Screening for Health-Related Social Needs of Emergency Department Patients.

STUDY OBJECTIVE: There has been increasing attention to screening for health-related social needs. However, little is known about the screening practices of emergency departments (EDs). Within New England, we seek to identify the prevalence of ED screening for health-related social needs, understand the factors associated with screening, and understand how screening patterns for health-related social needs differ from those for violence, substance use, and mental health needs. METHODS: We analyzed data from the 2018 National Emergency Department Inventory-New England survey, which was administered to all 194 New England EDs during 2019. We used descriptive statistics to compare ED characteristics by screening practices, and multivariable logistic regression models to identify factors associated with screening. RESULTS: Among the 166 (86%) responding EDs, 64 (39%) reported screening for at least one health-related social need, 160 (96%) for violence (including intimate partner violence or other violent exposures), 148 (89%) for substance use disorder, and 159 (96%) for mental health needs. EDs reported a wide range of social work resources to address identified needs, with 155 (93%) reporting any social worker availability and 41 (27%) reporting continuous availability. CONCLUSION: New England EDs are screening for health-related social needs at a markedly lower rate than for violence, substance use, and mental health needs. EDs have relatively limited resources available to address health-related social needs. We encourage research on the development of scalable solutions for identifying and addressing health-related social needs in the ED.

Change in opioid policies in New England emergency departments, 2014 vs 2018.

OBJECTIVE: The U.S. opioid epidemic persists, yet it is unclear if opioid-related emergency department (ED) policies have changed. We investigated: 1) the prevalence of opioid use disorder (OUD) prevention and treatment policies in New England EDs in 2018, and 2) how these policies have changed since 2014. METHODS: Using the National Emergency Department Inventory-USA, we identified and surveyed all New England EDs in 2015 and 2019 about opioid-related policies in 2014 and 2018, respectively. The surveys assessed OUD prevention policies (to use a screening tool, access the Prescription Drug Monitoring Program [PDMP], notify primary care providers, prescribe/dispense naloxone) and treatment policies (to refer to recovery resources, prescribe/dispense buprenorphine). RESULTS: Of 194 EDs open in 2018, 167 (86 %) completed the survey. Of 193 EDs open in 2018 and 2014, 147 (76 %) completed both surveys. In 2018, the most commonly-reported policy was accessing the PDMP (96 %); the least commonly-reported policy was prescribing/dispensing buprenorphine to at risk patients (37 %). EDs varied in prescribing/dispensing naloxone: 35 % of EDs offered naloxone to ≥80 % of patients at risk of opioid overdose versus 33 % of EDs to <10 % of patients at risk. Most EDs (74 %) reported prescribing/dispensing buprenorphine to <10 % of patients with OUD. Comparing 2018 to 2014, the greatest difference in policy use was in prescribing/dispensing naloxone (+55 %, p < 0.001). CONCLUSION: Implementation of opioid-related ED policies increased between 2014 and 2018. Continued effort is needed to understand the extent to which policy implementation translates to clinical care, and to best translate evidence-based policies into clinical practice.

Fecal Impaction With Multisystem Organ Involvement.

Fecal impactions are a common complaint in the emergency department (ED) population. The potential for significant derangement in physiologic processes of other organ systems is often underappreciated. A 19-year-old male, previously healthy, presented to the ED at our institution with complaint of abdominal pain, which was found to be secondary to severe fecal impaction. In the search for alternative diagnoses, imaging was performed, which revealed effects on multiple other organ systems. This case illustrates the secondary effects of a severe fecal impaction. The emergency physician must be aware of these consequences, as the opportunity to review labs and imaging is not often provided in the standard workup of these patients.

Activated chlorine dioxide solution can be used as a biocompatible antiseptic wound irrigant.

OBJECTIVE: The purpose of this study was to compare cosmesis at 3 to 4 months and infection in simple lacerations irrigated with normal saline (NS) versus activated chlorine dioxide (CD). DESIGN: This was a prospective, randomized trial of a convenience sample of patients. This study was approved by the institutional review board and Food and Drug Administration as a physician-sponsored trial (FDA investigational new drug no. 68762). SETTING: The study was conducted in a large urban, academic emergency department. PATIENTS: Patients aged 18 to 100 with simple, uncomplicated lacerations requiring repair that were less than 8 hours old were enrolled. INTERVENTIONS: Patients were randomized to receive either NS or CD wound irrigation. MAIN OUTCOME MEASURES: Demographics, infection, and cosmesis were analyzed and assessed. Cosmetic outcome was assessed at 3 to 4 months using a visual analog scale (VAS), wound evaluation score (WES), patient VAS (VASPt), and digital imaging VAS by 2 plastic surgeons (VASPlast). MAIN RESULTS: One hundred ninety-three patients were enrolled. Data analysis was available for 175 cases (86 NS and 89 CD). Wound infection follow-up was obtained in 74.9% of the patients. The 3- to 4-month cosmesis follow-up was 37.7% for VAS/WES, 40.0% for VASPt, and 37.7% for VASPlast. There were no significant differences in demographics, key wound characteristics, infection, adverse reactions, and cosmesis. CONCLUSION: The authors report the use of a novel antimicrobial irrigation solution. Chlorine dioxide appears to be a safe biologically acceptable antiseptic wound irrigant that does not appear to interfere with cosmetic outcomes.

Trauma in pregnancy.

The treatment of pregnant patients with traumatic injuries requires knowledge of the fundamentals of general trauma management as well as the specific anatomic and physiologic changes brought about by pregnancy. This article provides a review of the spectrum of trauma prevention and treatment in pregnant women, from counseling strategies that can be used during any emergency department visit to a step-by-step evaluation protocol for patients with trauma during pregnancy and the severe injuries that might be encountered by providers during the treatment of these women, including maternal cardiopulmonary arrest and the perimortem cesarean section.

Digital imaging analysis of scar aesthetics.

OBJECTIVE: Aesthetic outcome is an important end point of wound care. The purpose of this study was to compare a wound aesthetic scoring system by emergency physicians, patients, and digital imaging by blinded plastic surgeons. The goal was to see if digital photography could accurately analyze the aesthetics of closed lacerations for future research. METHODS: This was a subanalysis of a prospective, randomized trial conducted in an urban, academic emergency department. Patients aged 18 to 100 years were included if they had simple, uncomplicated lacerations 8 hours old or less located on the trunk, head or neck (not scalp), or extremities that required repair by sutures. Exclusion criteria included immunocompromised state of health, a complicated laceration, specialty consultant intervention in management of the wound, or current use of or need for antibiotics for wound prophylaxis. Complicated lacerations were defined in the article. Infection outcomes, demographics, and aesthetic outcomes were assessed. Scar appearance was assessed at 3 to 4 months after closure using a previously validated 0-to 100-mm visual analog scale (VAS) score and 6-point wound evaluation score (WES) done by 2 trained emergency physicians (MD1 and MD2). Patients also performed self-VAS (VAS(Pt)), whereas VAS was done using digital imaging by 2 trained plastic surgeons (VAS(Plast1) and VAS(Plast2)). Data were evaluated when both plastic surgeons independently believed that the digital images were able to be adequately scored. Pearson correlation coefficients were performed using mean values. RESULTS: Three- to 4-month VAS(MD) and WES(MD) follow-up was obtained in 66 of 175 (37.7%), 3- to 4-month VAS(Pt) follow-up was obtained in 70 of 175 (40.0%), and 3- to 4-month digital imaging assessment was obtained in 66 of 175 (37.7%). Digital images were evaluated for VAS(Plast) in 34 of 66 (51.5%). Mean scores for VAS(MD1) and VAS(MD2) were 84.2 (SD, 12.4) mm and 87.8 (SD, 10.5) mm. Mean scores for WES(MD1) and WES(MD2) were 5.5 (SD, 1.0) and 5.4 (SD, 1.0). Mean scores for VAS(Pt) were 86.6 (SD, 16.6) mm. Mean scores for VAS(Plast1) and VAS(Plast2) were 78.7 (SD, 26.6) mm and 66.2 (SD, 30.2) mm. Moderate correlation was noted for VAS(MD1) and VAS(MD2) (r = 0.63; n = 34; P < .001), WES(MD1) and WES(MD2) (r = 0.70; n = 34; P < .001), and VAS(Plast1) and VAS(Plast2) (r = 0.74; n = 34; P < .001). Correlations were also moderate for VAS(MD) and VAS(Plast) (r = 0.56; n = 34; P < .001), VAS(Pt) and WES(MD) (r =0.60; n = 34; P < .001), and VAS(MD) and WES(MD) (r = 0.64; n = 34; P < .001). However, correlations were weak for VAS(Pt) and VAS(Plast) at r = 0.25 (n = 34; P = .16), VAS(Pt) and VAS(MD) at r = 0.37 (n = 34; P =.03), and WES(MD) and VAS(Plast) at r = 0.13 (n = 34; P =.45). Three- to 4-month VAS(MD) and WES(MD) follow-up was obtained in 66 of 175 (37.7%), 3- to 4-month VAS(Pt) follow-up was obtained in 70 of 175 (40.0%), and 3- to 4-month digital imaging assessment was obtained in 66 of 175 (37.7%). Digital images were evaluated for VAS(Plast) in 34 of 66 (51.5%). Mean scores for VAS(MD1) and VAS(MD2) were 84.2 (SD, 12.4) mm and 87.8 (SD, 10.5) mm. Mean scores for WES(MD1) and WES(MD2) were 5.5 (SD, 1.0) and 5.4 (SD, 1.0). Mean scores for VAS(Pt) were 86.6 (SD, 16.6) mm. Mean scores for VAS(Plast1) and VAS(Plast2) were 78.7 (SD, 26.6) mm and 66.2 (SD, 30.2) mm. Moderate correlation was noted for VAS(MD1) and VAS(MD2) (r = 0.63; n = 34; P < .001), WES(MD1) and WES(MD2) (r = 0.70; n = 34; P < .001), and VAS(Plast1) and VAS(Plast2) (r = 0.74; n = 34; P < .001). Correlations were also moderate for VAS(MD) and VAS(Plast) (r = 0.56; n = 34; P < .001), VAS(Pt) and WES(MD) (r = 0.60; n = 34; P < .001), and VAS(MD) and WES(MD) (r = 0.64; n = 34; P < .001). However, correlations were weak for VAS(Pt) and VAS(Plast) at r = 0.25 (n = 34; P = .16), VAS(Pt) and VAS(MD) at r = 0.37 (n = 34; P =.03), and WES(MD) and VAS(Plast) at r = 0.13 (n = 34; P =.45).Three-to 4-month VAS(MD) and WES(MD) follow-up was obtained in 66 of 175 (37.7%), 3- to 4-month VAS(Pt) follow-up was obtained in 70 of 175 (40.0%), and 3- to 4-month digital imaging assessment was obtained in 66 of 175 (37.7%). Digital images were evaluated for VAS(Plast) in 34 of 66 (51.5%). Mean scores for VAS(MD1) and VAS(MD2) were 84.2 (SD, 12.4) mm and 87.8 (SD, 10.5) mm. Mean scores for WES(MD1) and WES(MD2) were 5.5 (SD, 1.0) and 5.4 (SD, 1.0). Mean scores for VAS(Pt) were 86.6 (SD, 16.6) mm. Mean scores for VAS(Plast1) and VAS(Plast2) were 78.7 (SD, 26.6) mm and 66.2 (SD, 30.2) mm. Moderate correlation was noted for VAS(MD1) and VAS(MD2) (r = 0.63; n = 34; P < .001), WES(MD1) and WES(MD2) (r = 0.70; n = 34; P < .001), and VAS(Plast1) and VAS(Plast2) (r = 0.74; n = 34; P < .001). Correlations were also moderate for VAS(MD) and VAS(Plast) (r = 0.56; n = 34; P < .001), VAS(Pt) and WES(MD) (r = 0.60; n = 34; P < .001), and VAS(MD) and WES(MD) (r = 0.64; n = 34; P < .001). However, correlations were weak for VAS(Pt) and VAS(Plast) at r = 0.25 (n = 34; P = .16), VAS(Pt) and VAS(MD) at r = 0.37 (n = 34; P =.03), and WES(MD) and VAS(Plast) at r = 0.13 (n = 34; P =.45). CONCLUSIONS: Correlations were moderate for VAS(MD) and VAS(Plast); however, correlations were weak for VAS(Pt) and VAS(Plast), VAS(Pt) and VAS(MD), and WES(MD) and VAS(Plast). This small study assessing digital imaging as a tool for evaluating scar aesthetics demonstrated limitations in its use. Future studies with larger populations and improved imaging modalities, such as 3-dimensional cameras and high-dynamic-range imaging, may provide potential for better assessment.

Factors associated with delay to emergency department presentation, antibiotic usage and admission for human bite injuries.

OBJECTIVES: Evidence and consensus on best practices on the management of human bite injuries is lacking. Our objective was to identify factors that are associated with delay to emergency department (ED) presentation, antibiotic usage and patient admission. METHODS: We present a retrospective chart review of adults treated for human bites. Multivariable logistic regression models used demographic characteristics and bite circumstances and characteristics as factors associated with ED presentation more than 24 hours after the bite, antibiotic usage and hospital admission. RESULTS: Of the 388 patients evaluated for a human bite, 66.5% were bitten during an altercation; 23.8% presented more than 24 hours after the bite; 50.3% were bitten on the hands or fingers, 23.5% on an extremity and 17.8% on the head or neck. Only 7.7% of all patients sustained closed-fist injuries; the majority had occlusional or other kinds of bites. The majority of patients (77.3%) received antibiotics and 11.1% were admitted to hospital. Patients who had greater odds of presenting more than 24 hours after the bite were black (odds ratio [OR] 1.79, 95% confidence interval [CI] 1.02-3.13), Hispanic (OR 2.68, 95% CI 1.22-5.89) and those who had a non-occupational bite (OR 3.87, 95% CI, 1.68-8.90). Patients had a greater chance of receiving antibiotics if they were bitten during an altercation (OR 1.87, 95% CI, 1.09-3.20) and were bitten on the hands or fingers (OR 2.23, 95% CI 1.31-3.80). Patients had a greater chance of being admitted to the hospital if they were bitten during an altercation (OR 4.91, 95% CI 1.65-14.64), bitten on the hands or fingers (OR 5.26, 95% CI, 1.74-15.87) and if they presented >or= 24 hours after the bite. CONCLUSION: Most patients presented to the ED within 24 hours of their injury and received antibiotics. The circumstances surrounding the bite appeared to be associated with delay to ED presentation, receipt of antibiotics and admission to the hospital. There are ethnic background differences in delay to ED presentation. ED clinicians in our study favour antibiotic usage and admission based on the body location of the bite, despite little evidence to support these practices.