Preventive care in the emergency department, part II: Clinical preventive services - An emergency medicine evidence-based review

Introduction: Emergency departments (EDs) provide an opportunity to initiat e preventive services for millions of Americans who have no other source fo r these services. Objectives: To identify primary and secondary preventive interventions appropriate for inclusion in routine emergency care and, seco ndarily, to recommend areas in which research into the efficacy and cost-ef fectiveness of interventions is needed. Methods: Systematic reviews were pe rformed on 17 candidate preventive interventions with potential applicabili ty in the ED. All but one was selected from those reviewed by the U.S. Prev entive Services Task Force (USPSTF. Each two-person review team followed a template that provided a uniform approach to search strategy, selection cri teria, methodology appraisal, and analysis of the results of primary studie s bearing on ED cost-effectiveness. Assigned proctors provided methodologic al guidance to the review teams throughout the review process. A grading sc heme was developed that took into account the evidence and recommendations of the USPSTF supporting primary efficacy of the intervention and the level of evidence supporting ED application identified by the Society for Academ ic Emergency Medicine Public Health and Education Task Force (PHTF) review teams. Results: Seventeen reviews were completed. The following interventio ns received an alpha rating, indicating that evidence is sufficient to supp ort offering these services in the ED setting, assuming sufficient resource s are available: alcohol screening and intervention, HN screening and refer ral tin high-risk, high-prevalence populations), hypertension screening and referral, adult pneumococcal immunizations (age greater than or equal to 6 5 years), referral of children without primary care physicians to a continu ing source of care, and smoking cessation counseling. Interventions receivi ng a beta or gamma rating, indicating that existing research is not suffici ent to recommend for or against instituting them routinely in the ED, inclu de: identification and counseling of geriatric patients at risk of falls, P ap tests in women having a pelvic exam in the ED, counseling for smoke dete ctor use, routine social service screening, depression screening, domestic violence screening, safe firearm storage counseling, motorcycle helmet use counseling, and youth violence counseling programs in the ED. Interventions not recommended for ED implementation (omega rating) include Pap test scre ening for women not having a routine pelvic exam, diabetes screening, and p ediatric immunizations. Conclusions: A set of recommendations for preventio n, screening, and counseling activities in the ED based on systematic revie ws of selected interventions is presented. The applicability of these prima ry and secondary preventive services will vary with the different clinical environments and resources available in EDs. The PHTF recommendations shoul d not be used as the basis of curtailing currently available services. This review makes clear the need for further research in this important area.