departments (EDs) have been a primary focus of these efforts. These revised CDC recommendations were primarily based on feasibility studies and have not been evaluated through the application of rigorous research methods. This article describes the design and implementation of a large prospective controlled clinical trial to evaluate the CDC's recommendations in an ED setting. From April 15, 2007, through April 15, 2009, a prospective quasi-experimental equivalent time-samples clinical trial was performed to compare the clinical effectiveness and efficiency of routine (nontargeted) opt-out rapid HIV screening (intervention) to physician-directed diagnostic rapid HIV testing (control) in a high-volume urban ED. In addition, three nested observational studies were performed to evaluate the cost-effectiveness and patient and staff acceptance of the two rapid HIV testing methods. This article describes the rationale, methodologies, and study design features of this program evaluation clinical trial. It also provides details regarding the integration of the principal clinical trial and its nested observational studies. Such ED-based trials are rare, but serve to provide valid comparisons between testing approaches. Investigators should consider similar methodology when performing future ED-based health services research.     

Attitudes and practices regarding influenza vaccination among emergency department personnel

In the United States, infections related to influenza result in a huge burden to the health care system and emergency departments (EDs). Influenza vaccinations are a safe, cost-effective means to prevent morbidity and mortality. We sought to understand the factors that contribute to the professional and personal influenza vaccination practices of health care workers in the ED setting by assessing their knowledge, attitudes, and practices with regards to the influenza vaccine. A cross-sectional study of all full-time ED staff (nurses, emergency medicine residents, and emergency medicine faculty) at an urban academic medical center in Boston treating > 90,000 ED patients annually, was performed. We examined knowledge, attitudes, and practices regarding personal influenza vaccination and support of an ED-based influenza vaccination program using an anonymous, self-administered questionnaire. Of 130 ED staff, 126 individuals completed the survey (97% response rate). Overall, 69% of respondents reported that they were very or extremely likely to be vaccinated before the coming influenza season. Residents (94%) and attending physicians (82%) were significantly more likely than nurses (42%) to be vaccinated (p < 0.001). Respondents likely to be vaccinated this year were more likely to support a vaccination program for ED patients (80% vs. 55% of those not vaccinated,p < 0.001). Providing regular education on the efficacy of preventive vaccination therapy and dispelling misconceptions regarding adverse effects may reduce barriers to vaccination programs. An educational initiative may result in acceptance of influenza vaccination by ED providers themselves, which could result in increased support for an influenza vaccination program for ED patients.     

Mammography promotion in the emergency department: a pilot study

ABSTRACT Objectives: The objective of this pilot study is to assess the need, desire, and applicability of a mammography promotion project in the emergency department (ED). Design and Sample: A convenience sample from the ED of a public University hospital was surveyed to determine their mammography status, interest in a program to promote mammography, and barriers to mammography. Measures: The survey included demographics information, health care access, including health insurance and primary care provider, mammography status and date of mammogram, as well as a checklist of potential barriers. Participants were also asked whether they would be interested in mammography promotion in this setting. Results: More than 15% of the 197 women surveyed had never received a mammogram, and more than half had not received 1 in the past year. The most common barriers to mammography were competing demands and money. Three quarters of the women said they would be interested in mammography promotion while waiting for care in the ED. Conclusions: This study provides promise that mammography promotion activities may be appropriately placed in the ED and provides a solid platform from which researchers and nurses may launch efforts to develop preventive health interventions in innovative public health care settings.     

Errors in Emergency Medicine Research Strategies

Medical errors in emergency departments (EDs) may be an important "public health risk." Therefore, scientific public health approaches should be used to 1) assess the magnitude of emergency medical errors with surveillance methods, 2) identify causal factors of these medical errors with clinical epidemiologic methods, and 3) evaluate the effectiveness of interventions aimed at reducing or eliminating emergency medicine errors with health service research techniques. Since errors result from complex human-system interaction, research efforts should focus on actions taken by the patient, factors concerning the ED environment, and actions taken by health care workers. Other medical and nonmedical fields have already made great advancements in studying and reducing human error. Many of these advancements could readily be adapted to study emergency medical errors.     

Smoking Cessation Counseling by Emergency Physicians: Opinions, Knowledge, and Training Needs

Objectives: To determine: 1) the extent of emergency physicians' (EPs') training in smoking cessation counseling; 2) their understanding of counseling and pharmacologic treatment techniques; 3) their current practices in screening, counseling, and referring patients who smoke; and 4) perceived barriers to routine smoking cessation counseling in emergency medical practice.
Methods: A 26-item questionnaire addressing the above issues was mailed to all 256 members of the Colorado Chapter of the American College of Emergency Physicians.
Results: Completed questionnaires were returned by 196 physicians (77% response rate). The majority of respondents were men (80%), practiced in urban settings (87%), and were board-certified in emergency medicine (82%). Most EPs lacked formal smoking cessation training (55%) and felt poorly prepared to counsel patients about smoking cessation (65%). A minority (27%) of the physicians reported routinely asking patients to quit smoking. The physicians with formal smoking cessation training were more likely to counsel and refer patients routinely (34% vs 20%, p = 0.03). The physicians cited the following barriers to routine smoking cessation counseling: a lack of time; a perception that patients are not interested; a belief that the ED setting is inappropriate for counseling; and a sense that counseling is ineffective. Lack of reimbursement was cited by only 13% of the respondents. The physicians who had formal smoking cessation training perceived fewer barriers to ED-based counseling.
Conclusions: Emergency physicians have received little training in smoking cessation and perceive many barriers to ED-based smoking cessation interventions. Not surprisingly, they infrequently take action to encourage or assist their patients to quit smoking.     

Emergency Department Nurses’ Perceptions of Patient Substance Use,Impact on Sexual Assault Care,and Access to Follow-up Behavioral Health Resources

IntroductionPatients may present to the emergency department for sexual assault care under the influence of drugs or alcohol. However, many emergency nurses are not prepared to meet their unique needs or aware of follow-up behavioral health resources. The purpose of this study was to (1) summarize current resources provided to patients and processes for referral to behavioral health services after sexual assault care, (2) explore emergency nurses’ attitudes and behaviors toward patient substance use, and (3) explore nurses’ perceptions of adjunct mobile health interventions for follow-up behavioral health care and describe anticipated barriers to use.MethodsFifteen emergency nurses participated in semi-structured qualitative interviews.ResultsParticipants had mixed perceptions of patient intoxication during sexual assault care. They felt that conversations about substance use may be more appropriate after the ED visit. Participants recognized the opportunity to connect ED patients with substance use treatment or prevention resources but perceived that there are few local service providers. Most participants were not referring patients with substance use issues to behavioral health services after sexual assault care and said that their emergency departments did not have processes for referral to these services. Acceptability of mobile health for follow-up behavioral health care was high, but participants had concerns for patient privacy and internet access. Participants gave recommendations to improve referral practices and patient engagement with mobile health interventions.DiscussionThis study highlights the need for emergency nurses to consider patient intoxication during sexual assault care and opportunities to connect patients with resources post-assault.     

Analgesia and public health: what are the challenges?

Pain is a common problem, but unfortunately, it is one that is still notoriously neglected and poorly managed. Although it usually is not rated highly in public health statistics, it forms a substantial proportion of the everyday work of health care professionals, and thus remains a major public health burden. The first challenge in successful pain management is overcoming the ineffective learning processes most health care practitioners use to update their procedures and therapies in response to the latest research. The ready availability of over-the-counter analgesics means that much of the pain in the community is now self-medicated, and it is vital that they also have ready access to the latest evidence-based recommendations. Second, better methods are needed to tailor treatment to individual patients because differences in comorbidities, drug metabolism, or the nature and severity of disease processes lead to different responses from individual patients. Such tailoring should also account for differences in side-effect profiles of the various treatment options available. Finally, even if health practitioners are aware of the latest in clinical evidence and recommended practices, they may not be able to implement the most appropriate treatment because of legal or financial barriers. This article will to review these three challenges to the management of pain and discuss practical ways in which they may be handled to help reduce the burden of pain care in society.     

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.     

The Rationale for Developing Public Health Surveillance Systems Based on Emergency Department Data

Emergency departments (EDs) are well positioned to provide national data on several aspects of public health. The large volume of patients seen annually, improving medical record technology, and emergency uniform data sets make the development of public health surveillance systems a realistic opportunity for emergency medicine. Such data could identify public health concerns and suggest interventions to improve the health of the nation. This article describes current concepts and status of ED surveillance systems, their advantages and disadvantages, the rationale for their existence, and recommendations to allow their continued consideration and development.