1. Purpose and scope

This policy relates to the role of emergency departments (EDs) and ACEM Fellows and trainees in supporting public health initiatives. The policy is applicable to emergency departments throughout Australia and Aotearoa New Zealand.

2. Definitions

Emergency medicine

Emergency medicine is a field of practice based on the knowledge and skills required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury affecting patients of all age groups with a full spectrum of episodic undifferentiated physical and behavioural disorders; it further encompasses an understanding of the development of pre-hospital and in-hospital emergency medical systems and the skills necessary for this development. (International Federation for Emergency Medicine 1991)

Public health

Public Health is the art and science of preventing disease, prolonging life and promoting health through the organised efforts of society. (WHO)

3. Policy

ACEM believes that emergency medicine has important and unique roles and responsibilities in the advancement of public health. Emergency medicine has significant overlays with public health, particularly in three key areas:

1. Health protection: Prevention and control of infectious disease risks and protecting against chemical, biological, radiation and environmental hazards (WHO)¹.
2. Health promotion: Activities at an individual, community and societal scale that seek to empower individuals to increase control over their own health. This encompasses activities that seek to promote wellbeing as well as preventing the root causes of disease. This incorporates the social determinants of disease and a focus on addressing health inequities. (WHO Ottawa Charter)².
3. Emergency Management and Disaster Response: Coordinating and responding to the health aspects of disaster events, including infectious disease outbreaks and pandemics, natural disasters, climate change and other health emergencies.

Examples of the ways in which emergency medicine contributes to public health are diverse. These include, but are not limited to:

• Disease, injury and health risk surveillance
• Provision of primary healthcare access to all members of society without discrimination
• Delivery  and  promotion  of  preventive  care  and  interventions,  where  appropriate,  for  example vaccinations that are clinically indicated in the ED
• Secondary and tertiary disease prevention
• Social crisis intervention and referral
• Health education initiatives
• Advocacy and development of policies to protect the health of the wider community
• Clinical and health systems research to advance population health^3,4

It is essential that emergency physicians and trainees recognise the roles that they have in contributing to and advancing public health, and are equipped and empowered to fulfill such roles. Correspondingly, EDs and ACEM have a role in supporting emergency physicians and trainees in this regard as well as engaging in relevant public health advocacy and action at their respective levels.

4. Procedures and actions

ACEM recognises and endorses an active role for EDs in national and international strategies aimed at emphasising the prevention of illness and injury and the promotion of healthy lifestyles. ACEM appreciates that public health is core to the practice of emergency medicine and must be embedded as a principle in all aspects of emergency medicine provision and training, including curriculum design, clinical practice, research and policy development. Public health roles and actions within each of these functional areas as they relate to emergency medicine and emergency clinicians are described further below.

4.1 Quality clinical care / practice

Inclusion of appropriate, evidence-based health promotion and prevention activities is standard of care for every clinical encounter, including in the ED.

All EDs should take every opportunity and be resourced to promote health and prevent illness and injury through the display and provision of health promotion materials. The best available information should be accessible and provided to patients. EDs should have procedures in place which ensure that every clinical contact is an opportunity to promote health and prevent illness and injury.

This may include but is not limited to participation in the following activities:

• Screening for drug and alcohol misuse, and undertaking brief interventions where appropriate

• Screening for family violence with appropriate referral and meeting mandatory reporting obligations where required

• Establishing linkages with support services which address social determinants of health (e.g., community-based geriatric supports, drug and alcohol services, housing assistance services, family violence support services and so forth.)

• Screening for tobacco use and promoting smoking cessation

• Promoting healthy eating and exercise programs

• Advocacy and advice on safe public health practices, especially during disasters, such as physical distancing and wearing of face masks

• Advocacy and advice on practical measures to take in regard to adverse environmental conditions, such as heatwaves, bushfires and prolonged smoke events

All ED care should also seek to provide individual patients and their families with appropriately tailored care that acknowledges the impact of their social and cultural context on their experience of health and illness. Although problems may be beyond the scope of the ED to resolve, failure to recognise and seek to address the impact of the social determinants of health will undermine efforts to improve individual and community health.

This may include but is not limited to the following activities:

• Appropriate use of interpreting services and cultural liaisons

• Appropriate referral to social work and allied health services

• Establishment of referral processes for homeless health support services

• Partnerships with community based and primary care services to improve collaboration in the management of priority populations, including First Nations Communities, people living with chronic conditions, mental health issues or addiction and the prison population

• Pathways to support medication access for those living with severe economic constraints

Finally, ED care should recognise and maintain its vital role in health equity. The ED represents an important safety net for vulnerable and marginalised populations. For many of these people, the ED may be their only contact with the health system, and therefore represent the only opportunity for healthcare provision, including for preventive care and health promotion.

Public health actions in ED clinical care and practice are supported by a previous survey of FACEMs andAdvanced Trainees, which found that 72% agreed that public health initiatives should be provided in the ED.⁵

However, ACEM recognises that the complexities and challenges of providing acute care can impede the capacity for EDs to provide comprehensive and holistic patient- and family-centred care that we aspire towards.

4.2 Training and education

ACEM recognises the importance and relevance of public health skill sets for emergency physicians and trainees. This is established in the ACEM Curriculum Framework⁶, predominantly under the Health Advocacy domain, but also in various competencies within the Communication, Scholarship and Teaching, and Professionalism domains.

ACEM recognises that the curriculum needs to be responsive to the public health knowledge and skill set needs of emergency physicians and trainees to meet emerging public health challenges as they relate to emergency medicine, and will require adaptation, enhancement and/or specification of additional knowledge and competencies. For example, important emergent areas for enhancement and inclusion (at the time of this revision) are responding to pandemics and public health emergencies and addressing climate change and health.

ACEM will continue to ensure that emergency physicians and trainees are adequately equipped with the necessary public health competencies (as prescribed in the ACEM Curriculum Framework) by routine assessment of these competencies, including within examinations and workplace based and summative assessments.

ACEM will seek and support opportunities for emergency physicians and trainees to gain and advance public health skills and experience, including:

• Identifying, accrediting and promoting CPD activities in public health with relevance to emergency medicine, such as courses or conferences on climate change and health
• Promoting and facilitating opportunities for funded and accredited trainee rotations in Public Health Medicine, Refugee Health, Indigenous Health, Global Health and other relevant areas for developing public health skill sets⁷
• Engaging in College and institutional partnerships to explore and facilitate advanced training and credentialing opportunities in Public Health Medicine, such as dual FACEM/FAFPHM training pathways or post-FACEM Fellowships⁸

EDs should encourage and support their emergency physicians and trainees in gaining and applying public health skills and experience relevant to emergency medicine. This may include:

• Ensuring public health principles and practices, such as health promotion, social determinants of health and health equity, are applied and measured as part of quality clinical care in the ED

• Incorporating public health competencies within training and assessment activities

• Supporting research activities in public health related areas such as health systems and ED access, public health emergency and disaster management, climate change and health, ED health promotion initiatives etc.

• Seeking and supporting opportunities for trainee non-ED rotations to Public Health Medicine

• Supporting emergency physicians and trainees in engaging in relevant public health initiatives and advocacy activities at departmental, organisational and/or community levels

4.3 Research

Research that supports the provision of evidence-based, high-value quality care aligns with public health research priorities. ACEM recognises the obvious value in research undertaken in Australasian EDs to provide a local evidence-base for quality improvement activities at practitioner, departmental and health system levels. EDs create rich data sets through routine patient care, but this is often underutilised. ACEM recognises the need for more investment and support for surveillance and IT systems that will simplify processes for translational research in EDs. To enable research at a population level, partnerships that support sharing of departmental, district or network, and jurisdictional datasets should be normalised.

Research that seeks to integrate, evaluate and improve the delivery of preventative care in EDs is as valuable as that which seeks to address clinical and technical innovations. For example, management of modifiable risk factors is vital to preventing mortality from non-communicable diseases, but further research is needed to tailor effective delivery of brief interventions for the ED setting and specific priority populations. Risk factor management can be considered as equally as important as delivering safe medical care in reducing mortality for major causes of death, like coronary heart disease, at a population level.⁹

Beyond this, however, ACEM also recognises the importance of supporting well-designed research conducted in Australasian EDs that has implications for broader public health policy, programmes and advocacy. This approach is perhaps best exemplified by ACEM’s research quantifying the burden of alcohol and other drugs on EDs. Since 2013 ACEM has conducted research, including Alcohol Harm Snapshot Surveys (also include methamphetamine-related presentations since 2018), seven-day continuous surveys and ED staff perception surveys.¹⁰ This work has helped to elucidate the true impact of community substance use on EDs, filling in gaps caused by nationally inconsistent data. This work is extremely valuable in supporting ACEM’s advocacy activities calling for policy and resources to prevent alcohol and other drug related harms in the community.

There is vast scope for further research in EDs exploring issues of public health significance, particularly where this aligns with unmet patient and community needs and ACEM advocacy priorities. In anticipating the worsening health impacts of climate change, research on its health impacts such as ED presentations, will be vital to guiding mitigation and adaptation efforts. Assessment and evaluation of disaster response is important for continuous quality improvement to guide future recovery, planning and preparation. The research requirement for Advanced Trainees provides an avenue for engagement with public health issues that align with local departmental priorities. Opportunities to disseminate and celebrate such work should continue to be strengthened.