Sam Robinson
Screening for illness is a staple of primary care initiatives—the early identification of disease is paramount to maintaining patient well-being. Healthcare providers who identify individuals at risk for disease can delay or eliminate the need for costly future intervention while creating a greater quality of life for their patient.
Unfortunately, many Americans don’t receive regular health screenings because they don’t receive regular primary care. The lack of access to primary care has become more apparent in recent decades—shortcomings in workforce growth and chronic U.S. underinvestment, among other reasons, have increasingly marginalized primary care. As a result, many patients are forced to look for alternative ways to meet their health needs—one of the most common being treatment in the emergency department (ED).
When picturing an ED, most people imagine a frenzied scene where patients in unstable conditions fight for their lives as they are rushed to treatment. While this may be characteristic of hospitals serving population-dense areas, the patient experience varies widely. For many Americans, the ED serves as one of the only healthcare access points in their community—those who lack regular access to holistic providers often have no choice but to visit the ED for their health needs (exemplified by higher ED usage rates among homeless populations).
Since the ED often serves as the only healthcare touchpoint for those without regular primary care access, it presents a critical opportunity to introduce proactive interventions—one of those being disease screening tools. So how can emergency providers effectively implement screening to make the most out of patient interactions and improve their community’s well-being?
Determining a patient’s health risks and social determinants of health (SDOHs)—the non-clinical factors that influence health outcomes—is essential for improving health outcomes. One of the best ways to uncover a patient’s SDOHs is through screening tools. Proactive HIV testing reduces AIDS-related morbidities, death, and the likelihood of HIV transmission. Screening for alcohol use alongside a brief intervention has been shown to decrease morbidity, mortality, consumption levels, and ED visits among patients. Screening for suicide risk led to a nearly twofold increase in risk detection—a significant finding, as identification is one of the most important steps in suicide prevention.
Screening initiatives like these demonstrate how a quick test can drastically improve a patient’s quality of life. The benefit goes beyond the patient—proactive screenings can decrease ED patient load, preserve valuable healthcare resources, and save money through reduced spending—making them a valuable tool for departments looking to maximize the value of each healthcare dollar. But not all screening tools are built the same, so how can providers implement those that are most effective?
Once ED administrators understand the effectiveness of proactive screening, they must decide which screening services to implement based on established research and recommendations from authoritative bodies. One of the best resources for selecting appropriate screening services is the U.S. Preventive Services Task Force (USPSTF), a volunteer panel of national experts in disease prevention and evidence-based medicine. They publish grades for preventive services based on the net benefit to patients, and all services graded as either an A or B are recommended for implementation—many of which include screening services, such as those for anxiety disorders and hypertension. The USPSTF’s recommendations are an excellent source for leaders who hope to make evidence-based screening decisions.
When USPSTF recommendations lack insight for screening certain diseases or SDOHs, healthcare leaders should consult literature. A large body of research exists on screening services, and previous works may provide in-depth information not available elsewhere. For example, this 2015 study on geriatric screening found that ED personnel (nurses) were just as effective as geriatric specialists in administering screenings, and that EDs with different resources need to tailor screening criteria to their specific populations. Research like this is essential in laying the foundation for novel screening tool development.
While screening criteria is an important consideration, ED leaders must assess how screening tools should be implemented to best fit their system—tools should only be utilized if the ED’s central functions and efficiency are unaffected. Increases in ED crowding are associated with higher rates of mortality, untreated pain, medication delays, and increased complications. For the providers on the ground, tools would need to be implemented without interrupting workflow—the effectiveness of screening initiatives depends on their ease of use and applicability.
Patient triage—the process of evaluating and prioritizing patients based on the severity of their medical needs—presents one of the best opportunities for screening interventions in the ED. Brief screening questionnaires can be included as a part of patient triage, providing essential information related to health needs without interrupting workflow. A prime example of this is screening for suicide. With as few as four questions, providers can quickly and accurately identify individuals who may be at risk for a suicide attempt and provide rapid social intervention.
All hospitals are not built the same, and the extent to which EDs approach proactive care depends heavily on the resources at their disposal. EDs within larger healthcare systems should emphasize integrating screenings into broader health networks, so that patients who test positive for certain comorbidities can be referred to the appropriate personnel for holistic treatment. With adequate resources, EDs can broaden the reach of screening tools to go beyond their facilities. By partnering with local community leaders like schools and religious organizations, EDs can lessen their patient burden by proactively testing for a wide range of health risk factors, such as high blood pressure, cholesterol, diabetes, and mental health.
Smaller EDs may need to consider how their limited resources relate to the population they treat, and should tailor screening tools to meet the needs of their patients. Despite their size, they can be just as proactive in promoting screening tools. Following the AI revolution, digital interventions are becoming a viable alternative for screening patients. Chat bots can be an effective screening resource for departments with less personnel, and may even be preferred by patients—by removing time pressures, stigma, and human bias, computer-based approaches to intimate partner violence screening leads to higher reporting rates. Leaders of smaller EDs should be conscious of the many developing resources at their disposal—their implementation could change someone’s life.
Until our healthcare system can evolve to provide more equitable primary care access to all Americans, the ED will remain an essential piece of the healthcare ecosystem. Healthcare leaders must understand the importance of the ED in their community and implement preventive tools as appropriate—for many patients, it may be the only proactive healthcare outreach they receive.
An often unrecognized and untreated problem among older adults is malnutrition. Studies have shown that one in two patients 65 years or older may either be suffering from or at risk for malnutrition when entering the hospital. Malnutrition can also develop during prolonged hospital stays or following a return home. This is a problem for healthcare systems oriented towards efficiency—malnutrition leads to longer hospital stays, increased mortality and morbidity, and greater healthcare costs.
Leadership at Advocate Health Care recognized this problem and implemented their Nutrition Quality Improvement Program (QIP) in 2014. As a part of this program, RNs at Advocate clinics screened all new patients and admissions for malnutrition using their malnutrition screening tool. Patients who met the criteria for malnutrition were instructed by nursing staff to drink two bottles of nutritional supplement daily and provided the patient with necessary care connections at discharge. Patients were encouraged to continue taking the supplements, provided supplement coupons, and were followed-up with by Advocate team members to answer any nutrition-related questions.
The initial phase of this nutritional intervention led to a 29% decrease in patient readmissions, a 26% decrease in length of hospital stay, and $5 million in cost-savings over the initial 6 months of the program’s implementation.
Advocate Health Care identified six recommendations for implementing nutrition care:
Through this program, Advocate health was able to exceed expectations in the provision of care to control health care costs and improve the holistic well-being of their patients. A comprehensive understanding of the risk factors for disease and developing a process to identifying them early is essential for healthcare systems seeking to control costs and improve outcomes in the long term.
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