Analysis of Alcohol Use Clusters among Subcritically Injured Emergency Department Patients

Objectives : 1) To cluster patients according to self-reported drinking patterns using cluster analysis; 2) to externally validate clustered groups on variables related to drinking but not used in the cluster analysis; and 3) to use the clustered patients' responses to alcohol consumption questions to develop a brief screening tool emergency physicians can use to identify patients in need of referral or intervention related to potentially hazardous alcohol consumption. Methods : A self-report battery was administered to 95 subcritically injured patients. Patients also were saliva alcohol-tested upon arrival to the ED. Using the patients' self-reported quantity, frequency of alcohol consumption, and frequency of having ≥6 drinks on a drinking occasion, patients were categorized into 3 groups using cluster analysis. The 3 clusters were externally validated using injury-related variables, alcohol-related consequences, and the patients' reported readiness to change drinking. A screening tool was developed using cutoff values reported by the patients' answers to drinking pattern questions. Results : Fifty-nine patients were alcohol-negative, and 36 tested alcohol-positive (i.e., >4 mmol/L [>20 mg/ dL]) or had elevated scores on an alcohol problem screening instrument. Three distinct drinking pattern clusters were found. Clusters were validated using discriminant function analysis and multivariate analyses of variance to confirm cluster classifications. Steady and high-intensity drinkers reported more alcohol-related negative consequences, and high-intensity drinkers indicated they would consider changing their drinking. The screening tool correctly classified 97% of the patient sample into their respective clusters. Conclusions : Using the drinking pattern questions in the clustering procedure was effective for grouping injured patients into clusters that could be differentiated on other drinking-related variables. The resulting screening tool can be used in the ED setting to screen patients for further assessment and intervention. The readiness-to-change results support the assertion that the injury event provides a “teachable moment” for subcritically injured patients whose injury may be related to their alcohol consumption.     

Socioeconomic factors, hazardous alcohol consumption, and smoking in patients with minor trauma in an inner-city emergency department

Emergency Department (ED) patients show a high prevalence of hazardous alcohol consumption and smoking. The objective of this study was to determine if socioeconomic factors and smoking status help to optimize screening for hazardous alcohol consumption (HAC) in patients with minor trauma. A survey was conducted in an ED in an inner-city university hospital. A total of 2562 patients with minor trauma were screened for HAC (≥ 8 points in men and ≥ 5 points in women on the Alcohol Use Disorders Identification Test), smoking status, and socioeconomic factors. The median age of participants was 32 years, with 62.1% being male. A total of 84.2% of patients had an Injury Severity Score of 1, indicating minor trauma. Overall, 23.5% of patients showed a pattern of HAC, whereas 46.2% were current smokers. Compared to patients without HAC, those with HAC were characterized by lower incomes, no partnership, living in a single-household, and being unemployed. The strongest discriminative variable for HAC for patients aged ≤ 53 years was smoking status. Gender differences played a role only in patients older than 53 years. Although socioeconomic factors showed a non-equal distribution in patients with respectively without HAC, solely age, gender, and smoking status may provide a successful stratification for alcohol screening and intervention in these patients.     

Mosher and Jernigan's 'Making the link: a public health approach to preventing alcohol-related violence and crime'

While alcohol problems are over-represented in primary care settings and in emergency departments (EDs), screening for alcohol use disorders has not been a routine part of care in the United States, and little is known of the performance of screening instruments for problem drinking, particularly among women and ethnic minorities. The sensitivity and specificity of the CAGE, BMAST, AUDIT, TWEAK, and RAPS are compared against DSM-IV and ICD-10 criteria for alcohol dependence in probability samples of black patients interviewed in the ED (n= 1091) and primary care clinics (n = 711) in Jackson, Mississippi. Instruments appeared to perform better in the ED than in primary care. The CAGE and RAPS appeared to perform best in the primary care sample, and the AUDIT and RAPS in the ED sample. While the prevalence of alcohol dependence in the primary care clinics was lower than in the ED, findings suggest that both sites are important for screening and identification of patients with alcohol use disorders. Further research is needed for determining those screening instruments which perform optimally in identifying problem drinking patients across clinical sites.     

Alcohol-related problems: emergency physicians' current practice and attitudes

To determine whether emergency physicians' (EPs) attitudes affect their support and practice of brief intervention in the Emergency Department (ED), EPs completed an anonymous survey. EPs were asked about their attitudes toward patients with alcohol problems, current ED screening, use of brief intervention, and barriers to use of brief intervention. Chi-square analysis was used and a step-wise regression model was constructed. Respondents reported a high prevalence of patients with alcohol-related problems: 18% in a typical shift. Eighty-one percent said it is important to advise patients to change behavior; half said using a brief intervention is important. Attending physicians had significantly less alcohol education than residents, but were significantly more likely to support the use of brief intervention. Support was not associated with gender, race, census, hours of education, or personal experience. EPs who felt that brief intervention was an integral part of their job were more likely to use it in their daily practice.     

Smoking Habits of Emergency Department Patients: An Opportunity for Disease Prevention

Objective: To determine smoking habits, levels of addiction, readiness to quit, and access to primary care among ED patients.
Methods: A questionnaire was administered prospectively to all non-critical adult patients who presented to one university hospital ED during 23 randomly selected four-hour time blocks; 336 (89%) of 376 eligible patients responded. Self-reported smoking was validated by carbon monoxide breath testing in a pilot sample of 49 patients.
Results: The study patients were mostly young (mean age = 35 ± 15 years), female (59%), white (62%), and high school-educated (73%). Of the 336 ED patients, 41% were current smokers (95% CI = 0.36–0.46); 42% of these were "moderately" to "very highly" dependent on nicotine (Fagerstrom Test for Nicotine Dependence > 4). Of those who smoked, 68% stated they wanted to quit, and 49% wanted to quit within the month. Fifty-six percent of all those who smoked stated that they had never been told to quit smoking by any physician. Thirty-five percent of the ED sample (118 patients) relied upon EDs for most or all of their routine, primary health care; 55% (95% CI = 0.46–0.64) of these patients were current smokers.
Conclusions: The prevalence rates of smoking and nicotine addiction among ED patients are high. Almost half of ED smokers are ready to quit, but most state they have never been told by a physician to do so. Finally, a large proportion of ED smokers receive their primary care in EDs. Therefore, the ED may be an underused setting for smoking cessation intervention.     

Feasibility of screening and intervention for alcohol problems among young adults in the ED

This study evaluates the feasibility of screening and brief intervention (SBI) for alcohol problems among young adults (18-39 years) in a rural, university ED. Research staff screened a convenience sample of patients waiting for medical treatment with the Alcohol Use Disorders Identification Test (AUDIT), used motivational interviewing techniques to counsel screen-positive patients (AUDIT >/= 6) during the ED visit, and referred patients to off-site alcohol treatment as appropriate. Patients were interviewed again at 3 months. Eighty-seven percent of age-eligible drinkers (2,067 of 2,371) consented to participate. Forty-three percent (894 of 2,067) screened positive, of which 94% were counseled. Forty percent of those counseled set a goal to decrease or stop drinking and 4% were referred for further treatment. Median times for obtaining consent, screening, and intervention were 4, 4, and 14 minutes, respectively. Project staff reported that 3% of patients screened or counseled were uncooperative. Seventy percent of 519 patients who participated in follow-up interviews agreed the ED is a good place to help patients with alcohol problems. High rates of informed consent and acceptance of counseling confirmed this protocol's acceptability to patients and indicated patients were comfortable divulging alcohol-related risk behavior. The modest times required for the process enhanced acceptability to patients as well as ED staff. The high prevalence of alcohol problems and the broad acceptance of SBI in this sample provide evidence of the ED's promise as a venue for this clinical preventive service.     

Prevalence of problem drinking and characteristics of a single-question screen

Hazardous drinking and alcohol use disorders (i.e, abuse and dependence) are common in Emergency Departments (EDs). This study examined 1) the prevalence of these conditions among ED patients and 2) characteristics of a single screening question (having consumed at least five drinks for males or four for females during a single day). Data from the National Epidemiologic Survey on Alcohol and Related Conditions were analyzed. Logistic regression for clustered data was used to estimate the relative risk for past-year ED use associated with hazardous drinking, abuse, and dependence. Contingency tables were analyzed to estimate the sensitivity and specificity of the single-question screen for detecting these conditions. Hazardous drinking was not associated with ED utilization. Alcohol abuse was associated with a relative risk of 1.3 (95% confidence interval [CI] 1.1-1.5) and alcohol dependence with a relative risk of 1.9 (95% CI 1.6-2.2). For current drinkers, the single question screen was 0.96, 0.85, and 0.90 sensitive for hazardous drinking, alcohol abuse, and alcohol dependence, respectively. Individuals with a positive screen in the past year were considered at least hazardous drinkers, and specificity was 0.80, 0.64, and 0.65 for hazardous drinking, abuse, and dependence, respectively. Specificity was modestly increased in women. Most problem drinkers were hazardous drinkers, but only severe alcohol use disorders were particularly prevalent in the ED. The single heavy-drinking-day item appears sensitive for problem drinking. Positive tests must be followed by additional assessment to differentiate hazardous drinking from alcohol use disorders.     

Trial study design to test a bilingual digital health tool for alcohol use disorders among Latino emergency department patients

We describe an emergency department (ED)-based, Latino patient focused, unblinded, randomized controlled trial to empirically test if automated bilingual computerized alcohol screening and brief intervention (AB-CASI), a digital health tool, is superior to standard care (SC) on measures of alcohol consumption, alcohol-related negative behaviors and consequences, and 30-day treatment engagement. The trial design addresses the full spectrum of unhealthy drinking from high-risk drinking to severe alcohol use disorder (AUD). In an effort to surmount known ED-based alcohol screening, brief intervention, and referral to treatment process barriers, while addressing racial/ethnic alcohol-related health disparities among Latino groups, this trial will purposively use a digital health tool and seek enrollment of English and/or Spanish speaking self-identified adult Latino ED patients. Participants will be randomized (1:1) to AB-CASI or SC, stratified by AUD severity and preferred language (English vs. Spanish). The primary outcome will be the number of binge drinking days assessed using the 28-day timeline followback method at 12 months post-randomization. Secondary outcomes will include mean number of drinks/week and number of episodes of driving impaired, riding with an impaired driver, injuries, arrests, and tardiness and days absent from work/school. A sample size of 820 is necessary to provide 80% power to detect a 1.14 difference between AB-CASI and SC in the primary outcome. Showing efficacy of this promising bilingual ED-based brief intervention tool in Latino patients has the potential to widely and efficiently expand prevention efforts and facilitate meaningful contact with specialized treatment services.     

Trial study design to test a bilingual digital health tool for alcohol use disorders among Latino emergency department patients

We describe an emergency department (ED)-based, Latino patient focused, unblinded, randomized controlled trial to empirically test if automated bilingual computerized alcohol screening and brief intervention (AB-CASI), a digital health tool, is superior to standard care (SC) on measures of alcohol consumption, alcohol-related negative behaviors and consequences, and 30-day treatment engagement. The trial design addresses the full spectrum of unhealthy drinking from high-risk drinking to severe alcohol use disorder (AUD). In an effort to surmount known ED-based alcohol screening, brief intervention, and referral to treatment process barriers, while addressing racial/ethnic alcohol-related health disparities among Latino groups, this trial will purposively use a digital health tool and seek enrollment of English and/or Spanish speaking self-identified adult Latino ED patients. Participants will be randomized (1:1) to AB-CASI or SC, stratified by AUD severity and preferred language (English vs. Spanish). The primary outcome will be the number of binge drinking days assessed using the 28-day timeline followback method at 12 months post-randomization. Secondary outcomes will include mean number of drinks/week and number of episodes of driving impaired, riding with an impaired driver, injuries, arrests, and tardiness and days absent from work/school. A sample size of 820 is necessary to provide 80% power to detect a 1.14 difference between AB-CASI and SC in the primary outcome. Showing efficacy of this promising bilingual ED-based brief intervention tool in Latino patients has the potential to widely and efficiently expand prevention efforts and facilitate meaningful contact with specialized treatment services.     

ExHALED Study: Prevalence of smoking and harm levels in an emergency department cohort

Objective: To determine the prevalence of smoking among ED patients compared with the general New Zealand (NZ) smoking prevalence. Secondary outcomes were to determine smokers' level of nicotine dependence, readiness to quit and engagement with primary health care. Methods: This was a prospective, cross‐sectional prevalence study of ED patients seen consecutively over 6 days in Wellington Hospital, Wellington South, NZ. Medically stable patients ≥18 years were asked about their smoking habits by a closed‐question survey. Results: Five hundred and twenty‐eight patients comprised the study group. The ED smoking prevalence was 33.1% and higher than the general NZ smoking prevalence of 20.7%. Of those who smoked, 26.3% were ‘moderately’ to ‘very highly’ dependent on nicotine (Fagerstrom Test for Nicotine Dependence, FTND score ≥5). Of those who smoked, 74.9% stated they wanted to quit, 42.9% wanted to quit within the next month and 60.6% wanted an ED quit smoking pack. There were 13.6% of ED patients not registered with a general practitioner; of this, 61.1% were current smokers and 70.5% wanted to quit smoking. Conclusions: The prevalence rates of smoking are higher among patients attending Wellington Hospital ED than the general NZ population and the majority would like to quit smoking. One in four ED smokers have a high FTND score and are considered nicotine‐dependent. Many patients who were not registered with a general practitioner smoked, and the majority wanted to quit. Finally, there is significant interest from ED patients in receiving quit smoking packs from the ED.     

Smoking Stage of Change and Interest in an Emergency Department–based Intervention

Objectives: To examine factors associated with motivation to quit smoking and interest in an emergency department (ED)‐based intervention. Methods: Consecutive ED patients 18 years of age and older were interviewed. Severely ill and cognitively disabled patients were excluded. Smoking history, stage of change, self‐efficacy, presence of a smoking‐related illness, interest in an ED‐based smoking intervention, and screening/counseling by the patient's ED provider were assessed. Results: A total of 1,461 of 2,314 patients (64%) were interviewed. A total of 581 (40%) currently smoked, with 21% in precontemplation (no intention to quit), 43% in contemplation (intention to quit but not within the next 30 days), and 36% in preparation (intention to quit within the next 30 days). Approximately 50% indicated a willingness to remain 15 extra minutes in the ED to receive counseling. Only 8% received counseling by their ED provider. A regression analysis showed that greater readiness to change was associated with multiple lifetime quit attempts, presence of a quit attempt in the past 30 days, and higher self‐efficacy. Interest in an ED‐based intervention was more likely among patients who reported higher self‐efficacy. Conclusions: Approximately 50% of smokers reported at least moderate interest in an ED‐based intervention and a willingness to stay 15 extra minutes, but only 8% reported receiving counseling during their ED visit. Considering time and resource constraints, counseling/referral may be best suited for patients characterized by a strong desire to quit, multiple previous quit attempts, high self‐efficacy, a smoking‐related ED visit, and strong interest in ED‐based counseling.     

An audit of health education services within UK hospitals

Rationale, aims and objective  UK public health policy requires hospitals to deliver health promotion services to patients for healthy lifestyles (i.e. health education), but there are currently few data on the health education delivered within hospitals. This audit aimed to collect data on the routine health education activities delivered to hospitalized patients to assess whether the following standards were met: 100% of hospitalized patients screened for smoking, alcohol use and obesity, 70% of smokers offered health education for smoking cessation and 50% of patients identified as misusing alcohol, obese, consuming an unhealthy diet and/or physically inactive delivered the appropriate health education.
Methods  An audit of data contained in hospitalized patients' written medical case notes for evidence that the above standards were met. Nine hospitals in Greater Manchester in England participated.
Results  Four hospitals screened all patients for smoking. None of the hospitals met the standards for screening alcohol or obesity. For health education delivery, all hospitals met the standard for diet, four for alcohol misuse and four for physical activity. None of the hospitals met the standards for smoking or obesity.
Conclusions  Improvements in practice for screening of alcohol and obesity are required. While some hospitals appeared to meet standards for health education delivery for alcohol, diet and physical activity, given the poor screening procedures for these risk factors, we can not conclude that health education delivery was adequate.     

Alcohol use among young adults presenting to the emergency department

Objectives: To determine the prevalence of young ED patients at risk from hazardous alcohol consumption, to identify high‐risk patient subgroups and evaluate the feasibility of use of the Alcohol Use Disorders Identification Test (AUDIT) in this setting. Methods: We undertook a cross‐sectional survey of 336 ED patients aged 18–30 years, inclusive. All were breathalysed prior to self‐administering the AUDIT. A ‘positive’ AUDIT score (≥8) defined hazardous alcohol consumption. AUDIT scores were correlated with sex and trauma diagnosis. Results: One hundred and thirty‐one (39.0%, 95% confidence interval [CI] 33.8–44.5) patients were classified as AUDIT‐positive. Men were significantly more likely to be AUDIT‐positive (49%vs 23%, P < 0.001) and had significantly higher total AUDIT scores (P < 0.001) than women. Trauma patients were significantly more likely to be AUDIT‐positive (P < 0.001) and had significantly higher AUDIT scores than non‐trauma patients (P < 0.001). Of the six patients who recorded a positive breath alcohol reading, all were AUDIT‐positive. One hundred (76.3%, 95% CI 68.0–83.1) AUDIT‐positive patients did not report others being concerned about their drinking or had not been given advice to cut down. Conclusion: It is feasible to use the AUDIT screening tool in the ED to identify those at risk from hazardous drinking. In our ED there is a high prevalence of hazardous alcohol consumption in young adult patients, many of whom have not previously received advice to cut down on their drinking.     

A Multicenter Study of Depression among Emergency Department Patients

Objectives: The authors sought to determine the 12‐month prevalence of depression among emergency department (ED) patients using a single‐question screen. Methods: This cross‐sectional study was conducted in four Boston‐area EDs. For two 24‐hour periods, consecutive patients aged 18 years or older were interviewed, excluding those who were severely ill, potential victims of sexual assault, or emotionally disturbed. During the interview, patients were asked “Have you had any of the following problems during the past 12 months?” Patients answered “yes” or “no” to a list of health problems that included depression. In a validation study, the authors found that this simple approach correlated well with results from the validated Center for Epidemiologic Studies Depression Scale. Results: Of 752 eligible patients, 539 (72%) were interviewed. Of these patients, 30% (95% confidence interval = 26% to 34%) reported depression within the past 12 months. Compared with their nondepressed counterparts, depressed patients were more likely middle‐aged, female, and of lower socioeconomic status. Depressed patients were more likely to be smokers and to report a diagnosis of asthma or arthritis/rheumatism. In a multivariate analysis, factors that were independently associated with depression were lower level of education, smoking, and self‐reported anxiety, chronic fatigue, and back problems. Conclusions: A 30% 12‐month prevalence of depression among ED patients was found. Depressed patients had a distinct sociodemographic and health profile. In the future, awareness of risk factors for depression in the ED setting and use of simple screening instruments could aid in the recognition of depression, with subsequent referral to mental health services.     

Prevalence of Smokers and Nicotine-addicted Patients in a Suburban Emergency Department

OBJECTIVE: To define the prevalence of smokers and nicotine-addicted patients in a suburban, community ED. METHODS: This was a prospective survey of consecutive ED patients seen in a suburban ED with an annual patient census of 48,000. Medically stable patients aged 18 years or older were eligible for inclusion. Patients were excluded if they had predominantly psychiatric complaints or were critically ill. Patients were queried about their smoking habits by a closed-question survey, which included the previously validated Fagerstrom Test for Nicotine Dependence. The study was conducted during a six-week period, only at times when there were dedicated research associates available to ensure consecutive patient entry. Continuous variables were analyzed by Student's t-tests. Clinical variables were analyzed by chi-square tests. All tests were two-tailed with alpha at 0.05. RESULTS: 1,515 patients comprised the study group. The mean age (+/-SD) was 45.6 (+/-18.9) years; 52% were female, 25% were nonwhite, and 47% were college graduates. There were 317 (21%) smokers. Patients having private physicians were less likely to smoke (18% vs 29%, p = 0.001). Of all smokers, 46% were moderately to severely nicotine-dependent, 69% wanted to quit, and 30% expressed an interest in joining a smoking cessation program. CONCLUSION: A substantial percentage of ED patients smoke, many of them are nicotine-addicted, and the majority would like to quit. Randomized, controlled trials are needed to determine whether interventions by physicians in the ED can have an impact on the smoking habits of these patients.     

Alcohol use and problems in daily and non-daily coffee drinking college females

Background: For more than a decade, a large proportion of research on caffeine use in college students has focused on energy drinks (ED), demonstrating an association between ED consumption and heavy/problem alcohol use. The present study examined the relationship between daily coffee (DC) consumption and varied measures of alcohol use and problems in a sample of college women. Methods: Participants were undergraduate females (N = 360) attending an urban university in 2001–02 and prior to the rise in ED popularity on college campuses. Analyses compared women who reported drinking coffee daily (DC; 16.9%), to women who did not (non-daily coffee [NDC]; 83.1%) on standardized measures of alcohol use and problems. Results: For both past month and year of drinking, DC women generally reported consuming more alcohol and were 2.1–2.6 times more likely to screen at risk for alcohol problems than their NDC counterparts. DC women were also more likely than NDC women to report problems related to drinking (e.g., experiencing blackouts, inability to stop drinking after they had started). Conclusions: Findings support potential benefits of health education and screening that goes beyond EDs, focusing on varied forms of caffeine consumption.     

Emergency clinician‐delivered screening and intervention for high‐risk alcohol use: A qualitative analysis

Objectives: To evaluate qualitative feedback from patients who received opportunistic screening and brief intervention for harmful alcohol use during an ED attendance; to evaluate emergency staff attitudes to performing alcohol screening and delivering opportunistic brief intervention; and to document process issues associated with the introduction of routine clinician‐initiated opportunistic screening and training and administration of brief intervention. Methods: Structured and semi‐structured interviews with emergency staff and recipients of brief intervention. Results: Sixty‐nine patients were interviewed 3 months after an ED attendance where they received emergency clinician‐delivered brief intervention for high‐risk alcohol use. Twenty‐two (32%; 95% CI 21–43%) reported a positive effect of brief intervention on thoughts or behaviour, but 29% (95% CI 18–40%) felt the intervention was not relevant for them or could not recall it. Four people (6%; 95% CI 1–12%) felt confronted or embarrassed, and 17 (25%; 95% CI 15–36%) felt timing or delivery could be improved. Staff had a positive attitude to delivering brief intervention, but nominated lack of time as the main barrier. Fourteen of 15 staff felt brief intervention should become routine in emergency care. Conclusion: Emergency clinicians can be trained to provide brief intervention for high‐risk alcohol in an ED. The use of emergency clinician brief intervention is acceptable to most staff and patients.     

Audit of health promotion practice within a UK hospital: results of a pilot study

Introduction and aim There is clear evidence that modifiable risk factors – smoking, alcohol misuse, poor diet, lack of exercise and obesity – are detrimental to health. UK public health policy now requires hospitals to have in‐place health promotion programmes to empower patients to swap risky for healthy behaviours. This audit aimed to determine a baseline level of health promotion practice for modifiable risk factors in a UK hospital. Method Case notes from two hundred and fifty hospitalized adult patients (excluding all terminally ill patients), discharged alive between January and June 2004, were audited for evidence of screening for risk factors (smoking, alcohol, diet, exercise and obesity) and the provision of health promotion to change these risk behaviours. Results The majority of inpatients were asked about smoking (88%) and alcohol consumption (74%), but few were screened for obesity (18%) or asked about their normal diet (5%) and physical activity (3%). Health promotion was delivered to a third of smokers and over half of inpatients reporting misuse of alcohol. Healthy diets, exercise and weight management were rarely discussed. Only three inpatients were screened for all risk factors. Conclusion This study indicates that the majority of hospital inpatients were screened for smoking and alcohol use, but improvements need to be made in the delivery of health promotion for smoking cessation and sensible drinking. It is clear that inpatients’ are not routinely screened for diet, exercise and weight status, nor delivered health promotion for the management of these risk behaviours.     

Return to the Emergency Department among Elders: Patterns And Predictors

OBJECTIVES: 1) To describe the pattern of return visits to the emergency department (ED) among elders over the six months following an index visit; 2) to identify the predictors of early return (within 30 days) and frequent return (three or more return visits in six months); and 3) to evaluate a newly developed screening tool for functional decline, Identification of Seniors At Risk (ISAR), with regard to its ability to predict return visits. METHODS: Subjects were patients aged 65 years or more who visited the EDs of four Canadian hospitals during the weekday shift over a three-month recruitment period. Excluded were patients who: could not be interviewed, due either to their medical conditions or to cognitive impairment, and no other informant was available; refused linkage of study data; or were admitted to hospital at the initial (index) visit. Measures made at the index ED visit included: 27 self-report screening questions on social, physical, and mental risk factors, medical history, use of hospital services, medications, and alcohol. Six of these questions comprised the ISAR scale. Return visits and diagnoses during the six months after the index visit were abstracted from the utilization database. RESULTS: Among 1,122 patients released from the ED, 492 (43.9%) made one or more return visits; 216 (19.3%) returned early and 84 (7.5%) returned frequently. Earlier returns were more likely than later returns to be for the same diagnosis (p = 0.003). Using logistic regression, hospitalization during the previous six months, feeling depressed, and certain diagnoses predicted both early and frequent returns. Also, a history of heart disease, having ever been married, and not drinking alcohol daily predicted early return; a history of diabetes, a recent ED visit, and lack of support predicted frequent use. CONCLUSIONS: In the first month after an ED visit, return rates are highest and are more likely to be for the same diagnosis. Both medical and social factors predict early and frequent returns to the ED; patients at increased risk of return can be quickly identified with a short, self-report questionnaire. The ISAR screening tool, developed to identify patients at increased risk of functional decline, can also identify patients who are more likely to return to the ED.     

Raising Our HEADSS: Adolescent Psychosocial Documentation in the Emergency Department

Objectives: To determine the effectiveness of a chart stamp featuring the acronym "HEADSS" (Home, Education, Alcohol, Drugs, Smoking, Sex) at improving adolescent psychosocial documentation in the emergency department (ED) chart. Methods: The study sample consisted of ten emergency physicians. The ED charts of 306 adolescent patients (aged 13–18 years) completed by these physicians were surveyed. An analysis of ED chart psychosocial documentation was conducted that compared a six-week control phase (with no chart stamp) with a four-week intervention phase (with a chart stamp featuring the HEADSS acronym). Presenting complaints in the ED, psychosocial documentation in the ED, and information from past medical records were compared between the two groups. Results: The ED charts surveyed consisted of 153 charts from each phase. HEADSS documentation ranged from 8% to 12% in the intervention phase and 0% to 7% in the control phase. Emergency physicians were more likely to document the topics of education (p = 0.029), alcohol (p = 0.045), and smoking (p = 0.009) as well as whether the patient was interviewed alone (p = 0.0001) in the intervention phase charts. Documentation of a detailed psychosocial assessment (>4/6 HEADSS topics addressed; p = 0.003) was more likely during the intervention phase. Conclusions: The HEADSS stamp is useful in prompting psychosocial documentation in the ED chart. Further study is needed to determine whether routine use of the HEADSS stamp technique can improve the detection and management of adolescent psychosocial problems.