The Division of Public Health Research is the most recent addition to the research structure of the Department of Emergency Medicine. This formal designation was made in response to the increasing interest of departmental faculty in the investigation of emergency medicine’s potential role in shaping the health of populations rather simply responding to the acute disease states of individual patients. The notion of our specialty assuming a mission of public health intervention remains novel and controversial. However, the University of Cincinnati Department of Emergency Medicine is leading our specialty into the future in this new focus area in a manner reminiscent of the department’s past research successes.

Dana L. Raab, RN, MS
Research Coordinator, Division of Public Health Research
raabd@ucmail.uc.edu

Michael S. Lyons, MD
Director, Division of Public Health Research
lyonsme@ucmail.uc.edu

Those most at-risk for adverse outcomes from preventable illness are assumed to be least likely to interact with the traditional health system. Unlike outreach programs seeking target populations for intervention in the community, emergency departments passively receive patients in a medical setting where an opportunity for interaction exists. Emergency departments routinely care for people from every background, socioeconomic group, and health status, and the emergency department is a key component of the health care safety net. Even for those who can use health insurance to access health care, risky behaviors often bring people to the emergency department in unanticipated situations that may constitute a teachable moment. Patients have been shown to accept preventive services and value counseling during emergency visits. The emergency department is therefore increasingly recognized as an ideal location for public health programs. The Society for Academic Emergency Medicine (SAEM) Public Health and Education Task Force has advanced a rationale for expanding prevention services into the emergency setting.[9]

Despite the many improvements in public health that could result from expanding the emergency medicine mission, implementing necessary changes remains controversial. The primary barrier is lack of time and resources. Paradoxically, but not surprisingly, EDs treating populations most in need of such programs have the fewest resources to do so, and the SAEM task force has affirmed that the desire to expand emergency department-based public health programs should not detract from the primary mission of providing acute medical diagnostic and stabilization services.[9] Rigorous investigation and dissemination of research findings will be required to 1) engender motivation to overcome obstacles to the inclusion of public health interventions in the emergency medicine mission, and 2) influence allocation of limited national resources in favor of emergency department programs. In this manner, it is anticipated that sufficiently powerful investigation will in the long-term be sufficient to translate research findings into practice, thereby changing fundamentally both emergency medicine and the national health system.

The ways in which emergency departments might endeavor to influence public health are many. While illness prevention is certainly a primary goal, there are many other issues such as bio-surveillance that have recently garnered national attention. While no accepted classification scheme exists, broad categories might be constructed (Figure)

With the development of the Division of Public Health Research in the Department of Emergency Medicine, it became important to recognize the public health implications of other departmental research efforts. A list of selected departmental publications with public health implications is included below. Examples include sex disparities, cholesterol screening, and patient education within the cardiovascular division, syndromic surveillance within the toxicology division, and estimates of public awareness of stroke symptoms within the neurovascular division. In addition, there are large scale funded research projects centered primarily within the Division of Public Health Research that primarily focus on screening and behavioral intervention. For example, the HIV Early Intervention Program (EIP) (WEB LINK), in existence since 1998, is a health department funded, emergency department based, HIV counseling and testing program. This clinical program identifies approximately 25% of all HIV positive patients diagnosed by publicly funded counseling and testing programs in Cincinnati. This program has also served as a basis for a variety of ongoing and future research investigations. Dr. Lynn Sommers (Associate Dean Institute for Nursing Research, College of Nursing) and Dr. Lyons were recently awarded funds by the CDC for completion of a project entitled ED Intervention to Reduce Risky Behaviors in Drivers. This randomized controlled study will test the utility of motivational interviewing in the ED setting to reduce injury among persons identified as having risky drinking and risky driving practices.

Diercks DB, Storrow AB, Gibler WB, Liu T, Comparison of diagnostic testing between females and males in an emergency department chest evaluation unit. Acad Emer Med 1998; 5:477.

Sztajnkrycer MD, Gesell LB, et al. Trends in Intentional Poisoning Presenting to an Urban Emergency Department Over a Five Year Period J Tox- Clin Tox 1999 37(5) 595.

Miller, R, Khoury J, Broderick J, Kothari R, Salisbury S, Mills D, Castelli V, Woo D, Pancioli A, Jauch E, Kissela B, Brott T. Outpatient Stroke: Experience In a Population-Based Epidemiological Study, 25th American Heart Association International Conference on Stroke and Cerebral Circulation, New Orleans , LA, February, 2000

Kosowsky JM, Han J, Collins SP, Mcafee AT, Storrow AB. Measurement of Stroke Index Using Impedance Cardiography: Comparison with Traditional Resting and Orthostatic Vital Signs for the Detection of Moderate Acute Blood Loss Acad Emerg Med 2001 8: 512-513.

Gibney LB, Blomkalns AL, Lindsell CJ, Lautz J, Nolting LA, Crocco TJ. (2002) Gender Bias in Pre-hospital ECG Acquisition. Academic Emergency Medicine 2002, 9, 427.

Panagos PD, Suyama J, Sztajnkrycer MD, FitzGerald DJ; Barnes D. Injury Pattern Related to Use of Less-Lethal Weapons During a Period of Civil Unrest. New England Regional SAEM Conference abstract. Shrewsbury, MS, April , 2002.

Schneider AT, Pancioli AM, Khoury J, Rademacher E, Tuchfarber A, Miller R, Woo D, Kissela B, Broderick JP: Stroke warning signs and risk factors: a comparative survey of community knowledge. Presented at the 27th American Heart Association International Stroke Conference, San Antonio, TX. February 2002.

Joe Suyama, Edward J Otten, Matthew D Sztajnkrycer, Christopher Lindsell, Amy B Kressel, and Judith M Daniels. Surveillance of Infectious Disease Occurrences in the Community: An Analysis of Symptom Presentation in the Emergency Department . Acad Emerg Med 2002 9: 358-359

Liu t, Wang X, Waterbor W, Weiss H, Soong SJ. Relationships between socioeconomic status and race-specific cervical cancer incidence and survival. J Health Care for the Poor and Undeserved 1998; 9:420-432.

Pancioli A, Broderick J, Kothari R, Brott T, Tuchfarber A, Miller, R, Khoury J, Jauch E. Public Perception of Stroke Warning Signs and Potential Risk Factors. JAMA 1998; 279(16):1288-1292.

Bailey WC, Kohler CL, Richards JM Jr., Windsor RA, Brooks Cm, Gerald LB, Martin B, Higgins DM, Liu T, Asthma self-management: Do patient education programs always have an impact? Arch Intern Med 1999 Nov 8;159(20):2422-8.

Liu T, Sayre MR, Carleton, SC. Emergency medical care: Types, trends, and factors related to non-urgent visit. Acad Emerg Med 1999; 6:1147-1152.

Miller R, Khoury J, Broderick J, Kothari R, Salisbury S, Mills D, Castelli V, Woo D, Pancioli A, Jauch E, Kissela B, Brott T. Outpatient Stroke: Experience In a Population-Based Epidemiological Study. Stroke 1999; 31(1): 280.

Wang X, Cosby LG, Harris MG, Liu T. Major Concerns and needs of breast cancer patients. Oncology Nursing 1999; 22:157-163.

Broderick JP, Miller R, Khoury JC, Alwell K, Kissela BM, Woo D, Shukla R, Moomaw C, Gebel J, Pancioli AM, Brott TG, Kothari RU, Incidence rates of stroke for blacks and whites: Preliminary results from the Greater Cincinnati/Northern Kentucky Stroke Study. Stroke 2001; 32:320.

Kissela BM, Khoury JC, Miller R, Alwell K, Woo D, Brott TG, Pancioli AM, Shukla R, Jauch EC, Gebel J, Kothari RU, Broderick JP. Incidence rates of ischemic stroke in diabetics: Preliminary race-specific results from the Greater Cincinnati/Northern Kentucky Stroke Study. Stroke 2001; 32:365.

Lyons MS, Thomas C, Lindsell CJ, Trott A (2002) An Emergency Department Based Intervention After Pelvic Examination to Increase Patient Knowledge Regarding Pap Smear Screening. Academic Emergency Medicine 2002; 9(5):465-466.

Prall D, Heistand B, Lindsell CJ, Gibler B, Pollack C, Hollander J, Tiffany B, Peacock F, Diercks D, Hoekstra J Does insurance status affect decisions in patients with ST-segment elevation MI or elevated cardiac enzymes? Academic Emergency Medicine 2002; 9:5, 373.

Miller ET, Spilker J. Readiness to change and brief educational interventions: Successful strategies to reduce stroke risk. Journal of Neuroscience Nursing. 2003;(35);215-22.

Schneider AT, Pancioli AP, Khoury JC, Rademacher E, Tuchfarber A, Miller R, Woo D, Kissela B, Broderick JP. Trends in community knowledge of the warning signs and risk factors for stroke. JAMA. 2003 Jan 15:289(3):343-6.

Suyama J, Panagos PD, et al. Injury patterns related to the use of less-lethal weapon. J Emerg Med. 2003 Aug;25(2):219-27.

Suyama J, Sztajnkrycer M, Lindsell C, Otten EJ, Daniels JM, Kressel AB. Surveillance of infectious disease occurrences in the community: An analysis of symptom presentation in the emergency department. Acad Emerg Med. 2003;10:753-763

Venkat A, Hoekstra J, Lindsell CJ, Prall D, Hollander JE, Pollack CV, Diercks D, Kirk JD, Tiffany B, Peacock F, Storrow AB, Gibler WB. The impact of race on the acute management of chest pain. Acad Emerg Med. 2003 Nov;10:1199-1208.

Blomkalns A.L., Gibler W.B., Emergency department crowding: Emergency physicians and cardiac risk stratification as part of the solution. Ann Emerg Med 2004; 43:77-78.

Blomkalns A.L., Lindsell, C.J., O’Connell, E.M., Eady, C.E., Gibler, W.B., Patients with Severe Hyperlipidemia Do Not Get Appropriate Treatment at Follow-Up. Acad Emerg Med 2004; 11:549.

Calvin, J., Roe, M.T., Chen, A., Brogan, G., DeLong, E.R., Gibler, W.B., Ohman, E.M., Fintel, D., Smith, S.C. Jr, Peterson, E.D.: Higher Mortality and Less Evidence-Based Therapies Among Medicaid-Insured Patients With High-Risk Acute Coronary Syndromes (ACS): Results from CRUSADE. Abstract presented at American College of Cardiology Scientific Sessions 2004. J Am Coll Cardiol 2004; 43:413A.

Kissela, B., Schneider, A., Kleindorfer, D., Khoury, J., Miller, R., Alwell, K., Woo, D., Szaflarski, J., Gebel, J., Moomaw, C., Pancioli, A., Jauch, E., Shukla, R., Broderick, J. Stroke in a biracial population: the excess burden of stroke among blacks. Stroke, 2004; 35(2):426-31.

Lyons, M.S., Lindsell, C.J., Trott, A.T. Emergency department pelvic examination and Pap testing: addressing patient misperceptions. Acad Emerg Med 2004, Apr;11(4):405-8.

Schmidt, M.J., Handel, D., Lindsell, C.J., Collett, L., Gallo, P., Locasto D. Evaluating disparities in an EMS-initiated non-transport system. Prehosp Emerg Care 2004; 8,1:108.

Walerius, H.K., Lyons, M.S., Lindsell, C.J., Frame, P.T., Trott, A.T. HIV Screening in the Emergency Department: An Ongoing Counseling and Testing Program in a Low Prevalence Setting. Acad Emerg Med 2004;11:532.

Williams AL, Lindsell CJ, Blomkalns AL, Emergency Department Education Improves Patient Knowledge of Cardiac Risk Factors but not the Accuracy of their Own Risk Perception. Acad Emerg Med 2004; 11:549a-550b.

Lyons MS, Lindsell CJ, Ledyard HK, Frame PT, Trott AT. Emergency Department HIV Testing and Counseling: An Ongoing Experience in a Low-Prevalence Area. Annals of Emergency Medicine. 2005; 46(1):22-28.

Lyons MS, Lindsell CJ, Ledyard HK, Frame PT, Trott AT. Health Department Collaboration with Emergency Departments as a Model for Public Health Programs Among At-risk Populations. Public Health Rep. 2005;120:259-265.