Violence in the emergency department: a survey of health care workers

BACKGROUND: Violence in the workplace is an ill-defined and underreported concern for health care workers. The objectives of this study were to examine perceived levels of violence in the emergency department, to obtain health care workers'' definitions of violence, to determine the effect of violence on health care workers and to determine coping mechanisms and potential preventive strategies. METHODS: A retrospective written survey of all 163 emergency department employees working in 1996 at an urban inner-city tertiary care centre in Vancouver. The survey elicited demographic information, personal definition of violence, severity of violence, degree of stress as a result of violence and estimate of the number of encounters with violence in the workplace in 1996. The authors examined the effects of violence on job performance and job satisfaction, and reviewed coping and potential preventive strategies. RESULTS: Of the 163 staff, 106 (65%) completed the survey. A total of 68% (70/103) reported an increased frequency of violence over time, and 60% (64/106) reported an increased severity. Most of the respondents felt that violence included witnessing verbal abuse (76%) and witnessing physical threats or assaults (86%). Sixty respondents (57%) were physically assaulted in 1996. Overall, 51 respondents (48%) reported impaired job performance for the rest of the shift or the rest of the week after an incident of violence. Seventy-seven respondents (73%) were afraid of patients as a result of violence, almost half (49%) hid their identities from patients, and 78 (74%) had reduced job satisfaction. Over one-fourth of the respondents (27/101) took days off because of violence. Of the 18 respondents no longer working in the emergency department, 12 (67%) reported that they had left the job at least partly owing to violence. Twenty-four-hour security and a workshop on violence prevention strategies were felt to be the most useful potential interventions. Physical exercise, sleep and the company of family and friends were the most frequent coping strategies. INTERPRETATION: Violence in the emergency department is frequent and has a substantial effect on staff well-being and job satisfaction.     

Bicycle-related injuries: a survey in a pediatric emergency department.

The number of bicycle-related injuries has risen significantly with the increased popularity of bicycle riding in Canada. The risk of injury is highest among children. To assess the magnitude of the problem and to identify the contributing factors we used a questionnaire, injury reports and patient charts to survey bicycle-related injuries among children brought to the emergency department of the Children''s Hospital of Eastern Ontario, Ottawa, between May 1 and Sept. 30, 1988. The questionnaire was completed for 517 (91%) of the 568 children; 70% were boys, and the mean age was 9.4 years. Only 2% of the patients had been wearing a helmet at the time of injury, although 13% claimed to own one for cycling. Over 60% of the accidents were attributable to carelessness or poor bicycle control; mechanical failure and environmental hazards were minor factors. Over 80% of the injuries occurred within a kilometre of the child''s home. Of the 97 children admitted to hospital 49% had head and skull injuries and 40% had limb fractures. Bicycle-related injuries represented 14.8% of all nonwinter (Apr. 1 to Oct. 31) trauma admissions among children 5 years or older. Our results further document bicycle-related injuries as an important childhood problem and underscore the need for improved safety measures.     

Triage: a working solution to overcrowding in the emergency department

Recently, emergency departments across the continent have become crowded with patients requiring non-urgent care. To alleviate this situation at The Hospital for Sick Children in Toronto, receptionists in the emergency department direct patients requiring urgent care to the emergency room and those requiring non-urgent care to a screening clinic (triage). During a two-month period, 13,551 patients visited the emergency department. The triage receptionist sent 8368 patients to the emergency room and 5183 to the screening clinic. About 45% of patients visiting the emergency room had suffered accidents and injuries, and 19% had respiratory illness; 15% of patient visits resulted in admission to hospital. In contrast to this, 49% of patients sent to the screening clinic had respiratory illness and 18% had infective disease; less than 1% of patients needed hospitalization.     

Risk of infection following a visit to the emergency department: a cohort study

Background:

The risk of infection following a visit to the emergency department is unknown. We explored this risk among elderly residents of long-term care facilities.

Methods:

We compared the rates of new respiratory and gastrointestinal infections among elderly residents aged 65 years and older of 22 long-term care facilities. We used standardized surveillance definitions. For each resident who visited the emergency department during the study period, we randomly selected two residents who did not visit the emergency department and matched them by facility unit, age and sex. We calculated the rates and proportions of new infections, and we used conditional logistic regression to adjust for potential confounding variables.

Results:

In total, we included 1269 residents of long-term care facilities, including 424 who visited the emergency department during the study. The baseline characteristics of residents who did or did not visit the emergency department were similar, except for underlying health status (visited the emergency department: mean Charlson Comorbidity Index 6.1, standard deviation [SD] 2.5; did not visit the emergency department: mean Charlson Comorbidity index 5.5, SD 2.7; p < 0.001) and the proportion who had visitors (visited the emergency department: 46.9%; did not visit the emergency department: 39.2%; p = 0.01). Overall, 21 (5.0%) residents who visited the emergency department and 17 (2.0%) who did not visit the emergency department acquired new infections. The incidence of new infections was 8.3/1000 patient-days among those who visited the emergency department and 3.4/1000 patient-days among those who did not visit the emergency department. The adjusted odds ratio for the risk of infection following a visit to the emergency department was 3.9 (95% confidence interval 1.4–10.8).

Interpretation:

A visit to the emergency department was associated with more than a threefold increased risk of acute infection among elderly people. Additional precautions should be considered for residents following a visit to the emergency department.Infections associated with health care are an important health risk. A recent survey by the World Health Organization reported that 8.7% of patients in hospital developed such infections.^1,2 The third leading cause of death in the United States is health care–associated deaths, with over 100 000 people dying from infections associated with health care each year.³ In Canada, a point-prevalence survey found that 11.6% of adults in hospital experience a health care–associated infection.⁴Little attention has been paid to infections acquired in other health care settings. Visiting an emergency department has been identified as a risk for disease during outbreaks of measles^5,6 and SARS,^7,8 but little is known about the potential risk of endemic infection from exposure in this setting. A visit to the emergency department differs from a stay in hospital: exposure and duration of contact with other patients is shorter, but the number and density of patients with acute illness with whom there could be contact is higher.Elderly residents of long-term care facilities are likely to be at the greatest risk of morbidity and mortality from communicable diseases acquired in the emergency department. When residents are transferred to the emergency department for assessment, they are likely to have longer stays and to be cared for in multibed observation areas and corridors.⁹ If they acquire an infection while in the emergency department, these residents may be the source of an outbreak upon return to their facility; this can lead to increases in workload and costs. A Canadian study estimated the cost of an influenza outbreak to be over $6000 per 30-day period, with an estimated incidence of death of 0.75/100 residents during the same period.¹⁰ In this study, we explored the risk of acute respiratory and gastrointestinal infection associated with a visit to the emergency department among elderly residents of long-term care facilities.     

Mental illness in people who kill strangers: longitudinal study and national clinical survey

Objectives To establish changes over time in the frequency of homicides committed by strangers, and to describe the personal and clinical characteristics of perpetrators of stranger homicides.Design Longitudinal study and national clinical survey.Participants People convicted of homicide in England and Wales between 1996 and 1999 and whether the victim was known to the perpetrator.Setting England and Wales.Main outcome measure Characteristics of perpetrators of homicides according to whether victims were strangers or not.Results Stranger homicides increased between 1967 and 1997, both in number and as a proportion of all homicides. No increase was found, however, in the number of perpetrators placed under a hospital order after homicide, whether all homicides or stranger homicides only. 358 of 1594 (22%) homicides were stranger homicides. In these cases the perpetrator was more likely to be male and young. The method of killing was more likely to be by hitting, kicking, or pushing (36% (130 of 358) for victims who were strangers to the perpetrator compared with 14% (145 of 1074) for victims who were known). Perpetrators were less likely to have a history of mental disorder (34%, n = 80 ν 50%, n = 142), a history of contact with mental health services (16%, 37 of 234 ν 24%, 200 of 824), and psychiatric symptoms at the time of the offence (6%, n = 14 ν 18%, n = 143). They were more likely to have a history of drug misuse (47%, n = 93 ν 37%, n = 272); alcohol (56%, n = 94 ν 41%, n = 285) or drugs (24% n = 44 ν 12%, n = 86) were more likely to have contributed to the offence.Conclusions Stranger homicides have increased, but the increase is not the result of homicides by mentally ill people and therefore the “care in the community” policy. Stranger homicides are more likely to be related to alcohol or drug misuse by young men.     

Serum anion gap,bicarbonate and biomarkers of inflammation in healthy individuals in a national survey

Background

In vitro data suggest that lower extracellular pH activates the immune system. We conducted a population-based study of the relation between serum acid–base status and inflammation.

Methods

We examined the serum anion gap and serum levels of bicarbonate and inflammatory biomarkers in 4525 healthy adults who participated in the National Health and Nutrition Examination Survey during 1999–2006. We excluded participants who had chronic disease, recent infection and an estimated glomerular filtration rate of less than 60 mL/min per 1.73 m².

Results

The mean values of serum anion gap, bicarbonate level, leukocyte count and C-reactive protein level were all within normal limits. After adjustment for age, sex, ethnic background, body mass index, serum albumin level and other factors, we found that a higher anion gap and lower bicarbonate level were associated with a higher leukocyte count and higher C-reactive protein level. Compared with participants in the lowest quartile of anion gap, those in the highest quartile had a leukocyte count that was 1.0 × 0⁹/L higher and a C-reactive protein level that was 10.9 nmol/L higher (p < 0.01). Compared with participants in the highest quartile of bicarbonate level, those in the lowest quartile had a leukocyte count that was 0.7 × 10⁹/L higher and a C-reactive protein level that was 4.0 nmol/L higher (p ≤ 0.02). A higher anion gap and lower bicarbonate level were also associated with a higher platelet count, a larger mean platelet volume and a higher ferritin level.

Interpretation

A higher serum anion gap and lower bicarbonate level were associated with higher levels of inflammatory biomarkers in a healthy sample of the general population. Further studies are needed to elucidate the relation between acid–base status and inflammation.Higher levels of inflammatory biomarkers are associated with increased mortality and the development of chronic disease. A recent study reported that all-cause mortality increased 11% for every increase of 1.0 × 0⁹/L in leukocyte count above 3.5 × 10⁹/L.¹ Other studies also reported a significant relation between mortality and markers of inflammation.² A higher leukocyte count, C-reactive protein level and mean platelet volume predict the development of cardiovascular disease and cancer.^3–5Despite the importance of low-grade inflammation in the pathogenesis of chronic disease, factors influencing inflammation in apparently healthy individuals are not well delineated. In vitro data suggest that extracellular pH may modulate inflammation. Trevani and colleagues reported that neutrophils were less active at a pH of 7.4 than at a lower pH.⁶ Lower extracellular pH also appeared to increase neutrophil production and delay neutrophil apoptosis. Additional studies have shown that lower extracellular pH activates other components of the immune system, including other immune cells⁷ and the complement system.⁸Existing studies linking acidosis to inflammation have generally examined the impact of acute large reductions in extracellular pH. However, chronic small reductions in pH affect a variety of physiologic processes and may have a substantial impact on inflammation and the development of chronic disease.⁹ For example, we previously reported that small increases in serum anion gap and small decreases in bicarbonate levels in healthy individuals whose acid–base parameters were within normal limits were associated with elevated blood pressure and increased insulin resistance,^10,11 independent of body size and kidney function.We conducted a population-based study of the relation between serum acid–base status and inflammation. We examined the association between serum anion gap and serum levels of bicarbonate and inflammatory biomarkers in healthy individuals who participated in the National Health and Nutrition Examination Survey during 1999–2006.     

Cigarette smoking and the young: a national survey.

Cigarette smoking behaviour among the young was examined in the light of the responses of over 78 000 students to a 1972 questionnaire survey of Canadian schools. As few as 2% (8-year-old girls) and as many as 60% (16 year--old boys) were smoking one or more cigarettes per week. The prevalence of smoking was higher than that reported in earlier studies. Students, particularly girls, were beginning to smoke at progressively earlier ages. Some differences in smoking behaviour were found between regions, language groups and groups of children whose parents did or did not smoke. Recognition of immediate rather than long-term effects of smoking on health was reported as an important consideration in not smoking.     

The new role of the hospital emergency department

The volume of medical services delivered within hospital emergency departments in the City of Saskatoon is increasing rapidly. These probably are not “new” medical services but rather represent a transfer of “old” services to the emergency departments from other sites where they were previously rendered. The visit to the emergency department is initiated more often by the patient than the doctor and once there the patient is treated in a relatively short period of time. The illnesses so managed do not have a diagnostic, therapeutic or prognostic uniformity but rather are characterized by their acute and totally unexpected onset. This acute and non-programmable nature of the illness makes it difficult to deliver the service in a physician''s office where the appointment system prevails and efficiently deals with the great majority of his patients. Data to determine whether or not this is a desirable development have not yet been obtained but it is clear that in its present usage the emergency department must be thought of as a facility which not only provides exceptional diagnostic and therapeutic equipment but as one which also provides a treatment facility without prior appointment available at any hour of the day or night.     

Incidence,severity and preventability of medication-related visits to the emergency department: a prospective study

Background

Medication-related visits to the emergency department are an important but poorly understood phenomenon. We sought to evaluate the frequency, severity and preventability of drug-related visits to the emergency department.

Methods

We performed a prospective observational study of randomly selected adults presenting to the emergency department over a 12-week period. Emergency department visits were identified as drug-related on the basis of assessment by a pharmacist research assistant and an emergency physician; discrepancies were adjudicated by 2 independent reviewers.

Results

Among the 1017 patients included in the study, the emergency department visit was identified as drug-related for 122 patients (12.0%, 95% confidence interval [CI] 10.1%–14.2%); of these, 83 visits (68.0%, 95% CI 59.0%–76.2%) were deemed preventable. Severity was classified as mild in 15.6% of the 122 cases, moderate in 74.6% and severe in 9.8%. The most common reasons for drug-related visits were adverse drug reactions (39.3%), nonadherence (27.9%) and use of the wrong or suboptimal drug (11.5%). The probability of admission was significantly higher among patients who had a drug-related visit than among those whose visit was not drug-related (OR 2.18, 95% CI 1.46–3.27, p < 0.001), and among those admitted, the median length of stay was longer (8.0 [interquartile range 23.5] v. 5.5 [interquartile range 10.0] days, p = 0.06).

Interpretation

More than 1 in 9 emergency department visits are due to drug-related adverse events, a potentially preventable problem in our health care system.Adverse drug-related events are unfavourable occurrences related to the use or misuse of medications.¹ It has been estimated that such events account for 17 million emergency department visits and 8.7 million hospital admissions annually in the United States.^2,3 Between 1995 and 2000, costs associated with adverse drug-related events rose from US$76.6 billion to over US$177.4 billion.^3,4Adverse drug-related events have recently been evaluated in ambulatory care settings and among patients admitted to hospital,^5–9 and it has been estimated that 5%–25% of hospital admissions are drug-related.^7,8 Unfortunately, emergency department visits are not reflected in most hospital studies, because patients seen in the emergency department for an adverse drug-related event are typically not admitted.¹⁰ In addition, most research evaluating drug-related visits to the emergency department has involved retrospective studies or analysis of administrative data.^11–13 Retrospective studies may underestimate the incidence of drug-related visits because information may be missing or inaccurately documented.¹⁴ Finally, studies performed to date have used variable definitions of “drug-related events,”^1,10 which limits comparative evaluation and generalizability.Despite the burden of drug-related morbidity and mortality, prospective research characterizing drug-related visits to the emergency department has been limited.^15–17 We sought to overcome some of the limitations of research in this area by using a prospective design and a comprehensive definition of adverse drug-related events. The purpose of this study was to evaluate the frequency, severity and preventability of drug-related visits to the emergency department of a large tertiary care hospital, to classify the visits by type of drug-related problem and to identify patient, prescriber, drug and system factors associated with these visits.     

Self referral to accident and emergency department: patients' perceptions.

A study was conducted (a) to assess the number of patients registered with a south London general practice who over 11 weeks referred themselves to an accident and emergency department, (b) to identify the characteristics of those patients, and (c) to determine their perceptions of the services and resources available within their general practices and of the role of accident and emergency departments. Two hundred and thirty four patients referred themselves to a casualty department during the study period, of whom 217 (93%) were interviewed by means of a semistructured questionnaire. Of the 217 patients interviewed, only 15 had tried to contact their general practitioner before attending the casualty department. Eighty nine patients considered that their problem was urgent and required immediate attention and many that they would need an x ray examination. A substantial minority of patients thought that their doctor would not be available. It is concluded that patients'' perceptions of their problems and of access to their doctors are the main determinants of self referral to a casualty department. These findings have important implications for patient education.