Trauma-Informed Care for Violently Injured Patients in the Emergency Department.

Violent traumatic injury remains a common condition treated by emergency physicians. The medical management of these patients is well described and remains an area of focus for providers. However, violently injured patients disproportionately carry a history of physical and psychological trauma that frequently affects clinical care in the emergency department. The alteration of our clinical approach, taking into consideration how a patient's previous experiences influence how he or she may perceive and react to medical care, is a concept referred to as trauma-informed care. This approach is based on 4 pillars: knowledge of the effect of trauma, recognition of the signs and symptoms of trauma, avoidance of retraumatization, and the development of appropriate policies and procedures. Using this framework, we provide practical considerations for emergency physicians in the delivery of trauma-informed care for violently injured patients.

Physician Adherence to Centers for Disease Control and Prevention Guidelines for Sexually Active Adolescents in the Pediatric Emergency Setting.

OBJECTIVES: There is limited literature about physicians' adherence to 2010 Centers for Disease Control and Prevention (CDC) Sexually Transmitted Diseases Treatment Guidelines specific to specimen collection testing methods in adolescent females in the emergency setting is limited. The objectives are to (1) determine physician adherence to CDC guidelines for specimen collection/testing for chlamydia and gonorrhea, (2) determine physician characteristics associated with guideline adherence, and (3) describe physicians' knowledge of expedited partner therapy (EPT) laws. METHODS: This is a cross-sectional, anonymous, Internet-based survey of physician members of the American Academy of Pediatrics Section of Emergency Medicine. Questions addressed practice patterns and knowledge through clinical scenarios of adolescent girls. Descriptive statistics are used to report frequency. Fisher exact and χ analyses are used to compare physician subgroups: gender, years in practice, practice setting, and geographical region. RESULTS: Overall, 257 physicians responded and 231 were analyzed; 62.4% females; 46.0% in practice for ≤ 7 years; 86.2% in academic medicine. Specimen collection/testing in an asymptomatic patient were consistent with guidelines for 85.6% of respondents, but decreased to 37.4% for a symptomatic patient. Guideline adherence was not different between physician subgroups. Only 30.4% of physicians reported state EPT law knowledge. CONCLUSIONS: Adherence with the CDC guidelines for chlamydia/gonorrhea specimen collection/testing for adolescents in the emergency setting is inadequate, and EPT knowledge is poor. With increased emergency department use by adolescents, it is critical that physicians know and implement the current recommendations to improve adolescent health outcomes.

Prediction of Suicide Attempts and Suicide-Related Events Among Adolescents Seen in Emergency Departments.

Importance: Screening adolescents in emergency departments (EDs) for suicidal risk is a recommended strategy for suicide prevention. Comparing screening measures on predictive validity could guide ED clinicians in choosing a screening tool. Objective: To compare the Ask Suicide-Screening Questions (ASQ) instrument with the Computerized Adaptive Screen for Suicidal Youth (CASSY) instrument for the prediction of suicidal behavior among adolescents seen in EDs, across demographic and clinical strata. Design, Setting, and Participants: The Emergency Department Study for Teens at Risk for Suicide is a prospective, random-series, multicenter cohort study that recruited adolescents, oversampled for those with psychiatric symptoms, who presented to the ED from July 24, 2017, through October 29, 2018, with a 3-month follow-up to assess the occurrence of suicidal behavior. The study included 14 pediatric ED members of the Pediatric Emergency Care Applied Research Network and 1 Indian Health Service ED. Statistical analysis was performed from May 2021 through January 2023. Main Outcomes and Measures: This study used a prediction model to assess outcomes. The primary outcome was suicide attempt (SA), and the secondary outcome was suicide-related visits to the ED or hospital within 3 months of baseline; both were assessed by an interviewer blinded to baseline information. The ASQ is a 4-item questionnaire that surveys suicidal ideation and lifetime SAs. A positive response or nonresponse on any item indicates suicidal risk. The CASSY is a computerized adaptive screening tool that always includes 3 ASQ items and a mean of 8 additional items. The CASSY's continuous outcome is the predicted probability of an SA. Results: Of 6513 adolescents available, 4050 were enrolled, 3965 completed baseline assessments, and 2740 (1705 girls [62.2%]; mean [SD] age at enrollment, 15.0 [1.7] years; 469 Black participants [17.1%], 678 Hispanic participants [24.7%], and 1618 White participants [59.1%]) completed both screenings and follow-ups. The ASQ and the CASSY showed a similar sensitivity (0.951 [95% CI, 0.918-0.984] vs 0.945 [95% CI, 0.910-0.980]), specificity (0.588 [95% CI, 0.569-0.607] vs 0.643 [95% CI, 0.625-0.662]), positive predictive value (0.127 [95% CI, 0.109-0.146] vs 0.144 [95% CI, 0.123-0.165]), and negative predictive value (both 0.995 [95% CI, 0.991-0.998], respectively). Area under the receiver operating characteristic curve findings were similar among patients with physical symptoms (ASQ, 0.88 [95% CI, 0.81-0.95] vs CASSY, 0.94 [95% CI, 0.91-0.96]). Among patients with psychiatric symptoms, the CASSY performed better than the ASQ (0.72 [95% CI, 0.68-0.77] vs 0.57 [95% CI, 0.55-0.59], respectively). Conclusions and Relevance: This study suggests that both the ASQ and the CASSY are appropriate for universal screening of patients in pediatric EDs. For the small subset of patients with psychiatric symptoms, the CASSY shows greater predictive validity.

Aggressive behavior in children and adolescents.

After completing this article, readers should be able to: 1. Describe the developmental stages of aggressive behavior in children.2. Know how to provide parents with support and resources in caring for a child who displays aggressive behavior.3. Delineate the prognosis for children who have aggressive behaviors.

Assessing improvements in emergency department referrals to a hospital-based violence intervention program.

BACKGROUND: Youth violence is a major public health concern in the United States. Hospital-based Violence Intervention Programs (HVIPs) are integral in connecting youth sustaining interpersonal violence-related injuries to medical, mental health, and social services. At our pediatric emergency department, our baseline referral rate to the established HVIP was 32.5%. From November 2018-2019, we aimed to increase the percent of eligible patients referred to our HVIP from 32.5 to 70% for patients aged 7-18 years who present to our Level 1 emergency department/trauma center with a violent injury. METHODS: For this quality improvement project, we recorded key aspects of the referral process, such as patient eligibility, who placed referrals, and when referrals were placed in relation to the ED admission. Key stakeholders were interviewed to identify specific interventions. Our key interventions were: 1. Educating providers on eligibility requirements. 2. Encouraging nurses to enter consults at the time of admission. 3. Publishing information about program referrals in the weekly nursing newsletter. 4. Updating social workers on eligibility requirements for the HVIP. We used PDSA cycles to inform our project. Our primary outcome measure was the number of eligible patients referred to our HVIP and measures were analyzed using statistical process control charts. RESULTS: The HVIP-eligible population had the following demographics: 31.1% female and a mean age 14.3 ± 2.7, 82.6% assaults and 17.4% gunshot wounds. From 11/2018 to 11/2019, there were 78 referrals to the HVIP, out of 167 eligible patients. The referral rate improved from 32.5% pre-interventions to 61.1% post-interventions, showing an 88% increase. CONCLUSION(S): We noted an increase in referrals to our HVIP following our interventions that centered on educating, advertising, and encouraging. Future studies will focus on analyzing other aspects of the enrollment process, such as obtaining patient consent.

An educational intervention for medical students to improve self-efficacy in firearm injury prevention counseling.

BACKGROUND: Most physicians support counseling patients about firearm injury prevention (FIP), but infrequently do so due to lack of training and low confidence. Interventions to increase counseling frequency should focus on improving physician self-efficacy. Firearm injuries affect many clinical specialties; therefore, trainees would benefit from early FIP education. This study aims to determine if a 20-min educational intervention improves self-efficacy in FIP counseling in third-year medical students. Knowledge and beliefs were also assessed as secondary indicators of self-efficacy. METHODS: This was a prospective study performed at a medical school associated with a tertiary care children's hospital during the 2016-17 academic year. Groups of 12-15 different third-year medical students were selected to receive either a 20-min intervention or control lecture during their monthly pediatric lectures. The intervention consisted of two clinical vignettes, a brief discussion about the importance of FIP, and suggestions for clinical integration. The control session was a case-based lecture about pediatric emergencies. Participants completed baseline electronic assessments. Intervention students also completed post-intervention assessments immediately following each session. All participants completed final assessments at 6 months. Data were analyzed using Wilcoxon signed-rank tests and Wilcoxon rank-sum. RESULTS: We surveyed a total of 130 students. Sixty-five students completed the entire series of assessments - 22 from the control and 43 from the intervention group. There were no significant differences between the control and intervention groups at baseline. Immediately after, intervention, participants reported feeling more self-efficacious, had improved knowledge of FIP risk factors, and had beliefs more consistent with providing FIP anticipatory guidance (p <  0.001 for all three measures). After 6 months, participants sustained improvement in one of two self-efficacy questions ("I feel ready to counsel patients about firearm injury prevention") and retained knowledge of risk factors (p <  0.05 for both). However, their beliefs did not significantly favor FIP counseling, and they were not more likely to engage in a conversation about firearm safety. CONCLUSIONS: A 20-min educational intervention acutely improved self-efficacy in FIP counseling in third-year medical students, but improvements weakened after six months. Without further training, the beneficial effects of a one-time intervention will likely wane with time.

Urban community characteristics and adolescent assault victims.

PURPOSE: To examine the relationship between neighborhood factors and adolescent victimization for low- and high-risk areas of Milwaukee, Wis. METHODS: In this cross-sectional study, we compared neighborhood characteristics based on the US Census Database by rates of adolescent victim rates as measured through victim client enrollment in an adolescent violence intervention program. Multiple regression procedures were used to analyze the data. RESULTS: The mean adolescent assault victim rate was 34.31 per 10,000 population (Standard deviation [SD] = 29.71) with range from 0.00 to 105.09 per 10,000 population in 35 ZIP-code areas in Milwaukee County. Neighborhood ZIP codes with low median household income and high rates of grandparents serving as heads of household were associated with high rates of adolescent assault victims (R2 = 0.75). CONCLUSIONS: Urban areas with higher rates of grandparent head of household and low median household income are associated with higher rates of adolescent assault victims.

Psychosocial needs of African American youth presenting to a pediatric emergency department with assault-related injuries.

OBJECTIVE: The purpose of this study was to identify the psychosocial needs confronting African American youth assaulted in their community. METHODS: A convenience sample of 36 African American youth (mean age, 14.8 years; range, 10-18 years) who presented to a pediatric emergency department with violent interpersonal injuries was interviewed to identify the psychosocial issues they were facing. Participants also completed self-report measures of violence exposure and trauma symptoms, and their parents completed a screening measure of the youths' emotional and behavioral functioning. RESULTS: During the interview, the youth reported 178 different concerns that were content-analyzed and placed into 10 thematic categories labeled anger/aggressive behavior (78% of respondents), general internalizing symptoms (61%), peer difficulties (53%), parent/family conflict (50%), posttraumatic stress symptoms (47%), academic concerns (42%), physical health concerns (39%), safety concerns (39%), and public service concerns (17%). Elevated rates of historical violence exposure and trauma symptoms were observed on the self-report measures, and one third of the youths' parents reported levels of emotional and behavioral problems that would warrant further clinical attention. CONCLUSION: African American assault victims are experiencing a broad range of psychosocial needs. To bolster youth recovery and reduce the risk of future injury, researchers and practitioners need to identify effective methods of assessing these needs in the emergency department so that youth victims of interpersonal violence can be referred for appropriate follow-up services.

Give Wisconsin children a boost.

In the United States, more children die from motor vehicle crashes than any other cause. Research has demonstrated that children ages 4-8 have a significantly reduced risk of injury if they are restrained in booster seats rather than adult seatbelts. Despite current recommendations, few children in this age group are properly restrained. Health care providers can help increase booster seat use by educating parents, participating in community campaigns, and advocating for mandatory booster seat laws.

Emergency department management of sexually transmitted infections in US adolescents: results from the National Hospital Ambulatory Medical Care Survey.

STUDY OBJECTIVE: Adolescents are at risk for developing a variety of sexually transmitted infections for many reasons. Many of these adolescents present to the emergency department (ED) for their care. We describe the management of adolescent sexually transmitted infections in US EDs. METHODS: Data were obtained from the 1992 to 1998 National Hospital Ambulatory Medical Care Survey. All visits by adolescents aged 12 to 19 years were identified by any International Classification of Diseases, Ninth Revision code related to sexually transmitted infections. Treatment was reviewed and compared with existing guidelines from the US Centers for Disease Control and Prevention (CDC). Multivariate logistic regression was used to determine the independent association of each of the following variables on antibiotic prescribing rates: sex, race and ethnicity, hospital location, age, and insurance. RESULTS: Eighteen thousand nine hundred ninety-nine records that represented 70,693,603 adolescent visits to US EDs were identified during the 7-year study period, of which 351 records representing 1.2 million visits were for a sexually transmitted infection. Mean age was 17.1 years, and 92% were female patients. Overall, 80% of patients diagnosed with a sexually transmitted infection were treated (received antibiotics or were admitted to the hospital); 91% of patients had pelvic inflammatory disease and 71% of patients had other sexually transmitted infections. Eight percent of patients diagnosed with pelvic inflammatory disease were admitted to the hospital. However, treatment for female patients with pelvic inflammatory disease was fully compliant with CDC recommendations in only 35% of cases (95% confidence interval [CI] 19% to 45%) and partially compliant in another 45%; 20% (95% CI 12% to 31%) of patients received either no treatment or treatment not in accordance with guidelines. Male patients were more likely to be treated for sexually transmitted infection (adjusted odds ratio [OR] 6.3; 95% CI 1.0 to 38.7), and Hispanic patients were less likely (adjusted OR 0.3; 95% CI 0.1 to 0.9) to be treated. Age, insurance type, and hospital location were not a factor in receiving antibiotics. For female patients who had a sexually transmitted infection, only 43% had a pregnancy test done, and of all adolescents diagnosed with a sexually transmitted infection, only 1 (0.3%) had an HIV test performed. CONCLUSION: Significant numbers of adolescents sought care for sexually transmitted infections in US EDs. Evaluation and treatment of these adolescents is not optimal. Male patients are more likely to be treated for a sexually transmitted infection. Hispanic patients are less likely to be treated for a sexually transmitted infection. Pelvic inflammatory disease is not always treated with antibiotics, and few patients with pelvic inflammatory disease are admitted to the hospital. HIV testing was almost never done. Further study is necessary to explain these disparities and optimize care.

Patient-controlled analgesia for sickle cell pain crisis in a pediatric emergency department.

OBJECTIVE: To determine whether a protocol to start patient-controlled analgesia (PCA) in the emergency department (ED-PCA) would shorten the length of time between narcotic bolus doses and PCA initiation as compared with standard inpatient initiation of PCA (IP-PCA). Also, to compare patient satisfaction and inpatient length of stay for the 2 groups. METHODS: To improve care, we developed a protocol to institute ED-PCA after an initial bolus dose of narcotics. This was a nonrandomized pilot study. Patient records were reviewed for location of PCA initiation, time from narcotic bolus to initiation of PCA, and length of stay. A brief patient/parent satisfaction survey was collected. RESULTS: Sixty-nine records were reviewed. Patients treated using the protocol had initiation of PCA therapy within 35 +/- 7 minutes from the last bolus narcotic dose in the emergency department versus 211 +/- 17 minutes for nonprotocol patients. Forty-eight of 50 patient surveys indicated preference for starting ED-PCA; 2 did not have a preference. No complications were identified in either group. CONCLUSIONS: A protocol to initiate PCA for sickle cell patients in a pediatric emergency department shortened the time of its initiation and was preferred by patients.

Developing community coalitions in youth violence prevention.

Youth violence is a public health problem that needs input from physician leaders to support efforts in their communities. By forming and supporting community coalitions, physicians can advocate for both their individual patients and their community in order to prevent youth violence. In this article, we review the definition, structure, and specific issues of community collaborative efforts in the area of youth violence prevention.

The effectiveness of a follow-up program at improving HIV testing in a pediatric emergency department.

BACKGROUND: HIV infection is on the rise in the adolescent population, with the most common risk for infection being sexual exposure for youth aged 15-24 years. Therefore screening for HIV infection should be performed on adolescent patients presenting to the emergency department (ED) with signs or symptoms of sexually transmitted disease (STD). Lack of opportunity for follow-up of HIV test results may prevent ED physicians from obtaining this test. OBJECTIVE: Our objective was to compare the rate of HIV testing in patients evaluated in the ED for STDs before and after the implementation of a follow-up program. METHODS: We conducted a retrospective chart review of all patients 12-18 years of age seen in the ED between April 1, 1993 and March 31, 1997 with ICD-9 codes for STD. The follow-up program started April 1, 1995. Rates of HIV testing were compared between the two years before and after the institution of the follow-up program to determine whether the follow-up program had an impact on the rate of HIV testing. RESULTS: We reviewed 862 records. Before the follow-up program was in place, 86 (18%) of the patients tested for STD in the ED were also tested for HIV and only 7 (8.1%) were called back with their results. After the follow-up program was in place, 100 (27%) of the patients tested for STD in the ED were also tested for HIV. Attempts were made to notify 57 (57%) of these patients of their HIV test results. Coincident with the implementation of the follow-up program, both the rate of HIV testing and patient notification of HIV results increased (p < 0.05). CONCLUSIONS: Coincident with the institution of an appropriate follow-up system, HIV testing in the ED increased and follow-up of these patients improved. However, further steps should be taken to improve the HIV testing in the pediatric ED.

Injury prevention: opportunities in the emergency department.

Because injury is the leading cause of morbidity and mortality in young patients, emergency departments have a significant opportunity to provide injury-prevention interventions at a teachable moment. The emergency department has the ability to survey injuries in the community, use the hospital setting to screen patients, provide products, offer resources to assist families within this setting to change their risky behaviors, and connect families to community resources. With a thoughtful, collaborative approach, emergency departments are an excellent setting within which to promote injury prevention among patients and families.

Concerns and coping of African-American mothers after youth assault requiring emergency medical treatment.

OBJECTIVE: To explore maternal experience following youth assault occurring in the community. METHODS: A semistructured interview was used to elicit concerns and coping strategies among 35 African-American mothers whose children received emergency department (ED) treatment for assault-related injuries. Mothers also completed measures of violence exposure, trauma symptoms, social support, and youth functioning. RESULTS: The most common concerns involved family safety, maternal mental health, and youth externalizing behavior. Faith and social support were the most common coping strategies. High levels of distress were found, which were directly related to maternal violence exposure, relationships that required mothers to nurture others, and youth functioning. Distress was inversely related to relationships that provided guidance from others. CONCLUSION: Distress is common among low-income African-American mothers of youth assault victims. To bolster youth recovery and to reduce the risk of future injury, ED staff should be knowledgeable regarding culturally sensitive resources to address maternal distress.

Assessment of trauma symptoms among adolescent assault victims.

PURPOSE: To identify and evaluate the effectiveness of an assessment tool that could be used to assess the psychological needs of youth injured by community violence. METHODS: The Trauma Symptom Checklist for Children (TSCC) was administered to 120 adolescents participating in Project Ujima, a hospital-based program providing Emergency Department support and home-based psychosocial follow-up to victims of violent crime (mean age = 14.8 years; 72% male; 70% African-American, 19% white, 8% Latino). Participants' TSCC scores were compared with normative data using one-sample, two-tailed, Student's t-tests. Comparisons of TSCC scale scores were also made based on participant age, gender, ethnicity, and injury type using one-way multivariate analysis of variance. RESULTS: Seventeen percent of the participants scored in the clinical range on the Underreporting Scale of the TSCC, reflecting a tendency to deny common thoughts, emotions, and behaviors. Elevations on all clinical scales were modest. Males showed elevations on Underreporting and decreased trauma symptoms, in comparison to normative data and to females in the sample. CONCLUSIONS: The reported low levels of symptomatology among this sample of youth may be due, in part, to a defensive response style.