Emergency care for vulnerable

populations
By Praneed Songwathana (RN, PhD, Dip. APMSN)
Assoc Prof. Faculty of Nursing
Prince of Songkla University, Hatyai, Songkhla
Email: praneed.sw@gmail.com
 Outline
• Significance of emergency care in global
healthcare contexts and Integrated emergency
care framework
• Concept of vulnerability and caring for
vulnerable populations
• Interventions for improvement of emergency
care service for vulnerable populations
• Lesson learnt and Challenges

P. Songwathana, 2024
 Paradigm shift of health service system management
to achieve better outcomes towards SDGs
• Reaching the best practice (not only a better)
• Innovative practice > routine care
• Integrated or multiple approaches > Single or separated
approach of interventions
• Less cost for More benefit > More for less
• Focus on prevention > care and require proactive action
• Outcome based > process based management
• Moving from mortality to non-mortality outcomes

P. Songwathana, 2024
Global leading causes of deaths and disability-adjusted life years (DALYs) and distribution of deaths and
DALYs (Chang CY., et al., 2017)
emergency care is addressed in global health priorities
(Chanahan, T. etal., 2018)
 Important issues related to access to emergency unit were identified

• vulnerable patients • emergency care unit professionals

• exemption from making upfront
payments,
• needs for listening, support,
reinsurance, privacy and
consideration of emergency
professionals,
• referral by general practitioners (GP),
• difficult access to GP,
• needs for immediacy and timely
healthcare services, permanent
opening of ECU.
• ambivalent emotions towards socially
vulnerable patients,
• a recurrence of passages leading to a
reduced medical attention,
• a feeling of failure to care for
vulnerable patients,
• coping strategies in caring for these
patients.

Vieille M. et al. (2019). Access to emergency care units by socially vulnerable patients: a qualitative research.
European Journal of Public Health, Volume 29, Issue Supplement_4
 Framework to identify issues “The right to health”
(Burkholder, TW. Et al.,2021)
1. Availability, accessibility, acceptability,
and quality (AAAQ):
• Availability: Health facilities and services
are present in sufficient quantity.
• Accessibility: Health facilities and services
are within reach and can be utilized by
everyone without discrimination.
• Acceptability: Health facilities and services
are respectful of medical ethics and
culturally appropriate.
• Quality: Health facilities and services are
scientifically and medically appropriate and
of good quality.
2. Respect, protect, and promote:
Respect: States refrain from
interfering with the enjoyment of
the right to health.
Protect: States take measures that
prevent third parties from interfering
with the right to health.
Promote: States adopt appropriate
legislative, administrative, budgetary,
judicial, promotional, and other
measures toward the full realization
of the right to health.
Significance of laws, right, roles of emergency care
for vulnerable populations
An emergency care is a lifesaving service
delivery platform with the potential to
address much of the death and disability
in low- and middle-income countries
(LMICs). Less than 10% of these countries
have laws explicitly protect the right to
emergency care (Burkholder et al. , 2021)
Services to increase access to emergency
care must be required for vulnerable
populations.
Burkholder TW. et al. (2021). A Global Review of
Provisions on Emergency Care in National
Constitutions, Health Human Rights 23(2): 187-200.
Systemic review by Change et al. (2016)
showed that low-income countries had higher
burden of emergency conditions and lower
rates of emergency care usage.
It is estimated that a substantial portion of the
global morbidity and mortality can be
attributed to emergency conditions which
highlights the potentially powerful role for
emergency care in reducing the global burden
of diseases.
Chang CY, et al. (2016). Burden of emergency conditions and
emergency care usage: new estimates from 40 countries
Emerg Med J;33:794–800.
Significance of
emergency care’s
role in the health
system within
the context of
global healthcare
delivery
(Carlson LC., et al., 2019)
New perspective: Integrated emergency care delivery value chain (Carlson LC., et al., 2019)
 What is vulnerability defined ?
Who are vulnerable population?
What are their health needs?
How to provide care for vulnerable groups?

(Ochieng B & Ward K., 2018)

Vulnerability: A concept synthesis and its application to the Emergency Department in International Emergency Nursing
Why do we need to focus on nursing outcomes?
(Wardrop, R. et al., 2021)

1. Vulnerability as a journey
reflected elements within
an individual’s life that
perpetuate and exacerbate
vulnerability

4. A shared
understanding indicat Concept of 2. vulnerability
ing the importance of
understanding the vulnerability in as susceptibility and
risk, highlighted
concept of
vulnerability for ED care intrinsic and extrinsic
patient care. elements that
contribute to a state
of risk
3. positive and negative
repercussions, which can be
learned from experience
 Definition of vulnerable populations
Who? (Defined in Medicine)
• include patients who are racial or ethnic
minorities, children, elderly,
socioeconomically disadvantaged,
underinsured or those with certain medical
conditions. Members of vulnerable
populations often have health conditions
that are exacerbated by unnecessarily
inadequate healthcare.
• 1. Chronically ill and disabled
• 2. Low-income and/or homeless individuals
• 3. Certain geographical communities
• 4. LGBTQ+ population
• 5. The very young and very old
• Who? (Defined in nursing)
• Is or may be unable to protect or take care of him or
herself , against significant harm or explotation
• is a group of individuals who are at increased risk for
health problems and health disparities.
• The very young and the very old
• Individuals with chronic illnesses, disabilities, or communication
barriers
• Veterans
• Racial and ethnic minorities
• Individuals who identify as lesbian, gay, bisexual, transgender, or
queer (LGBTQ)
• Victims of human trafficking or sexual violence
• Individuals who are incarcerated and their family members
• Rural Americans
• Migrant workers
• Individuals with chronic mental health disorders
• Homeless people
P. Songwathana, 2024 12
 What has been changed of patients seen
at ED and priority of care needed?
Trend Within 15
1. Overcrowded with non-emergency
2-4 hrs. minutes
has been continue increasing, many of
them are vulnerable populations with Level 2
multiple readmissions Level 4-5 20-30% Level 1 Immediately
2. Increased aging population 20-35% 1-3%
with emergency conditions and various
chronic illness Level 3
3. Dramatic reductions in trauma mortality 30-40%
and injury case deaths but increased of
care burden due to high disability and cost Within 60 min

P. Songwathana, 2024
Trends of pre-existing comorbidity & chronic conditions diagnosed in the ED has been decreased over ten years
but the proportion of ED admission is higher in the elderly population than in the non-elderly population

HU et al., (2021). Trends of chronic illness in emergency department admissions among

elderly adults in a tertiary hospital over ten years, BMC Health Service Research, 21.
Thai Nurses’ Experiences of Providing Care in Overcrowded Emergency
Rooms in Tertiary Hospitals (Kongcheep et al., 2022) (N=20)

Overcrowded situations at
Emergency Rooms prevent
nurses providing patient
care to a proper standard,
leading to lower nurse
satisfaction and is a major
barrier to safe, quality
patient care (Kongcheep et
al., 2022).
This has not been analyzed
in issues related to quality
of emergency care of
vulnerable groups.

Pacific Rim Int J Nurs Res • July-September 2022

Nurses’ experiences of emergency care for undocumented migrants who
travel by boats (Granero-Molina., et al., 2022) (N= 17)
Emergency Physicians’ and Nurses’ Experiences Caring for Patients With Psychiatric
Conditions and/or Substance Use Disorders (N=86)

Isbell LM. (2023). A Qualitative Study of Emergency Physicians’ and Nurses’ Experiences Caring for Patients With
Psychiatric Conditions and/or Substance Use Disorders. Ann Emerg Med;81:715-727.
 Why do we need to focus on nursing outcomes?
Role of nurses: Working with vulnerable populations as a nurse practitioner (Morris, 2023)

1. Raise Awareness

5. Enforce ethical Five major steps for 2. Educate

standards caring of vulnerable
populations

4. Improve
healthcare access 3. Advocate
 Assessment of vulnerable population
• Assessment of vulnerable elderly Some vulnerable population assessment tools
• Neurological status a. Elder populations (eg. The interRAI Emergency Department Screener (EDS))
b. Disabled populations (sensory, physical, mental)
• Psychological and mental status c. Non-English speaking populations

• Ability to meet ADL d. Populations residing in residential shelters (e.g., battered spouses,
homeless, etc.)

• General physical assessment e. Dialysis Clients

f. Developmentally Disabled Clients (e.g. independent supported living,
• Assessment of suspected nutritional small group homes)

and functional risks g. Community-based technology dependent clients (e.g. life support
equipment, oxygen, etc.)
• Assessment for the risks of fall h. Specialty care populations (e.g. r

injury i. adiation/oncology clinics, methadone clinics, etc)

j. Migrant populations
• Violence risk assessment k. Economically disadvantaged populations
 Interventions
Person-centred care
• It will improve the quality of patient care
and increase the job satisfaction of nurses
experiences among emergency room
nurses.
• Providing person-centred practice in the
emergency room is difficult although they
recognized the benefits. They reflected
experiences as: (1) feeling distanced from
patients; (2) guilt and frustration; (3)
accepting patients’ symptoms and
emotions as they are; (4) person-centred
care as a domain of nursing that cannot
be replaced by machines; and (5) nursing
as an art wherein the minutest details
make a difference (Kim, Kim & Lee, 2022).
Kim JM., Kim NG., Lee EN., (2022). Emergency Room Nurses’ Experiences
in Person-Centred Care Nurs Rep. 2022 Sep; 12(3): 472–481.
Team-based primary care
• (I) using team huddles to anticipate
patients’ needs by
• Addressing needs, offering information
about patients’ challenges accessing
various community resources and
identifying options to mitigate these
barriers.
• (II) mobilizing requisite expertise through
co-location and warm-handoffs.
• having access to different types of clinical
and non-clinical expertise to help address a
variety of patient demands.
• direct exchange of information and the
transition of patient accountability from
one team member to another.
DePuccio MJ., et al. (2021). Team strategies to manage vulnerable
patients’ complex health and social needs: considerations for
implementing team-based primary care Journal of Hospital Management
and Health Policy, Vol 5 (March)
 Interventions: team-based primary care

DePuccio MJ., et al. (2021). Team strategies to manage vulnerable patients’ complex health and social needs: considerations for implementing team-based
primary care Journal of Hospital Management and Health Policy, Vol 5 (March)
Interventions to manage use of the emergency and urgent care system by people from
vulnerable groups: a mapping review (Booth A. et al., 2019)
Interventions to manage use of the emergency and urgent care system by people from vulnerable
groups: a mapping review (Booth A. et al., 2019)
Interventions
Health Challenges in Victims of human
trafficking or sexual violence
Some warning signs Strategies
• Shares a scripted or inconsistent history
Is unwilling or hesitant to answer questions about to support health
an injury or illness
Is accompanied by an individual who does not let services for human
the patient speak for themselves, refuses to let the trafficking victims
patient have privacy, or who interprets for them
Shares information about controlling or dominating
relationships
Demonstrates fearful or nervous behavior or avoids
eye contact • Emergency Services
Is resistant to accept assistance or demonstrates • Crisis Intervention and Counseling
hostile behavior
Is unable to provide their address
• Emergency Shelter and Referrals
Is not aware of their location, the current date, or • Urgent Medical Care
time • Safety Planning
Is not in possession of their identification • Food and Clothing
documents
Is not in control of his or her own money
Is not being paid or wages are withheld

Tracy, E. E., & Macias-Konstantopoulos, W. (2021). Human trafficking: Identification and evaluation in the health care setting. UpToDate. Retrieved March 16, 2022, from www​.update.com.
 Interventions
Health Challenges in
Migrants Strategies
• Hazardous work environments to support health
• Poverty
• Insufficient support systems services for
• Inadequate or unsafe housing migrant workers
• Limited availability of clean
water and septic systems
• Inadequate health care access
and lack of continuity of care • Culturally sensitive health education and outreach
• Lack of health insurance • Educational materials at the appropriate literacy level
• Cultural and language barriers • Portable medical records and case management
• Fear of using health care due to • Mobile medical units
immigration status • Transportation services
• Lack of transportation • Translation services

Rural Health Information Hub. (2021, July 1). Rural migrant health. https://www​.ruralhealthinfo​.org/topics/migrant-health.
Tracy, E. E., & Macias-Konstantopoulos, W. (2021). Human trafficking: Identification and evaluation in the health care setting. UpToDate. Retrieved March 16, 2022, from www​.update.com.

Interventions
Health Challenges in Children and
Elderly Strategies
Some warning signs
• unique health care needs due to
to support health
increased incidence of illness and services for Children
disability, as well as the complex and Elderly
interactions of multiple chronic
illnesses and multiple medications.
• prone to difficulties in using the health
care system, including discontinuity • Hospice care;
and lack of coordination among • Aggressive community-based care to
multiple providers, inability to obtain those patients with mental illness
care from providers who have • Community-based care for the frail
expertise in treating their conditions, elderly
and difficulty in receiving approvals for
treatments that are expensive or not
widely used
Rural Health Information Hub. (2021, July 1). Rural migrant health. https://www​.ruralhealthinfo​.org/topics/migrant-health.
Interventions

Results:
Case management
and care plan
interventions based
in ED can decrease
ED use among
frequent users with
mental health
issues.
Clinical and social
outcomes should
be investigated in
the future.
Strategies to Improve Care in the Emergency Department for Culturally
and Linguistically Diverse Adults (CALD): a Systematic Review (Hayba N. et al., 2023)

4 main strategies
improving communication
improving self management between patients and
of health issues providers

Building health
workforce capacity adhering to
good clinical
practice
Interventions to reduce ED visits in older adults

The majority of TCIs with the high-intensity interventions have a beneficial

influence on ED visit rates among older patients, with the greatest benefit
occurring less than six months following discharge.
 SECSI South Initiative Project
Smart Emergency Care Services Integration-South
Concept and operational frameworks
Project Leader
Assoc Prof Dr. Praneed
Songwathana

• System development
• CoC
• Area based approach
through Research and Aquatic
development
• Generate innovative Borders

care model, process Geriatric EMS

strategies, tools,
EMS specific gr
resources for capacity
building

Note: RTI: Road traffic injury, STEMI: ST-elevation myocardial infarction, EMS: Emergency medical service, CBR: Community-based research, CVD:
Cardio-vascular disease, PoE: Point of entry, OHCA: Out of hospital cardiac arrest, BLS: Basic life support, IPC: Infection prevention and control,
NEC: Non-emergency care, ACLS: Advanced Cardiovascular Life Support, IMC: Intermediate care, CG: Caregiver, LTC: Long-term care P. Songwathana 2024

Research Projects: Development of Integrated Geriatric Emergency Care System in Southern Region, Thailand
Dr. Luppana Kitrungrote
Principal Investigator
Stroke (3)* COPD (1)
Development of Continuity of Care
for Older Adults With Stroke in
Southern Region, Thailand
Integrated Geriatric Emergency care (EMS)
Dr. Waris Kupkanjanakul
Emergency Physician
Co-Principal Investigator
Long dependent care (1) CPR training for carers (1)
Development Innovation of Self-
management by Integrating telehealth
1 Among Older Adults at the Risk of Stroke
Dr. Chantra Promnoi and team
Development Model of Access to the
Emergency Medical Service for Older Adults
2 with Stroke Examples
Dr. Luppana Kitrungrote and team
Development Model of Discharge Planning
3 and Continuity of Care for Older Adults with
Ischemic Stroke
Dr. Hathairat Sangchan and team
P. Songwathana 2024
1 2

P. Songwathana 2024
 A simple model to improve people, process and
Lesson learnt (1) practice development which could apply in
emergency care for vulnerable populations
Expected
Implement an improved or
outcomes/
changed strategy using insights
success/
out /innovative approach
sustainable

Develop/ implement and evaluate the

strategy to answer the question/
address an issue

Identify
issue/gap/
question Into action:
use several
strategies
People engage in
everyday practice P. Songwathana 2024
 Lesson learnt (2): Strategies to drive a success
“STRATEGIC”

C-
Communication
& coordination
I–
Implementation T – Teamwork
evaluation & & leadership
inspired change

G–
Guideline S-Strive for R – Role &
Responsibility
with Sustainability acknowledge
guidance ment

E– Education A–
with evidence Accumulative
idea from the
& Empower
T – Time users &
advocate policy
management
and facilitate
the enablers

P. Songwathana 2024
 Our Challenges and key messages:
A need of evidence based knowledge of emergency care for vulnerable populations

Mindset of Increase competency in

comprehensive assessment
• Standards and system management
Increase care
• Safety towards SDG quality and
• Quality outcomes
• Timely
• Speedy Accessibility &
evidence
• Systemic
Inappropriate practice
Diversity actions & burden
approach based on context
• Continuous
• Seamless
• Accessibility
• Affordability
• Friendly
• Advocacy High volume of cases
Complexity of cases
• Holistic P. Songwathana, 2023

Think, share, learn, act together through integrated emergency care framework
P. Songwathana
 Challenges: Research Roadmap
Research Center for Enhancing Well-being and Continuing Care System (RC-WellCare):
Focusing on Vulnerable populations

Direction of Develop strategies and supporting system for enhancing well-being Develop innovation and technology with wisdom from all
and continuing care in vulnerable populations both in normal and sectors for creating a smart and culturally based care to
Research emergency conditions addressing integration of all sectors in hospital enhance well-being and continuing care
center and community settings to be an excellent learning center

2024 2025 2026 2027 2028 • Excellent learning center for enhancing well-being
and continuing care in vulnerable populations at
R&D Innovation and Transformation individual, family, community and institutional levels
Agenda Outcome of Integrated System Management • Having an integrated care continuum management
system to meet the needs at normal and emergency
Productivity and People Performance
situations within independent function using
Prevention and Public Engagement appropriate knowledge, wisdom, and technology
Focused Health and well-being for vulnerable populations
Area
Culturally based Continuing of Care and System
Management
Emerging issues in Aging society

People Professional and public partnership at every sector

towards SDG
Welcome for discussion and share context
Thank you for your attention

Welcome for networking/partnership

Visit website: https://rcprecet.psu.ac.th/
Contact email address: rc.nurse1201@gmail.com

Faculty of Nursing, Prince of Songkla University

Hatyai, Songkhla Thailand