Preventive care in the emergency department, Part II: Clinical preventive services--an emergency medicine evidence-based review. Society for Academic Emergency Medicine Public Health and Education Task Force Preventive Services Work Group.

INTRODUCTION

Emergency departments (EDs) provide an opportunity to initiate preventive services for millions of Americans who have no other source for these services.

OBJECTIVES

To identify primary and secondary preventive interventions appropriate for inclusion in routine emergency care and, secondarily, to recommend areas in which research into the efficacy and cost-effectiveness of interventions is needed.

METHODS

Systematic reviews were performed on 17 candidate preventive interventions with potential applicability in the ED. All but one was selected from those reviewed by the U.S. Preventive Services Task Force (USPSTF). Each two-person review team followed a template that provided a uniform approach to search strategy, selection criteria, methodology appraisal, and analysis of the results of primary studies bearing on ED cost-effectiveness. Assigned proctors provided methodological guidance to the review teams throughout the review process. A grading scheme 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 Academic Emergency Medicine Public Health and Education Task Force (PHTF) review teams.

RESULTS

Seventeen reviews were completed. The following interventions received an alpha rating, indicating that evidence is sufficient to support offering these services in the ED setting, assuming sufficient resources are available: alcohol screening and intervention, HIV screening and referral (in high-risk, high-prevalence populations), hypertension screening and referral, adult pneumococcal immunizations (age >/=65 years), referral of children without primary care physicians to a continuing source of care, and smoking cessation counseling. Interventions receiving a beta or gamma rating, indicating that existing research is not sufficient to recommend for or against instituting them routinely in the ED, include: identification and counseling of geriatric patients at risk of falls, Pap tests in women having a pelvic exam in the ED, counseling for smoke detector 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 screening for women not having a routine pelvic exam, diabetes screening, and pediatric immunizations.

CONCLUSIONS

A set of recommendations for prevention, screening, and counseling activities in the ED based on systematic reviews of selected interventions is presented. The applicability of these primary and secondary preventive services will vary with the different clinical environments and resources available in EDs. The PHTF recommendations should not be used as the basis of curtailing currently available services. This review makes clear the need for further research in this important area.