Physician orders for life-sustaining treatment and emergency medicine: ethical considerations, legal issues, and emerging trends.

Since its original development in Oregon in 1993, Physician Orders for Life-Sustaining Treatment (POLST) is quickly growing in popularity and prevalence as a method of communicating the end-of-life care preferences for the seriously ill and frail nationwide. Early evidence has suggested significant advantages over advance directives and do-not-resuscitate/do-not-intubate documents both in accuracy and penetration within relevant populations. POLST also may contribute to the quality of end-of-life care administered. Although it was designed to be as clear as possible, unexpected challenges in the interpretation and use of POLST in the emergency department do exist. In this article, we will discuss the history, ethical considerations, legal issues, and emerging trends in the use of POLST documents as they apply to emergency medicine.

Paramedic attitudes regarding prehospital analgesia.

INTRODUCTION: Although pain is a major reason why patients summon emergency medical services (EMS), prehospital medical providers administer analgesic agents at inappropriately low rates. One possible reason is the role of EMS provider attitudes. OBJECTIVE: This study was conducted to elicit attitudes that may act as impediments or deterrents to administering analgesia in the prehospital environment. METHODS: A qualitative methodology was employed. We recruited experienced paramedics, with at least one year of full-time fieldwork, from a variety of agencies in New England. We sought to include a balance of rural and urban as well as both private and hospital-based agencies. Participants at each site were selected through purposive sampling. A semistructured discussion guide was designed to elicit the paramedics' past experiences with administering analgesia, as well as reflections on their role in the care of patients in pain. Both interviews and focus groups were conducted. These sessions were recorded and transcribed verbatim. The transcripts were topic-analyzed and iteratively coded by two independent investigators utilizing the constant comparative method of Glaser and Strauss' Grounded Theory; coding ambiguities were resolved by consensus. Through a series of conceptual mapping and iterative code refinement, themes and domains were generated. RESULTS: Fifteen paramedics from five EMS agencies in three New England states were recruited. Major themes were: 1) a reluctance to administer opioids to patients without significant objective signs (e.g., deformity, hypertension); 2) a preoccupation with potential malingering; 3) ambivalence about the degree of pain control to target or to expect (e.g., aiming to "take the edge off"); 4) a fear of masking diagnostic symptoms; and 5) an aversion to aggressive dosing of opioids (e.g., initial doses of morphine did not exceed 5 mg). CONCLUSIONS: A number of potentially modifiable attitudinal barriers to appropriate pain management were revealed.

Atraumatic headache in US emergency departments: recent trends in CT/MRI utilisation and factors associated with severe intracranial pathology.

OBJECTIVES: To estimate recent trends in CT/MRI utilisation among patients seeking emergency care for atraumatic headache in the USA and to identify factors associated with a diagnosis of significant intracranial pathology (ICP) in these patients. DESIGN/SETTING/PARTICIPANTS: Data were obtained from the USA National Hospital Ambulatory Medical Care Survey of emergency department (ED) visits between 1998 and 2008. A cohort of atraumatic headache-related visits were identified using preassigned 'reason-for-visit' codes. Sample visits were weighted to provide national estimates. RESULTS: Between 1998 and 2008 the percentage of patients presenting to the ED with atraumatic headache who underwent imaging increased from 12.5% to 31.0% (p < 0.01) while the prevalence of ICP among those visits decreased from 10.1% to 3.5% (p < 0.05). The length of stay in the ED was 4.6 h (95% CI 4.4 to 4.8) for patients with headache who received imaging compared with 2.7 (95% CI 2.6 to 2.9) for those who did not. Of 18 factors evaluated in patients with headache, 10 were associated with a significantly increased odds of an ICP diagnosis: age ≥ 50 years, arrival by ambulance, triage immediacy <15 min, systolic blood pressure ≥ 160 mm Hg or diastolic blood pressure ≥ 100 mm Hg and disturbance in sensation, vision, speech or motor function including neurological weakness. CONCLUSIONS: The use of CT/MRI for evaluation of atraumatic headache increased dramatically in EDs in the USA between 1998 and 2008. The prevalence of ICP among patients who received CT/MRI declined concurrently, suggesting a role for clinical decision support to guide more judicious use of imaging.

Stage-of-change Assessment Predicts Short-term Treatment Engagement for Opioid Use Disorder Patients Initiated on Buprenorphine.

INTRODUCTION: The emergency department (ED) is an effective setting for initiating medication for opioid use disorder (MOUD); however, predicting who will remain in treatment remains a central challenge. We hypothesize that baseline stage-of-change (SOC) assessment is associated with short-term treatment retention outcomes. METHODS: This is a longitudinal cohort study of all patients enrolled in an ED MOUD program over 12 months. Eligible and willing patients were treated with buprenorphine at baseline and had addiction medicine specialist follow-up arranged. Treatment retention at 30 and 90 days was determined by review of the Prescription Drug Monitoring Program. We used uni- and multivariate logistic regression to evaluate associations between patient variables and treatment retention at 30 and 90 days. RESULTS: From June 2018-May 2019, 279 patients were enrolled in the ED MOUD program. Of those patients 151 (54.1%) and 120 (43.0%) remained engaged in MOUD treatment at 30 and 90 days, respectively. The odds of treatment adherence at 30 days were significantly higher for those with advanced SOC (preparation/action/maintenance) compared to those presenting with limited SOC (pre-contemplation/contemplation) (60.0% vs 40.8%; odds ratio 2.18; 95% confidence interval 1.15 to 4.1; P <0.05). At 30 days, multivariate logistic regression determined that advanced SOC, age >40, having medical insurance, and being employed were significant predictors of continued treatment adherence. At 90 days, advanced SOC, non-White race, age > 40, and having insurance were all significantly associated with higher likelihood of treatment engagement. CONCLUSION: Greater stage-of-change was significantly associated with MOUD treatment retention at 30 and 90 days post index ED visit.

S100b immunoassay: an assessment of diagnostic utility in minor head trauma.

BACKGROUND: Over 1.4 million patients present annually to United States (US) emergency departments with minor head trauma. Many undergo unnecessary head computed tomography (HCT). OBJECTIVES: We sought to determine the diagnostic accuracy of S100B, a central nervous system peptide, to screen for HCT+ head injury. METHODS: This study was a prospective observational study of adults with minor head trauma. Patients presenting within 6h of injury and undergoing HCT for evaluation were eligible. All HCTs were blindly reviewed for presence of a priori defined intracranial injury (HCT+). Quantitative S100B levels were determined by enzyme-linked immunosorbent assay. RESULTS: A total of 346 patients were enrolled over 12 months, mean age 48 years (± 23 years), 62% male. Twenty-two (6.4%) were HCT+. Vomiting, headache, anterograde amnesia, Glasgow Coma Scale score<15, nausea, and loss of consciousness were associated with HCT+ results. Median S100B levels were significantly elevated in HCT+ (115 ng/dL) vs. HCT- (56.0 ng/dL) patients (p=0.032). Receiver operator characteristic analysis demonstrated an area under the curve of 0.643. Sensitivity and specificity were 86% (95% confidence interval [CI] 67-96) and 37% (95% CI 29-45%) at 42 ng/dL, 91% (95% CI 72-98%) and 24% (95% CI 17-31%) at 32 ng/dL, and 96% (95% CI 78-100%) and 13% (95% CI 9-20%) at 24 ng/dL, respectively. CONCLUSION: The study demonstrates that S100B may be a sensitive but non-specific marker of HCT+ injury.

Effect of 11 September 2001 terrorist attacks in the USA on suicide in areas surrounding the crash sites.

BACKGROUND: The terrorist attacks in the USA on 11 September 2001 affected suicide rates in two European countries, whereas overall US rates remained stable. The effect on attack site rates, however, has not been studied. AIMS: To examine post-attack suicide rates in areas surrounding the three airline crash sites. METHOD: Daily mortality rates were modelled using time series techniques. Where rate change was significant, both duration and geographic scope were analysed. RESULTS: Around the World Trade Center, post-attack 180-day rates dropped significantly (t = 2.4, P = 0.0046), whereas comparison condition rates remained stable. No change was observed for Pentagon or Flight 93 crash sites. CONCLUSIONS: The differential effect by site suggests that proximity may be less important that other event characteristics. Both temporal and geographic aspects of rate fluctuation after sentinel events appear measurable and further analyses may contribute valuable knowledge about how sociological forces affect these rates.

NIH Roundtable on Opportunities to Advance Research on Neurologic and Psychiatric Emergencies.

STUDY OBJECTIVE: The Institute of Medicine Committee on the Future of Emergency Care in the United States Health System (2003) identified a need to enhance the research base for emergency care. As a result, a National Institutes of Health (NIH) Task Force on Research in Emergency Medicine was formed to enhance NIH support for emergency care research. Members of the NIH Task Force and academic leaders in emergency care participated in 3 Roundtable discussions to prioritize current opportunities for enhancing and conducting emergency care research. We identify key research questions essential to advancing the science of emergency care and discuss the barriers and strategies to advance research by exploring the collaboration between NIH and the emergency care community. METHODS: Experts from emergency medicine, neurology, psychiatry, and public health assembled to review critical areas in need of investigation, current gaps in knowledge, barriers, and opportunities. Neurologic emergencies included cerebral resuscitation, pain, stroke, syncope, traumatic brain injury, and pregnancy. Mental health topics included suicide, agitation and delirium, substances, posttraumatic stress, violence, and bereavement. RESULTS: Presentations and group discussion firmly established the need for translational research to bring basic science concepts into the clinical arena. A coordinated continuum of the health care system that ensures rapid identification and stabilization and extends through discharge is necessary to maximize overall patient outcomes. There is a paucity of well-designed, focused research on diagnostic testing, clinical decisionmaking, and treatments in the emergency setting. Barriers include the limited number of experienced researchers in emergency medicine, limited dedicated research funding, and difficulties of conducting research in chaotic emergency environments stressed by crowding and limited resources. Several themes emerged during the course of the roundtable discussion, including the need for development of (1) a research infrastructure for the rapid identification, consent, and tracking of research subjects that incorporates innovative informatics technologies, essential for future research; (2) diagnostic strategies and tools necessary to understand key populations and the process of medical decisionmaking, including the investigation of the pathobiology of symptoms and symptom-oriented therapies; (3) collaborative research networks to provide unique opportunities to form partnerships, leverage patient cohorts and clinical and financial resources, and share data; (4) formal research training programs integral for creating new knowledge and advancing the science and practice of emergency medicine; and (5) recognition that emergency care is part of an integrated system from emergency medical services dispatch to discharge. The NIH Roundtable "Opportunities to Advance Research on Neurological and Psychiatric Emergencies" created a framework to guide future emergency medicine-based research initiatives. CONCLUSION: Emergency departments provide the portal of access to the health care system for most patients with acute neurologic and psychiatric illness. Emergency physicians and colleagues are primed to investigate neurologic and psychiatric emergencies that will directly improve the delivery of care and patient outcomes.

Patient willingness to be seen by physician assistants, nurse practitioners, and residents in the emergency department: does the presumption of assent have an empirical basis?

Physician assistants (PAs), nurse practitioners (NPs), and medical residents constitute an increasingly significant part of the American health care workforce, yet patient assent to be seen by nonphysicians is only presumed and seldom sought. In order to assess the willingness of patients to receive medical care provided by nonphysicians, we administered provider preference surveys to a random sample of patients attending three emergency departments (EDs). Concurrently, a survey was sent to a random selection of ED residents and PAs. All respondents were to assume the role of patient when presented with hypothetical clinical scenarios and standardized provider definitions. Despite presumptions to the contrary, ED patients are generally unwilling to be seen by PAs, NPs, and residents. While seldom asked in practice, 79.5% of patients fully expect to see a physician regardless of acuity or potential for cost savings by seeing another provider. Patients are more willing to see residents than nonphysicians.

Post-traumatic stress and stress disorders during the COVID-19 pandemic: Survey of emergency physicians.

OBJECTIVE: Emergency physicians routinely encounter stressful clinical situations, including treating victims of crime, violence, and trauma; facing the deaths of patients; and delivering bad news. During a pandemic, stress may be increased for healthcare workers. This study was undertaken to identify symptoms of post-traumatic stress disorder (PTSD) among emergency physicians during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: This cross-sectional survey was developed using the Life Events Checklist for Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5 (DSM-5) and the PTSD Checklist for DSM-5 (PCL-5). The survey was distributed to members of the American College of Emergency Physicians from May 21, 2020, through June 22, 2020. RESULTS: Among 1300 emergency physicians, a significant number of participants (22.3%; 95% confidence interval, 20.3-24.3%) reported symptoms of stress consistent with PTSD (PCL score ≥ 33). Higher PCL-5 scores were associated with age younger than 50 years (P < 0.05) and <10 years in practice (P < 0.05). The major sources of stress identified by participants included disinformation about COVID-19, computer work/electronic medical record, personal protective equipment concerns, and workload. The most common consequences of workplace stress were feeling distant or cut off from other people and sleep disturbance, such as trouble falling or staying asleep. CONCLUSIONS: A significant number of emergency physicians reported symptoms of stress consistent with PTSD. Higher PCL-5 scores were associated with age younger than 50 years and <10 years in practice.

Open Access Medical Journals: Promise, Perils, and Pitfalls.

The number of both print and electronic open access (OA) journals has increased dramatically. Although electronic availability of information on the Internet may offer greater potential for information sharing, it also gives rise to "predatory" journals and deceptive publishers. In this Invited Commentary, the authors describe both the opportunities and potential perils that come with OA publications.Definitions for four models of legitimate OA are provided: the gold model, the green model, the platinum model, and the hybrid model. Benefits and risks of each model are discussed. The authors also distinguish between legitimate OA journals and predatory journals, highlighting several existing tools and resources for distinguishing between the two.Finally, the authors provide a checklist to help authors evaluate the policies and processes of journals and thereby avoid predatory publications.

Cardiopulmonary resuscitation: knowledge and opinions among the U.S. general public. State of the science-fiction.

BACKGROUND AND OBJECTIVE: Cardiopulmonary resuscitation is undertaken more than 250,000 times annually in the United States. This study was undertaken to determine knowledge and opinions of the general public regarding cardiopulmonary resuscitation. DESIGN: Validated multisite community-based cross-sectional survey. OUTCOME MEASURES: Knowledge and opinions about resuscitative practices and outcomes, using hypothetical clinical scenarios and other social, spiritual, and environmental considerations. RESULTS: Among 1831 participants representing 38 states, markedly inaccurate perceptions of cardiac arrest were reported. Participants' mean estimate of predicted survival rate after cardiac arrest was 54% (median 50%, IQR 35-75%), and mean estimated duration of resuscitative efforts in the ED was 28min (median 15min; IQR 10-30). Projected age and health status were independent predictors of resuscitation preferences in a series of 4 hypothetical scenarios. Participants indicated that physicians should consider patient and family wishes as the most important factors when making resuscitation decisions. Participants considered advanced technology and physician communication to be the most important actions during attempted resuscitation. CONCLUSIONS: Inaccurate perceptions regarding resuscitation and survival rates exist among the lay public. Participants indicated strong preferences regarding resuscitation and advance directives.

The transtheoretical model in intimate partner violence victimization: stage changes over time.

The transtheoretical model of behavior change (TTM) has been extended to describe the process of change in victims of intimate partner violence (IPV); however, it has not been validated over time or in a population of women experiencing IPV who are not currently in shelter. This article examines the process of change in IPV victims longitudinally and identifies factors that may relate to staging and stage progression. Fifty-three women were enrolled on presentation to an emergency department for health care treatment and completed follow-up at 3 to 4 months. Measures of TTM staging, use of community resources, ongoing abuse, mental health, and social support were collected. Cluster analyses were conducted, and descriptive summaries of clusters and significant demographic, abuse, and outcome variables related to cluster membership are presented. A five-cluster solution was selected on the basis of parsimony, theory, and overall coherence with the data. Forward progression through the stages over time was related to both the use of community resources and ending the IPV relationship.

Impact of levetiracetam on mood and cognition during prednisone therapy.

PURPOSE: Corticosteroid excess is associated with impairment in declarative memory and hippocampal changes. In animals, phenytoin blocks the effects of stress on memory and hippocampal histology. Levetiracetam also shows neuroprotective properties in some animal models. This report examines whether levetiracetam prevents mood or cognitive changes secondary to prescription corticosteroids. MATERIALS AND METHODS: Thirty outpatients given systemic corticosteroid therapy for asthma were randomized to either levetiracetam (1500 mg/day) or placebo given concurrently with the corticosteroids. Mood was assessed with the Hamilton rating scale for depression (HRSD), Young mania rating scale (YMRS) and activation (ACT) subscale of the internal state scale, declarative memory with the Rey auditory verbal learning test (RAVLT), and attention and executive functioning with the Stroop color and word test at baseline and after approximately 7 days of corticosteroid plus levetiracetam or placebo therapy. RESULTS: Levetiracetam and placebo groups showed significant improvement from baseline to exit on RAVLT total words recalled with a non-significant change on other outcomes. No significant between-group differences were found. Initial prednisone dose showed a significant correlation with change in some cognitive domains. CONCLUSIONS: Levetiracetam was well tolerated when combined with prednisone. Significant between-group differences in mood and cognition were not found.

Emergency physicians and disclosure of medical errors.

Error in medicine is a subject of continuing interest among physicians, patients, policymakers, and the general public. This article examines the issue of disclosure of medical errors in the context of emergency medicine. It reviews the concept of medical error; proposes the professional duty of truthfulness as a justification for error disclosure; examines barriers to error disclosure posed by health care systems, patients, physicians, and the law; suggests system changes to address the issue of medical error; offers practical guidelines to promote the practice of error disclosure; and discusses the issue of disclosure of errors made by another physician.

Gifts to physicians from the pharmaceutical industry: an ethical analysis.

Gifts to physicians by the pharmaceutical industry pose numerous ethical questions. Although individual patients and physicians may benefit financially and educationally from certain gifts, the risk of bias resulting from such gifts makes them ethically challenging. After a brief description of the nature and scope of the practice of gift giving, this article examines major arguments for and against this practice. We then review the development of guidelines by professional societies, trade organizations, and government agencies. We conclude with a list of summary recommendations designed to help individual physicians, educators, and administrators engage in careful reflection and analysis and make sound ethical decisions about acceptance of gifts.

Self-injury Mortality in the United States in the Early 21st Century: A Comparison With Proximally Ranked Diseases.

Importance: Fatal self-injury in the United States associated with deliberate behaviors is seriously underestimated owing to misclassification of poisoning suicides and mischaracterization of most drug poisoning deaths as "accidents" on death certificates. Objective: To compare national trends and patterns of self-injury mortality (SIM) with mortality from 3 proximally ranked top 10 causes of death: diabetes, influenza and pneumonia, and kidney disease. Data, Setting, and Participants: Underlying cause-of-death data from 1999 to 2014 were extracted for this observational study from death certificate data in the US Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research online databases. Linear time trends were compared by negative binomial regression with a log link function. Self-injury mortality was defined as a composite of suicides by any method and estimated deaths from drug self-intoxication whose manner was an "accident" or was undetermined. Main Outcomes and Measures: Mortality rates and ratios, cumulative mortality in individuals younger than 55 years, and years of life lost in 2014. Results: There were an estimated 40 289 self-injury deaths in 1999 and 76 227 in 2014. Females comprised 8923 (22.1%) of the deaths in 1999 and 21 950 (28.8%) of the 76 227 deaths in 2014. The estimated crude rate for SIM increased 65% between 1999 and 2014, from 14.4 to 23.9 deaths per 100 000 persons (rate ratio, 1.03; 95% CI, 1.03-1.04; P < .001). The SIM rate continuously exceeded the kidney disease mortality rate and surpassed the influenza and pneumonia mortality rate by 2006. By 2014, the SIM rate converged with the diabetes mortality rate. Additionally, the SIM rate was 1.8-fold higher than the suicide rate in 2014 vs 1.4-fold higher in 1999. The male-to-female ratio for SIM decreased from 3.7 in 1999 to 2.6 in 2014 (male by year: rate ratio, 0.98; 95% CI, 0.97-0.98; P < .001). By 2014, SIM accounted for 32.2 and 36.6 years of life lost for male and female decedents, respectively, compared with 15.8 and 17.3 years from diabetes, 15.0 and 16.6 years from influenza and pneumonia, and 14.5 and 16.2 years from kidney disease. Conclusions and Relevance: The burgeoning SIM [self-injury mortality] rate has converged with the mortality rate for diabetes, but there is a 6-fold differential in the proportion of SIM vs diabetes deaths involving people younger than 55 years and SIM is increasingly affecting women relative to men. Accurately characterizing, measuring, and monitoring this major clinical and public health challenge will be essential for developing a comprehensive etiologic understanding and evaluating preventive and therapeutic interventions.

Effect of phenytoin on mood and declarative memory during prescription corticosteroid therapy.

BACKGROUND: In humans and animals, corticosteroid excess is associated with impairment in declarative memory and changes in hippocampal structure. In animals, phenytoin pretreatment blocks the effects of stress on memory and hippocampal histology, although no studies have examined the use of phenytoin to prevent corticosteroid-associated memory changes in humans. Mood changes are also common with corticosteroids, but few treatment data are available. This report examines whether phenytoin can prevent mood or declarative memory changes secondary to bursts of prescription corticosteroids. METHODS: Thirty-nine patients with allergies or pulmonary or rheumatologic illnesses and given systemic corticosteroid therapy were randomized to receive either phenytoin (300 mg/day) or placebo concurrently with the corticosteroids. Mood was assessed with the Hamilton Rating Scale for Depression, Young Mania Rating Scale, and Activation (ACT) subscale of the Internal State Scale; declarative memory was assessed with the Rey Auditory Verbal Learning Test (RAVLT) at baseline and after approximately 7 days of corticosteroid plus phenytoin or placebo therapy. RESULTS: The two groups were similar in age, gender, education, and corticosteroid dose. The phenytoin-treated group showed significantly smaller increases on the ACT, a mania self-report scale, than the placebo-treated group. Groups did not differ significantly on RAVLT change scores. CONCLUSIONS: This is the first placebo-controlled study to examine whether a medication can prevent mood and memory changes secondary to corticosteroids. Phenytoin blocked the hypomanic effects of prescription corticosteroids; however, phenytoin did not block the declarative memory effects of corticosteroids.

Psychosocial and substance-use risk factors for intimate partner violence.

OBJECTIVE: Few emergency department (ED) studies have described the relationship between family violence and subsequent intimate partner violence (IPV) or accounted for partner alcohol use in IPV victimization. This study sought to identify family history and substance-use factors associated with IPV among women presenting to an urban emergency department. METHODS: Case-control study in which cases (women identified as having IPV concerns and an IPV history) and controls (women without IPV) were frequency-matched by age group and race/ethnicity. Logistic regression was performed to calculate adjusted odds ratios (AOR) for any IPV, physical IPV, and sexual IPV. RESULTS: The sample included 182 cases and 147 controls. Living with a partner (not married) and witnessing parental violence were independent risk factors for any IPV (AOR 2.55 and AOR 2.21, respectively). Partner's alcohol use (AOR 1.22 for every five drinks consumed per week) and heavier drinking (AOR 5.07) were also significant risk factors, but not subject's substance-use. The pattern of risk factors varied only slightly for physical IPV and sexual IPV. CONCLUSION: This study suggests a substantial relationship between partner alcohol use and IPV among women beyond the woman's substance-use and confirms previous reports regarding the cycle of violence in women's lives.

Psychiatric emergency service use after implementation of managed care in a public mental health system.

OBJECTIVE: This study examined whether implementation of managed care in a public mental health system affected return visits to psychiatric emergency services within 180 days of an index visit. METHODS: Data were taken from an administrative database of 75,815 patient visits made to a hospital-based psychiatric emergency service for mental health care between January 1, 1995, and December 31, 2002. Rates of return visits for patients whose index visit occurred at least 26 weeks before a system of managed care was implemented in 1999 were compared with rates for patients whose index visit occurred after the implementation but at least 26 weeks before the data collection period ended. Declining-effects modeling was used to adjust for patients' gender, ethnicity, age, and admission status. RESULTS: A total of 37,371 patients met study criteria for inclusion: 21,135 before managed care was implemented and 16,236 after managed care was implemented. In the pre-managed care group, 3,687 patients (17 percent) made a repeat visit within 26 weeks of their index visit; 2,369 patients (15 percent) in the post-managed care group made such a repeat visit. For any given index visit to the psychiatric emergency department, patients who presented for treatment after managed care were only 90 percent as likely as patients who presented before managed care to have a return visit within the first five weeks after the index visit. However, there was essentially no difference between groups in the likelihood of a return visit by week 26 after the index visit, suggesting that managed care delayed, but did not eliminate, return visits. In addition, the number of police-accompanied index visits continued to rise after managed care was implemented (from 32.0 to 52.6 percent of all index visits), suggesting that increasing numbers of patients with mental illness in need of treatment were coming to the attention of law enforcement officials after managed care was implemented. CONCLUSIONS: Managed care strategies are often used to reduce reliance on emergency services. In this study, managed care delayed, rather than prevented, return visits to the psychiatric emergency service.

Is there a relationship between victim and partner alcohol use during an intimate partner violence event? Findings from an urban emergency department study of abused women.

OBJECTIVE: This study sought to identify factors associated with drinking during an intimate partner violence (IPV) event among abused women presenting to an urban emergency department (ED). METHODS: We use a cross-sectional study of IPV cases among adult female patients seen at an urban ED. Bivariate and logistic regression analyses were performed to identify substance use factors associated with an abused woman drinking while victimized or perpetrating IPV. RESULTS: Among the 182 cases, an increased number of drinks per week, consuming five or more drinks per occasion, alcohol abuse and dependence, and illicit drug use were significantly associated with the abused woman's drinking while victimized or perpetrating IPV Partner's drinking five or more drinks per occasion was associated only with the woman's drinking while victimized. Partners were more likely to drink while perpetrating IPV in the relationship whether or not the woman drank while victimized. Among couples in which the abused woman also perpetrated violence, the partner's drinking more closely paralleled the woman's drinking in events perpetrated by the woman. Independent risk factors associated with the abused woman drinking during victimization included number of drinks she consumed per week (adjusted odds ratio [adj. OR] = 1.31 for every five drinks) and her illicit drug use (adj. OR = 4.3). The odds of an abused woman drinking while perpetrating IPV increased 1.4 times for every five drinks she consumed per week. CONCLUSIONS: These findings suggest that alcohol-related behavior by both couples and individuals are important factors to consider in the relationship between IPV and alcohol use in this population.