Survey on trust and equity in emergency departments aims to improve system for all patients

No one wants to go to the emergency department, no matter where or who they are. Going to the emergency department means, inherently, that something has gone wrong. For those coming in, it's a time of pain, anxiety, maybe fear, maybe even anger.

None of the patients or their loved ones who show up for emergency care on a given day woke up that morning and envisioned taking that trip before they put their head back down at night.

"Emergency departments are, by their nature, high-emotion and high-stake settings," said Anish Agarwal, MD, MPH, an assistant professor of Emergency Medicine who works in the Penn Presbyterian Medical Center emergency department.

That's a tough role to play when the emergency department is also considered the hospital's "front door," Agarwal said.

And, in being the front door—ready to help patients with any injury or illness who arrive without warning—emergency departments are also "safety nets." For underserved communities, emergency departments are also often the most accessible and most used entry point many people have with health care.

"There are communities where there is this notion where you are connected to your hospital and, specifically, that emergency room," Agarwal said. "The connections between hospitals and communities is important to engender trust and reinforce public health. It's a critical link between medicine and people."

If someone has a bad experience or perceives their hospital poorly, it can mean that they're less likely to seek out care. That can lead to conditions that worsen over time and become more costly, in every sense of the word. It can lead to worse health outcomes community-wide.

But that coin has another side.

A hospital and an emergency department that works to make itself a better community partner, one that looks more like the people it serves and shows that it has their interests at heart, can be an invaluable asset for both the public and socioeconomic health of its neighbors.

"Trust in any relationship is built through a series of small actions that demonstrate that words are real," said Eugenia C. South, MD, MSHP, the Ralph Muller Presidential Associate Professor and associate vice president of Health Justice for the University of Pennsylvania Health System. "Justice is an action."

Trust and recognition

Agarwal, South, and colleagues recently published work in JAMA Health Forum detailing interviews conducted in 2021 and 2022 with 25 Black patients who'd visited an urban hospital's emergency department. The patients were asked about their experiences and what they might improve.

One of the main points the researchers found in their analysis of the patient interviews was a feeling of distrust of the medical system at large. This could trace back to ancestral or personal experiences with health care—or both—and could affect a patient's feelings before they even came through the door.

"Just take yourself out of your privilege and understand what our ancestors have been through and what we are still going through right now," one participant said.

That, Agarwal noted, is a significant factor that practitioners of emergency medicine across the United States need to build into their work.

"We need to recognize that we have blind spots in health care, that Black communities have significant and valid historical distrust in medicine, and really try to be sensitive to that," Agarwal said.

At Penn Medicine, efforts are underway in a variety of ways to make its emergency department "front doors" a better experience for anyone who comes in.

One of the main efforts is a task force created to specifically address potential racism in emergency departments across the health system.

"Early on, we were able to add principles of anti-racism, inclusion, and diversity into our departmental onboarding process, which I feel was beneficial," said Chidinma Nwakanma, MD, an assistant professor of Clinical Emergency Medicine who has served on the task force since the beginning.

"In its current form it provides a forum for hospital staff to discuss current issues regarding anti-racism in our department and in the world at large."

Other programs spurred by the group include a mentorship program for new nurses—as well as staff in other roles who aspire to become nurses—to help them better understand and care for people across any culture.

Additional efforts are aimed at recruiting more diverse workforces that better reflect the make-up of their surrounding communities. This directly answers something uncovered in Agarwal and South's study, where patients suggested that increasing the diversity of clinicians and staff could help them feel better and more trusting in their local hospital when they go in. And research backs this notion up.

Penn Medicine's Department of Emergency Medicine also established a small grants program called Advancing Inclusion, Diversity, Equity, and Antiracism (IDEA). Some of the projects funded included the creation of simulations for clinicians and staff to "improve health equity and cross-cultural communication," (a program led by Kristyn Smith, DO, an assistant professor of Emergency Medicine) and the establishment of another program called "Science Through Engagement, Action, and Mentoring (S.T.E.A.M.)" to provide greater exposure to science and medicine for young students from a West Philadelphia middle school (led by Tatiana Carrillo, DO, an assistant professor of Emergency Medicine).

"Advancing IDEA small grants is amazing because it allows faculty to actually implement and fund their ideas," said Nwakanma, who is the vice chair of IDEA in Emergency Medicine. "Putting money behind these ideas and projects really shows commitment and the belief that, with support, these projects can flourish and affect change."

Planting roots outside the emergency department

Doing work outside of emergency departments is also critical to fostering relationships with the neighborhoods and communities they serve. South has long been an advocate for the "greening" of under-served city areas, launching an initiative called "Deeply Rooted" to put more trees and parks in neighborhoods lacking them, which is linked to better overall health of those living nearby.

"Our research has demonstrated that turning vacant land into clean and green space reduces gun crime. People living nearby feel safer and less depressed, and they forge deeper social connections with their neighbors," South wrote not long ago in the Washington Post. "Green space has consistently been associated with health benefits."

South also created a program called Lift Every Voice, which established an anonymous digital system for clinicians and staff to report instances of racism they might witness. Those reports are then illustrated by a local artist of color and published on an internal system that clinicians and staff can view and engage with.

Despite the crises wrought by the COVID pandemic, Agarwal feels that efforts by the medical community since 2020 helped boost the overall reputation of health care in communities that have had complicated histories with the field.

"All the work our health system did to put COVID vaccines in the communities, for instance, was a great example of building trust by being humble and really seeking to serve," Agarwal said. "We say it all the time, but meeting people where they are is critical."

The researchers say that the commitment of time and energy that Penn Medicine and its staff have made for these initiatives could be replicated anywhere across the country. With generational trauma and mistrust among under-served populations to address, it's critical that emergency departments across the United States—the front doors to hospitals throughout the country—make conscious efforts to be welcoming.

"You have to rebuild trust by being humble, asking questions" Agarwal said, "and recognizing the opportunities where there can be growth."