Injury in West Virginia: A Statewide Survey

Objective: To determine an estimate of the period prevalence of medically attended injury in West Virginia via a statewide random telephone survey.
Methods: A statewide random telephone survey, the West Virginia Social Indicator Survey (WVSIS), was modified to incorporate questions regarding the incidence and mechanisms of injury. The WVSIS is periodically conducted on a representative cross-section of West Virginians to gather information about their social and economic conditions as well as to monitor change in the quality of their lives over time.
Results: Of the 1,498 households interviewed, 412 (28%) reported having sustained injuries for which medical care had been obtained. This translates to a conservative estimate of 231,000 medically attended injuries within West Virginia in 1993. The average age of those injured was 35 years. Falls were the most frequently reported causes of injury, with motor vehicle crashes being the second most reported cause. Most injury victims (70%) were treated in an ED. Most respondents (67%) were able to suggest ways in which the injuries might have been avoided. Only 37% of the respondents with children 13 years of age reported ever having received injury prevention information from a physician. The most commonly reported physician advice concerned childhood poisoning (34%).
Conclusions: Injury questions added to ongoing state health surveillance surveys provide valuable insight into population-based injury rates and potential preventive measures.     

A Truncated E-code System for Injury Surveillance in the Emergency Department: Description and Clinometric Testing

Objectives: ED injury surveillance requires accurate information about mechanism. This study explored the clinometric properties of an E-code system specifically designed to track ED injuries.
Methods: All patients assessed in the ED had cause-of-injury information documented using a truncated E-code system. Patient records were hand-searched to determine coding compliance. A selection of 98 charts (50 injury/48 noninjury) were coded by 7 physicians, 2 nurses, and 2 nosologists. Agreements (interrater and intrarater) on the diagnosis of trauma and exact E-codes were determined (using kappa; κ).
Results: E-coding compliance was high (overall 90%: 95% CI: 85–93%), and accuracy of injury classification was 99%. Compared with an expert's coding, agreement on injury classification was excellent for physicians (κ = 0.91; 95% CI: 0.80–1.0), nurses (κ = 0.88; 95% CI: 0.75–1.0), and nosologists (κ = 0.92; 95% CI: 0.81–1.0). Agreement was substantial for the exact E-codes between physicians (κ = 0.77; 95% CI: 0.60- 0.94) and nurses (κ = 0.72; 95% CI: 0.54–0.90). Recode reliability was also excellent for physicians (κ = 0.88; 95% CI: 0.75–1.0) and nurses (κ = 0.96; 95% CI: 0.88–1.0).
Conclusions: Injury coding using a truncated E-code system can provide valid and reliable data from the ED. Differences between nurses, physicians, and nosologists in the ability to accurately code using this system were minimal, thus eliminating the need for additional staff and resources.     

The Potential of Using Billing Data for Emergency Department Injury Surveillance

Objective: To determine the availability of and sample statewide ED injury information obtained from hospital billing data for the purpose of demonstrating the feasibility of information acquisition for subsequent data linkage.
Methods: A retrospective, database investigation was conducted to obtain data describing a statewide stratified sample of ED patients. The aim was to collect a computerized billing summary record for each injured ED patient seen at each sampled hospital over a 1-year period. All 215 Pennsylvania acute care hospitals in 1991 were eligible for sample selection. Data collection for the project was conducted in 1993. Participants included directors of hospital medical records and billing departments.
Results: Twenty-four hospitals contributed data sets from the original target goal of 31 strata. The final combined data set contained 187,404 records with injury diagnoses from approximately 616,000 ED patient visits, representing a 12% sample of all annual statewide ED visits. Age, sex, date of visit, and primary diagnosis fields were completed from the retrieved data >99% of the time. More than two-thirds of the sampled records had a social security number, and total charges were recorded >90% of the time. Other variables such as name and address were contained in <50% of the records submitted. E-codes were usually not available.
Conclusions: Retrospective compilation of multihospital ED billing data to create a statewide ED data sample—with the potential for injury research and probabilistic database linkage—can be accomplished; there are, however, important limitations.     

The Minor Injury Scale

Objective: To develop an injury scoring system suitable for non–life–threatening injuries.
Methods: A prospective cohort study was conducted using a representative sample of 1,396 injured adults to identify the outcomes of a range of injuries. Data were collected between March 12, 1992, and March 11,1993, in the Australian Capital Territory, a geographically circumscribed urban community of 296,000 people served by two hospital EDs. Outcomes included "injury–related health status immediately following injury occurrence" and "accumulated health loss over the period of recovery." The injury–related health status of each subject at the time of the injury occurrence was measured using the Health Consequences of Injury Questionnaire (HCIQ), which records this outcome as a value on a unitary scale. Injuries were then stratified by injury type, as identified by the Abbreviated Injury Scale numerical identifiers. The median health index value for each type of injury was designated the injury severity score for that injury type. The "accumulated health loss over time until recovery" for each injury was calculated from repeated administrations of the HCIQ over a six–month follow–up period, and the median outcome value for each injury type was designated the injury morbidity score for that injury.
Results: Injury severity scores for 46 types of minor injury and injury morbidity scores for 39 types of minor injury were tabulated to form the Minor Injury Scale.
Conclusion: This new injury scoring system provides a means of categorizing minor injury according to properties relevant to a public health approach to injury control. Expansion of the number of injury types scored requires further work, as does the testing of the results obtained to confirm the predictive power of the scales.     

Past-Year Intentional and Unintentional Injury Among Teens Treated in an Inner-City Emergency Department

An inner-city emergency department (ED) visit provides an opportunity for contact with high-risk adolescents to promote injury prevention. Objectives: To identify the prevalence of injuries sustained over the past year by teens presenting to an inner-city ED, and to identify factors associated with recent injury to inform future ED-based injury prevention initiatives. Methods: Over 1 year, 7 days a week, from 1:00–11:00 p.m., patients aged 14–18 years presenting to the ED participated in a survey regarding past-year risk behaviors and injuries. Results: Of the entire group of teens presenting to the ED (n = 1128) who completed the survey (83.8% response rate), 46% were male, and 58% were African-American. Past-year injuries were reported by 768 (68.1%) of the teens; 475 (61.8%) of those reported an unintentional injury and 293 (38.1%) reported an intentional injury. One-third of all youth seeking care reported a past-year sports-related injury (34.5%) or an injury related to driving or riding in a car (12.3%), and 8.2% reported a gun-related injury. Logistic regression found that binge drinking (adjusted odds ratio [AOR] 1.95) and illicit weapon carrying (AOR 2.31) predicted a past-year intentional injury. African-American youth (AOR 0.56) and those receiving public assistance (AOR 0.73) were less likely to report past-year unintentional injuries. Conclusions: Adolescents seeking care in an inner-city ED, regardless of the reason for seeking care, report an elevated prevalence of recent injury, including violence. Future injury screening and prevention efforts should consider universal screening of all youth seeking ED care.     

The Health Consequences of Injury Questionnaire

Objective: To study the properties of a new survey instrument, the Health Consequences of Injury Questionnaire (HCIQ), for measuring the impact of injury on health and to compare the new instrument with the more detailed, previously developed Quality of Well–being (QWB) scale.
Methods: The HCIQ is a three–page health status questionnaire, suitable for self–administration. Similar to the QWB scale, the HCIQ measures health on a unitary scale where 1 represents optimum health and 0, death. The HCIQ was developed and studied in representative samples of injured adults from an Australian population. The HCIQ was administered concurrently with the QWB instrument to a sample of injured subjects, and the QWB scale scores were compared with estimated scores from the HCIQ using QWB scale weightings. The reliability of the HCIQ was tested on a further sample of injured subjects using a mailed test–retest design.
Results: Of the 211 subjects in the validity sample, 98 completed both the HCIQ and the QWB scales. The intraclass correlation coefficient for the scores obtained from the two questionnaires was 0.86 (95% CI = 0.66–1.00). The mean difference between the scores was 0.04 ± 0.09 (SD). The HCIQ had a median completion time of 15 minutes. Of the 129 subjects in the reliability study, 53 completed the HCIQ on both postal administrations. The reliability coefficient was 0.90 (95% CI = 0.62–1.00).
Conclusion: The HCIQ is a practical and reliable questionnaire for identifying the health consequences of injury that, when used with QWB weights, successfully predicts the QWB score.     

2009-2010年浙江省28家哨点医院急诊室伤害监测结果分析

目的 对2009-2010年浙江省哨点医院急诊室伤害监测资料进行分析,了解伤害病例分布的主要流行病学特征,为制定科学合理的干预策略提供参考。 方法 采用统一格式的伤害报卡在全省28家哨点医院收集初诊伤害病例的一般情况及相关信息,按要求对报卡信息进行审核后完成网络在线填报。 结果 2年共收集144 039例伤害病例。男女性别比为1.66 ∶ 1,年龄构成以15~44岁为主(51.46%),常见职业有农/渔业劳动者(31.19%)、农民工(21.93%)和工人(19.56%);伤害发生地点以家(30.34%)、街道/城区(28.17%)和工作场所(26.45%)为主;主要受伤原因有跌伤/坠落(26.49%)、交通伤(22.71%)、钝器伤(18.46%)、刺割伤(12.58%)和动物伤(9.95%);伤害发生时的主要活动构成以空闲(43.79%)和工作(32.68%)多见;伤害病例严重程度以轻微的浅表伤(49.85%)和中等程度伤害(46.04%)为主;伤害意图方面,超过90%的病例均为非故意伤害,男性他伤的比例高于女性,而女性自伤的比例高于男性。 结论 本次研究揭示了2009-2010年浙江省哨点医院急诊室伤害监测病例的主要特征。体力劳动者是发生各类伤害的高危人群,而在儿童、青少年和老年人中,跌伤问题尤为突出。在今后的工作中需要实施有针对性的干预措施,以降低伤害的发生率。     

Demand on ED resources during periods of widespread influenza activity

The purpose of this study was to investigate ED resource demand during periods of Centers for Disease Control and Prevention (CDC)-declared widespread influenza activity (WIA). An observational analysis of secondary data describing ED resource demand was performed using computerized ED patient data over a 130-week period. Measures of ED resource utilization were compared during WIA and non-WIA periods. These measures included weekly census; percentage of patients triaged as having fever, infection, or respiratory (flu index) chief complaints; admission rate, ED LOS (length of stay), total bed time (TBT), the number of patients who left the ED without being seen by a physician (LWBS), and ED saturation time. The study included 34 weeks of CDC-designated WIA occurring over 3 distinct periods. During WIA, the flu index was elevated, 23% (95% confidence interval [CI], 20-25) versus 17% (95% CI, 16-17). There was increased resource utilization during WIA periods compared with the non-WIA periods for the following parameters: admission rate (24% [95% CI, 24-25%] versus 23% [23-23%]), ED LOS admitted (296 [95% CI, 280-313] versus 271 [95% CI, 265-277]), ED LOS discharged (162 [95% CI, 156-168] versus 152 [95% CI, 150-154]), ED saturation time (1292 [95% CI, 689-1894] versus 409 [95% CI, 209-609]) and LWBS (31 [95% CI, 19-42] versus 14 [95% CI, 12-15]). Although each WIA period was marked by an initial spike in patient volume, weekly census did not increase (1365 [95% CI, 1297-1433] during WIA versus 1297 [95% CI, 1275-1320] during non-WIA). An association between WIA and greater ED resource demand was observed. A spike in census was observed at the onset of each WIA period. In addition, the flu index increased during WIA, suggesting the use of the ED as a site for syndromic surveillance of WIA onset.     

Dating Aggression and Risk Behaviors Among Teenage Girls Seeking Gynecologic Care

Objectives: The objective was to describe rates of dating aggression and related high-risk behavior among teens presenting to the emergency department (ED) seeking gynecologic care, compared to those seeking care for other reasons. Methods: Female patients ages 14–18 years presenting to the ED during the afternoon/evening shift of a large urban teaching hospital over a 19-month period were approached to participate and completed a self-administered computerized survey regarding sexual risk behaviors, past-year alcohol use, dating aggression, and peer aggression. Logistic regression analysis was used to identify factors associated with the evaluation of gynecologic complaint as noted by completion of a pelvic exam. Results: A total of 949 teens were enrolled (87% response rate), with 148 receiving gynecologic evaluation. Among girls undergoing a gynecologic evaluation, 49% reported past-year dating aggression, compared to 34% of those who did not undergo gynecologic evaluation (odds ratio [OR] = 1.81, 95% confidence interval [CI] = 1.30 to 2.62). Logistic regression analysis predicting gynecologic evaluation found statistically significant variables to be older age (OR = 1.95, 95% CI = 1.24 to 3.06), African American race (OR = 1.58, 95% CI = 1.04 to 2.40), parental public assistance (OR = 1.64, 95% CI = 1.10 to 2.45), alcohol use (OR = 2.31, 95% CI = 1.57 to 3.38), and dating aggression (OR = 1.51, 95% CI = 1.03 to 2.21). Conclusions: Of the teens undergoing gynecologic evaluation in this urban ED, 49% reported dating aggression. These teens also reported higher rates of other sexual risk behaviors compared to their peers. Care providers in urban EDs treating all female teens and particularly those seeking gynecologic care should be aware of this high rate of dating aggression and screen for aggression in dating relationships in this high-risk group.     

2004-2006年浙江省5县(市)医院急诊伤害监测分析

目的 分析浙江省伤害情况,为今后开展相关干预提供依据.方法 运用浙江省5县(市)的15所医院的急诊伤害监测数据进行分析.结果 2年间共报告病例42 130例,男女性别比为1.99∶1;发生原因前5位为跌落、交通伤、钝器伤、刺/割伤和动物伤;发生地点主要集中在街道/城区、家里和工作场所;发生时活动状态为空闲时和工作(包括去工作的路上);以非故意伤害和轻中度伤害为主,伤害发生时间主要集中在8～9月和1天中的8～11时和14～16时;伤害性质以软组织系统和骨关节系统损伤为主,伤害部位以头部、上肢和下肢为主.结论 医院急诊伤害监测是获得浙江省非致死性伤害信息的重要来源,对确定伤害干预重点,有针对性的运用预防干预措施,减少伤害的发生有积极作用.     

Asymptomatic hypertension in the ED

A retrospective study in an urban, municipal, teaching hospital emergency department (ED) was conducted to evaluate (1) the frequency of asymptomatic hypertension in the ED, (2) the initial assessment and patterns of treatment by physicians, and (3) the changes in blood pressure (BP) in these patients. Patients with systolic BP ≥180 mm Hg or diastolic BP ≥110 mm Hg were included. Patients with cardiovascular, renal, or central nervous system dysfunction were excluded. Of the 11,531 charts reviewed, 269 (2.3%) met inclusion criteria. Of the 269 patients, 56 patients (20.8%) received antihypertensive treatment in the ED. The treatment group had a higher systolic BP (P < .001), diasytolic BP (P < .001), and mean arterial blood pressure (MAP) (P < .001) than the nontreatment group. Fundoscopy was also performed more frequently in the treatment group (30.2% v 8.9%, P < .001). MAP decreased for both groups in the ED, but was higher in the treatment group (−20 ± 21 v −11 ±21 mm Hg, P = .02). Despite the lack of support in the literature for the emergency treatment of asymptomatic hypertension in the ED, the individual physician's decision for treatment correlated with the degree of hypertension. Significantly elevated BP readings in the ED tended to decrease over time independent of any antihypertensive treatment, although the decrease was larger in the treated patients.     

Access block and ED overcrowding

Prospective and retrospective access block hospital intervention studies from 1998 to 2008 were reviewed to assess the evidence for interventions around access block and ED overcrowding, including over 220 documents reported in Medline and data extracted from The State of our Public Hospitals Reports. There is an estimated 20–30% increased mortality rate due to access block and ED overcrowding. The main causes are major increases in hospital admissions and ED presentations, with almost no increase in the capacity of hospitals to meet this demand. The rate of available beds in Australia reduced from 2.6 beds per 1000 (1998–1999) to 2.4 beds per 1000 (2002–2007) in 2002, and has remained steady at between 2.5–2.6 beds per 1000. In the same period, the number of ED visits increased over 77% from 3.8 million to 6.74 million. Similarly, the number of public hospital admissions increased at an average rate of 3.4% per year from 3.7 to 4.7 million. Compared with 1998–1999 rates, the number of available beds in 2006–2007 is thus similar (2.65 vs 2.6 beds per 1000), but the number of ED presentations has almost doubled. All patient groups are affected by access block. Access block interventions may temporarily reduce some of the symptoms of access block, but many measures are not sustainable. The root cause of the problem will remain unless hospital capacity is addressed in an integrated approach at both national and state levels.     

Review article: Phenytoin use and efficacy in the ED

This article reviews the evidence regarding the use of phenytoin in adult and paediatric patients experiencing seizures in the ED in Australasia, including relevant pharmacokinetics, dosage, therapeutic drug monitoring and methods of administration. It summarizes current evidence regarding the use of phenytoin in a number of seizure types commonly seen in ED. A search of Medline, Embase and Cochrane was performed using appropriate keyword and MeSH headings. A loading dose of phenytoin should be given to phenytoin naïve patients for the emergency treatment of seizures; parenteral administration results in therapeutic concentration sooner than oral administration but is associated with more frequent and significant adverse effects. Diluting phenytoin is safe but there is limited evidence regarding adverse effects of diluted phenytoin; a filter is probably not needed. Free phenytoin concentrations correlate best with antiseizure efficacy. Phenytoin is used in the treatment of status epilepticus although evidence here is limited; it may also be given to prevent early post‐traumatic seizures. It should not be given to treat or prevent eclamptic or alcohol‐related seizures. There is insufficient evidence regarding its use in preventing febrile convulsions, treating or preventing seizures due to space occupying lesions or intracerebral haemorrhage and thrombosis. In conclusion, phenytoin is appropriate for treatment of some seizures seen in the ED; it is associated with significant adverse effects; trials are ongoing regarding the use of other anticonvulsants in the treatment of status epilepticus.     

Causes and Patterns of Injury from Ladder Falls

Objectives: To review all ladder fall injuries seen in a community ED and to identify patterns of injury, factors that contribute to falls, and what pre-event and event factors could have reduced the likelihood of a fall or a resulting injury.
Methods: This was a retrospective, observational study involving patients who presented to a community hospital ED from January 1993 through December 1995 with injuries from a ladder fall. The medical records of all patients were reviewed. Patients then underwent a structured telephone interview to provide additional information about the circumstances of the fall.
Results: There were 59 patients who sustained injuries relating to ladder falls. All were adults, aged >18 years (mean 42.9 ± 16.2 years), were predominantly male (93%), and had fallen a distance of 1–15 feet (mean 7.2 ± 3.6 feet). Thirteen percent were admitted to the hospital, and there was 1 death. Fractures were observed in 21 patients (36%) and usually involved an extremity (77%). There was no relationship between the distance fallen and the occurrence of fracture. Other primary injuries included sprain (27%), contusion (24%), laceration (10%), abrasion (3%), and subdural hematoma (2%). Of the 59 patients, 42 (71%) were contacted directly. Most falls (79%) resulted from excessive reaching or incorrect ladder placement. Fifty percent of the described falls were occupationally related.
Conclusions: Falls from ladders, both in the occupational and nonoccupational settings, often result in significant injury. Simple safety measures may have prevented the majority of falls in this study. Public health efforts should emphasize education on safe ladder practices and techniques to reduce the possibility of injury in the event of a fall.     

Pediatric Trauma: Enabling Factors, Social Situations, and Outcome

Objectives: 1) To determine, for severely injured pediatric patients, which enabling factors and social situations are associated with the most severe and costly injuries; 2) to determine which subsets of patients are affected by particular enabling factors; and 3) to determine which enabling factors are associated with death.
Methods: Retrospective chart review of patients included in a pediatric trauma registry at a level I trauma center, plus review of medical examiner reports for deaths declared at the scene for one year. Abstracted data included age, gender, enabling factors (e. g., abuse/assault, neglect, endangerment, and nonuse of safety measures), mechanisms of injury, Injury Severity Scale (ISS) score, length of stay, need for intensive care unit (ICU) care, and expense.
Results: Records were reviewed for 336 identified children. There was a 2: 1 male-to-female ratio; 9. 5% died, 3. 5% at the scene. Active endangerment or neglect was associated with death (p = 0. 0004). However, the nonuse of safety devices was more common and resulted in a higher absolute number of deaths. Similarly, while inadvertent gunshot wounds, intentional injury, and environmental mishaps were more commonly lethal, motor vehicle crashes (MVCs) were more common and claimed the most lives. Cost was highest for the patients aged 14–16 years, in part reflecting the larger number of MVCs.
Conclusion: The severity of pediatric trauma is largely influenced by the mechanism of injury. Our data highlight the importance of enabling factors for such injuries overall and as a function of age group (reflecting developmental status). While injury prevention education for caregivers is necessary, the incorporation of passive safety measures also is vital for decreasing injuries and their severity.