Swimming injuries treated in US EDs: 1990 to 2008

Objective

Swimming is one of the most popular recreational activities in the United States. The objective of this study was to investigate the epidemiology of the complete spectrum of injuries associated with swimming and swimming pools treated in US hospital emergency departments.

Methods

Data from the National Electronic Injury Surveillance System from 1990 to 2008 were analyzed. Injury rates were calculated using US census swimming participation data.

Results

An estimated 1 688 924 swimming injuries occurred during the 19-year study, averaging 1 injury every 6 minutes. During the study period, the number of injuries and rate of injury among individuals 7 years or older significantly increased. Within this trend, injuries peaked in 1999 and significantly decreased during the last 10 years but still showed an overall increase of 18.6% in number and 29.3% in rate from 1900 to 2008. Patients 17 years or younger accounted for 60.5% of injuries, and patients 7 to 17 years of age had a greater mean annual swimming injury rate (18.78 per 10 000 participants) than patients older than 17 years (9.15). Most injuries occurred in or around a swimming pool (87.0%), and most were soft tissue injuries (54.7%), followed by strains/sprains (16.4%), fractures/dislocations (11.3%), and submersion (4.9%). Injuries to patients younger than 7 years, submersion injuries, and injuries occurring at home were more likely to result in hospital admission or fatality.

Conclusions

The observed increase in injuries among individuals older than 7 years underscores the need for increased prevention efforts, including education about safe swimming practices, supervision, and environmental modifications.     

Snow shovel-related injuries and medical emergencies treated in US EDs, 1990 to 2006

Background

Injuries and medical emergencies associated with snow shovel use are common in the United States.

Methods

This is a retrospective analysis of data from the National Electronic Injury Surveillance System. This study analyzes the epidemiologic features of snow shovel-related injuries and medical emergencies treated in US emergency departments (EDs) from 1990 to 2006.

Results

An estimated 195?100 individuals (95% confidence interval, 140?400-249?800) were treated in US EDs for snow shovel-related incidents during the 17-year study period, averaging 11?500 individuals annually (SD, 5300). The average annual rate of snow shovel-related injuries and medical emergencies was 4.15 per 100?000 population. Approximately two thirds (67.5%) of these incidents occurred among males. Children younger than 18 years comprised 15.3% of the cases, whereas older adults (55 years and older) accounted for 21.8%. The most common diagnosis was soft tissue injury (54.7%). Injuries to the lower back accounted for 34.3% of the cases. The most common mechanism of injury/nature of medical emergency was acute musculoskeletal exertion (53.9%) followed by slips and falls (20.0%) and being struck by a snow shovel (15.0%). Cardiac-related ED visits accounted for 6.7% of the cases, including all of the 1647 deaths in the study. Patients required hospitalization in 5.8% of the cases. Most snow shovel-related incidents (95.6%) occurred in and around the home.

Conclusions

This is the first study to comprehensively examine snow shovel-related injuries and medical emergencies in the United States using a nationally representative sample. There are an estimated 11?500 snow shovel-related injuries and medical emergencies treated annually in US EDs.     

Microwave oven-related injuries treated in hospital EDs in the United States, 1990 to 2010

Background

The widespread availability of microwave ovens has sparked interest in injuries resulting from their use.

Methods

Using a retrospective cohort design, the objective of this study is to investigate the epidemiology of microwave oven-related injuries treated in United States emergency departments (EDs) from 1990 through 2010 by analyzing data from the National Electronic Injury Surveillance System.

Results

An estimated 155 959 (95% confidence interval [CI], 133 515-178 402) individuals with microwave oven-related injuries were treated in US hospital EDs from 1990 through 2010, which equals an average of 21 individuals per day; 60.7% were female; 63.3% were adults (≥ 18 years); 98.1% of injury events occurred at home; and 3.9% of patients were hospitalized. During the 21-year study period, the number and rate of microwave oven-related injuries increased significantly by 93.3% and 50.0%, respectively. The most common mechanism of injury was a spill (31.3%), and the most common body region injured was the hand and fingers (32.4%). Patients younger than 18 years were more likely to sustain an injury to their head and neck (relative risk: 1.65; 95% CI, 1.39-1.96) than adults.

Conclusions

To our knowledge, this is the first study to investigate microwave oven-related injuries on a national scale. Microwave ovens are an important source of injury in the home in the United States. The large increases in the number and rate of these injuries underscore the need for increased prevention efforts, especially among young children.     

Stove-related injuries treated in EDs in the United States, 1990-2010

BackgroundHousehold stoves are a common source of injury in the United States.PurposeTo investigate the epidemiology of stove-related injuries.MethodsThe National Electronic Injury Surveillance System database was used to analyze cases of nonfatal stove-related injuries treated in US hospital emergency departments (EDs) from 1990 through 2010.ResultsAn estimated 910 696 (95% CI, 789 279-1 032 113) individuals were treated for stove-related injuries during the 21-year study period, yielding an average of 43 366 injured persons annually or 5 injuries every hour. The number (m = ? 252.85; P = .033) and rate (m = ? 0.026; P < .001) of injured individuals significantly decreased during the study. Injuries were highest in 1991 (50 656 cases; 2.0 per 10 000) and lowest in 2005 (38 669 cases; 1.31 per 10 000), although there was an increase in 2010 (48 990 cases; 1.58 per 10 000). Patients ≤ 19 years experienced 41.3% of stove-related injuries. The primary mechanism of injury was contact with stove parts (37.5%). The body region most commonly injured was the hand (44.6%), and a thermal burn was the most common diagnosis (51.8%). The majority (94.4%) of patients were treated and released from the ED. Patients > 60 years of age were 3.85 (95% CI, 2.97-4.98) times more likely to be admitted to the hospital than younger patients.ConclusionsThis is the first comprehensive study of stove-related injuries in the United States using a nationally representative sample. Strategies to prevent stove-related injuries should address the multiple mechanisms of injury.     

Throw rug-related injuries treated in US EDs: are children the same as adults?

BackgroundVarious characteristics of floors and floor coverings are well established as injury hazards. Loose carpeting, such as rugs, is often cited as a hazard leading to injury.PurposeTo describe the epidemiology and patterns of rug, mat, and runner-related injuries in patients seeking emergency treatment.MethodsData from the National Electronic Injury Surveillance System from 1990 through 2009 were investigated. Sample weights were used to calculate national estimates. US Census Bureau data were used to calculate injury rates per 100 000 individuals. Linear regression and computation of relative risks (RRs) with 95% confidence intervals (CIs) were performed.ResultsAn estimated 245 605 patients were treated in US emergency departments for rug-related injuries during the study period, with an average of 12 280 cases per year. Females (72.3%) and individuals older than 64 years (47.1%) sustained the largest number of injuries. Patients younger than 6 years were more likely to injure the head or neck region (RR, 3.52 [95% CI, 3.26-3.81]) compared with all other groups. Patients older than 18 years were more likely to experience a fracture or dislocation (RR, 2.52 [95% CI, 2.13-2.88]) and sustain an injury as a result of tripping or slipping on a rug (RR, 1.36 [95% CI, 1.26-1.41] compared with other age groups. Increasing age was associated with increased risk of hospitalization in this study. Patients who sustained an injury from a rubber or plastic mat/rug were significantly less likely to be admitted (RR, 0.67 [95% CI, 0.55-0.83]). Injuries occurring in kitchens or bathrooms resulted in significantly higher admission rates (RR, 1.45 [95% CI, 1.34-1.54]).ConclusionsRug-related injuries are an important source of injury for individuals of all ages.     

HIV testing in US EDs, 1993-2004

Objectives

The aims of the study were to (1) estimate the incidence rates (IRs) of human immunodeficiency virus (HIV) testing among 13-year-old to 64-year-old patients in US emergency departments (EDs); (2) determine ED compliance with Centers for Disease Control and Prevention (CDC) recommendations for HIV testing for patients with nonsexual blood or body fluid exposures, sexually transmitted diseases (STDs), and sexual assaults; and (3) ascertain if HIV testing in EDs varies by patient demographic characteristics.

Methods

The ED visits from the National Hospital Ambulatory Medical Care Survey databases (1993-2004) were analyzed. Visits for nonsexual blood or body fluid exposures, STDs, and sexual assaults were identified using diagnosis and cause codes. Incidence rates for HIV testing were estimated by year. Odds ratios (ORs) with 95% confidence intervals were estimated from multivariable logistic regression models using HIV testing as the outcome and demographic characteristics as covariates.

Results

The average IR of HIV testing for 13-year-old to 64-year-old patients from 1993 to 2004 was 0.31%. Of all patients, 35.1% with nonsexual blood or body fluid exposures, 20.4% with sexual assaults, and 2.6% with STDs were tested for HIV. The HIV testing was more frequent among Hispanics (OR, 1.39 [1.06-1.81]), blacks (OR, 1.52 [1.19-1.94]), patients with Medicaid (OR, 2.35 [1.81-3.03]), Medicare (OR, 1.95 [1.20-3.16]), and self-pay/no charge/other type of insurance (OR, 1.74 [1.35-2.23]), and those visiting EDs in the northeastern United States (OR, 1.57 [1.04-2.38]).

Conclusions

The HIV testing rates are low in US EDs and have changed little for a 12-year period. Compliance with CDC recommendations for HIV testing is poor and not in accordance with risk for infection. Hispanics, blacks, and those without private health care insurance are being tested more frequently than other ED patients.     

Use of midlevel providers in US EDs, 1993 to 2005: implications for the workforce

Objective

The aim of the study was to evaluate use of physician assistants (PAs) and nurse practitioners (NPs) in US emergency departments (EDs).

Methods

We analyzed visits from the 1993 to 2005 National Hospital Ambulatory Medical Care Survey, seen by midlevel provider (MLP), and compared characteristics of MLP visits to those seen by physicians only.

Results

From 1993 to 2005, 5.2% (95% CI, 4.6%-5.8%) of US ED visits were seen by PAs and 1.7% (95% CI, 1.5%-2.0%) by NPs. During the study period, PA visits rose from 2.9% to 9.1%, whereas NP visits rose from 1.1% to 3.8% (both P_trend < .001). Compared to physician only visits, those seen only by MLPs arrived by ambulance less frequently (6.0% vs 15%), had lower urgent acuity (37% vs 59%), and were admitted less often (3.0% vs 13%).

Conclusions

Midlevel provider use has increased in US EDs. Their involvement in some urgent visits and those requiring admission suggests that the role of MLPs extends beyond minor presentations.     

Quality of care for joint dislocation in 47 US EDs

Background

Little is known about emergency department (ED) quality of care for joint dislocation. We sought to determine concordance of ED management of dislocation with guideline recommendations and to assess whether higher concordance was associated with better patient outcomes.

Methods

We conducted a retrospective chart review study of joint dislocation as part of the National ED Safety Study (www.emnet-usa.org). We identified all charts with a primary ED or hospital discharge diagnosis of joint dislocation in 47 EDs across 19 US states between 2003 and 2005. Concordance with guideline recommendations was evaluated using 5 individual quality measures and composite guideline concordance scores. Concordance scores were calculated as the percentage of eligible patients receiving guidelines-recommended care. These percentage scores were rescaled from 0 to 100, with 100 indicating perfect concordance.

Results

The cohort consisted of 1980 ED patients; the patients' median age was 38 years, and 63% were men. Care for dislocation was excellent, with a concordance score of more than 85 across all quality measures. The median ED composite guideline concordance score was 93 (interquartile range, 90-95). In multivariable analyses, receiving treatment in EDs with the highest (fourth quartile) composite guideline concordance scores was independently associated with a significantly higher likelihood of successful joint reduction (adjusted odds ratio, 3.28; 95% confidence interval, 1.38-7.81), as compared with treatment in EDs with the lowest (first quartile) scores.

Conclusions

Concordance of ED management of joint dislocation with guideline recommendations was high. Greater concordance with guideline-recommended care may increase the likelihood of successful joint reduction.     

Prevalence and treatment of pain in EDs in the United States, 2000 to 2010

Objectives

To describe changes in the prevalence and severity of pain and prescribing of non-opioid analgesics in US emergency departments (EDs) from 2000 to 2010.

Methods

Analysis of serial cross-sectional data regarding ED visits from the National Hospital Ambulatory Medical Care Survey. Visits were limited to patients ≥ 18 years old without malignancy. Outcome measures included annual volume of visits among adults with a primary symptom or diagnosis of pain, annual rates of patient-reported pain severity, and predictors of non-opioid receipt for non-malignant pain.

Results

Rates of pain remained stable, representing approximately 45% of visits from 2000 through 2010. Patients reported pain as their primary symptom twice as often as providers reported a primary pain diagnosis (40% vs 20%). The percentage of patients reporting severe pain increased from 25% (95% confidence intervals [CI] 22%-27%) in 2003 to 40% (CI 37%-42%) in 2008. From 2000 to 2010, the proportion of pain visits treated with pharmacotherapies increased from 56% (CI 53%-58%) to 71% (CI 69%-72%), although visits treated exclusively with non-opioids decreased 21% from 28% (CI 27%-30%) to 22% (CI 20%-23%). The adjusted odds of non-opioid rather than opioid receipt were greater among visits for patients 18 to 24 years old (odds ratio [OR] 1.35, CI 1.24-1.46), receiving fewer medicines (OR 2.91, CI 2.70-3.15) and those with a diagnosis of mental illness (OR 2.24, CI 1.99-2.52).

Conclusions

Large increases in opioid utilization in EDs have coincided with reductions in the use of non-opioid analgesics and an unchanging prevalence of pain among patients.     

Hospital variation in risk-standardized hospital admission rates from US EDs among adults

Background

Variation in hospital admission rates of patients presenting to the emergency department (ED) may represent an opportunity to improve practice. We seek to describe national variation in hospital admission rates from the ED and to determine the degree to which variation is not explained by patient characteristics or hospital factors.

Methods

We conducted a cross-sectional analysis of a nationally representative sample of ED visits among adults within the 2010 National Hospital Ambulatory Care Survey ED data of hospitals with admission rates from the ED between 5% and 50%. We calculated risk-standardized hospital admission rates (RSARs) from the ED using contemporary hospital profiling methodology, accounting for patients' sociodemographic and clinical characteristics.

Results

Among 19 831 adult ED visits in 252 hospitals, there were 4148 hospital admissions from the ED. After accounting for patients' sociodemographic and clinical factors, the median RSAR from the ED was 16.9% (interquartile range, 15.0%-20.4%), and 8.1% of the variation in RSARs was attributable to an institution-specific effect. Even after accounting for hospital teaching status, ownership, urban/rural location, and geographical location, 7.0% of the variation in RSARs from the ED was still attributable to an institution-specific effect.

Conclusions and relevance

There was variation in hospital admission rates from the ED in the United States, even after adjusting for patients' sociodemographic and clinical characteristics and accounting for hospital factors. Our findings suggest that suggesting that the likelihood of being admitted from the ED is not only dependent on clinical factors but also at which hospital the patient seeks care.     

Factors associated with delayed evaluation of patients with potential stroke in US EDs

Background

The American Heart Association/American Stroke Association guidelines recommend all patients presenting to emergency departments (EDs) with a potential stroke be seen within 10 minutes of arrival, although this may not be achieved in all patients. We sought to identify factors associated with delayed evaluation of ED patients with potential stroke.

Methods

Using the National Hospital Ambulatory Medical Care Survey, we identified all patient ED visits from 2003 to 2010 and further identified those patients with strokes or stroke-like symptoms using International Classification of Disease, Ninth Revision codes. Visits were classified as those evaluated within 10 minutes of ED arrival or those where evaluation by the treating provider was 10 minutes or greater (delayed evaluation). We stratified visits, compared proportions, and calculated the unadjusted and adjusted odds ratios (ORs) in a multivariable model.

Results

We identified 743 cases in the database representing an estimated 2.3 million ED visits for patients with strokes. Of these, 600 000 were seen within 10 minutes and 1.7 million visits with delayed evaluation. Visits at nonmetropolitan statistical area hospitals were associated with decreased odds of delayed evaluation (OR, 0.41 [95% confidence interval, 0.26-0.64]; P < .001). Being triaged to a less urgent emergency severity index category was associated with increased odds of delayed evaluation (OR 3.08 (95% CI 1.94-4.89) p < 0.001). Other factors were not associated with delayed evaluation.

Conclusion

In this national sample of patients presenting with strokes to US EDs, patient visits to metropolitan statistical area hospitals and those triaged to less urgent categories were associated with delayed evaluation.     

Racial/ethnic differences in emergency care for joint dislocation in 53 US EDs

Objective

The aim of the study was to investigate racial/ethnic differences in emergency care for patients with joint dislocation.

Methods

We performed a secondary analysis of the dislocation component of the National Emergency Department Safety Study. Using a principal diagnosis of dislocation, we identified emergency department (ED) visits for joint dislocations in 53 urban EDs across 19 US states between 2003 and 2005. Quality of care was evaluated based on 9 guideline-concordant care measures.

Results

Of the 1945 patients included in this analysis, 1124 (58%) were white; 561 (29%), black, and 260 (13%), Hispanic. One-third of the 53 EDs cared for 51% of minority patients. After multivariable adjustment, black patients were less likely to receive any analgesic treatment (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.51-0.90) or opioid treatment (OR, 0.64; 95% CI, 0.41-0.997), waited longer to receive analgesia (mean difference in time to analgesic treatment, 32 minutes; 95% CI, 16-52 minutes), and were less likely to receive reassessments of pain (OR, 0.49; 95% CI, 0.34-0.70) compared with white patients. There were no ethnic disparities in most of the care measures between Hispanic and white patients. There were no disparities in initial pain assessment, pre- and postprocedural neurovascular assessment, procedural monitoring, or success of joint reduction across the racial/ethnic groups.

Conclusions

Black patients presenting to the ED with joint dislocations received lower quality of care in some, but not all, areas compared with white patients. Future interventions should target these areas to eliminate racial disparities in dislocation care.     

The association between hospital type and mortality among critically ill children in US EDs

Study aim

Little is known about the setting of care for critically ill children and whether differences in outcomes are related to the presenting hospital type. This study describes the characteristics of hospitals to which critically ill children present and explores the associations between hospital factors and mortality.

Methods

This is a retrospective cohort study using data from the 2007 Healthcare Cost and Utilization Project National Emergency Department Sample, representative of all US ED visits. Subjects include children aged 0–18 with ICD9 codes for cardiac arrest, respiratory arrest and/or respiratory failure. Predictor variables include: age, sex, presence of chronic illness, self-pay, public insurance, trauma diagnosis, major trauma center, urban hospital, ED volume and teaching hospital. Multivariate logistic regression estimates predictors of mortality. Analyses integrate clusters, strata, and weights from the probability sample.

Results

There were an estimated 29 million pediatric ED visits in 2007 including 42,036 (0.1%) visits for cardiac or respiratory failure. Teaching hospitals (OR 0.57, 95% CI 0.50–0.66), trauma centers (OR 0.76, 95% CI 0.67–0.86), and urban hospitals (OR 0.78, 95% CI 0.63–0.97) were associated with lower mortality odds. Presence of a chronic illness (OR 14.5, 95% CI 10.5–20.1), diagnosis of an injury (OR 1.2, 95% CI 1.1–1.4) and self-pay status (OR 3.6, 95% CI 2.9–4.4) were associated with increased mortality odds.

Conclusions

The majority of children with cardiac and respiratory arrest present to urban teaching hospitals and trauma centers. After accounting for important confounders, mortality is lower at teaching hospitals and/or major trauma centers.