Human Trafficking: A Guide to Identification and Approach for the Emergency Physician.

Human trafficking is a significant human rights problem that is often associated with psychological and physical violence. There is no demographic that is spared from human trafficking. Traffickers maintain control of victims through physical, sexual, and emotional violence and manipulation. Because victims of trafficking seek medical attention for the medical and psychological consequences of assault and neglected health conditions, emergency clinicians are in a unique position to recognize victims and intervene. Evaluation of possible trafficking victims is challenging because patients who have been exploited rarely self-identify. This article outlines the clinical approach to the identification and treatment of a potential victim of human trafficking in the emergency department. Emergency practitioners should maintain a high index of suspicion when evaluating patients who appear to be at risk for abuse and violence, and assess for specific indicators of trafficking. Potential victims should be evaluated with a multidisciplinary and patient-centered technique. Furthermore, emergency practitioners should be aware of national and local resources to guide the approach to helping identified victims. Having established protocols for victim identification, care, and referrals can greatly facilitate health care providers' assisting this population.

Resident Supervision and Patient Safety: Do Different Levels of Resident Supervision Affect the Rate of Morbidity and Mortality Cases?

BACKGROUND: In our academic emergency department, our senior residents lead their own patient care team, known as the red team (RT). Attending physicians are responsible for managing their own team (AT) and precepting the senior resident's cases. OBJECTIVE: We hypothesized that the RT would have the same number of morbidity and mortality (M&M) cases and similar numbers of adverse outcomes as the AT. We also hypothesized that there would be no increase in M&M cases during the first quarter of every academic year. METHODS: We obtained data from M&M cases from 2009-2013, including month and year of patient visit, standard of care code (SoCC), and whether the patient was seen by the RT or an AT. Data were analyzed using a χ(2) test comparing expected outcomes with observed outcomes. RESULTS: There was a total of 117 M&M cases during the study period with a SoCC ≥ 3; 76 cases were AT and 41 cases were RT. There was no statistically significant difference between expected and observed number of cases. Mean RT and AT SoCCs were 4.03 and 4.23, respectively. There was no statistically significant difference between the two groups for SoCC. Mean SoCC was not significantly different for the first quarter of the year. CONCLUSIONS: We found that our patient care model did not lead to an increased number of M&M cases and RT cases were not associated with worse outcomes overall. Additionally, there was no increased rate of M&M cases in the beginning of the academic year.

Increased rates of rapid point-of-care HIV testing using patient care technicians to perform tests in the ED.

BACKGROUND: Various emergency department (ED) HIV testing models are reported in the literature but may not all be sustainable. We sought to determine whether changing an ED rapid HIV testing program from counselor-based to ED technician-based resulted in more testing. METHODS: We evaluated data from an ED rapid HIV testing program. Triage nurses offered testing to patients. In 2009, counselors performed rapid testing weekdays from 10:00 am to 6:00 pm. In 2010, ED technicians were trained to perform the test and replaced counselors. We compared the numbers of tests performed during the same 6-month periods in 2009 and 2010. Study personnel abstracted results through medical record review. RESULTS: A total of 241 oral tests were performed in 2009 compared with 1483 in 2010, representing slightly more than a 6-fold increase. In 2010, there was a steady increase in testing month by month. Incorporating patient volume, testing rates increased from 1.3% to 8.1%. Oral testing yielded no positive test results in 2009, but 7 individuals (0.47%) tested newly positive during the testing period of 2010. Of those with a documented CD4 count within 100 days of the positive result, 4 of 5 had CD4 counts less than 200. CONCLUSIONS: We present a novel approach to HIV testing using existing staff within the ED. This new ED technician-based model led to large increases in rates of testing.

Computed tomography use in the adult emergency department of an academic urban hospital from 2001 to 2007.

STUDY OBJECTIVE: There is both increasing recognition and growing scrutiny of the increased utilization of computed tomography (CT) in medicine. For our primary objective, we determine and quantify the CT utilization rate in our emergency department (ED) during the last 7 years. As a secondary objective, we compare trends in utilization for various types of CT scans. METHODS: We performed an electronic chart review at our inner-city, academic ED with an annual census of 110,000 patients. We identified all patients older than 21 years who had a CT scan performed during ED management from January 2001 to December 2007. Specific, predetermined data elements (eg, subject demographics, type of CT scan) were extracted on standardized data forms by trained abstractors. We analyzed our data with standard descriptive statistics and linear regression. RESULTS: The rate of CT utilization increased steadily at approximately 10 CTs per 1,000 (95% confidence interval 7.5 to 13.6 CTs) patients annually during our study period, from 51 per 1,000 patient visits in 2001 to 106 per 1,000 in 2007. Among these CTs, chest CTs increased most, with a 6-fold increase from 1 [corrected] per 1,000 patient visits to 6 [corrected] per 1,000. Neck CTs increased by 5-fold, from 2 [corrected] per 1,000 patient visits to 10 [corrected] per 1,000 patients. Similarly, the utilization of abdomen-pelvis CTs, facial bone CTs, and head CTs increased from 13 per 1,000 to 33 per 1,000 patient visits (150%), 1 per 1,000 to 2 per 1,000 patient visits (100%), and 33 per 1,000 to 53 per 1,000 patient visits (60%), respectively. CONCLUSION: Recent CT utilization in our ED increased in all anatomic categories assessed, with chest CTs and neck CTs increasing the most, followed by abdomen-pelvis CTs, facial bone CTs, and head CTs.

Falling through the cracks? Missed opportunities for earlier HIV diagnosis in a New York City Hospital.

Summary Newly diagnosed HIV-positive patients have frequent health care encounters prior to diagnosis representing missed opportunities for diagnosis. This study determines the proportion of patients with new HIV diagnoses with encounters in the 3 years prior to diagnosis. We describe the characteristics of newly diagnosed patients and of "late testers" (CD4 <200 cells/mm(3) at the time of diagnosis). We identified all newly diagnosed with HIV in emergency department, inpatient, and outpatient settings between May 1, 2006, and December 31, 2009. Data abstractors searched hospital records to identify all emergency department, inpatient, and outpatient visits for the 3 years prior to diagnosis. In all, 23,271 HIV tests were performed and 253 persons were newly diagnosed (1.1%); 152 new positives (60.1%) made at least one prior visit. Of patients with CD4 counts available, 104/175 (59.4%) had CD4 <200 cells/mm(3). Patients with at least one prior visit had a median of three. There was no difference in numbers of visits between late testers and non-late testers, although late testers were more likely to have ED visits. Most newly diagnosed HIV-positive patients had multiple encounters prior to diagnosis. Many of these patients presented with CD4 counts below 200 cells/mm(3), indicating true missed opportunities for earlier diagnosis.