Using routine accident and emergency department data to describe local injury epidemiology

Socioeconomic Status and Non-Fatal Adult Injuries in Selected Atlanta (Georgia USA) Hospitals

BACKGROUND

Injury mortality data for adults in the United States and other countries consistently show higher mortality for those with lower socioeconomic status (SES). Data are sparse regarding the role of SES among adult, non-fatal US injuries. The current study estimated non-fatal injury risk by household income using hospital emergency department (ED) visits.

METHODS

A total of 1,308,892 ED visits at 10 Atlanta (Georgia USA) hospitals from 2001-2004 (347,866 injuries) were studied. The SES was based on US census-block group income, with subjects assigned to census blocks based on reported residence. Logistic regression was used to determine risk by SES for injuries versus all other ED visits, adjusting for demographics, hospital, and weather. Supplemental analyses using hospital data from 2010-2013, without data on SES, were conducted to determine whether earlier patterns by race, age, and gender persisted.

RESULTS

Risk for many injury categories increased with higher income. Odds ratio by quartiles of increasing income (lowest quartile as referent, 95% confidence interval [CI] given for upper most quartile) were 1.00, 1.23, 1.34, 1.40 (95% CI 1.36-1.45) for motor vehicle accidents; 1.00, 1.03, 1.11, 1.24 (95% CI 1.20-1.29) for being struck by objects; 1.00. 0.99, 1.04, 1.12 (95% CI 1.00-1.25) for suicide; and 1.00, 1.03, 1.05, 1.12 (95% CI 1.09-1.15) for falls. In contrast, decreased injury risk with increased household income was seen for assaults (1.00, 0.83, 0.73, 0.67 [95% CI 0.63-0.72], by increasing quartiles). These trends by income did not differ markedly by race and gender. Whites generally had less risk of injuries, with the exception of assaults and motor vehicle accidents. Males had higher risk of injury than females, with the exception of falls and suicide attempts. Patterns of risk for race, age, and gender were consistent between 2001-2004 and 2010-2013.

CONCLUSION

For most non-fatal injuries, those with higher income had more risk of ED visits, although the opposite was true for assault. Hulland E , Chowdhury R , Sarnat S , Chang HH , Steenland K . Socioeconomic status and non-fatal adult injuries in selected Atlanta (Georgia USA) hospitals. Prehosp Disaster Med. 2017;32(4):403-413.

The construction and implementation of a clinical decision-making algorithm reduces the cost of adult fracture clinic visits by up to £104,800 per year: a quality improvement study

INTRODUCTION Inappropriate referrals to the new patient fracture clinic unnecessarily consume hospital resources and many hospitals lack clear guidelines as to what should be referred. Many of these injuries can be definitively managed by the emergency department. Our aim was to construct and disseminate a clinical decision-making algorithm to reduce the frequency of inappropriate referrals to fracture clinics at our institution, to improve the management of patients with minor injuries and save the hospital and the patient the cost of unnecessary visits. MATERIALS AND METHODS Data were prospectively collected for all new fracture clinic referrals over two separate 1-week cycles with cohorts of 94 and 74 patients, respectively. After the first cycle, the referral algorithm was disseminated both electronically (intranet) and orally (presentations to emergency department staff). The results of this intervention were examined in the second cycle, which took place 6 months after the first cycle. RESULTS The introduction of this algorithm significantly reduced inappropriate referrals by almost 20% (P = 0.0445). DISCUSSION This simple intervention highlighted a potential annual cost saving of up to £104,000. We advocate the use of this concise algorithm in improving the efficiency of the referral system to fracture clinics.

Epidemiology of injuries and poisonings in emergency departments in Iran

OBJECTIVES

There are few reports on epidemiological patterns of injury and injury-related mortality in developing countries. This study aimed to report the epidemiology of injuries and poisonings in emergency departments in Iran.

STUDY DESIGN

Retrospective study using available data from 20 March 2005 to 19 March 2008.

METHODS

Recorded Injury Surveillance System (ISS) data including demographics, place of residence, type of injury, and outcome during emergency department stay were extracted from the databank of the national ISS and included in the final analysis.

RESULTS

In total, 2,991,624 emergency department admissions due to injury were recorded at university hospitals during the study period. According to the national census in 2006, Iran had a population of 70,472,846, so the injury admission rate to university hospital emergency departments was 1.4%/year in Iran. The mean age of the patients was 26.5 [standard deviation (SD) 16.9] years, and 72.7% of the cases were male. The most common cause of injury was road traffic accidents (RTAs) (31.9%), followed by hit (25.5%) and falls (10.9%). Intoxication was associated with 5.3% of all injuries. The overall emergency department mortality rate was 0.6%. Of those who died, the mean age was 32.6 (SD 21.1) years. All fatal injuries, except burn injuries, were more common in males. Intoxication-related deaths occurred in 3.8% of cases. In patients aged <13, 13-65 and >65 years, hit (28.2%), RTAs (34%) and RTAs (27.9%) were, respectively, the most common causes of injury. In all age groups, RTAs were the most common cause of death.

CONCLUSIONS

This study determined the epidemiology of injuries and poisonings in emergency departments in Iran. The mortality rate in this study was low in comparison with other research, which may be explained in the context of inappropriate prehospital or interhospital care in Iran. This finding can be employed to formulate targeted preventive strategies based on the incidence of the more common types of injury.

Population based estimates of non-fatal injuries in the capital of Iran

Background

Fatal injuries are at the top of the injury pyramid; however, non-fatal injuries are quite common and impose huge medical expenses on the population. Relying on hospital data will underestimate the incidence of non-fatal injuries. The aim of this study was to estimate the annual incidence and out of pocket medical expenses of all injuries in urban population of Tehran (the capital city of Iran).

Methods

Using the cluster random sampling approach, a household survey of residents of greater Tehran was performed on April 2008. At randomly selected residential locations, interviewers asked one adult person to report all injuries which have occurred during the past year for all household members, as well as the type of injury, place of occurrence, the activity, cause of accidents resulting in injuries, the amount of out of pocket medical expenses for injury, and whether they referred to hospital.

Results

This study included 2,450 households residing in Tehran during 2007-8. The annual incidence of all injuries was 188.7 (180.7-196.9), significant injuries needing any medical care was 68.8 (63.7-74.2), fractures was 19.3 (16.6 - 22.4), and injuries resulted in hospitalization was 16.7 (14.2 - 19.6) per 1000 population. The annual incidence of fatal injuries was 33 (7-96) per 100,000 Population. In children aged 15 or less, the annual incidence of all injuries was 137.2 (120.0 - 155.9), significant injuries needing any medical care was 64.2 (52.2 - 78.0), fractures was 21.8 (15.0 - 30.7), and injuries resulted in hospitalization was 6.8 (3.3 - 12.5) per 1000 population. The mean out of pocket medical expense for injuries was 19.9 USD.

Conclusion

This population based study showed that the real incidence of non-fatal injuries in the capital of Iran is more than the formal hospital-based estimates. These injuries impose non trivial medical and indirect cost on the community. The out of pocket medical expense of non-fatal injuries to Tehran population is estimated as 27 million USD per year. Effective strategies should be considered to minimize these injuries and decrease the great financial burden to public and the health system.

A review of injury epidemiology in the UK and Europe: some methodological considerations in constructing rates

BACKGROUND

Serious injuries have been stated as a public health priority in the UK. However, there appears to be a lack of information on population-based rates of serious injury (as defined by a recognised taxonomy of injury severity) at national level from either official statistics or research papers. We aim to address this through a search and review of literature primarily focused within the UK and Europe.

METHODS

The review summarizes research papers on the subject of population based injury epidemiology published from 1970 to 2008. We examined critically methodological approaches in measuring injury incident rates including data sources, description of the injury pyramid, matching numerator and denominator populations as well as the relationship between injury and socioeconomic status.

RESULTS

National representative rates come from research papers using official statistics sources, often focusing on mortality data alone. Few studies present data from the perspective of an injury pyramid or using a standardized measure of injury severity, i.e. Injury Severity Score (ISS). The population movement that may result in a possible numerator - denominator mismatch has been acknowledged in five research studies and in official statistics. The epidemiological profile shows over the past decades in UK and Europe a decrease in injury death rates. No major trauma population based rates are available within well defined populations across UK over recent time periods. Both fatal and non-fatal injury rates occurred more frequently in males than females with higher rates in males up to 65 years, then in females over 65 years. Road traffic crashes and falls are predominant injury mechanisms. Whereas a straightforward inverse association between injury death rates and socio-economic status has been observed, the evidence of socioeconomic inequalities in non-fatal injuries rates has not been wholly consistent.

CONCLUSION

New methodological approaches should be developed to deal with the study design inconsistencies and the knowledge gaps identified across this review. Trauma registries contain injury data from hospitals within larger regions and code injury by Abbreviated Injury Scale enabling information on severity; these may be reliable data sources to improve understanding of injury epidemiology.

Sport-related ankle injuries attending an accident and emergency department

INTRODUCTION

This study investigated the sport-related ankle injuries attending an accident and emergency (A&E) department during a 1-year period.

METHODS

A total of 1715 sports injuries cases attending an A&E department from 1 January 2005 to 31 December 2005 were prospectively recorded. Details of each classified case were recorded in a computerised record system by the triage nurse. At the end of the study period, all sport-related ankle injury cases were analysed.

RESULTS

A total of 240 sport-related ankle injury cases were reported. Most cases were sustained from basketball (32.9%), soccer (31.7%) and hiking (5.8%) sports. The majority of the cases was ligamentous sprains (81.3%) and fractures (10.4%). The mean age of all patients was 24.6 years (S.D. = 12.3). Four fifths (80.4%) were male patients. All cases were not life threatening. Most cases (99.2%) were referred to orthopedics specialty. Radiography was routinely employed in 99.2% of the cases. Ligamentous sprains were mostly sustained in basketball (37.4%) and soccer (28.7%), and were often treated with bandaging (60.0%) and analgesics (48.7%). Most cases were discharged with or without referral to physiotherapy and specialty clinic (95.4%). Fractures were mostly sustained in soccer (52.0%), basketball (20.0%) and hiking (16.0%), and were very often admitted to hospital wards (84.0%). The estimated A&E attendance rate for all sports injuries, ankle injuries, ligamentous sprains and fractures were 1.68, 0.24, 0.19 and 0.02/1000 person-year.

CONCLUSIONS

The results of this study together with the previous study on ankle sprain epidemiology suggested the following sports ankle injury pattern in Hong Kong-major and serious ankle ligamentous sprains and fractures were sustained from basketball, soccer and hiking, leading to A&E attendance, while minor sprains were sustained in running and jogging and racquet sports. We suggested that the Sports medicine specialists in Hong Kong should emphasise the ankle injury prevention strategies in these sports.

Attendance for injury at accident and emergency departments in London: a cross-sectional study

OBJECTIVE

In order to set the foundation for the possible development of injury surveillance initiatives in north-west London, data on all presentations during 2002 at the nine accident and emergency departments (AEDs) in the relevant strategic health authority were examined.

STUDY DESIGN

Descriptive, cross-sectional study.

METHODS

A search algorithm was devised to extract records pertaining to injury presentations. The results were validated against a manually checked sample. Descriptive, quantitative analyses were performed.

RESULTS

Only four of the nine hospitals in the study area routinely recorded data in a form useful for research on injury. In these four hospitals, presentations with injury accounted for 29.7% of total attendances at the AED, which is markedly lower than the national average.

CONCLUSIONS

Certain characteristics of London regarding provision of primary care may explain why attendances for injury are proportionately low. However, the unusual pattern also underlines the importance of improving the quality of AED data in order to support adequate local surveillance of injury as the basis of efforts to prevent such incidents and to plan services to deal with injuries.

Trauma rapid review process: efficient out-patient fracture management

INTRODUCTION

Our hospital operates a consultant-led, rapid review process of X-rays and case notes of all musculoskeletal injury patients on a daily basis. This compares with other centres where patients are reviewed in out-patient fracture clinics soon after injury. The aim of this study was to evaluate the effectiveness of this consultant-led, rapid review process compared to standard consultant fracture clinics.

PATIENTS AND METHODS

A prospective study of the rapid review process over 4 weeks of all musculoskeletal injury patients was conducted. The total number of patients referred per day, time taken to review these patients X-rays and case notes, number of recalls and reason for recall were documented. This was compared to consultant-led fracture clinics, which included time taken to review patients.

RESULTS

A total of 797 patients were processed through the rapid review over 4 weeks: 53 (6%) patients were recalled, 32 (4%) for a change of management and 21 (2.6%) because of lack of information. The mean number of patients referred per day was 28 taking a mean of 28 min; thus the mean time to review one patient was 1.0 min. The mean number of patients recalled per day was two. The mean time taken to review a patient in a standard fracture clinic was 11 min. Therefore, the total time that would have taken to review 28 patients in a standard fracture clinic would be 308 min.

CONCLUSIONS

A consultant-led, rapid review process of all patients with musculoskeletal injury is a very efficient process. The rapid review process saves clinic time and resources, minimises delays in clinical decision-making and saves the patient an unnecessary visit to the outpatient department.

A study of childhood attendance at emergency departments in the West Midlands region

INTRODUCTION

Research into childhood attendance at EDs in the UK has focused mainly on injury rather than medical conditions and studies have been relatively small. This study looks at all types of ED attendance by children across a large population.

DATA AND METHODS

Routine data on all new attendances by children under 16 years were available for 12 EDs in the West Midlands (period: 1 April 2002 to 31 March 2004, 365 695 records). The data were split into four age groups (<1, 1-4, 5-9, and 10-15 years).

RESULTS

Injury related conditions increased with age (with the exception of head injury). Respiratory and gastrointestinal were the most common medical conditions decreased with age. 11.5% of children were admitted to hospital and this varied from 8.2% (10-15 years) to 24.2% (<1 year).

CONCLUSIONS

This study has shown substantial variations in ED attendance by age and has given an insight into the variation among hospitals. This is the largest study of childhood ED attendance undertaken in the UK, and it is hoped that the questions raised will prompt more research in this field.

The potential of emergency department injury surveillance data: an illustration using descriptive analysis of data in 0-4 year olds from the Bath injury surveillance system

OBJECTIVES

To illustrate the potential of injury surveillance data from an emergency department surveillance system.

SETTING

Bath clinical area.

METHODS

Data for children (0-4 years old) resident in Bath city in UK were recoded and analysed.

RESULTS

There were a total of 3144 attendances and 2300 unintentional injuries - equivalent to an attendance rate of 131/1000. There were 91 thermal injuries and 162 poisoning/ingestions. Descriptive information is presented on the circumstances and consequences.

CONCLUSION

The majority of unintentional injuries in 0-4 year olds occur in the home, which is a modifiable environment. Detailed information around the circumstances available from the Bath injury surveillance system allows better focus for prevention messages and priority setting.

Identification and characteristics of victims of violence identified by emergency physicians, triage nurses, and the police

OBJECTIVES

The objectives of the study were threefold-to evaluate the identification and characteristics of victims of assault who attend an accident and emergency (A&E) department; to compare the total number of assaults recorded in the A&E department with the number recorded by the police; and to assess a system for collecting the location and method of assault.

SETTING

The A&E department of Chorley and South Ribble Hospital Trust, Lancashire, England.

METHODS

A three month prospective study was performed. Victims of violence recorded on computer by doctors at discharge were compared with those identified at initial nurse triage. A comparison of police data with the A&E data relating to Chorley residents was performed. Additional information on the method and location of assault was also collected.

RESULTS

During the period 305 (2.6%) of the patients attending A&E were identified as having been assaulted. Of the 305 individuals, 236 (77%) were identified by a doctor while 173 (57%) such patients were identified by a triage nurse. A&E identified twice the number of assaults involving Chorley residents as the police. Both men and women were most likely to have been injured on the street (44% and 37% respectively), although a greater proportion of women were injured at home (24%) than men (10%). The majority of injuries were sustained by blows from fists, feet, and heads (73%).

CONCLUSIONS

A&E doctors identify significantly more patients as the victims of violence than do nurses at triage. Using A&E data identifies assaulted individuals not identified by the police. Computer systems can be used in A&E to provide a more complete picture of the occurrence of violence in the community.

Cross sectional survey of socioeconomic variations in severity and mechanism of childhood injuries in Trent 1992-7

OBJECTIVE

To determine the relation between morbidity from injury and deprivation for different levels of injury severity and for different injury mechanisms for children aged 0-14 years.

DESIGN

Cross sectional survey of routinely collected hospital admission data for injury 1992-7.

SETTING

862 electoral wards in Trent Region.

SUBJECTS

21 587 injury related hospital admissions for children aged 0-4 years and 35 042 admissions for children aged 5-14.

MAIN OUTCOME MEASURES

Rate ratios for hospital admission for all injuries, all injuries involving long bone fracture, and all injuries involving long bone fracture requiring an operation; rate ratios for hospital admission for six types of injury mechanism divided by quintiles of the electoral wards' Townsend scores for deprivation. Rate ratios calculated by Poisson regression, with adjustment for distance from nearest hospital admitting patients with injuries, rurality, ethnicity, and percentage of males in each electoral ward.

RESULTS

Both total number of admissions for injury and admissions for injuries of higher severity increased with increasing socioeconomic deprivation. These gradients were more marked for 0-4 year old children than 5-14 year olds. In terms of injury mechanisms, the steepest socioeconomic gradients (where the rate for the fifth of electoral wards with the highest deprivation scores was > or =3 times that of the fifth with the lowest scores) were for pedestrian injuries (adjusted rate ratio 3.65 (95% confidence interval 2.94 to 4.54)), burns and scalds (adjusted rate ratio 3.49 (2.81 to 4.34)), and poisoning (adjusted rate ratio 2.98 (2.65 to 3.34)).

CONCLUSION

There are steep socioeconomic gradients for injury morbidity including the most common mechanisms of injury. This has implications for targeting injury prevention interventions and resources.