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

"The stay here is, of course, not appropriate for an old person": the perspective of healthcare providers on older patients in the emergency department

BACKGROUND

In aging societies, emergency departments (ED) face an increasing number of older, geriatric patients. Research shows that older emergency patients have a greater burden of comorbidities and a higher risk of adverse events. It has been questioned whether contemporary ED structures can meet the specific needs and characteristics of older patients. Little is known about how professional health care providers perceive and experience ED care for older patients. This study aimed to get insight into the perspective of healthcare providers working with older ED patients and to explore the challenges they experience in their daily work.

METHODS

The study used a qualitative research design with a social-constructivist perspective and a Grounded Theory based methodology. Data were collected through qualitative interviews with N = 25 healthcare providers from different urban EDs in Berlin, Germany, and adjacent healthcare institutions. Following the Ground Theory approach, categories and central themes were identified, analyzed, and interpreted to gain a comprehensive understanding of the healthcare provider perspective.

RESULTS

The interviews revealed a significant and increasing relevance of geriatric ED patients for healthcare providers. However, there was no shared definition of 'the geriatric patient'. Most interviewees found ED structures to be inadequate for older patients. They described specific challenges, such as information gathering and safety risks in the ED, as well as an increased use of resources (both time and personnel) when caring for older patients. In addition, specific problems in the collaboration with other professions and institutions were addressed, namely nursing homes, hospital wards, consultations, and the hospital social service.

CONCLUSION

Healthcare providers experience a structural mismatch between contemporary EDs and the specific needs of geriatric patients. They are aware of the vulnerabilities of geriatric patients and try to compensate for inherent structural shortcomings. Such structures and limited resources often cause practical, organizational, and ethical problems. There is a great need to develop, implement, and evaluate systematic approaches and care concepts that address the specifics of ED care for geriatric patients.

The Role of Emergency Medicine in Intimate Partner Violence: A Scoping Review of Screening, Survivor Resources, and Barriers

At the front line of our medical system and population health, emergency medicine (EM) settings serve as a commonly perceived place for safety. Survivors of intimate partner violence (IPV) may present to the emergency department (ED) with injuries, illness, or specifically to seek help for IPV. In 2018, the U.S. Preventive Services Task Force (USPSTF) recommended screening women of reproductive age for IPV across all healthcare settings. Our objective was to examine the application of IPV interventions, resource allocation, and persistent barriers for screening within the EM setting following the USPSTF recommendation. This scoping review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P). Our initial search of two major databases, PubMed and CINAHL, found 259 articles. After screening for inclusion and exclusion criteria, 15 articles met the full study criteria. Inconsistencies in screening women for IPV in EM are still prevalent. No study used the same validated IPV screening tool and four did not specify the tool. Significant barriers to screening included time constraints, patient acuity, language barriers, staff education, and inability to connect patients to resources. There is a need for more consistent IPV screening in the EM setting, which may include the development of a standardized, inclusive screening tool, as well as additional research and sharing of best practices. Advancement of IPV identification must go beyond a recommendation with greater awareness and education changes at all levels: personal, institutional, and policy.

RISE-EM: Resident Instruction in Social Emergency Medicine, a Cohort Study of a Novel Curriculum

There is recognition in the field of emergency medicine (EM) that social determinants of health (SDoH) are key drivers of patient care outcomes. Leaders in EM are calling for curricula integrating SDoH assessment and intervention, public health, and multidisciplinary approaches to EM care throughout medical school and residency. This intersection of SDoH and the emergency care system is known as social emergency medicine (SEM). Currently, there are few resources available for EM training programs to integrate this content; as a result, few EM trainees receive adequate education in SEM. To address this gap, we developed a four-part training in SEM tailored to EM residency programs and medical schools. This curriculum, known as RISE-EM (Resident Instruction in Social Emergency Medicine), uses video lectures, case examples, and group discussions to engage trainees and develop competency in providing sound care that is grounded in evidence-based principles of SEM. In the current study, we tested RISE-EM by delivering the video lectures to residents and medical students in two training programs. We administered pre- and post-course knowledge tests and a post-course participant attitudes survey to assess the acceptability and potential efficacy of the program for improving SEM knowledge and attitudes among EM learners. We found it to be both feasible and acceptable to introduce SEM content in residency conferences, with preliminary data showing statistically significant improvement in knowledge of the content and self-efficacy to apply it to their clinical practice. In summary, RISE-EM has been highly valued by EM learners and viewed as a strong supplement to their existing training, and it has been shown to successfully improve SEM knowledge and attitudes.

Acceptance of Automated Social Risk Scoring in the Emergency Department: Clinician, Staff, and Patient Perspectives

Introduction

Healthcare organizations are under increasing pressure from policymakers, payers, and advocates to screen for and address patients' health-related social needs (HRSN). The emergency department (ED) presents several challenges to HRSN screening, and patients are frequently not screened for HRSNs. Predictive modeling using machine learning and artificial intelligence, approaches may address some pragmatic HRSN screening challenges in the ED. Because predictive modeling represents a substantial change from current approaches, in this study we explored the acceptability of HRSN predictive modeling in the ED.

Methods

Emergency clinicians, ED staff, and patient perspectives on the acceptability and usage of predictive modeling for HRSNs in the ED were obtained through in-depth semi-structured interviews (eight per group, total 24). All participants practiced at or had received care from an urban, Midwest, safety-net hospital system. We analyzed interview transcripts using a modified thematic analysis approach with consensus coding.

Results

Emergency clinicians, ED staff, and patients agreed that HRSN predictive modeling must lead to actionable responses and positive patient outcomes. Opinions about using predictive modeling results to initiate automatic referrals to HRSN services were mixed. Emergency clinicians and staff wanted transparency on data inputs and usage, demanded high performance, and expressed concern for unforeseen consequences. While accepting, patients were concerned that prediction models can miss individuals who required services and might perpetuate biases.

Conclusion

Emergency clinicians, ED staff, and patients expressed mostly positive views about using predictive modeling for HRSNs. Yet, clinicians, staff, and patients listed several contingent factors impacting the acceptance and implementation of HRSN prediction models in the ED.

Social Determinants of Health and Pediatric Emergency Department Outcomes: A Systematic Review and Meta-Analysis of Observational Studies

STUDY OBJECTIVE

Social determinants of health contribute to disparities in pediatric health and health care. Our objective was to synthesize and evaluate the evidence on the association between social determinants of health and emergency department (ED) outcomes in pediatric populations.

METHODS

This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Equity Extension guidelines. Observational epidemiological studies were included if they examined at least 1 social determinant of health from the PROGRESS-Plus framework in relation to ED outcomes among children <18 years old. Effect direction plots were used for narrative results and pooled odds ratios (pOR) with 95% confidence intervals (CI) for meta-analyses.

RESULTS

Fifty-eight studies were included, involving 17,275,090 children and 103,296,839 ED visits. Race/ethnicity and socioeconomic status were the most reported social determinants of health (71% each). Black children had 3 times the odds of utilizing the ED (pOR 3.16, 95% CI 2.46 to 4.08), whereas visits by Indigenous children increased the odds of departure prior to completion of care (pOR 1.58, 95% CI 1.39 to 1.80) compared to White children. Public insurance, low income, neighborhood deprivation, and proximity to an ED were also predictors of ED utilization. Children whose caregivers had a preferred language other than English had longer length of stay and increased hospital admission.

CONCLUSION

Social determinants of health, particularly race, socioeconomic deprivation, proximity to an ED, and language, play important roles in ED care-seeking patterns of children and families. Increased utilization of ED services by children from racial minority and lower socioeconomic status groups may reflect barriers to health insurance and access to health care, including primary and subspecialty care, and/or poorer overall health, necessitating ED care. An intersectional approach is needed to better understand the trajectories of disparities in pediatric ED outcomes and to develop, implement, and evaluate future policies.

Evaluation of an emergency department opt-out provider-driven HIV and syphilis screening and linkage-to-care program

OBJECTIVE

While the effectiveness of emergency departments (ED) in screening for HIV and syphilis is understood, less is known about dual screening programs. We aim to evaluate the impact of an opt-out provider-initiated HIV and syphilis program on screening, diagnosis, and linkage to care outcomes.

METHODS

We performed a retrospective review of patients screened pre (2014-2017) and post (2017-2021) program implementation. Primary outcomes include HIV and syphilis screening, incidence of positive tests, and proportion of patients linked to care. Secondary outcomes included pre-exposure prophylaxis (PrEP) referral and successful linkage rates for HIV-negative syphilis-positive patients.

RESULTS

Pre-implementation, 882 HIV tests were performed, of which 22 (2.49%) were new cases and 18 (81.82%) were linked to care; 754 syphilis tests were performed, of which 33 (4.38%) were active infections and 30 (90.91%) were treated. No eligible patients received PrEP referral. Post-implementation, 12,999 HIV tests were performed, of which 73 (0.56%) were new cases and 55 (75.34%) were linked to care; 10,885 syphilis tests were performed, of which 216 (1.98%) were active infections and 188 (87.04%) were treated. 25 (9.09%) eligible patients were referred for PrEP, and four (16.0%) attended their appointment.

CONCLUSIONS

Post-implementation, there was a 1373.81% and 1343.63% increase in screening, and a 231.82% and 554.55% increase in positive cases of HIV and syphilis, respectively. Dual screening programs can be successfully implemented within the existing ED framework to increase screening and early detection for HIV and syphilis.

Structured and unstructured social risk factor documentation in the electronic health record underestimates patients' self-reported risks

OBJECTIVES

National attention has focused on increasing clinicians' responsiveness to the social determinants of health, for example, food security. A key step toward designing responsive interventions includes ensuring that information about patients' social circumstances is captured in the electronic health record (EHR). While prior work has assessed levels of EHR "social risk" documentation, the extent to which documentation represents the true prevalence of social risk is unknown. While no gold standard exists to definitively characterize social risks in clinical populations, here we used the best available proxy: social risks reported by patient survey.

MATERIALS AND METHODS

We compared survey results to respondents' EHR social risk documentation (clinical free-text notes and International Statistical Classification of Diseases and Related Health Problems [ICD-10] codes).

RESULTS

Surveys indicated much higher rates of social risk (8.2%-40.9%) than found in structured (0%-2.0%) or unstructured (0%-0.2%) documentation.

DISCUSSION

Ideally, new care standards that include incentives to screen for social risk will increase the use of documentation tools and clinical teams' awareness of and interventions related to social adversity, while balancing potential screening and documentation burden on clinicians and patients.

CONCLUSION

EHR documentation of social risk factors currently underestimates their prevalence.

A descriptive study of screening and navigation on health-related social needs in a safety-net hospital emergency department

BACKGROUND

Health-related social needs (HRSN) have been associated with worse clinical outcomes, increased Emergency Department (ED) utilization and higher healthcare costs. The ED is uniquely positioned to bring HRSN screening to the bedside and develop effective interventions. We evaluated whether navigation services for high-risk patients led to the resolution of HRSN.

METHODS

Navigators screened a convenience sample of patients for HRSN with the Accountable Health Communities Screening Tool from October 2019 to January 2022. Patients with HRSN were considered high-risk if they had at least two ED visits in the previous 12 months. Patients who were high-risk were eligible for navigation including community referrals and one-on-one close follow-up. The HRSN status (resolved, in-progress, unable to resolve) was queried from the Centers for Medicare and Medicaid database. The state hospital association provided data on ED visits and inpatient hospitalizations within 6 months of the screening visit.

RESULTS

Of 185,470 ED visits, HRSN screening occurred in 4050 (2%). HRSN were self-reported in 48% (1944) of patient visits, with 71% of these (1379) considered high-risk. 15% of high-risk patients with HRSN opted out of navigation. Food insecurity was the most identified HRSN (35%) followed by housing instability (26%), transportation needs (24%) and utility assistance (15%). Food insecurity was the most resolved HRSN (39%, in-progress 32%) followed by utility assistance (37%, in-progress 26%), transportation needs (35%, in-progress 35%) and housing instability (28%, in-progress 36%). High-risk visits in which the patient or guardian accepted navigation were less likely to be associated with an ED visit within 6 months of the screening visit (51%) compared to high-risk patients in which the patient or guardian opted out of navigation (61%, p < 0.001), but there was no difference in inpatient hospitalizations (p = 0.427).

CONCLUSIONS

During the study period, one-third of HRSN were successfully resolved with another one-third in-progress. Navigation in high-risk patients was associated with fewer subsequent ED visits.

Social Determinants of Health Are Associated With Visits for Ambulatory Care Sensitive Conditions

OBJECTIVES

Population health experts have described the link between social factors and health, but few studies link specific social needs to disease processes. Nationwide Children's Hospital implemented a universal, annual screener for social determinants of health (SDH) in 2018. Early analyses have shown that patients identifying an SDH need were more likely to have an emergency department (ED) or inpatient stay. The objective of this study is to identify links between SDH and ED presentation for ambulatory care sensitive conditions (ACSCs).

METHODS

This was a retrospective observational study of children aged 0-21 years receiving care at Nationwide Children's Hospital from 2018 to 2021 that were screened for SDH. Acute care utilization within 6 months of screener completion, sociodemographic, and clinical data were collected via EPIC data extraction. Patients that completed screening tool for the first time in the ED were excluded to minimize selection bias. Logistic regression was used to analyze the association between ED presentation for ACSCs and SDH needs.

RESULTS

A total of 108,346 social determinants screeners were included with 9% of screeners identifying a need. Five percent of the population expressed food needs, 4% transportation needs, 3% utility needs, and 1% housing needs. Eighteen percent of patients had an ED visit for ACSC, with the most common complaints being upper respiratory infections and asthma. Having any SDH need was associated with ED visits for ACSCs (odds ratio, 1.12; 95% confidence interval, 1.06-1.18). Needs in all domains were significantly associated with increased visits for ACSCs; however, patients with housing needs had the highest odds of utilization (odds ratio, 1.25; confidence interval, 1.11-1.41).

CONCLUSIONS

The odds of ED presentation for ACSCs are higher in patients with expressed social needs. Further delineating the connections between specific SDH and health outcomes can inform timely and appropriate interventions.

Survey of Vaccine Hesitancy in Patients Visiting Three Tertiary-care Emergency Departments in Southeast Louisiana

Objectives

Vaccine hesitancy has been a barrier to achieving herd immunity during the coronavirus 2019 (COVID-19) pandemic. Having low socioeconomic status and education levels, and being a person of color, are associated with higher COVID-19 infection risk and worse outcomes. These same groups are associated with higher vaccine hesitancy. The state of Louisiana has one of the lowest vaccination rates in the country. In this study we aimed to identify demographic, perspective, and health behavior factors associated with vaccine hesitancy in emergency departments (ED) in Southeast Louisiana.

Methods

A cross-sectional survey was distributed at three tertiary-care hospital EDs. Patients >18 years old and not in acute distress were recruited between April-July 2021. The 37-item questionnaire addressed socioeconomic demographics, social determinants of health, COVID-19 safety practices, thoughts and perceptions on COVID-19 and vaccines, sources of COVID-19 and vaccine information, and trust in the healthcare system.

Results

Overall, 247 patients completed our survey. Of those, 29.6% reported they were vaccine hesitant. These respondents were significantly more likely, when compared to vaccine-acceptant respondents, to never have married, to have some college education, make less than <$25,000 in household earnings yearly, be unsure whether vaccines prevent disease, not have discussed the COVID-19 vaccine with their primary care doctor, and to prefer to do their own research for COVID-19 vaccine information. We observed no statistically significant differences based on gender, race/ethnicity, parental status, area of living, or their perceived risk of needing hospitalization for treatment or dying from the virus.

Conclusion

Vaccine hesitancy was associated with multiple socioeconomic factors, perspectives, and beliefs. Vaccine-hesitant individuals were more uncertain about the safety of the COVID-19 vaccine, the feasibility of obtaining the vaccine, and its efficacy. Public health interventions aimed at these findings and improving public trust in healthcare systems are needed to increase vaccine acceptance.

Social Determinants of Health in EMS Records: A Mixed-methods Analysis Using Natural Language Processing and Qualitative Content Analysis

Introduction: Social determinants of health (SDoH) are known to impact the health and well-being of patients. However, information regarding them is not always collected in healthcare interactions, and healthcare professionals are not always well-trained or equipped to address them. Emergency medical services (EMS) professionals are uniquely positioned to observe and attend to SDoH because of their presence in patients' environments; however, the transmission of that information may be lost during transitions of care. Documentation of SDoH in EMS records may be helpful in identifying and addressing patients' insecurities and improving their health outcomes. Our objective in this study was to determine the presence of SDoH information in adult EMS records and understand how such information is referenced, appraised, and linked to other determinants by EMS personnel. Methods: Using EMS records for adult patients in the 2019 ESO Data Collaborative public-use research dataset using a natural language processing (NLP) algorithm, we identified free-text narratives containing documentation of at least one SDoH from categories associated with food, housing, employment, insurance, financial, and social support insecurities. From the NLP corpus, we randomly selected 100 records from each of the SDoH categories for qualitative content analysis using grounded theory. Results: Of the 5,665,229 records analyzed by the NLP algorithm, 175,378 (3.1%) were identified as containing at least one reference to SDoH. References to those SDoH were centered around the social topics of accessibility, mental health, physical health, and substance use. There were infrequent explicit references to other SDoH in the EMS records, but some relationships between categories could be inferred from contexts. Appraisals of patients' employment, food, and housing insecurities were mostly negative. Narratives including social support and financial insecurities were less negatively appraised, while those regarding insurance insecurities were mostly neutral and related to EMS operations and procedures. Conclusion: The social determinants of health are infrequently documented in EMS records. When they are included, they are infrequently explicitly linked to other SDoH categories and are often negatively appraised by EMS professionals. Given their unique position to observe and share patients' SDoH information, EMS professionals should be trained to understand, document, and address SDoH in their practice.

Social Determinants of Health Screening at an Urban Emergency Department Urgent Care During COVID-19

INTRODUCTION

Social determinants of health (SDoH) impact patients' health outcomes, yet screening methods in emergency departments (ED) are not consistent or standardized. The SDoH-related health disparities may have widened during the coronavirus 2019 (COVID-19) pandemic, especially among patients who primarily receive their medical care in EDs. We sought to identify SDoH among ED urgent care patients during the COVID-19 pandemic at an urban safety-net hospital, assess the impact of the pandemic on their SDoH, study the feasibility of SDoH screening and resource referrals, and identify preferred methods of resource referrals and barriers to accessing resources.

METHODS

Research assistants screened ED urgent care patients using a validated SDoH screener, inquiring about the impact of COVID-19 on their SDoH. A printed resource guide was provided. Two weeks later, a follow-up telephone survey assessed for barriers to resource connection and patients' preferred methods for resource referrals. This study was deemed exempt by our institutional review board.

RESULTS

Of the 418 patients presented with a screener, 414 (99.0%) patients completed the screening. Of those screened, 296 (71.5%) reported at least one adverse SDoH, most commonly education (38.7%), food insecurity (35.3%), and employment (31.0%). Housing insecurity was reported by 21.0%. Over half of patients (57.0%) endorsed COVID-19 affecting their SDoH. During follow-up, 156 of 234 (67%) attempted calls were successful and 36/156 (23.1%) reported attempting to connect with a resource, with most attempts made for stable housing (11.0%) and food (7.7%). Reasons for not contacting the provided resources included lack of time (37.8%) and forgetting to do so (26.3%). Patients preferred resource guides to be printed (34.0%) and sent via text message to their mobile devices (25.6%).

CONCLUSION

Many urgent care patients of this urban ED reported at least one adverse SDoH, the majority of which were exacerbated by the COVID-19 pandemic. This finding further emphasizes the need to allocate more resources to standardize and expand SDoH screening in EDs. Additionally, hospitals should increase availability of printed or electronic SDoH resource guides, resource navigators, and interpreters both during and after ED visits.

"To teach or not to teach- that is the question" The educational and clinical impact of introducing an outcome based, modular curriculum in Social Emergency Medicine (SEM) at a private tertiary care center in Karachi, Pakistan

INTRODUCTION

An enhanced knowledge of Emergency Medicine (EM) personnel regarding negative Social Determinants of Health (SDH) can impact EM service provision in a resource limited country like Pakistan. Interventions to build capacity in identifying and addressing these SDH through education in Social Emergency Medicine (SEM) can be one of the ways in which EM key performance indicators (KPIs) can be improved.

METHOD

A SEM based curriculum was administered to the EM residents at a tertiary care center in Karachi, Pakistan. Pre, post and delayed post-test was conducted for knowledge of EM residents and analyzed using Repeated Measures ANOVA (RMANOVA). Clinical impact of this intervention was assessed through the ability of the residents to identify the patients' SDH and determining appropriate disposition. Comparison of the bounce-back of patients in the pre-intervention (2020) and post-intervention year (2021) year was appreciated to see the clinical impact of this intervention.

RESULT

A significant improvement was seen in post intervention (p < 0.001) and follow up knowledge (p < 0.001) of residents regarding negative SDH. Bounce-back rate was higher in the pre-SEM curriculum (43%) as compared to the post-SEM curriculum year (27.7%). Post-intervention, the residents were able to identify the unique Pakistani SDH, however appropriate patient disposition needs further reinforcement.

CONCLUSION

The study highlights the beneficial impact of an educational intervention in SEM upon the knowledge of EM residents and the bounce-back of patients in the emergency department (ED) of a low resource setup. This educational intervention can be scaled up to other EDs across Pakistan for potential improvement in knowledge, EM process flow and KPIs.

Community-Academic Advocacy to Improve Shelter Access for Families Experiencing Homelessness

A 2012 Massachusetts shelter eligibility regulation required many families to spend a night in a location "not meant for human habitation" before qualifying for the state-run shelter system, and many families experiencing homelessness stayed in pediatric emergency departments (EDs) overnight to meet this requirement. ED clinicians initially recognized an increase in ED visits for homelessness after this regulation and began compiling and sharing stories with key institutional and community partners and stakeholders. To bolster advocacy efforts, the authors collected data on the magnitude of the problem and its associated health care costs. Guided by the policy knowledge of community partners, the authors leveraged the expertise and advocacy power of clinicians to share these data and stories with legislators via written and oral testimony, community events, and the media. Academic publication lent additional credibility and exposure to their research. In 2019, the Massachusetts Legislature passed budget language to overturn the 2012 shelter eligibility regulation. However, despite this policy victory, some families continue to present to EDs for homelessness. Therefore, current advocacy efforts have shifted focus toward implementation and enforcement of the new policy, monitoring issues, and developing new programmatic responses. In this advocacy case study, we illustrate how clinicians have unique abilities to serve as effective advocates for social policy change using a framework of strategies including storytelling, coalition building, tailored communication, and data sharing. Partnering with existing advocacy networks within their institution and community enhances the advocacy efforts of all stakeholders to influence social and health outcomes for children and families.

The Impact of an Experiential Social Medicine Curriculum in an Emergency Medicine Residency Training Program: Mixed-methods Curricular Evaluation

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Defining the observable processes of patient care related to social determinants of health

INTRODUCTION

An understanding of social determinants of health (SDH) and patients' social circumstances is recommended to deliver contextualised care. However, the processes of patient care related to SDH in clinical settings have not been described in detail. Observable practice activities (OPAs) are a collection of learning objectives and activities that must be observed in daily practice and can be used to describe the precise processes for professionals to follow in specific situations (process OPA.) METHODS: We used a modified Delphi technique to generate expert consensus about the process OPA for patient care related to SDH in primary care settings. To reflect the opinions of various stakeholders, the expert panel comprised clinical professionals (physicians, nurses, public health nurses, social workers, pharmacists and medical clerks), residents, medical students, researchers (medical education, health care, sociology of marginalised people), support members for marginalised people and patients. The Delphi rounds were conducted online. In Round 1, a list of potentially important steps in the processes of care was distributed to panellists. The list was modified, and one new step was added. In Round 2, all steps were acknowledged with few modifications.

RESULTS

Of 63 experts recruited, 61 participated, and all participants completed the Delphi rounds. A total of 14 observable steps were identified, which were divided into four components: communication, practice, maintenance and advocacy. The importance of ongoing patient-physician relationships and collaboration with professionals and stakeholders was emphasised for the whole process of care.

DISCUSSION

This study presents the consensus of a variety of experts on the process OPA for patient care related to SDHs. Further research is warranted to investigate how this Communication-Practice-Maintenance-Advocacy framework could affect medical education, quality of patient care, and patient outcomes.

The Interplay of Trust and Subjective Norms in Telemedicine Adoption by a Minority Community at Einstein Medical Center Philadelphia

Telemedicine is not released into a social vacuum. In some communities - such as the underserved, low income, mostly minority community served by Einstein Medical Center Philadelphia (EMCP) - the social context presents the medical center with unique challenges centered on a strong community sense of historical discrimination. That context is manifested in people being less inclined to trust symbols of external authority and in their strong reliance on subjective norms. Analyzing 540 survey responses by EMCP emergency department (ED) patients shows that trust in the EMCP portal was the strongest predictor of its acceptance. Being an African American had no effect on portal acceptance compared to others in the community. Importantly, there was a negative interaction effect of subjective norms and trust on portal acceptance - meaning that increasing this trust can reduce the importance of subjective norms or, alternatively, that lower subjective norms may increase the importance of trust in determining acceptance. This moderation may have very practical implications for EMCP because, while it might be challenging for EMCP to change long established subjective norms, it is within their power to increase trust in the portal. Theoretical and practical implications are discussed.

Discharge Navigator: Implementation and Cross-Sectional Evaluation of a Digital Decision Tool for Social Resources upon Emergency Department Discharge

Introduction

Many patients have unaddressed social needs that significantly impact their health, yet navigating the landscape of available resources and eligibility requirements is complex for both patients and clinicians.

Methods

Using an iterative design-thinking approach, our multidisciplinary team built, tested, and deployed a digital decision tool called “Discharge Navigator” (edrive.ucsf.edu/dcnav) that helps emergency clinicians identify targeted social resources for patients upon discharge from the acute care setting. The tool uses each patient’s clinical and demographic information to tailor recommended community resources, providing the clinician with action items, pandemic restrictions, and patient handouts for relevant resources in five languages. We implemented two modules at our urban, academic, Level I trauma center.

Results

Over the 10-week period following product launch, between 4–81 on-shift emergency clinicians used our tool each week. Anonymously surveyed clinicians (n = 53) reported a significant increase in awareness of homelessness resources (33% pre to 70% post, P<0.0001) and substance use resources (17% to 65%, P<0.0001); confidence in accessing resources (22% to 74%, P<0.0001); knowledge of eligibility criteria (13% to 75%, P<0.0001); and ability to refer patients always or most of the time (11% to 43%, P<0.0001). The average likelihood to recommend the tool was 7.8 of 10.

Conclusion

Our design process and low-cost tool may be replicated at other institutions to improve knowledge and referrals to local community resources.

Social Emergency Medicine: Capitalizing on the Pediatric Emergency Department Visit to Screen and Connect Patients and Families to Community Resources

OBJECTIVE

To describe the social needs of families screened by the Community Health Advocates Team (CHAT) Desk, situated within a pediatric emergency department (PED); and to evaluate the effectiveness of this help desk in connecting families to community resources.

METHODS

Trained undergraduates, onsite in the PED 30 hours/week during daytime and evening hours, weekdays and weekends, screened a convenience sample of families of patients in the PED for social needs, and provided information on available community resources. Families were offered a follow-up phone call several weeks after their PED visit to assess program satisfaction and success, and identify remaining social needs.

RESULTS

Between January 2019 and March 2020, CHAT Desk screened and assisted 682 families. CHAT routinely provided resources about free outdoor recreational activities for families, but after that, the most commonly provided informational resources pertained to: health care (n = 200), housing (n = 143), and food (n = 137). Of families who completed the follow-up phone call (n = 294), almost half (n = 134, 46%) reported being able to contact at least one of the resources; 100 reported that the resource was able to assist them, and 99 families planned to continue using the resource. When asked about satisfaction, 93% (n = 274) reported being very satisfied or somewhat satisfied with CHAT; 94% (n = 276) said they would recommend it to others.

CONCLUSIONS

The PED of a busy tertiary care children's hospital is an opportune location to screen families for social needs, and provide them with information on requested community resources.

HIV Testing at Visits to US Emergency Departments, 2018

BACKGROUND

An early HIV diagnosis improves patient outcomes, reduces the burden of undiagnosed HIV, and limits transmission. There is a need for an updated assessment of HIV testing rates in the emergency department (ED).

SETTING

The National Hospital Ambulatory Medical Care Survey sampling ED visits were weighted to give an estimate of ED visits across all US states in 2018.

METHODS

We analyzed patients aged 13-64 years without known HIV and estimated ED visits with HIV testing and then stratified by race, ethnicity, and region. Descriptive statistics and mapping were used to illustrate and compare patient, visit, and hospital characteristics for visits with HIV testing.

RESULTS

Of 83.0 million weighted visits to EDs in 2018 by patients aged 13-64 years without a known HIV infection (based on 13,237 National Hospital Ambulatory Medical Care Survey sample visits), HIV testing was performed in 1.05% of visits. HIV testing was more frequent for patients aged 13-34 years compared with that for patients aged 35-64 years (1.32% vs. 0.82%, P = 0.056), Black patients compared with that for White and other patients (1.73% vs. 0.79% and 0.41%, P = 0.002), Hispanic or Latino patients compared with that for non-Hispanic or Latino patients (2.18% vs. 0.84%, P = 0.001), and patients insured by Medicaid compared with that for patients insured by private or other insurance (1.71% vs. 0.64% and 0.96%, P = 0.003). HIV testing rates were the highest in the Northeast (1.72%), followed by the South (1.05%).

CONCLUSIONS

HIV testing occurred in a minority of ED visits. There are differences in rates of HIV testing by race, ethnicity, and location. Although rates of testing have increased, rates of ED-based HIV testing remain low.

Patient views on emergency department screening and interventions related to housing

Objectives Emergency departments (EDs) serve as a health care "safety net" and may be uniquely suited to screening for and addressing patients' unmet social needs. We aimed to better understand patient perspectives on ED-based screening and interventions related to housing instability, as a step toward improving future efforts. Methods We present findings from a qualitative study using in-depth, one-on-one interviews with ED patients who had become homeless in the past 6 months. Qualitative interviewees were asked their thoughts on ED staff asking about and helping to address homelessness and housing issues. Interviews were professionally transcribed verbatim. Multiple coders identified interview text segments focused on ED-based housing screening and intervention, which were then independently analyzed thematically and discussed to reach consensus. Researchers also categorized each participant's overall opinion on ED housing screening and interventions as positive, neutral, or negative. Results Qualitative interviews were conducted with 31 patients. Four themes related to ED-based housing screening and interventions emerged: (1) patients generally welcome ED staff/providers asking about and assisting with their housing situation, with caveats around privacy and respect; (2) ED conversations about housing have potential benefits beyond addressing unmet housing needs; (3) patients may not consider the ED as a site to obtain help with housing; (4) patients' experiences navigating existing housing services can inform best approaches for the ED. Most participants expressed overall positive views of ED staff/providers asking patients about their housing situation. Conclusions Study participants generally felt positively about screening and interventions for housing in the ED. Insights from this study can inform future ED-based housing instability screening and interventions.

Strategies to Integrate the Practice of Social Emergency Medicine Into Routine Patient Care

The Research to Practice column focuses on improving the research critique skills of advanced practice providers and to assist with the translation of research into practice. In this issue, we discuss the findings of a 2-phase, mixed-methods feasibility investigation conducted by A. S. Wallace et al. (2020) that developed and evaluated a screening process to identify social needs/risks for emergency department (ED) patients and connect them to community-based resources upon discharge. The results revealed that patients with identified social needs and referred to community resources tended to utilize the ED more than those without needs. This suggests the need for EDs to implement a standardized screening tool for social determinants of health (SDOH) on all ED patients for improved patient outcomes. Findings also highlighted a need for EDs to provide staff training and competence in the areas of patient communication and SDOH.

Social care practices and perspectives among U.S. pediatric emergency medicine fellowship programs

BACKGROUND

The emergence of social emergency medicine-the incorporation of social context into the structure and practice of emergency care-has brought forth greater embracement of the social determinants of health by medical professionals, yet workforce practices and training have remained elusive. Academic literature particularly in the field of pediatric emergency medicine (PEM) fellowship training is lacking relative to general pediatrics and adult emergency medicine.

METHODS

The primary objective of this study was to assess the social care knowledge, perspectives, and training of PEM program directors (PDs) and fellows across a national cross-sectional sample. A secondary aim was to uncover key actionable areas for the development of social care curricula in PEM training programs. A social care practices assessment tool was developed via snowball sampling interviews among clinician researcher experts and disseminated to PEM PDs and fellows nationally in accredited academic PEM training institutions.

RESULTS

A total of 153 participants-44 PDs (49% response rate) and 109 fellows (28%)-completed the assessment tool. Responses among PDs and fellows were highly concordant. Only 12% reported regular use of a standardized social needs screening tool. The majority felt unprepared to assist families with social needs and less than half felt comfortable talking to families about social need. At the same time, social care was highly valued by 73% of participants. All participants felt that providing social care training during PEM fellowship would be beneficial. PDs and fellows identified five priority areas for PEM curricular development.

CONCLUSIONS

PEM PDs and fellows have an overall favorable perception of social care yet report significant deficits in current practice organization and training. This study is part of a larger national collaborative advocacy project to organize and advance social care delivery across academic PEM training institutions through evidence-based approaches, best practices, and expert consensus.

Involuntary Psychiatric Hospitalization: How Patient Characteristics Affect Decision-Making

Emergency department (ED) psychiatrists face the consequential decision to pursue involuntary inpatient psychiatric admission. Research on the relationship between patient characteristics and the decision to pursue involuntary psychiatric admission is limited. Using data from 2017 to 2018 at an urban Los Angeles hospital, we used generalized linear mixed effects models to compare patients who were involuntarily admitted to inpatient psychiatry to patients who were discharged from the ED. Of 2,448 patients included in the study, 1,217 (49.7%) were involuntarily admitted to inpatient psychiatry and 1,231 (50.3%) were discharged. After controlling for sociodemographic characteristics, admitted patients were more likely to have been brought in by police, have had an organized suicide plan or recent attempt, physical signs of harm, psychosis, depression or hopelessness, lack social support, have diagnoses of schizophrenia or bipolar disorder, and be administered injectable psychotropic medications. Stimulant use, a diagnosis of anxiety or developmental disorders, and recent medical ED utilization were associated with discharge. Psychiatrists pursued involuntarily psychiatric hospitalization based on factors potentially indicative of dangerousness, leaving patients, particularly those with recent substance use, without immediate access to treatment. Policies should focus on increasing follow up to high quality, voluntary outpatient mental health care.

Healthy food prescription incentive programme for adults with type 2 diabetes who are experiencing food insecurity: protocol for a randomised controlled trial, modelling and implementation studies

INTRODUCTION

The high cost of many healthy foods poses a challenge to maintaining optimal blood glucose levels for adults with type 2 diabetes mellitus who are experiencing food insecurity, leading to diabetes complications and excess acute care usage and costs. Healthy food prescription programmes may reduce food insecurity and support patients to improve their diet quality, prevent diabetes complications and avoid acute care use. We will use a type 2 hybrid-effectiveness design to examine the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) of a healthy food prescription incentive programme for adults experiencing food insecurity and persistent hyperglycaemia. A randomised controlled trial (RCT) will investigate programme effectiveness via impact on glycosylated haemoglobin (primary outcome), food insecurity, diet quality and other clinical and patient-reported outcomes. A modelling study will estimate longer-term programme effectiveness in reducing diabetes-related complications, resource use and costs. An implementation study will examine all RE-AIM domains to understand determinants of effective implementation and reasons behind programme successes and failures.

METHODS AND ANALYSIS

594 adults who are experiencing food insecurity and persistent hyperglycaemia will be randomised to a healthy food prescription incentive (n=297) or a healthy food prescription comparison group (n=297). Both groups will receive a healthy food prescription. The incentive group will additionally receive a weekly incentive (CDN$10.50/household member) to purchase healthy foods in supermarkets for 6 months. Outcomes will be assessed at baseline and follow-up (6 months) in the RCT and analysed using mixed-effects regression. Longer-term outcomes will be modelled using the UK Prospective Diabetes Study outcomes simulation model-2. Implementation processes and outcomes will be continuously measured via quantitative and qualitative data.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Calgary and the University of Alberta. Findings will be disseminated through reports, lay summaries, policy briefs, academic publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04725630.

PROTOCOL VERSION

Version 1.1; February 2022.

Predictors of Elevated Social Risk in Pediatric Emergency Department Patients and Families

OBJECTIVE

This study aimed to identify predictors of high unmet social needs among pediatric emergency department (ED) patients. We hypothesized that obesity, frequent nonurgent visits, reported food insecurity, or an at-risk chief complaint (CC) would predict elevated social risk.

METHODS

We administered a tablet-based survey assessing unmet social needs in 13 domains to caregivers of patients aged 0 to 17 years presenting to an urban pediatric ED. Responses were used to tabulate a social risk score (SRS). We performed multivariable logistic regression to measure associations between a high SRS (≥3) and obesity, frequent nonurgent visits, food insecurity, or an at-risk CC (physical abuse, sexual abuse, assault, mammalian bites, reproductive/sexual health complaints, intoxication, ingestion/poisoning, psychiatric/behavioral complaints, or any complaint triaged as "least urgent").

RESULTS

Five hundred seventy caregivers completed the survey. Eighty-one percent reported at least one unmet social need, and 33% identified ≥3 social needs. Caregivers of patients with an at-risk CC had twice the odds of a high SRS (adjusted odds ratio [aOR], 1.8; 95% confidence interval [CI], 1.0-3.3). Caregivers of patients reporting food insecurity had 4 times the odds of a high SRS (aOR, 4.3; 95% CI, 2.5-7.3). Neither obesity (aOR, 1.5; 95% CI, 0.9-2.6) nor frequent nonurgent visits (aOR, 0.9; 95% CI, 0.4-1.9) were predictive of a high SRS.

CONCLUSIONS

Unmet social needs are prevalent among caregivers of pediatric ED patients, supporting universal screening in this population. Patients with an at-risk CC or reported food insecurity might benefit from proactive intervention. Future studies should examine optimal methods for ED-based interventions that address social determinants of health.

Care transitions and social needs: A Geriatric Emergency care Applied Research (GEAR) Network scoping review and consensus statement

OBJECTIVES

Individual-level social needs have been shown to substantially impact emergency department (ED) care transitions of older adults. The Geriatric Emergency care Applied Research (GEAR) Network aimed to identify care transition interventions, particularly addressing social needs, and prioritize future research questions.

METHODS

GEAR engaged 49 interdisciplinary stakeholders, derived clinical questions, and conducted searches of electronic databases to identify ED discharge care transition interventions in older adult populations. Informed by the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) framework, data extraction and synthesis of included studies included the degree that intervention components addressed social needs and their association with patient outcomes. GEAR convened a consensus conference to identify topics of highest priority for future care transitions research.

RESULTS

Our search identified 248 unique articles addressing care transition interventions in older adult populations. Of these, 17 individual care transition intervention studies were included in the current literature synthesis. Overall, common care transition interventions included coordination efforts, comprehensive geriatric assessments, discharge planning, and telephone or in-person follow-up. Fourteen of the 17 care transition intervention studies in older adults specifically addressed at least one social need within the PRAPARE framework, most commonly related to access to food, medicine, or health care. No care transition intervention addressing social needs in older adult populations consistently reduced subsequent health care utilization or other patient-centered outcomes. GEAR stakeholders identified that determining optimal outcome measures for ED-home transition interventions was the highest priority area for future care transitions research.

CONCLUSIONS

ED care transition intervention studies in older adults frequently address at least one social need component and exhibit variation in the degree of success on a wide array of health care utilization outcomes.

Histories of trauma: A qualitative analysis of lifetime traumatic experiences among emergency department patients

OBJECTIVE

Emergency medicine clinicians are excellent at identifying and treating physical trauma as a chief complaint, but are often unaware of patients' previous experiences of trauma. The purpose of this study was to describe emergency department (ED) patients' lifetime experiences of trauma.

METHODS

The investigative team used framework analysis to examine 1,282 participants' open-ended responses to the Vera Institute's Trafficking Victim Identification Tool questions. Of these, 204 participants were found to have experienced at least one form of trauma; none of these participants were assessed positive for a human trafficking experience.

RESULTS

From 204 participants, 343 instances of trauma were recorded and analyzed. Of the 204 patient-participants who reported trauma, 96 experienced one form of trauma and 108 experienced two or more. Three major themes emerged: work trauma (experiences of trauma originating in the workplace), coercion (being manipulated into activities), and trauma connections (some forms of trauma were commonly experienced with other kinds of trauma). A fourth, less prominent, theme was disclosure as witness (participants witnessing trauma).

CONCLUSION

ED patients have experienced many forms of lifetime trauma and, in this study, were willing to share about their experiences while in the acute care setting. Given the common experience of trauma among the ED patients in this investigation, more work is needed to examine if and how trauma-informed care principles should be employed in the ED. Additionally, the ED may be an underutilized data source for researchers seeking participants with experiences of trauma and/or a point of connection for trauma survivors to be linked to trauma care services.

Brief Motivational Intervention to Improve Adolescent Sexual Health Service Uptake: A Pilot Randomized Controlled Trial in the Emergency Department

OBJECTIVE

To test the hypothesis that our motivational sexual health intervention (SexHealth) would increase health service uptake when compared with control.

STUDY DESIGN

In a randomized controlled trial at a pediatric emergency department, sexually active adolescents received either the SexHealth intervention or printed materials (control). SexHealth, delivered by a health educator, was a tablet-based, interactive intervention that included motivational techniques to promote sexual health, condom skills training, and tailored service recommendations. We assessed feasibility (eg, intervention completion, recommendations discussed, intervention duration), acceptability (ie, proportion enrolled and rating intervention as satisfactory), and efficacy; secondary outcomes were sexual and care-seeking behaviors at 6 months. The efficacy outcome was completion of ≥1 service at the index visit (ie, counseling, condoms, emergency contraception for immediate or future use, pregnancy/sexually transmitted infection/HIV testing, sexually transmitted infection treatment, and clinic referral).

RESULTS

We enrolled 91 participants (intervention = 44; control = 47). The intervention demonstrated high feasibility: 98% completed the intervention; 98% of recommendations were discussed; duration was 24.6 minutes, and acceptability: 87% of eligible adolescents enrolled and 93% rated the intervention as fairly to very satisfactory. Compared with controls, intervention participants were more likely to complete ≥1 service (98% vs 70%, P < .001) including HIV testing (33% vs 6%, P = .02) and emergency contraception (80% vs 0%, P = .01). There were no meaningful differences between arms in behaviors at follow-up.

CONCLUSIONS

SexHealth was feasible to implement, acceptable to youth, and resulted in increased uptake of health services during the emergency department visit. Additional strategies may be needed to extend intervention effects over time.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; NCT03341975.

Screening for health-related social needs in the emergency department: Adaptability and fidelity during the COVID-19 pandemic

Background and objectives

We sought to evaluate a screening and referral program for health-related social needs (HRSN) in our ED. Our goals were to (1) quantify successful screenings prior to and during the initial peak of the pandemic, and (2) describe the HRSNs identified.

Methods

We performed an observational analysis of ED-based screening for HRSN in Medicare and Medicaid patients at our large urban safety-net hospital. Screening was performed by patient navigators utilizing the ten question, validated Accountable Health Communities (AHC) Screening Tool, which screens for food insecurity, housing instability, transportation needs and utility assistance and interpersonal safety. Patients who screened positive for HRSN were provided with handouts listing community resources. For patients with two or more self-reported ED visits in the last 12 months and any identified HRSN, ongoing navigation after discharge was provided utilizing community resource referrals. During the pre-pandemic period from November 1, 2019 – January 31, 2020, screening occurred in-person. Screening during the pandemic from March 1, 2020 – May 31, 2020 occurred remotely via telephone. Descriptive statistics including frequency rates and percentages were calculated. Successful screening was defined as completing the screening survey with a navigator and being triaged to either no assistance, resource handouts, or navigation services.

Results

Among the adult and pediatric patients screened for HRSN, 158 (16%) qualified for community resource handouts and 440 (44.4%) qualified for patient navigator services. The proportion of patients receiving both resources and care navigation remained similar in the pre- and post-periods of the study, at 227 (45%) and 213 (43.9%) respectively. However, the proportion of ED patients with a HRSN need doubled from 56 (11.1%) in the pre-period to 102 (21%) in the post-period. Food insecurity was the most identified HRSN in both the pre-pandemic period (27.3%) and during the pandemic (35.8%).

Conclusion

We found that remote HRSN screening for ED patients during the COVID-19 pandemic resulted in similar proportions of successfully completed screenings compared to pre-pandemic efforts. This demonstrates the feasibility of utilizing alternative methods of screening and referral to community resources from the ED, which could facilitate this type of intervention in other EDs. During the pandemic HRSN increased, likely reflecting the economic impact of the pandemic.

Social relationships, homelessness, and substance use among emergency department patients

BACKGROUND

Emergency department (ED) patients commonly experience both substance use and homelessness, and social relationships impact each in varied ways not fully captured by existing quantitative research. This qualitative study examines how social relationships can precipitate or ameliorate homelessness and the connection (if any) between substance use and social relationships among ED patients experiencing homelessness.

METHODS

As part of a broader study to develop ED-based homelessness prevention interventions, we conducted in-depth interviews with 25 ED patients who used alcohol or drugs and had recently become homeless. We asked patients about the relationship between their substance use and homelessness. Interviews were recorded, transcribed, and coded line-by-line by investigators. Final codes formed the basis for thematic analysis through consensus discussions.

RESULTS

Social relationships emerged as focal points for understanding the four major themes related to the intersection of homelessness and substance use: (1) Substance use can create strain in relationships; (2) Help is there until it's not; (3) Social relationships can create challenges contributing to substance use; and (4) Reciprocal relationship of substance use and isolation. Sub-themes were also identified and described.

CONCLUSIONS

The association between substance use and homelessness is multifaceted and social relationships are a complex factor linking the two. Social relationships are often critical for homelessness prevention, but they are impacted by and reciprocally affect substance use. ED-based substance use interventions should consider the high prevalence of homelessness and the impact of social relationships on the interaction between homelessness and substance use.

An analysis of social determinants of health and structural competency training in global emergency medicine fellowship programs in the United States

BACKGROUND

Clinicians must be aware of the structural forces that affect their patients to appropriately address their unique health care needs. This study aimed to assess the participation of global emergency medicine (GEM) fellowship programs in formal social determinants of health (SDH) and structural competency (SC) training to evaluate the existence and procedures of such programs.

METHODS

A cross-sectional study conducted with a short, online survey with questions regarding the presence of curriculum focused on SDH, SC, educational metrics, and the desire for further formal training in this domain was sent to all 25 GEM fellowship directors through the Global Emergency Medicine Fellowship Consortium (GEMFC) email listserv.

RESULTS

Eighty percent (20/25) of GEM fellowship directors responded to the survey. All (20/20) of participating fellowship programs included SDH and SC training in their didactic curriculum, and eight of 20 (40%) programs offered similar training for faculty. Additionally, 19 of 20 (95%) of respondents indicated interest in an open-source tool for emergency medicine (EM) fellowship training in SDH and SC.

CONCLUSIONS

While multiple GEM programs offer formal training on SDH and SC, gaps exist regarding similar training for faculty. Additionally, there is a lack of metrics to determine fellows' comfort with the content of this training. As a majority of GEMFC programs requested, an open-source tool would allow a uniform curriculum and measurement of EM fellowship training in SDH and SC.

An Assessment of the Social Determinants of Health in an Urban Emergency Department

Introduction: Social determinants of health (SDOH) have significant impacts on patients who seek care in the emergency department (ED). We administered a social needs screening tool and needs assessment survey to assess SDOH and evaluate for trends in the population of patients visiting our ED. Methods: A survey was distributed via convenience sampling to adult ED patients to capture self-reported demographic information and data about social needs. We categorized the questions related to SDOH based on the International Classification of Diseases, Tenth Revision, Clinical Modification coding format and created a composite variable called “SDOH Strata” based on the SDOH Index scores (0-5-low, 6-10-middle, or ≥11-high). We conducted bivariate analyses using the sociodemographic characteristics of the patients and their SDOH Strata using Fisher’s exact test. We then conducted multinomial logistic regression to examine the association between the patients’ sociodemographic characteristics and the SDOH Strata. Results: A total of 269 surveys were collected. We observed that Hispanic/Latino patients were more than two times as likely (odds ratio: 2.04, 95% confidence interval [CI], 1.12,-6.51) to be in the higher impact stratum than in the lower impact stratum. Those who were undocumented had 3.43 times increased adjusted odds (95% CI, 1.98, 9.53) of being in the higher than the lower impact stratum compared to US citizens. Additionally, people speaking Spanish as their primary language were 5.16 times as likely to be in the higher impact stratum compared to the reference (English-speaking and lower impact stratum). Conclusion: In our patient population, patients noted to have the highest impact burden of the SDOH were those who identified as Hispanic/Latino, Spanish-speaking, and undocumented immigrant status.

Cross-sectional Analysis of Food Insecurity and Frequent Emergency Department Use

INTRODUCTION

Emergency department (ED) patients have higher than average levels of food insecurity. We examined the association between multiple measures of food insecurity and frequent ED use in a random sample of ED patients.

METHODS

We completed survey questionnaires with randomly sampled adult patients from an urban public hospital ED (n = 2,312). We assessed food insecurity using four questions from the United States Department of Agriculture Household Food Security Survey. The primary independent variable was any food insecurity, defined as an affirmative response to any of the four items. Frequent ED use was defined as self-report of ≥4 ED visits in the past year. We examined the relationship between patient food insecurity and frequent ED use using bivariate and multivariable analyses and examined possible mediation by anxiety/depression and overall health status.

RESULTS

One-third (30.9%) of study participants reported frequent ED use, and half (50.8%) reported any food insecurity. Prevalence of food insecurity was higher among frequent vs. non-frequent ED users, 62.8% vs 45.4% (P <0.001). After controlling for potential confounders, food insecurity remained significantly associated with frequent ED use (adjusted odds ratio 1.48, 95% confidence interval, 1.20-1.83). This observed association was partially attenuated when anxiety/depression and overall health status were added to models.

CONCLUSION

The high observed prevalence of food insecurity suggests that efforts to improve care of ED patients should assess and address this need. Further research is needed to assess whether addressing food insecurity may play an important role in efforts to reduce frequent ED use for some patients.

Emergency department-based interventions affecting social determinants of health in the United States: A scoping review

BACKGROUND

Social determinants of health (SDoH) have significant implications for health outcomes in the United States. Emergency departments (EDs) function as the safety nets of the American health care system, caring for many vulnerable populations. ED-based interventions to assess social risk and mitigate social needs have been reported in the literature. However, the breadth and scope of these interventions have not been evaluated. As the field of social emergency medicine (SEM) expands, a mapping and categorization of previous interventions may help shape future research. We sought to identify, summarize, and characterize ED-based interventions aimed at mitigating negative SDoH.

METHODS

We conducted a scoping review to identify and characterize peer-reviewed research articles that report ED-based interventions to address or impact SDoH in the United States. We designed and conducted a search in Medline, CINAHL, and Cochrane CENTRAL databases. Abstracts and, subsequently, full articles were reviewed independently by two reviewers to identify potentially relevant articles. Included articles were categorized by type of intervention and primary SDoH domain. Reported outcomes were also categorized by type and efficacy.

RESULTS

A total of 10,856 abstracts were identified and reviewed, and 596 potentially relevant studies were identified. Full article review identified 135 articles for inclusion. These articles were further subdivided into three intervention types: a) provider educational intervention (18%), b) disease modification with SDoH focus (26%), and c) direct SDoH intervention (60%), with 4% including two "types." Articles were subsequently further grouped into seven SDoH domains: 1) access to care (33%), 2) discrimination/group disparities (7%), 3) exposure to violence/crime (34%), 4) food insecurity (2%), 5) housing issues/homelessness (3%), 6) language/literacy/health literacy (12%), 7) socioeconomic disparities/poverty (10%). The majority of articles reported that the intervention studied was effective for the primary outcome identified (78%).

CONCLUSION

Emergency department-based interventions that address seven different SDoH domains have been reported in the peer-reviewed literature over the past 30 years, utilizing a variety of approaches including provider education and direct and indirect focus on social risk and need. Characterization and understanding of previous interventions may help identify opportunities for future interventions as well as guide a SEM research agenda.

Development of an Emergency Department-Based Intervention to Expand Access to Medications for Opioid Use Disorder in a Medicaid Nonexpansion Setting: Protocol for Engagement and Community Collaboration

Background

The opioid epidemic has disproportionately impacted areas in the Appalachian region of the United States. Characterized by persistent Medicaid nonexpansion, higher poverty rates, and health care access challenges, populations residing in these areas of the United States have experienced higher opioid overdose death rates than those in other parts of the country. Jefferson County, Alabama, located in Southern Appalachia, has been especially affected, with overdose rates over 2 times greater than the statewide average (48.8 vs 19.9 overdoses per 10,000 persons). Emergency departments (EDs) have been recognized as a major health care source for persons with opioid use disorder (OUD). A program to initiate medications for OUD in the ED has been shown to be effective in treatment retention. Likewise, continued patient engagement in a recovery or treatment program after ED discharge has been shown to be efficient for long-term treatment success.

Objective

This protocol outlines a framework for ED-initiated medications for OUD in a resource-limited region of the United States; the study will be made possible through community partnerships with referral resources for definitive OUD care.

Methods

When a patient presents to the ED with symptoms of opioid withdrawal, nonfatal opioid overdose, or requesting opioid detoxification, clinicians will consider the diagnosis of OUD using the Diagnostic and Statistical Manual of Mental Disorders (fifth edition) criteria. All patients meeting the diagnostic criteria for moderate to severe OUD will be further engaged and assessed for study eligibility. Recruited subjects will be evaluated for signs and symptoms of withdrawal, treated with buprenorphine-naloxone as appropriate, and given a prescription for take-home induction along with an intranasal naloxone kit. At the time of ED discharge, a peer navigator from a local substance use coordinating center will be engaged to facilitate patient referral to a regional substance abuse coordinating center for longitudinal addiction treatment.

Results

This project is currently ongoing; it received funding in February 2019 and was approved by the institutional review board of the University of Alabama at Birmingham in June 2019. Data collection began on July 7, 2019, with a projected end date in February 2022. In total, 79 subjects have been enrolled to date. Results will be published in the summer of 2022.

Conclusions

ED recognition of OUD accompanied by buprenorphine-naloxone induction and referral for subsequent long-term treatment engagement have been shown to be components of an effective strategy for addressing the ongoing opioid crisis. Establishing community and local partnerships, particularly in resource-limited areas, is crucial for the continuity of addiction care and rehabilitation outcomes.

International Registered Report Identifier (IRRID)

DERR1-10.2196/18734

The Influence of Social Determinants of Health on Emergency Departments Visits in a Medicaid Sample

STUDY OBJECTIVE

We evaluate the relationship between social determinants of health and emergency department (ED) visits in the Medicaid Cohort of the District of Columbia.

METHODS

We conducted a retrospective cohort analysis of 8,943 adult Medicaid beneficiaries who completed a social determinants of health survey at study enrollment. We merged the social determinants of health data with participants' Medicaid claims data for up to 24 months before enrollment. Using latent class analysis, we grouped our participants into 4 distinct social risk classes based on similar responses to the social determinants of health questions. We classified ED visits as primary care treatable or ED care needed, using the Minnesota algorithm. We calculated the adjusted log relative primary care treatable and ED care needed visit rates among the social risk classes by using generalized linear mixed-effects models.

RESULTS

The majority (71%) of the 49,111 ED visits made by the 8,943 participants were ED care needed. The adjusted log relative rate of both primary care treatable and ED care needed visit rates increased with each higher (worse) social risk class compared with the lowest class. Participants in the highest social risk class (ie, unemployed and many social risks) had a log relative primary care treatable and ED care needed rate of 39% (range 28% to 50%) and 29% (range 21% to 38%), respectively, adjusted for age, sex, and illness severity.

CONCLUSION

There is a strong relationship between social determinants of health and ED utilization in this Medicaid sample that is worth investigating in other Medicaid samples and patient populations.

Social Determinants of Emergency Department Visits among Persons Diagnosed with Coronary Heart Disease and Stroke

Background

Social determinants of health (SDOH) are associated with a variety of health outcomes, yet their relation to emergency department (ED) visits among individuals with coronary heart disease (CHD) or stroke is unclear.

Methods

We performed a cross-sectional analysis of the 2010-2018 National Health Interview Survey, examining ED visits among individuals who self-reported CHD or stroke diagnosis. The outcome was defined as reporting ≥1 ED visit in the previous 12 months vs none. The SDOH examined were race, employment status, poverty, insurance status, marital status, and educational status.

Results

We included N=14,925 participants with a diagnosis of CHD or stroke. The mean (±SD) age was 68 (±.14) years. After adjusting for age and sex, non-Hispanic Blacks were more likely (adjusted odds ratio [AOR]: 1.29; 95%CI: 1.15-1.44) to report having ≥1 ED visits than Whites. Compared with Whites, Asians had lower odds of having ≥1 ED visit in the previous 12 months (AOR: .63, 95%CI: .49-.82). Those who were unmarried (AOR: 1.21, 95%CI: 1.12 - 1.31), unemployed (AOR: 1.53, 95%CI: 1.36- 1.72) and had a poverty income ratio of <1 (AOR: 1.47, 95%CI: 1.31-1.67) had higher odds of having ≥1 ED visits.

Conclusion

Being Black, unmarried, unemployed, and having lower income levels were associated with a higher likelihood of having ≥1 ED visits in the prior 12 months among individuals with a CHD or stroke diagnosis. SDOH should be considered when developing systematic interventions to prevent costly ED visits.

Improving Follow-up Attendance for Discharged Emergency Care Patients Using Automated Phone System to Self-schedule: A Randomized Controlled Trial

BACKGROUND

Automated phone appointment reminders have improved adherence with follow-up appointments in a variety of hospital settings, but have mixed results in patients discharged from the emergency department (ED). Increasing adherence to follow-up care has been a priority in the ED to improve patient outcomes and reduce unnecessary future visits.

METHODS

We conducted a prospective randomized open, blinded end-point (PROBE) trial of 278 adult patients discharged from the ED and referred to a provider for follow-up care. Participants in the intervention arm received a self-scheduling text or phone message that automatically connected them to their referral provider to schedule a follow-up appointment and sent them appointment reminders. Those in the control arm received standard-of-care written instructions to contact listed referral providers. The primary outcome was time to appointment. The secondary outcome was time to return visit to the ED.

RESULTS

The automated reminders increased the cumulative incidence of keeping the referral appointment after ED discharge (p < 0.001, Gray's test). Of participants randomized to the automated phone intervention, 49.3% (n = 74) kept their follow-up appointment versus 23.4% (n = 30) in the control arm, with a hazard ratio (HR) and 95% confidence interval (CI) over the duration of the study period of 2.4 (1.6 to 3.7; p < 0.001). In a sensitivity analysis using 30 days of follow-up data, 42.0% (n = 63) of participants randomized to the phone intervention kept their follow-up versus 21.1% (n = 27) in the control arm, with a HR (95% CI) of 2.2 (1.4 to 3.5; p < 0.001). There was no difference in ED revisits between the intervention and control group within 120 days postdischarge.

CONCLUSIONS

An automated self-scheduling phone system significantly improved follow-up adherence after ED discharge, but did not decrease ED revisits.

Prevalence of Emergency Department Social Risk and Social Needs

Introduction

Social risks, or adverse social conditions associated with poor health, are prevalent in emergency department (ED) patients, but little is known about how the prevalence of social risk compares to a patient’s reported social need, which incorporates patient preference for intervention. The goal of this study was to describe the relationship between social risk and social need, and identify factors associated with differential responses to social risk and social need questions.

Methods

We conducted a cross-sectional study with 48 hours of time-shift sampling in a large urban ED. Consenting patients completed a demographic questionnaire and assessments of social risk and social need. We applied descriptive statistics to the prevalence of social risk and social need, and multivariable logistic regression to assess factors associated with social risk, social need, or both.

Results

Of the 269 participants, 100 (37%) reported social risk, 83 (31%) reported social need, and 169 (63%) reported neither social risk nor social need. Although social risk and social need were significantly associated (p < 0.01), they incompletely overlapped. Over 50% in each category screened positive in more than one domain (eg, housing instability, food insecurity). In multivariable models, those with higher education (adjusted odds ratio [aOR] 0.44 [95% confidence interval {CI}, 0.24–0.80]) and private insurance (aOR 0.50 [95% CI, 0.29–0.88]) were less likely to report social risk compared to those with lower education and state/public insurance, respectively. Spanish-speakers (aOR 4.07 [95% CI, 1.17–14.10]) and non-Hispanic Black patients (aOR 5.00 [95% CI, 1.91–13.12]) were more likely to report social need, while those with private insurance were less likely to report social need (private vs state/public: aOR 0.13 [95% CI, 0.07–0.26]).

Conclusion

Approximately one-third of patients in a large, urban ED screened positive for at least one social risk or social need, with over half in each category reporting risk/need across multiple domains. Different demographic variables were associated with social risk vs social need, suggesting that individuals with social risks differ from those with social needs, and that screening programs should consider including both assessments.

Lifetime History of Sexual Assault and Emergency Department Service Use among Women Veterans

BACKGROUND

Although sexual assault survivors are at increased risk for adverse physical and mental health outcomes and tend to use more health care services, little is known about women veterans' lifetime history of experiencing sexual assault (lifetime sexual assault [LSA]) and emergency department (ED) use. We sought to examine associations between experiencing LSA, mental health diagnoses, and ED use among women veterans.

METHODS

Computer-assisted telephone interviews were conducted with 980 women veterans enrolled at two Veterans Affairs (VA) Medical Centers to assess history of experiencing LSA, health care use, sociodemographic characteristics, and military history. Administrative data provided VA use, mental health, and medical diagnoses. Logistic regression analyses examined associations between experiencing LSA and mental health diagnoses and past 5-year ED use. Classification tree analysis characterized ED use in participant subgroups.

RESULTS

Sixty-four percent of participants visited a VA or non-VA ED during the previous 5 years. Women veterans with histories of mental health diagnoses and who experienced sexual assault had an odds of ED use almost two times greater than those with no history of experiencing sexual assault and no mental health diagnoses. The odds were similar for experiencing attempted (adjusted odds ratio, 1.85) and completed (adjusted odds ratio, 1.95) sexual assault. Classification tree analysis identified reliance on VA care and the composite variable representing experiencing LSA and mental health diagnoses as factors that best discriminated ED users from nonusers.

CONCLUSIONS

Experiencing LSA is associated with greater ED use in women veterans enrolled in the VA. Whether finding this reflects greater emergent health care needs, suboptimal access and treatment for conditions that could be managed in other settings, lack of health care coordination, or some combination of these factors is unclear.

Socioeconomic Status and Bronchiolitis Severity Among Hospitalized Infants

OBJECTIVE

To investigate the relationship between socioeconomic factors and bronchiolitis severity among hospitalized infants.

METHODS

We performed a 17-center, prospective cohort study from 2011 to 2014. Children <1 year old hospitalized with bronchiolitis were enrolled. Socioeconomic factors included estimated median household income (MHI) per home ZIP code, parent-reported household income, number of adults and children in household, and insurance type. We defined higher bronchiolitis severity as receipt of intensive care treatment. Multivariable logistic regression was used to analyze the association between socioeconomic factors and bronchiolitis severity, with the final model adjusted for potential clustering by site.

RESULTS

In multivariable models adjusted for demographic and clinical characteristics, estimated MHI was the socioeconomic factor most strongly associated with severity. Compared to infants with an intermediate MHI ($40,000-$79,999), odds of receiving intensive care treatment were significantly higher for those with MHI of ≥$80,000 (aOR 2.05, 95% CI 1.19-3.53). No significant associations were found for the other socioeconomic factors (all P > .30). While there were no significant differences in clinical presentation between income groups (all P > .25) or in receipt of mechanical ventilation alone (P = .98), infants with estimated MHI ≥$80,000 were significantly more likely to specifically have been admitted to the intensive care unit (P = .01).

CONCLUSIONS

In this multicenter study of infants hospitalized with bronchiolitis, we identified higher median household income as a risk factor for intensive care treatment. This work may yield important biological or nonbiological insights for the future management of infants with bronchiolitis.

Toward Structural Competency in Emergency Medical Education

As the emergency department (ED) is the "front door" of the hospital and the primary site by which most patients access the health care system, issues of inequity are especially salient for emergency medicine (EM) practice. Improving the health of ED patients, especially those who are stigmatized and disenfranchised, depends on having emergency physicians that are cognizant and attentive to their needs in and out of the medical encounter. EM resident education has traditionally incorporated a "cultural competency" model to equip residents with tools to combat individual bias and stigma. Although this framework has been influential in drawing attention to health inequities, it has also been criticized for its potential to efface differences within groups (such as socioeconomic differences), overstate cultural or racial differences, and unintentionally reinforce stereotypes or blaming of patients for their ill health or difficult circumstances. In contrast, emerging frameworks of structural competency call for physicians to recognize the ways in which health outcomes are influenced by complex, interrelated structural forces (e.g., poverty, racism, gender discrimination, immigration policy) and to attend to these causes of poor health. We present here the framework of structural competency, extending it to the unique ED setting. We provide tangible illustrations of the ways in which this framework is relevant to the ED setting and can be incorporated in EM education.

Social determinants of health associated with hemodialysis non-adherence and emergency department utilization: a pilot observational study

Background

Dialysis patients who miss treatments are twice as likely to visit emergency departments (EDs) compared to adherent patients; however, prospective studies assessing ED use after missed treatments are limited. This interdisciplinary pilot study aimed to identify social determinants of health (SDOH) associated with missing hemodialysis (HD) and presenting to the ED, and describe resource utilization associated with such visits.

Methods

We conducted a prospective observational study with a convenience sample of patients presenting to the ED after missing HD (cases); patients at local dialysis centers identified as HD-compliant by their nephrologists served as matched controls. Patients were interviewed with validated instruments capturing associated risk factors, including SDOH. ED resource utilization by cases was determined by chart review. Chi-square tests and ANOVA were used to detect statistically significant group differences.

Results

All cases visiting the ED had laboratory and radiographic studies; 40% needed physician-performed procedures. Mean ED length of stay (LOS) for cases was 17 h; 76% of patients were admitted with average LOS of 6 days. Comparing 25 cases and 24 controls, we found no difference in economic stability, educational attainment, health literacy, family support, or satisfaction with nephrology care. However, cases were more dependent on public transport for dialysis (p = 0.03). Despite comparable comorbidity burdens, cases were more likely to have impaired mobility, physical limitations, and higher severity of pain and depression. (p < 0.05).

Conclusions

ED visits after missed HD resulted in elevated LOS and admission rates. Frequently-cited SDOH such as health literacy did not confer significant risk for missing HD. However, pain, physical limitations, and depression were higher among cases. Community-specific collaborations between EDs and dialysis centers would be valuable in identifying risk factors specific to missed HD and ED use, to develop strategies to improve treatment adherence and reduce unnecessary ED utilization.

Food for Thought: A Randomized Trial of Food Insecurity Screening in the Emergency Department

BACKGROUND

Despite the growing interest in screening for food insecurity in the clinical setting, little evidence exists regarding screening formats that maximize disclosure and caregiver comfort.

METHODS

In this randomized trial, we asked English-speaking adult caregivers of pediatric patients in the emergency department at an urban, freestanding children's hospital to complete a validated, 2-question screen for food insecurity. Respondents were assigned via block randomization to complete the survey by either verbal interview or electronic tablet. Caregivers reported the perceived importance of the screening questions, comfort level with screening in the emergency department or in their child's primary care site, and their preferred screening modality.

RESULTS

Of the 1818 participants, 20.6% screened positive for food insecurity. There was a significantly higher rate of reported food insecurity for those screened by tablet (23.6%) compared to those screened verbally (17.7%) (P = .002). Of those who had a preference of screening modality, 83.2% of all participants and 84.5% of patients reporting food insecurity preferred the tablet-based screen over verbal interview. Overall, more participants reported comfort completing the screen in the emergency department compared to their child's doctor's office; however, comfort in both of these setting was rated highly (86.1% vs 80.2%; P < .001).

CONCLUSIONS

Although both verbal interview and tablet-based screening modalities were effective in identifying food insecurity, tablet-based screening had a higher disclosure rate and was the participants' preferred screening method. There is a high level of comfort with screening regardless of clinical setting; it is possible that an added level of anonymity in the emergency department enhanced participants' comfort levels.