Recurrent violent injury: magnitude, risk factors, and opportunities for intervention from a statewide analysis.

INTRODUCTION: Although preventing recurrent violent injury is an important component of a public health approach to interpersonal violence and a common focus of violence intervention programs, the true incidence of recurrent violent injury is unknown. Prior studies have reported recurrence rates from 0.8% to 44%, and risk factors for recurrence are not well established. METHODS: We used a statewide, all-payer database to perform a retrospective cohort study of emergency department visits for injury due to interpersonal violence in Florida, following up patients injured in 2010 for recurrence through 2012. We assessed risk factors for recurrence with multivariable logistic regression and estimated time to recurrence with the Kaplan-Meier method. We tabulated hospital charges and costs for index and recurrent visits. RESULTS: Of 53 908 patients presenting for violent injury in 2010, 11.1% had a recurrent violent injury during the study period. Trauma centers treated 31.8%, including 55.9% of severe injuries. Among recurrers, 58.9% went to a different hospital for their second injury. Low income, homelessness, Medicaid or uninsurance, and black race were associated with increased odds of recurrence. Patients with visits for mental and behavioral health and unintentional injury also had increased odds of recurrence. Index injuries accounted for $105 million in costs, and recurrent injuries accounted for another$25.3 million. CONCLUSIONS: Recurrent violent injury is a common and costly phenomenon, and effective violence prevention programs are needed. Prevention must include the nontrauma centers where many patients seek care

Risk Factors for Unplanned Transfer to Intensive Care within 24 Hours of Admission from the Emergency Department in an Integrated Healthcare System

BACKGROUND: Emergency department (ED) ward admissions subsequently transferred to the intensive care unit (ICU) within 24 hours have higher mortality than direct ICU admissions

Hospital Strain and Variation in Sepsis ICU Admission Practices and Associated Outcomes

OBJECTIVES:. To understand how strain-process-outcome relationships in patients with sepsis may vary among hospitals. DESIGN:. Retrospective cohort study using a validated hospital capacity strain index as a within-hospital instrumental variable governing ICU versus ward admission, stratified by hospital. SETTING:. Twenty-seven U.S. hospitals from 2013 to 2018. PATIENTS:. High-acuity emergency department patients with sepsis who do not require life support therapies. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. The mean predicted probability of ICU admission across strain deciles ranged from 4.9% (lowest ICU-utilizing hospital for sepsis without life support) to 61.2% (highest ICU-utilizing hospital for sepsis without life support). The difference in the predicted probabilities of ICU admission between the lowest and highest strain deciles ranged from 9.0% (least strain-sensitive hospital) to 45.2% (most strain-sensitive hospital). In pooled analyses, emergency department patients with sepsis (n = 90,150) experienced a 1.3-day longer median hospital length of stay (LOS) if admitted initially to the ICU compared with the ward, but across the 27 study hospitals (n = 517-6,564), this effect varied from 9.0 days shorter (95% CI, –10.8 to –7.2; p < 0.001) to 19.0 days longer (95% CI, 16.7–21.3; p < 0.001). Corresponding ranges for inhospital mortality with ICU compared with ward admission revealed odds ratios (ORs) from 0.16 (95% CI, 0.03–0.99; p = 0.04) to 4.62 (95% CI, 1.16–18.22; p = 0.02) among patients with sepsis (pooled OR = 1.48). CONCLUSIONS:. There is significant among-hospital variation in ICU admission rates for patients with sepsis not requiring life support therapies, how sensitive those ICU admission decisions are to hospital capacity strain, and the association of ICU admission with hospital LOS and hospital mortality. Hospital-level heterogeneity should be considered alongside patient-level heterogeneity in critical and acute care study design and interpretation