Are sexual assault victims presenting to the emergency department in a timely manner?

Social workers regularly assist sexual assault victims and would benefit from a greater understanding of causes for delayed presentation to seek medical care. Delays in presentation of sexual assault victims affect the legal value of collected evidence. The authors of this study sought to characterize the nature and frequency of delayed presentation among victims. To do so, they performed a chart review from 2001 to 2007 of the Sexual Assault Forensic Examiner program at their institution. Delayed presentation was defined as presentation more than 12 hours after the assault. Chi-square test was used to contrast frequencies, and multivariate regression was used to control for confounders. Among 482 victims, more than half presented delayed. Of the victims who documented whether they knew the perpetrator, 63 percent knew the perpetrator, with 58 percent of these presenting delayed. Knowing the perpetrator was significantly associated with delayed presentation. Age, ethnicity, and gender were not associated with delayed presentation.

Paramedics accurately apply the pediatric assessment triangle to drive management.

OBJECTIVE: To provide an evaluation of the Pediatric Assessment Triangle (PAT) as an assessment tool for use by paramedic providers in the prehospital care of pediatric patients. METHODS: Paramedics from Los Angeles Fire Department (LAFD) received training in the Pediatric Education for Prehospital Professionals (PEPP) course, PAT study procedures, and completed training in applying the PAT to assess children 0-14 years of age. A convenience sample of LAFD paramedic assessments of the pediatric patients transported to 29 participating institutions, over an 18-month period ending July 2010, were eligible for inclusion. Patients who were not transported were excluded from the study, as were the assessments of children with special health-care needs (CSHCN). PAT Study Forms, emergency medical services (EMS) report forms, and emergency department (ED) and hospital charts were entered into a secure database. Two study investigators, blinded to paramedic PAT assessment, reviewed hospital charts and determined the category of illness or injury. RESULTS: A total of 1,552 PAT Study Forms were collected. Overall, 1,168 of the patient (75%) assessments met inclusion criteria, were transported, and had all three data points (PAT Study Form, paramedic EMS report form, and ED/hospital chart) available for analysis. When paramedics used the PAT to identify abnormalities in the three arms of the triangle (PAT Paramedic Pattern) and applied that pattern to form a general impression (PAT Paramedic Impression), the agreement resulted in a κ coefficient of 0.93 [95% CI: 0.91-0.95]. The PAT paramedic impression was congruent with field management, as the majority of patients received consistent interventions with local EMS protocols. The PAT Paramedic Impression for instability demonstrated a sensitivity of 77.4% [95% CI: 72.6-81.5%], a specificity of 90.0% [95% CI: 87.1-91.5%] with a positive likelihood ratio (LR+) of 7.7 [95% CI: 5.9-9.1] and a negative likelihood ratio (LR-) of 0.3 [95% CI: 0.2-0.3]. CONCLUSION: The PAT is a rapid assessment tool that can be readily and reliably used by paramedics in the prehospital setting. The PAT should be used in conjunction with other assessments but can safely drive initial field management.

Accuracy of paramedic Broselow tape use in the prehospital setting.

BACKGROUND: The Broselow tape is widely used to rapidly estimate weight and facilitate proper medication dosing in pediatric patients. OBJECTIVE: We aimed to determine the accuracy of prehospital use of the Broselow tape. METHODS: We prospectively enrolled a consecutive sample of pediatric patients transported to the emergency department (ED) at Harbor-UCLA Medical Center from February 2008 to January 2009. Eligible subjects arrived via ambulance and were less than 145 cm tall, the upper limit of height for Broselow measurements. Subjects were excluded if they had a medical condition preventing proper measurement (e.g., contractures). Per Los Angeles County protocol, paramedics obtained a Broselow weight on all pediatric patients. The paramedic Broselow weight was compared with the ED Broselow weight and the ED scale weight, which was obtained unless mobilization was contraindicated. Accuracy was determined by assessing Bland-Altman plots and the Pearson correlation coefficient. As part of a sensitivity analysis, multiple imputation was used to account for missing data. RESULTS: There were 572 subjects enrolled. The median age was 24 months (interquartile range [IQR] 10 to 49 months); 316 (55%) of the subjects were male. The weighted Cohen's kappa assessing agreement between the paramedic and ED Broselow colors was 0.74 (95% confidence interval [CI] 0.68 to 0.79). The median difference between the paramedic Broselow weight and the scale weight was -0.10 kg (IQR -1.7 to 0.7). The accuracy of the paramedic Broselow weight when compared with the ED scale weight and the ED Broselow weight as defined by Pearson's correlation coefficient was 0.92 (95% CI 0.90 to 0.93) and 0.97 (95% CI 0.97 to 0.98), respectively. Multiple imputation for missing data did not alter the results. CONCLUSION: Paramedic Broselow weight correlates well with scale weight and ED Broselow weight. Paramedics can use the Broselow tape to accurately determine weight for pediatric patients in the prehospital setting.

Can we defer/omit a type and screen blood test for pregnant women who know their blood type?

BACKGROUND: Current clinical practice in many emergency departments (EDs) includes checking a type and screen blood test (T&S) for Rhesus (Rh) status on all pregnant patients presenting with vaginal bleeding or abdominal pain. The test is expensive, and awaiting results may delay disposition. OBJECTIVE: To determine if there is a subset of pregnant women who reliably know their blood type and for whom a T&S blood test to determine Rh status can be safely omitted or deferred. METHODS: A prospective study at two associated urban academic centers with an annual ED census of 150,000 patients was performed between January 2007 and June 2008. Pregnant patients who had a T&S obtained as part of their ED evaluation were enrolled. Subjects completed a standardized data form that requested demographic information and were asked to select "no," "maybe," or "yes, definitely" if they knew their blood type. Standard descriptive statistics with 95% confidence intervals were performed. RESULTS: There were 319 pregnant women enrolled in the study. Among the 106 subjects that reported "yes, definitely" they knew their blood type, 103 (97.2%; 95% confidence interval [CI] 94.0-100%]) identified their correct blood type and 105 (99.1%; 95% CI 97.2-100%) identified their correct Rh status. None of these subjects selected a positive Rh when they were in fact a negative Rh. All 14 (13.2%) subjects with a negative Rh status identified themselves as having a negative Rh. CONCLUSION: Pregnant women reporting that "yes, definitely" they know their blood type, are reliable. Deferring T&S testing test may be reasonable.