Patterns of presentation of abused children to the accident and emergency department

Emergency Department Utilization in Children <36 Months Is Not an Independent Risk Factor for Maltreatment

BACKGROUND AND OBJECTIVES

Early childhood high-frequency use (HFU) of the emergency department (ED) has been endorsed as a marker for increased risk of child maltreatment. In a prior analysis of pediatric ED (PED) visits by 16,664 children, 0-36 months old, we defined early childhood HFU (the 90th percentile) as five or more visits. The purpose of this study was to follow HFU patients to determine if they had a higher likelihood of reported maltreatment.

METHODS

This is a single-center, cross-sectional, observational study of the association between PED use in early life and subsequent intervention by child protective services (CPS). CPS data were obtained from a Department of Social Services database for subjects meeting criteria for PED HFU as well as sex, race, and ethnicity-matched controls. Multivariable analyses were performed to assess if HFU was independently associated with child maltreatment.

RESULTS

While CPS involvement was more highly represented in the group with PED HFU, so were many confounding variables such as African American race, history of hospital admissions, and social work consultations in the PED for any reason. HFU, by itself, is not a risk factor for a major intervention by CPS.

CONCLUSIONS

In efforts to identify children at risk for maltreatment, objective assessments such as PED utilization are potential markers to utilize to aid in recognition. Unfortunately, there are many risk factors for increased PED utilization that act as confounders for this marker. Future work is necessary to identify children at risk for maltreatment in the ED.

Diagnosis of Elder Abuse in U.S. Emergency Departments

OBJECTIVES

To estimate the proportion of visits to U.S. emergency departments (EDs) in which a diagnosis of elder abuse is reached using two nationally representative datasets.

DESIGN

Retrospective cross-sectional analysis.

SETTING

U.S. ED visits recorded in the 2012 Nationwide Emergency Department Sample (NEDS) or the 2011 National Hospital Ambulatory Medical Care Survey (NHAMCS).

PARTICIPANTS

All ED visits of individuals aged 60 and older.

MEASUREMENTS

The primary outcome was elder abuse defined according to International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. The proportion of visits with elder abuse was estimated using survey weights. Odds ratios (ORs) were calculated to identify demographic characteristics and common ED diagnoses associated with elder abuse.

RESULTS

In 2012, NEDS contained information on 6,723,667 ED visits of older adults, representing an estimated 29,056,673 ED visits. Elder abuse was diagnosed in an estimated 3,846 visits, corresponding to a weighted diagnosis period prevalence of elder abuse in U.S. EDs of 0.013% (95% confidence interval (CI) = 0.012-0.015%). Neglect and physical abuse were the most common types diagnosed, accounting for 32.9% and 32.2% of cases, respectively. Multivariable analysis showed greater weighted odds of elder abuse diagnosis in women (odds ratio (OR) = 1.95, 95% CI = 1.68-2.26) and individuals with contusions (OR = 2.91, 95% CI = 2.36-3.57), urinary tract infection (OR = 2.21, 95% CI = 1.84-2.65), and septicemia (OR = 1.92, 95% CI = 1.44-2.55). In the 2011 NHAMCS dataset, no cases of elder abuse were recorded for the 5,965 older adult ED visits.

CONCLUSION

The proportion of U.S. ED visits by older adults receiving a diagnosis of elder abuse is at least two orders of magnitude lower than the estimated prevalence in the population. Efforts to improve the identification of elder abuse in EDs may be warranted.

Frequent pediatric emergency department use in infancy and early childhood

OBJECTIVE

To define the threshold and population factors associated with pediatric emergency department (PED) use above the norm during the first 36 months of life.

METHODS

We conducted a cross-sectional study of children born between 2003 and 2006, treated in a single PED within the first 36 months of life. Exclusion criteria included out-of-county residence or history of abuse or neglect. The primary outcome, frequent PED use, was defined by the 90th percentile for PED visits per patient. Multivariate analysis was used to identify factors associated with frequent PED use.

RESULTS

A total of 41,912 visits occurred for 16,664 patients during the study. Pediatric ED use skewed heavily toward less than 2 visits per patient (median, 2; range, 1-39; interquartile range, 2). The threshold for frequent PED use was 5 or more visits per patient and occurred for 14% (95% confidence interval [95% CI], 13%-15%) of patients. Most visits were coded with low acuity International Classifications of Diseases, 9th Revision, Clinical Modification codes. The following factors were strongly associated with frequent PED use: lack of primary care physician (odds ratio [OR], 6.03; 95% CI, 5.39%-6.80%; P < 0.0001), non private insurance (OR, 3.64; 95% CI, 2.99%-4.46%; P<0.0001), and history of inpatient admission (OR, 3.09; 95% CI, 1.66%-2.24%; P < 0.0001). Leaving without being seen, black race, Hispanic ethnicity, and residence in a poverty-associated zip code were also significantly associated, but less strongly predictive of, frequent PED use.

CONCLUSIONS

The threshold for frequent PED use was more than 5 visits per patient within the first 36 months of life. Further study is needed to better define this population and develop targeted interventions to ensure care provision occurs in the ideal setting.

Characteristics of family violence victims presenting to emergency departments in Hong Kong

BACKGROUND

The Emergency Department (ED) has been shown to be a valuable location to screen for family violence.

STUDY OBJECTIVE

To investigate the characteristics of family violence victims presenting to EDs in a Chinese population in Hong Kong.

METHODS

This study examined a retrospective cohort of patients presenting to the Accident and Emergency Departments of three regional hospitals in the Kwai Tsing district of Hong Kong for evaluation and management of physical injuries related to family violence during the period of January 1, 1997 to December 31, 2008.

RESULTS

A total of 15,797 patients were assessed. The sample comprised cases of intimate partner violence (IPV; n=10,839), child abuse and neglect (CAN; n=3491), and elder abuse (EA; n=1467). Gender differences were found in patterns of ED utilization among the patients. The rates of readmission were 12.9% for IPV, 12.8% for CAN, and 8.9% for EA. Logistic regression showed that being male, being discharged against medical advice, and arriving at the hospital via ambulance were the common factors associated with readmission to the EDs for patients victimized by IPV and CAN.

CONCLUSION

This study investigates the victim profile of a large cohort of a Chinese population, providing a unique data set not previously released in this cultural or medical system. The findings give insights to early identification of victims of family violence in the EDs and suggest that screening techniques focused on multiple forms of family violence would improve identification of violence cases. Multidisciplinary collaboration between health, legal, and social service professionals is also warranted to meet the various needs of victims and to reduce hospital readmissions.

Randomized prospective study to evaluate child abuse documentation in the emergency department

OBJECTIVES

The objective was to determine whether an educational intervention for health care providers would result in improved documentation of cases of possible physical child abuse in children <36 months old treated in the emergency department (ED) setting.

METHODS

This study had a statewide group-randomized prospective trial design. Participating EDs were randomized to one of three intervention groups: no intervention, partial intervention, or full intervention. Medical records for children <36 months of age were abstracted before, during, and after the intervention periods for specific documentation elements. The main outcome measure was the change in documentation from baseline. Generalized estimating equations (GEEs) were used to test for intervention effect.

RESULTS

A total of 1,575 charts from 14 hospitals EDs were abstracted. Hospital and demographic characteristics were similar across intervention groups. There were 922 (59%) injury visits and 653 (41%) noninjury visits. For each specific documentation element, a GEE model gave p-values of >0.2 in independent tests, indicating no evidence of significant change in documentation after the intervention. Even among the 26 charts in which the possibility of physical abuse was noted, documentation remained variable.

CONCLUSIONS

The educational interventions studied did not improve ED documentation of cases of possible physical child abuse. The need for improved health care provider education in child abuse identification and documentation remains. Future innovative educational studies to improve recognition of abuse are warranted.

Prediction of child abuse risk from emergency department use

OBJECTIVE

To examine whether pre-abuse rates and patterns of emergency department (ED) visits between children with supported child abuse and age-matched control subjects are useful markers for abuse risk.

STUDY DESIGN

A population-based case-control study using probabilistic linkage of four statewide data sets. Cases were abused children <13 years of age, identified between January 1, 2002, and December 31, 2002. For each case, a birth date-matched, population-based control was obtained. Outcome measures were rate ratios of ED visits in cases compared with control subjects.

RESULTS

Cases (n = 9795) and control subjects (n = 9795) met inclusion criteria; 4574 cases (47%) had an ED visit; thus linked to the ED database versus 2647 control subjects (27%). The crude ED visit rate per 10,000 person-days of exposure was 8.2 visits for cases compared with 3.9 visits for control subjects. Cases were almost twice as likely as control subjects (adjusted rate ratio = 1.8; 95% CI, 1.5, 1.8) to have had a prior ED visit. Leading ED discharge diagnoses were similar for both groups.

CONCLUSIONS

Children with supported child abuse have higher ED use before abuse diagnosis, when compared with the general pediatric population. However, neither the rate of ED use nor the pattern of diagnoses offers sufficient specificity to be useful markers of risk for abuse.