Dr. Seth Berkowitz and Economist Hunt Alcott join us to discuss nutrition, food insecurity, and their relevance to emergency medicine. What questions can we ask to identify food insecurity quickly? What resources can we offer patients? How might it affect our clinical decision making?     Objectives: Explore how nutrition affects the health of patients in the ED Identify factors that contribute to patient’s nutritional status Understand how to effectively and efficiently address nutrition with ED patients Take-home points: Food insecurity can play a critical role in the health outcomes of ED patients in the following ways: Food insecurity can lead to poor quality diet with health consequences Patients with food insecurity may have competing demands. If you are worrying about paying for meals, you might have to decide between food and important issues like housing or medications, all of which can affect your health. High levels of stress related to food can put a strain on a patient’s mental and physical health. Know your hospital and community’s ability to address food insecurity. If a patient screens positive on the Hunger Vital Sign, you can link them to community resources like food pantries, SNAP or WIC. Consider screening your patients for food insecurity using the Hunger Vital Sign (see link in references).  Low income neighborhoods have less access to lots of things, including grocery stores. Many stores in these neighborhoods limit options for healthy eating. Nutrition education for your patients can make a difference. Recognize that nutrition education may be the limiting factor as to why your patients are not eating nutritious food, so taking a moment to talk about it can make a difference. Be mindful of how food access may affect your treatment plan for your patient, particularly with food-sensitive conditions like diabetes.  Additional Resources: Food Deserts and the Causes of Nutritional Inequality, Alcott et al.   Health effects of dietary risks in 195 countries, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017, The Lancet.  The Hunger Vital Sign Gattu RK, Paik G, Wang Y, Ray P, Lichenstein R, Black MM. The Hunger Vital Sign Identifies Household Food Insecurity among Children in Emergency Departments and Primary Care. Children (Basel). 2019;6(10):107. Published 2019 Oct 2. doi:10.3390/children6100107 SNAP-ED   Guests: Dr. Seth Berkowitz is an assistant professor in the division of general medicine and clinical epidemiology of medicine at the University of North Carolina and has done extensive research on food insecurity and its relation to human health, particularly in low-income patients and patients suffering from type II diabetes. Hunt Allcott is an Associate Professor of Economics at NYU whose research includes investigation on consumer behavior.  He recently co-authored a 2018 study entitled “Food Deserts and the Causes of Nutritional Inequality”.    Contributors: Bobby Needleman Dennis Hsieh Shannon Moffett Tony Spadaro 

Announce

Nutrition and Food Insecurity

Drs. Otis Warren and Shannon Smith-Bernardin join us to discuss how alcohol relates to social issues. What more can we do for patients that are brought in drunk? What solutions exist at both the individual ED and healthcare system level?  Objectives:  Understand the challenges in treating alcohol use disorder in the emergency department Understand alcohol use in the context of social determinants of health Learn about diversion/sobering centers and their potential impact on the treatment of alcohol use disorder and emergency departments Take-home points:  Alcohol use disorder is a chronic disease that should be treated as such. Many of the drivers of alcohol-related ED encounters, however, are driven by social factors.  Sobering centers are an alternative to the emergency department or jail for people who are acutely intoxicated on alcohol. Diversion is a triage system that is based on an agreement between law enforcement and EMS allowing for diversion of intoxicated patients to sobering centers if they meet certain criteria.    Additional resources:  Warren O, Smith-Bernardin S, Jamieson K, Zaller N, Liferidge A. Identification and Practice Patterns of Sobering Centers in the United States. J Health Care Poor Underserved. 2016;27(4):1843‐1857. doi:10.1353/hpu.2016.0166 Smith-Bernardin SM, Kennel M, Yeh C. EMS Can Safely Transport Intoxicated Patients to a Sobering Center as an Alternate Destination. Ann Emerg Med. 2019;74(1):112‐118. doi:10.1016/j.annemergmed.2019.02.004 Smith-Bernardin S, Carrico A, Max W, Chapman S. Utilization of a Sobering Center for Acute Alcohol Intoxication. Acad Emerg Med. 2017;24(9):1060‐1071. doi:10.1111/acem.13219   Guests: Shannon Smith-Bernardin Dr. Smith-Bernardin is a professor at UCSF and has a PhD in nursing and health policy. She has extensive experience with sobering centers and diversion programs and has studied their safety, effectiveness, and implementation.   Otis Warren Otis Warren is an Associate Professor of Emergency Medicine at Brown University. Dr. Warren has been a champion for sobering centers in and around Providence, RI. He and Dr. Smith-Bernadin authored "Identification and Practice Patterns of Sobering Centers in the United States" in the Journal of Health Care for the Poor and Underserved, helping launch the national debate on diversion of intoxicated patients away from emergency departments and to sobering centers.   Contributors: Charles Zhang Harrison Alter Livia Santiago-Rosado Austin Tam 

Alcohol

Across the US, LatinX and Black people are dying from COVID-19 at twice the rate of their white counterparts. In this special episode of Announce, hosts Drs. Ayesha Khan & Quincy Moore explore some of the issues underlying these disparities and what EM providers need to be aware of to combat them.   Additional Resources: As a doctor, how do I tell a black family of five, struck by the virus, to ‘social distance’ in a two-bedroom apartment? -- Garth Walker   COVID-19 Racial Disparities in U.S. Counties, The Foundation for AIDS Research.   Vahidy FS, Nicolas JC, Meeks JR, et al. Racial and Ethnic Disparities in SARS-CoV-2 Pandemic: Analysis of a COVID-19 Observational Registry for a Diverse U.S. Metropolitan Population. medRxiv. January 2020:2020.04.24.20073148. doi:10.1101/2020.04.24.20073148   Guests: Dr. Garth Walker is an emergency physician in Chicago whose research focuses around health disparities and social determinants of health.   Dr. Italo Brown is an emergency physician at Stanford with an interest in health equity, and barbershop-based health initiatives.   Dr. Moises Gallegos is an emergency medicine physician at Stanford. He is a Faculty Fellow at the Hispanic Center of Excellence.    Contributors: Quincy Moore   Ayesha Khan    

Health Disparities in the Time of COVID

Drs. Sheryl Heron and Camara Phyllis Jones join us to discuss race and how it affects our practice in the ED.   Objectives:  Debunk misunderstandings about the biological basis of race Analyze the relationship between race, social determinants of health, and health outcomes Discuss interventions that work to improve racial health disparities Predict how race may play a role in current policy and public health problems   Take-home points:  Race is a social, not biological, construction  Ancestry is poor marker genetics, and race a poor indicator of ancestry Racial health disparities are driven by racial disparities in social determinants of health Residential segregation is a large driver of disparities in SDH Working deliberately to treat racial groups similarly on individual and population levels is necessary to ameliorating racial health disparities   Additional resources:    Allegories on Race and Racism. Camara Jones, TEDxEmory https://www.youtube.com/watch?v=GNhcY6fTyBM   Cohan D, Racist Like Me — A Call to Self-Reflection and Action for White Physicians. N Engl J Med 2019; 380:805-807   Jones CP. Levels of Racism: A Theoretical Framework and a Gardener’s Tale. Am J Public Health 2000; 90:1212-1215    Williams DR, American A, Wyatt R. Racial Bias in Health Care and Health Challenges and Opportunities. JAMA 2015;314(6):555–6   Washington, HA. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present.  Harlem Moon an imprint of DoubleDay Publishing 2007   Guests:   Sheryl L. Heron, MD, MPH, FACEP Sheryl Heron is a Professor and Vice Chair of Administrative Affairs in Emergency Medicine and an Assistant Dean of Medical Education and Student Affairs at Emory University. While her accomplishments are too numerous to list, her 20 year career in emergency medicine, academia and public health, has led to national recognition as an expert on diversity and inclusion in medicine. Dr. Heron has also lectured and published extensively on diversity and inclusion in medicine. Most recently, she served as co-editor of the textbook, Diversity and Inclusion in Patient Care.   Camara Phyllis Jones, M.D., M.P.H., Ph.D Jones is a former president of the American Public Health Association and Adjunct Professor at the Morehouse School of Medicine and Emory Rollins School of Public Health. She has also served as the Research Director on Social Determinants of Health and Equity in the Division of Adult and Community Health at the CDC. As a family physician and epidemiologist, Dr. Jones’s work focuses on the impacts of racism on the health and well-being of the nation. From TED talks to National Symposia, Dr. Jones’ allegorical pedagogy has elevated the national dialogue on race and health.   Contributors: John Lewis Dan Gingold Sean Schnarr Jenny Tsai

Race

Our team took a breather for the holidays. Tune in February 1st for another episode!

Happy New Year!

In the U.S., a homeless person’s lifespan is 25 years less than average. In this episode, hosts Dr. Ayesha Khan & Dr. Quincy Moore explore how the EM providers can be pivotal in improving health outcomes for those that lack basic shelter with Dr. Kelly Doran and Stephen Brown.   Objectives:   1.     Describe how housing and homelessness affect a person's health and health outcomes 2.     Describe why emergency physicians should be addressing housing and homelessness 3.     Define important terms relevant to housing and homelessness: transient, intermittent, and chronic 4.     Highlight strategies for eliciting key information from patients 5.     Discuss how best to process and address a patient’s housing status in the ED   Additional Resources: Housing and Health: An Overview of Literature https://www.healthaffairs.org/do/10.1377/hpb20180313.396577/full/ https://www.rwjf.org/en/library/research/2011/05/housing-and-health.html Medical Respites https://nhchc.org/clinical-practice/medical-respite-care/ How Can Emergency Departments Help End Homelessness? A Challenge to Social Emergency Medicine https://www.clinicalkey.com/#!/content/journal/1-s2.0-S0196064419311266   Uptodate: Healthcare of Homeless Persons in the United States https://www.uptodate.com/contents/health-care-of-homeless-persons-in-the-united-states?search=homelessness&source=search_result&selectedTitle=1~102&usage_type=default&display_rank=1   Take-home points:    1. There are 3 definitions within the category of homelessness.   Transitionally homeless: 80% of homeless individuals in the U.S. Often times these are people who have fallen off the grid maybe due a financial catastrophe and they're mostly back into housing within 3 months.   Episodic homelessness: People that are in and out of housing, couch surfing, or intermittently employed.  Many of the people that age out of foster care belong to this group. There's less known about this population.  Often, they also have a subacute mental illness that make it difficult to get the care they need.   Chronic homelessness: 10% of the overall homeless population, tend to have high comorbidity with psychiatric illness and substance abuse.  They're usually older and they're continually homeless over one year or homeless 4 times in the past 3 years. These tend to be the ones that are most easily identifiable in the ED.   2. With just 10% of homelessness being chronically homeless, we need to do a better job routinely asking people about their housing status.  Possible questions to identify homelessness in your history include: "Where have you been staying at these days?"    Ask a follow-up question like "Is that an apartment?  Someone else's house? A shelter?" 3. When dispositioning your patient, consider the treatment plan and if the patient is in a place they can follow it. Even shelters do not provide 24hour sheltering. Consider medical respite or admission if needed. 4. Half of homelessness is in urban areas, 25% in suburban areas, and 18% in rural areas.   5. Ideally when we think about homelessness, we're trying to address the tri-morbidity of homelessness, substance use, and psychiatric illness.  6. Don't forget, help your patient get undressed and do a physical exam.  It can be dangerous to avoid doing this.   7. This is a difficult population to work with and no one has all the answers including both of our experts, but it's important to recognize how challenging this is and support our especially young providers in trying to treat these patients even when you don't have a ton of resources.  Try to make a difference in policies locally and nationally or even within your hospital to both help the problem and help a little bit with your tolerance of day-to-day frustrations. Connect to partners in the community or the Public Health Department to find collaborators. Emergency physicians really are the experts in homelessness and we can make a big difference in people’s lives.     Contributors:   Crystal Donelan Sonal Batra Dennis Hsieh David Cheever Alexander Ulintz     Guests: Dr. Kelly Doran is an emergency physician and faculty in the NYU School of Medicine Departments of Emergency Medicine and Population Health who studies how healthcare systems can better address homelessness and other social determinants of health. Her research on homelessness has been published extensively and she was previously an advisor to the New York State Department of Health on an innovative program to use Medicaid funds to support housing.   Stephen Brown is a MSW LCSW who is faculty and Director of Preventative Emergency Medicine at the University of Illinois at Chicago.  After a career in business, he switched gears to work as a social worker in the ED and soon afterward, was promoted to build a program to provide care coordination for high-utilizers of the ED.  He is now the program director for Better Health Through Housing which transitions patients that are chronically homeless into permanent supportive housing. His work on this project has been featured in the Chicago Tribune.

Homelessness

Objectives: -       To introduce the concept of social determinants of health -       To outline the ways in which social determinants of health affect the practice of emergency medicine -       To highlight key reasons why emergency providers should care about social determinants of health -       Introduce ways in which emergency providers can effectively identify social issues that might be affecting their patients’ health     Take-home points: -       Try to avoid compartmentalizing your patients’ health. Social issues affect their health and you should take the time to identify and address them in the emergency department. -       Recognize when it is important to practice “slow medicine” and take the time to talk with your patients about how you can best help them. -       To change the culture of your department, first try to find, or create, impactful data. Then seek out funding to support your work. Data and funding will help garner support. -       Think about how you can make an impact on the population level. Be bold. Step outside your comfort zone and always do the right thing for the patient.   Additional resources: A centralized website for all things Social EM, highlighting important literature, a library of social EM initiatives, and creating a network for the social EM community.  www.SocialEMpact.com   ACEP Social Emergency Medicine Section. https://www.acep.org/how-we-serve/sections/social-emergency-medicine/   SAEM Social Emergency Medicine and Population Health Section. https://www.saem.org/resources/social-emergency-medicine-and-population-health/research   "Inventing Social Emergency Medicine," supplement to Annals of Emergency Medicine www.annemergmed.com/issue/S0196-0644(19)X0013-X   Anderson ES, Lippert S, Newberry J, Bernstein E, Alter HJ, Wang NE. Addressing social determinants of health from the emergency department through social emergency medicine. Western Journal of Emergency Medicine. 2016 Jul;17(4):487.   Alter HJ. Social determinants of health: from bench to bedside. JAMA internal medicine. 2014 Apr 1;174(4):543-5.   IDHEAL Social Emergency Medicine Teaching Modules. http://www.idheal-ucla.org/page-12/ Episode transcript   Contributors: Ayesha Khan Quincy Moore    

Structural determinants of health and unmet social needs

Objectives: Outline the scope of the opioid epidemic as it relates to Emergency Medicine Detail innovative treatment options for opioid use disorder and overdose Discuss strategies and barriers to implementing ED-based Medication for Opioid Use Disorder (MOUD) Provide possible future strategies and necessary policy changes   Take-home points:  Opioid use disorder is a disease that is often chronic and relapsing Prescribing buprenorphine is easy and it only takes one person to start doing it. See the show notes for resources to help.  It’s helpful to have a champion for OUD treatment in the ED. The medical director is well positioned for this.  Find a community champion who can help continue treatment outside of the ED Stigma affects both providers and patients. Learn your terms and try to be consistent with their use: opioid use disorder (OUD), Medication for Addiction Therapy (MAT), and Medication for Opioid Use Disorder (MOUD).  Treatment for OUD can be with naltrexone, methadone, and buprenorphine. Buprenorphine is a partial opioid agonist and the best-suited for ED treatment.  You can use the COWS score to assess your patients for opioid withdrawal.   Outside resources:  Emergency Department Contribution to the Prescription Opioid Epidemic https://www.ncbi.nlm.nih.gov/pubmed/29373155 What Role Has Emergency Medicine Played in theOpioid Epidemic: Partner in Crime or Canary in theCoal Mine? https://www.annemergmed.com/article/S0196-0644(18)30046-5/pdf ACEP opioid resources https://www.acep.org/by-medical-focus/mental-health--substance-abuse/opioids/#sm.0001e74hrth2sdxcqs82pd3l195ch Emergency department–initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial https://www.ncbi.nlm.nih.gov/pubmed/25919527   Resources that support medication-based treatment in the ED https://medicine.yale.edu/edbup/ https://www.bridgetotreatment.org/   Contributors: John Purakal Maureen Gang Caleb Scarth Nate Coggins Guests: Gail D’Onofrio, MD, MS, is the chair of emergency medicine at Yale Medicine. She is internationally known for her work in substance use disorders, women’s cardiovascular health, and mentoring physician scientists in developing independent research careers. For the past 25 years she has developed and tested interventions for alcohol, opioids and other substance use disorders, serving as the principal investigator (PI) on several large NIH, SAMSHA, and CDC studies. She is a founding Board member of Addiction Medicine, now recognized as a new specialty, subspecialty by the American Board of Medical Specialties. Lewis Nelson, MD, is Professor and Chair of the Department of Emergency Medicine and Chief of the Division of Medical Toxicology at Rutgers New Jersey Medical School in Newark, NJ. He is a member of the Board of Directors of the American Board of Emergency Medicine and a Past-President of the American College of Medical Toxicology. He is actively involved with several governmental and professional organizations and is an editor of Goldfrank’s Toxicologic Emergencies. His areas of specific interest include consequences of opioids, pain management, and emerging drugs of abuse.

Opioids

 Objectives: Explain what it means to view firearm violence as a public health problem.  Describe the roles of the emergency physician in addressing firearm violence. Recognize that access to firearms make suicide attempts more likely to succeed. Identify barriers to conducting research on firearm violence Resources: Provider resources: What Can You Do: UC Davis Violence Prevention Research Program: https://www.ucdmc.ucdavis.edu/vprp/WYCD.html American Association of Pediatrics: Addressing Gun Violence https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Pages/Unintentional-Injury-in-Practice.aspx  Resources for talking to patients about gun safety: Office of the Attorney General of Massachusetts. https://www.mass.gov/lists/resources-for-talking-to-patients-about-gun-safety   Firearm research and publications  Wintemute GJ, Betz M, Ranney M. Yes, You Can: Physicians, Patients and Firearms. Ann Intern Med. 2016;165(3):205-213. http://annals.org/aim/fullarticle/2522436/yes-you-can-physicians-patients-firearms  Carter PM, Walton MA, Zimmerman MA, Chermack ST, Roche JS, Cunningham RM. Efficacy of a Universal Brief Intervention for Violence Among Urban Emergency Department Youth. Acad Emerg Med. 2016 Sep;23(9):1061-70. doi: 10.1111/acem.13021. Epub 2016 Sep 7. https://www.ncbi.nlm.nih.gov/pubmed/27265097  Ranney ML, et al. A Consensus-Driven Agenda for Emergency Medicine Firearm Injury Prevention Research. Ann Emerg Med. 2017 Feb;69(2):227-240. https://www.ncbi.nlm.nih.gov/pubmed?term=A+consensus-driven+agenda+for+emergency+medicine+firearm+injury+prevention+research&TransSchema=title&cmd=detailssearch  Pallin R, Spitzer S, Ranney M, Betz M, Wintemute GJ. Preventing Firearm-Related Death and Injury. Ann Intern Med. 2019;170(11):ITC81-ITC96.  https://annals.org/aim/fullarticle/2735389/preventing-firearm-related-death-injury Transcript   Take-home points:  As emergency physicians, we are directly exposed to the toll of firearm violence, but also uniquely positioned to address it. Although mass shootings are a serious problem and attract a lot of media attention, the majority of firearm deaths in the USA are actually suicides. Firearm violence is a public health problem like drunk driving, and needs to be addressed on multiple levels of prevention. Research has been limited by political constraints on funding, and more data is needed to find the most effective solutions.   Contributors: Risha Cohen Vidya Eswaran Erik Kramer Aislinn D. Black   Guests: Dr Marian Emmy Betz is an Associate Professor of Emergency Medicine and in the School of Public Health at the University of Colorado.  You may have seen her TedX talk on how to talk about guns and suicide which highlights her interests in both suicide prevention and injury prevention.  She also has an extensive research background.   Dr Megan Ranney is an Associate Professor of both Emergency Medicine and Health Services Policy and Practice at Brown University.  She has an extensive research background and is the chief research officer for Affirm (The American Foundation for Firearm Injury Reduction in Medicine). 

Firearm Violence

In our debut episode, hosts Drs. Ayesha Khan & Quincy Moore along with special guest host Dr. Vibha Gupta sit down with our guests, Dr. Mary Cheffers (LA County), Dr. Todd Schneberk (LA County) and Mrs. Mayra Joachin (Attorney, National Immigration Law Center) to discuss what emergency providers should know about their patients with immigration-related issues.   Objectives: Learn the effects of anti-immigrant legislation on seeking care and ED presentation Learn barriers immigrants and undocumented patients face in seeking care Learn what rights undocumented patients in the ED have Learn where you can connect your patients to legal aid and healthcare resources Know your options when ICE shows up to your ED   Resources: Community health centers, migrant health centers, and free clinics https://findahealthcenter.hrsa.gov https://www.nafcclinics.org/find-clinic Legal aid Nonprofit organizations that provide low-cost help https://www.immigrationlawhelp.org List of lawyers that provide free services via immigration courts https://www.justice.gov/eoir/list-pro-bono-legal-service-providers Search engine for legal services near you https://www.adminrelief.org American Immigration Lawyers Association’s online directory https://www.ailalawyer.com National Immigration Project of the National Lawyers Guilde https://www.nationalimmigrationproject.org/find.html National Immigration Law Center Health Care Toolkits - https://healthtoolkit.nilc.org  How to make sure your ED is safe space Signs / posters / message to patients (in various languages) Know-your-rights cards for patients  Designating private and public spaces Make an ED protocol for interaction with ICE authorities Relationship with legal team  Transcript   Take-home points:  All ED docs are going to encounter undocumented immigrants in the ED and in the community Understand the barriers to care- much is related to fear ED docs can be advocates and create a safe space- create posters, talk to your hospital administration to come up with programs/direct people to resources Patients present to the ED more and more critically ill because they delay care  It is important to note that the protections that HIPAA provides as well as the stance on whether or not it is best to document a patient's immigration status in their medical record is controversial. The NILC states "Providers are strongly encouraged to avoid collecting or recording immigration-related information in the event that they are legally required to disclose their otherwise protected information". For further discussion of this challenging question, please reference the NILC Healthcare Toolkit or your hospital's legal department. Contributors: Vibha Gupta Lia Losonczy Sonali Gandhi Annette Dekker Jorge Aceves   Funding Acknowledgment - The development of this video podcast series was supported by a section grant of the American College of Emergency Physicians awarded to the ACEP Social Emergency Medicine Section. 

Immigration

Announce is a podcast series covering core concepts in Social Emergency Medicine. National experts discuss topics such as firearm violence, immigration, race, opioids, and more. The podcast is relevant to anyone in the healthcare field, particularly attendings, residents, medical students, and other emergency providers. Episodes are released monthly. This podcast is supported by American College of Emergency Physicians and Stanford University.

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Announce

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