First name
Cynthia
Last name
Mollen

Title

Workflow Analysis Driven Recommendations for Integration of Electronically-Enhanced Sexually Transmitted Infection Screening Tools in Pediatric Emergency Departments.

Year of Publication

2020

Number of Pages

206

Date Published

2020 Nov 10

ISSN Number

1573-689X

Abstract

<p>Adolescents are disproportionately affected by sexually transmitted infections (STIs). Failure to diagnose and treat STIs in a timely manner may result in serious sequelae. Adolescents frequently access the emergency department (ED) for care. Although ED-based STI screening is acceptable to both patients and clinicians, understanding how best to implement STI screening processes into the ED clinical workflow without compromising patient safety or efficiency is critical. The objective of this study was to conduct direct observations documenting current workflow processes and tasks during patient visits at six Pediatric Emergency Care Applied Research Network (PECARN) EDs for site-specific integration of STI electronically-enhanced screening processes. Workflow observations were captured via TaskTracker, a time and motion electronic data collection application that allows researchers to categorize general work processes and record multitasking by providing a timestamp of when tasks began and ended. Workflow was captured during 118 patient visits across six PECARN EDs. The average time to initial assessment by the most senior provider was 76&nbsp;min (range 59-106&nbsp;min, SD = 43&nbsp;min). Care teams were consistent across sites, and included attending physicians, advanced practice providers, nurses, registration clerks, technicians, and students. A timeline belt comparison was performed. Across most sites, the most promising implementation of a STI screening tool was in the patient examination room following the initial patient assessment by the nurse.</p>

DOI

10.1007/s10916-020-01670-y

Alternate Title

J Med Syst

PMID

33174093

Title

Food Allergy Management at School.

Year of Publication

2020

Number of Pages

395-406

Date Published

2020 05

ISSN Number

1746-1561

Abstract

<p><strong>BACKGROUND: </strong>Approximately 8% of schoolchildren in the United States experience potentially life-threatening food allergies. They must diligently avoid allergenic foods and have prompt access to epinephrine to treat anaphylaxis. These prevention strategies must be sustained without interruption, posing a range of challenges at school.</p>

<p><strong>METHODS: </strong>We conducted semi-structured interviews with 178 participants about their experiences managing food allergies outside the home. Interviews were transcribed and analyzed using an iterative approach in NVivo 10.</p>

<p><strong>RESULTS: </strong>Participants reported highly varied school experiences across the ecological model. They described the need to be proactive and self-sufficient to manage food allergies. Whereas food allergy-related social exclusion was common, participants also described positive peer interactions, including intensive peer engagement and support. They perceived that formal school policies were limited in scope and inconsistently implemented. Prevention-oriented policies were more common in lower grades than in higher grades.</p>

<p><strong>CONCLUSIONS: </strong>Poorly defined and implemented policies disrupted students' social and educational experiences at school, families' relationships with school staff, and, ultimately, the safety and wellbeing of students with allergies. Given the high prevalence of food allergies among children, these findings demonstrate the need for multiple layers of support to facilitate safe, socially inclusive food allergy management at schools.</p>

DOI

10.1111/josh.12885

Alternate Title

J Sch Health

PMID

32124441

Title

Examination of Caregiver Social Factors and Its Influence on Low-Acuity Pediatric Emergency Department Utilization.

Year of Publication

2021

Date Published

2021 Apr 09

ISSN Number

1535-1815

Abstract

<p><strong>OBJECTIVES: </strong>Social factors, such as adverse childhood experiences (ACEs), often influence health care utilization. Our study explores the association between caregiver social factors and low-acuity pediatric emergency department (ED) utilization, with the hypothesis that caregivers with high ACE exposure may use ED services more frequently for low-acuity complaints.</p>

<p><strong>METHODS: </strong>In this case-control study, we performed surveys of caregivers with children aged 1 to 12 years registered for care in our pediatric ED. We defined high utilizers (cases) as those children with ≥3 low-acuity visits in the previous year and low utilizers (controls) as having no prior low-acuity visits, exclusive of the current visit. We compared the proportion of high ACE exposure (≥4 ACEs) between both groups.</p>

<p><strong>RESULTS: </strong>We enrolled 114 cases and 134 controls. We found no association between number of ACEs and odds of being a case or control (ED utilization). Demographics were significantly different between the 2 groups (ie, caregiver age, race, education, and household income); caregiver ACE exposure was high in both groups (20.2% cases vs 29.1% controls with [≥4 ACEs]).</p>

<p><strong>CONCLUSIONS: </strong>Although we did not find an association between caregiver ACEs and frequent low-acuity pediatric ED utilization, our data shed light on the overall prevalence of caregiver ACEs in families that seek care in our pediatric ED, even for the first time. Our findings emphasize the risk of conscious bias that can lead to inaccuracy: assuming that it is only high utilizers who experience social stressors. Future work should explore the contribution of structural inequities that influence caretakers' decisions to seek care for their children for low-acuity complaints, and consider types of interventions that could address and mitigate these inequities.</p>

DOI

10.1097/PEC.0000000000002426

Alternate Title

Pediatr Emerg Care

PMID

33848096

Title

A Survivor-Derived Approach to Addressing Trafficking in the Pediatric ED.

Year of Publication

2020

Date Published

2020 Dec 17

ISSN Number

1098-4275

Abstract

<p><strong>OBJECTIVES: </strong>Our objective was to elicit the perspectives of survivors of child trafficking on addressing trafficking in the pediatric emergency department (ED) and, secondarily, to provide a survivor-derived framework to help pediatric emergency medicine (PEM) providers discuss trafficking with their patients.</p>

<p><strong>METHODS: </strong>We conducted in-depth, semistructured interviews with young adults who experienced trafficking as children and/or as adolescents. In the interviews, we employed a novel video-elicitation method designed by the research team to elicit detailed participant feedback and recommendations on the pediatric ED through an interactive, immersive discussion with the interviewer. A grounded theory approach was employed.</p>

<p><strong>RESULTS: </strong>Seventeen interviews were conducted revealing the following themes, which we present in an integrated framework for PEM providers: (1) fear is a significant barrier; (2) participants do want PEM providers to ask about trafficking, and it is not harmful to do so; (3) PEM providers should address fear through emphasizing confidentiality and privacy and encouraging agency; (4) PEM providers should approach the patient in a direct, sensitive, and nonjudgmental manner; and (5) changes to the ED environment may facilitate the conversation. Suggested wordings and tips from survivors were compiled.</p>

<p><strong>CONCLUSIONS: </strong>Trafficking survivors feel that the pediatric ED can be a place where they can be asked about trafficking, and that when done in private, it is not harmful or retraumatizing. Fear is a major barrier to disclosure in the pediatric ED setting, and PEM providers can mitigate this by emphasizing privacy and confidentiality and increasing agency by providing choices. PEM providers should be direct, sensitive, and nonjudgmental in their approach to discussing trafficking.</p>

DOI

10.1542/peds.2020-0772

Alternate Title

Pediatrics

PMID

33334922

Title

Missed Opportunities for HIV Screening Among a Cohort of Adolescents With Recently Diagnosed HIV Infection in a Large Pediatric Hospital Care Network.

Year of Publication

2018

Date Published

2018 Oct 02

ISSN Number

1879-1972

Abstract

<p><strong>PURPOSE: </strong>Routine human immunodeficiency virus (HIV) screening reduces HIV progression and transmission. Our aims were to determine prevalence and factors associated with prior HIV screening among a cohort of youth living with HIV.</p>

<p><strong>METHODS: </strong>Retrospective chart review of youth living with HIV aged 14-26 at an HIV clinic comparing characteristics between those with and without HIV screening within the year prior to diagnosis RESULTS: Subjects (n = 301) were male (85%), African-American (87%), and men who have sex with men (84%). Subjects seen 1 year prior to diagnosis (n = 58) contributed 179 visits for missed opportunities with 59% having a documented sexual history in the electronic health record and 48% tested for HIV. Subjects with symptoms suggesting acute HIV infection (51%) were more likely to be tested (p = .04). In the adjusted model, documentation of sexual history and demographic factors was not associated with prior testing.</p>

<p><strong>CONCLUSION: </strong>We identified high rates of missed opportunities for HIV testing and sexual history documentation in the year prior to diagnosis, underscoring the need for routine HIV screening in adolescents.</p>

DOI

10.1016/j.jadohealth.2018.07.010

Alternate Title

J Adolesc Health

PMID

30290980

Title

Pediatric Emergency Provider Sexually Transmitted Infection Screening Practices in Adolescents With Oropharyngeal or Anorectal Chief Complaints.

Year of Publication

2018

Date Published

2018 Feb 05

ISSN Number

1535-1815

Abstract

<p><strong>OBJECTIVES: </strong>Sexually transmitted infections (STIs) may present with oropharyngeal or anorectal symptoms. Little is known about the evaluation of adolescents with these complaints in the pediatric emergency department (PED). This study aimed to determine the frequency of and factors associated with STI consideration and testing in this population.</p>

<p><strong>METHODS: </strong>Retrospective chart review of patients aged 13 to 18 years who presented to an urban PED with oropharyngeal or anorectal chief complaints between June 2014 and May 2015. Sexually transmitted infection consideration was defined as sexual history documentation, documentation of STI in differential diagnosis, and/or diagnostic testing. Multivariate logistic regression models were used to identify factors associated with consideration.</p>

<p><strong>RESULTS: </strong>Of 767 visits for oropharyngeal (89.4%), anorectal (10.4%), or both complaints, 153 (19.9%) had STI consideration. Of the 35 visits (4.6%) that included gonorrhea and/or chlamydia testing, 12 (34.3%) included testing at the anatomic site of complaint. Of those 12 tests, 50.0% were the incorrect test. Patients with older age (adjusted odds ratio [aOR] = 1.5, 95% confidence interval [CI] = 1.3-1.7), female sex (aOR = 1.6, 95% CI = 1.03-2.5), or anorectal complaints (aOR = 2.4, 95% CI = 1.3-4.3) were more likely to have STI consideration.</p>

<p><strong>CONCLUSIONS: </strong>In an urban PED, only 20% of visits for adolescents with oropharyngeal or anorectal symptoms included STI consideration. Testing was performed in only 5% of cases and often at an inappropriate anatomic site or with the incorrect test. Interventions to increase awareness of appropriate STI consideration and testing for individuals presenting with possible extragenital complaints may help reduce STIs among adolescents.</p>

DOI

10.1097/PEC.0000000000001414

Alternate Title

Pediatr Emerg Care

PMID

29406475

Title

The Impact of Child Sexual Abuse Discovery on Caregivers and Families: A Qualitative Study.

Year of Publication

2017

Number of Pages

886260517714437

Date Published

2017 Jun 01

ISSN Number

1552-6518

Abstract

<p>In this qualitative study with nonoffending caregivers of suspected child sexual abuse victims, we aimed to explore the perceived impact of sexual abuse discovery on caregivers and their families, and caregivers' attitudes about mental health services for themselves. We conducted semistructured, in-person interviews with 22 nonoffending caregivers of suspected sexual abuse victims &lt;13 years old seen at a child advocacy center in Philadelphia. Interviews were audio-recorded, transcribed, coded, and analyzed using modified grounded theory. Recruitment continued until thematic saturation was reached. We found that caregivers experienced significant emotional and psychological distress, characterized by anger, depressed mood, and guilt, after learning that their child may have been sexually abused. We identified four specific sources of caregiver distress: concerns about their child, negative beliefs about their parenting abilities, family members' actions and behaviors, and memories of their own past maltreatment experiences. Some caregivers described worsening family relationships after discovery of their child's sexual abuse, while others reported increased family cohesion. Finally, we found that most caregivers in this study believed that mental health services for themselves were necessary or beneficial to help them cope with the impact of their child's sexual abuse. These results highlight the need for professionals working with families affected by sexual abuse to assess the emotional and psychological needs of nonoffending caregivers and offer mental health services. Helping caregivers link to mental health services, tailored to their unique needs after sexual abuse discovery, may be an acceptable strategy to improve caregiver and child outcomes after sexual abuse.</p>

DOI

10.1177/0886260517714437

Alternate Title

J Interpers Violence

PMID

29294788

Title

Improving Adolescent Pelvic Inflammatory Disease Follow-up From the Emergency Department: Randomized Controlled Trial With Text Messages.

Year of Publication

2016

Number of Pages

602-609.e3

Date Published

2016 May

ISSN Number

1097-6760

Abstract

<p><strong>STUDY OBJECTIVE: </strong>Centers for Disease Control and Prevention guidelines recommend follow-up within 72 hours of diagnosis of pelvic inflammatory disease because patients with inadequate treatment are at increased risk of acute and chronic complications. Follow-up rates in adolescents after diagnosis range between 10% and 16%. The primary objective is to assess the effect of text message reminders to adolescent patients receiving a diagnosis of pelvic inflammatory disease on obtaining follow-up care within 72 hours of emergency department (ED) discharge.</p>

<p><strong>METHODS: </strong>This was a single-blinded randomized controlled trial of adolescents receiving a diagnosis of pelvic inflammatory disease in the ED. Patients received standard discharge instructions or standard discharge instructions plus text message reminders. Patients in the text message group received daily, tailored text messages for 4 days, with a reminder to schedule and attend primary care provider follow-up. The primary outcome was follow-up within 72 hours of ED discharge.</p>

<p><strong>RESULTS: </strong>Ninety-five patients (48 standard; 47 text message) were randomized. Three patients were excluded, leaving 92 patients (46 standard; 46 text message) for analysis. Baseline characteristics were similar between treatment groups. Follow-up was 15.2% in the standard group and 43.5% in the text message group. Patients receiving text message reminders were more likely to follow up compared with the standard group (relative risk 2.9; 95% confidence interval [CI] 1.4 to 5.7). The absolute efficacy difference was 28.3% (95% CI 9.5% to 46.9%), yielding number needed to treat of 4 (95% CI 2.2 to 9.5).</p>

<p><strong>CONCLUSION: </strong>Personalized text message reminders were efficacious in improving follow-up for adolescents after ED diagnosis of pelvic inflammatory disease.</p>

DOI

10.1016/j.annemergmed.2015.10.022

Alternate Title

Ann Emerg Med

PMID

26686262

Title

Caregiver perceptions about mental health services after child sexual abuse.

Year of Publication

2016

Number of Pages

284-94

Date Published

2016 Jan

ISSN Number

1873-7757

Abstract

<p>The objective of this study was to describe caregiver perceptions about mental health services (MHS) after child sexual abuse (CSA) and to explore factors that affected whether their children linked to services. We conducted semi-structured, in-person interviews with 22 non-offending caregivers of suspected CSA victims&lt;13 years old seen at a child advocacy center in Philadelphia. Purposive sampling was used to recruit caregivers who had (n=12) and had not (n=10) linked their children to MHS. Guided by the Health Belief Model framework, interviews assessed perceptions about: CSA severity, the child's susceptibility for adverse outcomes, the benefits of MHS, and the facilitators and barriers to MHS. Interviews were audio-recorded, transcribed, coded, and analyzed using modified grounded theory. Recruitment ended when thematic saturation was reached. Caregivers expressed strong reactions to CSA and multiple concerns about adverse child outcomes. Most caregivers reported that MHS were generally necessary for children after CSA. Caregivers who had not linked to MHS, however, believed MHS were not necessary for their children, most commonly because they were not exhibiting behavioral symptoms. Caregivers described multiple access barriers to MHS, but caregivers who had not linked reported that they could have overcome these barriers if they believed MHS were necessary for their children. Caregivers who had not linked to services also expressed concerns about MHS being re-traumatizing and stigmatizing. Interventions to increase MHS linkage should focus on improving communication with caregivers about the specific benefits of MHS for their children and proactively addressing caregiver concerns about MHS.</p>

DOI

10.1016/j.chiabu.2015.09.009

Alternate Title

Child Abuse Negl

PMID

26602155

Title

Frequency of pregnancy testing among adolescent emergency department visits.

Year of Publication

2013

Number of Pages

816-21

Date Published

2013 Aug

ISSN Number

1553-2712

Abstract

<p><strong>OBJECTIVES: </strong>The objective was to estimate the frequency of pregnancy testing among adolescent emergency department (ED) patients and to determine factors associated with testing.</p>

<p><strong>METHODS: </strong>This was a retrospective cross-sectional study using the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2005 through 2009 of ED visits by females ages 14 to 21 years. The frequency of pregnancy testing among all visits was estimated for potential reproductive health complaints and for those associated with exposure to potentially teratogenic radiation. Multivariable logistic regression modeling was performed to calculate adjusted probabilities and odds ratios (ORs) with 95% confidence intervals (CIs) to evaluate factors associated with pregnancy testing by patient characteristics.</p>

<p><strong>RESULTS: </strong>The authors identified 11,531 visits, representing an estimated 41.0 million female adolescent ED visits. Of these, 20.9% (95% CI = 19.3% to 22.5%) included pregnancy testing. Among visits for potential reproductive health complaints and those associated with exposure to potentially teratogenic radiation, 44.5% (95% CI = 41.3% to 47.8%) and 36.7% (95% CI = 32.5% to 40.9%), respectively, included pregnancy testing. Among the entire study population, we found statistically significant differences in pregnancy testing by age, race or ethnicity, hospital admission, and geographic region (p &lt; 0.001 for all).</p>

<p><strong>CONCLUSIONS: </strong>A minority of female adolescent ED visits included pregnancy testing, even if patients presented with potential reproductive health complaints or received exposure to ionizing radiation. Small but statistically significant differences in pregnancy testing rates were noted based on age, race or ethnicity, ED disposition, and geographic region. Future studies should focus on designing quality improvement interventions to increase pregnancy testing in adolescent ED patients, especially among those in whom pregnancy complications or the risk of potentially teratogenic radiation exposure is higher.</p>

DOI

10.1111/acem.12186

Alternate Title

Acad Emerg Med

PMID

24033625

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