Emergency Medicine Commons^™

Impact Of Risk-Based Sexually Transmitted Infection Screening In The Emergency Department, Fahd A Ahmad, Kayleigh Fischer, Hongjie Gu, Thomas C Bailey, Donna B Jeffe, Christopher R Carpenter, Philip R O Payne

Faculty, Staff and Student Publications

OBJECTIVES: Sexually transmitted infections (STIs), including chlamydia, gonorrhea, and human immunodeficiency virus (HIV) pose a significant health burden in adolescents. Many adolescents receiving care in the emergency department (ED) are in need of testing, regardless of their chief complaint. Our objective was to determine whether an electronic, risk-based STI screening program in our ED was associated with an increase in STI testing among at-risk adolescents.

METHODS: We conducted a retrospective cohort analysis of patient outcomes in our pediatric ED after integrating an Audio-enhanced Computer-Assisted Self-Interview (ACASI) as standard of care. It obtained a focused sexual history and generated STI testing …

Challenges Created By The Covid-19 Pandemic: Pediatric Emergency Medicine And Disaster Management Perspectives, Thomas E Tanner, Nichole R Davis, Brent D Kaziny, Erin E Endom, Esther M Sampayo

Faculty, Staff and Students Publications

OBJECTIVE: The coronavirus disease (COVID-19) pandemic has presented unique challenges to pediatric emergency medicine (PEM) departments. The purpose of this study was to identify these challenges and ascertain how centers overcame barriers in creating solutions to continue to provide high-quality care and keep their workforce safe during the early pandemic.

METHODS: This is a qualitative study based on semi-structured interviews with physicians in leadership positions who have disaster or emergency management experience. Participants were identified through purposive sampling. Interviews were recorded and transcribed electronically. Themes and codes were extracted from the transcripts by 2 independent coders. Constant comparison analysis was …

Promotion Of Covid-19 Va(X)Ccination In The Emergency Department-Procovaxed: Study Protocol For A Cluster Randomized Controlled Trial., Robert M Rodriguez, Kelli O'Laughlin, Stephanie A Eucker, Anna Marie Chang, Kristin L. Rising, Graham Nichol, Alena Pauley, Hemal Kanzaria, Alexzandra Gentsch, Cindy Li, Herbie Duber, Jonathan Butler, Vidya Eswaran, Dave Glidden

Department of Emergency Medicine Faculty Papers

Background: We conducted in-depth interviews to characterize reasons for COVID-19 vaccine hesitancy in emergency department (ED) patients and developed messaging platforms that may address their concerns. In this trial, we seek to determine whether provision of these COVID-19 vaccine messaging platforms in EDs will be associated with greater COVID-19 vaccine acceptance and uptake in unvaccinated ED patients.

Methods: This is a cluster-randomized controlled trial (RCT) evaluating our COVID-19 vaccine messaging platforms in seven hospital EDs (mix of academic, community, and safety-net EDs) in four US cities. Within each study site, we randomized 30 1-week periods to the intervention and 30 …

Emergency Department Antimicrobial Use In A Low-Resource Setting: Results From A Retrospective Observational Study At A Referral Hospital In Liberia, Sojung Yi, Anu Ramachandran, Lane Epps, Alex Mayah, Taylor W Burkholder, Michael Senyu Jaung, Ahson Haider, Paul Whesseh, John Shakpeh, Kayla Enriquez, Corey Bills

Faculty, Staff and Students Publications

OBJECTIVE: Data on antimicrobial use in low-income and middle-income countries (LMICs) remain limited. In Liberia, the absence of local data impedes surveillance and may lead to suboptimal treatment, injudicious use and resistance against antimicrobials. This study aims to examine antimicrobial prescribing patterns for patients in the emergency department (ED) of a large Liberian public hospital. Secondarily, this prescribing was compared with WHO prescribing indicators.

DESIGN: Retrospective observational study.

SETTING: An adult ED of a large public hospital in Monrovia, Liberia.

PARTICIPANTS: A total of 1082 adult patients (>18 years of age) were recorded in the ED, from 1 January …

Multidisciplinary Care For Refractory Pediatric Functional Abdominal Pain Decreases Emergency And Inpatient Utilization, Andrew S Chu, Laura Torres, Grace Kao, Caroyl Gilbert, Evelyn Caro Monico, Bruno P Chumpitazi

Faculty, Staff and Students Publications

Children with refractory functional abdominal pain (FAP) experience functional disability and may utilize emergency department (ED) and/or inpatient services. Whether multidisciplinary programs which help care for children with refractory FAP affect acute healthcare utilization is unknown. A retrospective chart review of children initially evaluated by the outpatient Multidisciplinary Abdominal Pain Program (MAPP) from October 2016 to May 2019 was completed. Patient characteristics and number of ED visits and hospitalizations for abdominal pain in the year prior to versus year after MAPP evaluation were captured. Thirty-eight children (ages 9-17 years [median 13 years]) were included. The median number of ED visits/patient/year …

Validation Of An Electronic Trigger To Measure Missed Diagnosis Of Stroke In Emergency Departments, Viralkumar Vaghani, Li Wei, Umair Mushtaq, Dean F Sittig, Andrea Bradford, Hardeep Singh

Faculty, Staff and Students Publications

OBJECTIVE: Diagnostic errors are major contributors to preventable patient harm. We validated the use of an electronic health record (EHR)-based trigger (e-trigger) to measure missed opportunities in stroke diagnosis in emergency departments (EDs).

METHODS: Using two frameworks, the Safer Dx Trigger Tools Framework and the Symptom-disease Pair Analysis of Diagnostic Error Framework, we applied a symptom-disease pair-based e-trigger to identify patients hospitalized for stroke who, in the preceding 30 days, were discharged from the ED with benign headache or dizziness diagnoses. The algorithm was applied to Veteran Affairs National Corporate Data Warehouse on patients seen between 1/1/2016 and 12/31/2017. Trained …

An Assessment Of The Social Determinants Of Health In An Urban Emergency Department, Edgardo Ordonez, Katherine Dowdell, Natasha M Navejar, Deepa Dongarwar, Aya Itani, Hamisu M Salihu

Faculty, Staff and Students Publications

INTRODUCTION: Social determinants of health (SDOH) have significant impacts on patients who seek care in the emergency department (ED). We administered a social needs screening tool and needs assessment survey to assess SDOH and evaluate for trends in the population of patients visiting our ED.

METHODS: A survey was distributed via convenience sampling to adult ED patients to capture self-reported demographic information and data about social needs. We categorized the questions related to SDOH based on the International Classification of Diseases, Tenth Revision, Clinical Modification coding format and created a composite variable called "SDOH Strata" based on the SDOH Index …

Goals-Of-Care Course For Emergency Physicians During The Covid-19 Pandemic., Mari Siegel, Erica Westlake

Department of Emergency Medicine Faculty Papers

BACKGROUND

COVID-19 increased the need for goals of care (GOC) discussions in the Emergency Department (ED). Many Emergency Physicians (EPs) report no formal training in holding GOC discussions. COVID-19 created unique teaching challenges given social distancing requirements.

METHODS

Eight teaching sessions were held using Zoom in March and April at an urban institution in the United States. Sessions were limited to 4-8 participants. They were comprised of a 30-minute lecture and 15 minutes of role-playing, in which providers read scripts to practice communication skills. The lecture introduced vocabulary and models to shape GOC discussions. Participants were invited to complete an …

Barriers To Healthy Births At Nigerian Hospitals, Caroline Johnston

Senior Theses

Maternal mortality is a problem everywhere, but it is especially dangerous in Nigeria where the average woman experiences pregnancy six times during her lifetime (Population Reference Bureau, 2001). Many researchers focus on the medical complications associated with labor, such as hemorrhage, eclampsia, or infection. Although these birth complications are the direct sources of maternal death, it is also important to recognize how maternal mortality is a multifaceted issue influenced by local cultural groups, religions, politics, poverty level and the absence of basic infrastructures. Although maternal mortality is interconnected with social and geographical elements, my paper concentrates on Nigerian hospitals and …

Improving Emergency Department Quality Of Care, Carmen Smith

Doctor of Nursing Practice Projects

Emergency department (ED) crowding can cause an extended length of stay (LOS) and high rates of patients who leave without being seen (LWBS). This quality improvement ED project sought to reduce LOS and LWBS by implementing a triage (PIT) team. The design included an outcomes evaluation with available data and a staff pre and posttest. Length of stay and LWBS rates were compared before and after implementation. Results indicated a reduction in the average LOS and LWBS rates for the 30 days of project implementation compared to the 30 days before the project initiation. The overall goal of the PIT …

Acute Hyperkalemia In The Emergency Department: A Summary From A Kidney Disease: Improving Global Outcomes Conference, Gregor Lindner, Emmanuel A Burdmann, Catherine M Clase, Brenda R Hemmelgarn, Charles A Herzog, Jolanta Małyszko, Masahiko Nagahama, Roberto Pecoits-Filho, Zubaid Rafique, Patrick Rossignol, Adam J Singer

Faculty, Staff and Students Publications

Hyperkalemia is a common electrolyte disorder observed in the emergency department. It is often associated with underlying predisposing conditions, such as moderate or severe kidney disease, heart failure, diabetes mellitus, or significant tissue trauma. Additionally, medications, such as inhibitors of the renin-angiotensin-aldosterone system, potassium-sparing diuretics, nonsteroidal anti-inflammatory drugs, succinylcholine, and digitalis, are associated with hyperkalemia. To this end, Kidney Disease: Improving Global Outcomes (KDIGO) convened a conference in 2018 to identify evidence and address controversies on potassium management in kidney disease. This review summarizes the deliberations and clinical guidance for the evaluation and management of acute hyperkalemia in this setting. …

Development Of The Uncertainty Communication Checklist: A Patient-Centered Approach To Patient Discharge From The Emergency Department, Kristin L. Rising, Rhea E. Powell, Kenzie A Cameron, David H Salzman, Dimitrios Papanagnou, Amanda Doty, Lori Latimer, Katherine Piserchia, William C Mcgaghie, Danielle M Mccarthy

Department of Emergency Medicine Faculty Papers

Clear communication with patients upon emergency department (ED) discharge is important for patient safety during the transition to outpatient care. Over one-third of patients are discharged from the ED with diagnostic uncertainty, yet there is no established approach for effective discharge communication in this scenario. From 2017 to 2019, the authors developed the Uncertainty Communication Checklist for use in simulation-based training and assessment of emergency physician communication skills when discharging patients with diagnostic uncertainty. This development process followed the established 12-step Checklist Development Checklist framework and integrated patient feedback into 6 of the 12 steps. Patient input was included as …

Myocardial Dysfunction After Out-Of-Hospital Cardiac Arrest: Predictors And Prognostic Implications., Yuan Yao, Nicholas James Johnson, Sarah Muirhead Perman, Vimal Ramjee, Anne Victoria Grossestreuer, David Foster Gaieski

Department of Emergency Medicine Faculty Papers

We aim to determine the incidence of early myocardial dysfunction after out-of-hospital cardiac arrest, risk factors associated with its development, and association with outcome. A retrospective chart review was performed among consecutive out-of-hospital cardiac arrest (OHCA) patients who underwent echocardiography within 24 h of return of spontaneous circulation at three urban teaching hospitals. Our primary outcome is early myocardial dysfunction, defined as a left ventricular ejection fraction < 40% on initial echocardiogram. We also determine risk factors associated with myocardial dysfunction using multivariate analysis, and examine its association with survival and neurologic outcome. A total of 190 patients achieved ROSC and underwent echocardiography within 24 h. Of these, 83 (44%) patients had myocardial dysfunction. A total of 37 (45%) patients with myocardial dysfunction survived to discharge, 39% with intact neurologic status. History of congestive heart failure (OR 6.21; 95% CI 2.54-15.19), male gender (OR 2.27; 95% CI 1.08-4.78), witnessed arrest (OR 4.20; 95% CI 1.78-9.93), more than three doses of epinephrine (OR 6.10; 95% CI 1.12-33.14), more than four defibrillations (OR 4.7; 95% CI 1.35-16.43), longer duration of resuscitation (OR 1.06; 95% CI 1.01-1.10), and therapeutic hypothermia (OR 3.93; 95% CI 1.32-11.75) were associated with myocardial dysfunction. Cardiopulmonary resuscitation immediately initiated by healthcare personnel was associated with lower odds of myocardial dysfunction (OR 0.40; 95% CI 0.17-0.97). There was no association between early myocardial dysfunction and mortality or neurological outcome. Nearly half of OHCA patients have myocardial dysfunction. A number of clinical factors are associated with myocardial dysfunction, and may aid providers in anticipating which patients need early diagnostic evaluation and specific treatments. Early myocardial dysfunction is not associated with neurologically intact survival.

When Disaster Strikes: A Training Intervention To Improve Nurses' Confidence And Preparedness For The Surge, Nichole M. Weber

Evidence-Based Practice Project Reports

There has been an exponential rise in mass casualty incidents (MCI) internationally. These human induced and naturally occurring events have affected over 4.6 billion people, and are not discriminatory to region or community (World Health Organization, 2011). Governing bodies require training and education, but nurses continue to report suboptimal competence and self-reported readiness, and a need for standardized, evidence-based training remains. The purpose if this evidence-based practice project is to authenticate current research supporting implementation of competency-based education, to improve nurses’ self- perceived preparedness and confidence in their ability to respond to MCI. The project results can be utilized for …

Validation Of An Icd Code For Accurately Identifying Emergency Department Patients Who Suffer An Out-Of-Hospital Cardiac Arrest., Shelby K. Shelton, Steve B. Chukwulebe, David F. Gaieski, Benjamin S. Abella, Brendan G. Carr, Sarah M. Perman

Department of Emergency Medicine Faculty Papers

AIM: International classification of disease (ICD-9) code 427.5 (cardiac arrest) is utilized to identify cohorts of patients who suffer out-of-hospital cardiac arrest (OHCA), though the use of ICD codes for this purpose has never been formally validated. We sought to validate the utility of ICD-9 code 427.5 by identifying patients admitted from the emergency department (ED) after OHCA.

METHODS: Adult visits to a single ED between January 2007 and July 2012 were retrospectively examined and a keyword search of the electronic medical record (EMR) was used to identify patients. Cardiac arrest was confirmed; and ICD-9 information and location of return …

A Novel Approach To Addressing An Unintended Consequence Of Direct To Room: The Delay Of Initial Vital Signs., J. Basile, E. Youssef, B. Cambria, J. Chacko, K. Treval, B. Hahn, B. Ardolic

Journal Articles

Introduction: The concept of "direct to room" (DTR) and "immediate bedding" has been described in the literature as a mechanism to improve front-end, emergency department (ED) processing. The process allows for an expedited clinician-patient encounter. An unintended consequence of DTR was a time delay in obtaining the initial set of vital signs upon patient arrival.

Methods: This retrospective cohort study was conducted at a single, academic, tertiary-care facility with an annual census of 94,000 patient visits. Inclusion criteria were all patients who entered the ED from 11/1/15 to 5/1/16 and between the hours of 7 am to 11 pm. During …

Pain Perception In Latino Vs. Caucasian And Male Vs. Female Patients: Is There Really A Difference?, Molly Aufiero, Holly Stankewicz, Shaila Quazi, Jeanne Jacoby, Jill Stoltzfus

Jefferson Health - Northeast Papers (formerly Aria Health Papers)

INTRODUCTION: Pain is a common emergency department (ED) complaint. It is important to understand the differences in pain perception among different ethnic and demographic populations.

METHODS: We applied a standardized painful stimulus to Caucasian and Latino adult patients to determine whether the level of pain reported differed depending on ethnicity (N=100; 50 Caucasian [C], 50 Latino [L] patients) and gender (N=100; 59 female, 41 male). Patients had an initial pain score of 0 or 1. A blood pressure cuff was inflated 20 mm HG above the patient's systolic blood pressure and held for three minutes. Pain scores, using both a …

Implementation Of A Standardized Handoff During Transition Of Care From The Emergency Department To The Intensive Care Unit, Melinda Abbring

Evidence-Based Practice Project Reports

Patient safety and nursing communication are crucial to the nursing handoff during transition of care from the emergency department (ED) to the intensive care unit (ICU). The Institute of Medicine published To Err is Human: Building a Safer Health System (1999) and Crossing the Quality Chasm (2001) highlighting ED handoffs as a safety measure. In 2006, the Joint Commission recognized handoffs with the National Patient Safety Goal 2E. The purpose of this evidence-based practice project was to determine if implementation of a standardized handoff would improve nursing communication and patient safety during transition of care from the ED to the …

Clinician-Performed Bedside Ultrasound In Improving Diagnostic Accuracy In Patients Presenting To The Ed With Acute Dyspnea., Dimitrios Papanagnou, Michael Secko, John Gullett, Michael Stone, Shahriar Zehtabchi

Department of Emergency Medicine Faculty Papers

INTRODUCTION: Diagnosing acute dyspnea is a critical action performed by emergency physicians (EP). It has been shown that ultrasound (US) can be incorporated into the work-up of the dyspneic patient; but there is little data demonstrating its effect on decision-making. We sought to examine the impact of a bedside, clinician-performed cardiopulmonary US protocol on the clinical impression of EPs evaluating dyspneic patients, and to measure the change in physician confidence with the leading diagnosis before and after US.

METHODS: We conducted a prospective observational study of EPs treating adult patients with undifferentiated dyspnea in an urban academic center, excluding those …

Associations Of Emergency Department Length Of Stay With Publicly Reported Quality-Of-Care Measures., Anna Marie Chang, Amber Lin, Rongwei Fu, K. John Mcconnell, Benjamin Sun

Department of Emergency Medicine Faculty Papers

OBJECTIVE: The Institute of Medicine identified emergency department (ED) crowding as a critical threat to patient safety. We assess the association between changes in publicly reported ED length of stay (LOS) and changes in quality-of-care measures in a national cohort of hospitals.

METHODS: Longitudinal analysis of 2012 and 2013 data from the American Hospital Association (AHA) Survey, Center for Medicare and Medicaid Services (CMS) Cost Reports, and CMS Hospital Compare. We included hospitals reporting Hospital Compare timeliness measure of LOS for admitted patients. We used AHA and CMS data to incorporate hospital predictors of interest. We used the method of …

Design And Challenges Of A Randomized Clinical Trial Of Medical Expulsive Therapy (Tamsulosin) For Urolithiasis In The Emergency Department., Pamela K. Burrows, Judd E. Hollander, Allan B. Wolfson, Michael C. Kurz, Lorna Richards, Sara Difiore, Phillip Watts, Nivedita Patkar, Jeremy Brown, Stephen Jackman, Ziya Kirkali, John W. Kusek, Chloe Michel, Andrew C. Meltzer

Department of Emergency Medicine Faculty Papers

Urolithiasis or urinary stone disease has been estimated to affect about 1 in 11 Americans. Patients with urinary stone disease commonly present to the emergency department for management of their acute pain. In addition to providing analgesia, administration of drug (medical expulsive therapy) is often prescribed to assist passage of the urinary stone. In this methodology paper, we describe the design of a prospective, multi-center, randomized, double-blind placebo controlled clinical trial of the alpha-adrenergic blocker, tamsulosin, to evaluate its effectiveness as medical expulsive therapy. In addition, we describe the unique challenges of conducting a trial of this type within the …

The 2016 Academic Emergency Medicine Consensus Conference, "Shared Decision Making In The Emergency Department: Development Of A Policy-Relevant Patient-Centered Research Agenda" Diagnostic Testing Breakout Session Report., Tyler W. Barrett, Kristin L. Rising, M. Fernanda Bellolio, M. Kennedy Hall, Aaron Brody, Kenneth W. Dodd, Mira Grieser, Phillip D. Levy, Ali S. Raja, Wesley H. Self, Gail Weingarten, Erik P. Hess, Judd Hollander

Department of Emergency Medicine Faculty Papers

Diagnostic testing is an integral component of patient evaluation in the emergency department (ED). Emergency clinicians frequently use diagnostic testing to more confidently exclude "worst-case" diagnoses rather than to determine the most likely etiology for a presenting complaint. Increased utilization of diagnostic testing has not been associated with reductions in disease-related mortality but has led to increased overall healthcare costs and other unintended consequences (e.g., incidental findings requiring further workup, unnecessary exposure to ionizing radiation or potentially nephrotoxic contrast). Shared decision making (SDM) presents an opportunity for clinicians to discuss the benefits and harms associated with diagnostic testing with patients …

Practice Characteristics Of Emergency Department Extracorporeal Cardiopulmonary Resuscitation (Ecpr) Programs In The United States: The Current State Of The Art Of Emergency Department Extracorporeal Membrane Oxygenation (Ed Ecmo)., Joseph E. Tonna, Nicholas J. Johnson, John Greenwood, David F. Gaieski, Zachary Shinar, Joseph M. Bellezo, Lance Becker, Atman P. Shah, Scott T. Youngquist, Michael P. Mallin, James Franklin Fair, Kyle J. Gunnerson, Cindy Weng, Stephen Mckellar

Department of Emergency Medicine Faculty Papers

PURPOSE: To characterize the current scope and practices of centers performing extracorporeal cardiopulmonary resuscitation (eCPR) on the undifferentiated patient with cardiac arrest in the emergency department.

METHODS: We contacted all US centers in January 2016 that had submitted adult eCPR cases to the Extracorporeal Life Support Organization (ELSO) registry and surveyed them, querying for programs that had performed eCPR in the Emergency Department (ED ECMO). Our objective was to characterize the following domains of ED ECMO practice: program characteristics, patient selection, devices and techniques, and personnel.

RESULTS: Among 99 centers queried, 70 responded. Among these, 36 centers performed ED ECMO. …

Recurrent Violent Injury: Magnitude, Risk Factors, And Opportunities For Intervention From A Statewide Analysis., Elinore Kaufman, Kristin L. Rising, Md, Ms, Douglas J. Wiebe, David J. Ebler, Marie L. Crandall, M. Kit Delgado

Department of Emergency Medicine Faculty Papers

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 …

Psychiatric Boarding In New Hampshire: Violation Of A Statutory Right To Treatment, James A. Mcclure

The University of New Hampshire Law Review

[Excerpt] "New Hampshire law provides for the involuntary commitment of a patient such as Jane when she is a danger to herself or others as a result of mental illness. The patient has a right to treatment under N.H. Rev. Stat. Ann. § 135-C:1, et seq. Specifically, the patient should receive "adequate and humane treatment" pursuant to an "individual service plan" and "in the least restrictive environment necessary." However, appropriate facilities often are not available for patients waiting in emergency rooms, and patients can become trapped for hours or even days. This phenomenon is called "psychiatric boarding."

New Hampshire is …

Evaluation Of An Emergency Department Lean Process Improvement Program To Reduce Length Of Stay, Marian J. Vermeulen, Therese A. Stukel, Astrid Guttmann, Brian H. Rowe

Dartmouth Scholarship

In recent years, lean principles have been applied to improve wait times in the emergency department (ED). In 2009, an ED process improvement program based on lean methods was introduced in Ontario as part of a broad strategy to reduce ED length of stay and improve patient flow. This study seeks to determine the effect of this program on ED wait times and quality of care. We conducted a retrospective cohort study of all ED visits at program and control sites during 3 program waves from April 1, 2007, to June 30, 2011, in Ontario, Canada. Time series analyses of …

Optimizing Atraumatic Emergency Care In Child Sexual Abuse, Kristen A. Morris

Evidence-Based Practice Project Reports

Child sexual abuse has been identified as a common problem. According to the United States Department of Health and Human Services, in 2010 it was estimated that child victims of sexual abuse accounted for 9.2% (69,368) of the 573,794 children under the age of 12 years who were the victims of maltreatment. The emergency department (ED) is often the point of entry into the healthcare system for child sexual abuse victims, which adds to the resource burden of this department nationwide. The purpose of this evidence-based project was to develop a best-practice screening tool for medical providers to guide the …

Retrospective Analysis Of Youth Evaluated For Suicide Attempt Or Suicidal Ideation In An Emergency Room Setting, Julie Hagedorn, Hatim A. Omar

Pediatrics Faculty Publications

Suicide is the third leading cause of death in adolescents and a major contributor to morbidity in this age group. The objective of this study was to look at the demographics, major stressors and factors leading to attempting suicide as well as the methods of attempted suicide in adolescents admitted to two hospitals in a medium size city. Medical records were reviewed of adolescents admitted to two area hospitals for attempted suicide between 7/1/97-12/31/99. Coroner's data on completed suicide were also reviewed. In the study period a total of 287 persons aged 21 years or under were admitted for attempted …