Physical restraint use in children with mental and behavioral health emergencies in the prehospital setting.

Objective: Emergency medical services (EMS) transport for mental and behavioral health (MBH) emergencies occurs frequently in children, yet little is understood regarding prehospital physical restraint use despite the potential for serious adverse events. We aim to describe restraint use prevalence and primary impressions among children with MBH emergencies. Methods: This is a retrospective cross-sectional study of children with MBH emergencies evaluated by Alameda County (ALCO), California EMS from January 1, 2012 to December 31, 2018. Patient demographics and clinical variables were collected from the EMS records including sex, age at time of encounter, year of encounter, transport destination, medication use, and primary impression(s). The primary outcome was the use of physical restraints. Descriptive statistics were used to characterize the primary outcome and associated demographic and diagnostic features, as well as temporal use patterns. Sex and age were compared between restrained and non-restrained youth using chi-square analysis. Results: Over the 7-year study period, ALCO EMS transported 9775 children with MBH emergencies. Of these transports, 1205 (12.3%) were physically restrained. Most children restrained had the primary impression of "behavioral/psychiatric crisis" (51.1%), "psychiatric crisis" (27.4%), and "behavioral-other" (12.4%) and the remaining children (9.1%) had a non-psychiatric/behavioral health primary impression. Over time, there was no statistically significant change in either number of children with MBH emergencies transported or physical restraint rate. Conclusions: More than 1 in 8 children with MBH emergencies are being physically restrained during EMS transport. Restraint rate did not substantially change over time. Further studies to understand existing restraint rates and EMS resources available to address acute agitation in children are needed to inform quality and care enhancing initiatives.

E-scooter related injuries: Using natural language processing to rapidly search 36 million medical notes.

BACKGROUND: Shareable e-scooters have become popular, but injuries to riders and bystanders have not been well characterized. The goal of this study was to describe e-scooter injuries and estimate the rate of injury per e-scooter trip. METHODS AND FINDINGS: Retrospective review of patients presenting to 180 clinics and 2 hospitals in greater Los Angeles between January 1, 2014 and May 14, 2020. Injuries were identified using a natural language processing (NLP) algorithm not previously used to identify injuries, tallied, and described along with required healthcare resources. We combine these tallies with municipal data on scooter use to report a monthly utilization-corrected rate of e-scooter injuries. We searched 36 million clinical notes. Our NLP algorithm correctly classified 92% of notes in the testing set compared with the gold standard of investigator review. In total, we identified 1,354 people injured by e-scooters; 30% were seen in more than one clinical setting (e.g., emergency department and a follow-up outpatient visit), 29% required advanced imaging, 6% required inpatient admission, and 2 died. We estimate 115 injuries per million e-scooter trips were treated in our health system. CONCLUSIONS: Our observed e-scooter injury rate is likely an underestimate, but is similar to that previously reported for motorcycles. However, the comparative severity of injuries is unknown. Our methodology may prove useful to study other clinical conditions not identifiable by existing diagnostic systems.

Injuries Associated With Standing Electric Scooter Use.

Importance: Since September 2017, standing electric scooters have proliferated rapidly as an inexpensive, easy mode of transportation. Although there are regulations for safe riding established by both electric scooter companies and local governments, public common use practices and the incidence and types of injuries associated with these standing electric scooters are unknown. Objective: To characterize injuries associated with standing electric scooter use, the clinical outcomes of injured patients, and common use practices in the first US metropolitan area to experience adoption of this technology. Design, Setting, and Participants: This study of a case series used retrospective cohort medical record review of all patients presenting with injuries associated with standing electric scooter use between September 1, 2017, and August 31, 2018, at 2 urban emergency departments associated with an academic medical center in Southern California. All electric scooter riders at selected public intersections in the community surrounding the 2 hospitals were also observed during a 7-hour observation period in September 2018. Main Outcomes and Measures: Incidence and characteristics of injuries and observation of riders' common use practices. Results: Two hundred forty-nine patients (145 [58.2%] male; mean [SD] age, 33.7 [15.3] years) presented to the emergency department with injuries associated with standing electric scooter use during the study period. Two hundred twenty-eight (91.6%) were injured as riders and 21 (8.4%) as nonriders. Twenty-seven patients were younger than 18 years (10.8%). Ten riders (4.4%) were documented as having worn a helmet, and 12 patients (4.8%) had either a blood alcohol level greater than 0.05% or were perceived to be intoxicated by a physician. Frequent injuries included fractures (79 [31.7%]), head injury (100 [40.2%]), and contusions, sprains, and lacerations without fracture or head injury (69 [27.7%]). The majority of patients (234 [94.0%]) were discharged home from the emergency department; of the 15 admitted patients, 2 had severe injuries and were admitted to the intensive care unit. Among 193 observed electric scooter riders in the local community in September 2018, 182 (94.3%) were not wearing a helmet. Conclusions and Relevance: Injuries associated with standing electric scooter use are a new phenomenon and vary in severity. In this study, helmet use was low and a significant subset of injuries occurred in patients younger than 18 years, the minimum age permitted by private scooter company regulations. These findings may inform public policy regarding standing electric scooter use.

Emergency Medical Services Use Among Patients Receiving Involuntary Psychiatric Holds and the Safety of an Out-of-Hospital Screening Protocol to "Medically Clear" Psychiatric Emergencies in the Field, 2011 to 2016.

STUDY OBJECTIVE: Patients with acute psychiatric emergencies who receive an involuntary hold often spend hours in the emergency department (ED) because of a deficit in inpatient psychiatric beds. One solution to address the lack of prompt psychiatric evaluation in the ED has been to establish regional stand-alone psychiatric emergency services. However, patients receiving involuntary holds still need to be screened and evaluated to ensure that their behavior is not caused by an underlying and life-threatening nonpsychiatric illness. Although traditional regional emergency medical services (EMS) systems depend on the medical ED for this function, a field-screening protocol can allow EMS to directly transport a substantial portion of patients to a stand-alone psychiatric emergency service. The purpose of this investigation is to describe overall EMS use for patients receiving involuntary holds, compare patients receiving involuntary holds with all EMS patients, and evaluate the safety of field medical clearance of an established field-screening protocol in Alameda County, CA. METHODS: We obtained data for all EMS encounters between November 1, 2011, and November 1, 2016, using Alameda County's standardized data set. After unique patient identification, we describe the data at the patient level and at the encounter level. At the patient level, we compare "involuntary hold patients" (≥1 involuntary hold during the study period) with those who were "never held." Additionally, we assess the safety of out-of-hospital medical clearance by calculating the rate of failed diversion, defined as retransport of a patient to a medical ED within 12 hours of transport to the psychiatric emergency services by EMS. RESULTS: Of the 541,731 total EMS encounters in Alameda County during the study period, 10% (N=53,887) were identified as involuntary hold encounters. Of these involuntary hold patient encounters, 41% (N=22,074) resulted in direct transport of the patient to the stand-alone psychiatric emergency service for evaluation; 0.3% (N=60) failed diversion and required retransport within 12 hours. At the patient level, Alameda County EMS encountered 257,625 unique patients, and 10% (N=26,283) had at least one encounter for an involuntary hold during the study period. These "involuntary hold patients" were substantially younger, more likely to be men, and less likely to be insured. Additionally, they had higher overall EMS use: "involuntary hold patients" accounted for 24% of all encounters (N=128,003); 53,887 of these encounters were for involuntary holds, whereas an additional 74,116 were for other reasons. Similarly, 4% of "involuntary hold patients" had 20 or more encounters, whereas only 0.4% of "never held" patients were in this category. Last, the 7% of "involuntary hold patients" (N=1,907) who received greater than or equal to 5 involuntary holds during the study period accounted for 39% of all involuntary holds and 9% of all EMS encounters. CONCLUSION: Ten percent of all EMS encounters were for involuntary psychiatric holds. With an EMS-directed screening protocol, 41% of all such patient encounters resulted in direct transport of the patient to the psychiatric emergency service, bypassing medical clearance in the ED. Overall, only 0.3% of these patients required retransport to a medical ED within 12 hours of arrival to psychiatric emergency services. We found that 24% of all EMS encounters in Alameda County were attributable to "involuntary hold patients," reinforcing the importance of the effects of mental illness on EMS use.

Hepatitis C Virus Screening and Emergency Department Length of Stay.

BACKGROUND: Recent studies demonstrate high rates of previously undiagnosed hepatitis C virus (HCV) infection among patients screened in urban emergency departments (ED). Experts caution, however, that public health interventions, such as screening for infectious diseases, must not interfere with the primary mission of EDs to provide timely acute care. Increases in ED length of stay (LOS) have been associated with decreased quality of ED care. OBJECTIVE: In this study, we assess the influence of an integrated HCV screening protocol on ED LOS. METHODS: This was a retrospective cohort study analyzing timestamp data for all discharged patients over a 1-year period. The primary outcome compared the median LOS in minutes between patients who completed HCV screening and those who did not. Further analysis compared LOS for HCV screening by whether or not complete blood count (CBC) testing was conducted. RESULTS: Of 69,639 visits, 2,864 (4%) had HCV screening tests completed and 272 (9.5%) were antibody positive. The median LOS for visits that included HCV screening was greater than visits that did not include screening (151 versus 119 minutes, P < 0.001). Among the subset of visits in which CBC testing was conducted, there was no significant difference in median LOS between visits that also included HCV screening and those that did not (240 versus 242 minutes, P = 0.68). CONCLUSION: Integrated HCV screening modestly prolongs ED LOS. However, among patients undergoing other blood tests, screening had no effect on LOS. Programs may consider routinely offering HCV screening to patients who are undergoing laboratory testing.

Results of a Rapid Hepatitis C Virus Screening and Diagnostic Testing Program in an Urban Emergency Department.

STUDY OBJECTIVE: We describe the results of an emergency department (ED) hepatitis C virus testing program that integrated birth cohort screening and screening of patients with a history of injection drug use, as well as physician diagnostic testing, according to national guidelines. METHODS: We conducted a retrospective cohort study using data collected as part of clinical care. The primary outcome was the hepatitis C virus prevalence among tested patients. We evaluated factors associated with testing positive with logistic regression. RESULTS: Of the 26,639 unique adults aged 18 years or older and presenting to the ED during the 6-month study, 2,581 (9.7%) completed hepatitis C virus screening (2,028) or diagnostic testing (553), of whom 267 were antibody positive (10.3% prevalence). Factors associated with testing positive for hepatitis C virus included injection drug use (38.4% prevalence; odds ratio [OR] 10.8; 95% confidence interval [CI] 7.5 to 15.5), homeless (25.5% prevalence; OR 3.1; 95% CI 1.5 to 6.8), diagnostic testing (14.8% prevalence; OR 2.6; 95% CI 1.7 to 3.9), birth cohort (13.7% prevalence; OR 3.6; 95% CI 2.4 to 5.3), and male sex (12.4% prevalence; OR 1.4; 95% CI 1.0 to 2.0). Of the 267 patients testing positive for hepatitis C virus antibody, 137 (51%) had documentation of result disclosure and 180 (67%) had confirmatory ribonucleic acid testing performed, of whom 126 (70%) had a positive result. Follow-up appointments at the hepatitis C virus clinic were arranged for 57 of the 126 (45%) patients with confirmed positive results, of which 30 attended. CONCLUSION: This ED screening and diagnostic testing program found a high prevalence of hepatitis C virus antibody positivity across all groups. Challenges encountered with hepatitis C virus screening included result disclosure, confirmatory testing, and linkage to care. Our results warrant continued efforts to develop and evaluate policies for ED-based hepatitis C virus screening.

Differences Between Emergency Nurse Perception and Patient Reported Experience With an ED HIV and Hepatitis C Virus Screening Program.

INTRODUCTION: Nontargeted human immunodeficiency virus (HIV) screening and targeted hepatitis C virus (HCV) screening for selected high-risk patients (those born between 1945 and 1965 and those who report injection drug use) was integrated into our ED triage process and carried out by nurses. Determining whether emergency nurses accurately perceive what patients experience is important to know because staff misperceptions may pose a barrier to program adherence and sustainability. METHODS: We performed a cross-sectional survey study of emergency nurses and patients to assess the accuracy of emergency nurses' perception of patient experience with the HIV/HCV screening program. Respondents evaluated their level of agreement using a 5-item Likert scale for 9 statements across 4 domains related to the patient experience with the screening process (satisfaction, sense of autonomy, sense of privacy, and comfort level). RESULTS: Surveys were completed by 65 of the 153 eligible emergency nurses (42%). Of the 1040 patients approached, 610 (59%) were eligible, and 491 of the 610 eligible patients (80%) completed surveys. Across all domains, statistically significant differences were found between emergency nurse perception and patient report, P < .001. Emergency nurses perceived patients to be less satisfied with the screening program, more uncomfortable with being asked screening questions, more concerned about privacy issues, and less likely to feel that the decision to decline screening was autonomous than were patients. DISCUSSION: Emergency nurses not only frequently misperceive how patients experience ED-based HIV/HCV screening, but these misperceptions are skewed toward the negative, representing a type of staff bias. Further research is recommended to determine if such misperceptions adversely affect implementation of screening.

Clinical characteristics of norovirus-associated deaths: a systematic literature review.

Although deaths are often reported in the context of norovirus outbreaks, clinical and epidemiologic characteristics of the decedents prior to death are not well established. Through a literature review of published reports of deaths associated with norovirus infection, we identified and summarized 158 norovirus-associated deaths in 12 countries from 1988 to 2011.

Hospitalizations and mortality associated with norovirus outbreaks in nursing homes, 2009-2010.

CONTEXT: Norovirus outbreaks are common among vulnerable, elderly populations in US nursing homes. OBJECTIVES: To assess whether all-cause hospitalization and mortality rates are increased during norovirus outbreak vs nonoutbreak periods in nursing homes, and to identify factors associated with increased risk. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study of Medicare-certified nursing homes in Oregon, Wisconsin, and Pennsylvania that reported at least 1 confirmed or suspected norovirus outbreak to the Centers for Disease Control and Prevention's National Outbreak Reporting System (NORS), January 2009 to December 2010. Deaths and hospitalizations occurring among residents of these nursing homes were identified through the Medicare Minimum Data Set (MDS). MAIN OUTCOME MEASURES: Rates of all-cause hospitalization and mortality during outbreak compared with nonoutbreak periods were estimated using a random-effects Poisson regression model controlling for background seasonality in both outcomes. RESULTS: The cohort consisted of 308 nursing homes that reported 407 norovirus outbreaks to NORS. Per MDS, 67 730 hospitalizations and 26 055 deaths occurred in these homes during the 2-year study. Hospitalization rates were 124.0 (95% CI, 119.4-129.1) vs 109.5 (95% CI, 108.6-110.3) hospitalizations per nursing home−year during outbreak vs nonoutbreak periods, yielding a seasonally adjusted rate ratio (RR) of 1.09 (95% CI, 1.05-1.14). Similarly, mortality rates were 53.7 (95% CI, 50.6-57.0) vs 41.9 (95% CI, 41.4-42.4) deaths per nursing home−year in outbreak vs nonoutbreak periods (seasonally adjusted RR, 1.11; 95% CI, 1.05-1.18). The increases in hospitalizations and mortality were concentrated in the first 2 weeks (week 0 and 1) and the initial week (week 0) of the outbreak, respectively. Homes with lower daily registered nurse (RN) hours per resident (<0.75) had increased mortality rates during norovirus outbreaks compared with baseline (RR, 1.26; 95% CI, 1.14-1.40), while no increased risk (RR, 1.03; 95% CI, 0.96-1.12) was observed in homes with higher daily RN hours per resident (P = .007 by likelihood ratio test); the increase in hospitalization rates did not show a similar pattern. CONCLUSION: Norovirus outbreaks were associated with significant concurrent increases in all-cause hospitalization and mortality in nursing homes.