Mobile Social Screening and Referral Intervention in a Pediatric Emergency Department.

OBJECTIVE: Many families in pediatric emergency departments (PED) have unmet social needs, which may be detected and addressed with the use of a digital social needs intervention. Our objective was to characterize the feasibility and effectiveness of utilizing personal phones or a PED tablet for screening and referral to social services. METHODS: We conducted a prospective single-arm intervention study using a convenience sample of caregivers and adult patients in an urban PED between May 2019 and October 2020. Participants chose either their personal phone or a PED-provided tablet to use an app, "HelpSteps." Participants self-selected need(s) then referrals to service agencies. Participants completed a 1-month follow-up. Clinicians were surveyed about screening and impact on visit. RESULTS: Of 266 participants enrolled, 55% of participants elected to use their personal phone. Of all participants, 67% self-selected at least 1 health-related social need; 34% selected 3 or more. The top 3 "most important" needs were housing (14%), education (12%), and fitness (12%). At one month follow-up, 44% of participants reported their top need was "completely" or "somewhat" solved. For 95% of encounters, clinicians reported the intervention did not increase length of stay. CONCLUSIONS: A mobile social needs intervention was feasible and effective at identifying and referring participants in the PED setting. While more than half of participants used their personal phones, several smartphone owners cited barriers and elected to use a tablet. Overall, participants found the app easy to use, appropriate for the PED, and the intervention had minimal impact on clinical flow.

"Why bother?": Barriers to reporting gender and sexual harassment in emergency medicine.

BACKGROUND: Gender and sexual harassment in emergency medicine (EM) is persistent in the workplace but remains underreported. Barriers to reporting in EM are largely unknown. This study explored barriers to reporting gender and sexual harassment among EM faculty and residents and potential improvements to reporting systems. METHODS: We conducted semistructured interviews with EM faculty and residents across the United States, utilizing purposive sampling to ensure diverse representation. All interviews were recorded, transcribed, and coded by two independent investigators. Interviews were conducted until thematic saturation and prominent themes were identified from coded data. RESULTS: A total of 32 interviews were completed with women and men faculty and residents. Prominent themes were identified representing compounding barriers to reporting. Participants described confusion over what constitutes a reportable definition of gender and sexual harassment, unfamiliarity with reporting processes, and multiple avenues (both informal and formal through departmental, hospital, and institutional systems) for reporting. Participants expressed limited confidence in formal reporting systems and related several perceived and actual negative outcomes of reporting. A number of improvements were recommended centering around creating reporting systems that supported, empowered, and protected survivors; improving transparency about reporting processes; and ensuring accountability at a departmental and institutional level. CONCLUSIONS: Significant barriers to reporting exist and deter individuals from reporting. Given the negative consequences of ongoing gender and sexual harassment, emergency departments and institutions must take responsibility to reduce barriers and support individuals throughout the reporting process.

How Should Emergency Department Clinicians Respond to Unmet Dental Needs?

The division between medical and dental care exacerbates health inequity and forces many with compromised access to seek oral health care in emergency departments (EDs). Since dentists are best positioned to offer quality care for most patients' oral health problems, this commentary on a case suggests why ED clinicians should offer appropriate oral health referrals and resources to those they serve and why all health professionals should advocate for systems-level policy and organizational changes to increase patients' access to oral health care.

Association of limited English proficiency and increased pediatric emergency department revisits.

OBJECTIVE: Limited English proficiency (LEP) is a risk factor for health care inequity and an important focus for improving communication and care quality. This study examines the association between LEP and pediatric emergency department (ED) revisits. METHODS: This was a retrospective, cross-sectional study of patients 0 to 21 years old discharged home after an initial visit from an academic, tertiary care pediatric ED from January 1, 2017, to June 30, 2018. We calculated rates of ED revisits within 72 h resulting in discharge or hospitalization and assessed rate differences between LEP and English-proficient (EP) patients. Multivariable logistic regression models examined the association between revisits and LEP status controlling for age, race, ethnicity, triage acuity, clinical complexity, and ED arrival time. Sensitivity models including insurance were also conducted. RESULTS: There were 63,601 index visits in the study period; 12,986 (20%) were by patients with LEP. There were 2,387 (3.8%) revisits within 72 h of initial ED visit. Among LEP and EP patient visits, there were 4.53 and 3.55 revisits/100 initial ED visits, respectively (rate difference = 0.97, 95% confidence interval [CI] = 0.58 to 1.37). In the multivariable analyses, LEP was associated with increased odds of revisits resulting in discharge (odds ratio [OR] = 1.15, 95% CI = 1.01 to 1.30) and in hospitalization (OR = 1.28, 95% CI = 1.03 to 1.58). Sensitivity analyses additionally adjusting for insurance status attenuated these results. CONCLUSIONS: These results suggest that LEP was associated with increased pediatric ED revisits. Improved understanding of language barrier effects on clinical care is important for decreasing health care disparities in the ED.

Increasing inclusivity in patient centered research begins with language.

Emergency departments frequently serve marginalized populations. Spanish-speaking families who come to the ED often have high rates of unmet social needs. Our study investigated how to efficiently screen families for unmet social needs in an emergency department. Participants who screened positive for needs were referred to geographically convenient, community-based resources. It became clear that barriers related to language discordance existed for recruiting Spanish-speaking participants that were not present for English-speaking participants, which we believe exacerbate existing inequities and must be addressed. We advocate for the extension of the Affordable Care Act Section 1557 to mandate expanded teams of interpreters to meet both clinical and research demands in conjunction with purposeful hiring of multilingual research assistants, along with concerted effort to standardize the certification process for multilingual staff. Prohibitive costs for the translation of written research materials need to be decreased and journals should evaluate submitted research with a language equity lens, which will help the field of clinical research prioritize inclusivity and diversity in research populations. Currently, systemic barriers complicate enrolling research participants who speak a language other than English, and we believe the proposed changes are feasible solutions to overcome these obstacles. Equitable representation in research is a critical part of addressing the legacy of oppression and exclusion within healthcare systems. Language equity is not a panacea for the distrust and systemic racism patients of color experience within our healthcare system that often prevent participation in clinical research, but it is a key first step.

Geographically Indexed Referral Databases to Address Social Needs in the Emergency Department.

INTRODUCTION: Unmet health-related social needs (HRSN) are among the drivers of disparities in morbidity and mortality during public health emergencies such as the novel coronavirus 2019 (Covid-19) pandemic. Although emergency departments (ED) see a high volume of patients with HRSN, ED providers have limited time to complete detailed assessments of patients' HRSN and are not always able to provide up-to-date and comprehensive information to patients on available community resources. Electronic, geographically indexed resource database systems have the potential to provide an efficient way for emergency physicians to rapidly identify community resources in settings where immediate social work consultation is not accessible. METHODS: We conducted a systematic review of papers examining the use of geographically indexed resource database systems in healthcare to better understand how these services can be used in emergency care. We then conducted simulated, standardized searches using two nationally available databases (211 and Aunt Bertha), applied to a single metropolitan area (Boston). RESULTS: Our systematic review found that most public health and screening interventions using nationally available databases have focused on chronic care needs. A small subset of publications demonstrated that these databases were mobilized during disasters to successfully aid vulnerable populations during Hurricanes Katrina and Rita. A total of 408 standardized searches were conducted to identify community resources related to four domains of social needs (food, transportation, housing, and utilities). Although 99% of the resources identified by both databases were relevant to the search domains queried, a significant proportion of the resources identified by each database were restricted to a specific demographic (eg, veterans). CONCLUSION: Our findings demonstrate that geographically indexed referral databases may be an effective tool to help ED providers connect patients to nearby community resources during public health emergencies. We recommend that EDs select a referral database based on the greatest number of resources that are not demographically restricted.

Improving Understanding of Screening Questions for Social Risk and Social Need Among Emergency Department Patients.

INTRODUCTION: With recent healthcare policy changes, including the creation of accountable care organizations, screening for social risks such as food and housing insecurity has become increasingly common in the healthcare system. However, the wide variety of different tools used for screening makes it challenging to compare across systems. In addition, the majority of tools used to measure social risks have only been tested in primary care settings and may not be optimal for emergency department (ED) use. Therefore, the goal of this study was to create a brief social screening tool for use in EDs. METHODS: We developed an initial tool using publicly available questions corresponding to the five core categories of the Centers for Medicare & Medicaid Services' Accountable Health Communities Screening Tool. Iterative cycles of cognitive interviews with purposively sampled participants were performed using a hybrid model of think-aloud and verbal probing to understand/experience answering questions and potential comprehension challenges. After thematic saturation was reached in one cycle, the tool was changed per participant input; cycles were completed until thematic saturation was reached overall. RESULTS: A total of 16 participants (six patient guardians and 10 patients) completed cognitive interviews throughout three cycles. Participant feedback included suggestions for further clarification and simplification of survey questions for improved comprehension. The survey was thus reduced and simplified from 16 questions concerning five domains to 10 questions concerning four domains. CONCLUSION: We used an iterative cognitive interviewing process to develop a social screening tool for use in EDs. This process demonstrates the importance of patient input to refine questionnaires, and provides a brief screening tool for ED use.

Patient and Community Organization Perspectives on Accessing Social Resources from the Emergency Department: A Qualitative Study.

INTRODUCTION: Social risks adversely affect health and are associated with increased healthcare utilization and costs. Emergency department (ED) patients have high rates of social risk; however, little is known about best practices for ED-based screening or linkage to community resources. We examined the perspectives of patients and community organizations regarding social risk screening and linkage from the ED. METHODS: Qualitative interviews were conducted with a purposive sample of ED patients and local community organization staff. Participants completed a brief demographic survey, health literacy assessment, and qualitative interview focused on barriers/facilitators to social risk screening in the ED, and ideas for screening and linkage interventions in the ED. Interviews were conducted in English or Spanish, recorded, transcribed, and coded. Themes were identified by consensus. RESULTS: We conducted 22 interviews with 16 patients and six community organization staff. Three categories of themes emerged. The first related to the importance of social risk screening in the ED. The second category encompassed challenges regarding screening and linkage, including fear, mistrust, transmission of accurate information, and time/resource constraints. The third category included suggestions for improvement and program development. Patients had varied preferences for verbal vs electronic strategies for screening. Community organization staff emphasized resource scarcity and multimodal communication strategies. CONCLUSION: The development of flexible, multimodal, social risk screening tools, and the creation and maintenance of an accurate database of local resources, are strategies that may facilitate improved identification of social risk and successful linkage to available community resources.