Emergency Care and Health Systems: Consensus‐based Recommendations and Future Research Priorities

The theme of the 14th annual Academic Emergency Medicine consensus conference was “Global Health and Emergency Care: A Research Agenda.” The goal of the conference was to create a robust and measurable research agenda for evaluating emergency health care delivery systems. The concept of health systems includes the organizations, institutions, and resources whose primary purpose is to promote, restore, and/or maintain health. This article further conceptualizes the vertical and horizontal delivery of acute and emergency care in low‐resource settings by defining specific terminology for emergency care platforms and discussing how they fit into broader health systems models. This was accomplished through discussion surrounding four principal questions touching upon the interplay between health systems and acute and emergency care. This research agenda is intended to assist countries that are in the early stages of integrating emergency services into their health systems and are looking for guidance to maximize their development and health systems planning efforts.     

Regionalization of Emergency Care Future Directions and Research: Workforce Issues

The provision of emergency care in the United States, regionalized or not, depends on an adequate workforce. Adequate must be defined both qualitatively and quantitatively. There is currently a shortage of emergency care providers, one that will exist for the foreseeable future. This article discusses what is known about the current emergency medicine (EM) and non‐EM workforce, future trends, and research opportunities. ACADEMIC EMERGENCY MEDICINE 2010; 17:1286–1296 © 2010 by the Society for Academic Emergency Medicine     

Breastfeeding in a Global Context: Epidemiology,Impact, and Future Directions

IntroductionMore than 98% of infant deaths occur in low- and middle-income countries (LMICs). Breastfeeding improves infant survival and protects against certain illnesses, such as diarrhea and pneumonia, which are leading causes of deaths in those <5 years of age in LMICs. The World Health Organization (WHO) recommends early initiation of breastfeeding within 1 hour of birth, exclusive breastfeeding up to 6 months of age, and continued breastfeeding up to 2 years of age. However, fewer than half of infants in LMICs are breastfed optimally to these standards. The objectives of this article are to describe the global epidemiology and health benefits of breastfeeding with particular focus on LMICs.MethodsWe searched PubMed to identify original research articles on breastfeeding in LMICs and reviews related to the benefits of breastfeeding, with particular focus on articles published in the past 5 years. We used reports and data published by the WHO and the United Nations Children's Fund (UNICEF) related to global breastfeeding rates, targets, and programmatic initiatives. We used the Lives Saved Tool to estimate mortality related to breastfeeding practices.FindingsLess than half of infants globally receive early, exclusive, or continued breastfeeding. Certain high-risk groups, such as premature or HIV-exposed infants, face particular challenges and benefits related to breastfeeding. The WHO, UNICEF, and other global partners have developed a multipronged strategy to promote global breastfeeding, ranging from government-level advocacy to grassroots community support groups. Using the Lives Saved Tool, we estimate that nearly 200,000 lives of those <5 years of age could be saved in LMICs from 2020 to 2030 if early, exclusive, and continued breastfeeding rates were linearly increased from current rates to meet the WHO 2030 goals of 60% to 80% coverage. If this goal were exceeded and near-universal coverage were achieved, the number of lives would increase even further such that >820,000 lives per year could potentially be saved by universal breastfeeding. In this review, we delineate the health and economic benefit of breastfeeding in LMICs, discuss breastfeeding epidemiology in the global context, and describe targeted strategies to improve breastfeeding uptake.     

Patient‐centered Outcomes Research in Emergency Care: Opportunities,Challenges, and Future Directions

The Patient‐Centered Outcomes Research Institute (PCORI) was established by Congress in 2010 to promote the conduct of research that could better inform patients in making decisions that reflect their desired health outcomes. PCORI has established five national priorities for research around which specific funding opportunities are issued: 1) assessment of prevention, diagnosis, and treatment options; 2) improving healthcare systems; 3) communication and dissemination research; 4) addressing disparities; and 5) improving methods for conducting patient‐centered outcomes research. To date, implementation of patient‐centered research in the emergency care setting has been limited, in part because of perceived challenges in meeting PCORI priorities such as the need to focus on a specific disease state or to have planned follow up. We suggest that these same factors that have been seen as challenges to performing patient‐centered research within the emergency setting are also potential strengths to be leveraged to conduct PCORI research. This paper explores factors unique to patient‐centered emergency care research and highlights specific areas of potential alignment within each PCORI priority.     

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.     

Research Priorities for Data Collection and Management Within Global Acute and Emergency Care Systems

Barriers to global emergency care development include a critical lack of data in several areas, including limited documentation of the acute disease burden, lack of agreement on essential components of acute care systems, and a lack of consensus on key analytic elements, such as diagnostic classification schemes and regionally appropriate metrics for impact evaluation. These data gaps obscure the profound health effects of lack of emergency care access in low‐ and middle‐income countries (LMICs). As part of the Academic Emergency Medicine consensus conference “Global Health and Emergency Care: A Research Agenda,” a breakout group sought to develop a priority research agenda for data collection and management within global emergency care systems.     

Clinical and Translational Research in Global Health and Emergency Care: A Research Agenda

As policy‐makers increasingly recognize emergency care to be a global health priority, the need for high‐quality clinical and translational research in this area continues to grow. As part of the proceedings of the 2013 Academic Emergency Medicine consensus conference, this article discusses the importance of: 1) including clinical and translational research in the initial emergency care development plan, 2) defining the burden of acute disease and the barriers to conducting research in resource‐limited settings, 3) assessing the appropriateness and effectiveness of local and global acute care guidelines within the local context, 4) studying the local research infrastructure needs to understand the best methods to build a sustainable research infrastructure, and 5) studying the long‐term effects of clinical research programs on health care systems.     

Global Health and Emergency Care: A Resuscitation Research Agenda—Part 2

At the 2013 Academic Emergency Medicine global health consensus conference, a breakout session to develop a research agenda for resuscitation was held. Two articles are the result of that discussion. This second article addresses data collection, management, and analysis and regionalization of postresuscitation care, resuscitation programs, and research examples around the world and proposes a strategy to strengthen resuscitation research globally. There is a need for reliable global statistics on resuscitation, international standardization of data, and development of an electronic standard for reporting data. Regionalization of postresuscitation care is a priority area for future research. Large resuscitation clinical research networks are feasible and can give valuable data for improvement of service and outcomes. Low‐cost models of population‐based research, and emphasis on interventional and implementation studies that assess the clinical effects of programs and interventions, are needed to determine the most cost‐effective strategies to improve outcomes. The global challenge is how to adapt research findings to a developing world situation to have an effect internationally.     

Global Health and Emergency Care: A Resuscitation Research Agenda—Part 1

At the 2013 Academic Emergency Medicine global health consensus conference, a breakout session on a resuscitation research agenda was held. Two articles focusing on cardiac arrest and trauma resuscitation are the result of that discussion. This article describes the burden of disease and outcomes, issues in resuscitation research, and global trends in resuscitation research funding priorities. Globally, cardiovascular disease and trauma cause a high burden of disease that receives a disproportionately smaller research investment. International resuscitation research faces unique ethical challenges. It needs reliable baseline statistics regarding quality of care and outcomes; data linkages between providers; reliable and comparable national databases; and an effective, efficient, and sustainable resuscitation research infrastructure to advance the field. Research in resuscitation in low‐ and middle‐income countries is needed to understand the epidemiology, infrastructure and systems context, level of training needed, and potential for cost‐effective care to improve outcomes. Research is needed on low‐cost models of population‐based research, ways to disseminate information to the developing world, and finding the most cost‐effective strategies to improve outcomes.     

Revisiting the Emergency Medicine Services for Children Research Agenda: Priorities for Multicenter Research in Pediatric Emergency Care

Objectives:  To describe the creation of an Emergency Medical Services for Children (EMSC) research agenda specific to multicenter research. Given the need for multicenter research in EMSC and the unique opportunity afforded by the creation of the Pediatric Emergency Care Applied Research Network (PECARN), the authors revisited existing EMSC research agendas to develop a PECARN-specific research agenda. They sought to prioritize PECARN research efforts, to guide investigators planning to conduct research in PECARN, and to describe the creation of a prioritized EMSC research agenda specific for multicenter research.
Methods:  The authors used the Nominal Group Process and Hanlon Process of Prioritization (HPP), which are recognized research prioritization methods incorporating both quantitative and qualitative data collection in group settings. The formula used to generate the final priority list heavily weighted practicality of conduct in a multicenter research network. By using size, seriousness, and practicality measures of each health priority, PECARN was able to identify factors that could be scored individually and were weighted relative to each other.
Results:  The prioritization processes resulted in a ranked list of 16 multicenter EMSC research topics. Top among these priorities were 1) respiratory illnesses/asthma, 2) prediction rules for high-stakes/low-likelihood diseases, 3) medication error reduction, 4) injury prevention, and 5) urgency and acuity scaling.
Conclusions:  The PECARN prioritization process identified high-priority EMSC research topics specific to multicenter research. PECARN has the capacity to answer long-standing, important clinical controversies in EMSC, largely due to its ability to conduct randomized controlled trials and observational studies on a large scale.     

Patient‐centered Integrated Networks of Emergency Care: Consensus‐based Recommendations and Future Research Priorities

Patient‐centered care is defined by the Institute of Medicine (IOM) as care that is responsive to individual patient needs and values and that guides the treatment decisions. This article is a result of a breakout session of the 2010 Academic Emergency Medicine (AEM) consensus conference and describes the process of developing consensus‐based recommendations for providing patient‐centered emergency care. The objectives of the working group were to identify and describe the critical gaps in the provision of patient‐centered care, develop a consensus‐based research agenda, and create a list of future research priorities. Using e‐mail and in‐person meetings, knowledge gaps were identified in the areas of respect for patient preferences, coordination of clinical care, and communication among health care providers. Four consensus‐based recommendations were developed on the following themes: enhancing communication and patient advocacy in emergency departments (EDs), facilitating care coordination after discharge, defining metrics for patient‐centered care, and placing the locus of control of medical information into patients’ hands. The set of research priorities based on these recommendations was created to promote research and advance knowledge in this dimension of clinical care. ACADEMIC EMERGENCY MEDICINE 2010; 17:1322–1329 © 2010 by the Society for Academic Emergency Medicine     

Triage: Setting Priorities for Health Care

The concept of triage is central to the allocation of healthcare resources. As demands for health care increase, medical technologies and providers become more expensive and more scarce. Triage decisions occur at all levels in the distribution of resources. It is essential to explore the concept of triage and some of the underlying ethical principles for triage decision-making from the perspective of the discipline of nursing. Examining how definitions of triage apply to practice will enable nurses to participate in reform strategies for the healthcare system.     

Global Health and Emergency Care: A Postgraduate Medical Education Consensus‐based Research Agenda

Global emergency medicine (EM) is a rapidly growing field within EM, as evidenced by the increasing number of trainees and clinicians pursuing additional experiences in global health and emergency care. In particular, many trainees now desire opportunities at the postgraduate level by way of global EM fellowship programs. Despite this growing popularity, little is known of the effects of postgraduate training in global health and emergency care on learners and patients in the United States and abroad. During the 2013 Academic Emergency Medicine consensus conference on global health and emergency care, a group of leading educators at the postgraduate medical education level convened to generate a research agenda of pressing questions to be answered in this area. The consensus‐based research agenda is presented in this article.