Youth victim perspective: optimizing presentation of patient-reported outcomes in a violence intervention program.

INTRODUCTION: The health, well-being and psychological development of children in urban areas is threatened by exposure to interpersonal violence. Violence intervention programs, such as Project Ujima, provide children with comprehensive treatment following exposure to violence. Services focus on the interruption of the violence cycle, mental health, and developing resiliency. The collection of patient-reported outcomes (PROs) from youth victims of violence informs community-based, programmatic, and individual participant interventions. Although the collection of PROs throughout treatment has been demonstrated to be feasible, youth and crime victim specialist preferences for data presentation is unknown. We sought to determine patient and crime victim specialist preferences regarding which PROs are of interest and how best to visually display them for optimal engagement. RESULTS: Fifteen youth and nine crime victim specialists consented to participate. Both preferred visuals with the highest level of color-shading and descriptions. The domains with the highest level of interest among both youth and case workers were social, anger, emotional, school, physical, peer relations, and psychosocial well-being. Youth and crime victim specialists expressed low interest in positive affect, meaning/purpose, physical stress experience, and depression domains. Youth wanted to see their scores compared to others in the program, while crime victim specialists did not think such comparisons would be beneficial. In contrast to youth, crime victim specialists believed youth should see their physical functioning and PTSD scores. CONCLUSION: Youth participants and their crime victim specialists in a violence intervention program desired to see their PROs in a graphical form and agreed on their preference for many of the domains except for PTSD and physical functioning. Both groups preferred visuals with the highest level of shading and descriptions. Further investigation is needed to determine how to implement PRO visuals with the desired domains into regular violence intervention programming. METHODS: Participants in Project Ujima's 8-week summer camp, ages 7-18 years, who were either a victim of violent injury, a direct relative of a violent injury victim, or a homicide survivor were recruited for this qualitative study. Crime victim specialists, who work directly with these youth throughout the year, were also recruited to participate. We conducted structured interviews to determine which parameters and visual formats were of highest interest and best understood by youth participants and crime victim specialists.

Prediction of Suicide Attempts and Suicide-Related Events Among Adolescents Seen in Emergency Departments.

Importance: Screening adolescents in emergency departments (EDs) for suicidal risk is a recommended strategy for suicide prevention. Comparing screening measures on predictive validity could guide ED clinicians in choosing a screening tool. Objective: To compare the Ask Suicide-Screening Questions (ASQ) instrument with the Computerized Adaptive Screen for Suicidal Youth (CASSY) instrument for the prediction of suicidal behavior among adolescents seen in EDs, across demographic and clinical strata. Design, Setting, and Participants: The Emergency Department Study for Teens at Risk for Suicide is a prospective, random-series, multicenter cohort study that recruited adolescents, oversampled for those with psychiatric symptoms, who presented to the ED from July 24, 2017, through October 29, 2018, with a 3-month follow-up to assess the occurrence of suicidal behavior. The study included 14 pediatric ED members of the Pediatric Emergency Care Applied Research Network and 1 Indian Health Service ED. Statistical analysis was performed from May 2021 through January 2023. Main Outcomes and Measures: This study used a prediction model to assess outcomes. The primary outcome was suicide attempt (SA), and the secondary outcome was suicide-related visits to the ED or hospital within 3 months of baseline; both were assessed by an interviewer blinded to baseline information. The ASQ is a 4-item questionnaire that surveys suicidal ideation and lifetime SAs. A positive response or nonresponse on any item indicates suicidal risk. The CASSY is a computerized adaptive screening tool that always includes 3 ASQ items and a mean of 8 additional items. The CASSY's continuous outcome is the predicted probability of an SA. Results: Of 6513 adolescents available, 4050 were enrolled, 3965 completed baseline assessments, and 2740 (1705 girls [62.2%]; mean [SD] age at enrollment, 15.0 [1.7] years; 469 Black participants [17.1%], 678 Hispanic participants [24.7%], and 1618 White participants [59.1%]) completed both screenings and follow-ups. The ASQ and the CASSY showed a similar sensitivity (0.951 [95% CI, 0.918-0.984] vs 0.945 [95% CI, 0.910-0.980]), specificity (0.588 [95% CI, 0.569-0.607] vs 0.643 [95% CI, 0.625-0.662]), positive predictive value (0.127 [95% CI, 0.109-0.146] vs 0.144 [95% CI, 0.123-0.165]), and negative predictive value (both 0.995 [95% CI, 0.991-0.998], respectively). Area under the receiver operating characteristic curve findings were similar among patients with physical symptoms (ASQ, 0.88 [95% CI, 0.81-0.95] vs CASSY, 0.94 [95% CI, 0.91-0.96]). Among patients with psychiatric symptoms, the CASSY performed better than the ASQ (0.72 [95% CI, 0.68-0.77] vs 0.57 [95% CI, 0.55-0.59], respectively). Conclusions and Relevance: This study suggests that both the ASQ and the CASSY are appropriate for universal screening of patients in pediatric EDs. For the small subset of patients with psychiatric symptoms, the CASSY shows greater predictive validity.

An intervention to improve safe firearm storage for adolescents presenting with suicide ideation or attempt in a pediatric emergency department.

BACKGROUND: Firearm injuries are the second leading cause of death in American youth aged 15 to 24, and over half of these deaths are suicides. Self-harm deaths in Wisconsin among adolescents have increased by 34% since 2006. Each year, our pediatric emergency department (ED) staff care for over 1100 children and adolescents who present with suicidal ideation or self-harming behaviors. We implemented an ED-based program aimed at improving the education given to families on reducing self-directed violence and providing firearm storage devices to families with the goal of reducing access to lethal means. PROGRAM DESCRIPTION: Our program takes place in the pediatric ED of an academic children's hospital and seeks to assist families of all patients who present with suicidal ideation or suicide attempt (SI/SA). In collaboration with our social workers, we reviewed their processes for interviewing and counseling families of patients who present with SI/SA. Social workers previously used a hospital-wide patient and family education sheet for safety planning that included information about safely storing medications and community mental health services. We teamed with our hospital's health literacy and education committees and revised the teaching sheet to include more in-depth information about safe firearm storage. For families who were interested, we developed a process to provide up to two firearm lockboxes equipped with a combination lock. Working with risk management, the parent injury prevention product liability form was updated to include firearm lockboxes. CONCLUSION: We implemented a safe firearm storage program including development of a patient and family education sheet and provision of firearm lockboxes to families. Next steps under consideration include providing lockboxes for safe medication storage and establishing a follow-up system to assess proper use of firearm lockboxes and family and social worker satisfaction.

Understanding adolescent responses to differently worded suicide attempt questions: results from a large US pediatric sample.

BACKGROUND: Clinical assessments are a primary method for ascertaining suicide risk, yet the language used across measures is inconsistent. The implications of these discrepancies for adolescent responding are unknown, which is troubling as multiple research areas (i.e. on culture, mental health language, and suicide communication) indicate individuals from varying sociodemographic backgrounds may communicate differently regarding mental health concerns. The aims of the current study are to investigate whether a geographically diverse sample of adolescents respond differently to directly and indirectly phrased suicide attempt questions (i.e. directly phrased includes the term 'suicide' and indirectly asks about suicidal behavior without using 'suicide'), and to examine whether sociodemographic factors and history of mental health service usage relate to endorsement differences. METHODS: Participants were N = 5909 adolescents drawn from the Emergency Department Screening for Teens at Risk for Suicide multi-site study. The lifetime suicide attempt was assessed with two items from an adapted version of the Columbia Suicide Severity Rating Scale (C-SSRS; Posner et al., 2008): (1) a directly phrased question asking about 'suicide attempts' and (2) an indirectly phrased question providing the definition of an attempt. RESULTS: An adolescent majority (83.7%) consistently reported no lifetime suicide attempt across items, 10.1% consistently reported one or more lifetime attempts across items, and 6.2% of adolescents responded discordantly to the items. CONCLUSIONS: Multivariable models indicated multiple demographic and mental health service variables significantly predicted discordant responding, with a notable finding being that father/stepfather education level at or below high school education predicted endorsing only the direct question.

Assessing improvements in emergency department referrals to a hospital-based violence intervention program.

BACKGROUND: Youth violence is a major public health concern in the United States. Hospital-based Violence Intervention Programs (HVIPs) are integral in connecting youth sustaining interpersonal violence-related injuries to medical, mental health, and social services. At our pediatric emergency department, our baseline referral rate to the established HVIP was 32.5%. From November 2018-2019, we aimed to increase the percent of eligible patients referred to our HVIP from 32.5 to 70% for patients aged 7-18 years who present to our Level 1 emergency department/trauma center with a violent injury. METHODS: For this quality improvement project, we recorded key aspects of the referral process, such as patient eligibility, who placed referrals, and when referrals were placed in relation to the ED admission. Key stakeholders were interviewed to identify specific interventions. Our key interventions were: 1. Educating providers on eligibility requirements. 2. Encouraging nurses to enter consults at the time of admission. 3. Publishing information about program referrals in the weekly nursing newsletter. 4. Updating social workers on eligibility requirements for the HVIP. We used PDSA cycles to inform our project. Our primary outcome measure was the number of eligible patients referred to our HVIP and measures were analyzed using statistical process control charts. RESULTS: The HVIP-eligible population had the following demographics: 31.1% female and a mean age 14.3 ± 2.7, 82.6% assaults and 17.4% gunshot wounds. From 11/2018 to 11/2019, there were 78 referrals to the HVIP, out of 167 eligible patients. The referral rate improved from 32.5% pre-interventions to 61.1% post-interventions, showing an 88% increase. CONCLUSION(S): We noted an increase in referrals to our HVIP following our interventions that centered on educating, advertising, and encouraging. Future studies will focus on analyzing other aspects of the enrollment process, such as obtaining patient consent.

Prospective Development and Validation of the Computerized Adaptive Screen for Suicidal Youth.

Importance: The rate of suicide among adolescents is rising in the US, yet many adolescents at risk are unidentified and receive no mental health services. Objective: To develop and independently validate a novel computerized adaptive screen for suicidal youth (CASSY) for use as a universal screen for suicide risk in medical emergency departments (EDs). Design, Setting, and Participants: Study 1 of this prognostic study prospectively enrolled adolescent patients at 13 geographically diverse US EDs in the Pediatric Emergency Care Applied Research Network. They completed a baseline suicide risk survey and participated in 3-month telephone follow-ups. Using 3 fixed Ask Suicide-Screening Questions items as anchors and additional items that varied in number and content across individuals, we derived algorithms for the CASSY. In study 2, data were collected from patients at 14 Pediatric Emergency Care Applied Research Network EDs and 1 Indian Health Service hospital. Algorithms were independently validated in a prospective cohort of adolescent patients who also participated in 3-month telephone follow-ups. Adolescents aged 12 to 17 years were consecutively approached during randomly assigned shifts. Exposures: Presentation at an ED. Main Outcome and Measure: A suicide attempt between ED visit and 3-month follow-up, measured via patient and/or parent report. Results: The study 1 CASSY derivation sample included 2075 adolescents (1307 female adolescents [63.0%]; mean [SD] age, 15.1 [1.61] years) with 3-month follow-ups (72.9% retention [2075 adolescents]). The study 2 validation sample included 2754 adolescents (1711 female adolescents [62.1%]; mean [SD] age, 15.0 [1.65] years), with 3-month follow-ups (69.5% retention [2754 adolescents]). The CASSY algorithms had excellent predictive accuracy for suicide attempt (area under the curve, 0.89 [95% CI, 0.85-0.91]) in study 1. The mean number of adaptively administered items was 11 (range, 5-21). At a specificity of 80%, the CASSY had a sensitivity of 83%. It also demonstrated excellent accuracy in the study 2 validation sample (area under the curve, 0.87 [95% CI, 0.85-0.89]). In this study, the CASSY had a sensitivity of 82.4% for prediction of a suicide attempt at the 80% specificity cutoff established in study 1. Conclusions and Relevance: In this study, the adaptive and personalized CASSY demonstrated excellent suicide attempt risk recognition, which has the potential to facilitate linkage to services.

Participation of Children and Adolescents in Live Crisis Drills and Exercises.

Children and adolescents should be included in exercises and drills to the extent that their involvement advances readiness to meet their unique needs in the event of a crisis and/or furthers their own preparedness or resiliency. However, there is also a need to be cautious about the potential psychological risks and other unintended consequences of directly involving children in live exercises and drills. These risks and consequences are especially a concern when children are deceived and led to believe there is an actual attack and not a drill and/or for high-intensity active shooter drills. High-intensity active shooter drills may involve the use of real weapons, gunfire or blanks, theatrical makeup to give a realistic image of blood or gunshot wounds, predatory and aggressive acting by the individual posing to be the shooter, or other means to simulate an actual attack, even when participants are aware that it is a drill. This policy statement outlines some of the considerations regarding the prevalent practice of live active shooter drills in schools, including the recommendations to eliminate children's involvement in high-intensity drills and exercises (with the possible exception of adolescent volunteers), prohibit deception in drills and exercises, and ensure appropriate accommodations during drills and exercises based on children's unique vulnerabilities.

Youth Victims of Violence Report Worse Quality of Life Than Youth With Chronic Diseases.

OBJECTIVES: Measuring health-related quality of life (HRQOL) provides the patient's perspective of his/her well-being and offers a unique outcome measure to demonstrate the impact of violence on the victim. To date, no study has described HRQOL in youth victims of violence in the United States. The purpose of this study was to describe HRQOL in youth victims of violence as compared with healthy youth and youth with chronic disease. METHODS: We conducted an exploratory cross-sectional study of the HRQOL of victims of violence aged 8 to 18 years. Descriptive statistics were reported for participant and injury demographics. One sample t tests were used to compare the sample population's HRQOL to known HRQOL of healthy populations and specific disease populations. RESULTS: Fifty-eight victims of violence participated in the study. Youth victims of violence had significantly worse mean HRQOL scores (mean, 71.4) compared with healthy youth in overall functioning (mean, 83.9), P < 0.001. Youth victims of violence reported worse psychosocial (mean, 67.6), emotional (mean, 62.9), and school (mean, 63.8) functioning than youth with obesity (mean, 72.1, 68.6, 75.0, respectively) and cancer (mean, 72.1, 72.2, 68.3, respectively). Mean Patient-Reported Outcomes Measurement Information System T scores for youth victims of violence were significantly worse in anxiety (T = 51.9) and depression (T = 52.4) compared with youth with obesity (T = 48.3, 49.2), cancer (T = 47.7, 47.6), and sickle cell disease (T = 43, 44). CONCLUSIONS: Youth victims of violence suffer significant impairment in HRQOL compared with healthy populations and youth with specific disease burdens. Future studies into violence prevention effectiveness should use HRQOL as a comparative outcome measure to better tailor post injury management and interventions.

Patient at Risk: Emergency medical service providers' opinions on improving an electronic emergency information form database for the medical care of children with special health care needs.

BACKGROUND: Patient at Risk (PAR) is an online database using an emergency information form (EIF) that parents of children with special health care needs (CSHCN) complete to store their child's medical information. Emergency medical service (EMS) providers can then access PAR during medical emergencies or for pre-planning. PAR was active for over 10 years but use by patients and EMS was limited. OBJECTIVE: To determine EMS perspectives on why PAR was not used to its full potential and how to improve PAR for EMS. METHODS: Seven questions regarding PAR were developed and presented in focus groups at 32 fire/ambulance houses in southeast and central Wisconsin from June to August 2017. Responses were transcribed and reviewed for themes. RESULTS: 146 EMS providers participated and 11% were aware of PAR. Many did not use PAR because of a lack of follow up or barriers such as limited internet access, inconvenience, other urgent responsibilities, and not knowing when to use PAR. Solutions to these issues include developing or purchasing new technology, involving the dispatch operator in PAR, and returning to a paper-based EIF. The EIF layout and content received very positive reviews with few changes suggested. Most providers felt PAR was important because it would help them provide better care and feel more comfortable treating CSHCN. CONCLUSION: Despite technological and logistical barriers, EMS providers want online EIF databases for pre-planning and utilization during ambulance runs so they can practice more informed and focused care, especially for vulnerable and medically challenging CSHCN.

Five Profiles of Adolescents at Elevated Risk for Suicide Attempts: Differences in Mental Health Service Use.

OBJECTIVE: Adolescents at risk for suicide are highly heterogeneous in terms of psychiatric and social risk factors, yet there has been little systematic research on risk profiles, which would facilitate recognition and the matching of patients to services. Our primary study aims were to identify latent class profiles of adolescents with elevated suicide risk, and to examine the association of these profiles with mental health service use (MHSU). METHOD: Participants were 1,609 adolescents from the Emergency Department Screen for Teens at Risk for Suicide (ED-STARS) cohort. Participants completed baseline surveys assessing demographics, MHSU, and suicide risk. Telephone follow-up interviews were conducted at 3 months to assess suicide attempts. Participants met pre-established baseline criteria for suicide risk. RESULTS: Using latent class analysis, we derived 5 profiles of elevated suicide risk with differing patterns of eight risk factors: history of multiple suicide attempts, past-month suicidal ideation, depression, alcohol and drug misuse, impulsive-aggression, and sexual and physical abuse. In comparison to adolescents who did not meet baseline criteria for suicide risk, each profile was associated with increased risk of a suicide attempt within 3 months. The MHSU was lowest for adolescents fitting profiles with previous (but no recent) suicidal thoughts and behavior, and for adolescents from racial and ethnic minority groups. CONCLUSION: Adolescents at elevated risk for suicide present to emergency departments with differing profiles of suicide risk. MHSU varies across these profiles and by race/ethnicity, indicating that targeted risk recognition and treatment linkage efforts may be necessary to reach some adolescents at risk.

An educational intervention for medical students to improve self-efficacy in firearm injury prevention counseling.

BACKGROUND: Most physicians support counseling patients about firearm injury prevention (FIP), but infrequently do so due to lack of training and low confidence. Interventions to increase counseling frequency should focus on improving physician self-efficacy. Firearm injuries affect many clinical specialties; therefore, trainees would benefit from early FIP education. This study aims to determine if a 20-min educational intervention improves self-efficacy in FIP counseling in third-year medical students. Knowledge and beliefs were also assessed as secondary indicators of self-efficacy. METHODS: This was a prospective study performed at a medical school associated with a tertiary care children's hospital during the 2016-17 academic year. Groups of 12-15 different third-year medical students were selected to receive either a 20-min intervention or control lecture during their monthly pediatric lectures. The intervention consisted of two clinical vignettes, a brief discussion about the importance of FIP, and suggestions for clinical integration. The control session was a case-based lecture about pediatric emergencies. Participants completed baseline electronic assessments. Intervention students also completed post-intervention assessments immediately following each session. All participants completed final assessments at 6 months. Data were analyzed using Wilcoxon signed-rank tests and Wilcoxon rank-sum. RESULTS: We surveyed a total of 130 students. Sixty-five students completed the entire series of assessments - 22 from the control and 43 from the intervention group. There were no significant differences between the control and intervention groups at baseline. Immediately after, intervention, participants reported feeling more self-efficacious, had improved knowledge of FIP risk factors, and had beliefs more consistent with providing FIP anticipatory guidance (p <  0.001 for all three measures). After 6 months, participants sustained improvement in one of two self-efficacy questions ("I feel ready to counsel patients about firearm injury prevention") and retained knowledge of risk factors (p <  0.05 for both). However, their beliefs did not significantly favor FIP counseling, and they were not more likely to engage in a conversation about firearm safety. CONCLUSIONS: A 20-min educational intervention acutely improved self-efficacy in FIP counseling in third-year medical students, but improvements weakened after six months. Without further training, the beneficial effects of a one-time intervention will likely wane with time.

Trauma-Informed Care for Violently Injured Patients in the Emergency Department.

Violent traumatic injury remains a common condition treated by emergency physicians. The medical management of these patients is well described and remains an area of focus for providers. However, violently injured patients disproportionately carry a history of physical and psychological trauma that frequently affects clinical care in the emergency department. The alteration of our clinical approach, taking into consideration how a patient's previous experiences influence how he or she may perceive and react to medical care, is a concept referred to as trauma-informed care. This approach is based on 4 pillars: knowledge of the effect of trauma, recognition of the signs and symptoms of trauma, avoidance of retraumatization, and the development of appropriate policies and procedures. Using this framework, we provide practical considerations for emergency physicians in the delivery of trauma-informed care for violently injured patients.

Physician Adherence to Centers for Disease Control and Prevention Guidelines for Sexually Active Adolescents in the Pediatric Emergency Setting.

OBJECTIVES: There is limited literature about physicians' adherence to 2010 Centers for Disease Control and Prevention (CDC) Sexually Transmitted Diseases Treatment Guidelines specific to specimen collection testing methods in adolescent females in the emergency setting is limited. The objectives are to (1) determine physician adherence to CDC guidelines for specimen collection/testing for chlamydia and gonorrhea, (2) determine physician characteristics associated with guideline adherence, and (3) describe physicians' knowledge of expedited partner therapy (EPT) laws. METHODS: This is a cross-sectional, anonymous, Internet-based survey of physician members of the American Academy of Pediatrics Section of Emergency Medicine. Questions addressed practice patterns and knowledge through clinical scenarios of adolescent girls. Descriptive statistics are used to report frequency. Fisher exact and χ analyses are used to compare physician subgroups: gender, years in practice, practice setting, and geographical region. RESULTS: Overall, 257 physicians responded and 231 were analyzed; 62.4% females; 46.0% in practice for ≤ 7 years; 86.2% in academic medicine. Specimen collection/testing in an asymptomatic patient were consistent with guidelines for 85.6% of respondents, but decreased to 37.4% for a symptomatic patient. Guideline adherence was not different between physician subgroups. Only 30.4% of physicians reported state EPT law knowledge. CONCLUSIONS: Adherence with the CDC guidelines for chlamydia/gonorrhea specimen collection/testing for adolescents in the emergency setting is inadequate, and EPT knowledge is poor. With increased emergency department use by adolescents, it is critical that physicians know and implement the current recommendations to improve adolescent health outcomes.

Association of Hospital Resources and Imaging Choice for Appendicitis in Pediatric Emergency Departments.

OBJECTIVE: Abdominal pain and concern for appendicitis are common chief complaints in patients presenting to the pediatric emergency department (PED). Although many professional organizations recommend decreasing use of computed tomography (CT) and choosing ultrasound as first-line imaging for pediatric appendicitis, significant variability persists in imaging utilization. This study investigated practice variation across children's hospitals in the diagnostic imaging evaluation of appendicitis and determined hospital-level characteristics associated with the likelihood of ultrasound as the first imaging modality. METHODS: This was a multicenter (seven children's hospitals) retrospective investigation. Data from chart review of 160 consecutive patients aged 3-18 years diagnosed with appendicitis from each site were compared with a survey of site medical directors regarding hospital resource availability, usual practices, and departmental-level demographics. RESULTS: In the diagnostic evaluation of 1,090 children with appendicitis, CT scan was performed first for 22.4% of patients, with a range across PEDs of 3.1% to 83.8%. Ultrasound was performed for 54.0% of patients with a range of 2.5% to 96.9%. The only hospital-level factor significantly associated with ultrasound as the first imaging modality was 24-hour availability of in-house ultrasound (odds ratio = 29.2, 95% confidence interval = 1.2-691.8). CONCLUSION: Across children's hospitals, significant practice variation exists regarding diagnostic imaging in the evaluation of patients with appendicitis. Variation in hospital-level resources may impact the diagnostic evaluation of patients with appendicitis. Availability of 24-hour in-house ultrasound significantly increases the likelihood of ultrasound as first imaging and decreases CT scans. Hospitals aiming to increase the use of ultrasound should consider adding 24-hour in-house coverage.

Improvement in quality of life among violently injured youth after a brief intervention.

BACKGROUND: Youth directly exposed to violence are at risk for experiencing elevated rates of emotional and behavioral problems, revictimization, and becoming future perpetrators of violence. Violence intervention and prevention programs throughout the country attempt to alleviate some of this burden. To date, outcomes have been positive but largely qualitative. Patient-reported outcomes offer objective measures to evaluate well-being in youth victimization. Our primary aim was to use objective patient-reported quantitative measures to assess the change in health-related quality-of-life (HRQOL) scores of youth who attended a violence intervention summer camp. This is the first study to evaluate such measures in youth victims of violence during an intervention. METHODS: Eight- to 18-year-old youth who attended a violence intervention summer camp in a Midwest urban city over a two-year period participated in a HRQOL survey at baseline and at the end of programming (6 weeks). Consented youth used an electronic platform to answer validated HRQOL measures. Mean differences in scores from baseline to six weeks were calculated and reported. RESULTS: A total of 64 youth were recruited and consented to the study. Average change in scores improved in most HRQOL domains with the largest change in scores observed in school functioning (mean diff, +5.00), emotional functioning (mean diff, +5.26), and patient anxiety (mean diff, +3.04). Only participant anger scored worse following the intervention (mean diff, -2.26). CONCLUSION: A community-based summer program hosting violently injured youth resulted in overall improved HRQOL. This was especially significant in the school, anxiety, and emotional domains. Future evaluation into the effectiveness of youth programs should measure HRQOL to identify at-risk participants and to measure effectiveness. LEVEL OF EVIDENCE: Therapeutic/care management study, level III.

Medical providers' understanding of sex trafficking and their experience with at-risk patients.

BACKGROUND AND OBJECTIVES: Sex trafficking (ST) victims have unique medical and mental health needs and are often difficult to identify. Our objectives were to evaluate knowledge gaps and training needs of medical providers, to demonstrate the importance of provider training to meet the pediatric ST victim's specific needs, and to highlight barriers to the identification of and response to victims. METHODS: A survey was sent to providers in specialties that would be most likely to encounter victims of ST. Participants included physicians, nurses, physician assistants, social workers, and patient and family advocates at multiple hospitals and medical clinics in urban, suburban, and rural locations. RESULTS: Of ∼ 500 survey recipients, 168 participants responded. In 2 clinical vignettes, 48% correctly classified a minor as an ST victim, and 42% correctly distinguished an ST victim from a child abuse victim. In all, 63% of respondents said that they had never received training on how to identify ST victims. Those with training were more likely to report ST as a major problem locally (P ≤ .001), to have encountered a victim in their practice (P ≤ .001), and to have greater confidence in their ability to identify victims (P ≤ .001). The greatest barriers to identification of victims reported were a lack of training (34%) and awareness (22%) of ST. CONCLUSIONS: Health care providers demonstrate gaps in knowledge and awareness of ST, specifically of pediatric victims, that correlate with their limited experience and training. Training is crucial to improve identification of these victims and provide appropriate care for their specific needs.

Diagnostic findings in infants presenting to a pediatric emergency department for lethargy or feeding complaints.

OBJECTIVES: Lethargy is a common complaint among infants in the pediatric emergency department (ED), yet there is little data to guide appropriate evaluation. The objectives of the study were (1) to determine the frequency of diagnoses requiring intervention/monitoring and (2) to identify predictors of these diagnoses. METHODS: A retrospective chart review of patients aged 0 to 6 months with a chief complaint of lethargy or poor feeding from January 2004 to December 2009 was performed. Patients were excluded if they had a fever, hypothermia, a chronic medical condition, or a history of trauma. Charts were reviewed by a single investigator; 10% were reviewed by a second investigator for agreement. History, examination, laboratory and radiology results, ED and inpatient diagnoses, as well as return visits within 7 days were recorded. Frequencies of diagnoses and interventions were described, and history and examination findings associated with these categories were determined. RESULTS: Two hundred seventy-two patients were included; 34 patients (12.5%; 95% confidence interval [CI], 8.8%-17%) required intervention/monitoring. These patients were classified into 6 categories. Eighteen had hematologic disorders (6.6%; 95% CI, 4.0%-10.3%), 8 had dehydration (2.9%; 95% CI, 1.3%-5.7%), 2 had intracranial bleeds (0.7%; 95% CI, 0.09%-2.6%), 3 had serious bacterial infections (1%; 95% CI, 0.2%-3.2%), 1 had a cardiac disorder (0.4%; 95% CI, 0.009%-2%), and 2 had neurologic disorders (0.7%; 95% CI, 0.9%-2.6%). Of the patients, 76% had conditions that were clinically evident (dehydration and hyperbilirubinemia requiring phototherapy). The patients with cardiac disorders, neurologic disorders, and intracranial bleeds all had abnormal examination findings in the ED. The 3 patients with serious bacterial infections were younger than 2 months of age and ill appearing; all had urinary tract infections. CONCLUSIONS: Infants with lethargy or poor feeding who require an intervention are likely to have conditions that are clinically evident or focal examination findings that lead to the diagnosis. Well-appearing infants with normal findings in examinations are unlikely to have a condition requiring intervention and should receive minimal testing.

A comprehensive approach to pediatric injury prevention in the emergency department.

Injury is the leading cause of pediatric mortality and long-term disability. Although the primary care setting has traditionally been considered as the main venue to address injury anticipatory guidance, an emergency department (ED) visit may serve as a "teachable moment" because most injured children are cared for in this setting and the experience may elicit a greater chance of behavior change. However, EDs can also provide additional information and services beyond counseling to prevent injuries. These adjunct efforts and activities focus on primary injury prevention (screening for and promoting safe behaviors and collecting data to survey high-risk community locations), secondary prevention (use of safety products to mitigate injury), and tertiary prevention (maximizing injury care and minimizing injury sequelae). This review will describe several ways an ED can help to mitigate the epidemic of pediatric injuries through surveillance, screening, education, product disbursement, community engagement, and quality improvement efforts.