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Introduction: Previous studies have shown that substantial percentages of emergency department (ED) patients in the USA recommended for HIV or hepatitis C (HCV) decline testing. Evidence-based and cost-effective interventions to improve HIV/HCV testing uptake are needed, particularly for people who inject drugs (PWIDs) (currently or formerly), who comprise a group at higher risk for these infections. We developed a brief persuasive health communication intervention (PHCI) designed to convince ED patients who had declined HIV/HCV testing to agree to be tested. In this investigation, we will determine if the PHCI is more efficacious in convincing ED patients to be tested for HIV/HCV when delivered by a video or in person, and whether efficacy is similar among individuals who currently, previously or never injected drugs., Methods and Analysis: We will conduct a multisite, randomised controlled trial comparing PHCIs delivered by video versus in person by a health educator to determine which delivery method convinces more ED patients who had declined HIV/HCV testing instead to be tested. We will stratify randomisation by PWID status (current, former or never/non-PWID) to permit analyses comparing the PHCI delivery method by injection-drug use history. We will also perform a cost-effectiveness analysis of the interventions compared with current practice, examining the incremental cost-effectiveness ratio between the two interventions for the ED population overall and within individual strata of PWID. As an exploratory analysis, we will assess if a PHCI video with captions confers increased or decreased acceptance of HIV/HCV testing, as compared with a PHCI video without captions., Ethics and Dissemination: The study protocol has been approved by the institutional review board of the Icahn School of Medicine. The results will be disseminated at international conferences and in peer-reviewed publications., Trial Registration Number: NCT05968573., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: A substantial proportion of the 40 million people in the US who present to emergency departments (EDs) each year after traumatic events develop posttraumatic stress disorder (PTSD) or major depressive episode (MDE). Accurately identifying patients at high risk in the ED would facilitate the targeting of preventive interventions., Objectives: To develop and validate a prediction tool based on ED reports after a motor vehicle collision to predict PTSD or MDE 3 months later., Design, Setting, and Participants: The Advancing Understanding of Recovery After Trauma (AURORA) study is a longitudinal study that examined adverse posttraumatic neuropsychiatric sequalae among patients who presented to 28 US urban EDs in the immediate aftermath of a traumatic experience. Enrollment began on September 25, 2017. The 1003 patients considered in this diagnostic/prognostic report completed 3-month assessments by January 31, 2020. Each patient received a baseline ED assessment along with follow-up self-report surveys 2 weeks, 8 weeks, and 3 months later. An ensemble machine learning method was used to predict 3-month PTSD or MDE from baseline information. Data analysis was performed from November 1, 2020, to May 31, 2021., Main Outcomes and Measures: The PTSD Checklist for DSM-5 was used to assess PTSD and the Patient Reported Outcomes Measurement Information System Depression Short-Form 8b to assess MDE., Results: A total of 1003 patients (median [interquartile range] age, 34.5 [24-43] years; 715 [weighted 67.9%] female; 100 [weighted 10.7%] Hispanic, 537 [weighted 52.7%] non-Hispanic Black, 324 [weighted 32.2%] non-Hispanic White, and 42 [weighted 4.4%] of non-Hispanic other race or ethnicity were included in this study. A total of 274 patients (weighted 26.6%) met criteria for 3-month PTSD or MDE. An ensemble machine learning model restricted to 30 predictors estimated in a training sample (patients from the Northeast or Midwest) had good prediction accuracy (mean [SE] area under the curve [AUC], 0.815 [0.031]) and calibration (mean [SE] integrated calibration index, 0.040 [0.002]; mean [SE] expected calibration error, 0.039 [0.002]) in an independent test sample (patients from the South). Patients in the top 30% of predicted risk accounted for 65% of all 3-month PTSD or MDE, with a mean (SE) positive predictive value of 58.2% (6.4%) among these patients at high risk. The model had good consistency across regions of the country in terms of both AUC (mean [SE], 0.789 [0.025] using the Northeast as the test sample and 0.809 [0.023] using the Midwest as the test sample) and calibration (mean [SE] integrated calibration index, 0.048 [0.003] using the Northeast as the test sample and 0.024 [0.001] using the Midwest as the test sample; mean [SE] expected calibration error, 0.034 [0.003] using the Northeast as the test sample and 0.025 [0.001] using the Midwest as the test sample). The most important predictors in terms of Shapley Additive Explanations values were symptoms of anxiety sensitivity and depressive disposition, psychological distress in the 30 days before motor vehicle collision, and peritraumatic psychosomatic symptoms., Conclusions and Relevance: The results of this study suggest that a short set of questions feasible to administer in an ED can predict 3-month PTSD or MDE with good AUC, calibration, and geographic consistency. Patients at high risk can be identified in the ED for targeting if cost-effective preventive interventions are developed.

Introduction: African-Americans in the United States experience greater persistent pain than non-Hispanic Whites across a range of medical conditions, but to our knowledge no longitudinal studies have examined the risk factors or incidence of persistent pain among African-Americans experiencing common traumatic stress exposures such as after a motor vehicle collision (MVC). We evaluated the incidence and predictors of moderate to severe axial musculoskeletal pain (MSAP) and widespread pain six weeks after a MVC in a large cohort of Black adults presenting to the emergency department (ED) for care., Methods: This prospective, multi-center, cohort study enrolled Black adults who presented to one of 13 EDs across the US within 24 hours of a MVC and were discharged home after their evaluation. Data were collected at the ED visit via patient interview and self-report surveys at six weeks after the ED visit via internet-based, self-report survey, or telephone interview. We assessed MSAP pain at ED visit and persistence at six weeks. Multivariable models examined factors associated with MSAP persistence at six weeks post-MVC., Results: Among 787 participants, less than 1% reported no pain in the ED after their MVC, while 79.8 (95% confidence interval [CI], 77.1 - 82.2) reported MSAP and 28.3 (95% CI, 25.5 - 31.3) had widespread pain. At six weeks, 67% (95% CI, 64, 70%) had MSAP and 31% (95% CI, 28, 34%) had widespread pain. ED characteristics predicting MSAP at six weeks post-MVC (area under the curve = 0.74; 95% CI, 0.72, 0.74) were older age, peritraumatic dissociation, moderate to severe pain in the ED, feeling uncertain about recovery, and symptoms of depression., Conclusion: These data indicate that African-Americans presenting to the ED for evaluation after MVCs are at high risk for persistent and widespread musculoskeletal pain. Preventive interventions are needed to improve outcomes for this high-risk group.

Study Objective: We determine whether an emergency department (ED)-initiated fall-prevention intervention can reduce subsequent fall-related and all-cause ED visits and hospitalizations in older adults., Methods: The Geriatric Acute and Post-acute Fall Prevention intervention was a randomized controlled trial conducted from January 2018 to October 2019. Participants at 2 urban academic EDs were randomly assigned (1:1) to an intervention or usual care arm. Intervention participants received a brief, tailored, structured, pharmacy and physical therapy consultation in the ED, with automated communication of the recommendations to their primary care physicians., Results: Of 284 study-eligible participants, 110 noninstitutionalized older adults (≥65 years) with a recent fall consented to participate; median age was 81 years, 67% were women, 94% were white, and 16.3% had cognitive impairment. Compared with usual care participants (n=55), intervention participants (n=55) were half as likely to experience a subsequent ED visit (adjusted incidence rate ratio 0.47 [95% CI 0.29 to 0.74]) and one third as likely to have fall-related ED visits (adjusted incidence rate ratio 0.34 [95% CI 0.15 to 0.76]) within 6 months. Intervention participants experienced half the rate of all hospitalizations (adjusted incidence rate ratio 0.57 [95% CI 0.31 to 1.04]), but confidence intervals were wide. There was no difference in fall-related hospitalizations between groups (adjusted incidence rate ratio 0.99 [95% CI 0.31 to 3.27]). Self-reported adherence to pharmacy and physical therapy recommendations was moderate; 73% of pharmacy recommendations were adhered to and 68% of physical therapy recommendations were followed., Conclusion: Geriatric Acute and Post-acute Fall Prevention, a postfall, in-ED, multidisciplinary intervention with pharmacists and physical therapists, reduced 6-month ED encounters in 2 urban EDs. The intervention could provide a model of care to other health care systems aiming to reduce costly and burdensome fall-related events in older adults., (Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Study Objective: Brief, easily administered, and valid health literacy assessment tools are needed to optimize health care delivery in the emergency medicine setting. Three health literacy screening items have been proposed to assess health literacy in outpatient settings. We investigated their ability to identify English- and Spanish-speaking adult emergency department (ED) patients with lower health literacy., Methods: Participants were Spanish- or English-speaking adult patients randomly selected from 4 geographically spread, US, urban, safety-net EDs. Participants completed the 3 health literacy screening items, as well as the Short Assessment of Health Literacy-Spanish and English (SAHL-S&E). Test performance characteristics, including receiver operating characteristics area under the curve, of the 3 health literacy screening items were estimated, as compared with the SAHL-S&E., Results: According to the SAHL-S&E, 36% of the 1,165 English speakers and 35% of the 1,605 Spanish speakers had lower health literacy. Areas under the curve for each health literacy screening item individually were: needing others to help read materials (English 0.59, 95% confidence interval [CI] 0.56 to 0.62; Spanish 0.58, 95% CI 0.56 to 0.61), problems learning because of difficulty reading (English 0.63, 95% CI 0.60 to 0.66; Spanish 0.59, 95% CI 0.56 to 0.62), and confidence with completing forms (English 0.62, 95% CI 0.59 to 0.65; Spanish 0.60, 95% CI 0.57 to 0.63). Areas under the curve for the 3 screening items combined were: English 0.66 (95% CI 0.63 to 0.70) and Spanish 0.62 (95% CI 0.59 to 0.64)., Conclusion: The 3 health literacy screening items performed poorly in identifying adult ED patients with lower health literacy. Higher-validity screening measures are needed to better serve the health care needs of this vulnerable population in the ED setting., (Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

The need for HIV testing in US emergency departments (EDs) has not been assessed, particularly among Latino immigrants and Blacks. We surveyed Latino immigrant and Black 18 to 64-year-old patients at 4 EDs about demographic characteristics, HIV testing history, and health literacy. A subset of patients was further surveyed on HIV risk-taking behaviors. Of the 2,265 participants, 24% had never been tested for HIV. Latino immigrants were more likely than Blacks never to have been tested for HIV (28% vs. 16%). In multivariable logistic regression, for Latino immigrants, male gender and lower health literacy were associated with no previous HIV testing. Among the 1,141-participant subset providing HIV risk-taking behavior data, 23% reported at least one risk factor and of those with at least one risk factor, 23% had never been tested for HIV. There remains a need for HIV testing among adult Latino immigrant and Black patients in US EDs.

Objectives: We aimed to describe a new multidisciplinary team fall prevention intervention for older adults who seek care in the emergency department (ED) after having a fall, assess its feasibility and acceptability, and review lessons learned during its initiation., Design: Single-blind randomized controlled pilot study., Setting: Two urban academic EDs PARTICIPANTS: Adults 65 years old or older (n = 110) who presented to the ED within 7 days of a fall., Intervention: Participants were randomized to a usual care (UC) and an intervention (INT) arm. Participants in the INT arm received a brief medication therapy management session delivered by a pharmacist and a fall risk assessment and plan by a physical therapist (PT). INT participants received referrals to outpatient services (eg, home safety evaluation, outpatient PT)., Measurements: We used participant, caregiver, and clinician surveys, as well as electronic health record review, to assess the feasibility and acceptability of the intervention., Results: Of the 110 participants, the median participant age was 81 years old, 67% were female, 94% were white, and 16.3% had cognitive impairment. Of the 55 in the INT arm, all but one participant received the pharmacy consult (98.2%); the PT consult was delivered to 83.6%. Median consult time was 20 minutes for pharmacy and 20 minutes for PT. ED length of stay was not increased in the INT arm: UC 5.25 hours vs INT 5.0 hours (P < .94). After receiving the Geriatric Acute and Post-acute Fall Prevention Intervention (GAPcare), 100% of participants and 97.6% of clinicians recommended the pharmacy consult, and 95% of participants and 95.8% of clinicians recommended the PT consult., Conclusion: These findings support the feasibility and acceptability of the GAPcare model in the ED. A future larger randomized controlled trial is planned to determine whether GAPcare can reduce recurrent falls and healthcare visits in older adults. J Am Geriatr Soc 68:198-206, 2019., (© 2019 The American Geriatrics Society.)

Introduction: Effective approaches to increase engagement in treatment for opioid use disorder (OUD) and reduce the risk of recurrent overdose and death following emergency department (ED) presentation for opioid overdose remain unknown. As such, we aim to compare the effectiveness of behavioural interventions delivered in the ED by certified peer recovery support specialists relative to those delivered by licensed clinical social workers (LCSWs) in promoting OUD treatment uptake and reducing recurrent ED visits for opioid overdose., Methods and Analysis: Adult ED patients who are at high risk for opioid overdose (ie, are being treated for an opioid overdose or identified by the treating physician as having OUD) (n=650) will be recruited from two EDs in a single healthcare system in Providence, Rhode Island into a two-arm randomised trial with 18 months of follow-up postrandomisation. Eligible participants will be randomly assigned (1:1) in the ED to receive a behavioural intervention from a certified peer recovery support specialist or a behavioural intervention from an LCSW. The primary outcomes are engagement in formal OUD treatment within 30 days of the initial ED visit and recurrent ED visits for opioid overdose within 18 months of the initial ED visit, as measured through statewide administrative records., Ethics and Dissemination: This protocol was approved by the Rhode Island Hospital institutional review board (Approval Number: 212418). Data will be presented at national and international conferences and published in peer-reviewed journals., Trial Registration Number: NCT03684681., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Emergency department (ED) clinicians rely on the accuracy of written communication when assessing needs of nursing home (NH) residents. This study aimed to review the completeness of NH transfer documentation according to expected core components, as guided by the INTERACT 4.0 quality improvement tool. We also describe the association between patient or facility characteristics and transfer documentation completeness, as well as establish whether information gaps in NH-ED transfer documentation were associated with hospital admission., Design: Retrospective study using 2 abstractors blinded to the study aims., Setting and Participants: 474 records from NH residents transferred to the 3 EDs of Rhode Island's largest health care system from September 2015 to September 2016., Measures: NH-ED transfer documentation completeness was reviewed according to the expected core items of transfer documentation, guided by the INTERACT 4.0 quality improvement tool. We used multivariable linear regression with random effects to assess factors associated with NH-ED transfer documentation completion and logistic regression with random effects to assess the relation between information gaps and hospital admission., Results: Of the 474 NH-ED transfer visits, mean patient age was 76 years; 43% were male, 14% were nonwhite, and 34% had dementia. NH-ED transfer documents were present for 97% of visits, and an average 11.9 of 15 INTERACT core items were complete. Usual mental status and reason for transfer were absent for 75% of patients, whereas functional status was absent for 80%. The multivariable model showed that a higher Charlson Comorbidity Index score (coefficient 0.08, standard error 0.04, P = .03) was associated with more complete documentation. More complete documentation was associated with greater likelihood of hospital admission (adjusted odds ratio = 1.09, 95% confidence interval = 1.01-1.18)., Conclusions/implications: Usual mental and functional status and the reason for transfer are often missing in NH-ED transfer documents and should be incorporated into standardized transfer forms., (Copyright © 2018 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Emergency departments (EDs) are critical sites for hypertension (HTN) screening. Home blood pressure (BP) monitoring (HBPM) is used routinely in outpatient settings, yet its utility after the ED visit for those with elevated BP in the ED is unclear., Aim: In this pilot study, we assessed if HBPM could detect HTN in patients with elevated in-ED BP., Methods: From September 2014 to July 2017, we recruited adult patients at an urban, academic ED with a triage BP ≥ 120/80 mmHg and no history of HTN into this prospective cohort observational study. After their ED visit, participants obtained BP measurements for two weeks using a validated HBPM. HTN was considered probable if the average HBPM BP was ≥ 135/85 mmHg. We calculated the proportion of participants whose ED BP measurement accurately predicted HTN using HBPM after discharge., Results: Of 136 participants enrolled, 93 (68%) returned the HBPM with at least four home BP measurements [mean number of measurements obtained: 29 (SD: 17, range 4-59)]. Participants' median age was 40 years-old (IQR 34-48); 55% were female, 19% were black, and 58% were white. Forty-six percent of participants with elevated in-ED BP had HTN in follow-up., Conclusions: For patients with elevated BP in the ED, HBPM could be valuable for determining which patients have HTN and require expedient follow-up.

Background: Although this has not been fully studied, videos and pictorial brochures might be equivalent methods of delivering HIV/AIDS and HIV testing information to emergency departments (ED) patients. It also is not known how well or for how long such knowledge is retained, if this information should be tailored according to patient health literacy, and if retention of this knowledge impacts future HIV testing behavior., Methods: We will conduct a multi-site, randomized, controlled, longitudinal trial among 600 English- and 600 Spanish-speaking 18-64-year-old ED patients to investigate these questions. We will stratify our sample within language (English vs. Spanish) by health literacy level (lower vs. higher) and randomly assign patients to receive HIV/AIDS and HIV testing information by video or pictorial brochure. All patients will be tested for HIV in the ED. At 12-months post-enrollment, we will invite participants to be tested again for HIV. As primary aims, we will compare the efficacy of pictorial brochures and videos in improving short-term (in ED) HIV/AIDS and HIV testing knowledge and retaining this knowledge over 12 months. We will determine if and how short-term improvement and longer-term retention of knowledge interacts with information delivery mode (pictorial brochure or video), patient health literacy level (lower or higher), and language (English or Spanish). As secondary aims, using the Information-Motivation-Behavioral Skills (IMB) model as a heuristic framework, we will measure constructs from the IMB model relevant to our study, and assess their impact on HIV re-testing behavior; we will also examine the moderating influences of information delivery mode, language, and health literacy level. In addition, we will explore simplified screening strategies to identify ED patients with lower health literacy as ways to implement a tailored approach to HIV/AIDS and HIV testing information delivery in EDs., Discussion: Study findings will guide ED-based delivery of HIV/AIDS and HIV testing information; that is, whether delivery modes (video or pictorial brochure) should be selected for patients by language and/or health literacy level. The results also will inform EDs when, how, and for whom information needs to be provided for those undergoing testing again for HIV within a one-year period., Trial Registration: ClinicalTrials.gov Identifier: NCT02284451 . Posted November 6, 2014.

Objectives: Assess the 12-month efficacy of a brief intervention (BI) on reducing drug use and increasing drug treatment services utilisation among adult emergency department (ED) patients., Methods: This randomised, controlled trial enrolled 18-64-year-old ED patients needing a drug use intervention. Treatment arm participants received a tailored BI while control arm participants only completed the study questionnaires. Self-reported past 3-month drug use and engagement in drug treatment services were compared by study arm at 3-month intervals over 1 year. Multiple imputations were performed to overcome loss-to-follow-up., Results: Of the 1030 participants, follow-up completion ranged 55%-64% over the four follow-ups. At 12 months, the two study arms were similar in regards to mean: (1) proportion reporting any drug use (treatment: 67.1% (61.6 to 72.6), control: 74.4% (69.4 to 79.4)); (2) drug use frequency on a five-point scale (treatment: 3.7 (3.3 to 4.2), control: 4.6 (4.0 to 5.2)); (3) total days of drug use (treatment: 28.3 (23.2 to 33.4), control: 33.4 (28.5 to 38.2)); (4) most number of times drugs used/day (treatment: 4.6 (3.6 to 5.5), control: 6.1 (4.8 to 7.3)) and (5) typical number of times drugs used/day (treatment: 3.3 (2.5 to 4.1), control: 5.1 (3.9 to 6.2)). Utilisation of drug treatment services also was similar by study arm. In multivariable regression analyses, patients who were homeless or had higher drug use at baseline continued to have greater drug use in follow-up., Conclusions: Among adult ED patients requiring a drug use intervention, this BI did not decrease drug use or increase drug treatment services utilisation over a 12-month period more than the control condition., Trial Registration Number: NCT01124591; Pre-trial., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Most previous brief intervention (BI) studies have focused on alcohol or drug use, instead of both substances. Our primary aim was to determine if an alcohol- and drug-use BI reduced alcohol use and increased alcohol treatment services utilization among adult emergency department (ED) patients who drink alcohol and require an intervention for their drug use. Our secondary aims were to assess when the greatest relative reductions in alcohol use occurred, and which patients (stratified by need for an alcohol use intervention) reduced their alcohol use the most. In this secondary analysis, we studied a sub-sample of participants from the Brief Intervention for Drug Misuse in the Emergency Department (BIDMED) randomized, controlled trial of a BI vs. no BI, whose responses to the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) indicated a need for a BI for any drug use, and who also reported alcohol use. Participants were stratified by their ASSIST alcohol subscore: 1) no BI needed, 2) a BI needed, or 3) an intensive intervention needed for alcohol use. Alcohol use and alcohol treatment services utilization were measured every 3 months for 12 months post-enrollment. Of these 833 participants, median age was 29 years-old, 46% were female; 55% were white/non-Hispanic, 27% black/non-Hispanic, and 15% Hispanic. Although any alcohol use, alcohol use frequency, days of alcohol use, typical drinks consumed/day, and most drinks consumed/day decreased in both the BI and no BI arms, there were no differences between study arms. Few patients sought alcohol use treatment services in follow-up, and utilization also did not differ by study arm. Compared to baseline, alcohol use reduced the most during the first 3 months after enrollment, yet reduced little afterward. Participants whose ASSIST alcohol subscores indicated a need for an intensive intervention generally had the greatest relative decreases in alcohol use. These results indicate that the BI was not efficacious in reducing alcohol use among alcohol- and drug-using adult ED patients than the self-assessments alone, but suggest that self-assessments with or without a BI may confer reductions in alcohol use., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Falls are the leading cause of emergency department (ED) visits for fatal and non-fatal injuries among adults 65 years old and older. We aimed to better understand the fall history, risk for further falls, and actions taken to prevent further falls among this higher fall risk population. This cross-sectional study included older adults without cognitive impairment presenting to the Rhode Island Hospital ED from February to May 2017. Of the 76 participants, 35 self-reported no prior falls, and 41 self-reported at least one prior fall, of whom 20 fell on the day of ED presentation. Participants with vs. without self-reported prior falls were similar in age, gender, race, and substance use. Participants with prior falls scored lower on cognitive testing and had more comorbidities associated with falls. Only one quarter of those with prior falls reported making changes and few were evaluated by professionals to prevent future falls. This study highlights that older adult ED patients who sustain a fall are at higher risk for subsequent falls, and that greater fall prevention efforts are needed to protect this vulnerable group. [Full article available at http://rimed.org/rimedicaljournal-2017-12.asp].

In 2012, the Centers for Medicare & Medicaid Services (CMS) instituted a Physician Quality Reporting System measure for screening and referring patients with elevated blood pressure (BP). The aims of this study were to (1) assess the reliability of ED triage BP as a metric to establish when the CMS threshold (≥120/80 mm Hg), and other clinically relevant BP thresholds (≥140/90 and ≥160/100 mm Hg) have been met, using BP measured with a highly accurate device (BpTRU) in the emergency department as the gold standard; and (2) determine whether correct identification varies by gender, race, or triage acuity. Using the BpTRU, we calculated the proportion of patients whose triage BP accurately indicated a need for further referral and treatment for hypertension according to three suggested BP thresholds (≥120/80, ≥140/90, and ≥160/100 mm Hg). Of 354 patients, the median age was 39 years, 48.9% were women, and 66.4% were White. At the three suggested BP thresholds (≥120/80, ≥140/90, and ≥160/100 mm Hg), 66.1%, 74.0%, and 88.8% of patients were confirmed to meet the CMS threshold, respectively. There were no differences by gender, race, or triage acuity. Emergency department triage BP would reliably identify elevated BP using the CMS threshold in up to two-thirds of those without known hypertension., (Copyright © 2017 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.)

Each year millions of Americans present to the emergency department (ED) for care after a motor vehicle collision (MVC); the majority (>90%) are discharged to home after evaluation. Acute musculoskeletal pain is the norm in this population, and such patients are typically discharged to home with prescriptions for oral opioid analgesics or nonsteroidal antiinflammatory drugs (NSAIDs). The influence of acute pain management on subsequent pain outcomes in this common ED population is unknown. We evaluated the effect of opioid analgesics vs NSAIDs initiated from the ED on the presence of moderate to severe musculoskeletal pain and ongoing opioid use at 6 weeks in a large cohort of adult ED patients presenting to the ED after MVC (n = 948). The effect of opioids vs NSAIDs was evaluated using an innovative quasi-experimental design method using propensity scores to account for covariate imbalances between the 2 treatment groups. No difference in risk for moderate to severe musculoskeletal pain at 6 weeks was observed between those discharged with opioid analgesics vs NSAIDs (risk difference = 7.2% [95% confidence interval: -5.2% to 19.5%]). However, at follow-up participants prescribed opioids were more likely than those prescribed NSAIDs to report use of prescription opioids medications at week 6 (risk difference = 17.5% [95% confidence interval: 5.8%-29.3%]). These results suggest that analgesic choice at ED discharge does not influence the development of persistent moderate to severe musculoskeletal pain 6 weeks after an MVC, but may result in continued use of prescription opioids. Supported by NIAMS R01AR056328 and AHRQ 5K12HS022998., Competing Interests: The authors have no conflicts of interest to report.

Background: Despite increased concern about prescription opioid misuse among older adults, there is limited work examining the best means to identify misuse by older adults. The goal of this investigation was to examine the performance the Prescription Drug Use Questionnaire Patient Version (PDUQp), in detecting prescription opioid misuse and prescription opioid use disorders among adult emergency department (ED) patients aged 50 years and older., Methods: This was a cross-sectional study of a random sample of adult ED patients, aged 50 years and older. All participants were without cognitive impairment and reported prescription opioid use within the past 30 days. We evaluated the sensitivity, specificity, predictive values, and receiver operating characteristics of the PDUQp against a standard definition of opioid misuse and DSM-5 criteria for prescription opioid use disorder., Results: Overall, 112 participants completed the study; 74 were aged 50-64 years and 38 were aged 65 years and older. Over half of the participants satisfied DSM-5 criteria for prescription opioid use disorder, with slightly less participants reporting misuse. Overall, the respective sensitivity and specificity of the PDUQp was: 44% and 79% (Receiver Operating Characteristic [ROC] area under the curve: 0.61) for prescription opioid misuse, 38% and 81% (ROC area under the curve: 0.64) for the presence of any prescription opioid use disorder, and 56% and 75% (ROC area under the curve: 0.71) for moderate to severe prescription opioid use disorder., Conclusions: Based on this preliminary work, the PDUQp may be a viable instrument to screen for prescription opioid misuse and prescription opioid use disorder, but it likely requires modifications to optimize its predictive ability in adults over age 50 years., (Copyright © 2016 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Introduction: Among adult emergency department (ED) patients, we sought to examine how estimates of substance use prevalence and the need for interventions can differ, based on the type of screening and assessment strategies employed., Methods: We estimated the prevalence of substance use and the need for interventions using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in a secondary analysis of data from two cross-sectional studies using random samples of English- or Spanish-speaking 18-64-year-old ED patients. In addition, the test performance characteristics of three simplified screening strategies consisting of selected questions from the ASSIST (lifetime use, past three-month use, and past three-month frequency of use) to identify patients in need of a possible intervention were compared against using the full ASSIST., Results: Of 6,432 adult ED patients, the median age was 37 years-old, 56.6% were female, and 61.6% were white. Estimated substance use prevalence among this population differed by how it was measured (lifetime use, past three-month use, past three-month frequency of use, or need for interventions). As compared to using the full ASSIST, the predictive value and accuracy to identify patients in need of any intervention was best for a simplified strategy asking about past three-month substance use. A strategy asking about daily/near-daily use was better in identifying patients needing intensive interventions. However, some patients needing interventions were missed when using these simplified strategies., Conclusion: Substance use prevalence estimates and identification of ED patients needing interventions differ by screening strategies used. EDs should carefully select strategies to identify patients in need of substance use interventions.

Objectives: Determine if a brief intervention (BI) reduces the negative consequences of drug use/misuse among adult emergency department (ED) patients, and identify patients more likely to benefit from the BI., Methods: This randomized, controlled trial enrolled 1026 18-64 year-old ED patients whose drug misuse indicated a needed for a BI. Differences in total Inventory of Drug Use Consequences (InDUC) scores between the treatment (BI) and control arms (no BI) were assessed every 90 days over a one-year period. Regression models were constructed to identify demographic and clinical factors associated with greater reductions in total InDUC scores., Results: Although total InDUC scores decreased for both the treatment and control arms, there were no differences in scores between the treatment and the control arms at baseline at each follow-up. In the regression analyses, participants who were not using drugs or received drug treatment in the past 90 days generally had lower InDUC scores at each follow-up., Conclusions: Although negative consequences decreased in both study arms over time, receiving a BI did not lead to a greater reduction in the negative consequences of drug misuse than not receiving a BI. Of importance in the design of future ED drug misuse interventions, participants who were successful in stopping their drug misuse or receiving drug treatment did show fewer negative consequences of drug use/misuse., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: Substance use is prevalent among emergency department (ED) patients, and sex has been implicated as an important factor in the etiology, pathophysiology, sequelae, and treatment of substance use disorders. However, additional information is needed about the epidemiology of substance use as it relates to sex among ED patients., Objectives: This study examined sex differences in the prevalence and severity of self-reported tobacco, alcohol, and drug use among adult ED patients., Methods: A random sample of English- or Spanish-speaking, non-critically ill or injured, 18- to 64-year-old patients was approached at two urban EDs and asked to self-report their lifetime and past 3-month tobacco, alcohol, and drug use. Participants completed the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) using an audio computer-assisted self-interview. Participants were categorized by their substance severity (ASSIST score) and need for a brief or more intensive intervention per World Health Organization recommendations. Substance misuse prevalence, frequency, severity, and need for interventions were compared between sexes by substance category. Multivariable logistic regression models were used to examine the association between sexes and the need for intervention after adjusting for sociodemographic characteristics., Results: Of the 6,432 participants in the study, the median age was 37 years (interquartile range = 26 to 48 years), and 56.6% were female. Overall, lifetime, and past 3-month use was higher for men across all substances (tobacco, alcohol, and drugs). Among those reporting past 3-month use, the frequency of use was similar between sexes for tobacco and all drugs, but men reported more frequent alcohol use. Men had higher mean ASSIST scores compared to women, 30.3 (standard error [SE] ± 0.8) vs. 21.1 (SE ± 0.5); mean difference 9.2 (95% confidence interval [CI] = 7.4 to 10.9). The need for any intervention (brief or intensive) was similar between sexes for tobacco and drugs. After sociodemographic factors were adjusted for, women were less likely than men to need any intervention for alcohol (odds ratio [OR] = 0.6; 95% CI = 0.4 to 0.8), but not other substances: tobacco (OR = 0.9; 95% CI = 0.6 to 1.3), marijuana (OR = 0.8; 95% CI = 0.6 to 1.1), or other drugs (OR = 1.1; 95% CI = 0.7 to 1.7)., Conclusions: Although men have a higher overall prevalence of substance use, the frequency and severity of use were similar for men and women for most substances. After other characteristics were adjusted for, sex appears associated with the need for interventions for alcohol, but not tobacco, marijuana, or other drugs., (© 2015 by the Society for Academic Emergency Medicine.)

Objectives: Although brief interventions (BIs) have shown some success for smoking cessation and alcohol misuse, it is not known if they can be applied in the emergency department (ED) to drug use and misuse. The objectives of this investigation were to assess the 3-month efficacy of a BI to reduce drug use and misuse, increase drug treatment services utilization among adult ED patients, and identify subgroups more likely to benefit from the BI., Methods: This randomized, controlled trial enrolled 18- to 64-year-old English- or Spanish-speaking patients from two urban, academic EDs whose responses to the Alcohol, Smoking, and Substance Involvement Screening Test indicated a need for a brief or intensive intervention. Treatment participants received a tailored BI, while control participants only completed the study questionnaires. At the 3-month follow-up, each participant's past 3-month drug use and misuse and treatment utilization were compared to his or her baseline enrollment data. Regression modeling was used to identify subgroups of patients (per demographic and clinical factors) more likely to stop or reduce their drug use or misuse or engage in drug treatment by the 3-month follow-up assessment., Results: Of the 1,030 participants, the median age was 30 years (interquartile range = 24 to 42 years), and 46% were female; 57% were white/non-Hispanic, 24.9% were black/non-Hispanic, and 15% were Hispanic. The most commonly misused drugs were marijuana, prescription opioids, cocaine/crack, and benzodiazepines. Although at follow-up the proportions of participants reporting any past 3-month drug misuse had decreased in both study arms (control 84% vs. treatment 78%), the decreases were similar between the two study arms (Δ-6.3%; 95% confidence interval [CI] = -13.0% to 0.0). In addition, at follow-up there were no differences between study arms in those who were currently receiving drug treatment (Δ1.8; 95% CI = -3.5 to 6.8), who had received treatment during the past 3 months (Δ-2.0; 95% CI = -6.5 to 2.4), or who at least contacted a treatment program (Δ 1.7; 95% CI = -2.4 to 6.1). Those whose baseline screening indicated the need for a brief instead of a more intensive intervention, and those currently engaged in drug treatment at the 3-month follow-up, were generally more likely to stop or decrease their drug use/misuse., Conclusions: The BI employed in this study did not reduce drug use and misuse or increase treatment utilization more than the control condition over a 3-month period. Future research should help determine what role, if any, BIs should play in affecting drug use and misuse among ED patients., (© 2015 by the Society for Academic Emergency Medicine.)

Study Objective: We describe characteristics of patients with in-emergency department (ED) opioid-related adverse drug events, medication errors, and harm resulting from medication errors; identify patient-, provider-, and system-based factors associated with in-ED opioid-related medication errors and harm; and create a list of strategies to prevent future events., Methods: This retrospective study was conducted at 2 urban academic EDs. Potential iatrogenic opioid overdoses were identified by querying the ED electronic medical record for cases when naloxone was administered after an opioid was administered in the ED. Cases involving medication errors resulting in harm were reviewed qualitatively for common patient-, provider-, and systems-based factors that might have contributed to the event., Results: Of 73 ED patients with in-ED opioid-related adverse events that required reversal with naloxone, 43 had a medication error resulting in harm. Patient-, provider-, and systems-based factors that might have contributed to the events included chronic health conditions that could predispose an individual to an opioid-related adverse event, failure to adjust opioid dosing in the elderly and for hepatic or renal impairment, multiple doses and routes of administration of opioids, coadministration of opioids with other sedating medications, and systems-based problems with patient handoffs and pharmacy oversight., Conclusion: We identified patient-, provider-, and systems-based factors related to opioid-related adverse drug events and medication errors among ED patients who had received naloxone. The results from our assessment can be used to inform educational and policy initiatives aimed to prevent in-ED opioid-related adverse drug events and medication errors., (Copyright © 2014 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Objectives: The objective of this study was to test the effect of a brief educational and counseling intervention on increasing the uptake of free testing for Chlamydia trachomatis (chlamydia) and Neisseria gonorrhea (gonorrhea) among young female emergency department (ED) patients. Women are particularly vulnerable to more serious consequences of these infections due to asymptomatic presentation. Increased testing is important to detect, treat, and halt the spread of these infections among asymptomatic women., Methods: This was a randomized controlled trial. Research assistants (RAs) approached female patients in two EDs. Eligible patients were between 18 and 35 years of age, who reported having sex with males, but were not attending the ED for either treatment of sexually transmitted infection (STI) or testing for possible STI exposure. Participants responded to survey questions about their lifetime and past 3-month substance use, number of recent sexual partners, condom use, and perception of risks for chlamydia and gonorrhea infections. Following the survey, the RAs randomized participants into study control or treatment arms. Each treatment arm participant received a brief educational/counseling intervention from the RA. The brief intervention focused on the woman's personal risks for chlamydia and gonorrhea and condoms attitudes and usage. As the primary outcome of this study, participants were offered free urine tests for chlamydia and gonorrhea infection postintervention or post-survey completion, depending on group assignment., Results: A total of 171 women completed the baseline assessment and were offered chlamydia and gonorrhea testing. The mean (±SD) age was 26 (±4.76) years, 18% were Hispanic, and 12% were Spanish-speaking only. The brief intervention that was offered to increase these women's awareness of their STI risk did not result in increased acceptance of testing; 48% in the brief intervention group accepted testing (95% confidence interval [CI] = 32% to 64%) versus 36% in the control group (95% CI = 19% to 53%). In a multivariable logistic regression, only self-identifying as being Hispanic was associated with greater willingness to be tested. Of the asymptomatic women tested (n = 71), five tested positive for chlamydia. This represents a positivity rate of 7%. There were no positive test results for gonorrhea. Women who reported high-risk factors for STI, such as younger age (≤25 years), having sex in the past 90 days without using condoms, identified substance use, or previous STI, were not more likely to accept the offer of chlamydia and gonorrhea testing., Conclusions: The brief intervention used in this study did not increase the uptake of testing for chlamydia and gonorrhea infections in this sample, in comparison to receiving no intervention. Although Hispanic women were more likely to accept chlamydia and gonorrhea testing, it is concerning that those women who report STI risk factors were not more likely to accept the offer of chlamydia and gonorrhea testing. Future research should focus on the refinement of an intervention protocol to focus on prior STI and lack of condom use to increase the uptake of testing among this high-risk group., (© 2014 by the Society for Academic Emergency Medicine.)

Objectives: Low-dose ketamine has been used perioperatively for pain control and may be a useful adjunct to intravenous (IV) opioids in the control of acute pain in the emergency department (ED). The aim of this study was to determine the effectiveness of low-dose ketamine as an adjunct to morphine versus standard care with morphine alone for the treatment of acute moderate to severe pain among ED patients., Methods: A double-blind, randomized, placebo-controlled trial with three study groups was conducted at a large, urban academic ED over a 10-month period. Eligible patients were 18 to 65 years old with acute moderate to severe pain (score of at least 5 out of 10 on the numerical pain rating scale [NRS] and pain duration < 7 days) who were deemed by their treating physician to require IV opioids. The three study groups were: 1) morphine and normal saline placebo (standard care group), 2) morphine and 0.15 mg/kg ketamine (group 1), or 3) morphine and 0.3 mg/kg ketamine (group 2). Participants were assessed at 30, 60, and 120 minutes after study medication administration and received rescue analgesia as needed to target a 50% reduction in pain. The primary outcome measure of pain relief, or pain intensity reduction, was derived using the NRS and calculated as the summed pain-intensity (SPID) difference over 2 hours. The amount and timing of rescue opioid analgesia was evaluated as a secondary outcome. The occurrence of adverse events was also measured., Results: Sixty patients were enrolled (n = 20 in each group). There were no differences between study groups with respect to age, sex, race/ethnicity, preenrollment analgesia, or baseline NRS. Over the 2-hour poststudy medication administration period, the SPIDs were higher (greater pain relief) for the ketamine study groups than the control group (standard care 4.0, interquartile range [IQR] = 1.8 to 6.5; group 1 7.0, IQR = 4.3 to 10.8; and group 2 7.8, IQR = 4.8 to 12.8; p < 0.02). The SPIDs for the ketamine groups were similar (p < 0.46). When compared to standard care, group 2 sustained the reduction in pain intensity up to 2 hours, whereas group 1 was similar to standard care by 2 hours. Similar numbers of patients received rescue analgesia: standard care group, seven of 20, 35%; group 1, four of 20, 20%; and group 2, four of 20, 20% (p = 0.48). Among those receiving rescue analgesia, those in the standard care group received analgesia sooner than either low-dose ketamine group, on average. More participants in the low-dose ketamine groups reported dysphoria and dizziness., Conclusions: Low-dose ketamine is a viable analgesic adjunct to morphine for the treatment of moderate to severe acute pain. Dosing of 0.3 mg/kg is possibly more effective than 0.15 mg/kg, but may be associated with minor adverse events. Future studies should evaluate additional outcomes, optimum dosing, and use in specific populations., (© 2014 by the Society for Academic Emergency Medicine.)

Study Objective: We explore the relationship between Press Ganey emergency department (ED) patient satisfaction scores and ED administration of analgesic medications, including amount of opioid analgesics received, among patients who completed a patient satisfaction survey., Methods: We conducted a secondary data analysis of Press Ganey ED patient satisfaction surveys from patients discharged from 2 academic, urban EDs October 2009 to September 2011. We matched survey responses to data on opioid and nonopioid analgesics administered in the ED, demographic characteristics, and temporal factors from the ED electronic medical records. We used polytomous logistic regression to compare quartiles of overall Press Ganey ED patient satisfaction scores to administration of analgesic medications, opioid analgesics, and number of morphine equivalents received. We adjusted models for demographic and hospital characteristics and temporal factors., Results: Of the 4,749 patients who returned surveys, 48.5% received analgesic medications, and 29.6% received opioid analgesics during their ED visit. Mean overall Press Ganey ED patient satisfaction scores for patients receiving either analgesic medications or opioid analgesics were lower than for those who did not receive these medications. In the univariable polytomous logistic regression analysis, receipt of analgesic medications, opioid analgesics, and a greater number of morphine equivalents were associated with lower overall scores. However, in the multivariable analysis, receipt of analgesic medications or opioid analgesics was not associated with overall scores, and receipt of greater morphine equivalents was inconsistently associated with lower overall scores., Conclusion: Overall Press Ganey ED patient satisfaction scores were not primarily based on in-ED receipt of analgesic medications or opioid analgesics; other factors appear to be more important., (Copyright © 2014 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Objectives: In this study, Increasing Viral Testing in the Emergency Department (InVITED), the authors investigated if a brief intervention about human immunodeficiency virus (HIV) and hepatitis C virus (HCV) risk-taking behaviors and drug use and misuse in addition to a self-administered risk assessment, compared to a self-administered risk assessment alone, increased uptake of combined screening for HIV and HCV, self-perception of HIV/HCV risk, and impacted beliefs and opinions on HIV/HCV screening., Methods: InVITED was a randomized, controlled trial conducted at two urban emergency departments (EDs) from February 2011 to March 2012. ED patients who self-reported drug use within the past 3 months were invited to enroll. Drug misuse severity and need for a brief or more intensive intervention was assessed using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). Participants were randomly assigned to one of two study arms: a self-administered HIV/HCV risk assessment alone (control arm) or the assessment plus a brief intervention about their drug misuse and screening for HIV/HCV (intervention arm). Beliefs on the value of combined HIV/HCV screening, self-perception of HIV/HCV risk, and opinions on HIV/HCV screening in the ED were measured in both study arms before the HIV/HCV risk assessment (pre), after the assessment in the control arm, and after the brief intervention in the intervention arm (post). Participants in both study arms were offered free combined rapid HIV/HCV screening. Uptake of screening was compared by study arm. Multivariable logistic regression models were used to evaluate factors related to uptake of screening., Results: Of the 395 participants in the study, the median age was 28 years (interquartile range [IQR] = 23 to 38 years), 44.8% were female, 82.3% had ever been tested for HIV, and 67.3% had ever been tested for HCV. Uptake of combined rapid HIV/HCV screening was nearly identical by study arm (64.5% vs. 65.2%; Δ = -0.7%; 95% confidence interval [CI] = -10.1% to 8.7%). Of the 256 screened, none had reactive HIV antibody tests, but seven (2.7%) had reactive HCV antibody tests. Multivariable logistic regression analysis results indicated that uptake of screening was not related to study arm assignment, total ASSIST drug scores, need for an intervention for drug misuse, or HIV/HCV sexual risk assessment scores. However, uptake of screening was greater among participants who indicated placing a higher value on combined rapid HIV/HCV screening for themselves and all ED patients and those with higher levels of perceived HIV/HCV risk. Uptake of combined rapid HIV/HCV screening was not related to changes in beliefs regarding the value of combined HIV/HCV screening or self-perceived HIV/HCV risk (post- vs. pre-risk assessment with or without a brief intervention). Opinions regarding the ED as a venue for combined rapid HIV/HCV screening were not related to uptake of screening., Conclusions: Uptake of combined rapid HIV/HCV screening is high and considered valuable among drug using and misusing ED patients with little concern about the ED as a screening venue. The brief intervention investigated in this study does not appear to change beliefs regarding screening, self-perceived risk, or uptake of screening for HIV/HCV in this population. Initial beliefs regarding the value of screening and self-perceived risk for these infections predict uptake of screening., (© 2014 by the Society for Academic Emergency Medicine.)

Objectives: Compare the prevalence of recent alcohol, tobacco, and drug use among patients from two Rhode Island emergency departments (EDs) to Rhode Island state and United States national general population estimates between 2010 and 2012., Methods: Secondary analysis of ED patient data and the National Survey of Drug Use and Health., Results: Alcohol was the most commonly reported substance, and prevalence of its use was higher among ED patients than those in the national, but not the Rhode Island, general population. Drug use was higher among ED patients than in the state and national general population. For ED patients, tobacco and opioid use was highest among 26-34 year-olds, alcohol and marijuana highest among 18-25 years-olds, and cocaine highest among 35-49 years-olds., Conclusion: Rhode Island Hospital and The Miriam Hospital ED patients report a greater prevalence of substance use than the national population and in many cases the state general population.

In 1993, 2001, and 2006, the US Centers for Disease Control and Prevention (CDC) released revised recommendations aimed to expand HIV screening in health-care settings, increase the number of people who are aware of their infection, improve the health of those who are infected, and reduce HIV transmission. It is unclear how responsive health-care settings have been on a national level to these three successively revised sets of CDC recommendations. This study estimated the extent of HIV testing in US emergency departments (EDs), outpatient ambulatory medical care departments (OPDs), and physician offices among 13- to 64-year-olds from 1992 to 2010 to determine their responsiveness to CDC recommendations to expand HIV testing. The report includes data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) and the National Ambulatory Medical Care Survey (NAMCS), which are national probability sample surveys conducted by the National Center for Health Statistics (NCHS) for CDC. Over the entire study period, HIV testing was significantly greater in OPDs than in EDs (p < 0.01) and physician offices (p < 0.01). Multivariable logistic regression analysis showed that Hispanic and Black patients and those receiving Medicaid were more likely to be tested for HIV. Logistic regression tests of trend for the entire study period did not demonstrate significant increases in testing at EDs (Odds ratios [OR] 1.00 [0.97-1.03]) or OPDs (OR 1.01 [0.98-1.04]). For physician offices, there was no change in HIV testing for 1993-1999 (OR 1.03 [0.99-1.06]), but there was a relative increase for the entire study period (OR 1.04 [1.02-1.06]) because of more HIV testing in 2009 and 2010 in this setting. However, there were no differences in HIV testing for each setting for the interval years after revised CDC HIV testing recommendations were released for 1993-2001, 2002-2006, and 2007-2010.

Background: Skin and soft tissue infection (SSTIs) are commonly treated in emergency departments (EDs). While the precise role of antibiotics in treating SSTIs remains unclear, most SSTI patients receive empiric antibiotics, often targeted toward methicillin-resistant Staphylococcus aureus (MRSA). The goal of this study was to assess the efficiency with which ED clinicians targeted empiric therapy against MRSA, and to identify factors that may allow ED clinicians to safely target antibiotic use., Methods: We performed a retrospective analysis of patient visits for community-acquired SSTIs to three urban, academic EDs in one northeastern US city during the first quarter of 2010. We examined microbiologic patterns among cultured SSTIs, and relationships between clinical and demographic factors and management of SSTIs., Results: Antibiotics were prescribed to 86.1% of all patients. Though S. aureus (60% MRSA) was the most common pathogen cultured, antibiotic susceptibility differed between adult and pediatric patients. Susceptibility of S. aureus from ED SSTIs differed from published local antibiograms, with greater trimethoprim resistance and less fluoroquinolone resistance than seen in S. aureus from all hospital sources. Empiric antibiotics covered the resultant pathogen in 85.3% of cases, though coverage was frequently broader than necessary., Conclusions: Though S. aureus remained the predominant pathogen in community-acquired SSTIs, ED clinicians did not accurately target therapy toward the causative pathogen. Incomplete local epidemiologic data may contribute to this degree of discordance. Future efforts should seek to identify when antibiotic use can be narrowed or withheld. Local, disease-specific antibiotic resistance patterns should be publicized with the goal of improving antibiotic stewardship.

Because reliance on patients' self-perceived risk for HIV might mislead emergency department (ED) clinicians on the need for HIV testing, we aimed to measure congruency between self-perceived and reported HIV risk in a traditional lower prevalence, lower-risk cohort. A random sample of 18- to 64-year-old patients at a large academic urban ED who were by self-report not men-who-have-sex-with-men (MSM) or injection-drug users (IDUs) were surveyed regarding their self-perceived and reported HIV risk. Sixty-two percent of participants were white non-Hispanic, 13.8% Black, and 21.2% Hispanic; and 66.9% previously had been tested for HIV. Linear regression models were constructed comparing self-perceived to reported HIV risk. Among the 329 female ED patients, 50.5% perceived that they were "not at risk" for HIV, yet only 10.9% reported no HIV risk behaviors, while among the 175 male ED patients, 50.9% perceived that they were "not at risk" for HIV, yet only 12.6% reported no HIV risk behaviors. Only 16.9% of women and 15.7% of men who had no self-perceived risk for HIV also reported no HIV risk behaviors. Multivariable linear regression demonstrated a weak relationship between self-perceived and reported risk. Congruency between self-perceived risk and reported HIV risk was low among these non-MSM, non-IDU ED patients.

Introduction: This pilot study assessed the prevalence of physiologic and behavioral adverse effects among adolescent (13-17 years) and adult (18-25 years) emergency department patients who reported energy drink and/or caffeinated-only beverage use within the 30 days prior to emergency department presentation. It was hypothesized that energy drink users would report more adverse effects than those who used only traditional caffeinated beverages such as coffee, tea, or soft drinks., Methods: This cross-sectional pilot study was conducted in two urban emergency departments, one adult and one pediatric. Eligible patients were enrolled during a 6-week period between June and August 2010. Participants completed a tablet computer-based, self-administered, anonymous questionnaire about their past 30-day energy drink and/or caffeinated-only beverage use, substance use, and experience of 10 physiologic and 10 behavioral symptoms. Multivariable logistic regression and negative binomial regression models, adjusted for age, gender, and substance use, were created to compare the occurrence of each adverse effect between energy drink and caffeinated-only beverage users. Odds ratios (ORs) and incidence rate ratios (IRRs) were estimated., Results: Of those enrolled, 53.3% reported consuming energy drinks, 39.1% caffeinated-only beverages, and 7.6% no energy drinks or caffeinated-only beverages within the past 30 days. In multivariable logistic regression models, energy drink users were more likely than caffeinated-only beverage users to report having "gotten into trouble at home, school, or work" in the past 30 days (OR: 3.12 [1.24-7.88]). In the negative binomial regression multivariable models, more behavioral effects were reported among drug users (IRR: 1.50 [1.18-1.93]), and more physiologic effects were reported among tobacco users (IRR: 1.42 [1.13-1.80]) and females (IRR: 1.48 [1.21-1.80]), but not among energy drink users., Conclusions: Energy drink users and substance users are more likely to report specific physiologic and behavioral adverse effects. Emergency department clinicians should consider asking patients about energy drink and traditional caffeine usage and substance use when assessing patient symptoms.

Background: Blood and body fluid exposures are frequently evaluated in emergency departments (EDs). However, efficient and effective methods for estimating their incidence are not yet established., Objective: Evaluate the efficiency and accuracy of estimating statewide ED visits for blood or body fluid exposures using International Classification of Diseases, Ninth Revision (ICD-9), code searches., Design: Secondary analysis of a database of ED visits for blood or body fluid exposure., Setting: EDs of 11 civilian hospitals throughout Rhode Island from January 1, 1995, through June 30, 2001., Patients: Patients presenting to the ED for possible blood or body fluid exposure were included, as determined by prespecified ICD-9 codes., Methods: Positive predictive values (PPVs) were estimated to determine the ability of 10 ICD-9 codes to distinguish ED visits for blood or body fluid exposure from ED visits that were not for blood or body fluid exposure. Recursive partitioning was used to identify an optimal subset of ICD-9 codes for this purpose. Random-effects logistic regression modeling was used to examine variations in ICD-9 coding practices and styles across hospitals. Cluster analysis was used to assess whether the choice of ICD-9 codes was similar across hospitals., Results: The PPV for the original 10 ICD-9 codes was 74.4% (95% confidence interval [CI], 73.2%-75.7%), whereas the recursive partitioning analysis identified a subset of 5 ICD-9 codes with a PPV of 89.9% (95% CI, 88.9%-90.8%) and a misclassification rate of 10.1%. The ability, efficiency, and use of the ICD-9 codes to distinguish types of ED visits varied across hospitals., Conclusions: Although an accurate subset of ICD-9 codes could be identified, variations across hospitals related to hospital coding style, efficiency, and accuracy greatly affected estimates of the number of ED visits for blood or body fluid exposure., Competing Interests: Potential conflicts of interest. All authors report no conflicts of interest relevant to this article. All authors submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and the conflicts that the editors consider relevant to this article are disclosed here.

Objective: Our goal was to gain a better understanding of the femoral vessel anatomy as it relates to central venous cannulation. The primary objective of this study was to use bedside ultrasonography to determine the amount of exposed femoral vein at three sites corresponding to surface anatomy of the landmark-based procedure., Methods: This cross-sectional study enrolled a random sample of 180 adult patients presenting to a large urban academic emergency department. Subjects underwent standardized ultrasonography to identify and measure the depth and diameter of the femoral vessels and amount of exposed femoral vein at the level of the inguinal ligament (0 cm) 2 cm and 4 cm below. Repeated measures analysis of variance was used to determine significant relationships between vessel measurements and distance from the inguinal ligament., Results: The median age was 44.5 (range 19-90) years; 101 patients were male. The mean (± SD) percentage of exposed vein at the inguinal ligament was 83% (± 21). This decreased significantly (p < 0.01) with increasing distance from the inguinal ligament: 65% (± 25) at 2 cm and 56% (± 30) at 4 cm. At every distance away from the inguinal ligament, there were some subjects with no vein exposed., Conclusion: This study demonstrates significant overlap of the femoral vessels at sites where landmark-based femoral vein cannulation is often attempted. Our results suggest that ultrasound guidance would be beneficial as femoral vein cannulation may be difficult or impossible in certain individuals owing to anatomic variations.

Objectives: We seek to identify and analyze, from a group of participants experienced with HIV screening, the perceived challenges and solutions to the ethical, financial, and legal considerations of emergency department (ED)-based HIV screening., Methods: We performed a qualitative analysis of the focus group discussions from the ethical, financial, and legal considerations portion of the inaugural National Emergency Department HIV Testing Consortium conference. Four groups composed of 20 to 25 consortium participants engaged in semistructured, facilitated focus group discussions. The focus group discussions were audiotaped and transcribed. A primary reader identified major themes and subthemes and representative quotes from the transcripts and summarized the discussions. Secondary and tertiary readers reviewed the themes, subthemes, and summaries for accuracy., Results: The focus group discussions centered on the following themes. Ethical considerations included appropriateness of HIV screening in the ED and ethics of key elements of the 2006 Centers for Disease Control and Prevention HIV testing recommendations. Financial considerations included models of payment and support, role of health care insurance, financial ethics and downstream financial burdens, and advocacy approaches. Legal considerations included the adequacy of obtaining consent, partner notification, disclosure of HIV results, difficulties in addressing special populations, failure of not performing universal screening, failure to notify a person of being tested, failure to notify someone of their test results, liability of inaccurate tests, and failure to link to care., Conclusion: This qualitative analysis provides a broadly useful foundation to the ethical, financial, and legal considerations of implementing HIV screening programs in EDs throughout the United States., (Copyright © 2011. Published by Mosby, Inc.)

Objective: We determine whether (1) an audiocomputer-delivered tailored feedback intervention increases emergency department (ED) patient uptake of opt-in, nontargeted rapid HIV screening; and (2) uptake is greater among patients who report more HIV risk and among those whose self-perceived HIV risk increases from baseline after completion of an HIV risk assessment., Methods: ED patients aged 18 to 64 years were randomly assigned to receive either an assessment about reported and self-perceived HIV risk or an identical assessment plus feedback about their risk for having or acquiring an HIV infection, tailored according to their reported risk. All participants were offered a fingerstick rapid HIV test. Two-sample tests of binomial proportions were used to compare screening uptake by study arm. Multivariable logistic regression was used to assess the relationship of reported HIV risk and an increase in self-perceived HIV risk with uptake of HIV screening., Results: Of the 566 participants, the median age was 29 years, 62.2% were women, and 66.9% previously had been tested for HIV. Uptake of HIV screening was similar in the intervention and no intervention arms (54.1% versus 55.5% [Δ=-0.01%; 95% confidence interval {CI} -0.09% to 0.07%]). An increase in self-perceived HIV risk predicted greater uptake of HIV screening for women (odds ratio 2.15; 95% CI 1.08 to 4.28) but not men (odds ratio 1.61; 95% CI 0.60 to 4.30). Uptake of HIV screening was not related to reported HIV risk., Conclusion: Uptake of rapid HIV screening in the ED was not improved by this feedback intervention. Other methods need to be investigated to improve uptake of HIV screening by ED patients., (Copyright © 2011. Published by Mosby, Inc.)

Patients with psychogenic (nonepileptic) seizures (PS) are frequently encountered by clinicians in the emergency medicine setting. Despite the tendency for these patients to seek frequent medical attention, the time between onset of symptoms and diagnosis is often more than 7 years. The cause of PS is multifactorial, but most patients are thought to have an underlying dissociative condition. The diagnostic evaluation in the emergency department is challenging and relies heavily on clinical suspicion, based on historical and physical features. Laboratory testing and therapeutic maneuvers are of limited utility; prolonged video electroencephalography is the diagnostic gold standard. Once the diagnosis has been secured, the mainstay of treatment involves addressing the underlying psychological distress., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Study Objective: Among adult emergency department (ED) patients undergoing central venous catheterization, we determine whether a greater than or equal to 50% decrease in inferior vena cava diameter is associated with a central venous pressure of less than 8 mm Hg., Methods: Adult patients undergoing central venous catheterization were enrolled in a prospective, observational study. Inferior vena cava inspiratory and expiratory diameters were measured by 2-dimensional bedside ultrasonography. The caval index was calculated as the relative decrease in inferior vena cava diameter during 1 respiratory cycle. The correlation of central venous pressure and caval index was calculated. The sensitivity, specificity, and positive and negative predictive values of a caval index greater than or equal to 50% that was associated with a central venous pressure less than 8 mm Hg were estimated., Results: Of 73 patients, the median age was 63 years and 60% were women. Mean time and fluid administered from ultrasonographic measurement to central venous pressure determination were 6.5 minutes and 45 mL, respectively. Of the 73 participants, 32% had a central venous pressure less than 8 mm Hg. The correlation between caval index and central venous pressure was -0.74 (95% confidence interval [CI] -0.82 to -0.63). The sensitivity of caval index greater than or equal to 50% to predict a central venous pressure less than 8 mm Hg was 91% (95% CI 71% to 99%), the specificity was 94% (95% CI 84% to 99%), the positive predictive value was 87% (95% CI 66% to 97%), and the negative predictive value was 96% (95% CI 86% to 99%)., Conclusion: Bedside ultrasonographic measurement of caval index greater than or equal to 50% is strongly associated with a low central venous pressure. Bedside measurements of caval index could be a useful noninvasive tool to determine central venous pressure during the initial evaluation of the ED patient., (Copyright (c) 2009 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Objective: Among a random sample of emergency department (ED) patients, we sought to determine the extent to which reported risk for human immunodeficiency virus (HIV) is related to ever having been tested for HIV., Methods: A random sample of patients (aged 18-64 years) from an adult, urban, northeastern United States, academic ED were surveyed about their history of ever having been tested for HIV and their reported HIV risk behaviors. A reported HIV risk score was calculated from the survey responses and divided into 4 levels, based on quartiles of the risk scores. Pearson's X(2) testing was used to compare HIV testing history and level of reported HIV risk. Logistic regression models were created to investigate the association between level of reported HIV risk and the outcome of ever having been tested for HIV., Results: Of the 557 participants, 62.1% were female. A larger proportion of females than males (71.4% vs 60.6%; P < 0.01) reported they had been tested for HIV. Among the 211 males, 11.4% reported no HIV risk, and among the 346 females, 10.7% reported no HIV risk. The proportion of those who had been tested for HIV was greater among those reporting any risk compared with those reporting no risk for females (75.4% vs 37.8%; P < 0.001), but not for males (59.9% vs 66.7%; P < 0.52). However, certain high-risk behaviors, such as a history of injection-drug use, were associated with prior HIV testing for both genders. In the logistic regression analyses, there was no relationship between increasing level of reported HIV risk and a history of ever having been tested for HIV for males. For females, a history of ever having been tested was related to increasing level of reported risk, but not in a linear fashion., Conclusions: The relationship between reported HIV risk and history of testing among these ED patients was complex and differed by gender. Among these patients, having greater risk did not necessarily mean a higher likelihood of ever having been tested for HIV.

Objectives: We aimed to create a system for predicting which male emergency department (ED) patients with suspected chlamydial and/or gonococcal urethritis would have laboratory-confirmed infections based on clinical factors available at the initial ED encounter., Methods: We used statistical models to develop a system to predict either the presence or absence of laboratory-confirmed chlamydial and/or gonorrheal urethritis based on patient demographics and presenting symptoms. Data for the system were extracted from a retrospective chart review of adult male patients who were suspected of having, and were tested for, chlamydial and/or gonococcal urethritis at an adult, urban, northeastern United States, academic ED from January 1998 to December 2004., Results: Among the 822 patients tested, 29.2% had chlamydia, gonorrhea, or both infections; 13.8% were infected with chlamydia alone, 12.1% were infected with gonorrhea alone, and 3.3% were infected with both. From the statistical models, the following factors were predictive of a positive laboratory test for chlamydia and/or gonorrhea: age < or = 24 years, penile discharge, sexual contact with someone known to have chlamydia and/or gonorrhea, and not having health care insurance. A system using a hierarchical grouping of these factors based on the predicted probabilities of a laboratory-confirmed chlamydial and/or gonococcal urethritis, paired with baseline ED prevalence of these infections, was confirmed through internal validation testing to modestly predict which patients had or did not have a laboratory-confirmed infection., Conclusions: This system of a combination of risk factors available during the clinical encounter in the ED modestly predicts which adult male patients suspected of having chlamydial and/or gonorrheal urethritis are more likely to have or not have a laboratory-confirmed infection. A prospective study is needed to create and validate a clinical prediction rule based on the results of this system.

Objectives: Prior research has demonstrated that emergency department (ED) patient acceptance of human immunodeficiency virus (HIV) screening is partially dependent on patients' self-perceived risk of infection. The primary objective of this study was to determine the effectiveness of audio computer-assisted self-interview (ACASI)-based feedback. The intervention aimed to increase patient's self-perceived risk of being HIV infected by providing immediate feedback on their risk behaviors., Methods: This 1-year, randomized, controlled trial at a U.S. ED enrolled a random sample of 18- to 64-year-old subcritically ill or injured adult patients who were not known to be HIV infected. All participants completed an anonymous, ACASI-based questionnaire about their HIV risk behaviors related to injection drug use and sex, as well as their self-perceived risk for being HIV infected. Participants were randomly assigned to one of two study groups: an intervention group in which participants received immediate ACASI-based feedback in response to each of their reported risk behaviors or a no-intervention group without feedback. Participants were asked to indicate their level of HIV risk on a five-point scale before and after they answered the questions. Change in level of self-perceived HIV risk was calculated and compared by study group using Pearson's chi-square test. An HIV risk behavior score that summarized reported HIV risk behavior was devised. Because HIV risk behaviors differ by sex, scores were calculated separately for each sex. Linear regression models that adjusted for study group and same subject covariance were employed to determine if higher HIV risk behavior scores were associated with an increase in self-perceived HIV risk., Results: Of the 566 trial participants, the median age was 29 years (interquartile range [IQR] = 22-43 years), 62.2% were females, and 66.9% had been tested previously for HIV. After answering the reported HIV risk behavior questions, 12.6% of participants had an increase, 79.9% had no change, and 7.5% had a decrease in self-perceived HIV risk. Of the 46.6% of participants who initially indicated that they were not at risk for HIV, 11.4% had an increase in self-perceived HIV risk after answering the reported HIV risk behavior questions. Change in self-perceived HIV risk did not differ by study group (p = 0.77). There were no differences in reported HIV risk scores between the intervention and no-intervention groups for females (p = 0.78) or males (p = 0.86). In the linear regression models, a greater increase in self-perceived HIV risk was associated with higher reported HIV risk behavior scores for females (beta = 0.59, 95% confidence interval [CI] = 0.15, 1.04) but not for males (beta = 1.00, 95% CI = -0.13 to 2.14)., Conclusions: Some ED patients can be moved, although modestly, to recognize their risk for being HIV infected by asking about their HIV risk behaviors. However, ACASI-based feedback messages about HIV risk behaviors do not increase subjects' self-perceived HIV risk. Female ED patients appear to increase their self-perceived HIV risk more than males when queried about their HIV risk behaviors., ((c) 2009 by the Society for Academic Emergency Medicine.)

Objectives: The aims of the study were to (1) estimate the incidence rates (IRs) of human immunodeficiency virus (HIV) testing among 13-year-old to 64-year-old patients in US emergency departments (EDs); (2) determine ED compliance with Centers for Disease Control and Prevention (CDC) recommendations for HIV testing for patients with nonsexual blood or body fluid exposures, sexually transmitted diseases (STDs), and sexual assaults; and (3) ascertain if HIV testing in EDs varies by patient demographic characteristics., Methods: The ED visits from the National Hospital Ambulatory Medical Care Survey databases (1993-2004) were analyzed. Visits for nonsexual blood or body fluid exposures, STDs, and sexual assaults were identified using diagnosis and cause codes. Incidence rates for HIV testing were estimated by year. Odds ratios (ORs) with 95% confidence intervals were estimated from multivariable logistic regression models using HIV testing as the outcome and demographic characteristics as covariates., Results: The average IR of HIV testing for 13-year-old to 64-year-old patients from 1993 to 2004 was 0.31%. Of all patients, 35.1% with nonsexual blood or body fluid exposures, 20.4% with sexual assaults, and 2.6% with STDs were tested for HIV. The HIV testing was more frequent among Hispanics (OR, 1.39 [1.06-1.81]), blacks (OR, 1.52 [1.19-1.94]), patients with Medicaid (OR, 2.35 [1.81-3.03]), Medicare (OR, 1.95 [1.20-3.16]), and self-pay/no charge/other type of insurance (OR, 1.74 [1.35-2.23]), and those visiting EDs in the northeastern United States (OR, 1.57 [1.04-2.38])., Conclusions: The HIV testing rates are low in US EDs and have changed little for a 12-year period. Compliance with CDC recommendations for HIV testing is poor and not in accordance with risk for infection. Hispanics, blacks, and those without private health care insurance are being tested more frequently than other ED patients.

Objective: To determine the proportion of emergency department (ED) patients who have been tested for human immunodeficiency virus (HIV) infection and assess if patient history of HIV testing varies according to patient demographic characteristics., Design: From July 2005-July 2006, a random sample of 18-55-year-old English-speaking patients being treated for sub-critical injury or illness at a northeastern US ED were interviewed on their history of HIV testing. Logistic regression models were created to compare patients by their history of being tested for HIV according to their demography. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated., Results: Of 2107 patients surveyed who were not known to be HIV-infected, the median age was 32 years; 54% were male, 71% were white, and 45% were single/never married; 49% had private health-care insurance and 45% had never been tested for HIV. Of the 946 never previously tested for HIV, 56.1% did not consider themselves at risk for HIV. In multivariable logistic regression analyses, those less likely to have been HIV tested were male (OR: 1.32 [1.37-2.73]), white (OR: 1.93 [1.37-2.73]), married (OR: 1.53 [1.12-2.08]), and had private health-care insurance (OR: 2.10 [1.69-2.61]). There was a U-shaped relationship between age and history of being tested for HIV; younger and older patients were less likely to have been tested. History of HIV testing and years of formal education were not related., Conclusion: Almost half of ED patients surveyed had never been tested for HIV. Certain demographic groups are being missed though HIV diagnostic testing and screening programmes in other settings. These groups could potentially be reached through universal screening.

The objectives of this study were to estimate the incidence and identify the temporal patterns of visits to Rhode Island emergency departments (EDs) by adults who were sexually assaulted. Visits to all Rhode Island EDs from January 1995-June 2001 by adults who were sexually assaulted were identified using International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9) codes. Medical records of these visits were reviewed. Frequency distributions of the assault characteristics and patient demographics were generated. Incidence rates (IRs) of ED visits after sexual assault were estimated using 2000 US Census data. Analyses of the temporal patterns of the ED visits after sexual assault were conducted. Of the 823 ED visits, 796 (96.7%) were by females and 27 (3.3%) were by males. The median age for females was 25 years (range, 18-96 years) and was 28 years (range, 18-87 years) for males. Among the female patients, 76.6% sustained a vaginal/anal assault. Among the male patients, 59.3% sustained an anal assault. The average annual IR of ED visits after sexual assault was 30.3/100,000/year for females and 1.2/100,000/year for males, which is a 25-fold greater incidence of these visits for females than males. ED visits after adult sexual assault were more frequent during warmer months and around 5 P.M. There was a gradual 43% increase in the IRs of ED visits after sexual assault over the 6.5-year period. These findings should help direct EDs to maximize supportive services when they are needed most often.

Objectives: To determine how often sexually assaulted adult female emergency department (ED) patients are being offered testing and prophylaxis for sexually transmitted diseases (STDs) and pregnancy and identify factors associated with the offering of tests and prophylaxis., Methods: This is a retrospective study of ED visits for adult female sexual assault in all Rhode Island EDs from January 1995 through June 2001. The percentage of patients offered testing and prophylaxis was calculated. Multivariable logistic regression was used to identify factors related to testing and prophylaxis use for women sustaining an anal/vaginal assault., Results: Of the 780 patients, 78.2% sustained anal/vaginal penetration, 5.0% genital touching only, and 3.7% oral sex only, and 13.1% did not know what happened to them. Of those women anal/vaginally assaulted, 83.8% were offered chlamydia/gonorrhea testing, 69.4% syphilis testing, 82.9% pregnancy testing, 77.0% chlamydia/gonorrhea prophylaxis, 47.6% emergency contraception, and 19.2% HIV prophylaxis. In multivariable logistic regression models, patients evaluated at the state's women's hospital instead of academic or community hospitals and those who sustained anal/vaginal assault instead of other assaults had a greater odds of being offered testing and prophylaxis. In some cases, older women were offered testing and prophylaxis less often than younger women., Conclusions: Testing and prophylaxis for chlamydia/gonorrhea were used much more often than prophylaxis for emergency contraception and HIV, even for patients who were anal/vaginally assaulted. Disparities in testing and prophylaxis exist by type of hospital and, in some cases, by age. Educational campaigns should be instituted to ensure that all women receive adequate testing and prophylaxis commensurate with the exposure they sustained from a sexual assault.

Female Emergency Department (ED) patients were surveyed to determine their comprehension of the concept of emergency contraception (EC), to assess how often they had used EC in comparison to other forms of contraception, and to learn which patients want the ED to provide EC services. Most of the 761 respondents were aged < 35 years (62.1%), never married (42.9%), had been pregnant at least once (70.2%), had never had an abortion (76.1%), had never used EC (90.6%), and had sex with a man within the past month (70.7%). Respondents were 2.5 times more likely to have had an abortion than to have used EC; 85.3% could not correctly answer two questions that assessed comprehension of the concept of EC; 43.1% wanted the ED to offer EC, 55.6% to provide information about EC, and 52.6% to refer patients for EC. Younger patients, those who attended religious services infrequently, patients who had ever used EC, and those at risk of pregnancy were more likely to want the ED to provide EC services.

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.