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.     

Development of the Capacity Necessary to Perform and Promote Knowledge Translation Research in Emergency Medicine

Knowledge translation (KT) research in emergency medicine (EM) is in its infancy, and few EM investigators have the skills needed to perform KT research. Furthermore, the capacity to perform such KT research is underdeveloped in the field of EM. This consensus group used an iterative process to set forth initial recommendations and suggest methods for the development of EM KT research capacity. We have emphasized the need to form sustainable linkages, particularly between EM researchers and KT scientists, and to educate EM researchers in KT research methods to help create and sustain a culture of KT in our field. EM KT researchers must also engage local and national organizations and stakeholders to fund and promote KT research. Finally, we see the need to further develop and support EM research networks, as these networks will be both the clinical laboratories in which to perform the KT research and the incubators for the development of EM KT research experts.     

Knowledge Translation in International Emergency Medical Care

More than 90% of the world population receives emergency medical care from different types of practitioners with little or no specific training in the field and with variable guidance and oversight. Emergency medical care is being recognized by actively practicing physicians around the world as an increasingly important domain in the overall health services package for a community. The know-do gap is well recognized as a major impediment to high-quality health care in much of the world. Knowledge translation principles for application in this highly varied young domain will require investigation of numerous aspects of the knowledge synthesis, exchange, and application domains in order to bring the greatest benefit of both explicit and tacit knowledge to increasing numbers of the world's population. This article reviews some of the issues particular to knowledge development and transfer in the international domain. The authors present a set of research proposals developed from a several-month online discussion among practitioners and teachers of emergency medical care in 16 countries from around the globe and from all economic strata, aimed at improving the flow of knowledge from developers and repositories of knowledge to the front lines of clinical care.     

Knowledge Translation of the American College of Emergency Physicians Clinical Policy on Hypertension

Objectives To determine if dissemination of the American College of Emergency Physicians clinical policy on hypertension to emergency physicians would lead to improvements in blood pressure reassessment and referral of emergency department (ED) patients with elevated blood pressure.
Methods Two academic centers implemented a pre-post intervention design, with independent samples at pre and post phases. ED staff were blinded to the investigation. A total of 377 medical records were reviewed before policy dissemination and 402 were reviewed after policy dissemination. Medical records were eligible for review if the patient was at least 18 years of age, was not pregnant, was discharged from the ED, and had a triage systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg. Patient records with a chief complaint of chest pain, shortness of breath, or neurologic complaints were excluded. Demographics, blood pressures, and evidence of discharge referral were abstracted from the medical record. The policy was disseminated after the initial medical record review. Post—policy dissemination medical record review was conducted within two weeks.
Results A total of 779 medical records were reviewed. The mean age of patients was 45 years, 55% were male, and 46% were white, 13% Hispanic, 35% African American, and 6% other. No differences in reassessment or referral rates were found between study phases. Blood pressure reassessments were low during both phases: 33% (pre) and 37% (post). Referral rates of patients with elevated blood pressure were very low: 13% (pre) and 7% (post).
Conclusions Knowledge of guidelines did not translate into changes in physician practice. Additional systems-based approaches are necessary to effectively translate guidelines into clinical practice.     

The Canadian Prehospital Evidence-based Protocols Project: Knowledge Translation in Emergency Medical Services Care

Objectives:  The principles of evidence-based medicine are applicable to all areas and professionals in health care. The care provided by paramedics in the prehospital setting is no exception. The Prehospital Evidence-based Protocols Project Online (PEP) is a repository of appraised research evidence that is applicable to interventions performed in the prehospital setting and is openly available online. This article describes the history, current status, and potential future of the project.
Methods:  The primary objective of the PEP is to catalog and grade emergency medical services (EMS) studies with a level of evidence (LOE). Subsequently, each prehospital intervention is assigned a class of recommendation (COR) based on all the appraised articles on that intervention, in an effort to organize the evidence so it may be put into practice efficiently. An LOE is assigned to each article by the section editor, based on the study rigor and applicability to EMS. The section editor committee consists of EMS physicians and paramedics from across Canada, and two from Ireland and a paramedic coordinator. The evidence evaluation cycle is continuous; as the section editors send back appraisals, the coordinator updates the database and sends out another article for review.
Results:  The database currently has 182 individual interventions organized under 103 protocols, with 933 citations.
Conclusions:  This project directly meets recent recommendations to improve EMS by using evidence to support interventions and incorporating it into protocols. Organizing and grading the evidence allows medical directors and paramedics to incorporate research findings into their daily practice. As such, this project demonstrates how knowledge translation can be conducted in EMS.     

Geriatric Emergency Medicine and the 2006 Institute of Medicine Reports from the Committee on the Future of Emergency Care in the U.S. Health System

Three recently published Institute of Medicine reports, Hospital-Based Emergency Care: At the Breaking Point, Emergency Medical Services: At the Crossroads, and Emergency Care for Children: Growing Pains, examined the current state of emergency care in the United States. They concluded that the emergency medicine system as a whole is overburdened, underfunded, and highly fragmented. These reports did not specifically discuss the effect the aging population has on emergency care now and in the future and did not discuss special needs of older patients. This report focuses on the emergency care of older patients, with the intent to provide information that will help shape discussions on this issue.     

Bridging the Gap between Clinical Research and Knowledge Translation in Pediatric Emergency Medicine

In 2006, a multidisciplinary group of researchers from across Canada submitted a successful application to the Canadian Institutes for Health Research for a Canadian Institutes for Health Research Team in Pediatric Emergency Medicine. The conceptual foundation for the proposal was to bring together two areas deemed critical for optimizing health outcomes: clinical research and knowledge translation (KT). The framework for the proposed work is an iterative figure-eight model that provides logical steps for research and a seamless flow between the development and evaluation of therapeutic interventions (clinical research) and the implementation and uptake of those interventions that prove to be effective (KT). Under the team grant, we will conduct seven distinct projects relating to the two most common medical problems affecting children in the emergency department: respiratory illness and injury. The projects span the research continuum, with some projects targeting problems for which there is little evidence, while other projects involve problems with a strong evidence base but require further work in the KT realm. In this article, we describe the history of the research team, the research framework, the individual research projects, and the structure of the team, including coordination and administration. We also highlight some of the many advantages of bringing this research program together under the umbrella of a team grant, including opportunities for cross-fertilization of ideas, collaboration among multiple disciplines and centers, training of students and junior researchers, and advancing a methodological research agenda.     

Distances to Emergency Department and to Primary Care Provider's Office Affect Emergency Department Use in Children

Objectives:  Patients of all ages use emergency departments (EDs) for primary care. Several studies have evaluated patient and system characteristics that influence pediatric ED use. However, the issue of proximity as a predictor of ED use has not been well studied. The authors sought to determine whether ED use by pediatric Medicaid enrollees was associated with the distance to their primary care providers (PCPs), distance to the nearest ED, and distance to the nearest children's hospital.
Methods:  This historical cohort study included 26,038 children age 18 and under, assigned to 332 primary care practices affiliated with a Medicaid health maintenance organization (HMO). Predictor variables were distance from the child's home to his or her PCP site, distance from home to the nearest ED, and distance from home to the nearest children's hospital. The outcome variable was each child's ED use. A negative binomial model was used to determine the association between distance variables and ED use, adjusted for age, sex, and race, plus medical and primary care site characteristics previously found to influence ED use. Distance variables were divided into quartiles to test for nonlinear associations.
Results:  On average, children made 0.31 ED visits/person/year. In the multivariable model, children living greater than 1.19 miles from the nearest ED had 11% lower ED use than those living within 0.5 miles of the nearest ED (risk ratio [RR] = 0.89, 95% CI = 0.81 to 0.99). Children living between 1.54 and 3.13 miles from their PCPs had 13% greater ED use (RR = 1.13, 95% CI = 1.03 to 1.24) than those who lived within 0.7 miles of their PCP.
Conclusions:  Geographical variables play a significant role in ED utilization in children, confirming the importance of system-level determinants of ED use and creating the opportunity for interventions to reduce geographical barriers to primary care.     

Academic Departments of Emergency Medicine: The Effects of Managed Care

Abstract. Objective: To survey academic departments of emergency medicine (ADEMs) concerning the effects of managed care on their operation and practice. Methods: A 38-question survey was mailed to the chairs of all 52 ADEMs in the United States requesting information concerning managed care activity and its effects on ADEMs in academic years 1994–1995 and 1995–1996. Results: Forty-seven ADEMs (90.3%) responded. When comparing the 1995–1996 and 1994–1995 academic years, the following changes were noted: decreased overall growth in ED patient volume (38.3% vs 51.1%), larger percentage of respondents reporting an actual decrease in ED patient volume (38% vs 27.6%), less growth in ED gross revenue (43.7% vs 52.1%), larger percentage of ADEMs reporting actual decreased gross revenues (25% vs 12.5%), increase in ED patient acuity (76.6% vs 59.6%), and relative stability in the number of EM faculty (40.4% vs 44.7% reporting no change in faculty number). Two-thirds of ADEMs used mid-level providers (i.e., physician assistants, nurse practitioners), most commonly in a fast-track setting (41%). Thirty percent of ADEMs reported that other academic departments actively directed patients away from the ED, with pediatrics, family medicine, and internal medicine the most active. Ninety-eight percent of ADEMs reported ongoing negotiations between their institution or hospital and managed care organizations (MCOs); only 54.3% of ADEMs were involved in these negotiations. Twenty-eight percent of ADEMs reported MCOs have had an effect on their emergency medical services system, with 37% indicating HMOs routinely discouraged their enrollees from using 9-1-1 services and 16% reporting HMOs provided 9-1-1 services to take patients only to participating hospital EDs. Conclusion: ADEMs have experienced significant changes in nearly every aspect of their practice over the two academic years under study, much of which is due to managed care. ADEMs must take a leadership role in dealing with MCOs.     

The Impact of Health Maintenance Organization Care Authorization Policy on an Emergency Department before California's New Managed Care Law

Objective: To examine the effect on patient care of HMO–mandated calls for authorisation prior to ED evaluation. The study examined this phenomenon prior to implementation of a California law that discourages such calls.
Methods: Concurrent data were collected for patients who presented to the ED and who had authorization calls made to their HMOs prior to their ED evaluations during the period September through December 1994. Data collected included: 1) the number of authorization calls made, 2) the frequency that ED care was deemed unnecessary by the HMO, 3) the outcomes of patients denied authorization, and 4) the time and personnel involved in completing calls. Follow–up phone calls were made to patients who left the ED after the HMO denied authorization for payment.
Results: The total ED census was 19,935 patient visits for the four–month period. Authorization calls were made for 4,642 (23%) of the ED visits. There were 545 patients (12%) in this group who had authorization denied and only 29 (5%) chose to remain in the ED for continued evaluation. The total time required to complete a call ranged from 20 minutes to 2.6 hours. Authorization calls and denials caused the following problems: 1) patients for whom calls were made were subject to delays in ED care; 2) at least seven patients referred to HMO clinics were referred back to the ED because the patient was too sick to receive clinic care; 3) patients were inconsistently asked to sign an against–medical–advice form when they chose to leave with unstable conditions; and 4) high–risk patients denied authorization included patients with final diagnoses of ectopic pregnancy, acute myocardial infarction, pulmonary embolus, respiratory failure, and sepsis.
Conclusions: Calls for payment authorization prior to ED patient evaluation delay patient care and place some patients' health and safety in jeopardy.     

The Emerging Imperative for Health Care Quality Improvement

There are widespread and growing concerns about the variable and too often inadequate quality of health care in the United States. As a result, health care quality is being questioned and subjected to scrutiny as never before. Awareness of the quality deficits, combined with rising health care expenditures and changing attitudes of payers and consumers, has given rise to a nascent but growing quality improvement movement. Multiple barriers must be surmounted by this movement, but substantive work is under way on all fronts. Emergency medicine will definitely be affected by the quality improvement movement and should quickly move forward to define and establish performance measures for high-quality emergency care in an era when chronic disease dominates the agenda. Emergency medicine should also aggressively work to operationalize a culture of quality to minimize medical errors, to practice evidence-based medicine, to translate research results into clinical practice in a timely manner, and to establish accountability mechanisms for quality improvement and clinical excellence.     

Decision Support Technology in Knowledge Translation

Information technologies, and specifically clinical decision support systems (CDSSs), are tools that can support the process of knowledge translation in the delivery of emergency department (ED) care. It is essential that during the implementation process, careful consideration be given to the workflow and culture of the ED environment where the system is to be utilized. Despite significant literature addressing factors contributing to successful deployment of these systems, the process is frequently problematic. Careful research and analysis are essential to evaluate the impact of the CDSS on the delivery of ED care, its influence on the health care providers, and the impact of the CDSS on clinical decision-making processes and information behaviors. The logistical and educational implications of CDSSs in the ED must also be considered. The specialty of emergency medicine must actively collaborate with other stakeholders in the design, implementation, and evaluation of CDSSs that will be utilized during the delivery of care to our patients.     

Cognitive and Social Issues in Emergency Medicine Knowledge Translation: A Research Agenda

The individual practitioner is a linchpin in the process of translating new knowledge into practice, particularly in the emergency department, where physician autonomy is high, resources are limited, and decision‐making situations are complex. An understanding of the cognitive and social processes that affect knowledge translation (KT) in emergency medicine (EM) is crucial and at present understudied. As part of the 2007 Academic Emergency Medicine Consensus Conference on KT in EM, our group sought to identify key research areas that would inform our understanding of these cognitive and social processes. We combined an online discussion group of interdisciplinary stakeholders, an extensive review of the existing literature, and a “public hearing” of the recommendations at the Consensus Conference to establish relative preference for the recommendations, as well as their relevance and clarity to attendees. We identified five key research areas as follows. 1) What provider‐specific barriers/facilitators to the use of new knowledge are relevant in the EM setting? 2) Can social psychological theories of behavior change be used to develop better KT interventions for EM? 3) Can the study of “distributed cognition” suggest new vehicles for KT in the emergency department? 4) Can the concept of dual‐process reasoning inform our understanding of the KT process? 5) Can patient‐specific, immediate feedback serve as a vehicle for KT in EM? We believe that exploring these key research questions will directly lead to improved KT interventions and to further discussion of the cognitive and social factors impacting KT in EM.     

The Influence of Critical Care Medicine on the Development of the Specialty of Emergency Medicine: A Historical Perspective

Through their largely concurrent development, the specialties of emergency medicine and critical care medicine have exerted a great deal of influence on each other. In this article, the authors trace the commonalities that emergency medicine and critical care medicine have shared and report on the historical relationship between the two specialties. As issues between emergency medicine and critical care medicine continue to emerge, the authors hope to inform the current discussion by bringing to light the controversies and questions that have been debated in the past.     

Access to Health Care

Purpose: To describe and analyze conceptual and operational definitions of health care access for future nursing theory, practice, and policy. Access to health care is a major health policy concern. However, the elements of access to care are not well understood. As a result, how access is addressed is often inconsistent and unclear.
Organizing construct: Walker and Avant's framework for concept analysis.
Sources: Published literature in nursing and health services from the 1960s to the 1990s. The analysis was done in 1997 for this integrative review of nursing and nonnursing literature.
Methods: Integrative literature review in 1997.
Findings: Access is a complex idea defined in many ways. One of the most comprehensive definitions of access is by the World Health Organization (WHO). Multidementional barriers and facilitators to access vary by community and country.
Conclusions: Societies may define access differently at different stages of development. Scales to measure some dimensions of access are available; however, newer and better measures are needed and are being developed and tested. Data on each of the dimensions are needed for comprehensive assessment of access to health care in all countries at all stages of development.