Development and Pilot Testing of a Computerized Asthma Kiosk to Initiate Chronic Asthma Care in a Pediatric Emergency Department.

OBJECTIVES: Emergency department (ED) visits are an opportunity to initiate chronic asthma care. Ideally, this care should be implemented in a fashion that limits utilization of scarce ED resources. We developed, iteratively refined, and pilot tested the feasibility of a computerized asthma kiosk to (1) capture asthma information, (2) deliver asthma education, and (3) facilitate guideline-based chronic asthma management. METHODS: The following are the 4 phases of this study: (1) developing the content and structure of a computerized asthma kiosk, (2) iterative refinement through heuristic testing by human-computer interface experts, (3) usability testing with ED providers (n = 4) and caregivers of children with asthma (n = 4), and (4) pilot testing the kiosk with caregivers (n = 31) and providers in the ED (n = 18). Outcome measures for the pilot-testing phase were the proportion of ED providers who prescribed long-term controller medication (LTCM) and asthma action plans (AsAPs) and the proportion of children who took LTCMs and attended primary care providers follow-up. RESULTS: After kiosk development and refinement, pilot implementation resulted in LTCMs prescribing and AsAP provision for 19 (61%) of 31 and 17 (55%) of 31 patients, respectively. Before kiosk use, the proportion of the 18 ED providers who reported prescribing LTCM was 1 (5%) of 18, and providing AsAPs was 0 (0%) of 18. Eighteen (58%) of the 31 caregivers reported that their children used LTCMs after kiosk use and 13 (42%) of 31 reported following up with the primary care provider within 1 month of the ED visits. CONCLUSIONS: A rigorously developed asthma kiosk showed promise for initiating chronic asthma care in the ED.

Asthma-Related Educational Needs of Families With Children With Asthma in an Urban Pediatric Emergency Department.

OBJECTIVE: The aim of this study was to identify the educational needs of inner-city children with persistent asthma and their caregivers who utilize the emergency department (ED) for asthma care as well as determine their guideline adherence, factors associated with ED use, and comfort with computers. METHODS: Cross-sectional survey of children aged 2 to 18 years with previous diagnosis of asthma presenting with asthma-related complaints or acute asthma exacerbations to an urban pediatric ED. Data on demographics, families' response to acute asthma, approach to asthma prevention, access to care, educational topics of interest, and sources of health information were collected. RESULTS: Of approximately 1500 asthma-related visits, 218 caregivers were approached, and 200 completed the survey. In the past 12 months, 31% had experienced at least 1 asthma-related hospitalization, and 55.5% had had at least 3 ED visits. Although 184 (92.9%) of 198 caregivers were able to identify a primary physician, 37% reported they were more likely to take their child to the ED in response to acute asthma during the day as opposed to their physician (17%). Approximately half of patients were not on any preventive medication, with 57% not having had received an Asthma Action Plan. Caregivers expressed the most interest in learning about long-term controller medications (44.2%), use of metered dose inhalers or nebulizers (44.2%), and trigger avoidance (35.2%). Most caregivers (approximately 68%) reported ease of use with computers and the Internet. CONCLUSION: There was discordance between caregivers' reports of primary care provider teaching on asthma management and the use of the controller medications and possession of the Asthma Action Plans for persistent asthma. Education could focus on caregiver concerns of the safety and benefits of the controller medications.

Accuracy and safety of dry needle placement in the piriformis muscle in cadavers.

OBJECTIVES: The purpose of this anatomic investigation is to (1) establish accuracy of dry needle placement into the medial third of the piriformis muscle as it exits the pelvis from the greater sciatic notch in unembalmed cadaveric specimens, while avoiding puncture of the sciatic nerve, and (2) establish guidelines for dry needle length selection. METHODS: Dry needles were placed in nineteen unembalmed cadaveric posterior hips. Dissection of the posterior hip musculature was performed to confirm location of the needle. A binary decision (yes/no) was made to determine whether the needle reached the piriformis muscle, went through the piriformis muscle, and/or pierced the sciatic nerve. Additionally, mean adipose tissue thickness, gluteus maximus muscle thickness, and perpendicular distance from the needle to the exiting sciatic nerve were recorded. RESULTS: The needle reached the medial third of the piriformis in 16 out of 19 hips (84.2% accuracy) and never punctured the sciatic nerve. There was a fair (r = 0.493) and good (r = 0.759) correlation between the needle length and the mean fat thickness for the left and right hips, respectively. DISCUSSION: A physical therapist was able to use bony landmark palpation to locate the piriformis muscle and use estimated adipose tissue thickness to choose a sufficient needle length to reach the medial third of the piriformis muscle. While the needle placement technique was safe and no sciatic nerve puncture occurred, the proximity of the piriformis muscle to the sciatic nerve warrants caution during needle placement. LEVEL OF EVIDENCE: 2c.

A Learning Collaborative Approach to Improve Primary Care STI Screening.

The Bronx Ongoing Pediatric Screening (BOPS) project sought to improve screening for sexual activity and sexually transmitted infections (gonorrhea and chlamydia [GCC] and HIV) in a primary care network, employing a modified learning collaborative, real-time clinical data feedback to practices, improvement coaching, and a pay-for-quality monetary incentive. Outcomes are compared for 11 BOPS-participating sites and 10 non-participating sites. The quarterly median rate for documenting sexual activity status increased from 55% to 88% (BOPS sites) and from 13% to 74% (non-BOPS sites). GCC screening of sexually active youth increased at BOPS and non-BOPS sites. Screening at non-health care maintenance visits improved more at BOPS than non-BOPS sites. Data from nonparticipating sites suggests that introduction of an adolescent EMR template or other factors improved screening rates regardless of BOPS participation; BOPS activities appear to promote additional improvement of screening during non-health maintenance visits.