Follow 7 Principles for Disease and Risk Factor Screening in Emergency Departments

By Christopher Cheney

Health systems and hospitals should follow seven principles to conduct screening for disease or health risk factors in emergency departments, according to a new journal article.

Particularly for patients with limited resources, the emergency department is a key access point for care. Screening for disease and health risk factors in the emergency department can boost individual and population health.

There is a tremendous opportunity to conduct screening in emergency departments. Research has shown that about half of U.S. adults over age 35 have not received screening for common health risk factors such as tobacco use and depression.

The new journal article, which was published by Annals of Emergency Medicine, identifies seven principles for conducting disease and health risk screening in emergency departments.

1. Screening should be conducted with evidence-based practices from established sources such as the United States Preventive Services Task Force (USPSTF) and the Centers for Disease Control and Prevention. For example, the USPSTF has made several screening recommendations for substance use disorders, HIV, suicide, and other conditions in the emergency department setting.

2. Emergency department screening should account for local disease and health risk factor epidemiology.

“The epidemiology of a disease can vary substantially by geography. Furthermore, risk factors, including social determinants of health, are highly variable depending on community resources. Screening is most efficient when the prevalence of a disease or risk factor meets a clinically significant threshold in the screened population. However, epidemiology must be considered in conjunction with the potential morbidity and mortality associated with the disease or risk factor, test characteristics (including material and staff costs), and feasibility of the intervention,” the journal article’s co-authors wrote.

3. Screening should only be conducted in the emergency department as long as primary ED functions and quality metrics are not disrupted. “Although population health initiatives encourage a broader perspective on ED visits, screening should not detract from the primary purpose of the ED: management of acute illness and injury. Furthermore, an increased length of stay in the ED is associated with decreased patient satisfaction and increased morbidity and mortality,” the journal article’s co-authors wrote.

4. Screening should be designed to limit the burden on ED clinical staff. “Clinical staff in the ED often faces mismatched patient/staff ratios, boarding of admitted patients, and crowding. Adding numerous screening questions can detract from their care of emergency conditions. Shifting screening and referral roles to dedicated patient navigators or other nonclinical staff can focus clinician time on evaluation and treatment,” the journal article’s co-authors wrote.

5. Screening should be based on transparency and communication with patients and the community. “Many screening topics involve stigmatizing conditions, and those developing screening initiatives should attempt to educate patients and the broader community about the rationale behind the screening. Public awareness campaigns in the community, signage around the ED, and patient handouts can help patients anticipate the screening. Upfront discussions with the patient also help avoid surprise results, especially because a proportion of screening test results will be falsely positive. This is especially crucial for tests such as HIV or syphilis screening,” the journal article’s co-authors wrote.

Establishing community trust is crucial to avoid the perception that the ED clinical staff is “experimenting” on patients.

6. Screening should only be conducted when follow-up resources are available.

“Patients who screen positive for disease or risk factors should have support in addressing the identified concerns. First, health systems should develop processes to ensure that patients receive their screening results, including test results that return after discharge. Second, screening initiatives should develop mechanisms for patients to access further resources, regardless of their insurance status. Third, those developing screening programs should ensure that they have institutional support, including departmental and hospital leadership, as well as appropriate community partnerships to provide follow-up care or referral to social services,” the journal article’s co-authors wrote.

7. Screening should be financially sustainable for patients and the healthcare system. “Incorporating the ED as a screening location into national guidelines, such as those provided by the USPSTF or Centers for Disease Control and Prevention (CDC), can help ensure that costs are reimbursed by insurers. Continuing grants and community funding can also offset costs to promote sustainability,” the journal article’s co-authors wrote.

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.