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.     

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.     

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.     

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     

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.     

Mental Health and Emergency Medicine: A Research Agenda

The burden of mental illness is profound and growing. Coupled with large gaps in extant psychiatric services, this mental health burden has often forced emergency departments (EDs) to become the de facto primary and acute care provider of mental health care in the United States. An expanded emergency medical and mental health research agenda is required to meet the need for improved education, screening, surveillance, and ED-initiated interventions for mental health problems. As an increasing fraction of undiagnosed and untreated psychiatric patients passes through the revolving doors of U.S. EDs, the opportunities for improving the art and science of acute mental health care have never been greater. These opportunities span macroepidemiologic surveillance research to intervention studies with individual patients. Feasible screening, intervention, and referral programs for mental health patients presenting to general EDs are needed. Additional research is needed to improve the quality of care, including the attitudes, abilities, interests, and virtues of ED providers. Research that optimizes provider education and training can help academic settings validate psychosocial issues as core components and responsibilities of emergency medicine. Transdisciplinary research with federal partners and investigators in neuropsychiatry and related fields can improve the mechanistic understanding of acute mental health problems. To have lasting impact, however, advances in ED mental health care must be translated into real-world policies and sustainable program enhancements to assure the uptake of best practices for ED screening, treatment, and management of mental disorders and psychosocial problems.     

Knowledge Translation in the Emergency Medical Services: A Research Agenda for Advancing Prehospital Care

Little is known about knowledge translation in the practice of out-of-hospital medicine. It is generally accepted that much work is needed regarding "getting the evidence straight" in emergency medical services, given the substantial number of interventions that are performed regularly in the field but lack meaningful scientific support. Additional attention also needs to be given to "getting the evidence used," because there is some evidence that evidence-based practices are being incompletely or incorrectly applied in the field. In an effort to help advance a research agenda for knowledge translation in emergency medical services, nine recommendations are put forth to help address the problems identified.     

Defining and Measuring Successful Emergency Care Networks: A Research Agenda

The demands on emergency services have grown relentlessly, and the Institute of Medicine (IOM) has asserted the need for “regionalized, coordinated, and accountable emergency care systems throughout the country.” There are large gaps in the evidence base needed to fix the problem of how emergency care is organized and delivered, and science is urgently needed to define and measure success in the emerging network of emergency care. In 2010, Academic Emergency Medicine convened a consensus conference entitled “Beyond Regionalization: Integrated Networks of Emergency Care.” This article is a product of the conference breakout session on “Defining and Measuring Successful Networks”; it explores the concept of integrated emergency care delivery and prioritizes a research agenda for how to best define and measure successful networks of emergency care. The authors discuss five key areas: 1) the fundamental metrics that are needed to measure networks across time-sensitive and non–time-sensitive conditions; 2) how networks can be scalable and nimble and can be creative in terms of best practices; 3) the potential unintended consequences of networks of emergency care; 4) the development of large-scale, yet feasible, network data systems; and 5) the linkage of data systems across the disease course. These knowledge gaps must be filled to improve the quality and efficiency of emergency care and to fulfill the IOM’s vision of regionalized, coordinated, and accountable emergency care systems. ACADEMIC EMERGENCY MEDICINE 2010; 17:1297–1305 © 2010 by the Society for Academic Emergency Medicine     

Ethics in Acute Care Research: A Global Perspective and Research Agenda

The 2013 Academic Emergency Medicine consensus conference focused on global health and emergency care research. One conference breakout session discussed research ethics and developed a research agenda concerning global acute care research ethics. This article represents the proceedings from that session, particularly focusing on ethical issues related to protecting human subjects while conducting acute care research. Protecting human research subjects from unnecessary risk is an important component of conducting ethical research, regardless of the research site. There are widely accepted ethical principles related to human subjects research; however, the interpretation of these principles requires specific local knowledge and expertise to ensure that research is conducted ethically within the societal and cultural norms. There is an obligation to conduct research ethically while recognizing the roles and responsibilities of all participants. This article discusses the complexities of determining and applying socially and culturally appropriate ethical principles during the conduct of global acute care research. Using case studies, it focuses both on the procedural components of ethical research conducted outside of “Western” culture and on basic ethical principles that are applicable to all human subjects research. This article also proposes specific research topics to stimulate future thought and the study of ethics in these complex circumstances.     

Emergency Medicine Education and Health Care Disparities

Education is the means by which learning occurs and, thereby, behavior is changed. One means of improving health care disparities is changing the behavior and understanding of key personnel in academic health centers. These individuals influence policy and procedure, design and evaluate health systems, and define curricular standards for graduate and undergraduate medical education. Emergency medicine provides many opportunities to educate at all levels, including faculty, residents, and students. In addition to our responsibilities in educating emergency medicine residents, the emergency department also provides an ideal learning environment for medical students and other health care providers. The broad issue of disparities in emergency health care may be approached from a variety of directions. The Consensus Group on Education chose to focus on cultural competency education at several levels as a means of tangibly changing its status for both the immediate and long terms.     

Education for Palliative Care: An Undergraduate Perspective

Abstract

Background: Clinical prediction of survival (CPS) by clinicians is generally overestimated. No study has been done in Hong Kong addressing the accuracy of survival prediction in advanced cancer patients. The objective of this study was to examine CPS by a local palliative care physician in a palliative care unit.

Patients and methods: This was a prospective study in a local palliative care unit. After the enrolment of advanced cancer patients into the palliative care service, the physician-in-charge, experienced in palliative care, estimated the survival of the patients in weeks or months as a continuous variable. These were compared with the actual survival time (AS), accuracy being defined as observed survival = predicted survival ± 33%. CPS was also re-categorized into three groups (≤ 4 weeks, 5–12 weeks, ≥ 13 weeks) for the analysis.

Results: Of the 167 patients studied, 103 were men and 64 were women (mean age 69.3 years; SD 11.7 years). The median overall survival was 76 days (interquartile range 30–160 days). The median actual survivals among the three different clinical predicted groups were 12, 63 and 170 days, respectively. The differences were statistically significant (P < 0.0001). CPS correlated strongly with AS (r = 0.67; P < 0.0001). The difference between the median CPS and median AS was 6 days in a pessimistic direction and their ratio was 0.92. CPS was accurate in 53 patients (31.7%), overly optimistic in 70 patients (41.9%) and overly pessimistic in 44 patients (26.3%).

Conclusions: In this study, CPS was highly correlated with AS. Physicians with experience in palliative care may discriminate well the different prognostic groups, yet a significant proportion of CPS was still overestimated. Maybe over-optimism of prognostication is a cultural bias.     

Gender‐specific Issues in Traumatic Injury and Resuscitation: Consensus‐based Recommendations for Future Research

Traumatic injury remains an unacceptably high contributor to morbidity and mortality rates across the United States. Gender‐specific research in trauma and emergency resuscitation has become a rising priority. In concert with the 2014 Academic Emergency Medicine consensus conference “Gender‐specific Research in Emergency Care: Investigate, Understand, and Translate How Gender Affects Patient Outcomes,” a consensus‐building group consisting of experts in emergency medicine, critical care, traumatology, anesthesiology, and public health convened to generate research recommendations and priority questions to be answered and thus move the field forward. Nominal group technique was used for the consensus‐building process and a combination of face‐to‐face meetings, monthly conference calls, e‐mail discussions, and preconference surveys were used to refine the research questions. The resulting research agenda focuses on opportunities to improve patient outcomes by expanding research in sex‐ and gender‐specific emergency care in the field of traumatic injury and resuscitation.     

Emergency Medical Practice: Advancing Cultural Competence and Reducing Health Care Disparities

In an increasingly diverse patient population, language differences, socioeconomic circumstances, religious values, and cultural practices may present barriers to the delivery of quality care. These obstacles contribute to the health care disparities observed in all areas of medical care. Increasing cultural competence has been cited as part of the solution to reduce disparities. The emergency department (ED) is an environment where cultural sensitivity is particularly needed, as it is often a primary source of health care for the underserved and ethnic and racial minorities and a place where high patient volume and acuity place the provider under demanding time pressures, yet the emergency medicine (EM) literature on health care disparities and cultural competence is limited.
The authors present three clinical scenarios highlighting challenges in providing equitable emergency care to minority populations. Using these cases as illustrations, three processes are proposed that may improve the quality of care delivered to minority populations: 1) increase cultural awareness and reduce provider biases, enabling providers to interact more effectively with different patient populations; 2) accommodate patient preferences and needs in medical settings through practice adjustments and cultural modifications; and 3) increase provider diversity to raise levels of tolerance, awareness, and understanding for other cultures and create more racially and/or ethnically concordant patient–physician relationships.     

Global Health Education in Emergency Medicine Residency Programs

Background

Interest in global health and international electives is growing among Emergency Medicine (EM) residents in the United States (US). The majority of EM residency programs offer opportunities for international electives. The degree of participation among residents and type of support provided by the residency program, however, remains unclear.

Study Objectives

To explore the current state of global health education among EM residents who participate in international electives.

Methods

A 12-question survey was e-mailed to the program directors of the 192 EM residency programs in the US. The survey included questions about the number of residents participating in international electives and the types of preparation, project requirements, supervision, and feedback participating residents receive.

Results

The response rate was 53% with 102 responses. Seventy-five of 102 (74%) programs reported that at least one resident participated in an international elective in the 2010–2011 academic year. Forty-three programs (42%) report no available funding to support any resident on an international elective. Residents receive no preparation for international work in 41 programs (40%). Only 25 programs (26%) required their residents to conduct a project while abroad. Forty-nine programs (48%) reported no formal debriefing session, and no formal feedback was collected from returning residents in 57 of 102 (59%) programs.

Conclusion

The majority of EM residencies have residents participating in international electives. However, the programs report variable preparation, requirements, and resident supervision. These results suggest a need for an expanded and more structured approach to international electives undertaken by EM residents.     

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.