Contraception Initiation in the Emergency Department: A Pilot Study on Providers' Knowledge, Attitudes, and Practices.

OBJECTIVES: Almost half of all pregnancies in the United States are unintended; these pregnancies are associated with adverse outcomes. Many reproductive-age females seek care in the emergency department (ED), are at risk of pregnancy, and are amenable to contraceptive services in this setting. Through a pilot study, we sought to assess ED providers' current practices; attitudes; and knowledge of emergency contraception (EC) and nonemergency contraception (non-EC), as well as barriers with respect to contraception initiation. METHODS: ED physicians and associate providers in Georgia were e-mailed a link to an anonymous Internet questionnaire using state professional databases and contacts. The questionnaire included Likert scales with multiple-choice questions to assess study objectives. Descriptive statistics were generated as well as univariate analyses using χ(2) and Fisher exact tests. RESULTS: A total of 1232 providers were e-mailed, with 119 questionnaires completed. Participants were predominantly physicians (80%), men (59%), and individuals younger than 45 years (59%). Common practices were referrals (96%), EC prescriptions (77%), and non-EC prescriptions (40%). Common barriers were perceived as low likelihood for follow-up (63%), risk of complications (58%), and adverse effects (51%). More than 70% of participants correctly identified the highly effective contraceptive methods, 3% identified the correct maximum EC initiation time, and 42% correctly recognized pregnancy as a higher risk than hormonal contraception use for pulmonary embolism. CONCLUSIONS: Most ED providers in this pilot study referred patients for contraception; however, there was no universal contraceptive counseling and management. Many ED providers in this study had an incorrect understanding of the efficacy, risks, and eligibility associated with contraceptive methods. This lack of understanding may affect patient access and be a barrier to patient care.

A Comparison of Parallel and Integrated Models for Implementation of Routine HIV Screening in a Large, Urban Emergency Department.

OBJECTIVE: This study compared two approaches for implementation of non-targeted HIV screening in the emergency department (ED): (1) designated HIV counselors screening in parallel with ED care and (2) nurse-based screening integrated into patient triage. METHODS: A retrospective analysis was performed to compare parallel and integrated screening models using data from the first 12 months of each program. Data for the parallel screening model were extracted from information collected by HIV test counselors and the electronic medical record (EMR). Integrated screening model data were extracted from the EMR and supplemented by data collected by HIV social workers during patient interaction. For both programs, data included demographics, HIV test offer, test acceptance or declination, and test result. A Z-test between two proportions was performed to compare screening frequencies and results. RESULTS: During the first 12 months of parallel screening, approximately 120,000 visits were made to the ED, with 3,816 (3%) HIV tests administered and 65 (2%) new diagnoses of HIV infection. During the first 12 months of integrated screening, 111,738 patients were triaged in the ED, with 16,329 (15%) patients tested and 190 (1%) new diagnoses. Integrated screening resulted in an increased frequency of HIV screening compared with parallel screening (0.15 tests per ED patient visit vs. 0.03 tests per ED patient visit, p<0.001) and an increase in the absolute number of new diagnoses (190 vs. 65), representing a slight decrease in the proportion of new diagnoses (1% vs. 2%, p=0.007). CONCLUSION: Non-targeted, integrated HIV screening, with test offer and order by ED nurses during patient triage, is feasible and resulted in an increased frequency of HIV screening and a threefold increase in the absolute number of newly identified HIV-positive patients.

Kiosk versus in-person screening for alcohol and drug use in the emergency department: patient preferences and disclosure.

INTRODUCTION: Annually eight million emergency department (ED) visits are attributable to alcohol use. Screening ED patients for at-risk alcohol and substance use is an integral component of screening, brief intervention, and referral to treatment programs, shown to be effective at reducing substance use. The objective is to evaluate ED patients' acceptance of and willingness to disclose alcohol/substance use via a computer kiosk versus an in-person interview. METHODS: This was a cross-sectional, survey-based study. Eligible participants included those who presented to walk-in triage, were English-speaking, ≥18 years, were clinically stable and able to consent. Patients had the opportunity to access the kiosk in the ED waiting room, and were approached for an in-person survey by a research assistant (9am-5pm weekdays). Both surveys used validated assessment tools to assess drug and alcohol use. Disclosure statistics and preferences were calculated using chi-square tests and McNemar's test. RESULTS: A total of 1,207 patients were screened: 229 in person only, 824 by kiosk, and 154 by both in person and kiosk. Single-modality participants were more likely to disclose hazardous drinking (p=0.003) and high-risk drug use (OR=22.3 [12.3-42.2]; p<0.0001) via kiosk. Participants who had participated in screening via both modalities were more likely to reveal high-risk drug use on the kiosk (p=0.003). When asked about screening preferences, 73.6% reported a preference for an in-person survey, which patients rated higher on privacy and comfort. CONCLUSION: ED patients were significantly more likely to disclose at-risk alcohol and substance use to a computer kiosk than an interviewer. Paradoxically patients stated a preference for in-person screening, despite reduced disclosure to a human screener.

Screening for violence risk factors identifies young adults at risk for return emergency department visit for injury.

INTRODUCTION: Homicide is the second leading cause of death among youth aged 15-24. Prior cross-sectional studies, in non-healthcare settings, have reported exposure to community violence, peer behavior, and delinquency as risk factors for violent injury. However, longitudinal cohort studies have not been performed to evaluate the temporal or predictive relationship between these risk factors and emergency department (ED) visits for injuries among at-risk youth. The objective was to assess whether self-reported exposure to violence risk factors in young adults can be used to predict future ED visits for injuries over a 1-year period. METHODS: This prospective cohort study was performed in the ED of a Southeastern US Level I trauma center. Eligible participants were patients aged 18-24, presenting for any chief complaint. We excluded patients if they were critically ill, incarcerated, or could not read English. Initial recruitment occurred over a 6-month period, by a research assistant in the ED for 3-5 days per week, with shifts scheduled such that they included weekends and weekdays, over the hours from 8AM-8PM. At the time of initial contact in the ED, patients were asked to complete a written questionnaire, consisting of previously validated instruments measuring the following risk factors: a) aggression, b) perceived likelihood of violence, c) recent violent behavior, d) peer behavior, e) community exposure to violence, and f) positive future outlook. At 12 months following the initial ED visit, the participants' medical records were reviewed to identify any subsequent ED visits for injury-related complaints. We analyzed data with chi-square and logistic regression analyses. RESULTS: Three hundred thirty-two patients were approached, of whom 300 patients consented. Participants' average age was 21.1 years, with 60.1% female, 86.0% African American. After controlling for participant gender, ethnicity, or injury complaint at time of first visit, return visits for injuries were significantly associated with: hostile/aggressive feelings (Odds ratio (OR) 3.5, 95% Confidence interval (CI): 1.3, 9.8), self-reported perceived likelihood of violence (OR 10.1, 95% CI: 2.5, 40.6), and peer group violence (OR 6.7, 95% CI: 2.0, 22.3). CONCLUSION: A brief survey of risk factors for violence is predictive of increased probability of a return visit to the ED for injury. These findings identify a potentially important tool for primary prevention of violent injuries among at-risk youth seen in the ED for trauma-related and non-traumatic complaints.

Prevalence of Exposure to Risk Factors for Violence among Young Adults Seen in an Inner-City Emergency Department.

INTRODUCTION: To assess the prevalence of risk factors for violent injury among young adults treated at an urban emergency department (ED). METHODS: This study is a cross-sectional analysis of data collected as part of a longitudinal study. Enrollment took place in an urban ED in a Level 1 trauma center, June through December 2010. All patients aged 18-24 years were eligible. Patients were excluded if they were incarcerated, critically ill, or unable to read English. Study participants completed a 10-minute multiple-choice questionnaire using previously validated scales: a) aggression, b) perceived likelihood of violence, c) recent violent behavior, d) peer behavior, and e) community exposure to violence. RESULTS: 403 eligible patients were approached, of whom 365 (90.1%) consented to participate. Average age was 21.1 (95% confidence interval: 20.9, 21.3) years, and participants were 57.2% female, 85.7% African American, and 82.2% were educated at the high school level or beyond. Among study participants, rates of high-risk exposure to individual risk factors ranged from 7.4% (recent violent behavior) to 24.5% (exposure to community violence), with 32.3% of patients showing high exposure to at least one risk factor. When comparing participants by ethnicity, no significant differences were found between White, African-American, and Hispanic participants. Males and females differed significantly only on 1 of the scales - community violence, (20.4% of males vs. 30.3% of females, p= 0.03). Self-reported hostile/aggressive feelings were independently associated with initial presentation for injury-associated complaint after controlling for age, sex, and race (odds ratio 3.48 (1.49-8.13). CONCLUSION: Over 30% of young adults presenting to an urban ED reported high exposure to risk factors for violent injury. The high prevalence of these risk factors among ED patients highlights the potential benefit of a survey instrument to identify youth who might benefit from a targeted, ED-based violence prevention program.

The Emergency Department as a prevention site: a demographic analysis of substance use among ED patients.

OBJECTIVES: To identify rates of alcohol and drug use among patients presenting to an inner-city Emergency Department (ED) and to describe demographic and health characteristics of patients with high-risk use. METHODS: A cross-sectional study of patients presenting to the ED for any complaint. Patients were administered a brief screening about past 12-months alcohol and drug use. Patients who answered "yes" to any question were approached for a longer survey, the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). Based on ASSIST scores patients received a brief intervention, and, when appropriate, a referral for brief outpatient therapy or specialized substance abuse treatment. Patients whose score indicated high-risk or dependent use were also asked demographic and health questions. RESULTS: Over a 20-month period, 19,055 patients were pre-screened. 87.1% of patients were black, 57% were male, with average age 44.8 years. 27.6% of patients pre-screened positive for drug or alcohol use; among these patients 44.2% scored in the low-risk range on the ASSIST, 35.8% moderate risk, 10% high risk and 10% probable dependence. Among patients with high-risk or dependent use, 70% rated their current health as fair/poor, with a mean of 1.7 ED visits in the prior 30 days. 40.7% reported "extreme" stress due to their use. 34.6% reported that they had stable housing and 13.6% were fully employed. CONCLUSION: Among all patients seen in the ED for any complaint, a significant proportion is engaged in alcohol and drug use that increases their risk of health and social consequences.

Effect of a Targeted Women's Health Intervention in an Inner-City Emergency Department.

Objective. To evaluate the effect of an Emergency Department (ED) based, educational intervention for at-risk health behaviors. Methods. A randomized trial over a one-year period. African American women, aged 21-55, presenting to the ED waiting room were eligible. Each participant took a computer-based survey on health risk behaviors. Participants who screened positive on any of four validated scales (for IPV, nicotine, alcohol, or drug dependence) were randomized to standard information about community resources (control) or to targeted educational handouts based upon their screening results (intervention). Participants were surveyed at 3 months regarding contacts with community resources and harm-reduction actions. Results. 610 women were initially surveyed; 326 screened positive (13.7% for IPV, 40.1% for nicotine addiction, 26.6% for alcohol abuse, and 14.4% for drug abuse). 157 women were randomized to intervention and 169 to control. Among women who completed follow-up (n = 71), women in the Intervention Group were significantly more likely to have contacted local resources (37% versus 9%, P = 0.04) and were more likely to have taken risk-reducing action (97% versus 79%, P = 0.04). Conclusion. Targeted, brief educational interventions may be an effective method for targeting risk behaviors among vulnerable ED populations.

Impacts of metal detector use in schools: insights from 15 years of research.

BACKGROUND: Multiple approaches exist, both in theory and in practice, to reduce young people's risk of violent victimization when they are in school. Among these approaches, a growing number of school districts are choosing to install metal detectors. We sought to review the literature available on the impacts of metal detectors on school violence and perceptions about school violence. METHODS: We conducted an extensive literature search, including databases for the medical, public health, sociology, and political science literature. Of 128 papers that met our search criteria, 7 studies met inclusion criteria for the literature review. RESULTS: Each of the papers reviewed utilized data that originated from self-report surveys. Four of the studies consisted of secondary analyses of national databases, with the other 3 utilizing local surveys. The studies varied as to the outcome, ranging from student/staff perceptions of safety at school to student self-reports of weapon carrying and/or victimization, and showed mixed results. Several studies suggested potential detrimental effects of metal detectors on student perceptions of safety. One study showed a significant beneficial effect, linking metal detector use to a decrease in the likelihood that students reported carrying a weapon while in school (7.8% vs 13.8%), without a change in weapon carrying in other settings or a decline in participation in physical fights. CONCLUSION: There is insufficient data in the literature to determine whether the presence of metal detectors in schools reduces the risk of violent behavior among students, and some research suggests that the presence of metal detectors may detrimentally impact student perceptions of safety.

Correlation Between Intimate Partner Violence Victimization and Risk of Substance Abuse and Depression among African-American Women in an Urban Emergency Department.

OBJECTIVE: To assess rates of substance abuse (including tobacco, alcohol, and drug abuse) as well as rates of intimate partner violence (IPV) among African-American women seen in an urban emergency department (ED). METHODS: Eligible participants included all African-American women between the ages of 21-55 years old who were seen in an urban ED for any complaint and triaged to the waiting room. Eligible women who consented to participate completed a computer-based survey that focused on demographic information and general health questions, as well as standardized instruments to screen for alcohol abuse, tobacco abuse, and illicit drug use. This analysis uses results from a larger study evaluating the effects of providing patients with targeted educational literature based on the results of their screening. RESULTS: Six-hundred ten women were surveyed; 430 women reported being in a relationship in the past year and among these, 85 women (20%) screened positive for IPV. Women who screened positive for IPV were significantly more likely to also screen positive for tobacco abuse (56% vs. 37.5%, p< 0.001), alcohol abuse (47.1% vs. 23.2%, p < 0.001), and drug abuse (44.7% vs. 9.5%, p<0.001). Women who screened positive for IPV were also more likely to screen positive for depression and report social isolation. CONCLUSIONS: African-American women seen in the ED, who screen positive for IPV, are at significantly higher risk of drug, alcohol, tobacco abuse, depression and social isolation than women who do not screen positive for IPV. These findings have important implications for ED-based and community-based social services for women who are victims of intimate partner violence.

Violence prevention in the emergency department: future research priorities.

The 2009 Academic Emergency Medicine Consensus Conference working group session participants developed recommendations and research questions for violence prevention in the emergency department (ED). A writing group devised a working draft prior to the meeting and presented this to the breakout session at the consensus conference for input and approval. The recommendations include: 1) promote and facilitate the collection of standardized information related to violence victimization and perpetration in ED settings; 2) develop and validate brief practical screening instruments that can identify those at risk for perpetration of violence toward others or toward self; 3) develop and validate brief practical screening instruments that can identify victims at risk for violent reinjury and mental health sequelae; and 4) conduct efficacy, translational, and dissemination research on interventions for violence prevention. The work group emphasized the critical need and role of ED-based research to impact surveillance and prevention of future violence-related injury.

A longitudinal study of emergency medicine residents' malpractice fear and defensive medicine.

OBJECTIVES: To determine the baseline level and evolution of defensive medicine and malpractice concern (MC) of emergency medicine (EM) residents. METHODS: Using a validated instrument consisting of case scenarios and Likert-type scale questions, the authors performed a prospective, longitudinal (June 2001 to June 2005) study of EM residents at five 4-year California residency programs. RESULTS: All 51 EM interns of these residencies were evaluated; four residents left their programs and one took medical leave, resulting in 46 graduating residents evaluated. MC did not affect the residency choice of interns. Although perceived likelihood of serious disease increased in case scenarios over time, defensive medicine decreased in 27% of cases and increased in 20%. On a scale with 1 representing extremely influential and 5 representing not at all influential, the mean (+/-SD) influence of MC on interns' and graduates' case evaluation and management was 2.5 (+/-1.1) and 2.7 (+/-1.0), respectively. Comparing interns and graduates, there was no significant difference in the percentages of respondents who declared MC (mean difference in proportions, 3.3%; 95% CI = -8.4% to 15%) or refused procedures because of MC (11.5%; 95% CI = -1.3% to 24.3%). More interns, however, declared substantial loss of enjoyment of medicine than graduates (48%; 95% CI = 30.3% to 65.5%). CONCLUSIONS: Physicians enter four-year EM residencies in California with moderate MC and defensive medicine, which do not change significantly over time and do not markedly impact their decisions to perform emergency department procedures. Malpractice fear markedly decreases interns' enjoyment of medicine, but this effect decreases by residency completion.