- Email: [email protected]
Revisits of forensic cases to the emergency department
Journal of Forensic and Legal Medicine 65 (2019) 81–85
Contents lists available at ScienceDirect
Journal of Forensic and Legal Medicine journal homepage: www.elsevier.com/locate/yjflm
Research Paper
Revisits of forensic cases to the emergency department
T
Mehmet Ali Aslaner Nevsehir State Hospital, Emergency Department, Ragıp Üner Neighborhood, Nevsehir, Turkey
A R T I C LE I N FO
A B S T R A C T
Keywords: Forensic medicine Emergency medicine Demographics
Objective: The data of forensic cases who revisited to the emergency department (ED) more than once, remain uncertain. In this study, it was aimed that to determine characteristics of these cases and to investigate factors associated with forensic revisits. Methods: All forensic cases who presented to emergency department of a secondary care hospital in Turkey were evaluated between July 2017 and June 2018, retrospectively. During a year study period, 7580 visits were performed by 5870 forensic cases in the ED. Characteristics of cases which were gender, age, injury patterns, number of revisits, outcomes, and total cost were noted. Factors associated with forensic revisits were identified by multivariate logistic regression analysis. Results: During a year study period, 985 forensic cases had multiple ED visits (a total of 2692). Median revisit number was 2 (IQR 2–3). In logistic regression analysis, male gender (Odds ratio [OR], 1.76; 95% confidence interval [CI]: 1.47–2.10), physical assault (OR, 2.70; 95% CI: 1.40–5.20), and fall (OR, 0.21; 95% CI: 0.07–0.64) were associated with forensic revisits. Revisited group had lower hospitalization rate and hospital cost than those of non-revisited group (2.6% and 7.4%; 15.5 TL (interquartile range [IQR] 15.5-15.5) and 15.5 TL (IQR 15.5-107.8), respectively) (χ2; P < .001). Conclusion: One-sixth of all forensic cases revisited to the ED multiple times. Physical assault and male gender were the most important factors associated with forensic revisits in this study. Further, these revisits were often composed of simple reasons requiring less hospitalization and less cost.
1. Introduction
In addition, it was aimed to determine which parameters are related with these revisits.
Any event that causes the deterioration health, injury or death of a person as a result of his/her or others’ intent, negligence, imprudence and carelessness, is defined as a forensic (medico-legal) case. These medico-legal cases consist of injuries with firearms and sharp tools, falls, burns, electric and lightning strikes, sexual assaults, all kinds of suicide attempts, torture claims, all deaths originating from accidents and suspicious events, sudden and unexpected deaths.1,2 Forensic cases (except road traffic and occupational accidents) constitute 1–3% of all emergency department (ED) visits in Turkey.3–5 In addition, ED visits due to forensic reasons have been shown to increase over the years. From 2000 to 2005, it was reported that these visits has increased more than two-fold in a study that conducted by academic ED professionals.6 Nevertheless, data of revisits of these cases is not clear in the literature. These revisits may cause difficulties in the intensity and work flow of busy EDs, and may cause physicians to deal with more legal procedures. Further, it is not known which factors are associated with forensic revisits in the ED. The aim of this study was to find out demographics, outcomes and cost analysis of forensic revisits to the ED of a secondary care hospital.
2. Methods 2.1. Study design and settings All forensic cases who presented to emergency department of Nevşehir State Hospital in Turkey were evaluated retrospectively between July 2017 and June 2018. This hospital is the largest facility in the city and ED visits were 223.600 for one year in the study period. Data of cases were obtained from hospital medical records. All age groups were included in the study. Characteristics of cases which were gender, age, injury patterns, number of revisits, outcomes, and total cost were noted. Turkish lira (TL) used as a currency in cost analysis. Others than Turkish citizens were excluded from the study because of missing data entries. Ethical committee approval was obtained for the study.
E-mail address: [email protected]. https://doi.org/10.1016/j.jflm.2019.05.007 Received 6 September 2018; Received in revised form 20 November 2018; Accepted 12 May 2019 Available online 14 May 2019 1752-928X/ © 2019 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
Journal of Forensic and Legal Medicine 65 (2019) 81–85
M.A. Aslaner
Fig. 1. The first presentation types of all forensic cases in the ED.
Fig. 2. The number of revisits of forensic cases who had multiple presentation to the ED.
these injuries weren't included in forensic cases in this paper to use a common language among international studies.
2.2. Definitions Revisit group defined as forensic cases had multiple presentation to the ED during study period. Non-revisit group defined as cases presented only once in this period. These cases also were analyzed as age groups; 0–14 years, 15–24 years, 25–45, and 46 years and over. Forensic cases were consisted of poisoning, suicide attempt, fall, gunshot wound, physical assault, stab-cut injury, electrical-burn injury, sexual assault, and others. Road traffic accidents and occupational accidents are also considered as forensic cases in Turkey, but these injuries are not classed as forensic cases in Western countries. Therefore,
2.3. Data analysis Statistical analyses were performed using IBM SPSS statistical package for Windows, version 21 (Armonk, NY: IBM Corp.) and MedCalc® Version 15.8 (MedCalc Software bvba, Ostend, Belgium). Continuous variables were presented as median values and interquartile ranges (IQRs). Categorical variables were summarized as frequencies and percentages. Normality of the continuous variables was evaluated 82
Journal of Forensic and Legal Medicine 65 (2019) 81–85
M.A. Aslaner
Fig. 3. The first presentation of revisited group to the ED.
Fig. 4. All presentations of revisited group to the ED.
variable was tested in the univariate model, and those comparisons that have a loose p value of less than 0.1 were then tested in the multivariate model.
using the Kolmogorow Smirnow test. The differences between 2 groups according to continuous variables were determined by the MannWhitney U test. Categorical variables were compared using the Pearson χ2 or Fisher exact test. Odds ratios (ORs) were presented with 95% confidence intervals (95% CI). A critical α value of 0.05 was accepted as statistically significant. A binary logistic regression model was constructed to define factors predicting forensic revisits. The univariate model considered demographic data that included age, gender, type of injuries (physical assault, stab-cut injury, fall, poisoning, suicide attempt, electrical-burn injury, gunshot wound, sexual assault, and other forensic reasons). Each
3. Results During a year study period, 7580 visits were performed by 5870 forensic cases in the ED. These forensic visits constituted 2.6% of all ED presentations. Median age of these cases was 29 (IQR 21–40 [range 095]) and the rate of male was 71.1%. Physical assault was responsible for the first visits about 72.7% (n = 4270) in all cases, stab-cut injury 83
Journal of Forensic and Legal Medicine 65 (2019) 81–85
M.A. Aslaner
Table 1 Univariate analysis of revisited and non-revisited groups.
Age (y), median (IQR) Gender male, n (%) The type of injuriesa, n (%) Physical assault Stab-Cut Injury Fall Poisoning Suicide attempt Electrical-Burn injury Gunshot wound Sexual Assault Others Outcomes (hospitalization), n (%) Cost (TL), median (IQR)
• • • • • • • • •
a
Total n = 5870
Revisited cases n = 985
Non-revisited cases n = 4885
P
29 (21–40) 4172 (71.1%)
29 (23–38) 810 (82.2%)
30 (20–41) 3362 (68.8%)
0,497 < .001
4270 (72.7%) 303 (5.2%) 250 (4.3%) 248 (4.2%) 205 (3.5%) 54 (0.9%) 44 (0.7%) 20 (0.3%) 476 (8.1%) 386 (6.6%) 15.5 (15.5–98)
890 (90.4%) 32 (3.2%) 5 (0.5%) 14 (1.4%) 14 (1.4%) 3 (0.3%) 4 (0.4%) 3 (0.3%) 20 (2.0%) 26 (2.6%) 15.5 (15.5–15.5)
3380 (69.2%) 271 (5.5%) 245 (5.0%) 234 (4.8%) 191 (3.9%) 51 (1.0%) 40 (0.8%) 17 (0.3%) 456 (9.3%) 360 (7.4%) 15.5 (15.5–107.8)
< .001 .003 < .001 < .001 < .001 .027 .171 1.000 < .001 < .001 < .001
First visit of both revisited and non-revisited groups.
in Turkey. One of the most important problems in this regard is that emergency physicians are afraid or hesitant to face medico legal problems. The reason for this, although emergency physicians are well prepared to manage the acute medical issues of these cases, they often do not receive formal residency training in clinical forensic medicine.7 Eroğlu et al. showed that there is no standard approach for legal cases in the EDs in their country where the current study was also carried out. Further, forensic reports written by emergency physicians are usually affected by situations such as self-protection, prejudice or individual rules.8 Yemenici et al. showed that one or more deficiencies were detected in all forensic reports written by emergency physicians. Some of these deficiencies and errors can cause serious accusations such as "disregard for judicial accountability" and "false expertise".9 Many other authors believe that more attention should be given to this subject during or after emergency medicine residency training3,8–11. Beside these situations, revisit of these cases is another important topic that may lead to an increase in emergency service intensity and legal procedures. Frequency of forensic visits (except road traffic and occupational accidents) can be vary (1–3%) among EDs in Turkey due to different work flow, intensity, and whether it is an academic department or not. In this study, it was found that 2.6% of all ED visits was forensic type in accordance with the literature. Average age of forensic cases was between 24 and 32 years in the studies.5,10 Median age of forensic cases was 29 in current study. Many studies reported that forensic cases were often male gender (66–74%).3,12 The rate of male gender was 71.1% in this study similarly to the other ones. Brennan et al. showed that 21.5% of all violence-related injuries (excluding firearms) were inflicted with a sharp or blunt object and 78.5% were inflicted with body part (fist, feet and others) in an ED in United Kingdom.13 The rates of physical assault range from 14% to 43% among forensic cases (except road traffic and occupational accidents) in the studies in Turkey.3,5,6 This rate was over 70% of all forensic cases in this study unlike other studies conducted in this country.
Table 2 Multivariate logistic analysis of factors associated with forensic revisits. Variables
OR
95% CI
P
Gender, male Physical assault Fall
1.760 2.707 0.217
1.472–2.105 1.408–5.205 0.072–0.649
< 0.001 0.003 0.006
CI: confidence interval; OR: odds ratio.
was 5.2% (n = 303), and fall was 4.3% (n = 250) (Fig. 1). Median cost per forensic case was 15.5 (IQR 15.5-98) TL. Of all cases, 6.6% was hospitalized for further treatment. 3.1. Revisits of forensic cases In the study period, 985 forensic cases (revisited group) had multiple ED visits (a total of 2692). Median revisit number was 2 (IQR 2–3 [range 2–19]) (Fig. 2). Median age of revisited group was 29 (IQR 23–38 [range 0-81]) and the rate of male was 82.2%. As age groups, the rate of 0-14 years was 2% (n = 20), 15–24 years was 30.8% (n = 303), 25–45 years was 57.6% (n = 567), and 46 years and over was 9.6% (n = 95). The most common reason for the first visit (n = 985) in these cases was physical assault as 90.4%, stab-cut injury was 3.2%, and suicide attempt was 1.4% (Fig. 3). Among all visits of revisited group (n = 2692), the most common reason was physical assault as 91.4%, stab-cut injury was 1.9%, and suicide attempt was 1.8% (Fig. 4). Median cost per revisited forensic case was 15.5 (IQR 15.5–15.5) TL. Median age wasn't different statistically between revisited and nonrevisited group (Table 1). The rate of male gender was significantly higher in revisited group than that of other group (82.2% and 68.8%, respectively) (χ2; P < .001). Physical assault as a type of injury was more common in the revisited group than that of non-revisited group (90.4% and 69.2%, respectively) (χ2; P < .001). Revisited group had lower hospitalization rate and hospital cost than those of other group (2.6% and 7.4%; 15.5 TL (IQR 15.5-15.5) and 15.5 TL (IQR 15.5107.8), respectively) (χ2; P < .001). Table 2 summarizes the results of logistic regression for factors associated with forensic revisits (Hosmer and Lemeshow test, p = .887). After entering all the variables with p value < .1 in Table 1; male gender (OR, 1.76; 95% CI: 1.47–2.10), physical assault (OR, 2.70; 95% CI: 1.40–5.20), and fall (OR, 0.21; 95% CI: 0.07–0.64) were associated with forensic revisits.
4.1. Revisits of forensic cases While there is a sufficient amount of study regarding forensic cases in the ED, the data on revisits of these cases are insufficient both in our country database and in the literature. England and Wales government statistics indicated that 26% of victims were victimized by a person two or more times between 2004 and 2005.14 Oner et al. showed that 8% (453/5675) of pediatric forensic cases had multiple revisits in the ED in 2016 in Turkey. However, authors didn't state that how many revisits existed or which type of injuries was the most in the revisited group in their study.15 In this study, 16.8% (985/5870) of all cases had revisits more than once between July 2017 and June 2018. The median number
4. Discussion Although forensic cases are a matter of concern to many ED physicians, these cases constitute a significant part of the ED presentations 84
Journal of Forensic and Legal Medicine 65 (2019) 81–85
M.A. Aslaner
References
of revisits was 2 and the range of number was between 2 and 19. To the author's best knowledge, there is no other study on this subject. In this study, male gender constituted of majority of cases as 82.2% and the most common injury pattern was physical assault (90.4%) at the first visit of revisited group. In comparison, these rates were lower in the non-revisited group (68.8% and 69.2%, respectively). The findings of the logistic regression analysis in the study also clarified that physical assault and male gender were associated with forensic revisits. According to Centers for Disease Control and Prevention report in United States, the physical assault rate was approximately 77% higher for males than for females.16 However, data don't include all other forensic reasons and recurrent cases. Several studies reported different hospitalization rates from 2.5% to 26% for forensic cases.12,17 While, hospitalization rate was 7.4% in nonrevisited group in the current study, it was 2.6% in revisited group. In addition, hospital cost of revisit group was lower than that of non-revisited group. One of the limitations of the present study is that the study was conducted in a single center. Therefore, outcomes of the study are not generalized for now and there is need for other studies. Another limitation is that there could be missing case records and data loss due to retrospective study design.
1. Duramaz BB, Yıldırım HM, Kıhtır HS, Yeşilbaş O, Şevketoğlu E. Evaluation of forensic cases admitted to pediatric intensive care unit. Turk Arch Pediatr/Türk Pediatri Arşivi. 2015;50(3):145–150. 2. Tuğcu H, Toygar M, Can Ö, Safalı M. The responsibility of physician to prepare a forensic and medical report. TAF Prev Med Bull. 2006;5(6):466–475. 3. Korkmaz T, Kahramansoy N, Erkol Z, Sariçil F, Kilic A. Evaluation of the forensic patients presenting to the emergency department and legal reports. Med Bull Haseki. 2012;50:14–20. 4. Türkçüer İ, Gözlükaya A, Serinken M, Özen M, Aydın B. Application times of forensic cases to emergency department. Akademik Acil Tıp Dergisi. 2010;2:89–92. 5. Küçük E, Günel C. Demographic characteristics of forensic investigation in emergency service. Sakarya Med J. 2016;6(2):100–105. 6. Demircan A, Keleş A, Gurbuz N, et al. Forensic emergency medicine - six year experience of 13823 cases in a university emergency department. Turk J Med Sci. 2008;38:567–575. 7. Wiler JL, Bailey H, Madsen TE. The need for emergency medicine resident training in forensic medicine. Ann Emerg Med. 2007;50(6):733–738. 8. Eroğlu SE, Toprak SN, Karataş AD, et al. What is the meaning of “temporary” forensic reports for Emergency physicians? Self protection? Bias? Habit? Turk J Emerg Med. 2013;13(1):013–018. 9. Yemenici S, Sayhan MB, Salt Ö, Yılmaz A. Evaluation of medicolegal reports prepared in emergency department. J Harran Univ Med Fac. 2017;14(3):179–186. 10. Bozkurt S, Daraoğlu V, Okumuş M, Savrun A, Karanfil R, Gök AA. Evaluation of judicial reports which executing on emergency service and fixed deficiencies. J Clin Anal Med. 2015;6(3):331–334. 11. Aslaner MA, Eroğlu SE, Batur A, Arslan V. Emergency medicine physicians' perspectives on subspecialty training: a national survey. Turk J Emerg Med. 2018;18(3):119–122. 12. Levent S, Pamukçu Günaydın G, Şahin Kavaklı H, Kurtoğlu Çelik G, Coşkun S. A retrospective seasonal analysis of all forensic cases that presented to an emergency department in a year. J Med. 2015;29(1):22–28. 13. Brennan IR, Moore SC, Shepherd JP. Non-firearm weapon use and injury severity: priorities for prevention. Inj Prev. 2006;12(6):395–399. 14. Nicholas S, Povey D, Walker A, Kershaw C. Crime in England and Wales 2004/2005. Home Office Statistical Bulletin; 2005. 15. Oner S, Harmanogulları LU, Yapici G, Ozel S. Evaluation of forensic cases admitted to the pediatric emergency service of a hospital. Eur J Pharmaceut Med Res. 2017;4(8):90–95. 16. Nonfatal physical assault-related injuries treated in hospital emergency departments–United States, 2000. MMWR Morb Mortal Wkly Rep. 2002;51(21):460–463. 17. Seviner M, Kozacı N, Ay MO, et al. Analysis of judicial cases at emergency department. Cukurova Med J. 2013;38(2):250–260.
5. Conclusion One-sixth of all forensic cases revisited to the ED multiple times. Male gender and, especially, physical assault as a presentation type were associated with forensic revisits to the ED. Hospitalization and hospital cost were lower in the revisited group. Finally it can be said that with this findings, revisits regarding forensic cases to the EDs are frequently seen in male gender due to simple physical assault. Conflicts of interest M.A., reports no conflicts of interest. Financial disclosure * No financial disclosure is declared by the author.
85
Contents lists available at ScienceDirect
Journal of Forensic and Legal Medicine journal homepage: www.elsevier.com/locate/yjflm
Research Paper
Revisits of forensic cases to the emergency department
T
Mehmet Ali Aslaner Nevsehir State Hospital, Emergency Department, Ragıp Üner Neighborhood, Nevsehir, Turkey
A R T I C LE I N FO
A B S T R A C T
Keywords: Forensic medicine Emergency medicine Demographics
Objective: The data of forensic cases who revisited to the emergency department (ED) more than once, remain uncertain. In this study, it was aimed that to determine characteristics of these cases and to investigate factors associated with forensic revisits. Methods: All forensic cases who presented to emergency department of a secondary care hospital in Turkey were evaluated between July 2017 and June 2018, retrospectively. During a year study period, 7580 visits were performed by 5870 forensic cases in the ED. Characteristics of cases which were gender, age, injury patterns, number of revisits, outcomes, and total cost were noted. Factors associated with forensic revisits were identified by multivariate logistic regression analysis. Results: During a year study period, 985 forensic cases had multiple ED visits (a total of 2692). Median revisit number was 2 (IQR 2–3). In logistic regression analysis, male gender (Odds ratio [OR], 1.76; 95% confidence interval [CI]: 1.47–2.10), physical assault (OR, 2.70; 95% CI: 1.40–5.20), and fall (OR, 0.21; 95% CI: 0.07–0.64) were associated with forensic revisits. Revisited group had lower hospitalization rate and hospital cost than those of non-revisited group (2.6% and 7.4%; 15.5 TL (interquartile range [IQR] 15.5-15.5) and 15.5 TL (IQR 15.5-107.8), respectively) (χ2; P < .001). Conclusion: One-sixth of all forensic cases revisited to the ED multiple times. Physical assault and male gender were the most important factors associated with forensic revisits in this study. Further, these revisits were often composed of simple reasons requiring less hospitalization and less cost.
1. Introduction
In addition, it was aimed to determine which parameters are related with these revisits.
Any event that causes the deterioration health, injury or death of a person as a result of his/her or others’ intent, negligence, imprudence and carelessness, is defined as a forensic (medico-legal) case. These medico-legal cases consist of injuries with firearms and sharp tools, falls, burns, electric and lightning strikes, sexual assaults, all kinds of suicide attempts, torture claims, all deaths originating from accidents and suspicious events, sudden and unexpected deaths.1,2 Forensic cases (except road traffic and occupational accidents) constitute 1–3% of all emergency department (ED) visits in Turkey.3–5 In addition, ED visits due to forensic reasons have been shown to increase over the years. From 2000 to 2005, it was reported that these visits has increased more than two-fold in a study that conducted by academic ED professionals.6 Nevertheless, data of revisits of these cases is not clear in the literature. These revisits may cause difficulties in the intensity and work flow of busy EDs, and may cause physicians to deal with more legal procedures. Further, it is not known which factors are associated with forensic revisits in the ED. The aim of this study was to find out demographics, outcomes and cost analysis of forensic revisits to the ED of a secondary care hospital.
2. Methods 2.1. Study design and settings All forensic cases who presented to emergency department of Nevşehir State Hospital in Turkey were evaluated retrospectively between July 2017 and June 2018. This hospital is the largest facility in the city and ED visits were 223.600 for one year in the study period. Data of cases were obtained from hospital medical records. All age groups were included in the study. Characteristics of cases which were gender, age, injury patterns, number of revisits, outcomes, and total cost were noted. Turkish lira (TL) used as a currency in cost analysis. Others than Turkish citizens were excluded from the study because of missing data entries. Ethical committee approval was obtained for the study.
E-mail address: [email protected]. https://doi.org/10.1016/j.jflm.2019.05.007 Received 6 September 2018; Received in revised form 20 November 2018; Accepted 12 May 2019 Available online 14 May 2019 1752-928X/ © 2019 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
Journal of Forensic and Legal Medicine 65 (2019) 81–85
M.A. Aslaner
Fig. 1. The first presentation types of all forensic cases in the ED.
Fig. 2. The number of revisits of forensic cases who had multiple presentation to the ED.
these injuries weren't included in forensic cases in this paper to use a common language among international studies.
2.2. Definitions Revisit group defined as forensic cases had multiple presentation to the ED during study period. Non-revisit group defined as cases presented only once in this period. These cases also were analyzed as age groups; 0–14 years, 15–24 years, 25–45, and 46 years and over. Forensic cases were consisted of poisoning, suicide attempt, fall, gunshot wound, physical assault, stab-cut injury, electrical-burn injury, sexual assault, and others. Road traffic accidents and occupational accidents are also considered as forensic cases in Turkey, but these injuries are not classed as forensic cases in Western countries. Therefore,
2.3. Data analysis Statistical analyses were performed using IBM SPSS statistical package for Windows, version 21 (Armonk, NY: IBM Corp.) and MedCalc® Version 15.8 (MedCalc Software bvba, Ostend, Belgium). Continuous variables were presented as median values and interquartile ranges (IQRs). Categorical variables were summarized as frequencies and percentages. Normality of the continuous variables was evaluated 82
Journal of Forensic and Legal Medicine 65 (2019) 81–85
M.A. Aslaner
Fig. 3. The first presentation of revisited group to the ED.
Fig. 4. All presentations of revisited group to the ED.
variable was tested in the univariate model, and those comparisons that have a loose p value of less than 0.1 were then tested in the multivariate model.
using the Kolmogorow Smirnow test. The differences between 2 groups according to continuous variables were determined by the MannWhitney U test. Categorical variables were compared using the Pearson χ2 or Fisher exact test. Odds ratios (ORs) were presented with 95% confidence intervals (95% CI). A critical α value of 0.05 was accepted as statistically significant. A binary logistic regression model was constructed to define factors predicting forensic revisits. The univariate model considered demographic data that included age, gender, type of injuries (physical assault, stab-cut injury, fall, poisoning, suicide attempt, electrical-burn injury, gunshot wound, sexual assault, and other forensic reasons). Each
3. Results During a year study period, 7580 visits were performed by 5870 forensic cases in the ED. These forensic visits constituted 2.6% of all ED presentations. Median age of these cases was 29 (IQR 21–40 [range 095]) and the rate of male was 71.1%. Physical assault was responsible for the first visits about 72.7% (n = 4270) in all cases, stab-cut injury 83
Journal of Forensic and Legal Medicine 65 (2019) 81–85
M.A. Aslaner
Table 1 Univariate analysis of revisited and non-revisited groups.
Age (y), median (IQR) Gender male, n (%) The type of injuriesa, n (%) Physical assault Stab-Cut Injury Fall Poisoning Suicide attempt Electrical-Burn injury Gunshot wound Sexual Assault Others Outcomes (hospitalization), n (%) Cost (TL), median (IQR)
• • • • • • • • •
a
Total n = 5870
Revisited cases n = 985
Non-revisited cases n = 4885
P
29 (21–40) 4172 (71.1%)
29 (23–38) 810 (82.2%)
30 (20–41) 3362 (68.8%)
0,497 < .001
4270 (72.7%) 303 (5.2%) 250 (4.3%) 248 (4.2%) 205 (3.5%) 54 (0.9%) 44 (0.7%) 20 (0.3%) 476 (8.1%) 386 (6.6%) 15.5 (15.5–98)
890 (90.4%) 32 (3.2%) 5 (0.5%) 14 (1.4%) 14 (1.4%) 3 (0.3%) 4 (0.4%) 3 (0.3%) 20 (2.0%) 26 (2.6%) 15.5 (15.5–15.5)
3380 (69.2%) 271 (5.5%) 245 (5.0%) 234 (4.8%) 191 (3.9%) 51 (1.0%) 40 (0.8%) 17 (0.3%) 456 (9.3%) 360 (7.4%) 15.5 (15.5–107.8)
< .001 .003 < .001 < .001 < .001 .027 .171 1.000 < .001 < .001 < .001
First visit of both revisited and non-revisited groups.
in Turkey. One of the most important problems in this regard is that emergency physicians are afraid or hesitant to face medico legal problems. The reason for this, although emergency physicians are well prepared to manage the acute medical issues of these cases, they often do not receive formal residency training in clinical forensic medicine.7 Eroğlu et al. showed that there is no standard approach for legal cases in the EDs in their country where the current study was also carried out. Further, forensic reports written by emergency physicians are usually affected by situations such as self-protection, prejudice or individual rules.8 Yemenici et al. showed that one or more deficiencies were detected in all forensic reports written by emergency physicians. Some of these deficiencies and errors can cause serious accusations such as "disregard for judicial accountability" and "false expertise".9 Many other authors believe that more attention should be given to this subject during or after emergency medicine residency training3,8–11. Beside these situations, revisit of these cases is another important topic that may lead to an increase in emergency service intensity and legal procedures. Frequency of forensic visits (except road traffic and occupational accidents) can be vary (1–3%) among EDs in Turkey due to different work flow, intensity, and whether it is an academic department or not. In this study, it was found that 2.6% of all ED visits was forensic type in accordance with the literature. Average age of forensic cases was between 24 and 32 years in the studies.5,10 Median age of forensic cases was 29 in current study. Many studies reported that forensic cases were often male gender (66–74%).3,12 The rate of male gender was 71.1% in this study similarly to the other ones. Brennan et al. showed that 21.5% of all violence-related injuries (excluding firearms) were inflicted with a sharp or blunt object and 78.5% were inflicted with body part (fist, feet and others) in an ED in United Kingdom.13 The rates of physical assault range from 14% to 43% among forensic cases (except road traffic and occupational accidents) in the studies in Turkey.3,5,6 This rate was over 70% of all forensic cases in this study unlike other studies conducted in this country.
Table 2 Multivariate logistic analysis of factors associated with forensic revisits. Variables
OR
95% CI
P
Gender, male Physical assault Fall
1.760 2.707 0.217
1.472–2.105 1.408–5.205 0.072–0.649
< 0.001 0.003 0.006
CI: confidence interval; OR: odds ratio.
was 5.2% (n = 303), and fall was 4.3% (n = 250) (Fig. 1). Median cost per forensic case was 15.5 (IQR 15.5-98) TL. Of all cases, 6.6% was hospitalized for further treatment. 3.1. Revisits of forensic cases In the study period, 985 forensic cases (revisited group) had multiple ED visits (a total of 2692). Median revisit number was 2 (IQR 2–3 [range 2–19]) (Fig. 2). Median age of revisited group was 29 (IQR 23–38 [range 0-81]) and the rate of male was 82.2%. As age groups, the rate of 0-14 years was 2% (n = 20), 15–24 years was 30.8% (n = 303), 25–45 years was 57.6% (n = 567), and 46 years and over was 9.6% (n = 95). The most common reason for the first visit (n = 985) in these cases was physical assault as 90.4%, stab-cut injury was 3.2%, and suicide attempt was 1.4% (Fig. 3). Among all visits of revisited group (n = 2692), the most common reason was physical assault as 91.4%, stab-cut injury was 1.9%, and suicide attempt was 1.8% (Fig. 4). Median cost per revisited forensic case was 15.5 (IQR 15.5–15.5) TL. Median age wasn't different statistically between revisited and nonrevisited group (Table 1). The rate of male gender was significantly higher in revisited group than that of other group (82.2% and 68.8%, respectively) (χ2; P < .001). Physical assault as a type of injury was more common in the revisited group than that of non-revisited group (90.4% and 69.2%, respectively) (χ2; P < .001). Revisited group had lower hospitalization rate and hospital cost than those of other group (2.6% and 7.4%; 15.5 TL (IQR 15.5-15.5) and 15.5 TL (IQR 15.5107.8), respectively) (χ2; P < .001). Table 2 summarizes the results of logistic regression for factors associated with forensic revisits (Hosmer and Lemeshow test, p = .887). After entering all the variables with p value < .1 in Table 1; male gender (OR, 1.76; 95% CI: 1.47–2.10), physical assault (OR, 2.70; 95% CI: 1.40–5.20), and fall (OR, 0.21; 95% CI: 0.07–0.64) were associated with forensic revisits.
4.1. Revisits of forensic cases While there is a sufficient amount of study regarding forensic cases in the ED, the data on revisits of these cases are insufficient both in our country database and in the literature. England and Wales government statistics indicated that 26% of victims were victimized by a person two or more times between 2004 and 2005.14 Oner et al. showed that 8% (453/5675) of pediatric forensic cases had multiple revisits in the ED in 2016 in Turkey. However, authors didn't state that how many revisits existed or which type of injuries was the most in the revisited group in their study.15 In this study, 16.8% (985/5870) of all cases had revisits more than once between July 2017 and June 2018. The median number
4. Discussion Although forensic cases are a matter of concern to many ED physicians, these cases constitute a significant part of the ED presentations 84
Journal of Forensic and Legal Medicine 65 (2019) 81–85
M.A. Aslaner
References
of revisits was 2 and the range of number was between 2 and 19. To the author's best knowledge, there is no other study on this subject. In this study, male gender constituted of majority of cases as 82.2% and the most common injury pattern was physical assault (90.4%) at the first visit of revisited group. In comparison, these rates were lower in the non-revisited group (68.8% and 69.2%, respectively). The findings of the logistic regression analysis in the study also clarified that physical assault and male gender were associated with forensic revisits. According to Centers for Disease Control and Prevention report in United States, the physical assault rate was approximately 77% higher for males than for females.16 However, data don't include all other forensic reasons and recurrent cases. Several studies reported different hospitalization rates from 2.5% to 26% for forensic cases.12,17 While, hospitalization rate was 7.4% in nonrevisited group in the current study, it was 2.6% in revisited group. In addition, hospital cost of revisit group was lower than that of non-revisited group. One of the limitations of the present study is that the study was conducted in a single center. Therefore, outcomes of the study are not generalized for now and there is need for other studies. Another limitation is that there could be missing case records and data loss due to retrospective study design.
1. Duramaz BB, Yıldırım HM, Kıhtır HS, Yeşilbaş O, Şevketoğlu E. Evaluation of forensic cases admitted to pediatric intensive care unit. Turk Arch Pediatr/Türk Pediatri Arşivi. 2015;50(3):145–150. 2. Tuğcu H, Toygar M, Can Ö, Safalı M. The responsibility of physician to prepare a forensic and medical report. TAF Prev Med Bull. 2006;5(6):466–475. 3. Korkmaz T, Kahramansoy N, Erkol Z, Sariçil F, Kilic A. Evaluation of the forensic patients presenting to the emergency department and legal reports. Med Bull Haseki. 2012;50:14–20. 4. Türkçüer İ, Gözlükaya A, Serinken M, Özen M, Aydın B. Application times of forensic cases to emergency department. Akademik Acil Tıp Dergisi. 2010;2:89–92. 5. Küçük E, Günel C. Demographic characteristics of forensic investigation in emergency service. Sakarya Med J. 2016;6(2):100–105. 6. Demircan A, Keleş A, Gurbuz N, et al. Forensic emergency medicine - six year experience of 13823 cases in a university emergency department. Turk J Med Sci. 2008;38:567–575. 7. Wiler JL, Bailey H, Madsen TE. The need for emergency medicine resident training in forensic medicine. Ann Emerg Med. 2007;50(6):733–738. 8. Eroğlu SE, Toprak SN, Karataş AD, et al. What is the meaning of “temporary” forensic reports for Emergency physicians? Self protection? Bias? Habit? Turk J Emerg Med. 2013;13(1):013–018. 9. Yemenici S, Sayhan MB, Salt Ö, Yılmaz A. Evaluation of medicolegal reports prepared in emergency department. J Harran Univ Med Fac. 2017;14(3):179–186. 10. Bozkurt S, Daraoğlu V, Okumuş M, Savrun A, Karanfil R, Gök AA. Evaluation of judicial reports which executing on emergency service and fixed deficiencies. J Clin Anal Med. 2015;6(3):331–334. 11. Aslaner MA, Eroğlu SE, Batur A, Arslan V. Emergency medicine physicians' perspectives on subspecialty training: a national survey. Turk J Emerg Med. 2018;18(3):119–122. 12. Levent S, Pamukçu Günaydın G, Şahin Kavaklı H, Kurtoğlu Çelik G, Coşkun S. A retrospective seasonal analysis of all forensic cases that presented to an emergency department in a year. J Med. 2015;29(1):22–28. 13. Brennan IR, Moore SC, Shepherd JP. Non-firearm weapon use and injury severity: priorities for prevention. Inj Prev. 2006;12(6):395–399. 14. Nicholas S, Povey D, Walker A, Kershaw C. Crime in England and Wales 2004/2005. Home Office Statistical Bulletin; 2005. 15. Oner S, Harmanogulları LU, Yapici G, Ozel S. Evaluation of forensic cases admitted to the pediatric emergency service of a hospital. Eur J Pharmaceut Med Res. 2017;4(8):90–95. 16. Nonfatal physical assault-related injuries treated in hospital emergency departments–United States, 2000. MMWR Morb Mortal Wkly Rep. 2002;51(21):460–463. 17. Seviner M, Kozacı N, Ay MO, et al. Analysis of judicial cases at emergency department. Cukurova Med J. 2013;38(2):250–260.
5. Conclusion One-sixth of all forensic cases revisited to the ED multiple times. Male gender and, especially, physical assault as a presentation type were associated with forensic revisits to the ED. Hospitalization and hospital cost were lower in the revisited group. Finally it can be said that with this findings, revisits regarding forensic cases to the EDs are frequently seen in male gender due to simple physical assault. Conflicts of interest M.A., reports no conflicts of interest. Financial disclosure * No financial disclosure is declared by the author.
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