New center at Highland Hospital explores ways to improve health of emergency department patients

New center at Highland Hospital explores ways to improve health of emergency department patients
By Sandy Kleffman
Contra Costa Times

OAKLAND — Each year, more than 80,000 patients visit the emergency department at Highland Hospital in Oakland. For many, it will be their only time with a health care professional.

The hospital runs nearly 60,000 blood tests to measure numerous health factors, including levels of sugar in the blood, which can indicate diabetes.  But unless blood sugar levels are so high the patient is in immediate jeopardy, the emergency crew concentrates on the health crisis at hand. Patients often return home unaware of their blood sugar levels. Those who have diabetes may remain undiagnosed for years.  Such occurrences are typical at busy emergency departments across the nation.

But now a new center at Highland Hospital is exploring whether it would make sense to do things differently. Among the questions experts are asking:
•  Should emergency doctors pay closer attention to blood sugar levels and high blood pressure, inform at-risk patients and refer them for treatment?
•  Should they routinely test people for human immunodeficiency virus, or HIV?
•  Should they track emergency department usage to determine when a sudden influx of patients indicates that people’s health has been harmed by a neighborhood change or a shift in governmental policies?
•  Should the hospital have case managers to assist the homeless in obtaining food and shelter? Would that reduce repeat visitors?

The research at Highland illustrates how the roles of emergency departments are shifting as patients, both with and without insurance, find it increasingly difficult to get in to see a primary care doctor.
It also highlights a growing awareness that hospital emergency departments provide a unique perspective to analyze ways to improve community health.  “The emergency department is such a great place to study social medicine because so many people cross our paths,” said Dr. Harrison Alter, executive director of the new Andrew Levitt Center for Social Emergency Medicine at Highland. “It provides a glimpse into our communities that really is unmatched by any other institution,” he said.

On a typical day, the emergency department at Highland buzzes with activity. Its 45 beds are often full, forcing hospital officials to set up gurneys in hallways for an additional six to 15 patients. Another 20 to 50 people wait to be seen.

The county-owned hospital, officially known as Alameda County Medical Center, serves as a safety net for the region’s low-income and uninsured residents. It also has a trauma center and draws patients from throughout northern Alameda County.

The new center is named after Dr. Andrew Levitt, who directed research in the Highland emergency department from 1984 to 2004. Levitt published scores of articles and devoted his career to serving the disadvantaged. He died in 2004 at the age of 49.  His family decided to give a $400,000 endowment to create the center “to honor Andy’s memory and embody all of the good that he did when he practiced medicine,” said his brother, Dennis Levitt. “He did a lot of good and this is our effort to perpetuate that.”

Dr. Barry Simon, who chairs Highland’s emergency department, supports the center’s goals and is president of its board. But he notes that in an optimal world, emergency departments would not consider expanding their roles beyond tackling immediate health threats. The crisis in health care has prompted the change, he said.

“We’re forced to do this because we can’t get people into primary care clinics,” Simon said. “We shouldn’t be managing these patients in emergency departments. But we do it because we know it’s the right thing to do. We don’t turn anyone away.”

Simon and Alter hope the research under way at Highland will be used to improve care at emergency departments across the nation.  Public hospitals are not the only ones straining to treat patients in crowded emergency departments, Alter notes. Studies have shown that increasing numbers of emergency patients have insurance, but seek care in private and public hospitals because they cannot immediately see a primary care doctor.

“People are voting with their feet, away from this really very tangled primary care system that we have, to a system that meets their needs better,” Alter said. “So we have to think about retooling the primary care system in a way that maybe is more like the way we provide emergency care.”
In one of the initial studies overseen by the Andrew Levitt Center, Highland workers looked at blood sugar results for emergency patients and informed 2 to 3 percent of them that they should seek treatment for what appears to be undiagnosed diabetes. “We’re talking about identifying almost 2,000 diabetics every year, if we did this routinely,” Alter said. Untreated diabetes can lead to severe health problems, including heart, kidney, eye and foot damage. “This is huge because there’s an epidemic of diabetes that is attributed to all of the obesity that is going on in our community,” Simon said. “Picking them up early is enormously significant because if you don’t, and they go on to have their disease unrecognized and untreated for many years, then the damage that is done to the body is irreversible.”

In another study, Dr. Douglas White has explored for several years the best way to do rapid HIV testing for emergency patients who agree to be tested. The national Centers for Disease Control and Prevention has funded his research. One young man recently came to the emergency department for treatment of a rash and left knowing he had HIV. White has “tested hundreds of thousands of Alameda County residents for HIV and discovered hundreds of new cases and gotten them into care earlier than they otherwise would have,” Alter said.

One goal that Alter and Simon have for the Andrew Levitt Center is to explore how neighborhoods and socioeconomic factors influence health. Researchers have analyzed, for example, whether people living in racially segregated neighborhoods are more likely to have violent injuries. Their initial findings: this is true, except in Piedmont.

Researchers will also look at people who knew they had high blood pressure, but developed kidney failure prematurely because it went untreated for prolonged periods, either because they lacked access to primary care or lacked insurance and could not afford medication.

“Our overarching goal is to set a research agenda to understand better the interplay between social forces and the medical care system, as they interact through the emergency department,” Alter said. “We hope to create results that influence medical care in important ways.”