Study reignites debate on screenings in the ED

Some support public health model

Should EDs offer comprehensive care such as screenings and vaccinations to patients who may not be able to get it elsewhere, or should they emphasize providing efficient, but not comprehensive, care to all patients?

This ongoing discussion in emergency medicine was raised once again when the results of a study on high blood pressure were presented at this year’s Society of Academic Emergency Medicine meeting by David Karras, MD, professor of emergency medicine at Temple University School of Medicine and an ED physician at Temple University Hospital, both in Philadelphia.

Karras’ study, conducted in urban EDs in New York City, Philadelphia, Atlanta, and Miami, examined patients over a one-week period who had elevated blood pressure: above 140 systolic or 90 diastolic.

"Half of those patients were not being treated for hypertension," notes Karras. "We were able to get follow-up information on 75% of them, and in one-quarter of those patients, we were told by their primary care provider that they did have elevated blood pressure that had not previously been noted."

This leads Karras to conclude that the ED "is an excellent place to do [blood pressure] screening. One-quarter of those patients really did have a problem, and it was never suspected," he says.

Karras is quick to note that this conclusion doesn’t necessarily put him in the "comprehensive care" camp.

He’s on the side that supports doing screenings for diseases EDs already screen for, Karras notes.

"We already do vitals, so there is no incremental time involved with becoming cognizant of the fact that many people may have elevated blood pressure," he continues.

He does not support screening programs that require additional costs, manpower, or screening time. "The cost associated with informing a patient their blood pressure is elevated is the cost of providing discharge instructions," Karras says.

Beyond that exception, however, Karras indicates he is in that camp that asserts the following: The intent of the ED is to provide emergency medical care as efficiently as possible. Most EDs are relatively understaffed, given the number of patients they must treat; and almost every urban ED has long waiting times and chronic personnel shortages, Karras observes. The ED cannot become a substitute for primary care, he says.

"If someone comes to the ED for one complaint, that doesn’t require them to be seen for another, screened for other conditions, or given vaccinations," Karras says. "That could prevent you from fulfilling your core mission."

Despite the challenges outlined by Karras, in many respects, ED managers have an element of the public health mission that should be incorporated into patient care, says Leon L. Haley Jr., MD, chief of emergency medicine for Grady Health System in Atlanta.

"Not every patient can get all the care they might need, but when it’s appropriate, we should provide care that is outside the scope of emergency medicine and into the realm of primary care and public health, because often we are the only health care [our patients have access to]," he says. Haley says that not only does he practice in that fashion, but he encourages his staff to as well. "They may not always be able to do everything, but we want to make sure we are an extension of that public health system," he says.

So, what exactly does this more comprehensive care model entail? "My general practice is when we see people who have out-of-control blood pressure and have been out of meds for some time — say, several months — most of our folks will do basic screening tests to make sure they have not gotten out of control in terms of renal function or cardiovascular function; and most will rewrite or restart patient meds," Haley says.

If they are not taking any medications, the staff probably will select a simple starter medication such as a diuretic, and patients will follow up in the urgent care center in a week or so, he notes. "If they have a primary care provider visit the next day, we may not do anything, but in general, we will err on the side of making sure they are not out of control and/or at risk for organ dysfunction," Haley says.

Patients with elevated blood sugars will receive a battery of labs tests, he says. "We won’t do a hemoglobin A1c, but we will check and make sure they’re not in DKA [diabetic ketoacidosis]," Haley adds.

As for vaccinations, "with a patient population like ours, we will err on the side of caution," he says. Haley doesn’t recommend routinely giving out vaccines, but if there are elderly patients, for example, and it is time for their pneumovax, he will try to assess their access to other care. "If they are homeless or do not have access, we will go ahead and give it to them," he says. "That fits the Grady model."

Sources

For more information, contact:

  • Leon L. Haley Jr., MD, MHSA, Chief of Emergency Medicine, Vice Chairman of Clinical Affairs, Grady Health System, Atlanta; Associate Professor, Department of Emergency Medicine, Emory University, Atlanta. Phone: (404) 616-6419. E-mail: Leon_Haley@emoryhealthcare.org.
  • David Karras, MD, Professor of Emergency Medicine, Temple University School of Medicine, 3420 N. Broad St., Philadelphia, PA 19140. Phone: (215) 707-5032.