Jennifer A Newberry

Addressing Social Determinants of Health from the Emergency Department through Social Emergency Medicine

Dialogue and policy surrounding healthcare reform have drawn increasing interest to the social factors, accountable for nearly one-third of annual deaths in the United States,1 that affect the health of populations. The Affordable Care Act (ACA) includes provisions for health systems to address social determinants of health, but how this is to be accomplished remains uncertain. If we are to make progress as a health system in addressing social determinants of health, we must open a dialogue and practice that reaches patients at the front lines of the medical system and population health – including in the emergency department (ED). The fact that emergency physicians care for patients who are complicated both medically and socially is no surprise, but the idea that we have an important role to play in the social determinants of health of our patients is, while controversial, gaining increasing attention among emergency physicians across the country. This interest comes largely from necessity, as we face a daunting task of providing care to the large volume of vulnerable patients who seek refuge in our EDs. The ED is a window into the community, which starkly frames the contributions of the social determinants underlying the trauma resuscitations, repeat child visits for asthma exacerbation, or sepsis due to delay in seeking care. In the ED, we diagnose and treat the medical problem – but in order to improve the health of our patients we need to expand our role to diagnose and treat their social determinants of health as well. We urge our colleagues to not only consider the social determinants underlying health and illness, but to also develop systematic interventions, measure their effects, collaborate with others, and advocate for policies that will improve the health of our patients. We advocate physicians to address the social determinants of health from the ED, in other words, to practice Social Emergency Medicine. The World Health Organization defines the social determinants of health as “conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.”2 It seems obvious that poverty, racial and ethnic inequities, and lack of preventive care, would lead to poor health. But the social determinants of health extend beyond these more tangible aspects of our lives. Every aspect of how we live, including social class, influences health profoundly. Even among London-based British civil servants leading relatively stable lives with guaranteed employment, salary and health insurance, there is a steep and inverse correlation between job classification level, morbidity and death.3 From a policy standpoint, this gradient is compelling, as it affects all of our patients, not just those living in poverty, but the middle class as well. Given that the structure of our daily lives are the social determinants of health, doing something about them requires moving our focus from the single patient to the population level, from diagnostics and medications to environmental and social structures and the policies that create them. While it would be clear to most emergency physicians that a patient’s frequent visits for hyperglycemia reflect poorly managed diabetes, what is easily labeled willful noncompliance might instead be a lack of access to healthy foods, and ultimately insufficient social and technical support for the entire community. Thus, medical treatment of a disease such as diabetes, without regard to the social determinants of health, suffers the danger of being ineffective. Just as we cannot treat volume overload without understanding the physiology of the kidney, heart, lungs and their interaction, we cannot begin to treat a patient’s medical problems without understanding the social factors, the life he lives. Necessity mandates action. While the ACA tasks primary care with managing these social determinants, access to medical care increasingly occurs through the ED for insured, as well as poor and marginalized populations.4 The ED is the only door open to anyone for comprehensive medical and social services, 24 hours a day, 7 days a week, regardless of acuity or complaint, age, or insurance status. The status of the ED as society’s “safety net” is reinforced by a legal imperative, embodied in the Emergency Medical Treatment and Labor Act of 1986, which requires Medicare-participating hospitals offering emergency services to provide a medical screening examination and stabilization of emergency conditions regardless of ability to pay. What we face practicing in this safety net is an imperative to act. We must embrace this role and adopt our practice to our de facto environment, as a critical part of out healthcare safety net. Applying knowledge about social determinants of health to the bedside and developing effective, systematic interventions that reach out into the community is the practice of Social Emergency Medicine. With increasing ED volumes and ED crowding in the headlines, some argue that taking on this burden would interfere with the ED’s primary mission of caring for the acute and emergent medical problems of the patients, and only when funded appropriately, should EDs take on this mammoth task. However, practically speaking, patients inadequately treated will continue to return to the ED. Many EDs already screen for vulnerable patients and offer some preventive services. ED directors are not philosophically opposed to offering these services within the ED, but are concerned with added costs, effects on ED operations, and potential lack of follow up.5 We believe that to ignore the contribution of social determinants on disease simply because addressing them requires unbudgeted resources, including sophisticated coordination of clinical, statistical, social and policy expertise, is as great an omission as ignoring the contribution of genetics simply because we do not yet have the tools to reliably control gene expression. EDs are beginning to take ownership of social determinants of health for their patients. Recent examples of successful Social Emergency Medicine interventions have focused on the development of coordinated care models providing ED patients in need with comprehensive medical and social services. Emergency medicine researchers worked with the Housing First partnership between the Centers for Medicare and Medicaid Services and New York City, which provided housing for high-risk homeless patients, resulting in improved health and cost savings for the city.6 Boston Medical Center has a robust youth violence intervention program integrated into ED clinical care.7 Emergency medicine has advocated for policies and programs to improve the care of patients with substance use disorders such as implementing screening, brief intervention, and referral to treatment programs and providing take-home naloxone to prevent opioid overdose.8,9 A fundamental step towards making the practice of Social Emergency Medicine more feasible requires integrating the study of the social determinants of health into our education. Medical training in the social determinants cannot be relegated to a single lecture or seminar, but rather requires a proportional emphasis along with anatomy, pharmacology and pathophysiology of disease. Similarly, we must not only teach the relationship of social determinants and health, but also teach the tools to translate theory into practice. We should teach methods to collaborate with community groups and design interventions so that young doctors do not segregate their medical and social diagnoses and interventions. A fitting consequence of developing a subspecialty of Social Emergency Medicine would be that while all medical practitioners must know some theory, basic diagnostics and treatment; complicated cases require expert consultation and a systemwide effort. A single physician recognizing that a patient’s unstable housing is an impediment to proper management of his health is important, but the next steps can feel daunting – especially in the face of a full waiting room and critically ill patients. This burden cannot fall on the individual clinician; isolated interventions will fail. Although a physician can recognize that her patient is suffering an ST elevation myocardial infarction, she requires a system to achieve timely medical and procedural intervention resulting in favorable outcomes. Accordingly, successful Social Emergency Medicine interventions require specialty training, resources, and a multidisciplinary team. Physicians practicing Social Emergency Medicine must also network, establish, and foster collaborations. Screening programs and innovative interventions cannot be solely well intentioned, but must be needs based and proven effective. Sharing of resources, best practices, standardization of data collection, and research networks with the dissemination of findings are imperative. Social Emergency Medicine initiatives should culminate in advocacy for policies to combat the adverse health impacts that stem from the vastly disparate conditions in which people are born, grow, live, work, and age. One can view the ED (by law, the most accessible door into our healthcare system) as the social barometer of its community. Within the waiting room the emergency physicians witness the confluence of social determinants of health and their deconstruction into pathology. Our daily practice compels us to act, to systematically and collaboratively act on upstream social factors to positively and comprehensively influence downstream health outcomes. This paradigm shift is critical to effectively care for our patients. In the words of Rudolph Virchow, “Medicine has imperceptibly led us into the social field and placed us in a position of confronting directly the great problems of our time.”10

Characteristics and outcomes of women using emergency medical services for third-trimester pregnancy-related problems in India: a prospective observational study

Objectives Characterise the demographics, management and outcomes of obstetric patients transported by emergency medical services (EMS). Design Prospective observational study. Setting Five Indian states using a centralised EMS agency that transported 3.1 million pregnant women in 2014. Participants This study enrolled a convenience sample of 1684 women in third trimester of pregnancy calling with a ‘pregnancy-related’ problem for free-of-charge ambulance transport. Calls were deemed ‘pregnancy related’ if categorised by EMS dispatchers as ‘pregnancy’, ‘childbirth’, ‘miscarriage’ or ‘labour pains’. Interfacility transfers, patients absent on ambulance arrival and patients refusing care were excluded. Main outcome measures Emergency medical technician (EMT) interventions, method of delivery and death. Results The median age enrolled was 23 years (IQR 21–25). Women were primarily from rural or tribal areas (1550/1684 (92.0%)) and lower economic strata (1177/1684 (69.9%)). Time from initial call to hospital arrival was longer for rural/tribal compared with urban patients (66 min (IQR 51–84) vs 56 min (IQR 42–73), respectively, p<0.0001). EMTs assisted delivery in 44 women, delivering the placenta in 33/44 (75%), performing transabdominal uterine massage in 29/33 (87.9%) and administering oxytocin in none (0%). There were 1411 recorded deliveries. Most women delivered at a hospital (1212/1411 (85.9%)), however 126/1411 (8.9%) delivered at home following hospital discharge. Follow-up rates at 48 hours, 7 days and 42 days were 95.0%, 94.4% and 94.1%, respectively. Four women died, all within 48 hours. The caesarean section rate was 8.2% (116/1411). On multivariate regression analysis, women transported to private hospitals versus government primary health centres were less likely to deliver by caesarean section (OR 0.14 (0.05–0.43)) Conclusions Pregnant women from vulnerable Indian populations use free-of-charge EMS for impending delivery, making it integral to the healthcare system. Future research and health system planning should focus on strengthening and expanding EMS as a component of emergency obstetric and newborn care (EmONC).

Image diagnosis: Perilunate and lunate dislocations.

Perilunate Dislocation Anterior-posterior (AP) view (Figure 1) demonstrates the distal and proximal carpal rows overlapping, as well as a complete radial styloid fracture. Lateral view (Figures 2 and 3) demonstrates dorsal dislocation of the capitate, whereas the lunate remains articulated with the radius. More often seen in young men in their teens to twenties, rather than children or the elderly, it is a high-energy mechanism that causes wrist hyperextension resulting in perilunate dislocation. As seen here, it is more common to see an associated fracture of a carpal bone, such as the scaphoid, or an associated radial or ulnar styloid fracture, rather than a dislocation alone. An estimated 16% to 25% of perilunate dislocations are missed on initial exam, resulting in increased morbidity eventually requiring open reduction with fixation and sometimes salvage repair. Image Diagnosis: Perilunate and Lunate Dislocations

Comparison of online and classroom-based formats for teaching emergency medicine to medical students in Uganda

Severe global shortages in the health care workforce sector have made improving access to essential emergency care challenging. The paucity of trained specialists in low‐ and middle‐income countries translates to large swathes of the population receiving inadequate care. Efforts to expand emergency medicine (EM) education are similarly impeded by a lack of available and appropriate teaching faculty. The development of comprehensive, online medical education courses offers a potentially economical, scalable, and lasting solution for universities experiencing professional shortages.

Using an emergency response infrastructure to help women who experience gender-based violence in Gujarat India.

Abstract Problem Many women who experience gender-based violence may never seek any formal help because they do not feel safe or confident that they will receive help if they try. Approach A public–private-academic partnership in Gujarat, India, established a toll-free telephone helpline – called 181 Abhayam – for women experiencing gender-based violence. The partnership used existing emergency response service infrastructure to link women to phone counselling, nongovernmental organizations (NGOs) and government programmes. Local setting In India, the lifetime prevalence of gender-based violence is 37.2%, but less than 1% of women will ever seek help beyond their family or friends. Before implementation of the helpline, there were no toll-free helplines or centralized coordinating systems for government programmes, NGOs and emergency response services. Relevant changes In February 2014, the helpline was launched across Gujarat. In the first 10 months, the helpline assisted 9767 individuals, of which 8654 identified themselves as women. Of all calls, 79% (7694) required an intervention by phone or in person on the day they called and 43% (4190) of calls were by or for women experiencing violence. Lessons learnt Despite previous data that showed women experiencing gender-based violence rarely sought help from formal sources, women in Gujarat did use the helpline for concerns across the spectrum of gender-based violence. However, for evaluating the impact of the helpline, the operational definitions of concern categories need to be further clarified. The initial triage system for incoming calls was advantageous for handling high call volumes, but may have contributed to dropped calls.

Reducing early infant mortality in India: results of a prospective cohort of pregnant women using emergency medical services

Objectives To describe the demographic characteristics and clinical outcomes of neonates born within 7 days of public ambulance transport to hospitals across five states in India. Design Prospective observational study. Setting Five Indian states using a centralised emergency medical services (EMS) agency that transported 3.1 million pregnant women in 2014. Participants Over 6 weeks in 2014, this study followed a convenience sample of 1431 neonates born to women using a public-private ambulance service for a ‘pregnancy-related’ problem. Initial calls were deemed ‘pregnancy related’ if categorised by EMS dispatchers as ‘pregnancy’, ‘childbirth’, ‘miscarriage’ or ‘labour pains’. Interfacility transfers, patients absent on ambulance arrival, refusal of care and neonates born to women beyond 7 days of using the service were excluded. Main outcome measures: death at 2, 7 and 42 days after delivery. Results Among 1684 women, 1411 gave birth to 1431 newborns within 7 days of initial ambulance transport. Median maternal age at delivery was 23 years (IQR 21–25). Most mothers were from rural/tribal areas (92.5%) and lower social (79.9%) and economic status (69.9%). Follow-up rates at 2, 7 and 42 days were 99.8%, 99.3% and 94.1%, respectively. Cumulative mortality rates at 2, 7 and 42 days follow-up were 43, 53 and 62 per 1000 births, respectively. The perinatal mortality rate (PMR) was 53 per 1000. Preterm birth (OR 2.89, 95% CI 1.67 to 5.00), twin deliveries (OR 2.80, 95% CI 1.10 to 7.15) and caesarean section (OR 2.21, 95% CI 1.15 to 4.23) were the strongest predictors of mortality. Conclusions The perinatal mortality rate associated with this cohort of patients with high-acuity conditions of pregnancy was nearly two times the most recent rate for India as a whole (28 per 1000 births). EMS data have the potential to provide more robust estimates of PMR, reduce inequities in timely access to healthcare and increase facility-based care through service of marginalised populations.

Comparing Teaching Methods in Resource-Limited Countries

In Reply: As Dr. Al-Musawi states, hands-on clinical experience is an invaluable component of medical education. Our intention was not to suggest that online education can wholly replace hands-on learning, but rather should be seen as a viable method of augmenting and sustaining emergency care education worldwide. Our study conclusively demonstrated that classroom-based learning and online learning were equivalent in terms of knowledge acquisition by participating students. These results suggest that effective, online, core curriculum can serve as a scaffolding for an adjunct applied clinical curriculum, thus enabling countries with severely limited numbers of trained faculty to concentrate those human resources on leading hands-on workshops, simulation exercises, and emergency care drills, as well as engaging students in clinical bedside instruction. By designing a locally adaptable, online program, we can jumpstart knowledge acquisition, build partnerships, and enhance the pace of emergency care development in resource-limited settings.

Comparison of Live Versus Online Instruction of a Novel Soft Skills Course in Mongolia

Background Soft skills are essential for employee success in the global marketplace; however, many developing countries lack content experts to provide the requisite instruction to an emerging workforce. One possible solution is to use an online, open-access curriculum. To date, no studies on soft skills curricula using an online learning platform have been undertaken in Mongolia. Objective To evaluate the efficacy of an online versus classroom platform to deliver a novel soft skills course in Mongolia. Methods A series of eight lectures along with corresponding surveys and multiple choice question tests were developed and translated into the Mongolian language. Two different delivery modalities, online and traditional classroom lectures, were then compared for knowledge gain, comfort level, and satisfaction. Knowledge gain and comfort level were assessed pre- and post-course, while satisfaction was assessed only post-course. Results Enrollment in the online and classroom courses was 89 students and 291 students, respectively. Sixty-two online students (68% female) and 114 classroom students (77% female) completed the entire course and took the post-test. The online cohort had higher pre-test scores than the classroom cohort (46.4% and 37.3%, respectively, p < 0.01). The online cohort’s overall knowledge gain was not significant (0.4%, p=0.87), but the classroom cohort’s knowledge gain was significant (13.9%, p < 0.01). Both the online and classroom cohorts demonstrated significant improvement in overall comfort level for all soft skills topics (p < 0.01). Both cohorts were also highly satisfied with the course, as assessed on a Likert scale (4.59 for online, 4.40 for classroom). Conclusion The study compared two cohorts of Mongolian college students who took either an online or classroom-based soft skills course, and it was found that knowledge gain was significantly higher for the classroom group, while comfort and satisfaction with individual course topics was comparable.

Global Health and Emergency Care: Defining Clinical Research Priorities.

OBJECTIVES Despite recent strides in the development of global emergency medicine (EM), the field continues to lag in applying a scientific approach to identifying critical knowledge gaps and advancing evidence-based solutions to clinical and public health problems seen in emergency departments (EDs) worldwide. Here, progress on the global EM research agenda created at the 2013 Academic Emergency Medicine Global Health and Emergency Care Consensus Conference is evaluated and critical areas for future development in emergency care research internationally are identified. METHODS A retrospective review of all studies compiled in the Global Emergency Medicine Literature Review (GEMLR) database from 2013 through 2015 was conducted. Articles were categorized and analyzed using descriptive quantitative measures and structured data matrices. The Global Emergency Medicine Think Tank Clinical Research Working Group at the Society for Academic Emergency Medicine 2016 Annual Meeting then further conceptualized and defined global EM research priorities utilizing consensus-based decision making. RESULTS Research trends in global EM research published between 2013 and 2015 show a predominance of observational studies relative to interventional or descriptive studies, with the majority of research conducted in the inpatient setting in comparison to the ED or prehospital setting. Studies on communicable diseases and injury were the most prevalent, with a relative dearth of research on chronic noncommunicable diseases. The Global Emergency Medicine Think Tank Clinical Research Working Group identified conceptual frameworks to define high-impact research priorities, including the traditional approach of using global burden of disease to define priorities and the impact of EM on individual clinical care and public health opportunities. EM research is also described through a population lens approach, including gender, pediatrics, and migrant and refugee health. CONCLUSIONS Despite recent strides in global EM research and a proliferation of scholarly output in the field, further work is required to advocate for and inform research priorities in global EM. The priorities outlined in this paper aim to guide future research in the field, with the goal of advancing the development of EM worldwide.

Implementing an Innovative Prehospital Care Provider Training Course in Nine Cambodian Provinces.

Despite significant improvements in health outcomes nationally, many Cambodians continue to experience morbidity and mortality due to inadequate access to quality emergency medical services. Over recent decades, the Cambodian healthcare system and civil infrastructure have advanced markedly and now possess many of the components required to establish a well functioning emergency medical system. These components include enhanced access to emergency transportation through large scale road development efforts, widspread availability of emergency communication channels via the spread of cellphone and internet technology, and increased access to health services for poor patients through the implementation of health financing schemes. However, the system still lacks a number of key elements, one of which is trained prehospital care providers. Working in partnership with local providers, our team created an innovative, Cambodia-specific prehospital care provider training course to help fill this gap. Participants received training on prehospital care skills and knowledge most applicable to the Cambodian healthcare system, which was divided into four modules: Basic Prehospital Care Skills and Adult Medical Emergencies, Traumatic Emergencies, Obstetric Emergencies, and Neonatal/Pediatric Emergencies. The course was implemented in nine of Cambodia’s most populous provinces, concurrent with a number of overarching emergency medical service system improvement efforts. Overall, the course was administered to 1,083 Cambodian providers during a 27-month period, with 947 attending the entire course and passing the course completion exam.