Counseling for opioids prescribed at discharge of hospitalized adolescent trauma patients.

BACKGROUND: Expert consensus recommends prescription opioid safety counseling be provided when prescribing an opioid. This may be especially important for youth with preexistent alcohol and other drug (AOD) use who are at higher risk of developing opioid use disorder. This study examined the frequency that adolescent trauma patients prescribed opioids at hospital discharge received counseling and if this differed by adolescents' AOD use. METHOD: This study was embedded within a larger prospective stepped-wedge type III hybrid implementation study of AOD screening across a national cohort of pediatric trauma centers. Data were collected during 2018-2021 from admitted adolescent trauma patients (12-17 yo) at seven centers. Patient data were extracted from the electronic health record (EHR) on any prescribed discharged opioids, documentation of counseling delivered on prescribed opioid, who delivered counseling, and patients' AOD screening results. Additionally, adolescents received an online survey within 30 days of hospital discharge that included asking about hospital discussions on safe use of prescription pain medication. RESULTS: Of the 247 adolescent trauma patients enrolled, 158 completed the 30-day survey. AOD screening results were documented in the EHR for 139 patients (88%), with 69 (44.1%) screening AOD-positive. Opioids at discharge were prescribed to 86 (54.4%) adolescent patients, with no significant difference between those screened AOD-positive and AOD-negative (42.4% vs. 46.3%, p = 0.89). Counseling was documented in the EHR for 30 (34.9%) of those prescribed an opioid and was not significantly different by sex, age, race, ethnicity or between adolescent patients with documentation of AOD use (29.3%) versus those who did not (33.3%, p = 0.71). According to the adolescent survey, among those prescribed an opioid, 61.2% reported someone had talked with them about safe use of newly prescribed pain medications with again no difference between AOD-positive and AOD-negative screening results (p = 0.34). CONCLUSIONS: Although adolescent trauma patients recalled discussions on safe use of prescribed pain medication more often than was documented in the EHR, these discussions were not universal and did not differ if adolescents had screened positive or negative for AOD use as documented in the EHR. TRIAL REGISTRY: clinicaltrials.gov NCT03297060.

Developing and Implementing Electronic Consent Procedures in Response to Covid-19 Restrictions.

The Covid-19 pandemic resulted in unprecedented restrictions on many public, private, and workplace activities throughout the United States and elsewhere. When restrictions were imposed, we were conducting a type III hybrid effectiveness-implementation trial in 10 pediatric trauma centers. In response to several pandemic-based restrictions, we had to develop procedures for engaging with potential research participants while limiting nonclinical, in-person interactions. This manuscript describes the procedures and challenges of obtaining electronic informed consent and assent in a multisite trauma center-based research study. We developed, tested, and trained staff to implement three options for obtaining informed consent. Twenty-five participants were enrolled in the effectiveness-implementation multisite trial during the first six months of utilization of the consent options, with eleven of these individuals enrolled using hybrid or electronic consent procedures. The challenges we identified involving electronic consent procedures included confusion over who would complete the electronic consent process and difficulties reconnecting with families. Lessons learned can strengthen electronic consent and assent procedures for future studies. More research is needed to further strengthen this process and increase its utilization.

Variability in opioid pain medication prescribing for adolescent trauma patients in a sample of US pediatric trauma centers.

Objectives: The primary objective of this study was to examine opioid prescription frequency and identify differences across a national cohort of pediatric trauma centers in rates of prescribing opioids to injured adolescents at discharge. Methods: This was a retrospective observational study using electronic health records of injured adolescents (12-17 years) admitted to one of 10 pediatric trauma centers. Results: Of the 1345 electronic health records abstracted, 720 (53.5%, 95% CI 50.8 to 56.2) patients received opioid prescriptions at discharge with variability across sites (28.6%-72%). There was no association between patient factors and frequency of prescribing opioids. Center's trauma volume was significantly positively correlated with a higher rate of opioid prescribing at discharge (r=0.92, p=0.001). There was no significant difference between the frequency of opioid prescriptions at discharge among alcohol and other drugs (AOD)-positive patients (53.8%) compared with AOD-negative patients (53.5%). Conclusions: Across a sample of 10 pediatric trauma centers, just over half of adolescent trauma patients received an opioid prescription at discharge. Prescribing rates were similar for adolescent patients screening positive for AOD use and those screening negative. The only factor associated with a higher frequency of prescribing was trauma center volume. Consensus and dissemination of outpatient pain management best practices for adolescent trauma patients is warranted. Level of evidence: III-prognostic. Trial registration number: NCT03297060.

Screening Adolescent Trauma Patients for Substance Use at 10 Pediatric Trauma Centers.

BACKGROUND: The American College of Surgeons Committee on Trauma recommends universal alcohol screening be part of the evaluation of admitted trauma patients. Yet, suboptimal screening rates have been reported for admitted adult and adolescent trauma patients. This lack of screening, in turn, has limited the ability of trauma services to provide patients with brief interventions during their hospital admission and subsequent referrals to treatment after discharge. The primary aim of this study was to examine current rates of alcohol and other drug screening with admitted injured adolescents across a national cohort of 10 pediatric trauma centers. METHODS: This retrospective observational study was nested within a larger adolescent screening, brief intervention, and referral to treatment implementation study (Clinicaltrials.gov NCT03297060). Ten pediatric trauma centers participated in a retrospective chart review of a random sample of adolescent trauma patients presenting for care between March 1, 2018, and November 30, 2018. RESULTS: Three hundred charts were abstracted across the 10 participating trauma centers (n = 30 per site). Screening rates varied substantially across centers from five (16.7%) to 28 (93.3%) of the 30 extracted charts. The most frequent screening type documented was blood alcohol concentration (BAC) (N = 80, 35.2% of all screens), followed by the CRAFFT (N = 79, 26.3%), and then the urine drug screen (UDS) (N = 77, 25.6%). The BAC test identified 11 patients as positive for recent alcohol use. The CRAFFT identified 11 positive patients. CONCLUSIONS: Alcohol and drug screening is underutilized for adolescents admitted to pediatric trauma centers. More research is warranted on how best to utilize the teachable moment of the pediatric trauma visit to ensure comprehensive screening of adolescent alcohol or other drug (AOD) use.

Altered Mental Status at High Altitude.

Intrathecal baclofen pumps are commonly used in pediatric patients with spastic cerebral palsy. Baclofen binds to γ-aminobutyric acid receptors to inhibit both monosynaptic and polysynaptic reflexes at the spinal cord level. The blockade stops the release of excitatory transmitters and thereby decreases muscle contraction. It is commonly used for lower limb spasticity and has been shown to improve postural ability and functional status. The US Food and Drug Administration has approved baclofen for the treatment of spasticity of cerebral or spinal origin in adult and pediatric patients 4 years or older. Various complications of baclofen pumps are described in the literature. Immediately after surgery, problems from infection can arise and range from superficial skin infections to meningitis and bacteremia. Another early complication includes cerebrospinal fluid leak that can be observed by notable swelling beneath the lumbar incision. Additional problems that arise later are usually from the mechanics of the pump and catheter. Pump-related complications include failure, migration, and flipping. Catheter-related complications include disconnection, occlusion, fracture, or kink. Most of these complications typically lead to baclofen withdrawal, although there are a few case reports of overdose due to mechanical causes. Here we describe 2 cases of individuals experiencing complications of excessive baclofen exposure after significant changes in the atmospheric pressure due to travel involving ambient altitude change. These cases reflect the need to discuss this potential complication with families and patients with baclofen pumps before travel to high elevations.

Rapid urine drug screens: diphenhydramine and methadone cross-reactivity.

BACKGROUND: Rapid urine screens to detect drugs of abuse are often used in pediatric emergency departments (PEDs). A positive result may lead to further clinical testing, social evaluation, and increased stress/inconvenience. A PED patient with suspected diphenhydramine (DPH) ingestion had a positive methadone result on the rapid urine drug screen, One Step Multi-Drug, Multi-Line Screen Test Device (ACON Laboratories, San Diego, Calif). There was no history of methadone exposure so the patient was admitted while confirmatory testing was performed. Gas chromatography/mass spectroscopy testing of the urine failed to confirm the presence of methadone. We present this unreported false-positive methadone result and evaluation of the kit for cross-reactivity of DPH and methadone. METHODS: The same One Step urine drug screen was tested at an independent laboratory for cross-reactivity between methadone and DPH including the DPH metabolites. Drug-free urine was fortified with DPH, nordiphenhydramine, or dinordiphenhydramine at 0, 10, 25, 50, and 100 µg/mL for each analyte. One hundred microliters of the solutions were added to each of the 4 wells on test cassettes. Urine was allowed to migrate according to manufacturer instructions. Each cassette was interpreted by 2 analysts to ensure consistent interpretation and accurate data recording. RESULTS: In vitro laboratory testing results showed cross-reactivity between methadone and DPH but not for nordiphenhydramine or dinordiphenhydramine. CONCLUSIONS: Rapid urine drug screens using immunoassays based on the principle of competitive binding may show false-positive methadone results for patients who have ingested DPH. Product information for urine drug screens may not include all cross-reacting agents and should be used with caution when interpreting drug screen results in PED patients.

Independent risk factors for beach-related injuries in children.

This study was conducted in a resort area during the summer tourist season to identify independent risk factors for injuries to children in a beach environment. Surveys including demographics, environmental and beach conditions, group characteristics, and hypothesized risk factors were administered to 28 cases and 105 controls. The most common injuries were lacerations and puncture wounds, followed by musculoskeletal injuries. The following environmental factors were found to significantly increase the risk for pediatric beach-related injury: rough/choppy water, cloudy weather, greater than 3 children in the group, participation by the child in water safety classes, and use of beach equipment (including boogie boards, skim boards, and kayaks). Providers who care for children can use this information to educate parents about beach safety. Targeted interventions that address these risk factors may reduce injuries sustained by children in a beach environment.

Factors used by pediatric emergency medicine program directors to select their fellows.

BACKGROUND: Pediatric emergency medicine (PEM) recently has become a highly competitive subspecialty with twice the number of applicants for positions available. Little information exists on the characteristics that PEM programs desire in their applicants. We sought to assess the factors used by PEM program directors when ranking PEM fellow applicants in the National Resident Match Program (NRMP). METHODS: A 47-item questionnaire (adapted from a previously published questionnaire) was designed to assess the relative importance of various factors in the ranking of PEM fellow applicants in the NRMP. The questionnaire was mailed to all 43 PEM program directors that participated in the 2001 NRMP. The program directors were asked to grade selection factors based on a five-point Likert scale: 1, unimportant; 2, somewhat important; 3, important; 4, very important; 5, critical. The factors addressed in the questionnaire included academic criteria, letters of recommendation, applicant characteristics, and aspects of the interview. In addition, we asked 10 yes-or-no questions pertaining to specific aspects of each program. Responses were tabulated and means and standard deviations reported. RESULTS: A program response rate of 93% (40/43) was obtained. The most important factors in granting an interview were recommendations from colleagues in PEM (4.21 +/- 0.78), research potential (3.81 +/- 1.10), and reputation of the applicant's pediatric program (3.51 +/- 0.91). The least important factors in granting an interview were reputation of the applicant's undergraduate institution (1.76 +/- 0.86), medical school grades (1.83 +/- 0.87), and board scores (2.11 +/- 0.91). Letters from division chiefs of PEM (4.15 +/- 0.78) and clinical faculty in PEM (4.06 +/- 0.82) were considered the most important letters of recommendation, whereas letters from basic science faculty were considered the least important (1.89 +/- 0.96). Ability to work with a team (4.66 +/- 0.42), compatibility with the program (4.65 +/- 0.35), commitment to hard work (4.55 +/- 0.45), ability to grow in knowledge (4.41 +/- 0.58), ability to solve problems (4.36 +/- 0.63), ability to listen (4.34 +/- 0.65), and ability to articulate thoughts (4.32 +/- 0.59) were the most important characteristics in the final ranking of candidates. Thirty percent (12/40) of the program directors stated that it was important for the program to "match" its top choice. The majority of programs have a selection committee that contributes to the final ranking of applicants. CONCLUSIONS: The results of this study suggest that a rather subjective but uniform prioritization of criteria is used in evaluating PEM program applicants. Awareness of these factors would enable applicants to make a critical self-analysis of their strengths and weaknesses prior to the submission of their applications.