Improving Sexual History Documentation in Teenagers.

BACKGROUND AND OBJECTIVES: Teen access to sexual health care is essential. The 21st Century Cures Act mandates that most electronic health information be shared with patients; no standard exists for how to meet this mandate for teens and their proxy caregivers. Our confidential shared teen sexual history (SexHx) section, which is not note-based, allows clinicians to easily find information, promotes clinical decision support, and protects privacy. Nevertheless, significant variability existed in SexHx section usage, SexHx documentation, and teen note-sharing practices. For teens (aged 12-17) admitted to the Pediatric Hospital Medicine service, we aim to increase the use of the SexHx section by 10% and increase History and Physical notes (H&Ps) shared with teens by 5% over 12 months. METHODS: Quality improvement methodology and tools were used to conduct a barrier analysis and implement a series of interventions, which included education, training, and electronic health record clinical decision support. Statistical process control charts were used to examine the impact of the interventions. RESULTS: At baseline, from April to July 2021, sexual activity was documented or reviewed in the SexHx section for 56% of teen patients. Over the intervention period, the center line shifted to 72%. At baseline, 76% of teen H&Ps were shared with patients. The percentage of H&Ps shared revealed a center-line shift to 81% throughout the intervention period. CONCLUSIONS: The shared teen SexHx section is an innovative tool for capturing sensitive patient history discretely. We demonstrated increased and sustained SexHx section use and H&P note-sharing in this quality improvement initiative.

A Population Health Impact Pyramid for Health Care.

Policy Points To meaningfully impact population health and health equity, health care organizations must take a multipronged approach that ranges from education to advocacy, recognizing that more impactful efforts are often more complex or resource intensive. Given that population health is advanced in communities and not doctors' offices, health care organizations must use their advocacy voices in service of population health policy, not just health care policy. Foundational to all population health and health equity efforts are authentic community partnerships and a commitment to demonstrating health care organizations are worthy of their communities' trust.

Breastfeeding after return to work: An Australian national workplace survey.

Breastfeeding initiation rates in Australia are high but duration rates fall well below the World Health Organization targets. Return to work is a known factor impacting 6 months exclusive breastfeeding and continuation into the infants second year of life. Work related factors can influence a woman's confidence in maintaining breastmilk supply after return to employment and determine whether she meets her personal breastfeeding goals. This cross-sectional online survey is the first Australian study to explore women's experience of maintaining breastfeeding after return to work, in all work sectors. Results revealed variations across work sectors reflected in worker autonomy and confidence in speaking up about breastfeeding rights. Women who had autonomy or flexibility in planning their workday were more likely to be confident in maintaining breastmilk supply. The main predictors for milk supply confidence and meeting personal breastfeeding goals included having: a suitable place to express milk; confidence in speaking out about rights; a formal return-to-work plan; a supportive workplace; and returning to work after the period of exclusive breastfeeding. This study reveals that supportive workplace environments can lead to increased confidence in maintaining milk supply, extending durations of breastfeeding. Women who are confident in their rights to express breastmilk, or breastfeed at work, are more likely to meet their own breastfeeding goals. Education, and awareness raising, on the rights of breastfeeding women in the workplace, is a gender equity imperative that can improve experiences for breastfeeding women, and, increase manager and co-worker knowledge for creating enabling workplace environments for breastfeeding employees.

A practical guide to genetic testing in endocrinology.

Rapid advances in sequencing technology have led to significant improvements in genomic analysis, resulting in increased understanding of the molecular basis of many endocrine conditions. Genomic testing for rare disease is being integrated into everyday clinical practice, as the importance of confirming a genetic diagnosis earlier in a patient's pathway helps direct their clinical care and specialized management. In England, the new nationally commissioned Genomic Medicine Service has started to deliver testing for rare and inherited disease and cancer somatic tissue via seven Genomic Laboratory Hubs. The range of genetic tests, technology employed and eligibility criteria for patient testing are all defined in the National Genomic Test Directory. This review provides practical guidance on how to access genomic testing for endocrine disease, how to interpret and relay results, and details how genetic counselling can help integrate results into ongoing care of the individual and their family. This article discusses general principles as well as specifics related to the process of genomic testing in England. We illustrate mainstream genetic testing with a clinical scenario involving an individual with inherited endocrine neoplasia, followed by a generic description of the different steps involved, including informed consent to proceed to diagnostic testing. Most genetic tests analyse multiple genes simultaneously by next-generation sequencing, and variant interpretation may yield not only pathogenic explanatory results, but also ambiguous outcomes, with variants of unknown significance or incidental findings. Delivery of results and posttest genetic counselling are therefore key components of integrating genetic testing into routine endocrine care.

A quality improvement initiative to improve primary care referral rates for penicillin allergy delabeling.

BACKGROUND: Of the US population, 10% reports a penicillin allergy but more than 90% can ultimately tolerate penicillin. Confirmation of these allergies in the pediatric population may improve future health outcomes and decrease costs. Referring patients for confirmatory testing is the first step in clarifying penicillin allergies. OBJECTIVE: To increase the number of referrals of patients with listed penicillin allergies from the University of California, San Diego academic general pediatrics clinics to Rady Children's Hospital allergy clinics using an educational session and a best practice advisory (BPA) in the electronic medical record. METHODS: An educational session with attendings and 3 plan-do-study-act (PDSA) cycles were completed using a BPA alert that triggered for all patients with a documented penicillin-class drug allergy to draw attention and facilitate referral. The BPA was modified at each PDSA cycle based on physician input. RESULTS: At baseline, 1.9% of referrals to the allergy clinic were for penicillin-class drug allergies. After an attending physician educational session, the percentage increased to 13.7%. The BPA was implemented with further increase to 27.8% of all allergy referrals in the course of 3 PDSA cycles. Not all patients with penicillin-class drug allergies were referred, and the reasons were documented when the physicians dismissed the BPA. Physicians did not refer 35% of the time because of time constraints, as opposed to patient or parent disinterest, which was 8% of the time. CONCLUSION: Referrals to the allergist for confirmatory testing in patients with listed penicillin allergies increased by more than 10 fold. This study illustrates successful tools to support delabeling.

Assessing Parental Discharge Readiness by Using the Ticket to Home Survey Tool.

OBJECTIVES: Ticket to Home (TTH), a survey tool designed to assess parental comprehension of their child's hospitalization and postdischarge care needs, allows providers to address knowledge gaps before discharge. Our goal was to evaluate the impact of TTH on parents' retention of discharge teaching. METHODS: In this pilot study, we enrolled a convenience sample of families admitted to pediatric hospital medicine and randomly assigned families on the basis of team assignment. The intervention group received TTH before discharge. The control group received usual care (without TTH survey tool). Both groups were sent a survey 24 to 72 hours postdischarge to assess parental understanding of discharge teaching. A senior-level provider also completed a survey; responses were compared with evaluate parent level of understanding. Descriptive statistics and logistic regression were used for analysis. RESULTS: Although 495 parents consented to participate, only 100 completed the necessary surveys (41 intervention and 59 control). Both groups showed high parent-provider concordance regarding reason for admission (92.7% intervention versus 86.4% control; P = .33). The intervention group had significantly higher concordance for return precautions (90.2% vs 58.2%; P < .001), which remained significant when controlling for covariates (odds ratio 6.24, 95% confidence interval 1.78-21.93). Most parents in the intervention group felt sharing TTH responses with their medical team was beneficial (95.0%). CONCLUSIONS: Parents who received TTH before discharge were more likely to accurately recall return precautions and valued sharing TTH results with the team. Given that response bias may have affected pilot results, additional studies in which researchers use larger samples with more diverse patient populations is required.

A Quality Improvement Initiative to Improve Discharge Timeliness and Documentation.

INTRODUCTION: Discharge communication is critical for the continuity of patient care. However, discharge summaries are often not available in time for follow-up visits, and the content is inconsistent. We aimed to decrease the average time to discharge summary completion by 25%, reduce deficiencies (information errors) by 50%, and increase discharge summary template use to >80% in 6 months. METHODS: A pediatric interprofessional team used quality improvement methods to identify barriers and implement interventions, including discharge summary completion time expectation, electronic health record discharge summary template changes addressing gaps, and training. Notable changes to the template included embedded writing tips to guide writers and specific template choices for common diagnoses to standardize content. The primary outcome measure was the mean discharge summary completion time. Secondary measures were the percentage of discharge summaries with deficiencies and the rate of template use. RESULTS: After interventions, the mean discharge summary completion time decreased by 70% (from 71.5 to 21.8 hours). Discharge summary deficiencies decreased 44% (from 4.5% to 2.5%), and template use increased from 62% to 97%. CONCLUSION: Quality improvement methods and a newly designed electronic health record-discharge summary template were used to dramatically improve discharge summary timeliness and standardize content to streamline continuity of care.

Genetic testing for hereditary hyperparathyroidism and familial hypocalciuric hypercalcaemia in a large UK cohort.

BACKGROUND: Primary hyperparathyroidism (PHPTH) is a common endocrine disorder and an estimated 10% of cases are hereditary, related to syndromes including; multiple endocrine neoplasia (MEN) type 1, MEN type 4, MEN2A and hereditary hyperparathyroidism-jaw tumour syndrome. Establishing the underlying genetic cause for PHPTH allows for personalized and cost-effective management. Familial hypocalicuric hypercalcaemia (FHH) is a benign disorder of hypercalcaemia associated with an inappropriately low urinary calcium excretion, which is quantified by the calcium creatinine clearance ratio (CCCR). Recent NHS England National Genomic Test Directory testing criteria for familial hyperparathyroidism state testing patients presenting with PHPTH and CCCR > 0.02 presenting (i) <35 years of age, or (ii) <45y with one of (a) multiglandular disease, or (b) hyperplasia on histology, or (c) ossifying fibroma(s) of the maxilla and/ or mandible, or (d) a family history of unexplained PHPTH. The testing criterion for FHH is a CCCR < 0.02. AIMS AND METHODS: A retrospective review of patients referred for genetic testing over a 4 year period for suspected hereditary HPTH was performed. Genetic analysis was performed by next-generation sequencing of the following genes; MEN1, CDC73, CASR, CDKN1A, CDKN1B, CDKN2B, CDKN2C, RET, GCM2, GNA11, and AP2S1 in NHS-accredited Regional Genetic laboratories. Aims of this study were to better define testing criteria for suspected hereditary PHPTH in a UK cohort. RESULTS: A total of 121 patients were included in this study (92 female) with a mean age of 41 years (SD 17). A pathogenic germline variant was identified in 16% (n = 19). A pathogenic variant was identified in the PHPTH genes CDC73 in a single patient and MEN1 in six patients (6% of total), in the FHH genes, CASR in 11 patients and AP2S1 in a single paediatric case (10% of total). A variant of uncertain significance (VUS) was identified in eight patients (6%) but over the course of this study familial segregation studies and computational analysis enabled re-classification of four of the variants, with two VUS's in the CASR gene being upgraded to likely pathogenic variants. Age at diagnosis and multiglandular disease as sole risk factors were not predictive of a pathogenic germline variant in this cohort but a positive family history was strongly predictive (P = .0002). A significant difference in the mean calcium creatinine clearance ratio (CCCR) in those patients with an identified CASR pathogenic variant versus those without (P = .0001) was demonstrated in this study. Thirty-three patients were aged over 50 years and the diagnostic rate of a pathogenic variant was 15.1% in those patients >50 years of age compared to 15.9% in those <50 years. Five patients >50 years and with a CCCR of <0.01, were diagnosed with a pathogenic variant in CASR. CONCLUSION: Family history was the strongest predictor of hereditary PHPTH in this cohort. This study has highlighted the importance of re-evaluating VUS's in order to inform patient management and enable appropriate genetic counselling. Finally, this study has demonstrated the need to consider genetic testing for PHPTH in patients of any age, particularly those with additional risk factors.

Reducing Unnecessary Testing in Uncomplicated Skin and Soft Tissue Infections: A Quality Improvement Approach.

OBJECTIVES: Skin and soft tissue infections are common pediatric diagnoses with substantial costs. Recent studies suggest blood cultures are not useful in management of uncomplicated skin and soft tissue infections (uSSTIs). Complete blood cell count, erythrocyte sedimentation rate, and C-reactive protein are also of questionable value. We aimed to decrease these tests by 25% for patients with uSSTIs admitted to the pediatric hospital medicine service within 3 months. METHODS: An interdisciplinary team led a quality improvement (QI) project. Baseline assessment included review of the literature and 12 months of medical records. Key stakeholders identified drivers that informed the creation of an electronic order set and development of a pediatric hospital medicine-emergency department collaborative QI project. The primary outcome measure was mean number of tests per patient encounter. Balancing measures included unplanned readmissions and missed diagnoses. RESULTS: Our baseline-year rate was 3.4 tests per patient encounter (573 tests and 169 patient encounters). During the intervention year, the rate decreased by 35% to 2.2 tests per patient encounter (286 tests and 130 patient encounters) and was sustained for 14 months postintervention. There were no unplanned readmissions or missed diagnoses for the study period. Order set adherence was 80% (83 out of 104) during the intervention period and sustained at 87% postintervention. CONCLUSIONS: Our interdisciplinary team achieved our aim, reducing unnecessary laboratory testing in patients with an uSSTI without patient harm. Awareness of local culture, creation of an order set, defining appropriate patient selection and testing indications, and implementation of a collaborative QI project helped us achieve our aim.

Delaying voiding, limiting fluids, urinary symptoms, and work productivity: A survey of female nurses and midwives.

AIM: To examine the relationships between workplace bladder practices, urinary symptoms, and work productivity. DESIGN: Cross-sectional observational survey. METHODS: Surveys were distributed June-November 2016 to at least 600 female nurses and midwives at three urban hospitals in New South Wales, Australia. Nurses self-reported restricted workplace access to toilets, delaying voiding, limiting of fluid intakes and urinary symptoms at work. Logistic modelling was used to examine whether nurses' bladder practices impaired their time management, ability to concentrate or perform physical demands. RESULTS: Of 353 useable surveys, one in five nurses (22.4%; N = 79) reported restricted access to toilets at work, most (77.1%; N = 272) delayed voiding and one in four (26.9%; N = 95) limited fluid intakes to delay voiding at work. Almost half the sample had urinary symptoms at work (46.7%; N = 165); delaying voiding increased the likelihood of impaired mental concentration and limiting fluid intakes increased the likelihood of impaired time management. CONCLUSION: As workplace access to toilets and related bladder practices are modifiable, associated urinary symptoms and productivity loss may be preventable. IMPACT: Nurses' often experience restricted accesses to amenities due to job demands and workplace environments. The impact of nurses' poor bladder practices in the workplace is not known. In this study most nurses delayed voiding and many purposefully limited fluid intakes at work. These behaviours impacted a nurse's ability to manage time and/or concentrate at work. Results have implications for nurses' personal health, the design of workplace environments, workforce management, occupational health policy, and patient care.

Culture, teams, and organizations: A qualitative exploration of female nurses' and midwives' experiences of urinary symptoms at work.

AIM: To explore nurses' and midwives' experiences of urinary symptoms at work. BACKGROUND: Lower urinary tract symptoms are common in female nurses and midwives. There is limited understanding of the relationship between urinary symptoms, bladder health practices, and work. DESIGN: Qualitative design providing in-depth exploration of nurses' and midwives' experiences of urinary symptoms at work through focus group discussions. METHODS: Twelve focus groups were held July-September 2016 with 96 Registered Nurses and midwives working at two tertiary-referral hospitals in urban New South Wales, Australia. A semi-structured question schedule was used. An inductive process guided thematic analysis of data using a socioecological framework of health behaviours. RESULTS: Nurses' and midwives' experiences of urinary symptoms at work primarily relate to delaying voiding. This practice is explained by a work culture of "patient-first" care at expense of self-care, relationships in the nursing team, demands of the nursing role, and inadequacy of workplace amenities. The first two themes reflect cultural and social caring dilemmas central to nursing. The second two themes identify issues with workforce management and physical workplace environments. CONCLUSION: Nurses' and midwives' urinary symptoms and behaviours in response to sensory cues for bladder emptying are dependent on several socioecological influences. Occupational health initiatives in the workforce are required to break cultural norms that deter self-care and to promote work environments that support healthy bladder practices. Workforce management and physical workplace environments are key influences on nurses' timely and dignified access to amenities.

Imperative Instruction for Pressurized Metered-Dose Inhalers: Provider Perspectives.

BACKGROUND: Reports show that many patients do not use their pressurized metered-dose inhalers (pMDIs) effectively. The National Heart, Lung, and Blood Institute recommends that health-care providers educate and assess patients' pMDI technique at each opportunity. However, limited data exist regarding how often pediatric primary care providers perform assessments and which methods they use. We sought to (1) identify instructional methods used to teach pMDI use, (2) describe how pMDI use is reassessed at follow-up visits, and (3) describe primary care provider attitudes and barriers to in-office pMDI instruction. METHODS: A 34-item electronic survey was distributed from August to December 2016 via E-mail to local pediatric primary care providers. Descriptive statistics were used for analysis. RESULTS: Sixty two of 223 potential primary care providers (28%) responded. Physicians and nurse practitioners were identified most often as the providers of pMDI education (53%). When first prescribing a pMDI, only 10% reported having the patient practice inhaler use in the office and receive feedback. Only 19% "always" reassessed the technique, even for patients with poorly controlled asthma. Among those who reassessed the technique, most (76%) did so verbally, and only 42% asked the patients to demonstrate pMDI use. Only 32% reported that typical patient education in their setting was adequate to ensure proper pMDI use. Commonly cited barriers included time (84%) and access to demo pMDIs (67%). Provider solutions included video tutorials and access to demo inhalers. CONCLUSIONS: Many pediatric primary care providers did not demonstrate or have patients practice pMDI use when teaching or assessing pMDI technique, and the reassessment rate was low even for patients with poorly controlled asthma. Identifying and training a consistent pMDI educator and obtaining demo pMDIs may abate some barriers. Respiratory therapists could appropriately fulfill this educator role. Brief, repeated pMDI practice for motor learning could promote more stable pMDI mastery.

Urinary incontinence, work, and intention to leave current job: A cross sectional survey of the Australian nursing and midwifery workforce.

AIMS: To determine the prevalence and severity of urinary incontinence (UI) in a group of female nurses and midwives, and to examine the relationship between UI, work and intention to leave current job. METHODS: An electronic survey "Fit for the future" was distributed to nurses and midwives in NSW, Australia between May 2014 and February 2015. UI was investigated using the International Consultation on Incontinence UI-Short Form. Examined work characteristics included: work role, location, setting, contract, shift, job satisfaction, and plans to leave current job. Logistic regression modelling was performed to determine whether the severity of UI had an independent effect on intention to leave. RESULTS: Of 5041 survey responses, 68.5% answered the question on urine leakage. Of the included female sample (n = 2,907) the prevalence of UI was 32.0% (95% CI: 30-34%): of these 40.5% experienced moderate and 4.4% "severe or very severe" symptoms. UI was more likely to be reported in nurses or midwives working part-time or days only (not shifts). Those with "severe or very severe UI" were more likely to indicate an intention to leave at 12 months (OR: 2.68; 95% CI: 1.18-6.06) than those with slight or moderate symptoms, after accounting for age, body mass index, parity, pelvic organ prolapse, anxiety, depression, work contract, shift, and job satisfaction. CONCLUSIONS: UI is a condition of high prevalence and significant severity in female nurses and midwives. In this workforce, severe UI was associated with intentions related to future employment.