Prof V. Anantharaman - MCI

Emergency Medicine
Public Health
Policy Making
Prof V. Anantharaman
MBBS, FRCP (Edin), FRCS Ed (A&E), FAMS, FIFEM, PBM
Department of Emergency Medicine
Singapore General Hospital

Clearer understanding
needed of role of ED:
- not just by healthcare administrators
- but also by Emergency Physicians

Role of Emergency Departments
• Receive emergencies
• Resuscitate patients
• Maximize outcomes

Emergency Medicine
Primary Care
P5
Burden of Emergencies in the Community
P4
P3
P2
P1
P1
P2
P3
P4

The Community’s Safety Net ??
• Over reliance on EDs
– Less preventive medicine and chronic disease
management by 1 0 care and civil organisations
• We are the Hospital’s Safety Net
– Why should we also take on the community role?
• Prevention MUST be a central tenet of
community healthcare reform
– Role of civil organisations in prevention

Types of public health interventions at ED
• Provision of preventive interventions in EDs
depends on:
– factors related to disease process
– behavior involved that results in emergency
– underlying complexities of the ED itself.
• Do SBIRT (Screening, Brief Intervention and
Referral to Treatment) interventions constitute
another unfunded mandate for poorly
resourced, underfinanced, crowded EDs ?

Roles of EDs ????
EDs manage acute illness and injury and also:
• successfully provide food and shelter for the homeless
• arrange disposition for elders, pts with substance use
or mental illness
• provide screening for intimate partner violence, HIV
infection, substance abuse, seatbelt and helmet use
• provide vaccinations, when appropriate
• identify chronic medical conditions
• refer patients to primary care providers
for further evaluation and care.

Barriers precluding preventive care in ED
• Incorporating such activities into busy ED setting difficult and
for emergency care providers these services not a priority
• EPs more likely to perform critical resuscitation and diagnose
or exclude life-threatening medical conditions.
• Essential activities are already part of the care EDs provide.
• Numerous resources needed in preventive services delivery.
Availability of local resources will dictate local practice.
• Waiting areas can be stocked with literature addressing
prevention and health education measures
• SBIRT activities are not reimbursable
• Lack of formal training

Stages and Providers of Preventive Service Interventions
Public Health, Prevention, and Emergency Medicine: A Critical Juxtaposition. Steven L Bernstein MD, Jason
S. Haukoos MD, MSc. Academic Emergency Medicine. 2008; 15(2):190–3 .
Stage of ED Visit
Interve
ntion
Triage S X
Triage
Officer
Nu
rse
Physician/
Provider
Ancillary
Provider*
Waiting area S, RT X
History and physical
examination
Post-examination
waiting period
S, BI,
RT
S, BI,
RT
Discharge BI, RT X X
X
X X X X
Supple
mental†
BI = brief intervention; ED = emergency department; S = screening; RT = referral to treatment.
*May include respiratory therapists, phlebotomists, social workers, or others.
†May include brochures and other literature, posters, computerized information, or screening kiosks.
ROUTINE vs EXCEPTION

Issues
• Principal mission of EM is to care for patients with
acute illness and injury
• Community duty of EPs vs right siting of emergency
care and primary care
• Safety net presumes weak primary health care
infrastructure
• Is EM an excuse for a weak primary care system?

Policy Making
• Address need for right-siting of 1 0 care in community
• Ensure community-wide system of 1 0 and 2 0
prevention interwoven into the fabric of society
• Routine 1 0 prevention activities cannot be part of the
ED process of care
• Prevention activities that are part of the process of
management of acute illness and injury are crucial
elements of ED care
• Primary prevention that is not under purview of
primary care e.g. injury control

Conclusion
• Let’s not take on our shoulders the burdens
of the world
• Let’s be focused on our strengths in our care
delivery process
• Strong advocacy needed for communities to
allow primary care medicine to be easily
available and accessible
• Health policies for public health interventions
need to well-tuned for good effect

CHC-based Integrated Emergency
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Response
The Acute Observation Ward
CHC Support Facilities
The Ambulatory Clinic
CHC Specialist
Nurses
CHC Specialist
Doctors
Primary prevention
training materials
Life Skills
Training
facilities

Thank you