METHODS: ED patients at 10 US medical centers were surveyed about preferences for hypothetical smoking cessation interventions and specific counseling styles. Multivariable linear regression determined correlates of receptivity to bedside counseling.

RESULTS: Three hundred seventy-five patients were enrolled; 46% smoked at least one pack of cigarettes per day, and 11% had a smoking-related diagnosis. Most participants (75%) reported interest in at least one intervention. Medications were the most popular (e.g., nicotine replacement therapy, 54%), followed by linkages to hotlines or other outpatient counseling (33-42%), then counseling during the ED visit (33%). Counseling styles rated most favorably involved individualized feedback (54%), avoidance skill-building (53%), and emphasis on autonomy (53%). In univariable analysis, age (r = 0.09), gender (average Likert score = 2.75 for men, 2.42 for women), education (average Likert score = 2.92 for non-high school graduates, 2.44 for high school graduates), and presence of smoking-related symptoms (r = 0.10) were significant at the p < 0.10 level and thus were retained for the final model. In multivariable linear regression, male gender, lower education, and smoking-related symptoms were independent correlates of increased receptivity to ED-based smoking counseling.

CONCLUSIONS: In this multicenter study, smokers reported receptivity to ED-initiated interventions. However, there was variability in individual preferences for intervention type and counseling styles. To be effective in reducing smoking among its patients, the ED should offer a range of tobacco intervention options.

METHODS: A systematic search was conducted of electronic databases, references, key journals, and conference proceedings. Studies were included if they evaluated the use of computer-based technologies for ED-based screening, interventions, or referrals for high-risk health behaviors (e.g., unsafe sex, partner violence, substance abuse, depression); were published since 1990; and were in English, French, or Spanish. Study selection and assessment of methodologic quality were performed by two independent reviewers. Data extraction was performed by one reviewer and then independently checked for completeness and accuracy by a second reviewer.

RESULTS: Of 17,744 unique articles identified by database search, 66 underwent full-text review, and 20 met inclusion criteria. The greatest number of studies targeted alcohol/substance use (n = 8, 40%), followed by intentional or unintentional injury (n = 7, 35%) and then mental health (n = 4, 20%). Ten of the studies (50%) were randomized controlled trials; the remainder were observational or feasibility studies. Overall, studies showed high acceptability and feasibility of individual computer innovations, although study quality varied greatly. Evidence for clinical efficacy across health behaviors was modest, with few studies addressing meaningful clinical outcomes. Future research should aim to establish the efficacy of computer-based technology for meaningful health outcomes and to ensure that effective interventions are both disseminable and sustainable.

CONCLUSIONS: The number of studies identified in this review reflects recent enthusiasm about the potential of computers to overcome barriers to behavioral health screening, interventions, and referrals to treatment in the ED. The available literature suggests that these types of tools will be feasible and acceptable to patients and staff.

METHOD: Data were obtained from the National Hospital Ambulatory Medical Care Survey including all visits for attempted suicide and self-inflicted injury (E950-E959) during 1993-2008.

RESULTS: Over the 16-year period, there was an average of 420,000 annual ED visits for attempted suicide and self-inflicted injury [1.50 (95% confidence interval, 1.33-1.67) visits per 1000 US population], and the average annual number for these ED visits more than doubled from 244,000 in 1993-1996 to 538,000 in 2005-2008. During the same time frame, ED visits for these injuries per 1000 US population almost doubled for males (0.84 to 1.62), females (1.04 to 1.96), whites (0.94 to 1.82) and blacks (1.14 to 2.10). Visits were most common among ages 15-19, and the number of visits coded as urgent/emergent decreased from 0.95 in 1993-1996 to 0.70 in 2005-2008.

CONCLUSIONS: ED visit volume for attempted suicide and self-inflicted injury has increased over the past two decades in all major demographic groups. Awareness of these longitudinal trends may assist efforts to increase research on suicide prevention. In addition, this information may be used to inform current suicide and self-injury related ED interventions and treatment programs.

METHODS: A national survey of all 138 academic emergency departments in the United States was conducted.

RESULTS: Most emergency physicians (81%) had no systematic method for identifying psychiatric emergency patients with high recidivism. In order to promote outpatient care, sites commonly reported using intensive interventions, including scheduling outpatient appointments prior to discharge (72%) and in-house case management (64%).

CONCLUSION: While systematic identification of repeat psychiatric emergency patients was uncommon, emergency departments reported using a variety of fairly intensive strategies to promote continuity of care with outpatient mental health services.

Methods: Eight geographically diverse U.S. EDs each performed chart reviews of 100 randomly selected patients, ages 18 years or older, with visits in October 2009. Trained chart abstractors collected information on patient demographics, presentation, discharge diagnosis, suicide screening, and other mental health indicators. Univariate logistic regression was used to determine factors associated with suicide screening.

Results: The cohort of 800 patients had a median age of 41 years (interquartile range = 27 to 53 years) with 57% female, 16% Hispanic, 58% white, 23% black or African American, and 10% other race. Suicide screenings were documented for 39 patients (4.9%; 95% confidence interval [CI] = 3.4% to 6.4%). Of those screened, 23 (2.9% of total sample; 95% CI = 1.7% to 4.0%) were positive for suicidal ideation or behavior. Approximately 90% of those screened had documented complaints of a psychiatric nature at triage. About one-third had either documentation of alcohol abuse (33%) or intentional illegal or prescription drug misuse (36%).

Conclusions: The presence of known psychiatric problems and substance use had the strongest associations with suicide screening, yet even patients presenting with these indicators were not screened for suicide. Understanding factors that currently influence suicide screening in the ED will guide the design and implementation of improved suicide screening protocols and related interventions.

ACADEMIC EMERGENCY MEDICINE 2012; 1-5 (c) 2012 by the Society for Academic Emergency Medicine.

Citation: Radeos M, Boudreaux E. The Agitated Patient (Chapter 50). In: Evidence-Based Emergency Medicine (First Edition). (Volume 24 of Evidence-Based Medicine series) Editors: Rowe BH, Lang E, Brown M, Houry D, Newman D, Wyer P. John Wiley and Sons, London, UK; pp: 512 – 519, 2008. ISBN 9781405161435

Partial preview of chapter is available via Google Books.

DESIGN: A prospective cohort study conducted as part of the Multicenter Airway Research Collaboration.

PATIENTS: A structured interview was performed in 1,847 patients, ages 18 to 54 years, who presented to the ED with acute asthma.

SETTING: Sixty-four EDs in 21 US states and 4 Canadian provinces.

RESULTS: Thirty-five percent of the enrolled asthmatic patients were current smokers with a median of 10 pack-years (interquartile range, 4 to 20 pack-years), while 23% were former smokers, and 42% were never-smokers. Current smokers comprised 33% of asthmatic patients aged 18 to 29 years, 40% for ages 30 to 39 years, and 33% for ages 40 to 54 (p < 0.001). In a multivariate analysis, the factors independently associated with current smoking status (p < 0.05) were as follows: age 30 to 39 years; white race/ethnicity; non-high school graduate; lower household income; lack of private insurance; no recent inhaled steroid usage; and no history of systemic steroid usage. Although 50% of current smokers admitted that smoking worsens their asthma symptoms, only 4% stated that smoking was responsible for their current exacerbation.

CONCLUSIONS: Although cigarette smoke is generally recognized as a respiratory irritant, cigarette smoking is common among adults presenting to the ED with acute asthma. The ED visit may provide an opportunity for patients to be targeted for smoking cessation efforts.

METHODS: Secondary analysis of data collected at eight US EDs in 2006. Eligible patients were age 18 years or older, every- or some-day smokers, English or Spanish speaking, able to provide written informed consent, and not actively psychotic.

RESULTS: There were 1168 patients interviewed, median age 41 years (interquartile range 29-50), 48.5% female. Receiving a tobacco control intervention was strongly and consistently associated with higher satisfaction scores. Satisfaction scores improved as the number of tobacco control interventions recalled by the patient increased. In multivariate analysis, the number of tobacco control interventions recalled was the only variable associated with higher patient satisfaction (odds ratio 1.24, 95% confidence interval 1.04-1.49).

CONCLUSION: ED patients who report having received a tobacco control intervention are more likely to be satisfied with their care. There is a dose-response relationship between the number of patient-reported tobacco interventions received and the global satisfaction score. Of all providers, only physicians' performance of tobacco control was associated with improved satisfaction scores. Routine screening, intervention, and referral of ED patients for smoking will not harm, and may improve, satisfaction scores. The mechanism underlying this effect is unknown.

Methods: The study was performed at a large urban hospital emergency department (ED) in Camden, New Jersey. Enrollment included adults who reported tobacco use in the past 30 days. Study participants were informed about a "Stop Smoking Clinic" affiliated with the hospital and, depending on enrollment date, cost of treatment was advertised as $150 (standard fee), $20 (reduced fee), or $0 (no fee). Monitoring of patient inquiries and visits to the clinic was performed for 6 months following enrollment of the last study subject.

Results: The analyzed sample consisted of 577 tobacco users. There were no statistically significant demographic differences between treatment groups (p > 0.05). Two-hundred forty-seven (43%) participants reported "very much" interest in smoking cessation. However, there was no significant difference in initiating treatment with the Stop Smoking Clinic across experimental condition. Only a single subject, enrolled in the no-fee phase, initiated treatment with the clinic.

Conclusions: Cost is unlikely to be the only barrier to pursing outpatient tobacco treatment after an ED visit. Further research is needed to determine the critical components of counseling and referral that maximize postdischarge treatment initiation. (c) 2011 by the Society for Academic Emergency Medicine

METHOD: Sequential (before and after) surveys were completed voluntarily by EMTs at 1 month prior to, 2 months after, and 1 year after a workshift modification (change from 24- to 12-hour shifts). The surveys assessed job satisfaction, occupational burnout, and attitudes toward work schedules. The questionnaires were completed at emergency medical service stations.

RESULTS: Of 70 EMTs in the system, 51 (73%) completed the first 2 stages of this study; 35 (50%) completed all 3 stages. Paired-sample t-tests revealed significant differences between baseline and 2-month posttest scores on the following variables: the Maslach Burnout Inventory: Emotional Exhaustion Scale (less perceived exhaustion at 2 months); the Schedule Attitudes Survey: General Affect (perceived more positive view toward schedule at 2 months); Social/Family Impact (perceived less disruption of social/family life at 2 months); and Composite (less overall disruption in quality of life at 2 months). Statistically significant differences between baseline and 1-year posttest scores were found on the following: Schedule Attitudes Survey: General Affect (more positive view toward schedule at 1 year); Social/Family Impact (less disruption in social/family life at 1 year); and Composite (less overall disruption in quality of life at 1 year).

CONCLUSION: Modifying EMTs' work schedules from 24- to 12-hour shifts was associated with improvements in EMTs' general attitudes toward their schedules, less disruption of social and family life, and decreased levels of emotional exhaustion at 2 months after the change. While the improvements in EMTs' attitudes toward their schedules persisted at the 1-year follow-up, the measure of emotional exhaustion returned to baseline.