Should EM Engage in Community Preventive Medicine?

[docB]

Article in the March 2010 Annals

Preventing Falls in Community-Dwelling Older Adults by Christopher Carpenter, MD MSc

The author argues that EM should be involved in using data such as this systematic review to "develop and assess" interventions.

Exercise programs and home safety assessments for the visually impaired currently offer the most effective interventions to prevent falls in community-dwelling older adults. Falls represent one of the most complex and life-threatening geriatric syndromes; a simple interventional solution is unlikely. Facing an unprecedented demographic surge of older adults, emergency medicine should develop and assess comprehensive multidisciplinary models based on interventions that have been demonstrated to be effective in other settings.

I don't doubt any of the author's data or conclusions about what interventions might be helpful. I question if this should be the domain of the Emergency Physician. I would argue that these types of ongoing assessments about physical capabilities and competence would be better served in the domain of primary care. In service of that argument let me point out that these assessments could not be a one time endeavor. Periodic reassessments would be mandatory, hence a main component would be continuity of care. We must, of course, assist our colleagues by reporting the types of morbidity (mechanisms, demographics, cofactors, etc.) that we observe in the ED. Beyond that should prevention be the responsibility of EM?

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[Stitch]

I agree, it should fall under primary care with the rest of prevention. Most of us probably work in the ED to avoid that sort of guidance, and it would seem that a PCP's job should at least partly be to keep patients out of the ED.

There was an article a while ago out of Children's National stating that peds EM physicians should be more involved in asthma care and start chronic inhaled steroids on the frequent flyers. Their reasoning was that PCPs are overwhelmed already, and that we as emergency physicians are seeing more and more chronic type stuff, giving us an opportunity to provide preventitive counceling . I'm assuming the same reasoning is employed in the above article.

While I still think it's outside of what we should be doing, I guessing that there will be more pressure on us to do these sorts of things in the future, espeically as our census goes up.

 

[GeneralVeers]

Only if we have a nurse or full-time staff member available to do education for each patient on:

- Smoking cessation
- Alcohol abuse
- Domestic violence
- Car seat use
- Helmet use for kids
- Vaccinations
- Fall risks
- Blood pressure and cholesterol screening
- BMI measurement and dietary counseling.

If not, then no.

 

[Tiger26]

frequent flyers and parents insisting on their kids being r/o for epidural bleeds aside, we have to keep in mind that it's emergency medicine . . .

 

[Rendar5]

Only if we have a nurse or full-time staff member available to do education for each patient on:

- Smoking cessation
- Alcohol abuse
- Domestic violence
- Car seat use
- Helmet use for kids
- Vaccinations
- Fall risks
- Blood pressure and cholesterol screening
- BMI measurement and dietary counseling.

If not, then no.

Honestly not a bad idea at certain hospitals to set this sort of thing up in addition to regular everday follow-up stuff that such offices can provide. or a department of health focus on follow-ups. Of course, doable at some places and not others.

I would argue that these issues, well some of them, are the domain of emergency medicine (as trauma prevention is part of the domain of trauma medicine). But not necessarily the domain of the emergency physician.

 

[RxnMan]

Only if we have a nurse or full-time staff member available to do education for each patient on:

- Smoking cessation
- Alcohol abuse
- Domestic violence
- Car seat use
- Helmet use for kids
- Vaccinations
- Fall risks
- Blood pressure and cholesterol screening
- BMI measurement and dietary counseling.

If not, then no.

I think there's a place in the ED for the bolded point, because ED's will see changes in communicable diseases earlier than most other places in healthcare, and vaccines are a fast, lasting intervention with few side effects.

 

[GeneralVeers]

I think there's a place in the ED for the bolded point, because ED's will see changes in communicable diseases earlier than most other places in healthcare, and vaccines are a fast, lasting intervention with few side effects.

In a perfect world with competent patients you would be correct. How often do patients know their vaccination status?

I like how it's now being done, at the nursing level. Our nurses automatically screen for pneumovax, flu, and tetanus so I don't even have to think about it.

The last thing I need piled onto my overloaded plate is something that's non-emergent, and that primary care should be doing.

 

[RxnMan]

...I like how it's now being done, at the nursing level. Our nurses automatically screen for pneumovax, flu, and tetanus so I don't even have to think about it...

This is basically what I was talking about.

Along with this, if we had another H1N1-type epidemic, EDs would see it first, and EDs would be the place where the poor (those most likely to get and spread infection) would get their care, not a PCP. In that situation, EDs would be a logical place to dispense the vaccine (assuming we had one). Note that this is different from Tamiflu, which had dubious efficacy at best.

It would also be nice if all of the infections were automatically routed into a database for nation-wide monitoring, but wishes and horses...

 

[deleted109597]

I like how it's now being done, at the nursing level. Our nurses automatically screen for pneumovax, flu, and tetanus so I don't even have to think about it.

I wish our nurses came even close to that.
I have a hard enough time getting vital signs, much less status of vaccinations. Or PMHx. Or allergies.

 

[Stitch]

Along with this, if we had another H1N1-type epidemic, EDs would see it first, and EDs would be the place where the poor (those most likely to get and spread infection) would get their care, not a PCP. In that situation, EDs would be a logical place to dispense the vaccine (assuming we had one). Note that this is different from Tamiflu, which had dubious efficacy at best.

I think that in the event of a pandemic, we're going to have our hands full enough without trying to be a vaccination center as well. Yes, it does make sense, but we were crazy busy enough last October/November without people rushing in to get the vaccine. Placing this responsibility on emergency providers (even if it's just a nurse out front giving the shots) will further drain already pressed resouces in such an event. Because you know people are going to just stroll in and want the shot regardless of being well.

Would you like Tamiflu with that?

 

[The right Path]

Only if we have a nurse or full-time staff member available to do education for each patient on:

- Smoking cessation
- Alcohol abuse
- Domestic violence
- Car seat use
- Helmet use for kids
- Vaccinations
- Fall risks
- Blood pressure and cholesterol screening
- BMI measurement and dietary counseling.

If not, then no.

I agree that is a great role for the old, wise granny RN whose back and knees are too shot to wrestle the drunks but for some reason still loves nursing .

Are those needs best served by primary care? Of course. But in the ED you definitely have a captive audience. That may be the only golden opportunity for some of those that fall under the "stubborn old goat" category that "hate hospitals, doctors" etc. Sure they're 80 something with bad arthritis, but they still make sure the gutters on their house are clean.

Sure the government can make healthcare free and available to everyone, but that doesn't change people's attitudes and behavior. They are not alluvasudden going to take the initiative to get proper care. And the sad reality is, as always, the burden of the consequences of paying for the hypertensive ICH, renal failure, diabetes related wounds, etc will continue to be on society's shoulders.

Hey, I just had a brain fart!! Maybe we need an "Every 15 Minutes" type community outreach program for unhealthy adult behavior.

 

[RxnMan]

I think that in the event of a pandemic, we're going to have our hands full enough without trying to be a vaccination center as well. Yes, it does make sense, but we were crazy busy enough last October/November without people rushing in to get the vaccine. Placing this responsibility on emergency providers (even if it's just a nurse out front giving the shots) will further drain already pressed resouces in such an event. Because you know people are going to just stroll in and want the shot regardless of being well.

Would you like Tamiflu with that?

Fair enough.*

But here's an interesting point: I'm talking about the one intervention on that entire list that is safe, effective, easy and fast to administer, and has immediate and wide-ranging public health consequences. If we can't make a case for such an easy target, what does that say about the other items on the list?

*I will take the Upsize with the bladder busting high fructose corn syrup du jour and a side of heart attack fries. For 33 cents extra.

 

[notinkansas]

But I thought that EM was the hospital's version of free primary care!

 

[ccfccp]

Of course then we'd be seen as giving one out of every hundred patients autism. Or whatever the class-action vaccination lawsuit du jour is.

Fair enough.*

But here's an interesting point: I'm talking about the one intervention on that entire list that is safe, effective, easy and fast to administer, and has immediate and wide-ranging public health consequences. If we can't make a case for such an easy target, what does that say about the other items on the list?

*I will take the Upsize with the bladder busting high fructose corn syrup du jour and a side of heart attack fries. For 33 cents extra.

 

[El Cheba]

It would also be nice if all of the infections were automatically routed into a database for nation-wide monitoring, but wishes and horses...

Syndromic surveillance databases are out there but mainly used for bioterror type stuff. I've heard some places in Texas are linking syndromic surveillance and GIS/mapping capabilities to 'see' where there are large increases of syndromes in areas.

 

[RxnMan]

Of course then we'd be seen as giving one out of every hundred patients autism. Or whatever the class-action vaccination lawsuit du jour is.

Don't get me started.

 

[docB]

I think there's a place in the ED for the bolded point, because ED's will see changes in communicable diseases earlier than most other places in healthcare, and vaccines are a fast, lasting intervention with few side effects.

Now do you mean the one time type immunizations like pneumovax and tetanus* or do you mean more routine vaccinations like Hep Bs on every one who presents or updating every kid who comes through and is late on their shots? The latter would be a big departure and assumption of responsibility from current practice.


*I know it's not "one time" but every 5 years is close enough, + few EPs would argue we should quit giving dTs for acute lacerations

 

[RxnMan]

Now do you mean the one time type immunizations like pneumovax and tetanus*...

Yes.* +/- Flu with situations like H1N1.

...or do you mean more routine vaccinations like Hep Bs on every one who presents or updating every kid who comes through and is late on their shots?

No no no.

*I did run into an anti-vaxxer in my school's ED who refused to have her family be vaccinated, but made an exception when her son stepped on a nail (which is why he landed in our ED). Why tetanus is different, I don't know. I very much wanted to give her son TdAP instead of dT, just to give him a chance at some protection. Yes, I know that's ethically murky.

Funny coda, while she made an exception for vaccines just this once, she refused any Abx. So foot falling off < lockjaw ?

 

[jbar]

I wonder how vaccines work out in terms of billing? Like I assume most insurance covers it, and you could make the self pay people pay first (a lot would for something like H1N1 this past year). I wonder if the hospital would make enough money on doing vaccines in the ED to make it worth their while to have the staffing to do it.

 

[Hamhock]

I agree that is a great role for the old, wise granny RN whose back and knees are too shot to wrestle the drunks but for some reason still loves nursing .

Or these noctors (DNPs) with "residency" in emergency medicine (USF) who are 'so concerned about the "whole patient"

Let them carry their clipboard, wear a long white coat, pretend they are better medical practitioners and take care of this siht...for little money.

HH

 

[Stitch]

I wonder how vaccines work out in terms of billing? Like I assume most insurance covers it, and you could make the self pay people pay first (a lot would for something like H1N1 this past year). I wonder if the hospital would make enough money on doing vaccines in the ED to make it worth their while to have the staffing to do it.

Very poorly. I trained in primary care. You break even. Sometimes. Now if we could mark up...