Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
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This article is the outcome of a consensus building workshop entitled, "Overcoming Barriers to Implementation and Dissemination" convened at the 2009 Academic Emergency Medicine Consensus Conference, ''Public Health in the ED: Surveillance, Screening, and Intervention." The participants were asked to address potential methods for overcoming barriers to the dissemination and implementation in the emergency department (ED) of evidenced-based practices to improve public health. The panel discussed three broad areas of interest including methods for disseminating evidence-based practices, barriers encountered during the process of implementation, and the importance of involvement in activities outside the ED including engagement in policy development and improvement. ⋯ The recommendations included 1) researchers and advocates should disseminate findings through multiple forums beyond peer-reviewed publications when an ED-based public health intervention has enough evidence to support integration into the routine practice of emergency care; 2) local barriers to implementation of public health interventions should be recognized and well understood from multiple perspectives prior to implementation; 3) innovation must be put into place and adapted based on local institutional context and culture as barriers and the best methods for overcoming them will vary across institutions; and 4) use of legislation, regulation, and incentives outside of the ED should support and strengthen ED-based interventions. For each area of interest, research dimensions to extend the current understanding of methods for effectively and efficiently implementing evidence-based public health interventions in the ED were discussed and consensus was achieved.
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In the emergency department (ED), a significant amount of radiation exposure is due to computed tomography (CT) scans performed for the diagnosis of appendicitis. Children are at increased risk of developing cancer from low-dose radiation and it is therefore desirable to utilize CT only when appropriate. Ultrasonography (US) eliminates radiation but has sensitivity inferior to that of CT. We describe an interdisciplinary initiative to use a staged US and CT pathway to maximize diagnostic accuracy while minimizing radiation exposure. ⋯ Half of the patients who were treated using this pathway were managed with definitive US alone with an acceptable negative appendectomy rate (7%) and a missed appendicitis rate of less than 0.5%. Visualization of a normal appendix (negative US) was sufficient to obviate the need for a CT in the authors' experience. Emergency physicians (EPs) used an equivocal US in conjunction with clinical assessment to care for one-third of study patients without a CT and with no known cases of missed appendicitis. These data suggest that by employing US first on all children needing diagnostic imaging for diagnosis of acute appendicitis, radiation exposure may be substantially decreased without a decrease in safety or efficacy.
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This article provides recommendations for incorporating conceptual models of health behavior change into research conducted in emergency care settings. The authors drafted a set of preliminary recommendations, which were reviewed and discussed by a panel of experienced investigators attending the 2009 Academic Emergency Medicine consensus conference. ⋯ Three recommendations were made: 1) research conducted in emergency care settings that focuses on health behaviors should be grounded in formal conceptual models, 2) investigators should clearly operationalize their outcomes of interest, and 3) expected relations between theoretical constructs and outcomes should be made explicit prior to initiating a study. A priori hypothesis generation grounded in conceptual models of health behavior, followed by empirical validation of these hypotheses, is needed to improve preventive and public health-related interventions in emergency care settings.
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Abstract Public health research requires sound design and thoughtful consideration of potential biases that may influence the validity of results. It also requires careful implementation of protocols and procedures that are likely to translate from the research environment to actual clinical practice. ⋯ In addition, a number of recommendations related to research methods and future investigations related to public health work in the ED are provided. Public health investigators are poised to make substantial contributions to this important area of research, but this will only be accomplished by employing sound research methodology in the context of rigorous program evaluation.