A Quality Measurement Framework for Emergency Department Care of Psychiatric Emergencies.

As a primary access point for crisis psychiatric care, the emergency department (ED) is uniquely positioned to improve the quality of care and outcomes for patients with psychiatric emergencies. Quality measurement is the first key step in understanding the gaps and variations in emergency psychiatric care to guide quality improvement initiatives. Our objective was to develop a quality measurement framework informed by a comprehensive review and gap analysis of quality measures for ED psychiatric care. We conducted a systematic literature review and convened an expert panel in emergency medicine, psychiatry, and quality improvement to consider if and how existing quality measures evaluate the delivery of emergency psychiatric care in the ED setting. The expert panel reviewed 48 measures, of which 5 were standardized, and 3 had active National Quality Forum endorsement. Drawing from the measure appraisal, we developed a quality measurement framework with specific structural, process, and outcome measures across the ED care continuum. This framework can help shape an emergency medicine roadmap for future clinical quality improvement initiatives, research, and advocacy work designed to improve outcomes for patients presenting with psychiatric emergencies.

Comparison of Self-Administered Post Traumatic Stress Disorder Tool vs. Researcher Administered Tool in the Emergency Department.

BACKGROUND: Recent studies have shown that there is a high rate of post traumatic stress disorder in the inner city. OBJECTIVE: The purpose of this study was to determine whether patients in the Emergency Department would use a post traumatic stress disorder (PTSD) assessment. Additionally, did the type of administration of the PTSD tool impact the usage of PTSD services? METHODS: The sample population was taken from patients, 12 years or older, who presented with a non psychiatric illness. This study was done at a level one inner city adult and pediatric Emergency Department. The PTSD validated survey, was randomized between being self or research fellow administered. Half of the patients completed the survey on their own and half were administered by a research fellow. Those who screen positive on the tool were contacted one week later. This was done to determine if they have scheduled an appointment or were seen for a follow-up appointment. This study was IRB approved. RESULTS: A total of 299 participants completed the survey. Half (149) of which used a PTSD tool that was self administered. The total amount of participants who tested positive for PTSD was 35% (105). There was a significant difference (0.01) between those who self administered the tool 26% (40) and those who had the tool administered 12% (18). This was seen in relationship to who was more likely to follow up with behavioral health referrals. CONCLUSIONS: These results reveal that 35% of the participants tested positive for PTSD. The majority of those that screened positive and used follow up services had self administered the tool. This indicates that they are more likely to seek out services based on their results.

Evidence-Based Review Of Pharmacotherapy For Acute Agitation. Part 2: Safety.

BACKGROUND: The management of acute agitation in the emergency department often requires the administration of rapid-acting antipsychotic agents. However, there are few comparative studies and little guidance regarding the risks associated with use of such drugs in the acute setting. OBJECTIVE: This structured evidence-based review compared the safety of antipsychotic pharmacotherapies for acute agitation using data from randomized controlled trials identified by a literature search of the PubMed database. RESULTS: Based on findings from 34 blinded, randomized controlled trials, common acute adverse effects of second-generation antipsychotics and haloperidol were headache, dizziness, insomnia, and somnolence. There were some differences in incidence of extrapyramidal symptoms (EPS), degree of sedation, and acute QTc prolongations between agents. CONCLUSIONS: The results of this review demonstrate the improved safety (particularly regarding EPS and over-sedation) of certain newer-generation antipsychotic agents compared with haloperidol and benzodiazepines for the treatment of acutely agitated patients. The risk of prolonged QT interval and torsade de pointes needs to be considered with haloperidol and some of the second-generation antipsychotics.

Evidence-Based Review of Pharmacotherapy for Acute Agitation. Part 1: Onset of Efficacy.

BACKGROUND: The main goal of antipsychotic medication in the management of acute agitation in the emergency department is to rapidly induce calm without oversedation, enabling patients to participate in their own care. However, there is a paucity of comparative studies, particularly with newer fast-acting second-generation antipsychotic agents. OBJECTIVE OF THE REVIEW: This structured evidence-based review compared the onset of efficacy of antipsychotic treatments for acute agitation using data from randomized controlled trials identified by a literature search of the PubMed database. RESULTS: Based on findings from 28 blinded randomized controlled trials, onset of efficacy was rapid and generally observed at the first time point after intramuscular administration of ziprasidone (15-30 min) or olanzapine (15-30 min), but was more likely to be delayed with intramuscular haloperidol, even when combined with lorazepam (30-60 min), and intramuscular aripiprazole (45-90 min). When administered orally, rapid onset of efficacy was also consistently observed at the first assessment time point with olanzapine (15-120 min), risperidone (30-120 min), and sublingual asenapine (15 min). Significant effects were apparent for inhaled loxapine within 10-20 min. Effects were apparent within approximately 5-10 min with i.v. droperidol. Onset of efficacy was typically more rapid with second-generation antipsychotic agents than benzodiazepines, but data are limited. CONCLUSIONS: Although the patient populations of trials included in this review do not truly reflect that of the emergency department, the results provide useful information to emergency physicians on the rapid efficacy of certain newer-generation antipsychotic agents for the treatment of acutely agitated patients.

Identifying Undiagnosed Pediatric Mental Illness in the Emergency Department.

BACKGROUND: It is well known that pediatric psychiatric patients frequent emergency department (ED), but the number of patients with undiagnosed psychiatric illness presenting to an ED is not well known. Identification and referral of these patients may provide an opportunity for improved patient care. The primary study objective was to identify a tool that can screen for unsuspected psychiatric illness in pediatric patients who present to the ED with non-psychiatric-related complaints. METHODS: The MINI International Neuropsychiatric Interview for Children and Adolescents screening tool was administered to 200 pediatric consenting patients and guardians. The inclusion criteria were English-speaking patients who presented in the ED with a nonpsychiatric complaint who were stable and able to communicate. The study was conducted in a level 1 trauma center ED of an inner-city hospital that serves a predominantly African American and Hispanic population. This study was institutional review board approved. RESULTS: The study populations consisted of 53% African American (107), 45% Hispanic (90), 1% white (2), and 0.5% Asian (1). Their age range was divided, with 49% between 12 and 14 years (98) and 51% between 15 and 17 years (102). The sex was evenly split, with 50% male (100) and 50% female (100). The 41% who did screen positive for an undiagnosed mental illness had a range of diagnoses. The top modules with positive results were oppositional defiant (13.5%, 27), attention-deficit/hyperactivity disorder (13%, 25), depression (10%, 11), conduct disorder (9%, 19), and anxiety (5%, 11). CONCLUSIONS: The pediatric Mini International Neuropsychiatric Interview was effective in screening for undiagnosed mental illness in pediatric patients who presented to the ED with no psychiatric-related illness. The screening tool indicated that 41% of pediatric patients screened positive for an undiagnosed mental illness, with attention deficit-related disorders being the most widely seen. Further study should be conducted to test the tools used in a range of ED settings.

Reasons for readmissions: what are the reasons for 90-day readmissions of psychiatric patients from the ED?

BACKGROUND: Frequent users of the emergency department (ED) contribute to the problem of overcrowding and are more likely to have psychiatric problems and a higher than average 90-day readmission rate. In addition, ED visits due to mental health problems have increased in recent years, thus driving up 90-day readmission rates. OBJECTIVES: The objective of the study is to determine the reasons for readmissions of psychiatric patients who have previously presented to the ED. METHODS: This is a retrospective chart review of a random sample of 350 psychiatric patients who presented to the ED and had a return visit within 90 days. This study was conducted at a 432-bed, urban, level I adult and pediatric trauma center with 50000 ED visits per year. The inclusion criterion was all psychiatric patients who presented to the ED since August 2011 and had a least 1 return visit within 90 days. The exclusion criterion was patients who presented with nonpsychiatric complaints. SPSS version 14 was used, and the study was institutional review board approved. RESULTS: There was a significant difference (P=.01) between the reasons for psychiatric patients to be readmitted to the hospital between their first, second, and third ED visits. The most common reasons for admission on the first visit were depression, schizophrenia, schizoaffective disorder, bipolar disorder, and psychosis. The most common reasons for the second and third visits, however, were psychiatric (61.9%), musculoskeletal (9.2%), cardiovascular (5.7%), neurologic (4.3%), and dermatological (3.2%). CONCLUSIONS: Psychiatric patients are not returning to the ED repeatedly for the same complaints or for only psychiatric complaints. A total of 30% of patients who presented for a second and third time within 90 days were admitted for medical illness, as opposed to their initial psychiatric presentation. This indicates that a 2-pronged approach toward treatment might have to be developed-one that focuses on specific types of mental illness and one that focuses on a separate set of physical illnesses-to reduce 90-day readmission rates within this patient population.

Implementing a third-year emergency medicine medical student curriculum.

BACKGROUND: Emergency medicine (EM) is commonly introduced in the fourth year of medical school because of a perceived need to have more experienced students in the complex and dynamic environment of the emergency department. However, there is no evidence supporting the optimal time or duration for an EM rotation, and a number of institutions offer third-year rotations. OBJECTIVE: A recently published syllabus provides areas of knowledge, skills, and attitudes that third-year EM rotation directors can use to develop curricula. This article expands on that syllabus by providing a comprehensive curricular guide for the third-year medical student rotation with a focus on implementation. DISCUSSION: Included are consensus-derived learning objectives, discussion of educational methods, considerations for implementation, and information on feedback and evaluation as proposed by the Clerkship Directors in Emergency Medicine Third-Year Curriculum Work Group. External validation results, derived from a survey of third-year rotation directors, are provided in the form of a content validity index for each content area. CONCLUSIONS: This consensus-derived curricular guide can be used by faculty who are developing or revising a third-year EM medical student rotation and provide guidance for implementing this curriculum at their institution.

Who pays? How reimbursement impacts the emergency department.

BACKGROUND: Nationwide from 1996 to 2004, the overall proportion of Emergency Department (ED) reimbursement ratios for outpatient ED visits decreased from 57% to 42%. The continued falling of ED reimbursement ratios, which is the share of ED charges that are ultimately paid, is an indicator of the financial pressures facing the ED. Once the healthcare reforms are put in place what will the impact be on reimbursement rates of overburdened and underfunded emergency departments. PURPOSE: The purpose of this study is to examine if there is a declining disparity in payment rates for ED care based on payment sources in a safety net ED provider. Findings of this study could indicate how the healthcare reforms might impact these types of ED reimbursement ratios in the upcoming years. METHODS: This was a retrospective study that examined randomly selected charts of all ED visits charts from May 2002 to May 2008 at a level one adult and pediatric emergency trauma center with 45,000 annual visits. This study was IRB approved. RESULTS: A regression model was used to predict if there was a relationship between amount received and types of insurance payers within the ED. A significant relationship was found between types of insurance (payers) as the independent variable, and the dependent variables of charges (p = .00), payments (p = .00), amount of adjustments (p= .00), and balance remaining after 90 days (p = .00). CONCLUSIONS: Who pays for the ED services does impact the ED's bottom line. The privately funded patients will provide an ED with a higher reimbursement ratio per year as compared to those patients who are publicly or self pay. This explains why EDs that provide care for 40% or more publicly or self pay patients have seen a decline in reimbursement ratios. Healthcare reform has the potential to change and possibly improve safety net ED rate of reimbursement depending on how private, public and self pay patients pay for ED services.

Does gun accessibility lead to violence-related injury?

OBJECTIVES: Because of high rates of violent gun-related injuries seen in emergency department (EDs), the ED has become involved in prevention violence intervention. The purpose of the study was to determine the relation between access to guns and the risk of violence-related injuries in youth and young adults. METHODS: This study was a convenience sample in an inner-city level I trauma center. A 28-item validated questionnaire consisting of a short questionnaire about guns, the New York City Youth Violence Survey, and the SAGE Baseline Survey was given to 201 subjects. Half of the subjects were victims of violence and half were seen for nonviolence-related problems. RESULTS: Subjects with violence-related injuries did not have a higher rate of accessibility to guns. They did, however, show a difference in their attitudes toward guns. The subjects who came into the ED with violence-related injuries believed that having a weapon was a way to avoid a fight (F = 4.68, P = 0.032). They were more likely to have grabbed or shoved someone in the last 6 months (F = 5.18, P = 0.025), punched someone in the last 6 months (F = 11.9, P = 0.011), and have been seen in the ED within the last 6 months for a injury related to being punched, attacked, or shot (F = 117, P = 0.00), as compared to those with nonviolence-related injuries. CONCLUSIONS: There was no difference between the two subject groups in terms of their being victims of violence and the rate of gun accessibility. There was, however, a difference in their attitudes toward guns.

Pitfalls in the care of the psychiatric patient in the emergency department.

BACKGROUND: Care of the psychiatric patient in the Emergency Department (ED) is evolving. As with other disease states, there are a number of pitfalls that complicate the care of the psychiatric patient. OBJECTIVE: The purpose of this article is to update Emergency Physicians concerning the pitfalls in caring for the psychiatric patient, and possible solutions to deal with these pitfalls. DISCUSSION: The article will address the burden of the psychiatric patient, staff attitudes, medical clearance process, treatment of the agitated patient, suicidal patients, and admission decisions. CONCLUSIONS: Alternative care resources, collaboration with Psychiatry, staff education, improvement in the medical clearance process, proper use of restraint and seclusion, and appropriate choice of medication for agitated patients can help avoid some of the top pitfalls in the care of the psychiatric patient in the ED.

Undiagnosed mental illness in the emergency department.

BACKGROUND: Mental illness affects 8% of the population. The early identification and treatment of mental illness can reduce the progression and complications of the illness. OBJECTIVE: The objective of this study was to identify unsuspected psychiatric illness in patients presenting to the emergency department (ED) with non-psychiatric-related complaints. A comparison of the test results and the emergency physician assessments were then compared. METHODS: All consenting and stable patients who presented to the ED with non-psychiatric complaints were given the Mini-International Neuropsychiatric Interview (MINI). It was administered to the patient by a trained research fellow before the patient was seen by the physician. Before the patient's departure from the ED, the research fellow notified the emergency physician of the results of the MINI interview. After the emergency physician was notified of the diagnosis of the MINI, any change in the treatment was reviewed. RESULTS: A total of 211 patients were enrolled in the study. The majority of patients (55%) tested negative for all undiagnosed mental illnesses. The top diagnoses were as follows: major depression (24%), general anxiety (9%), and drug abuse (8%). Of all those patients who tested positive for an undiagnosed mental illness, only 2% were diagnosed by the ED attending. CONCLUSIONS: The idea that the ED is a good place to identify undiagnosed mental health illnesses was confirmed. The use of an independent test such as the MINI was also shown to be useful to aid the emergency physician in identifying undetected mental illnesses.

The impact of watching cartoons for distraction during painful procedures in the emergency department.

OBJECTIVE: The purpose of this study was to determine whether the viewing of cartoons in the acute care setting reduces the perception of pain by pediatric patients. METHODS: A convenience prospective study of pediatric patients in pain was performed at a community teaching level I pediatric and adult emergency department, with 44,000 patient visits per year. The inclusion criteria for entry into the study were any child who presented to the emergency department in acute pain from any cause. The younger children were randomized to watch a Barney cartoon in Spanish or English, and the older children were randomized to view a Tarzan cartoon in Spanish or English. The younger children were assessed 5 minutes before the procedure, during the procedure, and 5 minutes after the procedure using Poker Chip Tool and Faces Scale. The older children were assessed at the same time interval using self-reporting and a visual analog scale. The study was internal review board approved. A difference of 20% or greater was considered a significant difference. The data were analyzed using a general linear model-repeated measures a priori level of significance of P < 0.05. RESULTS: There was a significant difference within subject effects: F(1)= 9.268, significant at 0.03, with observed power at 0.85 or 85%, with the α set at 0.05 or less. A comparison of the groups revealed that there were no differences in the causes of pain (F(1) = 0.301, P = 0.585), pain duration (F(1) = 0.062, P = 0.084), or type of anesthesia, if used (F(1) = 0.064, P = 0.804) between groups. This lack of difference was upheld for age (F(1) = 3.0407, P = 0.068), race (F(1) = 0.537, P = 0.466), and sex (F(1) = 0.002, P = 0.964). CONCLUSIONS: The finding that cartoon viewing was effective does illustrate 1 more pain relief tool for use in the ED when pediatric patients present. It is useful because of the fact that it does not interfere with assessment of patients' presenting or underlying problems. The need for more ways in which to address pediatric pain persists.

The correlation between patient comprehension of their reason for hospital admission and overall patient satisfaction in the emergency department.

OBJECTIVES: (1) To determine the patient's comprehension of the reasons for admission in the emergency department and (2) to examine what, if any, correlation there is between patients' understanding and satisfaction with care. METHODS: Using a convenience sample over a 6-month period, patients from an urban, level 1 adult and pediatric trauma center were interviewed by research fellows in a patient care area. A total of 287 patients were given the Emergency Department Quality Study (EDQS) survey in either English or Spanish. Only patients 18 years or older, who were able to consent, spoke English or Spanish, and were medically stable were included in the study. The study was approved by the institutional review board. An analysis of variance was used to determine if any significant difference exists between patient understanding and satisfaction with care. In order to determine which of these variables could predict patient satisfaction levels, a log linear regression was used. RESULTS: The majority (90%) of patients rated their care as good to excellent, and 78% of them did understand why they were being admitted. A total of 22%, however, did not understand their test results and the cause for their being admitted to the hospital. There was a significant negative finding among the patient not having an understanding of tests, reason for admission, returning to the emergency department for care, and their overall patient satisfaction. CONCLUSIONS: Successful communication between doctors and patients around the reasons for admission and test results can be an important predictor of patient satisfaction. Medical information not communicated in an understandable way to patients can lead to lower levels of patient satisfaction.

The effects of deep breathing training on pain management in the emergency department.

PURPOSE: The purpose of this study was to measure the impact of deep breathing exercises on the pain levels in patients who presented to the emergency department (ED) with pain as their chief complaint. A secondary purpose was to measure the impact of deep breathing teaching on indicators of patient satisfaction. METHODS: This was an observational study of patients who presented to the ED with pain as their chief complaint to an urban level one Emergency Department. Patients were randomized into a control group and an experimental group. The control group received the usual treatment for pain. The experimental group received the usual treatment for pain, but also received deep breathing exercises. For the measurement of pain prior to treatment, the brief pain inventory (BPI) was used. The visual analogy system (VAS) was used to measure pain prior to and after treatment and deep breathing were administered. For the measurement of patient satisfaction, the medical interview satisfaction scale (MISS) was used. RESULTS: There was no significant difference between those who received the deep breathing education and those that did not with regards to postmedication pain levels. There was however, a significant difference in customer service satisfaction within the area of doctor/patient rapport and intention to follow treatment. CONCLUSION: The usefulness of deep breathing exercises was shown to be ineffective in reducing pain levels; however, the majority of those who received deep breathing education felt it was useful. The exercise was effective in increasing patient's feelings of rapport and intentions to follow their doctor's directives.

Level of agitation of psychiatric patients presenting to an emergency department.

OBJECTIVES: The primary purpose of this study was to determine the level of agitation that psychiatric patients exhibit upon arrival to the emergency department. The secondary purpose was to determine whether the level of agitation changed over time depending upon whether the patient was restrained or unrestrained. METHOD: An observational study enrolling a convenience sample of 100 patients presenting with a psychiatric complaint was planned, in order to obtain 50 chemically and/or physically restrained and 50 unrestrained patients. The study was performed in summer 2004 in a community, inner-city, level 1 emergency department with 45,000 visits per year. The level of patient agitation was measured using the Agitated Behavior Scale (ABS) and the Richmond Agitation-Sedation Scale (RASS) upon arrival and every 30 minutes over a 3-hour period. The inclusion criteria allowed entry of any patient who presented to the emergency department with a psychiatric complaint thought to be unrelated to physical illness. Patients who were restrained for nonbehavioral reasons or were medically unstable were excluded. RESULTS: 101 patients were enrolled in the study. Of that total, 53 patients were not restrained, 47 patients were restrained, and 1 had incomplete data. There were no differences in gender, race, or age between the 2 groups. Upon arrival, 2 of the 47 restrained patients were rated severely agitated on the ABS, and 13 of 47 restrained patients were rated combative on the RASS. There was a statistical difference (p = .01) between the groups on both scales from time 0 to time 90 minutes. Scores on the agitation scales decreased over time in both groups. One patient in the unrestrained group became unarousable during treatment. CONCLUSION: This study demonstrated that patients who were restrained were more agitated than those who were not, and that agitation levels in both groups decreased over time. Some restrained patients did not meet combativeness or severe agitation criteria, suggesting either that use of other criteria is needed or that restraints were used inappropriately. Further study of the level of agitation and the effects of restraints is needed.

Assessing adult health literacy in urban healthcare settings.

OBJECTIVE: To determine if health literacy is lower among those using the emergency department as compared to those using community health clinics. A comparison was done of the health literacy level of patients at a level-I adult and pediatric emergency department and 3 community health clinics. The second purpose of the study was to identify and assess predictors of low or adequate health literacy in order to better accommodate the communication needs of these patients. METHODS: The study used a convenience, cross-sectional design. The settings for the study were varied. The emergency department was a level-I inner-city pediatric and adult trauma center with 45,000 annual visits. The 3 outpatient clinics were all members of a 44-clinic network of private, community health centers that serve 175,000 underserved patients annually. Overall, 536 patients were approached to complete an in-person survey that included a 15-item written questionnaire and the Short Test of Functional Health Literacy in Adults (S-TOFHLA), a English- and Spanish-validated health literacy measure. Based on language spoken with healthcare providers, patients were given either the Spanish or English S-TOFHLA. RESULTS: The refusal rate was 25.7%, with 536 patients approached and 398 completing the survey. Three of the four sites had a refusal rate of 8% per site. The fourth site had a higher refusal rate at 38%. Overall, 20% of subjects had marginal or inadequate functional health literacy. There was a significant difference at p=18.42, df=3, p=0.001 among sites. Three of the sites had > or =78% of the participants scoring at the adequate level. The fourth site, however, only had 66% who scored at the adequate level, with 34% of the scores in the inadequate functioning level as compared with 14% for the emergency department and its adjacent clinic and 3% for the clinic located at the city's edge. Using logistical regression, there was an association between literacy level and education (t=2.653, sig 0.008) and age (t=-6.451, sig 0.001). CONCLUSION: Less-than-adequate functional health literacy was seen at 20% of all sites. The location of healthcare access was not as predictive of low functional health literacy as were demographic indicators, such as age and education levels.

Frequency of alternative to restraints and seclusion and uses of agitation reduction techniques in the emergency department.

INTRODUCTION: The use of restraints to manage patients in the emergency department (ED) is controversial. The Joint Commission on Accreditation of Healthcare Organization (JCAHO) and numerous advocacy groups have pushed for the use of alternatives to restraints. The need to protect the patients' rights while also reducing the risks they may pose to themselves, other patients, and medical staff is difficult to balance. The purpose of this study was to assess which agitation reduction techniques, if any, are used prior to restraints in the ED as recommended by the JCAHO. The second purpose was to determine the reasons for differing levels of usage and/or compliance with the JCAHO recommendations. METHODS: A survey tool was developed to include the new restraint and seclusion standards from Joint JCAHO. It was sent to a random sample of the EDs from a randomized list of hospitals in the United States and to all psychiatric EDs from the American Association for Emergency Psychiatrists (AAEP). A mailed survey allowed for institutions to review their yearly census for the information to questions. The survey included questions on the use of agitation reduction techniques, what are those methods, what methods are most effective for ED doctors, has staff received training in how and when to use those methods, and reasons why they do or do not use them in the ED. The study was IRB approved as exempt. RESULTS: A 40% response rate was obtained overall (391 out of 960). The majority, 70%, of general ED have no psychiatric unit vs. 87% of specialized EDs having a unit attached. The overwhelming majority of both, at 90% to 98%, do use alternatives to restraints prior to restraints. When restraints are used, 30% used physical and 30% used physical and chemical restraints combined. A management protocol is in place at 90% of the institutions to use alternative first and 76% of the staff is educated on the use of alternative methods. The methods in order of popularity are verbal interventions at 84%, one-to-one at 79%, decrease in stimulation at 74%, and food or drink at 69%. The rating of the effectiveness of those methods is low, with the following percentages feeling that the respective techniques were effective: one-to-one, less than 48%; verbal intervention, 36%; decreasing stimulation, 15%; and food or drink, 18%. However, 61% feel that chemical restraints were effective. DISCUSSION: The majority of respondents have training on alternatives to restraints. They do use alternatives to restraints, with one-to-one, food or drink, and verbal interventions being the most frequently used. These are seen as not very effective. The use of physical and/or a combination of physical and chemical restraints is used by 60% of respondents due to the perceived high level of effectiveness.

Violence prediction in the Emergency Department.

The purpose of this study was to examine whether the SAGE assessment survey could predict, within the Emergency Department setting, those youth at risk for engaging in violent behavior. It also examined whether those who test positive for engaging in high-risk violent behavior during the initial baseline SAGE survey were prone to continue this behavior 1 month later. This was an observation, convenience sample of young male and female patients, half of whom had injuries related to violence and half of whom had injuries unrelated to violence, who presented when a research fellow was available. They were given the SAGE aggression assessment survey and questioned about their risk behavior in the past 6 months to 1 year. Those youths were contacted 1 month after enrollment to determine the incidence of continued at-risk behavior. Demographic information was used to contact the patient on follow-up but not for identification purposes. The study was IRB-approved. The setting was a Level I pediatric and adult trauma center in an inner city with 45,000 annual visits. The inclusion criteria were: age 10-24 years, consenting patient or guardian, medically stable, and able to communicate. The exclusion criteria were: those youths who were uncooperative or refused to participate. The comparison between the SAGE overall scores of the 182 subjects with 46% who had injuries related to violence vs. 54% who presented with injuries not related to violence did not show a significant difference. Those who presented with non-violent injuries had an overall score range of 7-8 with a mean of 7.4 and those who presented with violent injuries had an overall scale of 10-11 with a mean of 10.1 out of a possible 12 total. There were, however, significant differences at the .05 or less level when looking at specific questions asking about certain behaviors such as physical fighting, shoving, needing medical attention, and kicking, in the initial survey. At the 1-month follow-up, with 118 subjects, the SAGE tool also showed differences in the areas of physical fighting, shoving, and kicking between the 56% who had injuries not related to violence vs. the 44% who did have violence-related injuries. It identified 18-50% of those who presented with violence-related injuries and who continued to engage in high-risk behavior at the 1-month follow-up. These results indicate that the SAGE survey scores based on the responses to all 12 questions is not effective in identifying those youths at risk for general violent behavior, especially with a high-risk population. A set of four questions from the 12-question SAGE survey, however, was successful at tracking specific types of at-risk behaviors. This indicates that certain questions within the SAGE survey may be effective at tracking those who engage in high-risk violent behavior. These same questions were able to track those who continued to engage in high-risk violent behaviors 1 month later.