The emergency department approach to violently injured patient care: a regional survey.

OBJECTIVE: Since the early 1990s public health workers have challenged healthcare practitioners to take an active role in violence prevention with patients aged 10-24 years. Emergency department (ED) clinicians are uniquely positioned to identify, assess, and refer youth involved in violent events. The objective of this study was to describe ED directors' estimate of the number of violently injured youth seen, the presence of established protocols or guidelines for handling youth violence, and the type of training programs offered to ED physicians regarding this issue. METHODS: The authors conducted a survey of EDs (n = 64) in the Philadelphia metropolitan region to determine the standard of ED care for violently injured youths. Half of the EDs were in urban areas and half in suburban. RESULTS: A total of 41 out of 64 (64.1%) ED directors completed and returned the written questionnaire. In addition to treating the specific injuries sustained, ED responses to youth violence primarily involved talking with patients about the events surrounding the injury. The estimated number of violently injured youth seen per month varied considerably. Twenty four directors (58.5%) estimated that their institution treated fewer than 10 per month; 10 (24.4%) reported 11-30, and seven (17.1%) mostly large urban hospitals, saw more than 30 per month. Although most hospitals reported that the staff counsels patients about safety concerns, only 17% offered their staff formal training programs on youth violence. CONCLUSIONS: To address the prevention of youth violence, EDs need specific training programs for ED staff, as well as systematic risk assessment and referral resources for structured intervention and follow up.     

Persistence of posttraumatic stress in violently injured youth seen in the emergency department

OBJECTIVE: To determine if symptoms of posttraumatic stress, initially evaluated in the emergency department (ED) setting, persist over time. DESIGN: Prospective cohort study. SETTING: Two urban, academic medical center EDs. PATIENTS: Sixty-nine injured patients, aged 12 to 24 years, were assessed for acute posttraumatic stress symptoms at the time of their enrollment in an ongoing ED-based study of intentional youth violence, and assessed for posttraumatic stress symptoms up to 5 months later. MAIN OUTCOME MEASURES: The Immediate Stress Reaction Checklist, administered during the ED visit, and the Symptom Checklist of the Child and Adolescent Trauma Survey, administered during routine telephone follow-up. RESULTS: Patients in the emergency department reported a range of acute stress symptoms on the Immediate Stress Reaction Checklist, with 25% reporting clinically significant distress. On follow-up assessment, 15% reported significant posttraumatic stress symptoms. The severity of acute stress symptoms was strongly associated with the severity of posttraumatic stress symptoms at follow-up (r = 0.55, P<.005). Age, sex, injury type, and time from injury to follow-up were not associated with the degree of acute stress or posttraumatic stress symptom severity at initial or follow-up assessment. CONCLUSION: This study provides preliminary evidence that acute stress symptoms, assessed in the ED in the immediate aftermath of a traumatic injury, are useful indicators of risk for later posttraumatic stress.     

Dating violence, sexual assault, and suicide attempts among urban teenagers

OBJECTIVE: To evaluate the relationship between dating violence, sexual assault, and suicide attempts among urban adolescents. DESIGN: Secondary analysis of the 2005 New York City Youth Risk Behavior Survey. SETTING: Eighty-seven New York City public high schools. PARTICIPANTS: Representative population-based sample of 8080 students, 14 years and older. MAIN EXPOSURES: Dating violence in the past year and lifetime history of sexual assault. OUTCOME MEASURE: One or more suicide attempts in the past year. RESULTS: Respondents were 50.0% female and primarily black (36.0%) or Hispanic (40.1%). In the past year, 11.7% of females and 7.2% of males reported 1 or more suicide attempts. Lifetime history of sexual assault was reported by 9.6% of females and 5.4% of males. Dating violence in the past year was reported by 10.6% of females and 9.5% of males. In multivariate models, controlling for persistent sadness, sexual orientation, and significant risk behaviors, recent dating violence (odds ratio, 1.61; 95% confidence interval, 1.05-2.47) was associated with suicide attempts in adolescent girls, while lifetime history of sexual assault (odds ratio, 3.86; 95% confidence interval, 2.11-7.06) was associated with suicide attempts in adolescent boys. CONCLUSIONS: In this population of urban youth, recent dating violence among females and lifetime history of sexual assault among males were significantly associated with suicide attempts. Clinicians and educators should be trained to routinely screen adolescents for violence victimization and should have a low threshold for referring these at-risk teenagers for mental health services.     

Comparing pediatric intentional injury surveillance data with data from publicly available sources: consequences for a public health response to violence

OBJECTIVE: A hospital based intentional injury surveillance system for youth (aged 3-18) was compared with other publicly available sources of information on youth violence. The comparison addressed whether locally conducted surveillance provides data that are sufficiently more complete, detailed, and timely that clinicians and public health practitioners interested in youth violence prevention would find surveillance worth conducting. SETTING: The Boston Emergency Department Surveillance (BEDS) project was conducted at Boston Medical Center and the Children's Hospital, Boston. METHOD: MEDLINE and other databases were searched for data sources that report separate data for youth and data on intentional injury. Sources that met these criteria (one national and three local) were then compared with BEDS data. Comparisons were made in the following categories: age, gender, victim-offender relationship, injury circumstance, geographic location, weapon rates, and violent injury rates. RESULTS: Of 14 sources dealing with violence, only four met inclusion criteria. Each source provided useful breakdowns for age and gender; however, only the BEDS data were able to demonstrate that 32.6% of intentional injuries occurred among youth aged 12 and under. Comparison data sources provided less detail regarding the victim-offender relationship, injury circumstance, and weapon use. Comparison of violent injury rates showed the difficulties for practitioners estimating intentional injury from sources based on arrest data, crime victim data, or weapon related injury. CONCLUSIONS: Comparison suggests that surveillance is more complete, detailed, and timely than publicly available sources of data. Clinicians and public health practitioners should consider developing similar systems.     

Injury Prevention Opportunities in the Pediatric Emergency Department

Injury is the leading cause of death in children over 1 year of age, causes considerable morbidity, and is a significant source of health care cost. Injury prevention methodology has helped to decrease pediatric injuries over the last several decades; however, significant room for improvement remains. Emergency medicine providers have the expertise and opportunity to participate in injury prevention. Injury risk identification and injury prevention interventions in the emergency department have been increasingly explored over the last decade. This review discusses promising emergency department–based approaches such as safety behavior screening; screening for suicide risk, violence risk, and exposure to firearms; education and interventions; and advocacy opportunities.     

Addressing violence in the emergency department

Violent injury remains a major cause of death and disability for children and youth in this country, even with the dramatic declines in violent injury rates experienced in recent years. Most youth and adolescents with or who are at risk for violence-related injuries present in emergency department (ED) settings, although some come to the attention of the police. Similarly, many women present to EDs with injuries related to domestic violence, and it is well described that children exposed to such situations suffer both short- and long-term consequences from these exposures. Given the significance of these issues with respect to the health and well-being of children, it is important for emergency care and primary care professionals to consider the roles they can play in the acute management, assessment for future risk, screening for risk, and follow-up services involved in the response to violent injury.     

Pediatric residents' telephone triage experience: do parents really follow telephone advice?

BACKGROUND: A previous study showed that calls received by our continuity clinic residents were similar to those in private practice. However, that study did not address the compliance of the parents to the advice given. OBJECTIVE: To determine parents' compliance to after-hours telephone advice given by pediatric residents in a continuity clinic. DESIGN: Advice given during initial telephone contact of 493 after-hours telephone calls was categorized into 3 groups: only telephone advice, appointment the next day, or immediate visit to the emergency department (ED). Follow-up telephone calls were made to all families 3 to 7 days after initial contact to determine compliance with the advice given. SETTING: Pediatric resident continuity clinic of a tertiary hospital in Augusta, Georgia. PATIENTS: Children registered in the pediatric resident continuity clinic. RESULTS: Overall, 412 (83.6%) of 493 caregivers followed the telephone advice that residents gave them. Of the 270 callers only given telephone advice, 244 (90.4%) followed the advice, 15 (5.6%) went to the ED, and 11 (4.1%) made an appointment for the next day. Of the 112 patients instructed to make an appointment, 82 (73.2%) reported at the scheduled time, 18 (16.1%) improved and did not come to the appointment, and 1 (.9%) reported worsened symptoms and went to the ED. When a visit to the ED was recommended, 86 (93.5%) of 92 complied, 2 (2.2%) improved and did not come, 1 (1.1%) had transportation problems, and 3 (3.3%) did not think an ED visit was warranted. CONCLUSION: If an after-hours line is used by caregivers, they are more likely to follow the recommendations given by pediatric residents in a tertiary center.     

Implementation of a program to teach pediatric residents and faculty about domestic violence

OBJECTIVES: To obtain information about pediatric resident and staff knowledge, attitudes, and screening practices related to domestic violence (DV), to implement a domestic violence education program, and to evaluate whether the program resulted in changes in these 3 domains. DESIGN: Interventional with before and after survey evaluation. SETTING: A hospital-based, pediatric residency continuity clinic that serves families in Pittsburgh, Pa. PARTICIPANTS: Pediatric residents (n = 51), medicine-pediatric residents (n = 6), continuity clinic faculty (n = 22), and certified-registered nurse practitioners (n = 5). RESULTS: Prior to implementation of the DV education program, respondents correctly answered questions about the prevalence of DV (74 participants [90%]), the racial distribution of DV victims (66 participants [80%]), and the significant overlap between child abuse and DV (75 participants [91%]). Seventy-nine participants (96%) believed that screening for the presence of DV was part of their role as pediatric health care providers. At baseline, 17 (21%) of the 82 participants reported that they were routinely screening for signs of DV during well-child care visits compared with 39 (46%) after attending the education program (P =.005).Among participants who attended both educational session 25% (9/36) were routinely screening for the presence of DV prior to the intervention, compared with 46% (16/35) after the intervention (P =.008). At baseline, 33 (40%) of the 82 participants had identified at least 1 case of DV in the prior 6 months compared with 45 (53%) after training. Prior to training, 18 participants (22%) were aware of resources for DV victims compared with 45 (53%) after training (P<.001). CONCLUSIONS: To our knowledge, this is one of the first pediatric studies to demonstrate that using a short, multifaceted educational module, it is possible to change DV screening practices and to increase identification of DV victims among pediatric residents, continuity clinic faculty, and certified-registered nurse practitioners at a pediatric teaching hospital.     

Improving guideline adherence for the diagnosis of ADHD in an ambulatory pediatric setting.

BACKGROUND: The American Academy of Pediatrics (AAP) has published clinical practice guidelines for the diagnosis of Attention Deficit Hyperactivity Disorder (ADHD). However, implementation of guidelines has been notoriously difficult to achieve in the wider context of changing individual physicians' clinical practice. OBJECTIVE: Implement a formalized diagnostic protocol for ADHD and study whether this protocol improved adherence of pediatric residents and faculty to published guidelines for the diagnosis of ADHD. METHODS: Quasi-experimental retrospective record review of 63 pediatric patients evaluated for ADHD by pediatric residents and faculty in an outpatient pediatric clinic before (n = 25) and after (n = 38) implementation of a formal diagnostic process for ADHD. The key elements of the new diagnostic process include completion of a semistructured interview and mandatory rating scales for home and school. The published AAP guidelines include 1) documentation of Diagnostic and Statistical Manual for Mental Disorders (DSM) IV criteria; 2) evidence of core symptoms obtained directly from home and 3) from school; and 4) assessment for coexisting conditions. Adherence was assessed to each criterion individually (yes/no) and was summarized in a single score. RESULTS: Only 4% of clinicians and nurse practitioners diagnosing children in the before group adhered to all 4 AAP guidelines, compared to 82% in the after group (P < .001). Significant improvement was observed across each of the 4 criteria in the AAP guidelines. Moreover, the improvement in adherence to all 4 guidelines was noted for residents and faculty. CONCLUSION: A significant improvement in adherence to AAP guidelines was obtained for all providers through implementation of a structured diagnostic approach to ADHD.     

Rapid sequence intubation for pediatric emergency airway management

OBJECTIVES: To characterize current practice with respect to pediatric emergency airway management using a multicenter data set. METHODS: A multicenter collaboration was undertaken to gather data prospectively regarding emergency intubation. Analysis of data on adult emergency department (ED) intubations clearly demonstrated that rapid sequence intubation (RSI) was the method used most often. We then conducted an observational study of the prospectively collected database of pediatric ED intubations (EDIs) using the National Emergency Airway Registry Phase One data, gathered in 11 participating EDs over a 16-month time period. A data form completed at the time of EDI enabled analysis of patients' ages, weights, and indications for EDI; personnel; methods employed to facilitate EDI; success rates; and adverse events. Data forms were analyzed regarding the methods of intubation employed, and frequencies, success rates, and adverse event rates among various intubation modalities were compared. RESULTS: Of 1288 EDIs, there were 156 documented pediatric patients. Initial intubation attempts were all oral, including rapid sequence intubation in 81%, without medications (NOM) in 13%, and sedation without neuromuscular blockade (SED) in 6%. Older children and trauma patients were more likely to be intubated with RSI compared to younger children and patients presenting with medical illnesses. Intubation using RSI was more successful on the first attempt (78%) compared with either NOM (47%, < 0.01) or SED (44%, < 0.05), though this finding is likely explainable by the age differences among groups. Intubation was successfully performed by the initial intubator in 85% of RSI, 75% of NOM, and 89% of SED attempts ( = NS for both comparisons vs RSI). Overall, successful intubation occurred in 99% of RSI and 97% of non-RSI intubation attempts ( = NS). Only one of 156 patients required surgical airway management. True complications occurred in 1%, 5%, and 0% of RSI, NOM, and SED attempts, respectively ( = NS for both comparisons vs RSI). The majority of initial intubation attempts were by emergency medicine residents (59%), pediatric emergency medicine fellows (17%), and pediatrics residents (10%). These groups were 77%, 77%, and 50% successful, respectively, on the first laryngoscopy attempt, and 89%, 89%, and 69% successful overall. CONCLUSIONS: A large, prospective, multicenter observational study of pediatric EDIs was conducted at university-affiliated EDs. RSI is the method of choice for the majority of pediatric emergency intubations; it is associated with a high success rate and a low rate of serious adverse events. Pediatric intubation as practiced in academic EDs, with most initial attempts by emergency and pediatrics residents and fellows under attending physician supervision, is safe and highly successful.     

Pediatric and adolescent mental health emergencies in the emergency medical services system

Emergency department (ED) health care professionals often care for patients with previously diagnosed psychiatric illnesses who are ill, injured, or having a behavioral crisis. In addition, ED personnel encounter children with psychiatric illnesses who may not present to the ED with overt mental health symptoms. Staff education and training regarding identification and management of pediatric mental health illness can help EDs overcome the perceived limitations of the setting that influence timely and comprehensive evaluation. In addition, ED physicians can inform and advocate for policy changes at local, state, and national levels that are needed to ensure comprehensive care of children with mental health illnesses. This report addresses the roles that the ED and ED health care professionals play in emergency mental health care of children and adolescents in the United States, which includes the stabilization and management of patients in mental health crisis, the discovery of mental illnesses and suicidal ideation in ED patients, and approaches to advocating for improved recognition and treatment of mental illnesses in children. The report also addresses special issues related to mental illness in the ED, such as minority populations, children with special health care needs, and children's mental health during and after disasters and trauma.     

Correlates of violent behavior among adolescents presenting to an urban emergency department

OBJECTIVE: To examine rates and correlates of self-reported perpetrated violence among teens presenting to an urban emergency department. STUDY DESIGN: Cross-sectional study of a consecutive sample of youth (12-17 years) presenting to an urban emergency department. The youth were surveyed about demographics, community violence exposure, parental monitoring, substance use, weapon carriage, group fighting, and aggression (past 12 months). Bivariate and multivariate analyses were performed to identify correlates of the severity of the violence (none, moderate, or severe) perpetrated in the past year. RESULTS: A total of 115 youth were surveyed (males, 47%; response rate, 85%). The sample group was 51% African American. A total of 77% of the youth reported that they perpetrated violence in the past year, with 37% reporting severe violence (use of a weapon, group fighting, causing an injury requiring medical care). All patients who self-reported perpetrating severe violence in the past year were discharged home from the emergency department. The diagnosis made in the emergency department (illness versus injury) was not associated with the violence perpetrated in the past year. Sex was not a significant predictor of severe perpetrated violence. CONCLUSIONS: Youth presenting to urban emergency departments report high rates of perpetrating violence in the past year that, on the basis of other studies, is likely to continue. These results suggest that future emergency department-based violence prevention efforts should consider universal screening of adolescents.     

Association of emergency department care factors with admission and discharge decisions for pediatric patients

OBJECTIVE: We evaluated overutilization or underutilization of inpatient resources to measure the emergency department (ED) decision-making process and its association with the following care factors: annual pediatric volume, presence or absence of a pediatric emergency medicine specialist; and presence or absence of ED residents. STUDY DESIGN: Block random selection, using the three care factors, of 16 hospitals with pediatric intensive care units. The Pediatric Risk of Admission (PRISA II) Score was used to measure illness severity. Decision-making was evaluated for admissions (Admission Index: observed minus predicted admissions) and returns (Return Index: observed minus predicted 72-hour returns). The Combined Index was a weighted average of the Admission and Return Indexes. RESULTS: There were 11,664 patients enrolled. Residents but not volume or pediatric emergency medicine specialists were associated with the decision-making performance indexes in multivariable analysis (no residents versus residents: Admission Index: 2.5 of 1000 patients versus 34.8 of 1000, P = .082; Return Index: -3.0 of 1000 versus 33.6 of 1000, P = .039; Combined Index: 1.9 of 1000 versus 35.5 of 1000, P = .024. CONCLUSIONS: There is significant variability in ED decision-making for children. Residents but not volume or presence of a pediatric emergency medicine specialist are associated with increased differences in admission decisions. The process by which these differences occur was not investigated.     

Pediatric Asthma in the Community Emergency Department: Room for Improvement and Aligned Incentives

Asthma is a common reason for emergency department (ED) visits in children. Over 80% of children who visit an ED go to a general, not a pediatric-specific, ED. The treatment children with asthma receive in general EDs is not as compliant with national guidelines as is treatment in pediatric-specific centers. Several studies document improvements in pediatric asthma care through quality improvement initiatives, but few address the emergency care of pediatric asthma in the community setting. National programs such as Pathways for Improving Pediatric Asthma and Translating Emergency Knowledge for Kids provide resources to community EDs for improving pediatric asthma care. More research is needed to determine if programs such as these, as well as partnerships at the local level, can have a positive impact on the emergency care of pediatric asthma. It is essential that we bridge the gaps in care between community and pediatric-specific EDs to improve the quality of emergency care for the over 7 million children in the US with asthma.     

Pediatric Agitation in the Emergency Department: A Survey of Pediatric Emergency Care Coordinators

ObjectiveAcute agitation episodes in the emergency department (ED) can be distressing for patients, families, and staff and may lead to injuries. We aim to understand availability of ED resources to care for children with acute agitation, perceived staff confidence with agitation management, barriers to use of de-escalation techniques, and desired resources to enhance care.MethodsWe conducted a survey of pediatric emergency care coordinators (PECCs) in EDs in Massachusetts, Rhode Island, and Los Angeles County, California.ResultsPECCs from 63 of 102 (61.8%) EDs responded. PECCs reported that ED staff feel least confident managing agitation due to developmental delay (DD) or autism spectrum disorder (ASD) (52.4%). Few EDs had a separate space to care for children with mental health conditions (22.5%), a standardized agitation scale (9.6%), an agitation management guideline (12.9%), or agitation management training (24.2%). Modification of the environment was not perceived possible for 42% of EDs. Participants reported that a barrier to the use of the de-escalation techniques distraction and verbal de-escalation was perceived lack of effectiveness (22.6% and 22.6%, respectively). Desired resources to manage agitation included guidelines for medications (82.5%) and sample care pathways (57.1%).ConclusionsED PECCs report low confidence in managing agitation due to DD or ASD and limited pediatric resources to address acute agitation. Additional pediatric-specific resources and training, especially for children with DD or ASD, are needed to increase clinician confidence in agitation management and to promote high-quality, patient-centered care. Training programs can focus on the early identification of agitation and the effective use of non-invasive de-escalation strategies.     

Teen Dating Violence: Old Disease in a New World

Teen dating violence (TDV) is an underrecognized and significant public health problem that affects millions of adolescents each year. Many teens seek care in the emergency department (ED) for their injuries due to TDV, and are at risk for negative short- and long-term outcomes. With a better understanding by ED clinicians of normal adolescent development, as well as the impact of TDV on the health and safety of teen patients, the ED setting can serve as an effective site for both intervention and violence prevention. This article provides an overview of the importance of this issue, the impact of technology and social media on TDV, and best practices for ED screening, documentation, and referral.     

Recording of community violence by medical and police services

OBJECTIVES: To determine the extent to which community violence that results in injury treated in emergency departments appears in official police records and to identify age/gender groups at particular risk of under-recording by the police. METHODS: Non-confidential data for patients with assault related injury treated in the emergency departments of two hospitals in one South Wales city (Swansea) during a six month period were compared with data relating to all recorded crimes in the category "Violence against the person" in the police area where the hospitals were located. RESULTS: Over the six month period a total of 1513 assaults were recorded by Swansea emergency departments and the police (1019, 67.3% injured males and 494, 32.7% injured females). The majority of these assaults (993, 65.6%) were recorded exclusively by emergency departments; 357 (23.6%) were recorded only by the police and 163 (10.8%) were recorded by both emergency departments and the police. Equal proportions of males (67.3%) and females (67.5%) injured in assaults were recorded by both emergency departments and the police, but men were more likely to have their assault recorded exclusively in emergency departments (odds ratio (OR) 2.1, 95% confidence interval (CI) 1.7 to 2.7) while women were more likely to have their assault recorded exclusively by the police (OR 2.5, 95% CI 2.0 to 3.2). There were no significant relationships between exclusive emergency department recording and increasing age (OR 1.0, 95% CI 0.9 to 1.2), exclusive police recording and increasing age (OR 1.1, 95% CI 1.0 to 1.2), or between age and dual recording (OR 0.9, 95% CI 0.8 to 1.0). CONCLUSIONS: Most assaults leading to emergency department treatment, particularly in which males were injured, were not recorded by the police. Assaults on the youngest group (0-10, particularly boys) were those least likely to be recorded by police and females over age 45, the most likely. Emergency department derived assault data provide unique perspectives of community violence and police detection.