Between Emergency Department Visits: The Role of Harm Reduction Programs in Mitigating the Harms Associated With Injection Drug Use.

Injection drug use is a major public health problem in the United States. Cocaine, heroin, and methamphetamine are the most commonly injected illicit drugs, whereas opioids are responsible for the majority of overdose fatalities. Although recent emergency department (ED) efforts have focused on expanding capacity for buprenorphine induction for opioid use disorder treatment, the injection of illicit drugs carries specific health risks that require acknowledgment and management, particularly for patients who decline substance use treatment. Harm reduction is a public health approach that aims to reduce the harms associated with a health risk behavior, short of eliminating the behavior itself. Harm-reduction strategies fundamental to emergency medicine include naloxone distribution for opioid overdose. This clinical Review Article examines the specific health complications of injection drug use and reviews the evidence base for 2 interventions effective in reducing morbidity and mortality related to drug injection, irrespective of the specific drug used, that are less well known and infrequently leveraged by emergency medicine clinicians: syringe service programs and supervised injection facilities. In accordance with the recommendations of health authorities such as the Centers for Disease Control and Prevention, emergency clinicians can promote the use of harm-reduction programs in the community to reduce viral transmission and other risks of injection drug use by providing patients with information about and referrals to these programs after injection drug use-related ED visits.

Intimate Partner Violence and Sexual Violence.

Intimate partner violence and sexual violence represent significant public health challenges that carry many individual and societal costs. More than 1 in 3 women (35.6%) and more than 1 in 4 men (28.5%) in the United States have experienced rape, physical violence, and/or stalking by an intimate partner in their lifetime. Clinicians play an integral role on the screening, identification, and management of these sensitive issues.

From delay to diagnosis: Chronic invasive fungal rhinosinusitis presenting with facial and orbital complications.

Key Clinical Message: Early identification and management of chronic invasive fungal rhinosinusitis (CIFRS) is key to optimizing outcomes. A missed diagnosis can result in permanent vision loss, chronic facial pain, or death. We present a case of CIFRS and literature review. Abstract: This case report presents a 56-year-old female with CIFRS involving orbital and facial complications. The patient experienced delayed diagnosis despite multiple ED visits for sinusitis with progressive facial pain and ocular deficits not alleviated with antibiotics, emphasizing the importance of early identification and maintaining high clinical suspicion for CIFRS. Prompt recognition, initiation of antifungal therapy, and aggressive surgical debridement were crucial for preventing disease progression and improving the patient's quality of life.

Race, Healthcare, and Health Disparities: A Critical Review and Recommendations for Advancing Health Equity.

An overwhelming body of evidence points to an inextricable link between race and health disparities in the United States. Although race is best understood as a social construct, its role in health outcomes has historically been attributed to increasingly debunked theories of underlying biological and genetic differences across races. Recently, growing calls for health equity and social justice have raised awareness of the impact of implicit bias and structural racism on social determinants of health, healthcare quality, and ultimately, health outcomes. This more nuanced recognition of the role of race in health disparities has, in turn, facilitated introspective racial disparities research, root cause analyses, and changes in practice within the medical community. Examining the complex interplay between race, social determinants of health, and health outcomes allows systems of health to create mechanisms for checks and balances that mitigate unfair and avoidable health inequalities. As one of the specialties most intertwined with social medicine, emergency medicine (EM) is ideally positioned to address racism in medicine, develop health equity metrics, monitor disparities in clinical performance data, identify research gaps, implement processes and policies to eliminate racial health inequities, and promote anti-racist ideals as advocates for structural change. In this critical review our aim was to (a) provide a synopsis of racial disparities across a broad scope of clinical pathology interests addressed in emergency departments-communicable diseases, non-communicable conditions, and injuries-and (b) through a race-conscious analysis, develop EM practice recommendations for advancing a culture of equity with the potential for measurable impact on healthcare quality and health outcomes.

Workplace violence in emergency medicine: current knowledge and future directions.

BACKGROUND: Workplace violence (WPV) has increasingly become commonplace in the United States (US), and particularly in the health care setting. Assaults are the third leading cause of occupational injury-related deaths for all US workers. Among all health care settings, Emergency Departments (EDs) have been identified specifically as high-risk settings for WPV. OBJECTIVE: This article reviews recent epidemiology and research on ED WPV and prevention; discusses practical actions and resources that ED providers and management can utilize to reduce WPV in their ED; and identifies areas for future research. A list of resources for the prevention of WPV is also provided. DISCUSSION: ED staff faces substantially elevated risks of physical assaults compared to other health care settings. As with other forms of violence including elder abuse, child abuse, and domestic violence, WPV in the ED is a preventable public health problem that needs urgent and comprehensive attention. ED clinicians and ED leadership can: 1) obtain hospital commitment to reduce ED WPV; 2) obtain a work-site-specific analysis of their ED; 3) employ site-specific violence prevention interventions at the individual and institutional level; and 4) advocate for policies and programs that reduce risk for ED WPV. CONCLUSION: Violence against ED health care workers is a real problem with significant implications to the victims, patients, and departments/institutions. ED WPV needs to be addressed urgently by stakeholders through continued research on effective interventions specific to Emergency Medicine. Coordination, cooperation, and active commitment to the development of such interventions are critical.

Symptoms and Physical Exam Findings in Sexual Assault-related Non-fatal Strangulation.

OBJECTIVE: Our goal was to investigate the frequency of specific signs and symptoms following sexual assault-related non-fatal strangulation (NFS) and to explore the interaction between assault characteristics and physical exam findings. METHODS: This retrospective observational study included all adults (>18 years) reporting strangulation during sexual assault who presented for a forensic sexual assault exam at one of six urban community hospitals contracted with a single forensic nurse agency. Demographic information, narrative elements, and physical exam findings were abstracted from standardized sexual assault reporting forms. We analyzed data with descriptive statistics and compared specific variables using chi-square testing. RESULTS: Of the 580 subjects 99% were female, with a median age of 27 (interquartile range 22-35 years). The most common injury location was the neck (57.2%), followed by the mouth (29.1%). We found that 19.1% of the victims had no injuries evident on physical exam and 29.8% reported a loss of consciousness. Eye/eyelid and neck findings did not significantly differ between subjects who reported blows to the head in addition to strangulation and those who did not. The time that elapsed between assault and exam did not significantly correlate with the presence of most head and torso physical exam findings, except for nose injury (P = 0.02). CONCLUSION: Slightly more than half of the victims who reported strangulation during sexual assault had visible neck injuries. Other non-anogenital findings were present even less frequently, with a substantial portion of victims having no injuries documented on physical exam. The perpetrators' use of blows to the head may account for many of the non-anogenital injuries observed, but not for the neck and eye/eyelid injuries, which may be more specific to non-fatal strangulation. More research is needed to definitively establish strangulation as the causal mechanism for these findings, and to determine whether any long-term neurologic or vascular sequelae resulted from the observed injuries.

Approach considerations for the management of strangulation in the emergency department.

Patients with a history of strangulation present to the emergency department with a variety of different circumstances and injury patterns. We review the terminology, pathophysiology, evaluation, management, and special considerations for strangulation injuries, including an overview of forensic considerations and legal framework for strangulation events.

Impact of participation in a community-based intimate partner violence prevention program on medical students: a multi-center study.

BACKGROUND: Physicians are generally poorly trained to recognize, treat or refer adolescents at risk for intimate partner violence (IPV). Participation in community programs may improve medical students' knowledge, skills, and attitudes about IPV prevention. OBJECTIVE: To determine whether the experience of serving as educators in a community-based adolescent IPV prevention program improves medical students' knowledge, skills, and attitudes toward victims of IPV, beyond that of didactic training. PARTICIPANTS: One hundred and seventeen students attending 4 medical schools. DESIGN: Students were randomly assigned to didactic training in adolescent IPV prevention with or without participation as educators in a community-based adolescent IPV prevention program. Students assigned to didactic training alone served as community educators after the study was completed. MEASUREMENT: Knowledge, self-assessment of skills and attitudes about intimate partner violence and future plans to pursue outreach work. RESULTS: The baseline mean knowledge score of 10.25 improved to 21.64 after didactic training (p

Sexual assault nurse examiners' application of statutory rape reporting laws.

INTRODUCTION: The objective of this study was to compile a list of current state laws that mandate medical providers' reporting of statutory rape and assess the subjective interpretation of such laws by sexual assault nurse examiners (SANEs) throughout the country. METHODS: We contacted an SANE representative from each state by use of the International Association of Forensic Nurses' Web site to obtain information on his or her interpretation of the respective state's statutory rape reporting laws. We compared current state laws and SANE interpretation of such laws with legal interpretation of state laws 5 years previously. RESULTS: According to practitioners, the number of states that legislate mandatory reporting has increased over the past 5 years. State law routinely mandates reporting in 26 states and does not mandate reporting in 10 states. In 3 of those 10, the law prohibits reporting. The law requires reporting only under certain conditions in 14 states. DISCUSSION: Practitioner interpretation of state laws regarding definitions and mandatory reporting of statutory rape varies widely from state to state, and these laws have changed significantly in many states over the past 5 years. Practitioners wishing to comply with state reporting laws require updated legislation information.

Systems Opportunities to Reduce ED Crowding From Nonemergency Referrals.

Emergency department (ED) crowding threatens patient safety and is associated with increased mortality. This study explored the role of nonurgent referrals to the ED in crowding and collaborated on a large quality initiative with the study institution's accountable care organization (ACO) to provide timely alternatives to such referrals. Fifty-two percent of nonemergent ED patients report contacting a medical provider prior to coming to the ED, with 70% of those providers directing the patient to go to the ED. Fifty-nine percent of patients indicated that they would have accepted a clinic appointment in lieu of going to the ED. The authors collaborated on a multidisciplinary ED alternatives quality improvement effort with leadership to address these nonemergent referrals. ED visits per 1000 ACO patients declined significantly following survey results and ACO implementation of increased alternative ambulatory resources.

Effectiveness of SBIRT for Alcohol Use Disorders in the Emergency Department: A Systematic Review.

INTRODUCTION: Alcohol use disorders (AUD) place a significant burden on individuals and society. The emergency department (ED) offers a unique opportunity to address AUD with brief screening tools and early intervention. We undertook a systematic review of the effectiveness of ED brief interventions for patients identified through screening who are at risk for AUD, and the effectiveness of these interventions at reducing alcohol intake and preventing alcohol-related injuries. METHODS: We conducted systematic electronic database searches to include randomized controlled trials of AUD screening, brief intervention, referral, and treatment (SBIRT), from January 1966 to April 2016. Two authors graded and abstracted data from each included paper. RESULTS: We found 35 articles that had direct relevance to the ED with enrolled patients ranging from 12 to 70 years of age. Multiple alcohol screening tools were used to identify patients at risk for AUD. Brief intervention (BI) and brief motivational intervention (BMI) strategies were compared to a control intervention or usual care. Thirteen studies enrolling a total of 5,261 participants reported significant differences between control and intervention groups in their main alcohol-outcome criteria of number of drink days and number of units per drink day. Sixteen studies showed a reduction of alcohol consumption in both the control and intervention groups; of those, seven studies did not identify a significant intervention effect for the main outcome criteria, but nine observed some significant differences between BI and control conditions for specific subgroups (i.e., adolescents and adolescents with prior history of drinking and driving; women 22 years old or younger; low or moderate drinkers); or secondary outcome criteria (e.g. reduction in driving while intoxicated). CONCLUSION: Moderate-quality evidence of targeted use of BI/BMI in the ED showed a small reduction in alcohol use in low or moderate drinkers, a reduction in the negative consequences of use (such as injury), and a decline in ED repeat visits for adults and children 12 years of age and older. BI delivered in the ED appears to have a short-term effect in reducing at-risk drinking.

Preventive care in the emergency department: screening for domestic violence in the emergency department.

OBJECTIVES: The most effective methods for identification and management of domestic violence (DV) victims in health care settings are unknown. The objective of this study was to systematically review screening for DV in the emergency department (ED) to identify victims and decrease morbidity and mortality from DV. METHODS: Using the terms "domestic violence" or "partner violence," and "identification" or "screening," and "emergency," the authors searched MEDLINE, the Cochrane Database, and Emergency Medical Abstracts from 1980-2002. They selected articles studying screening tools, interventions, or determining the incidence or prevalence of DV among ED patients. The studies were analyzed using evidence-based methodology. RESULTS: Three hundred thirty-nine articles resulted from the literature search. Based on selection criteria, 45 were reviewed in detail and 17 pertained to the ED. From references of these 17 articles, three additional articles were added. Screening can be conducted using a brief verbal screen and existing ED personnel. A randomized, controlled trial did not demonstrate a difference in screening rates between experimental and control hospitals. No studies assessed the effect of ED screening for DV on morbidity or mortality of domestic violence. An ED-based advocacy program resulted in increased use of shelters and counseling. CONCLUSIONS: Because of the paucity of outcomes research evaluating ED screening and interventions, there is insufficient evidence for or against DV screening in the ED. However, because of the high burden of suffering caused by DV, health care providers should strongly consider routinely inquiring about DV as part of the history, at a minimum for all female adolescent and adult patients.

Predictors of genitorectal injury in female victims of suspected sexual assault.

OBJECTIVE: Legal decisions in sexual assault cases often hinge on the presence or absence of genitorectal injury. Unfortunately, the forensic literature does not explain why some victims sustain genitorectal injury and others do not. This study explores possible predictors of genitorectal injury in adult female sexual assault victims. METHODS: This retrospective cross-sectional analysis forms the derivation set for a larger planned prospective analysis. The authors extracted data describing consecutive female sexual assault victims who met inclusion criteria between July 1995 and July 1998. Exclusion criteria included male sex, lack of estrogen in females, consensual intercourse within the previous 72 hours, and lack of penetration during the assault. The authors explored associations between genitorectal injury and seven demographic variables, nine assault characteristics, and the time between assault and exam or postcoital interval (PCI). Variables thought to be predictive were incorporated into a logistic regression model. RESULTS: Five hundred forty-eight sexual assault victims were seen during the study time period; 209 of these met the inclusion criteria. Logistic regression controlling for important covariates showed an increase risk of genitorectal injury with a PCI < 24 hours (OR 7.47, 95% CI = 1.78 to 31.35), physical/verbal resistance (OR 5.96, 95% CI = 1.21 to 29.36), rectal penetration (OR 7.47, 95% CI = 1.05 to 53.07), and greater than high school education (OR 7.13, 95% CI = 1.03 to 49.65). CONCLUSIONS: This study presents an important first look at variables that may predict genitorectal injury in sexual assault victims. Future studies that examine more data are needed to corroborate this preliminary derivation set analysis.

Sexual assault.

Sexual assault is a problem that permeates all socioeconomic classes and impacts hundreds of thousands in the United States and millions worldwide. Most victims do not report the assault; those that do often present to an emergency department. Care must encompass the patients' physical and emotional needs. Providers must be cognizant regarding handling of evidence and possible legal ramifications. This article discusses the emergency medicine approach to history taking, physical examination, evidence collection, chain of custody, psychological and medical treatment, and appropriate follow-up. Special circumstances discussed include intimate partner violence, male examinations, pediatric examinations, suspect examinations, and drug-facilitated assaults.

Reliability of female genital injury detection after sexual assault.

OBJECTIVE: To establish inter-rater reliability for genital injury detection among experienced forensic sexual assault (SA) examiners. METHODS: Cross-sectional observational study testing inter-rater agreement of injury assessment among eight experienced SA examiners who each viewed 2-4 digital images from 50 cases. Each case was rated by 4 examiners and included images before and after toluidine blue dye application. We calculated overall agreement and kappa (κ). RESULTS: Examiners had perfect agreement in 60 cases; in 24 cases 3 examiners agreed; in 5 cases 2 agreed and 1 was unsure; and in 9 cases there were 2 "yes" and 2 "no" ratings or 1 "yes," 1 "no," and 2 "unsure" ratings. Overall agreement was 82% (κ, 0.57) when yes|unsure and no|unsure combinations equaled disagreement and 86% (κ, 0.66) when only yes|no dyads equaled disagreement. Neither the number of images nor any single examiner fundamentally influenced results. Highly experienced examiners tended to agree with each other (86%) slightly more often than moderate examiners agreed with each other (75%). CONCLUSIONS: Our set of experienced forensic examiners achieved moderate inter-rater agreement in assessment of the presence of female genital injury on selected digital images obtained during SA examination.