North Carolina Emergency Departments Research Articles

Pregnancy and Emergency Department Utilization in North Carolina, 2016–2021: A Population-Based Surveillance Study

Pregnancy-associated complaints are a common reason for emergency department visits for women of reproductive age. Emergency department utilization during pregnancy is associated with worse birth outcomes for both mothers and infants. We used statewide North Carolina emergency department surveillance data between 2016 and 2021 to describe the sociodemographic factors associated with the use of emergency department for pregnancy-associated problems and subsequent hospital admission. North Carolina Disease Event Tracking and Epidemiologic Collection Tool is a syndromic surveillance system that includes all emergency department encounters at civilian acute-care facilities in North Carolina. We analyzed all emergency department visits between January 1, 2016 and December 31, 2021 for female patients aged 15-44 years residing in North Carolina with at least 1 ICD-10-CM code (analysis occurred in July 2021-October 2022). Each emergency department visit was categorized as pregnancy-associated if assigned ICD-10-CM code(s) indicated pregnancy. We stratified visits by age, race, ethnicity, county of residence, and insurance and compared them with estimated pregnant population proportions using 1-sample t-tests. We used multivariable logistic regression to determine whether pregnancy-associated visits were more likely to be associated with hospital admission and then to determine sociodemographic predictors of admission among pregnancy-associated emergency department visits. More than 6.4 million emergency department visits were included (N=6,471,197); 10.1% (n=655,476) were pregnancy-associated, significantly higher than the proportion of women estimated to be pregnant at any given time in North Carolina (4.6%, p<0.0001) and increased over time (8.6% in 2016 vs 11.1% in 2021, p<0.0001). Pregnancy-associated visits were lower than expected for ages 25-44 years and higher than expected for those aged 15-24 years, for those of Black race, and for patients residing in rural or suburban areas. The proportion admitted was higher for pregnancy-associated emergency department visits than for nonpregnancy associated (15.6% vs 7.0%, AOR=3.06 [95% CI=3.03, 3.09]). Pregnancy-associated emergency department visits for patients of Black race had 0.58 times (95% CI=0.57, 0.59) the odds of admission compared with White patients. Emergency department utilization during pregnancy is common. The proportion of pregnancy-associated emergency department visits among reproductive-age women is increasing, as are inpatient admissions from the emergency department for pregnancy-associated diagnoses. Use of public health surveillance databases such as the North Carolina Disease Event Tracking and Epidemiologic Collection Tool may help identify opportunities for improving disparities in maternal health care, especially related to access to care.

Characterizing Social Insecurity in a Rural North Carolina Emergency Department.

Social insecurity, a form of deprivation of social amenities, if present among patients presenting in a rural emergency department (ED) can be a source of medical burden and poor health outcomes. Although knowledge and understanding of the insecurity profile of such patients is necessary for targeted care that improves their health outcomes, the concept has not been comprehensively quantified. In this study we explored, characterized, and quantified the social insecurity profile of ED patients at a rural teaching hospital in southeastern North Carolina with a large Native American population. A paper survey questionnaire was administered by trained research assistants between May-June 2018 to patients who presented to the ED and consented to participate in this cross-sectional, single-center study. The survey was anonymous with no identifying information collected on the respondents. A general demographic section and questions derived from the literature capturing sub-constructs of social insecurity-communication access, access to transportation, housing insecurity and home environment, food insecurity, and exposure to violence-were captured in the survey. We assessed the factors included in the index of social insecurity based on a rank ordering using the magnitude of their coefficient of variation and the Cronbach's alpha reliability index of the constituent items. Overall, we collected 312 surveys from the approximately 445 administered and included them in the analysis, representing a response rate of about 70%. The average age of the 312 respondents was 45.1 (±17.7) years with a range of 18.0-96.0. More females (54.2%) than males participated in the survey. Native Americans (34.3%), Blacks (33.7%), and Whites (27.6%) comprised the three major racial/ethnicity groups of the sample, which are representative of the study area's population distribution. Social insecurity was observed among this population regarding all the subdomains and an overall measure (P <.001). We identified three key determinants of social insecurity-food insecurity, transportation insecurity, and exposure to violence. Social insecurity significantly differed overall and among the three of its key constituent domains by patients' race/ethnicity and gender (P <.05). Emergency department visits in a rural North Carolina teaching hospital are characterized by a diverse patient population, including patients with some degree of social insecurity. Historically marginalized and minoritized groups including Native Americans and Blacks demonstrated overall higher rates of social insecurity and higher indexes on exposure to violence than their White counterparts. Such patients struggle with basic needs such as food, transportation, and safety. As social factors play a critical role in health outcomes, supporting the social well-being of a historically marginalized and minoritized rural community would likely help build the foundation for safe livelihood with improved and sustainable health outcomes. The need for a more valid and psychometrically desirable measurement tool of social insecurity among ED populations is compelling.

Investigating the Impact of Covid-19 on Telepsychiatry Use Across Sex and Race: A Study of North Carolina Emergency Departments.

Introduction: The COVID-19 pandemic and the intervention measures have increased mental health problems among Americans. Telepsychiatry provides a safe and efficient way to serve mental health patients in emergency departments (EDs). The objective of this study is to evaluate the impact of COVID-19 on telepsychiatry consultations in North Carolina (NC) and analyze the differences across sex and race. Methods: This longitudinal observational study used data from the NC Statewide Telepsychiatry Program to examine temporal changes in ED telepsychiatry consultations from January 2019 to March 2021 (117 weeks), including 4,739 telepsychiatry consultations conducted by 27 hospitals in 24 counties in NC during the period. The outcome measures were telepsychiatry consultation counts. Weekly ED telepsychiatry consultation counts were calculated overall and stratified by sex and race. Results: The overall weekly ED telepsychiatry consultation counts were decreasing before the national lockdown but started increase after the lockdown. Moreover, the counts of telepsychiatry consultations for white patients had a stronger increasing trend than that for black patients. Comparing telepsychiatry counts during the lockdown period (March and April) in 2020 and the same period in 2019, male patients had higher counts while female patients had lower counts, and white patients had higher counts while black patients had lower counts. Discussion: It seems that the COVID-19 crisis has led to a heightening demand for telepsychiatry consultations in NC, and there is a possible race disparity in these demands between black and white mental health patients. These findings underscore the need to further develop telepsychiatry services and enhance access to black patients.

A Mixed-Methods Comparison of a National and State Opioid Overdose Surveillance Definition.

We assessed the differences between the first version of the Centers for Disease Control and Prevention (CDC) opioid surveillance definition for suspected nonfatal opioid overdoses (hereinafter, CDC definition) and the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT) surveillance definition to determine whether the North Carolina definition should include additional International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes and/or chief complaint keywords. Two independent reviewers retrospectively reviewed data on North Carolina emergency department (ED) visits generated by components of the CDC definition not included in the NC DETECT definition from January 1 through July 31, 2018. Clinical reviewers identified false positives as any ED visit in which available evidence supported an alternative explanation for patient presentation deemed more likely than an opioid overdose. After individual assessment, reviewers reconciled disagreements. We identified 2296 ED visits under the CDC definition that were not identified under the NC DETECT definition during the study period. False-positive rates ranged from 2.6% to 41.4% for codes and keywords uniquely identifying ≥10 ED visits. Based on uniquely identifying ≥10 ED visits and a false-positive rate ≤10.0%, 4 of 16 ICD-10-CM codes evaluated were identified for NC DETECT definition inclusion. Only 2 of 25 keywords evaluated, "OD" and "overdose," met inclusion criteria to be considered a meaningful addition to the NC DETECT definition. Quantitative and qualitative trends in coding and keyword use identified in this analysis may prove helpful for future evaluations of surveillance definitions.

Hurricane flooding and acute gastrointestinal illness in North Carolina

Hurricanes often flood homes and industries, spreading pathogens. Contact with pathogen-contaminated water can result in diarrhea, vomiting, and/or nausea, known collectively as acute gastrointestinal illness (AGI). Hurricanes Matthew and Florence caused record-breaking flooding in North Carolina (NC) in October 2016 and September 2018, respectively. To examine the relationship between hurricane flooding and AGI in NC, we first calculated the percent of each ZIP code flooded after Hurricanes Matthew and Florence. Rates of all-cause AGI emergency department (ED) visits were calculated from NC's ED surveillance system data. Using controlled interrupted time series, we compared AGI ED visit rates during the three weeks after each hurricane in ZIP codes with a third or more of their area flooded to the predicted rates had these hurricanes not occurred, based on AGI 2016–2019 ED trends, and controlling for AGI ED visit rates in unflooded areas. We examined alternative case definitions (bacterial AGI) and effect measure modification by race and age. We observed an 11% increase (rate ratio (RR): 1.11, 95% CI: 1.00, 1.23) in AGI ED visit rates after Hurricanes Matthew and Florence. This effect was particularly strong among American Indian patients and patients aged 65 years and older after Florence and elevated among Black patients for both hurricanes. Florence's effect was more consistent than Matthew's effect, possibly because little rain preceded Florence and heavy rain preceded Matthew. When restricted to bacterial AGI, we found an 85% (RR: 1.85, 95% CI: 1.37, 2.34) increase in AGI ED visit rate after Florence, but no increase after Matthew. Hurricane flooding is associated with an increase in AGI ED visit rate, although the strength of effect may depend on total storm rainfall or antecedent rainfall. American Indians and Black people—historically pushed to less desirable, flood-prone land—may be at higher risk for AGI after storms.

Pelvic Inflammatory Disease Trends Among Emergency Department Visits in North Carolina, 2008 to 2017.

Pelvic inflammatory disease (PID) is an infection of the upper female reproductive organs that can lead to infertility and ectopic pregnancies. It is a reportable condition in North Carolina (NC) but is likely underreported. We aimed to quantify PID diagnoses in NC emergency department (ED) visits. The NC Disease Event Tracking and Epidemiology Collection Tool tracks all ED visits in NC. We identified PID diagnoses among women of reproductive age (15-44 years) between 2008 and 2017 using International Classification of Diseases, Ninth/Tenth Revision, Clinical Modification codes, and calculated the yearly proportion with PID diagnoses. We assessed the number of PID visits per patient each year, and the proportion of ED visits with a PID diagnosis by age, proportion of the patient's ZIP code living below the poverty line, insurance coverage, and NC provider region. The percent of women with PID decreased from 6189 (1.0%) in 2008 to 4337 (0.58%) in 2016 before increasing slightly to 4371 (0.61%) in 2017. We identified 54,502 (0.45%) ED visits among 51,847 (0.76%) women with ≥1 PID diagnosis code. Most (95.5%) women with PID had one ED visit during the calendar year. Each year, the proportion with PID was highest among women aged 20 to 24 years, covered under public insurance, from the most impoverished areas, and whose provider was in the Coastal region of NC. The percent with PID among women visiting EDs decreased between 2008 and 2017 in NC. Although this decline was observed across all demographics, disparities associated with PID continued to persist over time.

Examining the Effect of Pedestrian Crashes on Vulnerable Populations in North Carolina.

Over the last several years, pedestrian fatalities have increased in North Carolina; however, fatalities represent a small proportion of the total number of nonfatally injured pedestrians. Therefore, we linked statewide motor vehicle crash (MVC) and emergency department (ED) visit data to better understand the circumstances and characteristics of pedestrians treated in North Carolina emergency departments (EDs) for injuries related to crashes. We linked information for pedestrians and bicyclists from 2017 North Carolina police-reported MVCs to population-based ED visit data using hierarchical deterministic methods. We linked 45% of pedestrian crash records to ED visit records (N = 1383 incident ED visits). The rate of pedestrians treated in North Carolina EDs for their injuries was 13.6 ED visits per 100,000 person years. For pedestrian injuries treated in North Carolina EDs, rates (per 100,000 person years in parentheses) were higher among men (15.5) and Black pedestrians (22.7) than women (10.6) and White pedestrians (8.2). Sociodemographic characteristics associated with serious injuries included age, sex, race/ethnicity, and expected source of payment for the ED visit. Crash characteristics associated with serious injuries included posted speed limit, ambient light, number of lanes, and striking vehicle type. The study involved the use of secondary data, not collected specifically for pedestrian injury surveillance. Pedestrian injuries and fatalities place a considerable burden on the population of North Carolina, especially among persons of color and older adults. Injury prevention programs are actively addressing this problem, but more needs to be done.

The impact of the COVID-19 pandemic on the utilization of emergency department services for the treatment of injuries.

ContextThe global COVID-19 pandemic has had a major impact on the utilization of healthcare services; however, the impact on population-level emergency department (ED) utilization patterns for the treatment of acute injuries has not been fully characterized.ObjectiveThis study examined the frequency of North Carolina (NC) EDs visits for selected injury mechanisms during the first eleven months of the COVID-19 pandemic.MethodsData were obtained from the NC Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT), NC's legislatively mandated statewide syndromic surveillance system for the years 2019 and 2020. Frequencies of January – November 2020 NC ED visits were compared to frequencies of 2019 visits for selected injury mechanisms, classified according to International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) injury diagnosis and mechanism codes.ResultsIn 2020, the total number of injury-related visits declined by 19.5% (N = 651,158) as compared to 2019 (N = 809,095). Visits related to motor vehicle traffic crashes declined by a greater percentage (29%) and falls (19%) declined by a comparable percentage to total injury-related visits. Visits related to assault (15%) and self-harm (10%) declined by smaller percentages. Medication/drug overdose visits increased (10%), the only injury mechanism studied to increase during this period.ConclusionBoth ED avoidance and decreased exposures may have contributed to these declines, creating implications for injury morbidity and mortality. Injury outcomes exacerbated by the pandemic should be addressed by timely public health responses.

Emergency department visits among patients transported by law enforcement officers.

Law enforcement officers frequently encounter people with health conditions. We sought to estimate the rates, diagnoses, and characteristics of emergency department (ED) visits among patients transported directly by law enforcement. We analyzed statewide North Carolina Emergency Department data for adults, aged 18+ years, from 2009 to 2016. We estimated transport rates using census data; categorized primary ED diagnoses into 13 major and 8 substituent categories; compared county transport rates by rurality; and examined patient characteristics. There were 136,240 patients transported by law enforcement; annual rates increased from 186.9 (per 100,000 adult residents) in 2009 to 279.2 in 2016. Among visits, 67.7% were among men, the median age was 37 years, and 20.4% resulted in a hospital admission. Most common primary diagnoses were Mental Health Diagnoses (43.1%)-including Schizophrenia and other Psychotic Disorders (7.6%), Mood Disorders (9.7%), and Alcohol and Substance Use (10.7%)-followed by Injury and Poisoning (12.4%) and Circulatory conditions (4.1%). Involuntary commitments constituted 22% of all visits. The median transport rate in rural counties, 291.1, was 2 times that of large metro counties, 145.1. The visit rate increased by nearly 50% during the study period, with the highest rates in rural counties. Many transports were for Mental Illness and involuntary commitments. The relatively common occurrence of law enforcement transports suggests the need for greater research to understand factors influencing law enforcement transport decisions, the impact of these transports on patient health and safety, and the repercussions on patient care of a growing officer presence in EDs.

Selected characteristics and injury patterns by age group among pedestrians treated in North Carolina emergency departments

Objective The objective of this study was to describe pedestrian demographic characteristics, crash characteristics, selected health outcomes, and injury patterns by age using linked North Carolina (NC) crash–emergency department (ED) visit data for the period October 1, 2010, to September 30, 2015. Methods This was a descriptive epidemiologic study. To examine both crash and health outcomes, NC pedestrian crash records were linked to statewide NC ED visit records using hierarchical deterministic methods. Pearson chi-square tests were used to compare the frequencies of pedestrians treated in NC EDs by sex, race/ethnicity, crash location, rurality, estimated driver speed at impact, ambient light, hospitalization/death, location of injury, and nature of injury, stratified by the following age groups: 0–14, 15–24, 25–64, and ≥65 years. Results Most pedestrians treated in NC EDs were male (57.5%), except among adults ≥65 years old (47.5%). Over half of all injured pedestrians aged 0–14 (52.6%) and 15–24 (50.5%) years were Black/African American, and 70.8% of injured pedestrians ≥65 years were white. Among pedestrians aged 25–64 years, no single racial/ethnic group was the majority. Though most pedestrians were injured on trafficways (71.7%) and at speeds ≤35 mph (80.1%), adults ≥65 years were less likely to be involved in on-trafficway crashes (51.0%) and pedestrians aged 15–24 years were more likely to be involved in >35 mph crashes (22.9%) compared to other age groups. Most pedestrians were injured under daylight conditions (56.9%). Regarding selected health outcomes, the highest frequency of hospitalization/death was for pedestrians aged ≥65 years (26.3%), compared to those aged 0–14 years (18.8%) and 15–64 years (12.4%). In terms of location of injury, 0- to 14-year-olds had the highest proportion of head injuries (39.5%), and adults ≥65 years of age had the highest proportion of spinal column/vertebral column (12.6%) and upper extremity injuries (33.2%). For nature of injury, 0- to 14-year-olds had the highest proportion of traumatic brain injuries (11.4%) and superficial wounds and contusions (62.8%). Adults aged ≥65 years had the highest proportion of open wounds/amputations and fractures (16.1%). Adults aged 25–64 years had the highest proportion of strains/sprains/dislocations (18.7%). Conclusions There were considerable differences in demographic characteristics, crash characteristics, frequency of hospitalization/death, and injury patterns by age group. It is important to design streets and implement transportation policies and programs that improve safety for all pedestrians.

Optimization of Linkage between North Carolina EMS and ED Data: EMS Naloxone Cases

Optimization of Linkage between North Carolina EMS and ED Data: EMS Naloxone Cases

Identifying Emergency Department Care in the Year Prior to Suicide Death

ObjectiveTo identify potential emergency department (ED) visits prior to suicide deaths in North Carolina (NC) and describe pre-suicide care-seeking in EDs.IntroductionSuicide is a leading cause of mortality in the United States, causing about 45,000 deaths annually1. Research suggests that universal screening in health care settings may be beneficial for prevention, but few studies have combined detailed suicide circumstances with ED encounter data to better understand care-seeking behavior prior to death.MethodsThis project used data from the NC Violent Death Reporting System (NC-VDRS), a repository of all violent deaths in North Carolina, and the NC Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT), which includes all visits to 24/7, acute-care, civilian, hospital-affiliated EDs in NC. We identified all suicide deaths recorded in the NC-VDRS between 1/1/2014 – 9/30/2015, and all NC DETECT ED visits between 1/1/2013 – 9/30/2015. Descriptive analyses were conducted for each data source, separately. For all NC-VDRS suicides, we identified ED visits likely made by the same individual within the 48 hours prior to death. We identified these ED visits based on the variables arrival date, sex, date of birth (DOB), county of residence, and a chief complaint consistent with self-harm/suicide; we refer to these as suicide-related ED visits. For the subset of NC-VDRS suicides with a suicide-related ED visit, made within 48 hours of death, we identified all ED visits associated with the decedent made to the same facility or healthcare system in the year prior to death. We then categorized the pre-suicide ED visits according to the primary reason healthcare was sought by the patient (e.g. mental health problem, substance abuse/overdose, pain, etc.).ResultsFrom 1/1/2014-9/30/2015, there were 2,953 suicide deaths captured in NC-VDRS data; 2,435 (82%) of these included DOB. Between 1/1/2013 – 9/30/2015, there were 13,463,345 ED visits captured by NC DETECT; 12,884,596 (96%) included DOB. For 961 suicides (32.5%), no ED visit was found with the same DOB, sex and county of residence. For the remaining 1,474 suicides, at least one ED visit was found for a patient with the same DOB, sex and county of residence and occurring on or before the date of death. For 406 suicides, a suicide-related ED visit was identified; 122 of these patients had at least one additional ED visit in the year prior to death. A total of 516 ED visits were identified for these 122 suicides, including the suicide-related ED visit, with an average of 3.2 (range: 1-25) visits.ConclusionsFor nearly a third of NC-VDRS suicides, no indication of any ED visit by a patient with the same DOB, sex, and county of residence was found. While it is likely we were unable to identify all ED visits prior to suicide, the findings from this pilot study suggest many suicide victims did not seek NC ED care in the year prior to death. Overall, a suicide-related ED visit was found for only 13.7% of NC suicides in the study period, indicating that most people who self-inflict fatal injury do not make it to an ED for care prior to death. ED visits in the year prior to death by suicide indicated a variety of diagnoses, but rarely depression or suicidality; this suggests that universal screening at ED visits would have been necessary to identify any suicide risk present. Limitations of this study include that we were unable to directly link suicide deaths and ED visits using patient identifiers. Additionally, we relied solely on secondary data used for public health surveillance and, therefore, had no access to medical record information that may have documented depression or suicidal ideation that was not coded as such. Findings from this pilot study can inform future work to identify ED visits prior to suicide.References1National Center for Injury Prevention and Control. Suicide Rising Across the US. Vital Signs, June 2018; Atlanta, GA: Centers for Disease Control and Prevention 2018. https://www.cdc.gov/vitalsigns/suicide/. Accessed Sept 25, 2018.

Controlled Substance Use Among Psychiatric Patients in a Rural North Carolina Emergency Department.

IntroductionEmergency department (ED) visits for mental health and substance use disorders have been on the rise, with substance use disorders frequently coexisting with mental health disorders. This study evaluated substances commonly used/abused by patients presenting to the ED of a rural, regional medical center with subsequent admission for mental health treatment in Robeson County, North Carolina.MethodsThis retrospective, single-center study was approved by the Southeastern Health Institutional Review Board. We reviewed medical records of psychiatric patients presenting to the ED with ultimate admission to the inpatient psychiatric unit between January 1, 2016, and June 30, 2016. Frequencies of controlled substances testing positive on urine drug and alcohol screenings in admitted patients were obtained and analyzed. We also made ethnic and gender comparisons.ResultsA total of 477 patients met inclusion criteria. The percentage of patients testing positive were as follows: tetrahydrocannabinol (THC) (40%); cocaine (28.7%); alcohol (15.1%); benzodiazepines (13%); opiates (9.6%); amphetamines (2.9%); barbiturates (2.3%); and methadone (0.8%). A relatively higher proportion of patients tested positive for THC than any other substance (p≤.0002). We found statistically significant differences for gender (p=.0004) and ethnicity (p<.0001) compositions regarding substance use/abuse.ConclusionThe majority of admitted psychiatric patients in this study tested positive for at least one controlled substance. The two substances that most often returned positive on the urine drug screen test in our sample were THC (marijuana) and cocaine. These findings may provide insight into concomitant substance abuse and psychiatric disorders, which could instigate public policy development of preventative health initiatives that explore the relationship between controlled substance use/abuse and mental health disorders in rural counties like Robeson County.

Beyond Mortality: Violent Injury Surveillance Using NC DETECT ED Visit Data

ObjectiveTo describe violent injuries treated in North Carolina (NC) emergency departments (EDs) and compare to deaths reported by the NC Violent Death Reporting System (NC-VDRS).IntroductionViolence-related injuries are a major source of morbidity and mortality in NC. From 2005-2014, suicide and homicide ranked as NC’s 11th and 16th causes of death, respectively. In 2014, there were 1,932 total violent deaths, of which 1,303 were due to suicide (67%), 536 due to homicide (28%), and 93 due to another mechanism of violent injury (5%). These deaths represent a fraction of the total number of violence-related injuries in NC.1 This study examined ED visit data captured by NC DETECT to identify and describe violent injuries treated in NC EDs and compare/contrast with fatalities reported by NC-VDRS.MethodsThis descriptive epidemiologic study included all NC ED visits made to a 24/7, acute-care, civilian, hospital-affiliated ED from January 1, 2012 – September 30, 2015 reported to NC DETECT with an injury mechanism code indicating a violent injury due to one of the following injury types: self-harm, assault, legal intervention, or unintentional firearm. In addition, ED visits of an undetermined intent were separately examined. Violence-related NC ED visits were classified according to definitions developed by the National Center for Injury Prevention and Control for WISQARS™.2 Descriptive analyses consisted of counts, percentages, and incidence rates.ResultsFrom January 1, 2012-September 30, 2015, there were 182,385 violence-related NC ED visits captured by NC DETECT (492.1/100,000 person-years). The most common type of violent injury treated in NC EDs was assault, with 132,550 visits (357.6/100,000 person-years), followed by self-inflicted injury (41,455 visits; 111.8/100,000 person-years), unintentional firearm-related injury (5,940 visits; 15.9/100,000 person-years), and legal intervention (2,440 visits; 6.6/100,000 person-years). Twelve percent of all violence-related NC ED visits were made by children 0-17 years of age (21,876 ED visits). There were an additional 20,867 NC ED visits for injuries of an undetermined intent.Males visited a NC ED for treatment of violent injuries more often than females (550.3 versus 436.2 visits/100,000 person-years, respectively). Young adults 20-24 years of age had the highest rate of violence-related NC ED visits (1,242.9), followed by individuals aged 25-34 (997.4), 15-19 (935.3), 35-44 (635.6) and 45-54 (461.3) (visits/100,000 person-years in parentheses). Among violence-related NC ED visits, the most common mechanism of injury was struck by/against an object or person 35.0%), the most common mode of transport to the ED was private transportation (37.7%), the most common discharge disposition was discharged home from the ED (77.7%), the most common expected source of payment was self-pay (37.5%), and the most common time of visit was the evening hours of 6-11 PM (33.6%).Violence-related ED visits differed from violence-related deaths reported by the NC-VDRS. On average, there were 25 times more annual violence-related ED visits than deaths. Table 1 displays the average annual number of violence-related ED visits and deaths stratified by type of violent injury. The proportion of ED visits due to assault was greater than the proportion of deaths due to homicide, while the proportion of injuries/deaths attributable to self-inflicted injury/suicide was higher among fatalities. A comparison of the self-inflicted injury and suicide data shows that women have a higher rate of ED visits for self-harm while men have a higher rate of suicide (data not shown).ConclusionsViolence-related injuries are a common source of morbidity and mortality in NC. The annual number of violence-related ED visits exceeds the number of violence-related deaths, 25 to 1. Because there are important differences between violent injury leading to ED visits and fatalities, comparing NC DETECT surveillance with NC-VDRS fatality data expands our understanding of violent injury in NC and better informs prevention efforts.

Informing Public Health Prevention in NC Using Falls Surveillance Data

ObjectiveTo describe how a successful partnership between state public health and a university organization has used epidemiologic data, such as mortality, hospital discharge, and emergency department (ED) visit data, to inform falls prevention activities in North Carolina (NC).IntroductionFalls are a leading cause of fatal and nonfatal injury in NC. As the size of the older adult population is predicted to increase over the next few decades, it is likely that the incidence of falls-related morbidity and mortality will increase in tandem.1 In order to address this public health emergency, the Injury and Violence Prevention Branch (IVPB) of the NC Division of Public Health has partnered with the Carolina Center for Health Informatics (CCHI) in the Department of Emergency Medicine at the University of North Carolina at Chapel Hill to perform falls surveillance activities. This abstract describes some of the specific research and surveillance activities currently ongoing in NC.MethodsIVPB developed the Special Emphasis Report (SER) on Fall Injuries among Older Adults, 2005-2014 to describe the demographic characteristics and trends of falls-related mortality and hospitalization among adults 65 and older, associated costs of falls-related injury, and current falls prevention activities in NC. The NC SER was based on the Centers for Disease Control and Prevention’s Injury SER template, a tool designed to facilitate the dissemination of injury data for public health action.While the SER focused primarily on falls among adults &gt;65 years of age, CCHI was interested in using ED visit data to identify the age at which falls morbidity begins to increase as a means of informing prevention activities to be implemented before the advent of an injurious fall. Therefore, CCHI performed a descriptive epidemiologic study using ED visit data collected by NC DETECT. CCHI identified all NC ED visits from January 1, 2010 – December 31, 2014 that met the National Center for Injury Prevention and Control definition of a fall of unintentional intent.2 During 2010-2014, NC DETECT captured ED visit data from all 125 24/7, acute care, hospital-affiliated, civilian EDs and over 99% of all ED visits in the state.3ResultsAnalysis for the SER found that falls-related death rates increased by 43.1% from 2005 (47.0 per 100,000) to 2014 (67.3 per 100,000), with the greatest increase among males (61.3%) and adults 85 and older (74.4%). Conversely, rates of non-fatal hospitalization remained relatively stable and were 1.6 times higher among females than males in 2014 (84.0 and 56.8 per 100,000 respectively). Projected lifetime costs associated with falls among NC older adults was approximately $1.4 billion in 2014.NC DETECT captured 986,024 ED visits during the period 2010-2014 among adults &gt;20 years of age (27.4 ED visits/1,000 person-years; 95% CI: 27.4-27.5). Throughout the adult lifespan, fall incidence rates in women (33.0 ED visits/1,000 person-years; 95% CI: 32.9-33.1) exceeded those in men (21.3 ED visits/1,000 person-years; 95% CI: 21.3-21.4). Starting at age 45, fall rates in women continued to exceed fall rates in men, climbing each year, while rates in men remained stable until after age 65. These results suggest that the risk of having an injurious fall may increase before age 65, particularly among women.Due to the public health implications of the results obtained by IVPB and CCHI, both organizations are working closely to ensure that relevant information reaches a wide net of potential partners in the effort to reduce falls morbidity and mortality. To date, IVPB and CCHI have collaborated on generating fact sheets and short reports available to the public, syndromic surveillance custom event reports available to authorized users, and presenting information to local, state, and national partners.ConclusionsFalls morbidity and mortality are major concerns for the state of NC and the country as a whole. Falls surveillance benefits from the collaboration of governmental and university organizations with community partners. For example, when CCHI identified an increase in falls incidence in middle age, and, therefore, the potential need to begin falls risk assessment activities at ages &lt; 65, particularly among women, NC DPH had the resources to communicate these results to relevant local and state programs and organizations.

Snakebites Treated in North Carolina Emergency Departments, October 2013–September 2015

North Carolina (NC) is home to more than 30 species of indigenous venomous and nonvenomous snakes. Snakebites can cause debilitating and potentially fatal injuries. However, there is a lack of current information available describing the incidence of snakebites in NC. Therefore, we performed this study of snakebites treated in NC emergency departments (EDs) using the statewide syndromic surveillance system, the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT). This was a descriptive epidemiologic study characterizing NC ED visits collected by NC DETECT between October 1, 2013 and September 30, 2015 with an assigned International Classification of Diseases, 9th Revision, Clinical Modification code or keyword indicating a snakebite. Over the 2-year period, the absolute count of snakebite-related ED visits was 2080 visits with an incidence rate of 10.4 visits per 100 000 person-years (95% confidence interval: 10.0-10.9). The frequency of snakebite was highest during the summer months and evening hours. Men had higher incidence rates of snakebite-related ED visits than women, and residents of the Coastal Plain geographic region of NC had higher incidence rates than persons in other regions. The current study indicated that snakebites are common injuries treated at NC EDs, with a strong seasonal and geographic component. Additional research is needed to further characterize the circumstances associated with snakebites for the development of preventive measures and public health education.

Reducing Emergency Department Visits for Acute Gastrointestinal Illnesses in North Carolina (USA) by Extending Community Water Service.

Background:Previous analyses have suggested that unregulated private drinking water wells carry a higher risk of exposure to microbial contamination than regulated community water systems. In North Carolina, ~35% of the state’s population relies on private wells, but the health impact associated with widespread reliance on such unregulated drinking water sources is unknown.Objectives:We estimated the total number of emergency department visits for acute gastrointestinal illness (AGI) attributable to microbial contamination in private wells in North Carolina per year, the costs of those visits, and the potential health benefits of extending regulated water service to households currently relying on private wells for their drinking water.Methods:We developed a population intervention model using 2007–2013 data from all 122 North Carolina emergency departments along with microbial contamination data for all 2,120 community water systems and for 16,138 private well water samples collected since 2008.Results:An estimated 29,400 (95% CI: 26,600, 32,200) emergency department visits per year for acute gastrointestinal illness were attributable to microbial contamination in drinking water, constituting approximately 7.3% (95% CI: 6.6, 7.9%) of all AGI-related visits. Of these attributable cases, 99% (29,200; 95% CI: 26,500, 31,900) were associated with private well contamination. The estimated statewide annual cost of emergency department visits attributable to microbiological contamination of drinking water is 40.2 million USD (95% CI: 2.58 million USD, 193 million USD), of which 39.9 million USD (95% CI: 2.56 million USD, 192 million USD) is estimated to arise from private well contamination. An estimated 2,920 (95% CI: 2,650, 3,190) annual emergency department visits could be prevented by extending community water service to 10% of the population currently relying on private wells.Conclusions:This research provides new evidence that extending regulated community water service to populations currently relying on private wells may decrease the population burden of acute gastrointestinal illness.Citation:DeFelice NB, Johnston JE, Gibson JM. 2016. Reducing emergency department visits for acute gastrointestinal illnesses in North Carolina (USA) by extending community water service. Environ Health Perspect 124:1583–1591; http://dx.doi.org/10.1289/EHP160

PHS18 - Prevalence and burden of Ankle injuries in North Carolina emergency departments

In the US, an estimated 2 million ankle injuries occurred in 2012 costing $4.5 billion, associated with approximately 1.6 million physician office visits and 8000 hospitalizations. We examined the prevalence and burden of ankle injuries in North Carolina emergency departments. Using a cross-sectional study of the 2010 NC Emergency Department Database, we identified ankle injury patients (ICD-9-CM: 845.xx). Patients were categorized into two groups: lateral and non-lateral ankle injury (medial, high, and unknown). Frequencies and percentages for patient demographics were compared using bivariate statistics. Multivariable analyses were used to assess the outcomes associated with type of ankle injury while adjusting for confounding, including a generalized linear model for charges and logistic regression for use of X-ray. The study contained a sample of 35,729 patients including 32,651 (91%) lateral and 3,078 (9%) non-lateral ankle injury events. Most (66%) were below the age of 35 and female (57%). The mean total charge for an ankle injury event was $1,057. Patients with non-lateral ankle injuries had higher proportion of X-rays than lateral [1145 (37%), 7323 (22%)] but more events with total charges below $1500 (94% and 87%) respectively. However, lateral ankle injuries were associated with a $52 greater charge than non-lateral. Additionally, non-lateral ankle injuries were 2 times more likely to have an X-ray than lateral (OR= 2.00, 95% CI: 1.86-2.18). Patients with private insurance were 20% less likely to have an X-ray than Medicare patients (OR= 0.80, 95% CI: 0.71-0.90). Females below 35 years of age represent higher proportion of ankle injury emergency room visits than males. Older patients are more likely to receive X-rays but are associated with lower charges because of Medicare coverage. Older patients are more likely to have non-lateral ankle injuries. Further research is required to understand cost drivers in both groups.

Prehospital care of traumatic brain injury in North Carolina.

Traumatic brain injury results in more than 140,000 visits to North Carolina emergency departments annually. North Carolina first implemented a systematically organized approach to brain injury management in 1967, and the state's emergency medical services community continues to optimize patient care by incorporating evolving knowledge into protocols and procedures.

Utilization of Emergency Department Data for Drug Overdose Surveillance in North Carolina

The United States is in the midst of a drug overdose epidemic, primarily due to opioid analgesics. Emergency department data are an important source of morbidity data for public health surveillance. This population-based study will describe visits to North Carolina emergency departments for drug, and more specifically, opioid overdoses.