Elizabeth M. Datner

Does Stress Influence Early Pregnancy Loss

PURPOSE The purpose of this study is to examine the relationship between stress, cortisol level and the risk for spontaneous abortion and determine the influence of stress on health-related behaviors. METHODS Three hundred and twenty-six pregnant women presenting to the emergency department at the Hospital of the University of Pennsylvania from March 1999 through March 2000 were recruited and followed through 22 weeks gestation. Cases were women who experienced a spontaneous abortion and controls were women who maintained their pregnancy. Stress was measured by the Perceived Stress Scale (PSS), the Prenatal Social Environment Inventory (PSEI) and the Index of Spousal Abuse (ISA) prior to confirmation of spontaneous abortion. Blood samples were collected to measure cortisol and sex hormone levels. Urine samples were collected to assess cotinine, cocaine and marijuana use. RESULTS No relationship was found between psychosocial stress, as determined by the three stress scales or cortisol level, and the risk for spontaneous abortion. Women with high stress, as measured by the PSEI, were more likely to use cigarettes and marijuana during pregnancy. High psychosocial stress during early pregnancy was not related to spontaneous abortion but high stress was associated with substance use during pregnancy. CONCLUSION The influence of psychosocial stress on the risk of spontaneous abortion is unclear.

The Effect of Emergency Department Crowding on Length of Stay and Medication Treatment Times in Discharged Patients With Acute Asthma

OBJECTIVES This study sought to determine if emergency department (ED) crowding was associated with longer ED length of stay (LOS) and time to ordering medications (nebulizers and steroids) in patients treated and discharged with acute asthma and to study how delays in ordering may affect the relationship between ED crowding and ED LOS. METHODS A retrospective cohort study was performed in adult ED patients aged 18 years and older with a primary International Classification of Diseases, 9th Revision (ICD-9), diagnosis of asthma who were treated and discharged from two EDs from January 1, 2007, to January 1, 2009. Four validated measures of ED crowding (ED occupancy, waiting patients, admitted patients, and patient-hours) were assigned at the time of triage. The associations between the level of ED crowding and overall LOS and time to treatment orders were tested by analyzing trends across crowding quartiles, testing differences between the highest and lowest quartiles using Hodges-Lehmann distances, and using relative risk (RR) regression for multivariable analysis. RESULTS A total of 1,716 patients were discharged with asthma over the study period (932 at the academic site and 734 at the community site). LOS was longer at the academic site than the community site for asthma patients by 90 minutes (95% confidence interval [CI] = 79 to 101 minutes). All four measures of ED crowding were associated with longer LOS and time to treatment order at both sites (p < 0.001). At the highest level of ED occupancy, patients spent 75 minutes (95% CI = 58 to 93 minutes) longer in the ED compared to the lowest quartile of ED occupancy. In addition, comparing the highest and lowest quartiles of ED occupancy, time to nebulizer order was 6 minutes longer (95% CI = 1 to 13 minutes), and time to steroid order was 16 minutes longer (95% CI = 0 to 38 minutes). In the multivariable analysis, the association between ED crowding and LOS remained significant. Delays in nebulizer and steroid orders explained some, but not all, of the relationship between ED crowding and ED LOS. CONCLUSIONS Emergency department crowding is associated with longer ED LOS (by more than 1 hour) in patients who ultimately get discharged with asthma flares. Some but not all of longer LOS during crowded times is explained by delays in ordering asthma medications.

Identifying Pregnant Women Experiencing Domestic Violence in an Urban Emergency Department

The article describes characteristics of pregnant women presenting to the Emergency Department (ED) who are experiencing current violence and presented a screening tool to identify pregnant women experiencing violence. Women completed an in-person interview regarding violence, sociodemo-graphic factors, health status, and drug use. Fifteen percent of women reported at least one episode of violence during the pregnancy. Young age (OR = 3.37, 95% CI: 1.79-6.36), current alcohol use (OR = 1.53, 95% CI: 1.06-2.19), current marijuana use (OR = 1.96, 95% CI: 1.32-2.92), less than a high school education (OR = 1.46, 95% CI: 1.01-2.12), and a prior diagnosis of trichomonas (OR = 1.81, 95% CI: 1.20-2.72) were significantly related to experiencing current violence. Screening patients using these five characteristics identified 8 out of 10 women reporting violence (sensitivity = 75.6%). These results identify a set of predictors that may be helpful in identifying pregnant women who are experiencing current domestic violence.

VIOLENCE DURING PREGNANCY

This article discusses intimate partner abuse during pregnancy. The population at risk is defined, including risk behaviors, possible identifying factors during presentation to the emergency department, and available outcome data on violence to the fetus and the pregnant mother. Legal and ethical issues are also discussed. Intervention techniques are presented, emphasizing the role of the emergency physician in coordinating referrals to social service agencies and helping victims develop safety plans.

Trends in Boarding of Admitted Patients in US Emergency Departments 2003–2005

BACKGROUND Boarding of admitted patients in the Emergency Department (ED) is common and is associated with poor patient outcomes. OBJECTIVES We sought to estimate the magnitude of and trends for ED boarding in the US. METHODS We used the 2003-2005 National Hospital Ambulatory Medical Care Survey to estimate the time patients spent boarding in EDs in the US. We used fixed and imputed times required to evaluate, treat, and decide to admit each patient using the number of medications and diagnostic tests received. We calculated the absolute and relative patient-care hours spent boarding in US EDs over the 3-year period. RESULTS Total patient-hours spent in US EDs increased from 209 million to 217 million between 2003 and 2005. Overall admission rates decreased between 2003 and 2005 (13.9% in 2003, 12.3% in 2005), whereas intensive care unit admission rates increased (1.3% in 2003, 2.0% in 2005). Mean ED length of stay decreased (5.4 h in 2003, 4.6 h in 2005). The proportion of patient-hours accounted for by ED boarding decreased over the study period (11.3-17.1% in 2003, 5.9-15.3% in 2004, and 2.8-12.0% 2005). CONCLUSIONS Boarding of admitted patients in the ED accounts for a substantial portion of ED patient-care hours. Overall boarding time decreased over the 3 years.

Brief motivational intervention for intimate partner violence and heavy drinking in the emergency department: a randomized clinical trial

IMPORTANCE Intimate partner violence (IPV) and heavy drinking are co-occurring public health problems, but integrated brief interventions for these conditions have not been tested. OBJECTIVE To determine whether a brief motivational intervention provided at the time of an emergency department (ED) visit reduces IPV and heavy drinking. DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial conducted at 2 US academic urban EDs between January 2011 and December 2014 to assess the effectiveness of a motivational intervention for IPV-involved female ED patients (ages: 18-64 years; N = 600) who exceeded sex-specific safe drinking limits. All received social service referrals; 2:2:1 to brief intervention (n = 242), assessed control (n = 237), or no-contact control (n = 121). INTERVENTIONS A 20- to 30-minute manual-guided motivational intervention (recorded and monitored for fidelity) delivered by masters-level therapists with a follow-up telephone booster. The assessed control group received the same number of assessments as the brief intervention group; the no-contact control group was assessed only once at 3 months. MAIN OUTCOMES AND MEASURES Incidents of heavy drinking and experiencing IPV measured over prespecified, 12 weekly assessments using an interactive voice response system. RESULTS Of 600 participants, 80% were black women with a mean age of 32 years. Retention was 89% for 2 or more interactive voice response system calls. Seventy-eight percent of women completed the 3-month interview, 79% at 6 months, and 71% at 12 months. During the 12-week period following the brief motivational intervention, there were no significant differences between the intervention group and the assessed control group on weekly assessments for experiencing IPV (odds ratio [OR], 1.02; 95% CI, 0.98-1.06) or heavy drinking (OR, 0.99; 95% CI, 0.96-1.03). From baseline to 12 weeks, the number of women with any IPV in the past week decreased from 57% (134 of 237) in the intervention group to 43% (83 of 194) and from 63% (145 of 231) in the assessed control group to 41% (77 of 187) (absolute difference of 8%). From baseline to 12 weeks, the number of women with past week heavy drinking decreased from 51% (120 of 236) in the intervention group to 43% (83 of 194) and from 46% (107 of 231) in the assessed control group to 41% (77 of 187) (absolute difference of 3%). At 12 months, 43% (71 of 165) of the intervention group and 47% (78 of 165) of the assessed control group reported no IPV during the previous 3 months and 19% (29 of 152) of the intervention group and 24% (37 of 153) of the control group had reduced their alcohol consumption to sex-specific National Institute on Alcohol Abuse and Alcoholism safe drinking levels. CONCLUSIONS AND RELEVANCE For women experiencing IPV and heavy drinking, the use of a brief motivational intervention in the ED compared with assessed and no-contact controls did not significantly reduce the days of heavy drinking or incidents of IPV. These findings do not support a brief motivational intervention in this setting. TRIAL REGISTRATION clinicaltrials.gov Identifer: NCT01207258.

Utility of point-of-care testing in ED triage ☆,☆☆

BACKGROUND Triage systems are commonly used in emergency departments (ED) to prioritize patients. Laboratory testing is not typically used to help risk-stratify patients at triage. OBJECTIVES We studied the utility of point-of-care (POC) testing at triage in ED patients with high-risk complaints. METHODS We conducted a prospective observational study on a convenience sample of ED patients at an urban academic hospital with 60,000 annual visits. Patients who were triaged to the waiting area with any of the following criteria were approached for enrollment: (1) chest pain or shortness of breath in patients older than 40 years, (2) possible infection in the presence of two or more systemic inflammatory response system criteria in patients older than 18 years, and (3) patients >65 years with non-traumatic complaints. A total of 300 subjects were enrolled. All enrolled patients received POC testing that included a combination of Chem8+, hemoglobin, troponin, B-type natriuretic peptide, and lactate. The triage nurse completed a survey after receiving the results. RESULTS POC results was reported to be helpful in 56% of patients, changed the triage level in 15% of patients and led to 6% of patients being brought back for rapid physician evaluation. Overall, 50% of patients had one or more abnormal POC laboratory tests. There was no relationship between ED census and the likelihood of being helpful, changing the triage level, changing management, or bringing patients back any faster. CONCLUSION POC testing at triage is a helpful adjunct in triage of patients with high-risk ED complaints.

Detecting intimate partner violence: more than trauma team education is needed.

BACKGROUND Intimate partner violence (IPV) is an underappreciated cause of morbidity and mortality in female trauma patients. We investigated the impact of a domestic violence education program for trauma residents on the detection of IPV. STUDY DESIGN In January 2008, an educational IPV program was implemented for all trauma residents. A retrospective review of all female patients evaluated by the trauma service before and after institution of the IPV program was performed. Medical records were reviewed for demographic data, injury mechanism, social habits, and IPV documentation. Chi-square and Fishers exact tests were used to compare patients before and after institution of the educational IPV program. RESULTS The records of 645 female trauma patients evaluated in 2007 and 2008 were reviewed. Patients were not routinely asked about IPV, despite implementation of the educational program; 39.9% were asked about IPV in 2007 versus 46.1% in 2008 (p = 0.11). The positive disclosure of IPV did not increase from 2007 to 2008 (20.1% versus 21.2%; p = 0.83). Documentation about social habits increased considerably. In 2008, patients were asked more regularly about alcohol (71.8% versus 80.8%; p = 0.01), drugs (64.1% versus 73.7%; p = 0.01), and tobacco use (67.0% versus 78.1%; p = 0.002). Importantly, patients with documented IPV (n = 57) frequently presented to the trauma team with nonviolent mechanisms of injury (n = 30, 52.6%). CONCLUSIONS IPV is a frequent finding in female trauma patients. Despite increased education, questions about IPV are not documented routinely. In addition, screening at-risk patients by mechanism will underestimate the prevalence of IPV. Universal screening should be mandated to increase IPV detection and enhance opportunities for intervention.

Violence does not influence early pregnancy loss

OBJECTIVE To examine the relationship between physical violence, controlling behavior, and spontaneous abortion (SAB). DESIGN Nested case-control study. SETTING Emergency department of a university hospital. PATIENT(S) One thousand one hundred ninety-nine pregnant women. MAIN OUTCOME MEASUREMENT(S) Physical violence and controlling behavior. RESULT(S) Cases experienced a SAB (n = 392) and controls maintained their pregnancy through 22 weeks (n = 807). Fifteen percent of women reported violence during the pregnancy, and 49% had reported one or more past episodes of violence. We found no relationship between any measure of physical violence (past, current, or by perpetrator) and the risk of SAB. CONCLUSION(S) Although physical violence was very prevalent in the study population, exposure to violence did not influence the risk of SAB.

Feasibility of an automated telephone survey to enable prospective monitoring of subjects whose confidentiality is paramount: a four-week cohort study of partner violence recurrence after Emergency Department discharge

Objective A goal in intimate partner violence (IPV) research is to identify victims when they are treated in a hospital Emergency Department (ED) and predict which patients will sustain abuse again after discharge, so interventions can be targeted. Following patients to determine those prognostic factors is difficult, however, especially to study IPV given the risk to be assaulted if their partner learns of their participation. We assessed the feasibility of an automated telephone survey and a wireless incentive delivery system to follow ED patients after discharge, enabling detection of IPV recurrence. Methods A four-week prospective cohort pilot study was conducted at an urban academic medical center ED in the U.S. Thirty patient subjects (24 women, 6 men; 18–54 years) who had sustained IPV in the past six months, 12 of whom presented for an acute IPV-related condition, were interviewed in the ED and were asked to report weekly for four weeks after discharge to a toll-free, password protected telephone survey, and answer recorded questions using the telephone keypad. A