Screening Adolescents in the Emergency Department for Weapon Carriage

Objectives: The objective was to describe the prevalence and correlates of past‐year weapon involvement among adolescents seeking care in an inner‐city emergency department (ED). Methods: This cross‐sectional study administered a computerized survey to all eligible adolescents (age 14–18 years), 7 days a week, who were seeking care over an 18‐month period at an inner‐city Level 1 ED. Validated measures were administered, including measures of demographics, sexual activity, substance use, injury, violent behavior, weapon carriage, and/or weapon use. Zero‐inflated Poisson (ZIP) regression models were used to identify correlates of the occurrence and past‐year frequency of these weapons variables. Results: Adolescents (n = 2069, 86% response rate) completed the computerized survey. Fifty‐five percent were female; 56.5% were African American. In the past year, 20% of adolescents reported knife or razor carriage, 7% reported gun carriage, and 6% pulled a knife or gun on someone. Although gun carriage was more frequent among males, females were as likely to carry a knife or pull a weapon in the past year. Conclusions: One‐fifth of all adolescents seeking care in this inner‐city ED have carried a weapon. Understanding weapon carriage among teens seeking ED care is a critical first step to future ED‐based injury prevention initiatives. ACADEMIC EMERGENCY MEDICINE 2010; 17:168–176 © 2010 by the Society for Academic Emergency Medicine     

History of Domestic Violence among Male Patients Presenting to an Urban Emergency Department

OBJECTIVE: To establish the prevalence of domestic violence committed by women against male patients presenting to an urban ED for any reason. METHODS: This was a prospective survey in which male patients of legal age presenting to the ED over a 13-week period were interviewed. Patients answered a series of six questions adapted from the George Washington University Universal Violence Prevention Screening Protocol. Patients who could not speak English, those refusing to participate, those unable to give informed consent, and those meeting regional criteria for major trauma were excluded. RESULTS: Of 866 male patients interviewed, 109 (12.6%) had been the victims of domestic violence committed by a female intimate partner within the preceding year. Victims were more likely to be younger, single, African American, and uninsured. The most common forms of assault were slapping, grabbing, and shoving (60.6% of victims). These were followed by choking, kicking, biting, and punching (48.6%), or throwing an object at the victim (46.8%). Thirty-seven percent of cases involved a weapon. Seven percent of victims described being forced to have sex. Nineteen percent of victims contacted the police; 14% required medical attention; 11% pressed charges or sought a restraining order; and 6% pursued follow-up counseling. CONCLUSIONS: Almost 13% of men in this sample population had been victims of domestic violence committed by a female intimate partner within the previous year. Further attention to the recognition and management of domestic violence committed by women against men may be warranted.     

Telephone Follow-up for Case Finding of Domestic Violence in an Emergency Department

Objective: To determine whether telephone follow-up of selected female patients seen in an urban ED would improve domestic violence (DV) case finding.
Methods: A prospective, cross-sectional study was conducted on consecutive female patients between the ages of 16 and 65 years treated in an urban trauma center during July and August 1995. Record review identified those patients with conditions suggesting increased risk for DV: injury; substance abuse; complaints or diagnoses related to stress, anxiety, depression, or panic attack; or complaints of headache, nonspecific abdominal pain, generalized fatigue, or numbness lasting >] week. Attempts were made to telephone all patients who had high-risk presentations within 3 days of their emergency visits. Patients were contacted by a trained interviewer regarding the circumstances of their visits.
Results: There were 142 (9%) high-risk presentations out of 1,500 ED visits by women. Of these high-risk visits, 68 patients denied DV, 19 patients did not speak English, 16 patients gave an incorrect telephone number, 18 patients could not be reached after 3 telephone calls, and 6 patients did not give a telephone number. Of the remaining 15 patients, 5 were diagnosed at the initial visit as having experienced DV, and 10 admitted on the follow-up call that the visit had been related to DV or emotional stress at home.
Conclusion: A structured interview, conducted via telephone in follow-up of released ED patients, identified an additional 10 victims out of 142 high-risk presentations and 1,500 total ED presentations. This approach is labor-intensive, with a relatively low yield. Nonetheless, prospective identification of selective high-risk cases by physicians, coupled with subsequent social service telephone contact, may be a complement in department case finding.     

Sledding Injuries in Patients Presenting to the Emergency Department in a Northern City

OBJECTIVES: Sledding is a common recreational activity in northern communities. The objective of this study was to examine the frequency and nature of sledding injuries (SIs) in patients presenting to emergency departments (EDs). METHODS: The data were derived from a cohort of patients treated at all five EDs in an urban Canadian health region over a two-year period. Following chart review, consenting patients were interviewed by telephone about their sledding activities and the circumstances surrounding the injury. RESULTS: Three hundred twenty-eight patients were correctly coded as having SIs, with 212 patients (65%) reached during the follow-up survey. The median age of those with SIs was 12 years (IQR = 8, 21), and 206 (59%) were male. Injury rates peaked in the 10--14-year age group (87/100,000) for boys and in the 5--9-year age group (75/100,000) for girls. Most patients stated they were drivers (75%), fewer than half were thrown from the sled (42%), and fewer than half (44%) were sledding on community-designated sledding hills at the time of injury. Injuries to the lower extremity (32%), upper extremity (31%), and head (13%) were most common. Thirty-seven (11%) patients with SIs were admitted to hospital vs 4% of patients with other sports/recreation injuries (p < 0.05). CONCLUSIONS: Sledding injuries are common and potentially serious wintertime injuries in northern communities, involving primarily younger patients, with a large pre-adolescent group. However, older sledders (>20 years) have poorer outcomes (hospitalization, lost time from work/school) than their younger counterparts. The SIs treated in the ED appear to lead to hospitalization more frequently than other types of sport/recreation injury, and injury prevention strategies appear warranted.     

External Causes of Pediatric Injury-related Emergency Department Visits in the United States

OBJECTIVES: To characterize the types and external causes of pediatric injury-related visits (IRVs) to emergency departments (EDs), in particular, sports-related injuries. To compare the characteristics of children with IRVs with those with non-IRVs, specifically, differences in IRV rates by race and ethnicity and by health insurance. METHODS: This was a stratified random-sample survey of EDs in the National Hospital Ambulatory Medical Care Survey (NHAMCS), including all IRVs for patients less than 19 years of age in 1998 (n = 2,656). National estimates of pediatric IRVs were obtained using the assigned patient visit weights in the NHAMCS databases and SUDAAN analyses. Measures of association between predictor variables (patient and health insurance characteristics) and whether a child had an IRV were calculated using multivariate logistic regression analyses to determine adjusted odds ratios with 95% confidence intervals. RESULTS: Pediatric IRVs accounted for more than 11 million ED visits annually. The most common diagnoses for IRVs were open wounds, contusions, sprains and strains, and fractures and dislocations. The leading external causes of IRVs were sports-related injuries, accidental falls, being struck by objects, and motor vehicle collisions. Children with IRVs differed from those who presented for non-IRVs in many characteristics: they were more likely to be male, to be older, to be of white race, and to have private insurance, and less likely to be of Asian or Hispanic ethnicity. CONCLUSIONS: Sports and recreation are the leading external causes of pediatric IRVs to EDs in the United States. There are different patterns of IRVs according to gender, age, race, ethnicity, and insurance. Identification of specific patterns of injury is necessary for the design of effective prevention strategies.     

Emergency Physician Recognition of Adverse Drug-related Events in Elder Patients Presenting to an Emergency Department

Objectives: The authors examined the ability of emergency physicians (EPs) to recognize adverse drug‐related events (ADREs) in elder patients presenting to the emergency department (ED). Methods: This was a prospective observational study of patients at least 65 years of age who presented to the ED. ADREs were identified using a validated, standardized scoring system. EP recognition of ADREs was assessed through physician interview and subsequent chart review. Results: A total of 161 patients were enrolled in the study. Thirty‐seven ADREs were identified, which occurred in 26 patients (16.2%; 95% confidence interval [CI] = 10.5% to 22.0%). The treating EPs recognized 51.2% (95% CI = 35.2% to 67.4%) of all ADREs. There was better recognition of those ADREs related to the patient's chief complaint (91%; 95% CI = 74.1% to 100%) as compared with recognition of ADREs that were not associated with the chief complaint (32.1%; 95% CI = 14.8% to 49%). EPs recognized six of seven severe ADREs (85.7%), 13 of 23 moderate ADREs (56.5%; 95% CI = 36.8% to 77%), and none of the mild ADREs. Recognition of ADREs varied with medication class. Conclusions: EP performance was superior at identifying severe ADREs relating to the patients' chief complaints. However, EP performance was suboptimal with respect to identifying ADREs of lower severity, having missed a significant number of ADREs of moderate severity as well as ones unrelated to the patients' chief complaints. ADRE detection methods need to be developed for the ED to aid EPs in detecting those ADREs that are most likely to be missed.     

Weapon Carriage among Major Trauma Victims in the Emergency Department

Objective: To determine the occurrence of weapon carriage by major trauma patients at a university/county hospital ED.
Methods: Retrospective observational study of major trauma patients seen in the ED of a major urban trauma center in Los Angeles from 1979 to 1993. All major trauma patients were searched routinely for weapons by the security police. Cases of violence in the ED caused by these weapons were reviewed.
Results: Over the 14-year period, 26.7% of the victims of major trauma presenting to ED were armed with lethal weapons. The occurrence of automatic weapon seizure increased significantly from an annual rate of only 0.2 in the first five years to an average of 17 over the last five years (p < 0.001). A total of 115 "incidents" of violence involving weapons in the ED were recorded during this period; 1.7% of the weapons brought to the ED led to violence and injury. There were four fatalities of armed and dangerous patients, but only six minor injuries to the staff. No other (unarmed) patient in the ED at the time of these incidents was injured.
Conclusions: ED major trauma patients at one urban trauma center in Los Angeles frequently carry weapons, including automatic military weapons. In addition to violence prevention measures such as weapon confiscation, plans must be made and practiced for the management of violence within the "sacrosanct" hospital doors to protect both patients and ED personnel.     

How Often Do Women in the Emergency Department without Intimate Violence Injuries Return with Such Injuries?

Abstract. Objective:lb determine the rate at which a group of women visiting the ED for reasons other than intimate violence return to the ED at a later time for intimate-violence-related injuries.
Methods:Retrospective cohort study of a group of women with intimate-violence-related injuries on an index visit and a matched comparison group. Return visit rates to the ED for intimate violence injuries over the next 5 years were then compared.
Results:The 95 women in each group were followed an average of 57 months. The return rates in the positive index case group and matched comparison group, respectively, for any reason were 74.9% vs 77.9% (p = 0.463) and for intimate violence injuries were 29.5% vs 18.9% (p = 0.118).
Conclusion:Women in the ED without intimate violence injuries often return to the ED later with such injuries. This suggests the ED may play an important role in identifying women at risk for future intimate-violence-related injury.     

Lumbosacral Spinal Imaging for Patients Presenting to the Emergency Department With Nontraumatic Low Back Pain

BackgroundChoosing Wisely Canada (CWC) guidelines recommend that in the absence of clinical indicators suggestive of serious underlying pathology, physicians should not order radiological imaging for patients presenting with nonspecific low back pain (LBP).ObjectiveOur aim was to determine how many patients presenting to the emergency department (ED) with nontraumatic LBP had spinal imaging before and after the release of the CWC guideline.MethodsWe conducted a retrospective medical record review for patients aged 18–70 years presenting to an academic tertiary care ED with nontraumatic LBP from April 1, 2014 to March 31, 2015 (pre-guideline) and April 1, 2017 to March 31, 2018 (post-guideline).ResultsOne-thousand and sixty (545 pre-guideline, 515 post-guideline) patients were included. Pre-guideline, 45 patients (8.3%) had spinal imaging compared to 39 (7.6%) post-guideline (Δ 0.7%; 95% confidence interval [CI] −2.6% to 4.0%). Of the 84 patients (7.9%) who had spinal imaging, 4 (8.9%) had pathologic findings pre-guideline compared to 11 patients (28.2%) post-guideline (Δ 19.3%; 95% CI 2.7% to 35.8%).ConclusionsCWC guidelines did not appear to alter the rate of imaging for patients presenting to the ED with nontraumatic LBP. Future clinical recommendations should consider active knowledge dissemination and education strategies to help facilitate guideline adoption.     

综合性医院急诊科护士遭受工作场所暴力的调查

目的探讨综合性医院急诊科护士遭受工作场所暴力的现状及其原因,为采取干预措施提供依据。方法 2009年9月至2010年9月采用便利抽样的方法选择北京市4所三级甲等综合性医院的168名急诊科护士作为调查对象,调查内容包括一般资料和护士遭受工作场所暴力的情况。结果在166份有效问卷中,有149名(89.8%)护士遭受过工作场所暴力。不同年龄、工作时间、学历和职称的护士遭受工作场所暴力的发生率差异无统计学意义(P>0.05);急诊科护士遭受工作场所暴力的形式依次为语言伤害(86.1%)、躯体冲突(32.5%)、特定威胁(20.5%)和性暴力(3.0%);而等待时间过久(67.1%)、未满足患方要求(64.8%)、肇事方醉酒或药物滥用(58.4%)、认为医疗费用高(53.4%)是发生暴力的主要原因;暴力发生可使护士出现委屈(75.8%)、愤怒(66.4%)、不安全感(47.6%)等不良心理反应。结论急诊科护士遭受工作场所暴力的现象普遍存在,而且工作场所暴力事件对护士造成了严重的心理伤害,因此医院管理部门应给予充分重视,从多方面采取有效措施预防和控制工作场所暴力的发生。     

Causes of Emergency Department Overcrowding and Blockage of Access to Critical Services in Beijing: A 2-Year Study

Background

Emergency department (ED) overcrowding is a serious issue worldwide.

Rates of At-risk Drinking among Patients Presenting to the Emergency Department with Occupational and Nonoccupational Injury

OBJECTIVES: To compare the characteristics and rates of at-risk drinking among patients presenting to the emergency department (ED) with occupational and nonoccupational injury. METHODS: Cross-sectional survey of injured patients presenting to a university hospital ED. Injured patients were prospectively identified, and consenting patients completed a survey including questions regarding quantity/frequency of alcohol use, TWEAK, CAGE, and work-relatedness of injury. Major trauma and motor-vehicle collisions were excluded. Demographic and injury information was obtained from the medical record. Patients with a TWEAK score > or =3, CAGE score > or =2, or who exceeded NIAAA quantity/frequency guidelines were defined as at-risk drinkers. Analysis utilized the Student t-test for continuous variables, and frequency and chi-square analysis for categorical variables. RESULTS: Among 3,476 enrolled patients, 766 (22%) had work injuries and 2,710 (78%) had nonwork injuries. Patients with work injuries were as likely as patients with nonwork injuries to be at-risk drinkers; 35% of patients with an occupational injury and 36% of those with a nonoccupational injury were at-risk drinkers (odds ratio = 0.96). CONCLUSIONS: Patients presenting to the ED with an occupational injury have rates of at-risk drinking similar to other injury patients, and may be an important group in which to target brief alcohol interventions.     

Lyme Disease: Emergency Department Considerations

Background

Lyme disease (LD) is the most common vector-borne illness in North America. Reported cases of LD have increased from approximately 10,000 cases annually in 1991 to >25,000 cases in 2014. Greater recognition, enhanced surveillance, and public education have contributed to the increased prevalence, as have geographic expansion and the number of infected ticks. Cases are reported primarily in the Northeastern United States, Wisconsin, and Minnesota, with children having the highest incidence of LD among all age groups. The increased incidence and prevalence of LD in the United States makes it increasingly more common for patients to present to the emergency department (ED) for tick bites and LD-related chief complaints, such as the characteristic erythema migrans skin manifestation.

Adolescent Suicide Risk Screening in the Emergency Department

Objectives: Many adolescents who die by suicide have never obtained mental health services. In response to this, the National Strategy for Suicide Prevention recommends screening for elevated suicide risk in emergency departments (EDs). This cross‐sectional study was designed to examine 1) the concurrent validity and utility of an adolescent suicide risk screen for use in general medical EDs and 2) the prevalence of positive screens for adolescent males and females using two different sets of screening criteria. Methods: Participants were 298 adolescents seeking pediatric or psychiatric emergency services (50% male; 83% white, 16% black or African American, 5.4% Hispanic). The inclusion criterion was age 13 to 17 years. Exclusion criteria were severe cognitive impairment, no parent or legal guardian present to provide consent, or abnormal vital signs. Parent or guardian consent and adolescent assent were obtained for 61% of consecutively eligible adolescents. Elevated risk was defined as 1) Suicidal Ideation Questionnaire‐Junior [SIQ‐JR] score of ≥31 or suicide attempt in the past 3 months or 2) alcohol abuse plus depression (Alcohol Use Disorders Identification Test‐3 [AUDIT‐3] score of ≥3, Reynolds Adolescent Depression Scale‐2 [RADS‐2] score of ≥76). The Beck Hopelessness Scale (BHS) and Problem Oriented Screening Instrument for Teenagers (POSIT) were used to ascertain concurrent validity. Results: Sixteen percent (n = 48) of adolescents screened positive for elevated suicide risk. Within this group, 98% reported severe suicide ideation or a recent suicide attempt (46% attempt and ideation, 10% attempt only, 42% ideation only) and 27% reported alcohol abuse and depression. Nineteen percent of adolescents who screened positive presented for nonpsychiatric reasons. One‐third of adolescents with positive screens were not receiving any mental health or substance use treatment. Demonstrating concurrent validity, the BHS scores of adolescents with positive screens and the POSIT scores of those with positive screens due to alcohol abuse and depression indicated substantial impairment. The addition of alcohol abuse with co‐occurring depression as a positive screen criterion did not result in improved case identification. Among the subgroup screening positive due to depression plus alcohol abuse, all but one (>90%) also reported severe suicide ideation and/or a recent suicide attempt. This subgroup (approximately 17% of adolescents who screened positive) also reported significantly more impulsivity than other adolescents who screened positive. Conclusions: The suicide risk screen showed evidence of concurrent validity. It also demonstrated utility in identifying 1) adolescents at elevated risk for suicide who presented to the ED with unrelated medical concerns and 2) a subgroup of adolescents who may be at highly elevated risk for suicide due to the combination of depression, alcohol abuse, suicidality, and impulsivity.