- Email: [email protected]
154: Impact of Care Management on the Highest Utilizers of Camden NJ's Emergency Departments
Research Forum Abstracts patients were unemployed, 42.8% reported having a chronic illness. 33.8% of patients did not have insurance health insurance, 40.7% had Medicaid or Medicare. 23.9% had private health insurance. Having to choose between buying food and buying medicine was reported in: 4.5% weekly, 5.4% monthly, 7.5% yearly, and 76.8% never. 20.4% of patients reported having asthma, 46.7% of whom were on an asthma medication, 58.1% of whom had a peak flow ⬍50% of predicted (median 260, range 60 –700). 33.7% of patients reported having hypertension, 13.5% of whom were on a medication for hypertension, 44.5% of whom had a blood pressure ⬎140 while in the ED. A blood pressure ⬎140 in a patient with HTN or a peak flow ⬍50% of predicted in a patient with asthma was associated with (coefficient and 95% CI included): being on a hypertension or asthma medication (⫺0.42, ⫺0.83 to 0.02), and choosing between food and medicine (0.32, 0.07 to 0.63), being on a medication for hypertension or asthma in patients with the disease was associated with; access to a primary care provider (0.61, 0.41 to 0.81). Conclusions: Being treated for asthma or hypertension was associated with access to a primary care provider, but not insurance, employment, housing, or hunger status. Not having effective control of asthma or hypertension was associated with not being on a medication for the problem and having to choose between buying medication and buying food.
151
Emergency Department Patient Acceptance of Rapid HIV Testing Practices, Revisited: The 2006 CDC Recommendations for Non-Targeted, Opt-Out HIV Screening
Prekker ME, Olives T, Hanley O, Miner JR/Hennepin County Medical Center, Minneapolis, MN
Study Objective: Patient acceptance of non-targeted, opt-out HIV screening in the emergency department (ED) is variable based on published reports. We sought to evaluate patient approval of Centers for Disease Control and Prevention (CDC)recommended HIV testing practices in an urban ED without rapid HIV testing currently available, apart from occupational exposures. Methods: Cross-sectional survey conducted in an urban, county hospital with 98,000 annual visits. The estimated prevalence of known HIV infection in the ED population is 1.8%. Trained research assistants administered a previously developed, standardized survey to all adult, non-critically ill, English-speaking patients who presented to the ED during randomized shifts over a three-month period. Results: Of the 2197 enrolled patients, 53% were men, 41% were black, 37% were white, 7% were Native American, 6% were Hispanic, 9% were another ethnicity, and the median age was 39 years (interquartile range 27–50 years). A larger proportion of patients would accept testing if an opt-out methodology were used (78%, 95% confidence interval [CI] 76% to 80%) versus an opt-in methodology (73%, 95% CI 72% to 75%) (absolute difference 5%, 95% CI 4 to 6%). If their physician recommended an HIV test during the ED visit, 87% (95% CI 86 – 89%) would accept testing. A minority of patients believed that consent for HIV testing needed to be separate from general consent for medical care (37%, 95% CI 35% to 39%). Regarding counseling, 65% (95% CI 63% to 67%) of patients did not feel pretest counseling was necessary, while 60% (95% CI 58% to 62%) of patients did not feel post-test counseling was necessary after a negative result. Conclusion: The majority of ED patients in an institution naı¨ve to HIV screening would accept an HIV test regardless of selection strategy or criteria. This finding supports continued efforts to expand non-targeted, opt-out HIV screening in the ED, in accordance with current CDC recommendations.
152
Epidemiology of Advance Directives in Extended Care Facility Patients Presenting to the Emergency Department
Wall JJ, Hiestand BC/The Ohio State University, Columbus, OH
Study Objectives: In the emergency department (ED), the documented existence of an advance directive (AD) or Do-Not-Resuscitate (DNR) order may affect initial treatment decisions, even in non-life threatening situations. We performed an epidemiologic evaluation of AD and DNR prevalence among residents of extended care facilities (ECF) presenting to the ED of a large university hospital. Methods: We retrospectively identified patients originating from an ECF from the ED medical record. Data was collected from the hospital electronic medical record on age, sex, race (white vs. non-white), triage acuity, ED disposition, and AD status. In Ohio, AD consist of DNR-CC (comfort measures only), DNRCC-Arrest
Volume , . : September
(complete care up to arrest), living wills (LW) and health care power of attorney (POA). Descriptive statistics were generated, Fisher’s exact test was used to compare categorical variables, and multiple variable logistic regression was used to evaluate predictors of DNR status. Results: A total of 238 patients were identified over 4 months. 170 (71%) were white, 107 (45%) were male, and the mean age was 64 ⫹/⫺ 16.3 years, with 163 (68%) admitted. Of the 238 patients, 44 (18.5%, CI95 13.5–23.4%) had DNR orders, of which 15 were DNR-CC. In addition, 94 (39.5%, CI95 33.2– 45.8%) had a POA, and 60 (25.2%, CI95 19.7–30.8%) had LW. There was a significant difference in AD by race (51% whites with AD vs. 37% non-whites, p⫽0.046) and DNR by race (24% of whites with DNR vs. 6% of non-whites, p⬍0.001). Using multiple variable logistic regression, the variables significant in predicting DNR status (both CC and CC-Arrest) were LW (OR 11.54, CI95 5.03–26.46, p⬍0.0005), age (OR 1.061 per year increase in age, CI95 1.03–1.10, p⬍0.0005) and white race (OR 3.83, CI95 1.16 –12.65, p⬍0.028). Sex was not found to be a significant predictor (p⫽0.18) of DNR use. There were no interaction terms that affected the model. Patients with DNR orders were more likely to be transported by EMS than private ambulance (p⫽0.032), although though there was no relationship between DNR status and initial triage acuity (p⫽0.527) or admission rate (34/44 [77%, CI95 64 – 90%] DNR vs. 129/194 [66%, CI95 60 –73%] p⫽0.21). We also found that DNR status was not a significant predictor of death in the hospital (3/44 DNR [6.8%, CI95 0 –15%] vs. 41/194 non-DNR [4.1%, CI95 1.3– 6.9%] p⫽0.43). Conclusion: Age and LW use are strong predictors of ECF patient DNR use. Non-white race greatly decreases the odds of DNR use; whether this represents a preference or a lack access to full patient education cannot be determined from this retrospective study. AD provide the ability to decide care prior to incapacitation and are an invaluable tool in respecting patient decisions. ED clinicians should be alert for opportunities to discuss end-of-life care preferences in appropriate patients.
153
Do Attitudes About Homosexuality Affect Emergency Medicine Practice? Results of a Survey
Shearer P/Mount Sinai School of Medicine, New York, NY
Study Objectives: The diversity of patients in the emergency department provides unexpected rewards and challenges. There are no studies in the emergency medicine literature that address emergency physicians attitudes towards homosexuals. The purpose of this study was to evaluate emergency physicians beliefs about homosexuality and whether such beliefs impact patient care. Methods: An anonymous, self-administered survey was competed by emergency physicians, physicians assistants (PAs) and nurse practitioners (NPs) attending the 2003 ACEP Scientific Assembly. Data were analyzed using a chi-square analysis; a pvalue ⱕ 0.05 indicated statistical significance. Results: 608 surveys were completed; 379 (63%) attending physicians; 169 (28%) residents/fellows; 54 (9%) PA or NP; 44 (73%) were male; respondents came from all regions of the United States. 15.5% of emergency physicians agreed with the statement “homosexuality is immoral.” More respondents from the Southeast agreed with that statement (p⫽.02) than from other areas of the country. 76.7% of the respondents reported having co-workers who are gay, lesbian, bisexual or transgender (GLBT). Significantly more emergency physicians with a known GLBT co-worker disagreed that “homosexuality is immoral” (73.9%) compared to those without a GLBT co-worker (57.3%) (absolute difference 16.6; 95%CI [4.9, 28.3]). Emergency physicians who believe that homosexuality is immoral were more likely to be uncomfortable giving post-exposure prophylaxis to males after unprotected same-sex intercourse (26.9%) than emergency physicians who do not believe that homosexuality is immoral (14.2%) (absolute difference 12.6; 95%CI [2.4, 22.9]). Conclusion: Emergency physicians attitudes and acceptance of homosexuality differ geographically. Positive attitudes towards homosexuality are reported by emergency physicians with GLBT co-workers. Negative attitudes towards homosexuality affect some aspects of the care received by GLBT patients in the ED.
154
Impact of Care Management on the Highest Utilizers of Camden NJ’s Emergency Departments
Sciorra D, Brenner J, Gill J, Linden A, Mazzarelli A/University of Medicine and Dentistry of New Jersey, Camden, NJ; Cooper University Hospital, Camden, NJ; Delaware Valley Outcomes Research, Newark, DE; Linden Consulting Group, Hillsboro, OR
Study Objectives: The highest utilizers of emergency department (ED) services typically have complex medical conditions compounded by an array of social issues.
Annals of Emergency Medicine S47
Research Forum Abstracts Programs that improve the outpatient management of these complicated patients are likely to reduce ED utilization. The objective of this study was to examine the effect of a citywide care management (CM) project on the subsequent ED utilization of enrolled high utilizers. Methods: We conducted a retrospective cohort study of 33 patients who met the CM project enrollment criteria of Camden City residency with five or more ED visits during a one-year period of time. Enrolled high-utilizing patients were provided with targeted care management to help them towards stabilizing their social environment and finding an appropriate medical home. CM patients were recruited from 11/1/ 2007– 4/30/2008 and followed until 6/30/2008. These patients were then retrospectively matched into a citywide database of all Camden City hospital visits to determine both utilization rates before and after project enrollment. Based on each individual CM patient’s age, sex, and baseline utilization, three matched control patients were selected from the database to form a comparison group of 99 patients. Time to event analysis was performed using multivariable Cox regression. Insurance status, a history of substance abuse, and homelessness were explored as potential confounders. The event of interest was defined as a subsequent ED visit and censoring took place in the event of death, loss to follow-up, and at study completion on 6/30/2008. Results: Fourteen patients in the CM group (42.4%) and 60 patients in the matched control group (60.6%) experienced a subsequent ED visit. Through multivariable Cox regression, having a history of substance abuse was associated with a 60% increased risk of a returning ED visit (hazard ratio 1.60 [CI, 1.01 to 2.55]). After adjustment for a history of substance abuse, CM project enrollment was associated with a 69% reduced risk of subsequent ED utilization (hazard ratio 0.31 [CI, 0.15 to 0.62]). Conclusion: In the early evaluation of this intervention, participation in the CM project was associated with a significantly lower risk of experiencing a subsequent ED visit. This suggests that providing primary medical care and social support, over a relatively short period of time, is effective in decreasing ED visits for high utilizers.
155
Preliminary Results of the Survivors of Torture Presenting to an Urban Emergency Department Prevalence Study
Hexom B, Beattie L/Mount Sinai School of Medicine, New York, NY
Study Objectives: It has been reported that 8 –11% of patients presenting to urban primary care clinics have experienced torture. Given potential barriers to health care access, we hypothesize that emergency departments (EDs) may see higher rates of survivors of torture. As our medical center is located in the most ethnically diverse county in the United States, with the highest portion of foreign-born New York City residents, we sought to determine the prevalence of survivors of torture presenting to our urban ED. Methods: A previously validated survey instrument regarding exposure to torture - the Detection of Torture Survivors Survey - was administered by convenience sample to patients presenting to a New York City ED. Additional questions were asked to determine whether individuals’ experiences met internationally accepted definitions of torture. Surveys were verbally administered to patients regardless of ethnicity or complaint and language interpretation was provided if needed. Prisoners, children under 18 years, critically ill, demented, or disoriented patients were excluded. Results: Preliminary results of the first 185 surveys are presented here and enrollment is ongoing. Mean age was 49.21, 48.6% were female, and 79.5% foreign born. 41 countries of origin were represented; most frequently the United States (n⫽38), Columbia (23), Dominican Republic (18), Mexico (12), Bangladesh (11), and Ecuador (11). Mean duration of residence in the United States for foreign-born patients was 19 years. 9.2% of respondents (17) stated that they had been harmed by groups such as the government, police, military, or rebel soldiers. 10.8% (20) stated they or their family had experienced torture (10 self, 5 family, 5 both). 23 were further asked about their experiences including torture by military (7), police (6), family (5), rebel soldiers (3), individuals (1), or groups of individuals (1). 73.9% (17) of these suffered physical harm, 47.8% (11) emotional harm, 8.7% (2) sexual harm, and 21.7% (5) other. Countries of origin for those reporting torture include the U.S. (7), Columbia (5), Dominican Republic (4), and 1 each for Bangladesh, El Salvador, Honduras, Morocco, Nepal, and Tanzania. Reasons for torture included ethnicity/ tribal affiliation (4), political affiliation (3), religion (2), local customs (2), sexual orientation (1), no reason (4), and other (9). 13 of 22 (59%) left home or country as a result of their torture. 5 of 22 (22.7%) have physical disabilities, 6 of 22 (27.3%)
S48 Annals of Emergency Medicine
have recurrent intrusive or distressing memories, 6 of 22 (27.3%) have ever had a physician ask them about their torture and 3 have requested political asylum. Conclusion: Survivors of torture are a distinct cohort of patients presenting to our urban ED and are of diverse background. We found prevalence rates similar to previously reported studies. Patients self-report torture by many groups including abuse by family, governments, military, and police and for varied reasons including no reason at all. Further data collection will help determine significance and whether self-identification of torture is a significant predictor of torture as defined by international standards. Practitioners should consider asking patients about torture.
156
Large Increase in Emergency Department Visits for Head Trauma After Natasha Richardson’s Death
Campo C, Walsh B, Cochrane D, Allegra J/Morristown Memorial Hospital, Morristown, NJ
Study Objective: Actress Natasha Richardson died from a head injury on March 18, 2009. According to some reports, she initially appeared well after sustaining the injury. We hypothesize that the publicity surrounding this tragic event would be associated with an increase in emergency department (ED) visits for evaluation of head trauma. Methods: Design: Retrospective cohort. Setting: Consecutive patients seen by ED physicians in 19 urban, suburban and rural EDs in New Jersey and New York during March 2009. Protocol: We classified patients as having head injury based on ICD9 codes. A priori, we chose to compare the daily visits for head injury for the ten days before and after March 18. We used the Student’s t-test for statistical significance with alpha set at 0.05. Results: Of the 86,791 total ED visits in March, 2009, 2567 (3%) were for head trauma. Of these, females comprised 46%. The median age was 21 years (interquartile range: 7 years to 51 years). There was a 73% (95% confidence interval, 53% to 94%, p ⬍ 0.0001) increase in daily ED visits for head trauma for the 10 days following March 18, 2009 compared to the 10 days before. There was little difference in median age, interquartile age range and sex before and after March 18 for patients presenting to the ED with head injuries. The number of visits for head trauma returned to the pre-March 18 range by March 31. Conclusion: There was a large increase in ED visits for head trauma for a brief period following the death of Natasha Richardson. Media coverage can have a profound influence on ED visits.
157
Patient Perceived Alcohol and Substance Abuse Treatment Needs: An Urban Emergency Department Pilot Study
Scott S, Kassem JN, Nagurka R, Velasco W, Valenzuela R, Grant WD, Lamba S/ The University of Medicine and Dentistry of New Jersey, Newark, NJ; State University of New York Upstate Medical University-University Hospital, Syracuse, NY
Background: Substance abuse (SA) increases the risk of disease, injury, and disability, and this vulnerable population often seeks the emergency department (ED) for their routine health care needs. The ED may represent the only opportunity to connect these patients with adequate referrals to SA rehabilitation facilities. Study Objective: This study is a needs assessment to identify alcohol and SA treatment needs among our ED population with our purpose to further address the patient-perceived barriers. Methods: This pilot study is a convenience sample using a cross-sectional descriptive design to explore the prevalence of alcohol and SA. We used the selfreport survey methodology to assess demographics and patient-perceived barriers. Our study population consisted of consenting adult patients presenting to our urban hospital ED from September ‘08 –February ‘09. Data were analyzed using Microsoft SPSS. Results: We enrolled: 102 patients; 51 male and 51 female; 58% of the respondents were in the age range 30 –53; 57% (58/102) African-Americans; 20% (20/102) Hispanic; 58% (59/101) were high school educated; 72% (72/100) were health insured; 44% (45/101) did not have a primary care provider; 92% (94/102) sought treatment in the ED within the past 1 year; 31% (32/101) identified the ED as their sole health care provider. Sixty-three percent (64/102) of respondents reported depression and 66% (67/102) reported anxiety within the past month. Forty-seven percent (41/88) of respondents reported using drugs for non-medical reasons with 38% (9/24) perceiving a need for drug rehabilitation now. Half (12/24) of those perceiving a need for rehabilitation, used cocaine; 38% (9/24) used heroin;
Volume , . : September
151
Emergency Department Patient Acceptance of Rapid HIV Testing Practices, Revisited: The 2006 CDC Recommendations for Non-Targeted, Opt-Out HIV Screening
Prekker ME, Olives T, Hanley O, Miner JR/Hennepin County Medical Center, Minneapolis, MN
Study Objective: Patient acceptance of non-targeted, opt-out HIV screening in the emergency department (ED) is variable based on published reports. We sought to evaluate patient approval of Centers for Disease Control and Prevention (CDC)recommended HIV testing practices in an urban ED without rapid HIV testing currently available, apart from occupational exposures. Methods: Cross-sectional survey conducted in an urban, county hospital with 98,000 annual visits. The estimated prevalence of known HIV infection in the ED population is 1.8%. Trained research assistants administered a previously developed, standardized survey to all adult, non-critically ill, English-speaking patients who presented to the ED during randomized shifts over a three-month period. Results: Of the 2197 enrolled patients, 53% were men, 41% were black, 37% were white, 7% were Native American, 6% were Hispanic, 9% were another ethnicity, and the median age was 39 years (interquartile range 27–50 years). A larger proportion of patients would accept testing if an opt-out methodology were used (78%, 95% confidence interval [CI] 76% to 80%) versus an opt-in methodology (73%, 95% CI 72% to 75%) (absolute difference 5%, 95% CI 4 to 6%). If their physician recommended an HIV test during the ED visit, 87% (95% CI 86 – 89%) would accept testing. A minority of patients believed that consent for HIV testing needed to be separate from general consent for medical care (37%, 95% CI 35% to 39%). Regarding counseling, 65% (95% CI 63% to 67%) of patients did not feel pretest counseling was necessary, while 60% (95% CI 58% to 62%) of patients did not feel post-test counseling was necessary after a negative result. Conclusion: The majority of ED patients in an institution naı¨ve to HIV screening would accept an HIV test regardless of selection strategy or criteria. This finding supports continued efforts to expand non-targeted, opt-out HIV screening in the ED, in accordance with current CDC recommendations.
152
Epidemiology of Advance Directives in Extended Care Facility Patients Presenting to the Emergency Department
Wall JJ, Hiestand BC/The Ohio State University, Columbus, OH
Study Objectives: In the emergency department (ED), the documented existence of an advance directive (AD) or Do-Not-Resuscitate (DNR) order may affect initial treatment decisions, even in non-life threatening situations. We performed an epidemiologic evaluation of AD and DNR prevalence among residents of extended care facilities (ECF) presenting to the ED of a large university hospital. Methods: We retrospectively identified patients originating from an ECF from the ED medical record. Data was collected from the hospital electronic medical record on age, sex, race (white vs. non-white), triage acuity, ED disposition, and AD status. In Ohio, AD consist of DNR-CC (comfort measures only), DNRCC-Arrest
Volume , . : September
(complete care up to arrest), living wills (LW) and health care power of attorney (POA). Descriptive statistics were generated, Fisher’s exact test was used to compare categorical variables, and multiple variable logistic regression was used to evaluate predictors of DNR status. Results: A total of 238 patients were identified over 4 months. 170 (71%) were white, 107 (45%) were male, and the mean age was 64 ⫹/⫺ 16.3 years, with 163 (68%) admitted. Of the 238 patients, 44 (18.5%, CI95 13.5–23.4%) had DNR orders, of which 15 were DNR-CC. In addition, 94 (39.5%, CI95 33.2– 45.8%) had a POA, and 60 (25.2%, CI95 19.7–30.8%) had LW. There was a significant difference in AD by race (51% whites with AD vs. 37% non-whites, p⫽0.046) and DNR by race (24% of whites with DNR vs. 6% of non-whites, p⬍0.001). Using multiple variable logistic regression, the variables significant in predicting DNR status (both CC and CC-Arrest) were LW (OR 11.54, CI95 5.03–26.46, p⬍0.0005), age (OR 1.061 per year increase in age, CI95 1.03–1.10, p⬍0.0005) and white race (OR 3.83, CI95 1.16 –12.65, p⬍0.028). Sex was not found to be a significant predictor (p⫽0.18) of DNR use. There were no interaction terms that affected the model. Patients with DNR orders were more likely to be transported by EMS than private ambulance (p⫽0.032), although though there was no relationship between DNR status and initial triage acuity (p⫽0.527) or admission rate (34/44 [77%, CI95 64 – 90%] DNR vs. 129/194 [66%, CI95 60 –73%] p⫽0.21). We also found that DNR status was not a significant predictor of death in the hospital (3/44 DNR [6.8%, CI95 0 –15%] vs. 41/194 non-DNR [4.1%, CI95 1.3– 6.9%] p⫽0.43). Conclusion: Age and LW use are strong predictors of ECF patient DNR use. Non-white race greatly decreases the odds of DNR use; whether this represents a preference or a lack access to full patient education cannot be determined from this retrospective study. AD provide the ability to decide care prior to incapacitation and are an invaluable tool in respecting patient decisions. ED clinicians should be alert for opportunities to discuss end-of-life care preferences in appropriate patients.
153
Do Attitudes About Homosexuality Affect Emergency Medicine Practice? Results of a Survey
Shearer P/Mount Sinai School of Medicine, New York, NY
Study Objectives: The diversity of patients in the emergency department provides unexpected rewards and challenges. There are no studies in the emergency medicine literature that address emergency physicians attitudes towards homosexuals. The purpose of this study was to evaluate emergency physicians beliefs about homosexuality and whether such beliefs impact patient care. Methods: An anonymous, self-administered survey was competed by emergency physicians, physicians assistants (PAs) and nurse practitioners (NPs) attending the 2003 ACEP Scientific Assembly. Data were analyzed using a chi-square analysis; a pvalue ⱕ 0.05 indicated statistical significance. Results: 608 surveys were completed; 379 (63%) attending physicians; 169 (28%) residents/fellows; 54 (9%) PA or NP; 44 (73%) were male; respondents came from all regions of the United States. 15.5% of emergency physicians agreed with the statement “homosexuality is immoral.” More respondents from the Southeast agreed with that statement (p⫽.02) than from other areas of the country. 76.7% of the respondents reported having co-workers who are gay, lesbian, bisexual or transgender (GLBT). Significantly more emergency physicians with a known GLBT co-worker disagreed that “homosexuality is immoral” (73.9%) compared to those without a GLBT co-worker (57.3%) (absolute difference 16.6; 95%CI [4.9, 28.3]). Emergency physicians who believe that homosexuality is immoral were more likely to be uncomfortable giving post-exposure prophylaxis to males after unprotected same-sex intercourse (26.9%) than emergency physicians who do not believe that homosexuality is immoral (14.2%) (absolute difference 12.6; 95%CI [2.4, 22.9]). Conclusion: Emergency physicians attitudes and acceptance of homosexuality differ geographically. Positive attitudes towards homosexuality are reported by emergency physicians with GLBT co-workers. Negative attitudes towards homosexuality affect some aspects of the care received by GLBT patients in the ED.
154
Impact of Care Management on the Highest Utilizers of Camden NJ’s Emergency Departments
Sciorra D, Brenner J, Gill J, Linden A, Mazzarelli A/University of Medicine and Dentistry of New Jersey, Camden, NJ; Cooper University Hospital, Camden, NJ; Delaware Valley Outcomes Research, Newark, DE; Linden Consulting Group, Hillsboro, OR
Study Objectives: The highest utilizers of emergency department (ED) services typically have complex medical conditions compounded by an array of social issues.
Annals of Emergency Medicine S47
Research Forum Abstracts Programs that improve the outpatient management of these complicated patients are likely to reduce ED utilization. The objective of this study was to examine the effect of a citywide care management (CM) project on the subsequent ED utilization of enrolled high utilizers. Methods: We conducted a retrospective cohort study of 33 patients who met the CM project enrollment criteria of Camden City residency with five or more ED visits during a one-year period of time. Enrolled high-utilizing patients were provided with targeted care management to help them towards stabilizing their social environment and finding an appropriate medical home. CM patients were recruited from 11/1/ 2007– 4/30/2008 and followed until 6/30/2008. These patients were then retrospectively matched into a citywide database of all Camden City hospital visits to determine both utilization rates before and after project enrollment. Based on each individual CM patient’s age, sex, and baseline utilization, three matched control patients were selected from the database to form a comparison group of 99 patients. Time to event analysis was performed using multivariable Cox regression. Insurance status, a history of substance abuse, and homelessness were explored as potential confounders. The event of interest was defined as a subsequent ED visit and censoring took place in the event of death, loss to follow-up, and at study completion on 6/30/2008. Results: Fourteen patients in the CM group (42.4%) and 60 patients in the matched control group (60.6%) experienced a subsequent ED visit. Through multivariable Cox regression, having a history of substance abuse was associated with a 60% increased risk of a returning ED visit (hazard ratio 1.60 [CI, 1.01 to 2.55]). After adjustment for a history of substance abuse, CM project enrollment was associated with a 69% reduced risk of subsequent ED utilization (hazard ratio 0.31 [CI, 0.15 to 0.62]). Conclusion: In the early evaluation of this intervention, participation in the CM project was associated with a significantly lower risk of experiencing a subsequent ED visit. This suggests that providing primary medical care and social support, over a relatively short period of time, is effective in decreasing ED visits for high utilizers.
155
Preliminary Results of the Survivors of Torture Presenting to an Urban Emergency Department Prevalence Study
Hexom B, Beattie L/Mount Sinai School of Medicine, New York, NY
Study Objectives: It has been reported that 8 –11% of patients presenting to urban primary care clinics have experienced torture. Given potential barriers to health care access, we hypothesize that emergency departments (EDs) may see higher rates of survivors of torture. As our medical center is located in the most ethnically diverse county in the United States, with the highest portion of foreign-born New York City residents, we sought to determine the prevalence of survivors of torture presenting to our urban ED. Methods: A previously validated survey instrument regarding exposure to torture - the Detection of Torture Survivors Survey - was administered by convenience sample to patients presenting to a New York City ED. Additional questions were asked to determine whether individuals’ experiences met internationally accepted definitions of torture. Surveys were verbally administered to patients regardless of ethnicity or complaint and language interpretation was provided if needed. Prisoners, children under 18 years, critically ill, demented, or disoriented patients were excluded. Results: Preliminary results of the first 185 surveys are presented here and enrollment is ongoing. Mean age was 49.21, 48.6% were female, and 79.5% foreign born. 41 countries of origin were represented; most frequently the United States (n⫽38), Columbia (23), Dominican Republic (18), Mexico (12), Bangladesh (11), and Ecuador (11). Mean duration of residence in the United States for foreign-born patients was 19 years. 9.2% of respondents (17) stated that they had been harmed by groups such as the government, police, military, or rebel soldiers. 10.8% (20) stated they or their family had experienced torture (10 self, 5 family, 5 both). 23 were further asked about their experiences including torture by military (7), police (6), family (5), rebel soldiers (3), individuals (1), or groups of individuals (1). 73.9% (17) of these suffered physical harm, 47.8% (11) emotional harm, 8.7% (2) sexual harm, and 21.7% (5) other. Countries of origin for those reporting torture include the U.S. (7), Columbia (5), Dominican Republic (4), and 1 each for Bangladesh, El Salvador, Honduras, Morocco, Nepal, and Tanzania. Reasons for torture included ethnicity/ tribal affiliation (4), political affiliation (3), religion (2), local customs (2), sexual orientation (1), no reason (4), and other (9). 13 of 22 (59%) left home or country as a result of their torture. 5 of 22 (22.7%) have physical disabilities, 6 of 22 (27.3%)
S48 Annals of Emergency Medicine
have recurrent intrusive or distressing memories, 6 of 22 (27.3%) have ever had a physician ask them about their torture and 3 have requested political asylum. Conclusion: Survivors of torture are a distinct cohort of patients presenting to our urban ED and are of diverse background. We found prevalence rates similar to previously reported studies. Patients self-report torture by many groups including abuse by family, governments, military, and police and for varied reasons including no reason at all. Further data collection will help determine significance and whether self-identification of torture is a significant predictor of torture as defined by international standards. Practitioners should consider asking patients about torture.
156
Large Increase in Emergency Department Visits for Head Trauma After Natasha Richardson’s Death
Campo C, Walsh B, Cochrane D, Allegra J/Morristown Memorial Hospital, Morristown, NJ
Study Objective: Actress Natasha Richardson died from a head injury on March 18, 2009. According to some reports, she initially appeared well after sustaining the injury. We hypothesize that the publicity surrounding this tragic event would be associated with an increase in emergency department (ED) visits for evaluation of head trauma. Methods: Design: Retrospective cohort. Setting: Consecutive patients seen by ED physicians in 19 urban, suburban and rural EDs in New Jersey and New York during March 2009. Protocol: We classified patients as having head injury based on ICD9 codes. A priori, we chose to compare the daily visits for head injury for the ten days before and after March 18. We used the Student’s t-test for statistical significance with alpha set at 0.05. Results: Of the 86,791 total ED visits in March, 2009, 2567 (3%) were for head trauma. Of these, females comprised 46%. The median age was 21 years (interquartile range: 7 years to 51 years). There was a 73% (95% confidence interval, 53% to 94%, p ⬍ 0.0001) increase in daily ED visits for head trauma for the 10 days following March 18, 2009 compared to the 10 days before. There was little difference in median age, interquartile age range and sex before and after March 18 for patients presenting to the ED with head injuries. The number of visits for head trauma returned to the pre-March 18 range by March 31. Conclusion: There was a large increase in ED visits for head trauma for a brief period following the death of Natasha Richardson. Media coverage can have a profound influence on ED visits.
157
Patient Perceived Alcohol and Substance Abuse Treatment Needs: An Urban Emergency Department Pilot Study
Scott S, Kassem JN, Nagurka R, Velasco W, Valenzuela R, Grant WD, Lamba S/ The University of Medicine and Dentistry of New Jersey, Newark, NJ; State University of New York Upstate Medical University-University Hospital, Syracuse, NY
Background: Substance abuse (SA) increases the risk of disease, injury, and disability, and this vulnerable population often seeks the emergency department (ED) for their routine health care needs. The ED may represent the only opportunity to connect these patients with adequate referrals to SA rehabilitation facilities. Study Objective: This study is a needs assessment to identify alcohol and SA treatment needs among our ED population with our purpose to further address the patient-perceived barriers. Methods: This pilot study is a convenience sample using a cross-sectional descriptive design to explore the prevalence of alcohol and SA. We used the selfreport survey methodology to assess demographics and patient-perceived barriers. Our study population consisted of consenting adult patients presenting to our urban hospital ED from September ‘08 –February ‘09. Data were analyzed using Microsoft SPSS. Results: We enrolled: 102 patients; 51 male and 51 female; 58% of the respondents were in the age range 30 –53; 57% (58/102) African-Americans; 20% (20/102) Hispanic; 58% (59/101) were high school educated; 72% (72/100) were health insured; 44% (45/101) did not have a primary care provider; 92% (94/102) sought treatment in the ED within the past 1 year; 31% (32/101) identified the ED as their sole health care provider. Sixty-three percent (64/102) of respondents reported depression and 66% (67/102) reported anxiety within the past month. Forty-seven percent (41/88) of respondents reported using drugs for non-medical reasons with 38% (9/24) perceiving a need for drug rehabilitation now. Half (12/24) of those perceiving a need for rehabilitation, used cocaine; 38% (9/24) used heroin;
Volume , . : September