Inventing social emergency medicine
Inventing Social Emergency Medicine: Summary of Common and Critical Research Themes Using a Modified Haddon Matrix

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Social Emergency Medicine and the Haddon Matrix

As Fahimi and Goldfrank1 discuss in this monograph, the Haddon matrix was initially developed in 1970 to apply a public health approach to injury prevention, conceptualizing a motor vehicle crash in the context of time (pre-event, event, and postevent) with respect to the identified factors involved affecting injury severity (host, agent, and environment).2 But the framework is apt for social emergency medicine as well; every ED visit has an array of factors that influence a patient’s outcomes

A 3-Dimensional Haddon Matrix for Social Emergency Medicine Research

In 1998, Runyan3 proposed a 3-dimensional Haddon matrix as a design and decision aid for injury prevention interventions. We present a similar 3-dimensional enhancement of Haddon’s matrix for social emergency medicine as a framework to organize common themes and controversies that arose during the conference proceedings and in the summary session for the conference (Figure). For example, social emergency medicine interventions may target factors upstream of the ED encounter (pre-event), but

Effectiveness

Patient-centered primary outcomes are critical to most emergency medicine research, but in social emergency medicine these outcomes must also take a societal perspective. While we consider proximal, immediate, and long-term outcomes, it will be important to evaluate various factors that improve health and safety for the individual or his or her physical and social environment. This type of evaluation may stray from more visible and easily abstracted use or health systems outcomes.

Interventions

Sustainability

The primary mission of our emergency care system is to provide high-quality and timely acute care services. Social emergency medicine investigators are encouraged to keep this mandate in mind as they plan. When social emergency medicine initiatives or research questions are integrated into standard ED operations, the generalizability of these programs will be severely hampered without an assessment of their effect on widespread ED metrics such as length of stay, boarding, and rates of leaving

Disparities

Health disparities are a core competency for social emergency medicine, and research focused on identifying and addressing disparities in care with a focus on vulnerable groups should be fundamental to social emergency medicine research. Social emergency medicine can train its focus on the structural and socioeconomic drivers of health disparities as they affect our communities and the emergency care system itself. As a paradigm, social emergency medicine departs from a myopic view of “blaming

Education

Emergency physicians are uniquely positioned in society at the threshold separating the community and the medical care system. Social determinants of health straddle both of these realms, leading emergency physicians to be content experts in this area. At various levels of medical education, emergency physicians can take ownership of social context in disease and health through integration into curricula at the level of undergraduate medical education and in residency tracks.

Emergency

Policy and Advocacy

Emergency physicians can use their unique community-facing position in the health care system to develop and affect policy at a hospital level and at a legislative and regulatory level. At the consensus conference, policy was discussed in terms of “little p” policy and “big P” policy.

Little p policy refers to developing ED, hospital, or even sometimes health department policies that can address population health through the ED. This type of policy is accessible to all clinicians with the help

Dissemination

For social emergency medicine investigators to increase the scope and influence of their work, participants agreed that any interventions must take into consideration that many of the EDs that serve vulnerable populations operate with fewer resources than those in which most funded research is conducted. Coordinated social emergency medicine research efforts may be particularly suited to a hub-and-spoke model such as that embraced by Strategies to Innovate Emergency Care Clinical Trials because

Conclusion

Social emergency medicine research seeks to define the role of the ED in population health and to emphasize our role in improving care for vulnerable populations. The Haddon matrix helps to frame social emergency medicine in the context of time and in regard to host, agent, and environment; most of the research themes and challenges identified at the consensus conference can be viewed through this lens. Here, we present common research domains generated by the Inventing Social Emergency

Acknowledgement

The authors would like to acknowledge Dr. Serene Chen for her support with the creation of the figure.

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Supervising editor: Richelle J. Cooper, MD, MSHS. Specific detailed information about possible conflict of interest for individual editors is available at https://www.annemergmed.com/editors.

Authorship: All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). This work was supported by the Robert Wood Johnson Foundation. The views and opinions expressed in this supplement are those of the authors and do not necessarily reflect the views of the Robert Wood Johnson Foundation. The conference was supported through a grant from the Robert Wood Johnson Foundation. Support for the conference included travel support for participants. Additional administrative support was provided through a grant to the Levitt Center, Emergency Medicine Foundation, and the American College of Emergency Physicians.

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