- Email: [email protected]
Childhood Obesity: Assessing the Parents’ Perceptions of Children’s Weight as a Health Risk
Research Forum Abstracts physician or the emergency department for re-evaluation. Phone follow-up was obtained from parents regarding satisfaction and complications from IV. Among patients returning to the emergency department nursing surveys were obtained to assess IV for complications and functionality on follow-up visit. Results: Sixty-four children were enrolled with 100% follow-up. Forty-four out of 64 (69%) returned for re-evaluation in the emergency department, the remainder sought follow up with their primary physician. Two patients had minor complications. One catheter became accidentally dislodged and another child experienced pain at IV site. Among patients who returned to the ED, 43/44 (98%) of IV catheters were intact, and 39/44 (88%) were used on follow-up visit. Fifty-nine out of 64 (92%) of parents were satisfied with IV and 62/64 (97%) would want to be discharged with IV again in similar scenario. Conclusions: It is safe to discharge pediatric patients who are appropriate for discharge with close follow-up with IV catheter in place until time of follow-up.
189
Diagnostic Characteristics of Abdominal Radiographs for Intussusception
Hom J, Kaplan C, Kunkov S/Stony Brook University School of Medicine, Stony Brook, NY
Study Objectives: To perform a systematic review describing the diagnostic characteristics of abdominal radiographs to diagnose intussusception Methods: PubMED and EMBASE were searched to indentify studies, enrolling children less than 18 years old, with abdominal radiographs performed to diagnose intussusception. A literature search was performed at March 2012. A second search was performed in November 2012 to identify any additional studies. Data were summarized, stratified by retrospective and retrospective study designs, to limit selection bias. The data were analyzed by statistical software package, Meta-DiSc, version 1.4. The likelihood ratios were based upon a random effect model. Results: There were 274 citations identified, of which 45 were reviewed for possible inclusion. Seven studies met inclusion criteria. Data from two prospective studies were pooled, while data from five retrospective studies were pooled. From the prospective studies, the pooled sensitivity (Sen) was 0.82 [95% Confidence Interval (CI)], 0.69 - 0.97) and pooled specificity (Spec) was 0.69 (95% CI, 0.64 - 0.74). The pooled positive likelihood ratio, LR(þ), was 2.64 (95% CI, 1.05 - 5.67) and negative likelihood ratio, LR(), was 0.28 (95% CI, 0.16 - 0.49). The diagnostic odds ratio (DOR) was 11.1 (95% CI, 5.3 - 23.2) From the retrospective studies, the pooled Sen was 0.86 (95% CI, 0.81 - 0.91), and pooled Spec was 0.59 (95% CI, 0.53 - 0.64). The pooled LR(þ) was 2.97 (95% CI, 1.50 to 4.08), and pooled LR() was 0.22 (0.15 to 0.31). The DOR was 15.0 (95% CI, 7.8 - 28.7) See Tables 1 and 2 for 2x2 tables. Conclusions: Abdominal radiographs have poor diagnostic characteristics to identify intussusception. Radiographs do not aid the ruling-in or ruling-out intussusception. Those radiographs with highly specific finding for intussusception may have diagnostic utility. Table 1. Abdominal Radiographs in Suspected Intussusception among Prospective Studies
X-ray (þ) X-ray ()
Intuss (D)
Intuss (L)
44 10 54
115 258 373
159 268 427
Intuss: Intussusception
Table 2. Abdominal Radiographs in Suspected Intussusception among Retrospective Studies
X-ray (þ) X-ray ()
Intuss (D)
Intuss (L)
197 31 228
148 190 338
Intuss: Intussusception
Volume 62, no. 4s : October 2013
345 221 566
190
IV Access Delay in Neonatal Severe Sepsis Remains Common
Kelly JJ, Cotton-Betteridge M, Skovran J, Haines C, Deitch K/Einstein Medical Center Philadelphia, Philadelphia, PA; St. Christopher Hospital for Children, Philadelphia, PA
Study Objectives: To identify “first hour” delays to immediate neonatal severe sepsis care in the emergency department (ED), including IV access, cultures (Cx) and labs, fluid bolus, and broad spectrum antibiotics (AB). Methods: This was a retrospective chart review of 72 neonates less than 3 months old transferred from a level 1 academic ED to a pediatric specialty hospital with a final diagnosis of sepsis from 1/2011-1/2013. Of the 72 transfers, 25% (N¼18, 95% CI, 9.13% to 26.87%) patients met SIRS criteria and had suspected infection at the time of presentation. These 18 charts were then evaluated for time to IV access, Cx and labs obtained, fluid bolus administered, and broad spectrum AB given, consistent with routine management. Results: We divided the neonates into 2 groups. Group A (n¼10): IV access was obtained within 1 hour. Group B (n¼8): IV access was delayed greater than 1 hour. Within group A, 70% (n¼7,95%CI, 41.6% to 98.4%) received IVF bolus, 60% (n¼6, 95%CI, 29.64% to 90.36%) received antibiotics and 100% (n¼10,95%CI, 8.59% to 28.59%) received all necessary blood work. Within Group B 50% (n¼4,95%CI, 9.58% to 17.58%) received IVF bolus, 50% (n¼4,95%CI,9.58% to 17.58%) received antibiotics and 37.5% (n¼3, 95%CI, 8.82% to 14.82%) received all necessary blood work. Direct comparison of both groups in each category, revealed no significant difference (95% CI, 0.27 to 59.0%); however, a clinically significant trend towards a delay to appropriate care (timely IV fluid bolus, antibiotics, serum lab evaluation) was observed when a delay to IV access occurred. Conclusions: Almost half of neonates identified as sepsis/SIRS at the time of presentation had a delay of >1 hour in this retrospective analysis. Of the neonates that had this delay, there was a small but important clinical difference that trends toward missed blood work, no IVF bolus, and no antibiotics. A larger study may help to reveal these differences. Innovation and practice policy on neonatal IV access is essential in adult EDs and may include introduction of ultraviolet and ultrasound vein finders, formation of pediatric IV specialist team, surgical cutdown and intraosseous IV access. Each failed mode must be linked to timed “cascade” with immediate activation of next (and more invasive) Innovation to reduce IV access delays. These initial aggressive steps speed time to severe sepsis resuscitation.
191
Childhood Obesity: Assessing the Parents’ Perceptions of Children’s Weight as a Health Risk
Josephson E, Teitell R, Prota D, Waseem M, Kornberg. R, Reynolds T/Lincoln Medical & Mental Health Center, Bronx, NY; St Luke’s-Roosevelt Hospital Center, New York City, NY
Study Objectives: Childhood obesity has become an important public health issue, especially in inner city populations. Parents’ perceptions of their child’s weight could be a contributing factor. We sought to evaluate the perception of parents whose children were seeking care in our pediatric emergency department (PED) with respect to their child’s body habitus, any previous physician input and also to calculate the child’s body mass index (BMI). By evaluating this underserved area population we intend to highlight the significant need to better understand how to promote health awareness issues with the goal of subsequently educating parents in ways to intervene to reduce childhood obesity. Methods: We used an observational prospective cohort study design in the setting of a PED located in an urban teaching hospital. The participants were the parents who accompanied the patients of school age children from 4 to 16 years old visiting the PED. A bilingual survey was given depending on parents’ language preference, which consisted of the following: estimated height (inches) and weight (pounds) of child, perception of the child’s weight (body habitus) with respect to whether they consider it a health issue or informed about this by a physician. BMI and its percentiles were calculated based on parents’ estimation of height and weight. A Pearson and Kendall Tau statistical analysis of the survey data was performed. Results: Forty-seven parents completed the survey. The mean age of their children was 9 years (range 4-16) and mean BMI Percentile was 71.6. A comparison of the parent’s perception of the child’s body habitus vs. BMI percentile did achieve statistical significance (p<.01). Parents however, did not perceive their children’s weight as a health problem when compared with their BMI percentile (p<0.02). Despite being previously informed by a physician about their children’s weight as
Annals of Emergency Medicine S71
Research Forum Abstracts posing a health risk, the parent’s did not perceive this as issue with respect to the BMI percentile (<0.01). Conclusions: The parents presenting to our PED in this study recognized that their children were overweight but did not perceive it to be a significant risk to their wellbeing. Physicians involved in the care of at risk children as part of their intervention should focus on improving ways to better communicate and educate parents toward changing their understanding of this particular health issue.
192
Ovarian Torsion in Pediatric Patients: A Review of Eleven Years’ Experience
Rudser AKE, Rudser K, Patterson RJ, VanderVelden H, Reid S/Children’s Hospitals and Clinics of Minnesota, Minneapolis, MN; University of Minnesota, Minneapolis, MN
Study Objective: We evaluated the following previously published diagnostic criteria regarding the volumetric diagnosis of ovarian torsion (OT) in pediatric patients with acute pain: 1) Affected-side adnexal volume <20mL is negatively associated with OT. 2) Affected-side adnexal volume >75mL is associated with OT. 3) The ratio of affected-side to unaffected-side adnexal volume >15 is associated with OT. We also examined presenting clinical features to determine their utility in distinguishing patients with OT from those diagnosed with acute pelvic pain or ovarian cysts. Methods: Retrospective case-control study of patients presenting to the emergency department of a free-standing children’s hospital who underwent pelvic imaging (sonography or computered tomography) for the evaluation of acute abdominal or pelvic pain. Cases were defined as patients found to have ovarian torsion at surgery. Controls were defined as patients who received a clinical diagnosis of either acute pelvic pain or ovarian cyst. Images for all patients were reviewed by a single, blinded pediatric radiologist who determined bilateral adnexal volumes. Results: There were 80 unique cases of OT and 80 randomly selected controls. Clinical features that were associated with OT include duration of pain greater than 48 hours (p < 0.001), vomiting (p < 0.001), and heart rate greater than 100 beats per minute on physical exam (p < 0.001). Adnexal volumes were unattainable on one or both sides in 76 patients (48%) resulting in 43 cases and 41 controls for volume evaluation. The sensitivity for OT using a cutoff adnexal volume of < 20 mL was 50% (95% CI: 35%-65%) and the specificity was 29% (95% CI: 15%-43%). The sensitivity for OT using a cutoff adnexal volume of > 75 mL was 18% (95% CI: 7%30%) and the specificity was 93% (95% CI: 85%-100%). The ratio of affected-side volume to the unaffected-side volume of >15 had a sensitivity of 16% (95% CI: 5%27%) and a specificity of 98% (95% CI: 93%-100%). Conclusions: The previously published diagnostic criteria regarding the volumetric diagnosis of ovarian torsion (OT) were inadequately sensitive for the diagnosis of OT in our patients. However, an affected-side adnexal volume > 75 ml, and an affectedside to unaffected-side adnexal volume ratio > 15 were reasonably specific.
193
Clinical and Demographic Characteristics Associated With Opioid Overdose Visits to United States Emergency Departments
Yokell MA, Zaller ND, Delgado MK, Wang NE, McGowan SK, Green TC/Stanford University School of Medicine, Stanford, CA; Warren Alpert Medical School of Brown University, Providence, RI; The Miriam Hospital, Providence, RI
Study Objectives: Opioid overdose (OD) is the leading cause of adult accidental death in the United States, causing more than 16,000 deaths in 2009. Most current OD-related research utilizes hospital discharges and death certificate information. Little is currently known about the number of emergency department (ED) presentations for opioid OD or the clinical and demographic characteristics of the presenting patients. We aimed to use a nationally representative dataset to describe the clinical and demographic characteristics of patients presenting to US EDs with opioid OD. Methods: Data were extracted for patients with International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9CM) diagnosis codes for opioid poisoning in the 2009 Nationwide Emergency Sample (NEDS). Patients were classified as having a heroin OD if they had a diagnosis code 965.01 or E-code E850.0; as having a methadone OD if they had a diagnosis code 965.02 or E-code E850.1; or as having a prescription opioid OD if they had a diagnosis code 965.09 or E-code 850.2. Patients with incongruous diagnosis and E-codes were excluded. Our primary outcome was the type of opioid involved in the overdose event. Our secondary outcome was
S72 Annals of Emergency Medicine
survival of the overdose event (discharged alive vs. died in the hospital or in the ED). NEDS sample weights were applied to generate national estimates. Chi-squared analyses were performed for discrete variables and unpaired t-tests were performed for continuous variables. A multiple logistic regression, which adjusted for sex, age, opioid type, and comorbidities, was performed to identify potential risk factors for death among patients presenting to the ED with opioid overdose. All reported figures represent nationally weighted estimates. Results: In 2009, there were 106,813 emergency department visits for opioid OD. The mean patient age was 42 years, 52% were male, and 84% lived in metropolitan areas. The majority of ODs involved prescription opioids (67%), while heroin and methadone were involved in 19% and 11%, respectively. The mean age was 35 years for those overdosing on heroin and 44 years for those overdosing on prescription opioids. Approximately 15% of patients experienced respiratory failure during their OD. A significant proportion of patients had comorbid mental health disorders (35%), circulatory diseases (28.5%), and respiratory diseases (25%). Fifty-one percent (51%) of patients were admitted to the hospital to which they presented, while 46% were discharged from the ED. Among those presenting to EDs, 1,684 died in the ED or as inpatients (1.6%). In multivariate analysis, those who overdosed on heroin (OR 1.7, 95% CI: 1.2-2.4) and those who suffered respiratory failure (OR 12.8, 95% CI: 9.717.1) had a higher risk of mortality. Of note, a diagnosis of chronic pain was not statistically associated with OD mortality in the multivariate analysis. Conclusions: Our data demonstrate that there are approximately 63 non-fatal opioid overdose visits to US EDs occurring for each OD visit to an ED that results in death. These figures add critical knowledge to the current literature utilizing hospital discharge data and death records. Comorbidities, such as mental health disorders and chronic illnesses, should be assessed when prescribing opioids to patients in the community and ED and when treating patients with acute OD.
194
A Novel Way to Evaluate Health Care Utilization Characteristics of Intimate Partner Violence Victims
Hoelle R, Elie M-C, Hardt N, Hou W, Yan H, Carden D/University of Florida, Gainesville, FL
Study Objectives: Intimate partner violence (IPV) is a far-reaching public health problem difficult to identify and address. Practitioners need more information about IPV victims’ health care utilization trends to create successful identification and intervention strategies. We used a novel data linkage method and complaint categorization allowing us to evaluate IPV victims’ health care utilization trends compared to the date of their victimization. Methods: This was a retrospective case series using data linking techniques cross-referencing databases of Medicaid-eligible women between the ages of 16 and 55 years, the Florida State Attorney’s Office of Victim Witness Services Eighth Circuit Court IPV Case Database for 2007 and the Florida State Agency for Healthcare Administration which tracks hospital inpatient, ambulatory and emergency department (ED) utilization within the state of Florida. Resulting health care visits were analyzed in the 1.5 years before and 1.5 years after the women’s IPV offense. Using all available claims data a “complaint category” representing categories of presenting chief complaints was assigned to each health care visit. Analysis included descriptive statistics, correlation coefficients between time of offense and visits and a logistic regression analysis comparing victims who used the ED and those who used other health care sites. Results: The 695 victims were linked with 4,344 health care visits in the four-year study period. The victims were young (45% in the 16-25 age group and 78% were younger than 35) and most of the health care visits were in the ED (82.2%) rather than other health care sites. In the ED, IPV victims most often had complaint categories of trauma-related visits (34.9%), infection-related visits (14.6%) and OB-GYN-related visits (14.5%). ED utilization escalated approaching the victim’s date of offense (r¼0.48, p0.0001) compared to use of other sites of health care utilization (r¼-0.02,p¼0.8747). (Figure) ED utilization deescalated significantly after dates of victimization for ED visits (r¼0.60,p0.0001) versus non-ED utilization (r¼0.03,p¼0.8124). Victims were more likely to utilize ED healthcare settings before the date of offense versus after with an OR of 1.21 (CI 1.01, 1.49, p¼0.043). The victim’s age group more likely to use the ED than any other age group was the 36-45 age group (OR 3.97, 2.48, 2.50). Conclusions: IPV victims present to the ED increasingly approaching their date of victimization. Presenting complaints were varied and did not reveal unique identifiers of IPV victims. While there are increasing interactions between victims and emergency physicians there were no complaints differentiating victims and suggesting narrowing screening protocols. This novel method of database matching between
Volume 62, no. 4s : October 2013
189
Diagnostic Characteristics of Abdominal Radiographs for Intussusception
Hom J, Kaplan C, Kunkov S/Stony Brook University School of Medicine, Stony Brook, NY
Study Objectives: To perform a systematic review describing the diagnostic characteristics of abdominal radiographs to diagnose intussusception Methods: PubMED and EMBASE were searched to indentify studies, enrolling children less than 18 years old, with abdominal radiographs performed to diagnose intussusception. A literature search was performed at March 2012. A second search was performed in November 2012 to identify any additional studies. Data were summarized, stratified by retrospective and retrospective study designs, to limit selection bias. The data were analyzed by statistical software package, Meta-DiSc, version 1.4. The likelihood ratios were based upon a random effect model. Results: There were 274 citations identified, of which 45 were reviewed for possible inclusion. Seven studies met inclusion criteria. Data from two prospective studies were pooled, while data from five retrospective studies were pooled. From the prospective studies, the pooled sensitivity (Sen) was 0.82 [95% Confidence Interval (CI)], 0.69 - 0.97) and pooled specificity (Spec) was 0.69 (95% CI, 0.64 - 0.74). The pooled positive likelihood ratio, LR(þ), was 2.64 (95% CI, 1.05 - 5.67) and negative likelihood ratio, LR(), was 0.28 (95% CI, 0.16 - 0.49). The diagnostic odds ratio (DOR) was 11.1 (95% CI, 5.3 - 23.2) From the retrospective studies, the pooled Sen was 0.86 (95% CI, 0.81 - 0.91), and pooled Spec was 0.59 (95% CI, 0.53 - 0.64). The pooled LR(þ) was 2.97 (95% CI, 1.50 to 4.08), and pooled LR() was 0.22 (0.15 to 0.31). The DOR was 15.0 (95% CI, 7.8 - 28.7) See Tables 1 and 2 for 2x2 tables. Conclusions: Abdominal radiographs have poor diagnostic characteristics to identify intussusception. Radiographs do not aid the ruling-in or ruling-out intussusception. Those radiographs with highly specific finding for intussusception may have diagnostic utility. Table 1. Abdominal Radiographs in Suspected Intussusception among Prospective Studies
X-ray (þ) X-ray ()
Intuss (D)
Intuss (L)
44 10 54
115 258 373
159 268 427
Intuss: Intussusception
Table 2. Abdominal Radiographs in Suspected Intussusception among Retrospective Studies
X-ray (þ) X-ray ()
Intuss (D)
Intuss (L)
197 31 228
148 190 338
Intuss: Intussusception
Volume 62, no. 4s : October 2013
345 221 566
190
IV Access Delay in Neonatal Severe Sepsis Remains Common
Kelly JJ, Cotton-Betteridge M, Skovran J, Haines C, Deitch K/Einstein Medical Center Philadelphia, Philadelphia, PA; St. Christopher Hospital for Children, Philadelphia, PA
Study Objectives: To identify “first hour” delays to immediate neonatal severe sepsis care in the emergency department (ED), including IV access, cultures (Cx) and labs, fluid bolus, and broad spectrum antibiotics (AB). Methods: This was a retrospective chart review of 72 neonates less than 3 months old transferred from a level 1 academic ED to a pediatric specialty hospital with a final diagnosis of sepsis from 1/2011-1/2013. Of the 72 transfers, 25% (N¼18, 95% CI, 9.13% to 26.87%) patients met SIRS criteria and had suspected infection at the time of presentation. These 18 charts were then evaluated for time to IV access, Cx and labs obtained, fluid bolus administered, and broad spectrum AB given, consistent with routine management. Results: We divided the neonates into 2 groups. Group A (n¼10): IV access was obtained within 1 hour. Group B (n¼8): IV access was delayed greater than 1 hour. Within group A, 70% (n¼7,95%CI, 41.6% to 98.4%) received IVF bolus, 60% (n¼6, 95%CI, 29.64% to 90.36%) received antibiotics and 100% (n¼10,95%CI, 8.59% to 28.59%) received all necessary blood work. Within Group B 50% (n¼4,95%CI, 9.58% to 17.58%) received IVF bolus, 50% (n¼4,95%CI,9.58% to 17.58%) received antibiotics and 37.5% (n¼3, 95%CI, 8.82% to 14.82%) received all necessary blood work. Direct comparison of both groups in each category, revealed no significant difference (95% CI, 0.27 to 59.0%); however, a clinically significant trend towards a delay to appropriate care (timely IV fluid bolus, antibiotics, serum lab evaluation) was observed when a delay to IV access occurred. Conclusions: Almost half of neonates identified as sepsis/SIRS at the time of presentation had a delay of >1 hour in this retrospective analysis. Of the neonates that had this delay, there was a small but important clinical difference that trends toward missed blood work, no IVF bolus, and no antibiotics. A larger study may help to reveal these differences. Innovation and practice policy on neonatal IV access is essential in adult EDs and may include introduction of ultraviolet and ultrasound vein finders, formation of pediatric IV specialist team, surgical cutdown and intraosseous IV access. Each failed mode must be linked to timed “cascade” with immediate activation of next (and more invasive) Innovation to reduce IV access delays. These initial aggressive steps speed time to severe sepsis resuscitation.
191
Childhood Obesity: Assessing the Parents’ Perceptions of Children’s Weight as a Health Risk
Josephson E, Teitell R, Prota D, Waseem M, Kornberg. R, Reynolds T/Lincoln Medical & Mental Health Center, Bronx, NY; St Luke’s-Roosevelt Hospital Center, New York City, NY
Study Objectives: Childhood obesity has become an important public health issue, especially in inner city populations. Parents’ perceptions of their child’s weight could be a contributing factor. We sought to evaluate the perception of parents whose children were seeking care in our pediatric emergency department (PED) with respect to their child’s body habitus, any previous physician input and also to calculate the child’s body mass index (BMI). By evaluating this underserved area population we intend to highlight the significant need to better understand how to promote health awareness issues with the goal of subsequently educating parents in ways to intervene to reduce childhood obesity. Methods: We used an observational prospective cohort study design in the setting of a PED located in an urban teaching hospital. The participants were the parents who accompanied the patients of school age children from 4 to 16 years old visiting the PED. A bilingual survey was given depending on parents’ language preference, which consisted of the following: estimated height (inches) and weight (pounds) of child, perception of the child’s weight (body habitus) with respect to whether they consider it a health issue or informed about this by a physician. BMI and its percentiles were calculated based on parents’ estimation of height and weight. A Pearson and Kendall Tau statistical analysis of the survey data was performed. Results: Forty-seven parents completed the survey. The mean age of their children was 9 years (range 4-16) and mean BMI Percentile was 71.6. A comparison of the parent’s perception of the child’s body habitus vs. BMI percentile did achieve statistical significance (p<.01). Parents however, did not perceive their children’s weight as a health problem when compared with their BMI percentile (p<0.02). Despite being previously informed by a physician about their children’s weight as
Annals of Emergency Medicine S71
Research Forum Abstracts posing a health risk, the parent’s did not perceive this as issue with respect to the BMI percentile (<0.01). Conclusions: The parents presenting to our PED in this study recognized that their children were overweight but did not perceive it to be a significant risk to their wellbeing. Physicians involved in the care of at risk children as part of their intervention should focus on improving ways to better communicate and educate parents toward changing their understanding of this particular health issue.
192
Ovarian Torsion in Pediatric Patients: A Review of Eleven Years’ Experience
Rudser AKE, Rudser K, Patterson RJ, VanderVelden H, Reid S/Children’s Hospitals and Clinics of Minnesota, Minneapolis, MN; University of Minnesota, Minneapolis, MN
Study Objective: We evaluated the following previously published diagnostic criteria regarding the volumetric diagnosis of ovarian torsion (OT) in pediatric patients with acute pain: 1) Affected-side adnexal volume <20mL is negatively associated with OT. 2) Affected-side adnexal volume >75mL is associated with OT. 3) The ratio of affected-side to unaffected-side adnexal volume >15 is associated with OT. We also examined presenting clinical features to determine their utility in distinguishing patients with OT from those diagnosed with acute pelvic pain or ovarian cysts. Methods: Retrospective case-control study of patients presenting to the emergency department of a free-standing children’s hospital who underwent pelvic imaging (sonography or computered tomography) for the evaluation of acute abdominal or pelvic pain. Cases were defined as patients found to have ovarian torsion at surgery. Controls were defined as patients who received a clinical diagnosis of either acute pelvic pain or ovarian cyst. Images for all patients were reviewed by a single, blinded pediatric radiologist who determined bilateral adnexal volumes. Results: There were 80 unique cases of OT and 80 randomly selected controls. Clinical features that were associated with OT include duration of pain greater than 48 hours (p < 0.001), vomiting (p < 0.001), and heart rate greater than 100 beats per minute on physical exam (p < 0.001). Adnexal volumes were unattainable on one or both sides in 76 patients (48%) resulting in 43 cases and 41 controls for volume evaluation. The sensitivity for OT using a cutoff adnexal volume of < 20 mL was 50% (95% CI: 35%-65%) and the specificity was 29% (95% CI: 15%-43%). The sensitivity for OT using a cutoff adnexal volume of > 75 mL was 18% (95% CI: 7%30%) and the specificity was 93% (95% CI: 85%-100%). The ratio of affected-side volume to the unaffected-side volume of >15 had a sensitivity of 16% (95% CI: 5%27%) and a specificity of 98% (95% CI: 93%-100%). Conclusions: The previously published diagnostic criteria regarding the volumetric diagnosis of ovarian torsion (OT) were inadequately sensitive for the diagnosis of OT in our patients. However, an affected-side adnexal volume > 75 ml, and an affectedside to unaffected-side adnexal volume ratio > 15 were reasonably specific.
193
Clinical and Demographic Characteristics Associated With Opioid Overdose Visits to United States Emergency Departments
Yokell MA, Zaller ND, Delgado MK, Wang NE, McGowan SK, Green TC/Stanford University School of Medicine, Stanford, CA; Warren Alpert Medical School of Brown University, Providence, RI; The Miriam Hospital, Providence, RI
Study Objectives: Opioid overdose (OD) is the leading cause of adult accidental death in the United States, causing more than 16,000 deaths in 2009. Most current OD-related research utilizes hospital discharges and death certificate information. Little is currently known about the number of emergency department (ED) presentations for opioid OD or the clinical and demographic characteristics of the presenting patients. We aimed to use a nationally representative dataset to describe the clinical and demographic characteristics of patients presenting to US EDs with opioid OD. Methods: Data were extracted for patients with International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9CM) diagnosis codes for opioid poisoning in the 2009 Nationwide Emergency Sample (NEDS). Patients were classified as having a heroin OD if they had a diagnosis code 965.01 or E-code E850.0; as having a methadone OD if they had a diagnosis code 965.02 or E-code E850.1; or as having a prescription opioid OD if they had a diagnosis code 965.09 or E-code 850.2. Patients with incongruous diagnosis and E-codes were excluded. Our primary outcome was the type of opioid involved in the overdose event. Our secondary outcome was
S72 Annals of Emergency Medicine
survival of the overdose event (discharged alive vs. died in the hospital or in the ED). NEDS sample weights were applied to generate national estimates. Chi-squared analyses were performed for discrete variables and unpaired t-tests were performed for continuous variables. A multiple logistic regression, which adjusted for sex, age, opioid type, and comorbidities, was performed to identify potential risk factors for death among patients presenting to the ED with opioid overdose. All reported figures represent nationally weighted estimates. Results: In 2009, there were 106,813 emergency department visits for opioid OD. The mean patient age was 42 years, 52% were male, and 84% lived in metropolitan areas. The majority of ODs involved prescription opioids (67%), while heroin and methadone were involved in 19% and 11%, respectively. The mean age was 35 years for those overdosing on heroin and 44 years for those overdosing on prescription opioids. Approximately 15% of patients experienced respiratory failure during their OD. A significant proportion of patients had comorbid mental health disorders (35%), circulatory diseases (28.5%), and respiratory diseases (25%). Fifty-one percent (51%) of patients were admitted to the hospital to which they presented, while 46% were discharged from the ED. Among those presenting to EDs, 1,684 died in the ED or as inpatients (1.6%). In multivariate analysis, those who overdosed on heroin (OR 1.7, 95% CI: 1.2-2.4) and those who suffered respiratory failure (OR 12.8, 95% CI: 9.717.1) had a higher risk of mortality. Of note, a diagnosis of chronic pain was not statistically associated with OD mortality in the multivariate analysis. Conclusions: Our data demonstrate that there are approximately 63 non-fatal opioid overdose visits to US EDs occurring for each OD visit to an ED that results in death. These figures add critical knowledge to the current literature utilizing hospital discharge data and death records. Comorbidities, such as mental health disorders and chronic illnesses, should be assessed when prescribing opioids to patients in the community and ED and when treating patients with acute OD.
194
A Novel Way to Evaluate Health Care Utilization Characteristics of Intimate Partner Violence Victims
Hoelle R, Elie M-C, Hardt N, Hou W, Yan H, Carden D/University of Florida, Gainesville, FL
Study Objectives: Intimate partner violence (IPV) is a far-reaching public health problem difficult to identify and address. Practitioners need more information about IPV victims’ health care utilization trends to create successful identification and intervention strategies. We used a novel data linkage method and complaint categorization allowing us to evaluate IPV victims’ health care utilization trends compared to the date of their victimization. Methods: This was a retrospective case series using data linking techniques cross-referencing databases of Medicaid-eligible women between the ages of 16 and 55 years, the Florida State Attorney’s Office of Victim Witness Services Eighth Circuit Court IPV Case Database for 2007 and the Florida State Agency for Healthcare Administration which tracks hospital inpatient, ambulatory and emergency department (ED) utilization within the state of Florida. Resulting health care visits were analyzed in the 1.5 years before and 1.5 years after the women’s IPV offense. Using all available claims data a “complaint category” representing categories of presenting chief complaints was assigned to each health care visit. Analysis included descriptive statistics, correlation coefficients between time of offense and visits and a logistic regression analysis comparing victims who used the ED and those who used other health care sites. Results: The 695 victims were linked with 4,344 health care visits in the four-year study period. The victims were young (45% in the 16-25 age group and 78% were younger than 35) and most of the health care visits were in the ED (82.2%) rather than other health care sites. In the ED, IPV victims most often had complaint categories of trauma-related visits (34.9%), infection-related visits (14.6%) and OB-GYN-related visits (14.5%). ED utilization escalated approaching the victim’s date of offense (r¼0.48, p0.0001) compared to use of other sites of health care utilization (r¼-0.02,p¼0.8747). (Figure) ED utilization deescalated significantly after dates of victimization for ED visits (r¼0.60,p0.0001) versus non-ED utilization (r¼0.03,p¼0.8124). Victims were more likely to utilize ED healthcare settings before the date of offense versus after with an OR of 1.21 (CI 1.01, 1.49, p¼0.043). The victim’s age group more likely to use the ED than any other age group was the 36-45 age group (OR 3.97, 2.48, 2.50). Conclusions: IPV victims present to the ED increasingly approaching their date of victimization. Presenting complaints were varied and did not reveal unique identifiers of IPV victims. While there are increasing interactions between victims and emergency physicians there were no complaints differentiating victims and suggesting narrowing screening protocols. This novel method of database matching between
Volume 62, no. 4s : October 2013