The emergency department—a laboratory for public health

Charles, a longtime smoker and drinker, once had a job delivering pizzas. After the pizza place closed, he lost the job and started to drink more heavily. That led to a car crash that brought him to the emergency department (ED) with minor injuries. Over the years, he made several more ED visits with intoxication or asthma flare-ups. Then one day he showed up with chest pain; his EKG was concerning. When Charles’ emergency physician (EP) reviewed his medical record, she noticed he had been hypertensive during his previous ER visits, but there was no record of this finding having been discussed with him. Charles says he didn’t know he had high blood pressure; he doesn’t know where to go for primary care, much less how to quit drinking.

Though Charles is imaginary, he has traits that are common to many ED patients—his smoking and drinking underlie many of his visits; and doctors missed more than one chance to help him quit those addictions, address his hypertension, and even help prevent heart disease.

Gail D’Onofrio, M.D., M.S., chair of the Department of Emergency Medicine, is one of a growing number of EPs who want to change the way EDs do business. Patients like Charles, say these doctors, should receive ED care not just for such immediate problems as asthma attacks and chest pain, but also for those problems’ root causes, like substance abuse or the lack of a “medical home.” Such problems bring patients back to the ED time and again. That pattern contributes to crowding, a longstanding nationwide crisis that has forced the Yale-New Haven Hospital ED to routinely park gurneys in the hallway—one of the reasons behind its major renovation last year. Intervening in root causes may not only help patients but also reduce repeat visits and alleviate pressure on the ED’s limited resources. So alongside a group of like-minded Yale faculty, D’Onofrio is guiding the ED into relatively uncharted territory: she is turning it into a public health laboratory.

“Maybe they came in with a broken ankle, and I just found out that they were hypertensive,” she said. “I have an opportunity to really improve their health ... It’s a different paradigm than it was years ago, [when] we called it ’treat ’em and street ’em.’ ... Now we know that’s not really improving health.”

About 20 years ago some EPs began to realize that risky choices underlie not only chronic health problems like diabetes and hypertension but also contribute to many acute conditions that were being treated in the ED. Problem drinking and car crashes, recalled Steven L. Bernstein, M.D., FW ’01, associate professor of emergency medicine. Domestic violence and broken bones. Or smoking and its many consequences. “Asthma attacks, exacerbation of emphysema, chest pain—we can treat that,” Bernstein said. “But we weren’t really doing anything about the proximate behaviors that underlie those acute medical or traumatic conditions.”

“You have to treat everything or you’re not going to improve the health of the community,” said D’Onofrio. “The emergency department is really a reflection of the community. It has no walls.”

If you build it, they will come

Emergency department crowding has been discussed in the medical literature since at least the early 1980s, and in recent years EPs have grown downright alarmed. Crowded EDs mean ambulances are turned away; providers and resources are stretched thinner and thinner; and care can become haphazard. Crowding also leaves the ED poorly equipped to cope with disasters. The Institute of Medicine called attention to the problem in a 2007 report titled “Hospital-Based Emergency Care: At the Breaking Point.”

In 2011 Yale-New Haven Hospital’s ED saw 83,757 patients and 24,496 more at its Shoreline Medical Center in Guilford; D’Onofrio estimates that last year saw a 2 percent rise in visit numbers at Yale. While a 2 percent increase may seem small, like compound interest it adds up and can increase the workload on already stressed emergency departments. At Yale, for example, that increase would add about five patients a day in 2012—with a typical ER doc able to see perhaps three patients an hour, that adds up to about two hours of a doctor’s time. (The Centers for Disease Control and Prevention estimates that ED visits nationwide rose 3.2 percent per year between 1996 and 2006—over a third of them in trauma centers like Yale’s.) Crowding is a complex problem with many underlying causes, including a poor primary-care network; widespread hospital closures; and the use of the ED by primary-care doctors who know their patients can get tests done faster there.

In the same way that building a new expressway can draw more vehicles and create newer, worse traffic jams, building more ED beds isn’t necessarily the answer. “If you build it bigger and bigger, they will come,” said D’Onofrio, adding that what is ultimately needed are more primary care physicians and a fix to the broken health care system. So while the renovated Yale ED will be more spacious and contain better equipment, it will not add more capacity; the plans call simply for converting informal “hallway” beds into formal beds in private rooms, allowing providers to focus on treating patients efficiently—and with prevention in mind.

Bernstein, for example, has his sights set on smokers. He trained first in internal medicine, then began a hematology/oncology fellowship, much of it at a Veterans Administration hospital in Brooklyn where many patients suffered from tobacco-related cancers. “That was also in an era when the VA still sold cigarettes in the canteen,” Bernstein recalled. When he suggested to his professors that they ask the commissary to stop selling cigarettes, he got an angry response. “[They] told me that’s not really our job. ‘We’re oncologists—our job is to treat people with cancer.’ I thought … If he is right, I probably need to do something else.” He left the fellowship after the first year and retrained in emergency medicine, where his background gave him fresh eyes. “[In] the ED I saw the same kinds of tobacco-related illnesses I saw as an intern—asthma, COPD, ischemic chest pain, gastritis.” The ED, he said, seemed like a “rich environment” in which to intervene with smokers.

At that time, the late 1980s, some early efforts to “capture” ED patients for public health interventions had begun. Emory physicians were studying firearm injuries, while researchers at Johns Hopkins were beginning to study the prevalence of undiagnosed HIV infection in ER patients. The latter drew a lot of media attention, Bernstein recalled. Yet he was finding 40 percent prevalence rates for smoking in his ED.

“I understand we need to treat HIV; it’s a terrible disease,” Bernstein recalls thinking. “But smoking’s the number one cause of death in the United States. We’ve got this enormous pool of people here [in the ED] with tobacco-related problems. Why not do something about that?” Along with D’Onofrio and colleagues, Bernstein is now studying ED-based tobacco cessation programs as well as alcohol and drug screening.

Today, academic centers’ efforts in the field continue. The University of Michigan’s ED studies both stroke and injury prevention, while the Emory Center for Injury Control funds studies of fall prevention among the elderly—a very common cause of ED visits. And researchers at Boston Medical Center, where D’Onofrio trained and which is home to the busiest ED in New England, have for years studied the effects of screening, brief interviews, and referral for treatment by emergency physicians for problem drinkers—a protocol known as SBIRT.

An innovative program in Camden, New Jersey, that was featured in The New Yorker in January 2011, serves as a vivid example of what might be possible. There, a grant-funded medical team began aggressive outpatient care for a group of so-called super-utilizers, helping prevent the kinds of problems that led those people to EDs. The team arranged for disability insurance, home health aides, regular physician appointments, and even visits to church. In the first group of patients the team studied, ED visits dropped by 40 percent and their hospital bills by 56 percent. Author Atul Gawande, M.D., referred to the approach as “focusing on the hot spots of medicine.”

So far most public health work of this kind is emerging from academic medical centers that can fund health workers or research assistants through their affiliate hospitals’ budgets or through grants. Translating that on a large scale to the thousands of more modestly funded EDs across the country may require training the providers themselves to do the public health work. With a grant from the Substance Abuse and Mental Health Services Administration (SAMHSA), D’Onofrio has spearheaded a program now in its third year that aims to train all of Yale-New Haven’s medical residents in primary-care specialties to perform SBIRT for alcohol and drug use. She estimates they have provided training to 300 physicians in emergency medicine and several other specialties.

Bringing public health into the ED

Because public health outreach focuses on preventing injury and disease, there are a thousand ways to go about it, from educational pamphlets to safety laws to screening tests. In addition to its tobacco and physician-centered SBIRT programs, the Yale ED is approaching public health on several other fronts.

Injury, for example, particularly in the context of violence or traffic collisions, can be considered and studied as a disease epidemic. Federico Vaca, M.D., M.P.H., professor of emergency medicine, wants to cut down on traffic collisions in the New Haven area by targeting young Latino men, a group whose members come to the ED as crash victims all too often. “Injury has been my passion in my work,” Vaca said, recalling an epiphany in which he saw a child in an ER with fatal injuries from a car crash. He did a fellowship with the National Highway Traffic Safety Administration, where he reviewed research and policy, prepared public education documents on traffic safety, and represented the agency to both English- and Spanish-speaking populations. “It really changed my career, and how I saw my career as an [emergency] physician. ... Many of us and indeed many people before me, [are] really trying and aching and wanting to get outside the doors of the ED.”

In New Haven, Vaca works with the Latino advocacy organization Junta for Progressive Action and the Fair Haven Community Health Center (FHCHC) to try to isolate what familial or cultural factors spur young men to do risky things like drag race or drive without a license or seat belt. The FHCHC, said director Katrina Clark, M.P.H. ’71, plans to implement interventions that Vaca develops through his research.

“A few of our youth believed that it was okay to have a drink or two or three, and then be able to drive home,” said Sandra Trevino, director of Junta for Progressive Action. “That’s what they were exposed to and they didn’t see that there were any issues with that. ... It’s great that emergency medicine doctors [are] willing to go out to the community to try to do some preventive work.”

Then there is opiate abuse, a problem that is skyrocketing as prescription drugs are being sold on the street. Yale EPs, funded by a National Institute of Drug Abuse grant, are now beginning to place eligible patients on the methadone-like drug buprenorphine—an unusual drug for an ED to dispense—before referring them to the hospital’s Primary Care Center for intensive outpatient care.

Lay advocates for patients

The ED’s oldest and flagship public-health initiative is called Project ASSERT. Its team of trained laypeople, called Health Promotion Advocates (HPAs), screen patients for alcohol and drug abuse as well as for other vulnerabilities like depression and domestic violence. After screening, the HPAs do a “brief negotiated interview” to encourage change in patients who need help, then link them to area outpatient organizations that do detox or rehab, among other services. Because patients know there’s a spot waiting for them, they are highly likely to go. Sponsored by the hospital, the program is 12 years old. Its HPAs, who might be thought of as community health workers, had screened almost 40,000 people as of spring 2010. That year, 88.6 percent of the 510 people whom Project ASSERT referred to an alcohol or drug treatment program and reached for follow-up were found to have enrolled in that program. SAMHSA has calculated that each SBIRT, the treatment protocol, like those done in Project ASSERT saves $644 in health care per patient over a six-month period, and $1,206 with savings added from averted car crashes, work absences, and brushes with the law.

Gregory Johnson, one of the program’s first hires as an HPA, fell in love with the job because of “the immediate impact that I have in someone’s life.” The key to ASSERT’s effectiveness, he said, is its ability to catch patients at a vulnerable moment and link them to follow-up treatment immediately.

Take, for instance, a patient addicted to crack. “If I see you on the street, I might say ‘Hey, you need to get some help,’ and I might even give you a pamphlet,” Johnson said. “You might take it out of respect and then go around the corner and throw it out.” By contrast, a patient sitting nervously in an ER experiencing a crack-induced medical emergency may be much more receptive to treatment suggestions. “If you give them a positive solution right then and there,” Johnson said, “then they’re more apt to go along with it.”

That wouldn’t happen, he suspects, if ASSERT were to set up an office on the New Haven Green. Its proper home is the ED. Not only can the stress of an ED visit leave patients feeling ready for a change in their lives, but also those who are referred have been deemed eligible for the referral site as well as stable enough to leave the hospital. Though patients can always self-refer for outpatient treatment, said Johnson, if they go through the ED, “the referral sites are confident that the patient is medically cleared ... and since we constantly deal with the referral sites, we know exactly what they’re looking for to get this person admitted.”

Such connections may cut down on ED visits over time—no small thing when the Yale ED’s visit numbers have jumped 23 percent in the last five years and continue to rise in keeping with national trends. A relatively low number of high utilizers, some of them substance abusers, are responsible for a disproportionately large number of those visits. Alexei Nelayev, M.A. ’02, a research associate in the Department of Emergency Medicine who serves as the HPAs’ supervisor, recalls crunching data with the ED’s medical records software. He was astounded to see that some patients had visited the ED more than 200 times in the past six years. “The data were so staggering that I picked up the phone and called the [software company],” Nelayev recalled; he said to them, “ ‘Forgive my skeptical mind—I think there is a mistake here. It’s impossible that someone would show up in the emergency room for 250 times!’ They said ... ‘You are way too naive.’ ”

Resistance from behind

The idea of doing public health work in the ED hasn’t gone over altogether smoothly. If the conventional wisdom is true, doctors’ personalities sort themselves by specialty, and emergency medicine physicians are the cowboys. Adrenaline-charged, quick to react, they ride to the rescue of the sick and injured, performing lifesaving procedures, keeping it all together, racing from the beginning of the shift till the end. They’re the kind of docs who relish the instant gratification of a patch-up or dramatic save but prefer to leave questions of long-term and preventive medicine to their colleagues in primary care.

“To some extent, this butts up against the historic ethos of emergency medicine,” said Bernstein. “Our basic goal is diagnosis, management, and stabilization of people with acute illness and injury, and now we’re talking about interventions for people with tough behaviors. And that’s not how emergency docs thought of themselves.

“We encounter a fair amount of resistance among our colleagues about doing this kind of work,” he continued, “and not without justification—not only because there’s a cultural difference, but because everybody in the ED is already as busy as can be.” And yet the pressure of missed opportunities to prevent more visits may be overcoming that resistance.

Apart from innovative programs, there are also well-established precedents for ED involvement with public health. In addition to EPs’ important role in surveillance (disease outbreaks may show up early in EDs), they have long been trained to offer tetanus vaccine boosters to every eligible patient who comes in with broken skin, whether they be there for an open fracture or a bee sting. “That’s in part why there’s almost no tetanus left in the United States,” said Bernstein. “We’ve played a role in that.” The trick is to extend that way of thinking to other risk factors like a cigarette habit, a lack of housing, or a nonexistent asthma plan. Docs who trained in more recent decades, he said, are beginning to do so.

Vaca believes most academic EPs would agree that public health is a core piece of the specialty. “Not all EM academic sites see that as a primary call, [but] for us here at Yale, it certainly is,” he said. “You really can’t ignore it.”

Maybe in 20 years, said D’Onofrio, there will be a good network of primary care centers, and the ED will once again become the domain of severely sick or injured people that it was always intended to be. But that will be a long time coming. “I tell my new residents who come in, ‘Maybe in your lifetime. But not in mine.’ ” she said. “Here we are. Let’s do what we can.”