Evaluating the Proportion of Low-Value Blood Cultures Obtained in a Pediatric Emergency Department.

BACKGROUND: Existing literature suggests that for some pediatric conditions, blood cultures may be of low value in specific clinical circumstances. The goals of our study were to: 1) identify common pediatric illnesses and define criteria for low-value blood cultures in children aged from 91 days to 19 years, 2) apply these criteria retrospectively to identify the patients in our emergency department (ED) who had low-value blood cultures obtained, and 3) describe this cohort and assess the proportion of true bacteremia in low-value blood cultures. METHOD: The study team reviewed the literature and developed consensus criteria to identify conditions in which blood cultures were of low value for our study population. The criteria were applied retrospectively to well-appearing patients aged from 91 days to 19 years, without a central venous catheter, and evaluated in our ED with a peripheral blood culture from June 2018 to April 2020. Children admitted to the intensive care/hematology-oncology/cardiology/pulmonary units, those transferred from our ED to an outside facility, who transferred to our ED due to a positive blood culture from an outside facility, and repeat visits of a patient within 30 days from a previous visit were excluded from the study. After chart review, children with fever for 7 days or more, who were unvaccinated, immunosuppressed, had implanted devices, had a complex medical history, or had provider concerns for bacteremia/sepsis were excluded. RESULTS: The study population consisted of 1436 children. Children at risk for bacteremia (n = 718) were excluded. Four hundred twenty-four children had discharge diagnoses not included in our study. There were 294 (20.5%) patients who had low-value cultures per our study criteria. Nine children (9/294, 3.1%) had false-positive blood cultures, and three (3/294, 1.0%) had true-positive blood cultures. CONCLUSIONS: We identified a cohort of patients in our ED with blood cultures obtained when available literature indicates they were of low value.

Development, Implementation, and Provider Perception of Standardized Critical Event Debriefing in a Pediatric Emergency Department.

OBJECTIVE: Hot debriefings are communications among team members occurring shortly after an event. They have been shown to improve team performance and communication. Best practice guidelines encourage hot debriefings, but these are often not routinely performed. We aim to describe the development and implementation of a multidisciplinary hot debriefing process in our pediatric emergency department (ED), and its impact on hot debriefing completion and provider perceptions. METHODS: An internal tool and protocol for hot debriefings were developed by integrating responses from a survey of those who work in the ED at our institution and previously published debriefing tools. Charge nurses and pediatric emergency medicine physicians were trained to lead hot debriefings. Surveys on the perception of hot debriefings were administered before and 6 months postimplementation.Twelve-month baseline data were established by asking physicians who cared for patients who died in the ED or within 48 hours of admission to recall debrief completion. Debriefs were then prospectively tracked for 6 months postimplementation. RESULTS: Debrief completion for patient deaths in the ED or within 48 hours of admission increased from 23% (5/22) to 75% (12/16) ( P < 0.001). When assessing just those deaths within the ED, this number increased from 31% (5/16) to 85% (11/13) ( P < 0.001).There were 98 responses to a baseline survey (response rate, 60.5%). Most who were surveyed felt that debriefs rarely occurred, preferred hot debriefings to cold debriefings, and felt that more hot debriefings should occur. Perceived barriers included lack of time, interest, protocol, trained facilitators, departmental support, and inability to gather the team.There were 88 responses to a postintervention survey (response rate, 56.8%), 50 of which had participated in a debrief and were included in analysis. Those surveyed felt that debriefs occurred more often and were more often valuable. Most perceived that barriers were significantly reduced. Most respondents felt that hot debriefs helped address systems issues and improved performance. CONCLUSIONS: Implementation of a protocol for physician or charge nurse-led hot debriefings in our pediatric ED resulted in increased completion, perceived barrier reduction, and a uniform approach to address identified issues. Pediatric EDs should consider adoption of a hot debriefing protocol given these benefits.

Factors Influencing Parental Willingness to Consent to a Survey Study for Patients in the Pediatric Emergency Department.

OBJECTIVE: To identify factors that impact parental willingness to consent to research studies conducted for their children during visits to pediatric emergency departments (EDs). METHODS: Parents and guardians of children receiving care in our pediatric ED were approached and asked if they would be willing to let their child participate in a research study requiring the child to complete an electronic questionnaire. No such questionnaire existed, however, because the primary purpose was to ascertain the parent's willingness to let their child participate. All parents were debriefed and informed of the true purpose of the study and asked to complete a survey themselves to help understand factors that influenced their initial decision of whether to consent. Bivariate tests and logistic regression were used to evaluate unadjusted and adjusted associations between parent and patient characteristics and parental consent decision. RESULTS: We approached 431 eligible parents about the hypothetical research study involving their children, and 386 (89.6%) consented for their children to participate. After the debriefing, 392 (91.0%) parents consented to complete the parental survey. We observed statistically significant associations between shorter length of ED stay to approach for consent for the study ( P = 0.048) as well as longer travel time ( P = 0.03) and willingness to consent in bivariate analysis, though this did not hold in regression analysis. Regression analysis revealed parents of children who have previously participated in research had 79 times lower odds of consenting to participate in our study adjusted for parent race, ethnicity, actual and perceived length of stay, travel time to the ED, and altruism. CONCLUSIONS: A high proportion of parents consented to their child participating in research in our ED with previous child participation in research being associated with lower odds of parental consent even when adjusted for other factors. Our findings may inform future research practices and studies investigating parental perceptions and motivations surrounding research studies.

Pediatric Emergency Physicians' Knowledge, Attitudes, and Behaviors Regarding Confidential Adolescent Care.

OBJECTIVES: More than 19 million adolescents seek care in the emergency department (ED) annually. We aimed to describe the knowledge, attitudes, and behaviors related to confidential adolescent care among pediatric ED physicians. METHODS: We conducted a cross-sectional questionnaire of US physician members of the Pediatric Emergency Medicine Collaborative Research Committee survey listserv. The 24-item questionnaire assessed familiarity with adolescent confidentiality laws, attitudes toward providing confidential care, frequency of discussing behavioral health topics confidentially, and factors influencing the decision to provide confidential care. We dichotomized Likert responses and used χ 2 to compare subgroups. RESULTS: Of 476 eligible physicians, 151 (32%) participated. Most (91. 4%) had completed pediatric emergency medicine fellowship. More participants reported familiarity with all sexual health-related laws compared with all mental health-related laws (64% vs 49%, P < 0.001). The median age at which participants thought it was important to begin routinely providing confidential care was 12 years; 9% thought confidential interviews should not be routinely conducted until older adolescence or at all. Their decision to provide confidential care was influenced by the following: chief complaint (97%), time (43%), language (24%), presence of family (23%) or friends (14%), and space (22%). CONCLUSIONS: Respondents reported moderate familiarity with adolescent confidentiality laws. Although they viewed confidential care as something they were comfortable providing, the likelihood of doing so varied. Barriers to confidential care were influenced by their assessment of adolescents' behavioral health risk, which may contribute to health inequity. Future efforts are needed to develop strategies that augment confidential ED care for adolescents.

Intranasal fentanyl and discharge from the emergency department among children with sickle cell disease and vaso-occlusive pain: A multicenter pediatric emergency medicine perspective.

Children with sickle cell disease (SCD) commonly experience vaso-occlusive pain episodes (VOE) due to sickling of erythrocytes, which often requires care in the emergency department. Our objective was to assess the use and impact of intranasal fentanyl for the treatment of children with SCD-VOE on discharge from the emergency department in a multicenter study. We conducted a cross-sectional study at 20 academic pediatric emergency departments in the United States and Canada. We used logistic regression to test bivariable and multivariable associations between the outcome of discharge from the emergency department and candidate variables theoretically associated with discharge. The study included 400 patients; 215 (54%) were female. The median age was 14.6 (interquartile range 9.8, 17.6) years. Nineteen percent (n = 75) received intranasal fentanyl in the emergency department. Children who received intranasal fentanyl had nearly nine-fold greater adjusted odds of discharge from the emergency department compared to those who did not (adjusted odds ratio 8.99, 95% CI 2.81-30.56, p < .001). The rapid onset of action and ease of delivery without intravenous access offered by intranasal fentanyl make it a feasible initial parenteral analgesic in the treatment of children with SCD presenting with VOE in the acute-care setting. Further study is needed to determine potential causality of the association between intranasal fentanyl and discharge from the emergency department observed in this multicenter study.

The Use of the Consolidated Framework for Implementation Research to Understand Facilitators and Barriers to Sexually Transmitted Infection Screening in Primary Care.

BACKGROUND: Adolescents bear a disproportionate burden of sexually transmitted infections (STIs) and the sequelae of delayed treatment, yet STI screening is infrequently performed in pediatric primary care clinics with many of those at-risk not administered testing. This study aims to understand contextual factors influencing STI screening and testing among adolescents in pediatric primary care. METHODS: We used the Consolidated Framework for Implementation Research (CFIR) as part of a stepwise approach to facilitate a deep understanding the pediatric primary care environment. We conducted semistructured interviews of physicians, nurses, and patient-parent dyads from 4 pediatric primary care practices in the St. Louis metropolitan area about STI screening practices and common concerns regarding STI screening. Qualitative analysis was conducted using a categorical coding technique informed by the CFIR followed by a thematic coding technique. RESULTS: We interviewed 23 physicians/nurses and 12 patient-parent dyads. Individual-level barriers to STI screening and testing included wide variability in clinicians' practice patterns and their perception of STI risk in the patient population. Structural barriers included a lack of capacity to perform testing in clinic and time constraints during patient visits. Confidentiality issues also created significant barriers to screening and testing on both individual and structural levels. Adopting confidential methods for testing and educating providers on patients' recommendations for STI testing were discussed as ways to potentially improve STI care in pediatric patients. CONCLUSIONS: Our use of the CFIR facilitated a systematic approach to identify gaps in STI care for adolescents and identified opportunities to close those gaps. An integrated, systematic approach that enhances patient confidentiality and improves clinicians' knowledge could address gaps in STI care in pediatric primary care settings.

Adolescent alcohol use predicts cannabis use over a three year follow-up period.

Background: Alcohol and cannabis use frequently co-occur, which can result in problems from social and academic impairment to dependence (i.e., alcohol use disorder [AUD] and/or cannabis use disorder [CUD]). The Emergency Department (ED) is an excellent site to identify adolescents with alcohol misuse, conduct a brief intervention, and refer to treatment; however, given time constraints, alcohol use may be the only substance assessed due to its common role in unintentional injury. The current study, a secondary data analysis, assessed the relationship between adolescent alcohol and cannabis use by examining the National Institute of Alcohol Abuse and Alcoholism (NIAAA) two question screen's (2QS) ability to predict future CUD at one, two, and three years post-ED visit. Methods: At baseline, data was collected via tablet self-report surveys from medically and behaviorally stable adolescents 12-17 years old (n = 1,689) treated in 16 pediatric EDs for non-life-threatening injury, illness, or mental health condition. Follow-up surveys were completed via telephone or web-based survey. Logistic regression compared CUD diagnosis odds at one, two, or three-year follow-up between levels constituting a single-level change in baseline risk categorization on the NIAAA 2QS (nondrinker versus low-risk, low- versus moderate-risk, moderate- versus high-risk). Receiver operating characteristic curve methods examined the predictive ability of the baseline NIAAA 2QS cut points for CUD at one, two, or three-year follow-up. Results: Adolescents with low alcohol risk had significantly higher rates of CUD versus nondrinkers (OR range: 1.94-2.76, p < .0001). For low and moderate alcohol risk, there was no difference in CUD rates (OR range: 1.00-1.08). CUD rates were higher in adolescents with high alcohol risk versus moderate risk (OR range: 2.39-4.81, p < .05). Conclusions: Even low levels of baseline alcohol use are associated with risk for a later CUD. The NIAAA 2QS is an appropriate assessment measure to gauge risk for future cannabis use.

Adolescent Substance Abuse Risk: A Comparison of Pediatric Emergency Care Applied Research Network Emergency Department Patients and 2 Nationally Representative Samples.

OBJECTIVES: The aim of this study was to understand the prevalence of alcohol and other substance use among teenagers in generalized samples. METHODS: This study compared the alcohol and other substance use of adolescents enrolled in a screening study across 16 Pediatric Emergency Care Applied Research Network emergency departments (EDs) (ASSESS) with those sampled in 2 nationally representative surveys, the Youth Risk Behavior Surveillance System (YRBSS) and the National Survey of Drug Use and Health (NSDUH). The analysis includes 3362 ASSESS participants and 11,142 YRBSS and 12,086 NSDUH respondents. RESULTS: The ASSESS patients had a similar profile to the NSDUH sample, with small differences in marijuana and cocaine use and age at first tobacco smoking and smoking within the last 30 days and higher use of snuff or chewing tobacco. The YRBSS participants had higher rates of using marijuana, snuff/chewing tobacco, methamphetamine, and hallucinogens and higher smoking rates compared with ASSESS and NSDUH. CONCLUSIONS: Adolescents visiting Pediatric Emergency Care Applied Research Network EDs have substantial rates of substance use, similar to other nationally representative studies on this topic, although not as high as a school-based survey. Future ED studies should continue to investigate adolescent substance use, including exploring optimal methods of survey administration.

Emergency Information Forms for Children With Medical Complexity: A Qualitative Study.

OBJECTIVES: Children with medical complexity (CMC) are at risk for poor outcomes during medical emergencies. Emergency information forms (EIFs) provide essential medical information for CMC during emergencies; however, they are not widely used. We sought to identify factors related to optimal care for CMC to inform development of EIFs for CMC. METHODS: We interviewed 26 stakeholders, including parents of CMC, healthcare providers, health information technology, and privacy compliance experts. We inquired about barriers and facilitators to emergency care of CMC, as well as the desired content, structure, ownership, and maintenance of an EIF. Audio recordings were transcribed and analyzed inductively for common themes using thematic analysis techniques. RESULTS: Providers identified problems with documentation and poor caregiver understanding as major barriers to care. Parents reported poor provider understanding of their child's condition as a barrier. All groups reported that summary documents facilitate quality care. Recommended content included demographic/contact information, medical history, medications, allergies, advance directives, information about the patient's disease, and an action plan for anticipated emergencies. Twenty-three participants indicated a preference for electronic EIFs; 19 preferred a Web-based EIF that syncs with the medical record, with paper or portable electronic copies. Although 13 participants thought that EIFs should be patient owned to ensure availability during emergencies, 19 expected medical providers to create and update EIFs. CONCLUSIONS: Stakeholders interviewed reported a preference for Web-based, sync-capable EIFs with portable copies. Emergency information forms could be maintained by providers but owned by patients to optimize emergency care and align with the concept of the medical home.

Normal saline bolus use in pediatric emergency departments is associated with poorer pain control in children with sickle cell anemia and vaso-occlusive pain.

Vaso-occlusive pain events (VOE) are the leading cause of emergency department (ED) visits in sickle cell anemia (SCA). This study assessed the variability in use of intravenous fluids (IVFs), and the association of normal saline bolus (NSB), on pain and other clinical outcomes in children with SCA, presenting to pediatric emergency departments (PED) with VOE. Four-hundred charts of children age 3-21 years with SCA/VOE receiving parenteral opioids at 20 high-volume PEDs were evaluated in a retrospective study. Data on type and amount of IVFs used were collected. Patients were divided into two groups: those who received NSB and those who did not. The association of NSB use on change in pain scores and admission rates was evaluated. Among 400 children studied, 261 (65%) received a NSB. Mean age was 13.8 ± 4.9 years; 46% were male; 92% had hemoglobin-SS. The IVFs (bolus and/or maintenance) were used in 84% of patients. Eight different types of IVFs were utilized and IVF volume administered varied widely. Mean triage pain scores were similar between groups, but improvement in pain scores from presentation-to-ED-disposition was smaller in the NSB group (2.2 vs 3.0, P = .03), while admission rates were higher (71% vs 59%, P = .01). Use of NSB remained associated with poorer final pain scores and worse change in pain scores in our multivariable model. In conclusion, wide variations in practice utilizing IVFs are common. NSB is given to >50% of children with SCA/VOE, but is associated with poorer pain control; a controlled prospective trial is needed to determine causality.

Screening for Adolescent Alcohol Use in the Emergency Department: What Does It Tell Us About Cannabis, Tobacco, and Other Drug Use?

BACKGROUND: The pediatric emergency department (PED) represents an opportune time for alcohol and drug screening. The National Institute of Alcohol Abuse and Alcoholism (NIAAA) recommends a two-question alcohol screen for adolescents as a predictor of alcohol and drug misuse. OBJECTIVE: A multi-site PED study was conducted to determine the association between the NIAAA two-question alcohol screen and adolescent cannabis use disorders (CUD), cigarette smoking, and lifetime use of other drugs. METHODS: Participants included 12-17-year olds (n = 4834) treated in one of 16 participating PEDs. An assessment battery, including the NIAAA two-question screen and other measures of alcohol, tobacco and drug use, was self-administered on a tablet computer. RESULTS: A diagnosis of CUD, lifetime tobacco use or lifetime drug use was predicted by any self-reported alcohol use in the past year, which indicates a classification of moderate risk for middle school ages and low risk for high school ages on the NIAAA two-question screen. Drinking was most strongly predictive of a CUD, somewhat weaker for lifetime tobacco use, and weakest for lifetime drug use. This same pattern held for high school and middle school students and was stronger for high school students over middle school students for all three categories. This association was also found across gender, ethnicity and race. The association was strongest for CUD for high school students, sensitivity 81.7% (95% CI, 77.0, 86.5) and specificity 70.4% (95% CI, 68.6, 72.1). Conclusions/Importance: A single question about past year alcohol use can provide valuable information about other substance use, particularly marijuana.

Methodology and Demographics of a Brief Adolescent Alcohol Screen Validation Study.

OBJECTIVE: The aim of this study was to determine the psychometric properties of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) 2-question alcohol screen within 16 Pediatric Emergency Care Applied Research Network pediatric emergency departments. This article describes the study methodology, sample characteristics, and baseline outcomes of the NIAAA 2-question screen. METHODS: Participants included 12- to 17-year-olds treated in one of the participating pediatric emergency departments across the United States. After enrollment, a criterion assessment battery including the NIAAA 2-question screen and other measures of alcohol, drug use, and risk behavior was self-administered by participants on a tablet computer. Two subsamples were derived from the sample. The first subsample was readministered the NIAAA 2-question screen 1 week after their initial visit to assess test-retest reliability. The second subsample is being reassessed at 12 and 24 months to examine predictive validity of the NIAAA 2-question screen. RESULTS: There were 4834 participants enrolled into the study who completed baseline assessments. Participants were equally distributed across sex and age. Forty-six percent of the participants identified as white, and 26% identified as black. Approximately one quarter identified as Hispanic. Using the NIAAA 2-question screen algorithm, approximately 8% were classified as low risk, 12% were classified as moderate risk, and 4% were classified as highest risk. Alcohol use was less likely to be reported by black participants, non-Hispanic participants, and those younger than 16 years. DISCUSSION: This study successfully recruited a large, demographically diverse sample to establish rates of the NIAAA screen risk categories across age, sex, ethnicity, and race within pediatric emergency departments.

Characteristics of youth agreeing to electronic sexually transmitted infection risk assessment in the emergency department.

OBJECTIVES: Adolescents and young adults are at high risk for sexually transmitted infections (STIs). We previously reported an increase in STI testing of adolescents in our ED by obtaining a sexual history using an Audio-enhanced Computer-Assisted Self-Interview (ACASI). We now examine associations among demographics, sexual behaviour, chief complaint and willingness to be tested. METHODS: This was a prospective study conducted in a paediatric ED between April and December 2011. After triage, eligible patients between 15 and 21 years presenting with non-life-threatening conditions were asked to participate in the study. Consenting participants used an ACASI to provide their demographic data and answer questions about their sexual history and willingness to be tested. Our primary outcome was the association of demographics, chief complaint and ACASI recommendation with the participant's willingness to be tested. RESULTS: We approached 1337 patients, of whom 800 (59%) enrolled and completed the ACASI. Eleven who did not answer questions related to their sexual history were excluded from analysis. Of 789 participants, 461 (58.4%) were female and median age was 16.9 years (IQR 16.0-17.8); 509 (64.5%) endorsed a history of anal, oral and/or vaginal intercourse. Disclosing a sexual history and willingness to be tested did not differ significantly by gender. 131 (16.6%) had a chief complaint potentially referable to an STI; among the 658 participants with non-STI-related complaints, 412 (62.6%) were sexually active, many of whom disclosed risky behaviours, including multiple partners (46.4%) and inconsistent condom use (43.7%). The ACASI identified 419 patients as needing immediate STI testing; the majority (81%) did not have a chief complaint potentially related to STIs. 697 (88.3%) participants were willing to receive STI testing. Most (94.6%) of the patients with STI-related complaints were willing to be tested, and 92.1% of patients with a recommendation for immediate testing by the ACASI indicated a willingness to be tested. CONCLUSIONS: Adolescents were willing to disclose sexual activity via electronic questionnaires and were willing to receive STI testing, even when their chief complaint was not STI related. The ACASI facilitated identification of adolescent ED patients needing STI testing regardless of chief complaint.

Impact of an Institutional Guideline on the Care of Neonates at Risk for Herpes Simplex Virus in the Emergency Department.

BACKGROUND AND OBJECTIVES: Herpes simplex virus (HSV) is rare in neonates but carries significant morbidity and mortality in that group. Emergency department (ED) clinicians have little guidance to decide when to test for HSV and give acyclovir. We created an institutional guideline to provide guidance in patients younger than 6 weeks. Our objective was to evaluate whether guideline implementation affected the ED's decision to test for HSV, and ED use of HSV polymerase chain reactions (PCRs) and acyclovir. METHODS: We reviewed charts for patients 1 year before implementation and 1 year after implementation of our guideline. Inclusion criteria were younger than 60 days, admitted through the ED, symptom onset younger than 6 weeks, and any one of the following criteria: (1) ED blood culture obtained, (2) ED or inpatient HSV PCR obtained, and (3) ED or inpatient acyclovir treatment. Premature patients and transfer patients were excluded. We compared whether the decision to initiate HSV testing, ED use of HSV PCRs, serum alanine aminotransferase, and acyclovir use changed post-guideline implementation. RESULTS: We reviewed 173 charts pre-implementation and 129 post-implementation. We found a significant decrease in ED testing for HSV among patients who did not meet guideline criteria (P < 0.01). We saw an improvement in the use of alanine aminotransferase among patients who met criteria for testing (P = 0.02), but no change in the use of HSV PCRs or acyclovir use among tested patients. CONCLUSIONS: Guideline implementation reduced HSV evaluations in low-risk patients, but did not improve test utilization or acyclovir administration among those tested. Additional work is needed to improve guideline utilization.

Initial Presentation of Neonatal Herpes Simplex Virus Infection.

OBJECTIVE: To inform the decision to test and empirically treat for herpes simplex virus (HSV) by describing the initial clinical presentation and laboratory findings of infants with a confirmed diagnosis of neonatal HSV. STUDY DESIGN: This is a retrospective case series performed at 2 pediatric tertiary care centers. Infants who developed symptoms prior to 42 days of age with laboratory confirmed HSV from 2002 through 2012 were included. We excluded infants <34 weeks gestation, those who developed illness before discharge from their birth hospital, and those who developed symptoms after 42 days of age. RESULTS: We identified 49 infants with HSV meeting these criteria. Most infants (43/49, 88%) came to medical attention at ≤28 days. Of 49 infants, 22 (45%) had disseminated, 16 (33%) central nervous system, and 10 (20%) skin, eye, mouth HSV disease. Eight infants (16%) had nonspecific presentations without the classic signs of seizure, vesicular rash, or critical illness (intensive care admission). All infants with nonspecific presentation were ≤14 days, had cerebrospinal fluid pleocytosis, or both. CONCLUSIONS: The majority of infants with HSV (84%) presented with seizure, vesicular rash, or critical illness. A subset of patients (16%) lacked classic signs at hospitalization; most manifested signs suggestive of HSV within 24 hours. Further studies are needed to validate the risk factors identified in this study including age <14 days and cerebrospinal fluid pleocytosis at presentation.

Computerized self-interviews improve Chlamydia and gonorrhea testing among youth in the emergency department.

STUDY OBJECTIVE: National guidelines recommend annual Chlamydia trachomatis and Neisseria gonorrhoeae screening for sexually active youth at risk for infection. These infections have serious sequelae in women if untreated, and methods to improve testing are needed. We hypothesize that an electronic method of identifying at-risk youth will significantly increase testing for these sexually transmitted infections during emergency department (ED) visits. METHODS: We developed an audio-enhanced computer-assisted self-interview (ACASI) to obtain sexual histories from ED patients and an embedded decision tree to create a sexually transmitted infection testing recommendation. ED health care providers were prompted by the electronic medical record to review the participant answers and testing recommendations, and to offer testing to at-risk youth. Patients aged 15 to 21 years and visiting the St. Louis Children's Hospital ED, regardless of complaint, were eligible for participation. RESULTS: Sexually transmitted infection testing among all 15- to 21-year-old ED patients increased from 9.3% in the 3 months before the ACASI to 17.8% during the 8-month period the ACASI was available and diminished to 12.4% in the 3 months after ACASI withdrawal (P<.001). During the ACASI period, we approached 51.4% of eligible patients and enrolled 59.8% (800/1,337) of those approached. Among ACASI participants, 52.4% (419/800) received a recommendation to receive sexually transmitted infection testing. Of these patients, 52.7% (221/419) received testing in the ED and 18.1% (40/221) of those tested had positive results for chlamydia or gonorrhea, 55% of whom (22/40) had chief complaints unrelated to sexually transmitted infections. Most participants (89%) rated the ACASI easy to use. CONCLUSION: Sexually transmitted infection testing in the ED significantly increased during ACASI use and diminished after withdrawal. The ACASI was well accepted by youth and holds promise for enhancing sexually transmitted infection testing in the ED.

PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study.

BACKGROUND: Cervical spine injuries in children are uncommon but potentially devastating; however, indiscriminate neck imaging after trauma unnecessarily exposes children to ionising radiation. The aim of this study was to derive and validate a paediatric clinical prediction rule that can be incorporated into an algorithm to guide radiographic screening for cervical spine injury among children in the emergency department. METHODS: In this prospective observational cohort study, we screened children aged 0-17 years presenting with known or suspected blunt trauma at 18 specialised children's emergency departments in hospitals in the USA affiliated with the Pediatric Emergency Care Applied Research Network (PECARN). Injured children were eligible for enrolment into derivation or validation cohorts by fulfilling one of the following criteria: transported from the scene of injury to the emergency department by emergency medical services; evaluated by a trauma team; and undergone neck imaging for concern for cervical spine injury either at or before arriving at the PECARN-affiliated emergency department. Children presenting with solely penetrating trauma were excluded. Before viewing an enrolled child's neck imaging results, the attending emergency department clinician completed a clinical examination and prospectively documented cervical spine injury risk factors in an electronic questionnaire. Cervical spine injuries were determined by imaging reports and telephone follow-up with guardians within 21-28 days of the emergency room encounter, and cervical spine injury was confirmed by a paediatric neurosurgeon. Factors associated with a high risk of cervical spine injury (>10%) were identified by bivariable Poisson regression with robust error estimates, and factors associated with non-negligible risk were identified by classification and regression tree (CART) analysis. Variables were combined in the cervical spine injury prediction rule. The primary outcome of interest was cervical spine injury within 28 days of initial trauma warranting inpatient observation or surgical intervention. Rule performance measures were calculated for both derivation and validation cohorts. A clinical care algorithm for determining which risk factors warrant radiographic screening for cervical spine injury after blunt trauma was applied to the study population to estimate the potential effect on reducing CT and x-ray use in the paediatric emergency department. This study is registered with ClinicalTrials.gov, NCT05049330. FINDINGS: Nine emergency departments participated in the derivation cohort, and nine participated in the validation cohort. In total, 22 430 children presenting with known or suspected blunt trauma were enrolled (11 857 children in the derivation cohort; 10 573 in the validation cohort). 433 (1·9%) of the total population had confirmed cervical spine injuries. The following factors were associated with a high risk of cervical spine injury: altered mental status (Glasgow Coma Scale [GCS] score of 3-8 or unresponsive on the Alert, Verbal, Pain, Unresponsive scale [AVPU] of consciousness); abnormal airway, breathing, or circulation findings; and focal neurological deficits including paresthesia, numbness, or weakness. Of 928 in the derivation cohort presenting with at least one of these risk factors, 118 (12·7%) had cervical spine injury (risk ratio 8·9 [95% CI 7·1-11·2]). The following factors were associated with non-negligible risk of cervical spine injury by CART analysis: neck pain; altered mental status (GCS score of 9-14; verbal or pain on the AVPU; or other signs of altered mental status); substantial head injury; substantial torso injury; and midline neck tenderness. The high-risk and CART-derived factors combined and applied to the validation cohort performed with 94·3% (95% CI 90·7-97·9) sensitivity, 60·4% (59·4-61·3) specificity, and 99·9% (99·8-100·0) negative predictive value. Had the algorithm been applied to all participants to guide the use of imaging, we estimated the number of children having CT might have decreased from 3856 (17·2%) to 1549 (6·9%) of 22 430 children without increasing the number of children getting plain x-rays. INTERPRETATION: Incorporated into a clinical algorithm, the cervical spine injury prediction rule showed strong potential for aiding clinicians in determining which children arriving in the emergency department after blunt trauma should undergo radiographic neck imaging for potential cervical spine injury. Implementation of the clinical algorithm could decrease use of unnecessary radiographic testing in the emergency department and eliminate high-risk radiation exposure. Future work should validate the prediction rule and care algorithm in more general settings such as community emergency departments. FUNDING: The Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Health Resources and Services Administration of the US Department of Health and Human Services in the Maternal and Child Health Bureau under the Emergency Medical Services for Children programme.

Adapting an Electronic STI Risk Assessment Program for Use in Pediatric Primary Care.

OBJECTIVES: Sexually transmitted infections (STIs) are an ongoing public health issue in adolescents. the Centers for Disease Control and Prevention and American Academy of Pediatrics have and continue to recommend STI screening in at-risk adolescents, however screening and testing continues to lag behind the need. We previously designed and implemented an electronic risk assessment tool to support STI testing in our pediatric emergency department. Pediatric primary care clinics may be better positioned for STI risk assessments, as they can offer greater privacy and confidentiality, a lower stress environment, and greater opportunity for longitudinal care. STI risk assessment and testing continues to be a challenge in this setting. The goal of this work was to evaluate the usability of our electronic tool to support adaptation and implementation in pediatric primary care practices. METHODS: We conducted qualitative interviews of pediatricians, clinic staff, and adolescents from 4 pediatric practices as part of a study whose goal is to ultimately implement STI screening in pediatric primary care. The goal of the interviews were (1) to understand contextual factors related to STI screening in primary care, which we have reported previously, and (2) to obtain feedback on our electronic platform, the questionnaire content, and their perspective on implementing it in primary care settings, which we report here. We received quantitative feedback using the System Usability Scale (SUS). The SUS is a validated, reliable tool to measure the usability of hardware, software, websites, and applications. SUS scores range from a score of 0 to 100, with a score of 68 or higher indicating above average usability. We additionally obtained qualitative feedback via interviews and used inductive analysis to identify common themes. RESULTS: We recruited 14 physicians, 9 clinic staff, and 12 adolescents. Participants rated the tool highly using the SUS, with a median score of 92.5 (threshold for average usability is 68) and an interquartile range of 82.5 to 100. Thematically, all participants perceived a need for such a screening program and indicated the format would encourage more honest responses on the topic adolescents. We used these results to modify the questionnaire prior to implementing it into participating practices. CONCLUSION: We demonstrated that our electronic STI risk assessment tool had a high level of usability and could be adapted for use in pediatric primary care.

Decision-making for pediatric cervical spine imaging after blunt trauma: Investigating team dynamics in the emergency department.

Objective: Cervical spine imaging decision-making for pediatric traumas is complex and multidisciplinary. Implementing a risk assessment tool has the potential to reduce variation in these decisions and unnecessary radiation exposure for pediatric patients. We sought to determine how emergency department-trauma team dynamics may affect implementation of such a tool. Methods: We interviewed (pediatric and general emergency physicians, trauma surgeons, neurosurgeons, orthopedic surgeons and ED nurses at 21 hospitals to ascertain how team dynamics affect the pediatric cervical spine imaging decision-making process. Data were coded following a framework-driven deductive coding process and thematic analysis was used. Results: Forty-eight physicians, advanced practice providers, and nurses from 21 hospitals (inclusive of three US regions, trauma levels I-III, and serving towns/cities of various population sizes) were interviewed. Overall, emergency physicians and trauma surgeons indicate being generally responsible for pediatric cervical spine imaging decisions. Conflict often occurs between these specialties due to differential weighting of concerns for missing an injury versus avoiding radiation exposure. Participants described a lack of trust and unclear roles regarding ownership for the final imaging decision. Nurses commonly described low psychological safety that prohibits them from participating in the decision-making process. Conclusions: Implementation of a standardized risk assessment tool for cervical spine trauma imaging decisions must consider perspectives of both emergency medicine and trauma. Policies to define appropriate use of standardized tools within this team environment should be developed.