Download Prevention, Wellness, and Disease Management

EMERGENCY NURSES ASSOCIATION
POSITION STATEMENT
PREVENTION, WELLNESS, AND DISEASE MANAGEMENT
STATEMENT OF PROBLEM
According to the Centers for Disease Control and Prevention (CDC), chronic disease is the
leading cause of death and disability in the U.S., accounting for approximately 70% of all deaths
each year and affecting the lives of more than 125 million people who have chronic conditions.1
The majority of deaths in the U.S. can be attributed to five major chronic diseases: heart disease,
cancer, stroke, chronic obstructive pulmonary disease, and diabetes.2 Chronic conditions such as
arthritis, asthma, diabetes, and complications following a stroke are common and may lead to
disability and/or a diminished quality of life for many people.1 Chronic disease was responsible
for more than 75% of the $1.4 trillion spent on medical care in the U.S in 2001.1,2
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In addition to chronic disease, unintentional injury was a leading cause of death in the U.S. in
2002, and was ranked the number one cause of death for persons 1 to 44 years old.3 Deaths from
unintentional injury include those resulting from motor vehicle crashes, falls, poisonings,
drownings, and accidental discharge of firearms. For many of the millions of Americans who
survive injury each year, a nonfatal injury may result in severe disability, chronic pain, and
increased health care costs. In 2001, the costs due to injuries (e.g., medical care, rehabilitation,
lost wages, lost productivity, etc.) were estimated to be greater than $224 billion annually.4
Clearly, chronic disease and injury are extremely costly in terms of our nation’s health and
wealth. Fortunately, through prevention, wellness, and disease management interventions in the
health care setting, the serious consequences of chronic disease and injury may be mitigated or
prevented.1
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Although prevention, wellness, and disease management are separate concepts, there are features
common to all three. They all serve to reduce the risk and consequences of disease, illness, and
injury. The purpose of prevention is to “minimize the occurrence of disease or its
consequences.”5 The three levels of prevention are primary, secondary, and tertiary.5 Primary
prevention involves actions that avert the onset of disease or injury through intervention
strategies such as reducing risk factor levels (e.g., child safety-seat distribution and education to
promote proper and routine use). Secondary prevention aims to detect disease at an early stage
when signs and symptoms are not evident so that disease can be controlled and its effects limited
(e.g., HIV testing following a possible exposure). Tertiary prevention focuses on treating disease
and injury that is already present in an effort to reduce disability and assist individuals in gaining
a higher level of functioning (e.g., referral to a community-based treatment program for alcohol
or drug addiction). Preventive interventions in the health care setting are varied and may include
screenings, immunizations, health education, and referrals to community services.6,7
Wellness refers to “an optimal state of health and well being achieved through the utilization of
measures to maintain health and prevent illness and/or injury”8 (e.g., routine gynecological
exams). Health care providers promote patient wellness through health promotion education and
interventions that address the whole person, that is, physical, mental, spiritual, social, and
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environmental health.9 Disease management is a system of coordinated health care interventions
and communications for delivering care to populations of patients with specific diseases and
conditions.10,11 In regard to chronic disease, the purpose of disease management is to eliminate or
lessen acute events and improve short- and long-term health of individuals through programs
involving patient education, self-management instruction, and clinical protocols (e.g., self-care
instruction for diabetes). Asthma, congestive heart failure, depression, and diabetes are some of
the most common health conditions addressed in disease management programs.10,12,13 Research
indicates that disease management programs lessen patients’ risk for acute episodes and lead to
significant reductions in emergency department visits.10,14
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Prevention of disease and injury and promotion of wellness are essential components of
emergency nursing practice and emergency care.8 Emergency nurses are in a unique position to
assist persons with or at risk for disease and injury. For many individuals, the emergency
department may be their only source of care, and thus their only opportunity to receive health
care services. Chronic disease and injury are especially prevalent in the emergency care setting.
According to a report by the Institute for the Future (IFTF), chronically ill persons use more
health care services, accounting for 80% of all hospital stays, 70% of all hospital admissions, and
55% of all emergency department visits.10 Injury-related diagnoses account for more than a third
(35.5%) of all emergency department visits.15
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Prevention, wellness, and disease management services that focus on lifestyle behavior have the
potential to prevent, improve, or slow the progression of many diseases and injuries.10 Unhealthy
yet modifiable behaviors are responsible for a large proportion of death and disability in the
U.S.1 In fact, smoking, lack of exercise, and poor nutrition are leading risk factors for chronic
disease.2 It is estimated that lifestyle behaviors contribute to approximately 50% of health
status.10 The remaining determinants of health are comprised of genetics, the environment, and
access to care. In its Guide to Clinical Preventive Services, the U.S. Preventive Services Task
Force (USPSTF) recommends that all health care providers regularly assess patients’ risk factors
and assist them in achieving healthy behaviors such as smoking cessation, regular exercise, a
healthy diet, responsible use of contraceptives, appropriate alcohol consumption, and regular
seatbelt use.6,7 Risk assessment is crucial for identifying underlying risk factors that may
contribute to current and future disease and injury. Conducting risk assessments and screenings
for risk factors that are most prevalent in the surrounding community and patient population may
lead to appropriate and earlier intervention, helping patients to adopt healthier behaviors in order
to maintain wellness and prevent disease and injury.6,7
The Emergency Nurses Association’s Institute for Injury Prevention provides many programs
that emergency nurses and others in the community can use to teach children and adults about
bicycle safety,16 gun safety,17 seat belt and child passenger safety,18 alcohol and drug
awareness,19-22 safe driving decisions,19,21 safe medication use,20 falls prevention,20 pedestrian
safety and safe mobility,21 and the dangers of drinking and driving.19,21 Information about these
programs can be obtained by contacting ENA at 800-243-8362 or visiting the ENA web site at
www.ena.org/store. In addition, the Clinician’s Handbook of Preventive Services, available
through the U.S. Department of Health and Human Services (DHHS), is a reference tool and
practical guide to help health care providers offer preventive services in the clinical setting.23 To
reinforce health messages, patient education materials can be provided to patients in a variety of
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forms including pamphlets, books, videotapes, audiotapes, and CD-ROMs.23,24 These materials
are available from agencies and organizations such as the Centers for Disease Control and
Prevention (CDC), and businesses such as medical supply and pharmaceutical companies.
Of particular relevance to the emergency nurse, is the fact that for many individuals a visit to the
emergency department serves as a unique opportunity to influence risky behaviors. Emergency
department visits are usually precipitated by an event, often a crisis, which results in a “teachable
moment” – an opportunity to present an educational intervention at a time when the patient is
more receptive and motivated to consider behavior change.25,26 For example, even brief
interventions (5 to 15 minutes) to address alcohol-drinking behavior following an alcohol-related
motor vehicle crash or smoking cessation following an acute episode of respiratory illness, have
been shown to be effective for emergency department patients.25,27
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A predominant focus on more medically urgent issues;
Time constraints;
Inadequate provider training in prevention;
Skepticism about effectiveness of some preventive services on the part of both
patients and health care providers;
Lack of evidence-based prevention practices;
Low patient demand for preventive services (e.g., lack of awareness, lack of money to
pay for services); and
Lack of supportive resources.
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Services that include prevention, wellness, and disease management may lead to decreases in
health care costs and improvements in patient outcomes.1 Although the benefits of preventive
care are generally well-regarded, the health care setting remains dominated by a focus on acute
illness care.1,6,7,10 Many barriers to the provision of preventive care interventions exist in health
care settings, including: 6,7,28,29
Several of these barriers are especially relevant in the emergency department due to its fastpaced environment, at-risk patient population, and diversity of disease and injury encountered. It
is well known that emergency departments act as our nation’s health care safety net, serving as a
primary source of care for at-risk populations, such as the uninsured, the homeless, the mentally
ill, the poor, the elderly, the chronically ill, and members of ethnic minorities.10,15 Because these
populations typically lack access to routine quality health care, they may be at greater risk for
disease and injury.6,7,10 When made available in the emergency department, prevention, wellness,
and disease management services have the potential to impact not only an individual’s health,
but also the health of the community.
Despite a prevalence of barriers, emergency nurses and other health care professionals provide
early intervention for many preventable health conditions related to injury, alcohol/drug abuse,
infectious disease, chronic disease, and mental health.30 Effective primary and secondary
preventive services in the emergency department include assessment, behavioral counseling,
patient education, treatment, and/or referral for follow-up care.25,29,31,32 Some examples are:
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Alcohol screening, brief intervention, and referral;
Dietary counseling;
STD screening, treatment, and referral;
Domestic violence assessment and referral;
Child and elder abuse/neglect assessment, reporting, and referral;
Depression assessment and referral;
Hypertension screening, treatment, and referral;
Adult pneumococcal immunizations; and
Smoking cessation counseling.
A type of intervention that is particularly well-suited to the emergency department environment
is preventive care offered to patients while they spend time in waiting rooms. This can be done
without the direct involvement of a health care provider through tools such as educational
videotapes and computer-based programs that are culturally and developmentally appropriate for
the target population.24,33,34
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ASSOCIATION POSITION
It is the position of ENA that:
1. Emergency nurses play a proactive role in providing prevention, wellness, and
disease management care through interventions that influence patients to adopt
healthy behaviors in order to prevent disease and illness and improve health.
Preventive services are crucial to reducing health care costs and improving the overall
health of our nation.
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2. Improved training and education for emergency nurses and other health care
providers is needed to increase knowledge and confidence in providing effective
health interventions in the emergency care setting. Ongoing and continuing education
can reduce the amount of time between the discovery of effective prevention tools
and strategies and the application of those strategies in health care practice.
3. Emergency nurses should assume a leadership role in establishing prevention,
wellness, and disease management treatment guidelines within their respective
departments.
4. Emergency nurses should be involved in the provision of health and safety education
in their communities and should help to advocate for public policies that aim to
protect the public from preventable disease and injury.
5. Emergency nurses and other health care providers need to be actively involved in
research to identify and develop efficacious and effective interventions for the
emergency care setting that support the prevention of disease and injury. As part of
research efforts, emergency nurses need to take part in evaluation activities to assess
the effectiveness of preventive interventions.
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RATIONALE
For many patients, a visit to the emergency department may be their only source of health care,
and thus their only opportunity to receive preventive care. Moreover, circumstances that result in
a visit to the emergency department often place patients in a state of mind that is more receptive
to preventive care messages. The emergency nurse is a vital link between the community and the
hospital, and possesses numerous opportunities to influence the health and well being of
individuals, including those who are at most risk for disease and injury. Prevention, wellness,
and disease management services in the emergency department have the potential to benefit
individual patients and their families, the emergency department environment, and the greater
community by slowing the progression of disease, preventing disease and injury, boosting patient
satisfaction and staff morale, reducing repeat visits to the emergency department, decreasing
health care costs, and improving overall community health.
REFERENCES
Centers for Disease Control and Prevention (CDC). (2003). The power of prevention.
Reducing the health and economic burden of chronic disease. Atlanta, GA:
Department of Health and Human Services, Centers for Disease Control and
Prevention.
2.
Centers for Disease Control and Prevention (CDC). (2004). The burden of chronic
diseases and their risk factors: National and state perspectives. Retrieved February 7,
2005, from http://www.cdc.gov/nccdphp/burdenbook2004/index.htm
3.
Kochanek, K. D., & Smith, B. L. (2004). Deaths: Preliminary data for 2002. National
Vital Statistics Reports, 52(13). Hyattsville, MD: National Center for Health
Statistics.
5.
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4.
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1.
National Center for Injury Prevention and Control. (2001). Injury fact book 20012002. Atlanta, GA: Centers for Disease Control and Prevention.
Turnock, B. J. (2001). Public health: What it is and how it works (2nd ed.).
Gaithersburg, MD: Aspen.
6.
U.S. Preventive Services Task Force. (1996). Guide to clinical preventive services:
Report of the U.S. Preventive Services Task Force (2nd ed.). Washington, DC: Office
of Disease Prevention and Health Promotion, U.S. Government Printing Office.
7.
U.S. Preventive Services Task Force. (2004). Guide to clinical preventive services,
third edition: Periodic updates (AHRQ Publication No. 04-IP003). Rockville, MD:
AHRQ Publications Clearinghouse.
8.
Emergency Nurses Association (ENA). (1999). Standards of emergency nursing
practice (4th ed.). Des Plaines, IL: Author.
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Herbert-Ashton, M. (n.d.). Paradigm shift from illness to wellness: The nurse as the
wellness coach. Nursing Spectrum: Weekly Guest Lecture. Retrieved January 12,
2005, from http://nsweb.nursingspectrum.com/cfforms/GuestLecture/paradigm.cfm
10.
Institute for the Future (IFTF). (2003). Health and health care 2010: The forecast, the
challenge (2nd ed.). San Francisco: Jossey-Bass.
11.
Disease Management Association of America. (n.d.). Definition of disease
management. Retrieved January 13, 2005, from http://www.dmaa.org/definition.html
12.
Goldsmith, C. (2004). Disease management empowers patients, improves lives.
Nursing Spectrum: Self-Study Modules, CE 354. Retrieved January 12, 2005, from
http://nsweb.nursingspectrum.com/ce/ce354.htm
13.
Task Force on Community Preventive Services. (2002). Recommendations for
healthcare system and self-management education interventions to reduce morbidity
and mortality from diabetes. American Journal of Preventive Medicine, 22(4S), 1014.
14.
Agency for Healthcare Research and Quality (AHRQ). (2002). Preventing disability
in the elderly with chronic disease (AHRQ Publication No. 02-0018). Rockville, MD:
AHRQ Publications Clearinghouse.
15.
McCaig, L. F., & Burt, C. W. (2004). National hospital ambulatory medical care
survey: 2002 emergency department summary. Advance data from vital and health
statistics (Publication No. 340). Hyattsville, MD: National Center for Health
Statistics.
16.
Emergency Nurses Association (ENA). (2001). Bike with CARE: Bicycle and helmet
safety program. Des Plaines, IL: Author.
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17.
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9.
Emergency Nurses Association (ENA). (2001). Gun Safety: Its no accident. Des
Plaines, IL: Author.
18.
Emergency Nurses Association (ENA). (n.d.). Child Passenger Safety: Basic car seat
use for parents. [Brochure]. Des Plaines, IL: Author.
19.
Emergency Nurses Association (ENA). (2002). Dare to Care 2002 – Alcohol
awareness and the dangers of drinking and driving (Teen Program). Des Plaines, IL:
Author.
20.
Emergency Nurses Association (ENA). (2002). Take Care I – Safe medication use
and falls prevention for mature adults. Des Plaines, IL: Author.
21.
Emergency Nurses Association (ENA). (2002). Take Care II - Safe mobility for
mature adults: Safe driving decisions and pedestrian safety. Des Plaines, IL: Author.
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Emergency Nurses Association (ENA). (1997). Healthy living for mature adults. Des
Plaines, IL: Author.
23.
U.S. Public Health Service. (1998). Clinician’s handbook of preventive services (2nd
ed.). Germantown, MD: International Medical Publishing.
24.
Emergency Nurses Association (ENA). (2003). Sheehy’s emergency nursing
principles and practice (5th ed.) (L. Newberry, Ed.). St. Louis, MO: Mosby.
25.
Bock, B. C., Becker, B., Monteiro, R., Partridge, R., Fisher, S., & Spencer, J. (2001).
Physician intervention and patient risk perception among smokers with acute
respiratory illness in the emergency department. Preventive Medicine, 32, 175-181.
26.
Gorin, A. A., Phelan, S., Hill, J. O., & Wing, R. R. (2004). Medical triggers are
associated with better short- and long-term weight loss outcomes. Preventive
Medicine, 39, 612-616.
27.
National Center for Injury Prevention and Control. (2002). Alcohol problems among
emergency department patients: Proceedings of a research conference on
identification and intervention. Atlanta, GA: Centers for Disease Control and
Prevention.
28.
U.S. Department of Health and Human Services (DHHS). (2000). Healthy people
2010 (2nd ed., vol. 1). Washington, DC: U.S. Government Printing Office.
29.
Pollock, D. A., Lowery, D. W., & O’Brien, P. M. (2001). Emergency medicine and
public health: New steps in old directions. Annals of Emergency Medicine, 38, 675683.
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30.
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22.
Bernstein, E., Bernstein, J., Lowe, R. A., Crowder, V. R., Kellermann, A. L.,
Lowenstein, S. R., & Marx, J. A. (1997). Timely access to health care: The critical
role of EM, written for the Public Health and Education Task Force of the Society for
Academic Emergency Medicine. Retrieved February 7, 2005, from
http://www.saem.org/inform/access.htm
31.
Rothman, R. E. (2004). Current Centers for Disease Control and Prevention
guidelines for HIV counseling, testing, and referral: Critical role of and a call to
action for emergency physicians. Annals of Emergency Medicine, 44, 31-42.
32.
Bernstein, S. L., & Becker, B. M. (2002). Preventive care in the emergency
department: Diagnosis and management of smoking and smoking-related illness in
the emergency department: A systematic review. Academic Emergency Medicine, 9,
720-729.
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33.
Oermann, M. H., Webb, S. A., & Ashare, J. (2003). Outcomes of videotape
instruction in clinic waiting area. Orthopaedic Nursing, 22, 102-105.
34.
Rhodes, K. V., Lauderdale, D. S., Stocking, C. B., Howes, D. S., Roizen, M. F., &
Levinson, W. (2001). Better health while you wait: A controlled trial of a computerbased intervention for screening and health promotion in the emergency department.
Annals of Emergency Medicine, 37, 284-291.
Developed: 2005.
Approved by the ENA Board of Directors: March, 2005.
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© Emergency Nurses Association, 2005.
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