Emergency Department Visits for Behavioral Health Concerns After Sexual Assault: A Retrospective Mixed Methods Study.

The mental health issues that can follow sexual assault are well described. Mental health service (MHS) referrals can be beneficial but can be challenging to obtain. Absence of MHS can exacerbate mental health issues and lead to subsequent emergency visits. Sexual assault victims may therefore have an increased risk of returning to the emergency department (ED). OBJECTIVES: The primary purpose of this study was to identify the prevalence of patients who are victims of sexual assault who subsequently return to the ED with behavioral health (BH) concerns. The secondary purpose of this study was to explore potential factors that may affect whether a patient returns to the ED. METHODS: Using a retrospective design, we examined electronic medical records and a quality improvement database of patients aged 12 to 15 years (inclusive) who sought care in a large, urban, freestanding, tertiary care children's hospital ED after an acute sexual assault. RESULTS: Our primary finding was that of 192 included patients, 24.5% (95% confidence interval, 18.6%-31.2%) subsequently returned to the ED with BH concerns. Of these, 14 (7.3%) returned within 6 months. Secondary aim results included observed trust and mistrust in providers as documented in ED provider notes among patients with previous experience in the MHS system. CONCLUSIONS: A substantial proportion of patients who are victims of sexual assault return to the ED for BH concerns at some point. Further investigation is needed to determine factors affecting a return visit to the ED, which can lead to improved services when caring for sexual assault victims.

Clustering user preferences for personalized teleoperation control schemes via trajectory similarity analysis.

Successful operation of a teleoperated robot depends on a well-designed control scheme to translate human motion into robot motion; however, a single control scheme may not be suitable for all users. On the other hand, individual personalization of control schemes may be infeasible for designers to produce. In this paper, we present a method by which users may be classified into groups with mutually compatible control scheme preferences. Users are asked to demonstrate freehand motions to control a simulated robot in a virtual reality environment. Hand pose data is captured and compared with other users using SLAM trajectory similarity analysis techniques. The resulting pairwise trajectory error metrics are used to cluster participants based on their control motions, without foreknowledge of the number or types of control scheme preferences that may exist. The clusters identified for two different robots shows that a small number of clusters form stably for each case, each with its own control scheme paradigm. Survey data from participants validates that the clusters identified through this method correspond to the participants' control scheme rationales, and also identify nuances in participant control scheme descriptions that may not be obvious to designers relying only on participant explanations of their preferences.

Enhancing the emergency department approach to pediatric sexual assault care: implementation of a pediatric sexual assault response team program.

OBJECTIVES: The objectives of this study were to describe the experience of a novel pediatric sexual assault response team (SART) program in the first 3 years of implementation and compare patient characteristics, evaluation, and treatment among subpopulations of patients. METHODS: This was a retrospective chart review of a consecutive sample of patients evaluated at a pediatric emergency department (ED) who met institutional criteria for a SART evaluation. Associations of evaluation and treatment with sex, menarchal status, and presence of injuries were measured using logistic regression. RESULTS: One hundred eighty-four patients met criteria for SART evaluation, of whom 87.5% were female; mean age was 10.1 (SD, 4.6) years. The majority of patients underwent forensic evidence collection (89.1%), which varied by menarchal status among girls (P < 0.01), but not by sex. Evidence of acute anogenital injury on physical examination was found in 20.6% of patients. As per the Centers for Disease Control and Prevention guidelines for acute sexual assault evaluations in pediatric patients, menarchal girls were more likely to undergo testing for sexually transmitted infections and pregnancy (P < 0.01) and to be offered pregnancy, sexually transmitted infection, and HIV prophylaxis (P < 0.01). CONCLUSIONS: In an effort to improve quality and consistency of acute sexual assault examinations in a pediatric ED, development of a SART program supported the majority of eligible patients undergoing forensic evidence collection. Furthermore, a substantial number of patients had evidence of injury on examination. These findings underscore the importance of having properly trained personnel to support ED care for pediatric victims of acute sexual assault.

Contraceptive counseling for adolescents in the emergency department: A novel curriculum for nurse practitioners and physician assistants.

ABSTRACT: Many adolescents use the emergency department (ED) as their primary source of health care. As a result, the ED serves as a unique opportunity to reach adolescents. Although many adolescent visits to the ED are related to reproductive health, ED providers report barriers to providing this care, including lack of training. Nurse practitioners (NPs) and physician assistants (PAs) serve a vital role in the provision of consistent care to adolescents in the ED. The purpose of this study was to create a curriculum to train NPs and PAs at two pediatric institutions to provide patient-centered contraceptive counseling to adolescents in the pediatric ED regardless of their chief complaint. To do this, we created a four-part webinar followed by an in-person training session. Participants completed training and then conducted counseling sessions with adolescents in the ED. Counseling sessions were recorded and reviewed for fidelity to delineated counseling principles, and data from post-counseling surveys were collected. 27 NPs and PAs completed the training and conducted 99 counseling sessions. Nearly all sessions incorporated essential content and communication principles such as shared decision making (90%) and teach-back methods (75%). All NPs and PAs who participated reported satisfaction and subjective improvement in knowledge and competence from the training. This curriculum offers a novel and feasible approach to train NPs and PAs to deliver patient-centered contraception counseling to adolescents in the ED setting, and it can serve as a model for how to educate different providers to incorporate reproductive health education into the busy ED visit.

Characterizing Multiple Perpetrator Sexual Assaults in the Adolescent Female Population.

STUDY OBJECTIVE: To determine whether differences exist between the acute presentations and post-assault needs of youth presenting to an emergency department (ED) following multiple perpetrator sexual assault (MPSA) compared with those presenting after single perpetrator sexual assault. METHODS: A retrospective cohort study of all female adolescents evaluated in an urban pediatric ED between 2014 and 2021 for acute sexual assault was conducted. Demographic characteristics and assault outcomes were assessed using bivariate analyses. RESULTS: Survivors of MPSA were not more likely than survivors of single perpetrator assaults to be diagnosed with an anal-genital injury or sexually transmitted infection but were more likely to re-present in the subsequent year for an emergent mental health concern (31% vs 11%, P = .001), including suicide attempt (6% vs 1%, P = .022). CONCLUSION: The high rate of subsequent ED visits for mental health concerns among female adolescent survivors of MPSA highlights the need for providing specialized support to this population.

Improving Anaphylaxis Care: The Impact of a Clinical Pathway.

BACKGROUND: Recommended durations of observation after anaphylaxis have been widely variable, with many ranging from 4 to 24 hours. Prolonged durations often prompt admission for ongoing observation. METHODS: In a multidisciplinary quality improvement initiative, we revised our emergency department (ED) anaphylaxis clinical pathway. Our primary aim was to safely decrease the recommended length of observation from 8 to 4 hours and thereby decrease unnecessary hospitalizations. Secondary aims included provider education on anaphylaxis diagnostic criteria, emphasizing epinephrine as first-line therapy, and implementing a practice of discharging ED patients with an epinephrine autoinjector in hand. The study period consisted of the 18 months before pathway revision (baseline) and the 18 months after revision. RESULTS: The overall admission rate decreased from 58.2% (106 of 182) in the baseline period to 25.3% (65 of 257) after pathway revision (P < .0001). There was no significant difference in the percentage of patients returning to the ED within 72 hours, and there were no adverse outcomes or deaths throughout the study period. After pathway revision, the median time to first epinephrine administration for the most critical patients was 10 minutes, and 85.4% (164 of 192) of patients were discharged with an epinephrine autoinjector in hand. CONCLUSIONS: By revising an anaphylaxis clinical pathway, we were able to streamline the care of patients with anaphylaxis presenting to a busy pediatric ED, without any compromise in safety. Most notably, decreasing the recommended length of observation from 8 to 4 hours resulted in a near 60% reduction in the average rate of admission.

Improving HIV post-exposure prophylaxis rates after pediatric acute sexual assault.

The purpose of our study was to increase the rate of children with appropriate HIV-PEP regimens among those diagnosed with sexual assault in The Children's Hospital of Philadelphia Emergency Department (ED). The outcome measure was the percent of patients receiving correct HIV-PEP. We retrospectively reviewed 97 charts over 31 months to define the baseline rate of children receiving appropriate HIV-PEP regimens (pre QI-implementation period: 2/2012-8/2014). Among children in which HIV-PEP was indicated following sexual assault, 40% received the recommended 28-day course. Root cause analysis indicated prescribing errors accounted for 87% of patients not receiving appropriate HIV-PEP. Process drivers included standardizing care coordination follow-up calls to elicit specific information about HIV-PEP, ED educational initiatives targeted at HIV-PEP prescribing, revision of the clinical pathway to specify indicated duration of HIV-PEP, and revision of the order set to auto-populate the number of days for the HIV-PEP prescription. During the QI-implementation period (9/2014-4/2015), the rate of appropriate HIV-PEP increased to 64% (median 60%) and the average number of days between incorrect HIV-PEP regimens was 24.5. Post QI-implementation (5/2015-3/2016), the rate of appropriate HIV-PEP increased to 84% (median 100%) and the average number of days between incorrect HIV-PEP regimens increased to 78.4. A multifaceted quality improvement process improved the rate of receipt of appropriate HIV-PEP regimens for pediatric victims of sexual assault. Decision support tools are instrumental in sustaining ideal care delivery, but require ongoing evaluation and improvement in order to remain optimally effective.

Evaluating the role of coastal habitats and sea-level rise in hurricane risk mitigation: An ecological economic assessment method and application to a business decision.

Businesses may be missing opportunities to account for ecosystem services in their decisions, because they do not have methods to quantify and value ecosystem services. We developed a method to quantify and value coastal protection and other ecosystem services in the context of a cost-benefit analysis of hurricane risk mitigation options for a business. We first analyze linked biophysical and economic models to examine the potential protection provided by marshes. We then applied this method to The Dow Chemical Company's Freeport, Texas facility to evaluate natural (marshes), built (levee), and hybrid (marshes and a levee designed for marshes) defenses against a 100-y hurricane. Model analysis shows that future sea-level rise decreases marsh area, increases flood heights, and increases the required levee height (12%) and cost (8%). In this context, marshes do not provide sufficient protection to the facility, located 12 km inland, to warrant a change in levee design for a 100-y hurricane. Marshes do provide some protection near shore and under smaller storm conditions, which may help maintain the coastline and levee performance in the face of sea-level rise. In sum, the net present value to the business of built defenses ($217 million [2010 US$]) is greater than natural defenses ($15 million [2010 US$]) and similar to the hybrid defense scenario ($229 million [2010 US$]). Examination of a sample of public benefits from the marshes shows they provide at least $117 million (2010 US$) in coastal protection, recreational value, and C sequestration to the public, while supporting 12 fisheries and more than 300 wildlife species. This study provides information on where natural defenses may be effective and a replicable approach that businesses can use to incorporate private, as well as public, ecosystem service values into hurricane risk management at other sites.