Assessment of the Smoke Free Families Tobacco Screening, Counseling, and Referral Program in Pediatric Primary Care Practices.

OBJECTIVE: The Smoke Free Families (SFF) program trained pediatric providers to use an SFF tool during well-child visits (WCVs) of infants ≤12 months to "Ask" caregivers about tobacco use, "Advise" smokers to quit, and "Refer" smokers to cessation services (AAR). The primary objectives were to assess the prevalence and changes in caregiver tobacco use after being screened and counseled by providers using the SFF tool. A secondary objective was to examine providers' AAR behavior facilitated by using the SFF tool. METHODS: Pediatric practices participated in 1 of 3 6-9-month SFF program waves. Over the 3 waves, all initial SFF tools completed on caregivers during their infant's WCV were evaluated for the caregiver and household tobacco use and providers' AAR rates. An infant's first and next WCV was matched to determine changes in caregiver tobacco product use. RESULTS: In total, the SFF tool was completed at 19,976 WCVs; 2081 (18.8%) infants were exposed to tobacco smoke. A total of 834 (74.1%) caregivers who smoked received counseling: 786 (69.9%) were advised to quit, 700 (62.2%) were given cessation resources, and 198 (17.6%) were referred to the Quitline. In total, 230 (27.6%) of caregivers who smoked had a second visit; 58 (25.2%) self-reported that they quit using tobacco. Among cigarette users (n = 183), 89 (48.6%) reported that they used fewer cigarettes or quit at their infants' second WCV. CONCLUSIONS: Systematic use of the SFF AAR tool during infants' WCVs could improve the health of caregivers and children, resulting in decreases in tobacco-related morbidity.

Types of Tobacco Products Used by Caregivers of Newborns in the Primary Care Setting.

This study determined the types of tobacco products used by caregivers who presented to infant well-child visits (WCVs), tobacco product use by other household members, and caregivers' readiness to quit. The Ohio Chapter of the American Academy of Pediatrics conducted a 10-month quality improvement collaborative to improve providers' tobacco screening and cessation counseling practices. A sub-analysis of the initial screenings was performed to determine types of tobacco products used and caregivers' readiness to quit. Fourteen practices (60 providers) participated, and 3972 initial screens were analyzed; 320 (8.1%) caregivers and 490 (12.4%) household members used tobacco products. Most smoking caregivers and household members exclusively used cigarettes (79% and 72%, respectively). There was no difference in caregiver intention to quit by tobacco type, yet 53% of smoking caregivers were ready to quit. Providers should provide screening and cessation counseling to caregivers of infants at WCVs since many are ready to quit.

Attitudes and perceived barriers to firearm safety anticipatory guidance by pediatricians: a statewide perspective.

BACKGROUND: Firearms are the second leading cause of injury-related death in American children. Safe storage of firearms is associated with a significantly decreased odds of firearm-related death, however more than half of US firearm owners store at least one firearm unlocked or accessible to a minor. While guidance by primary care providers has been shown to improve storage practices, firearm safety counseling occurs infrequently in the primary care setting. The primary objective of this study was to describe pediatricians' perceived barriers to providing firearm safety education to families in the pediatric primary care setting. Secondary objectives included identifying pediatric provider attitudes and current practices around firearm counseling. METHODS: This was a cross-sectional survey of pediatric primary care providers in Ohio. Participants were recruited from the Ohio AAP email list over a 3-month period. Only pediatric primary care providers in Ohio were included; subspecialists, residents and non-practicing physicians were excluded. Participants completed an anonymous online survey detailing practice patterns around and barriers to providing firearm safety counseling. Three follow-up emails were sent to pediatricians that failed to initially respond. Response frequencies were calculated using Microsoft Excel. RESULTS: Two hundred eighty-nine pediatricians completed the survey and 149 met inclusion criteria for analysis. One hundred seven (72%) respondents agreed that it is the responsibility of the pediatric primary care provider to discuss safe storage. Counseling, however, occurred infrequently with 119 (80%) of respondents performing firearm safety education at fewer than half of well child visits. The most commonly cited barriers to providing counseling were lack of time during office visits, lack of education and few resources to provide to families. A majority, 82 of pediatric providers (55%), agreed they would counsel more if given additional training, with 110 (74%) conveying they would distribute firearm safety devices to families if these were available in their practice. CONCLUSION: Ohio pediatricians agree that it is the responsibility of the primary care provider to discuss firearm safety. However, counseling occurs infrequently in the primary care setting due to a lack of time, provider education and available resources. Improving access to resources for primary care pediatricians will be critical in helping educate families in order to protect their children through improved storage practices.

Personalising Safe Sleep Messaging for Infant Caregivers in the United States.

The purpose of our study was to better understand why parents/caregivers might not practice safe sleep behaviours. In autumn 2016, we conducted 'pulse' interviews with 124 parents/caregivers of children under the age of one year at a variety of local community events, festivals and meetings in cities with high infant mortality rates around the Midwestern US state of Ohio. Through an inductive approach, pulse interviews were analysed using thematic coding and an iterative process which followed for further clarification of themes (Qualitative Research in Psychology, 2006, 3, 77; BMC Medical Research Methodology, 2013, 13, 117). The six major themes of underlying reasons why parents/caregivers might not practice safe sleep behaviours that were identified in our coding process included the following: (a) culture and family tradition, (b) knowledge about safe sleep practices, (c) resource access, (d) stressed out parents, (f) lack of support and (g) fear for safety of baby. Using the descriptive findings from the pulse interviews, qualitative themes and key informant validation feedback, we developed four diverse fictional characters or personas of parents/caregivers who are most likely to practice unsafe sleep behaviours. These personas are characteristic scenarios which imitate parent and caregiver experiences with unsafe sleep behaviours. The personas are currently being used to influence development of health promotion and education programs personalised for parents/caregivers of infants less than one year to encourage safe sleep practices.

Pilot of primary care physician discussion and resource allocation after screening for unintentional injuries and social determinants of health.

BACKGROUND: Standardized screening tools used by pediatric providers can help determine a child's injury and social risks. This study determined if an office-based quality improvement program could increase targeted anticipatory guidance and community resource distribution to families. METHODS: Practices recruited from the Ohio Chapter, American Academy of Pediatrics' database self-selected to participate in a quality improvement project. Two age-appropriate screening tools, corresponding talking points and local resources for birth-1 year and 1-5 year aged children were developed for unintentional injury and social health determinant topics. After a one-day learning session, practice teams implemented the tools into well-child care visits for children < 5 years of age. Two months of retrospective baseline data was collected for each participating clinician. During the 6-month collaborative, physicians randomly reviewed 5 screening tools monthly for each age category to identify injury and social risk discussions and to determine if resources were provided. Frequencies of counseling and resource distribution were calculated. Participating providers received Maintenance of Certification IV credit. RESULTS: Ten practices (18 providers) participated and 667 tools (n = 313, birth-1 year, n = 354, 1-5 year) were collected. For birth-1 year, the most common risky behaviors were related to unintentional injuries: no CPR training 164(52%), car seat not checked 149(48%) and home furniture not secured 117 (37%). For 1-5 year screens, unintentional injuries were also most common: no CPR training 222(63%), car seat not checked 203(57%) and access to choking hazards 198(56%). Families practiced riskier behaviors for unintentional injuries compared to social risks for both age groups (birth - 1 year, social 189/4801 (4%) vs. unintentional injury questions 999/6260 (16%) and 1-5 years, social 271/5451 (5%) vs unintentional injury questions 1140/6372 (18%). From baseline, discussions increased from 31% to 83% for birth - 1 year and 24% to 86% for 1-5 year families. Resource distribution increased by 63% for birth-1 year and 69% for 1-5 year families by pilot conclusion. CONCLUSIONS: Using standardized screening tools in an office setting shows that families often practice unintentional injury risks more than having social concerns. After screening, appropriate resources can be provided to families to encourage behavior change.

The EASE Project Revisited: Improving Safe Sleep Practices in Ohio Birthing and Children's Hospitals.

Literature has shown hospitalized infants are not often observed in recommended safe sleep environments. Our objective was to implement a quality improvement program to improve compliance with appropriate safe sleep practices in both children's and birthing hospitals. Hospitalists from both settings were recruited to join an Ohio American Academy of Pediatrics collaborative to increase admitted infant safe sleep behaviors. Participants used a standardized tool to audit infants' sleep environments. Each site implemented 3 PDSA (Plan-Do-Study-Act) cycles to improve safe sleep behaviors. A total of 37.0% of infants in children's hospitals were observed to follow the current American Academy of Pediatrics recommendations at baseline; compliance improved to 59.6% at the project's end (P < .01). Compliance at birthing centers was 59.3% and increased to 72.5% (P < .01) at the collaborative's conclusion. This study demonstrates that a quality improvement program in different hospital settings can improve safe sleep practices. Infants in birthing centers were more commonly observed in appropriate sleep environments than infants in children's hospitals.

The EASE Quality Improvement Project: Improving Safe Sleep Practices in Ohio Children's Hospitals.

BACKGROUND: Despite American Academy of Pediatrics (AAP) recommendations, many hospitalized infants are not observed in the appropriate safe sleep environment. Caregivers tend to model sleep patterns observed in a hospital setting. This project assessed the change in infant safe sleep practices within 6 children's hospitals after the implementation of a statewide quality improvement program. METHODS: The AAP recruited hospitalists from each of the state's children's hospitals and asked them to form "safe sleep teams" within their institutions. Teams used a standardized data tool to collect information on the infant's age and sleep position/environment. They collected baseline data and then weekly for the duration of the 12-month project. Teams were required to implement at least 3 Plan-Do-Study-Act cycles. We calculated changes in safe sleep practices over time. Providers received Maintenance of Certification Part IV credit for participation. RESULTS: Teams collected 5343 audits at all participating sites. At baseline, only 279 (32.6%) of 856 of the sleeping infants were observed to follow AAP recommendations, compared with 110 (58.2%) of 189 (P < .001) at the project's conclusion. The presence of empty cribs was the greatest improvement (38.1% to 67.2%) (P < .001). Removing loose blankets (77.8% to 50.0%) (P < .001) was the most common change made. Audits also showed an increase in education of families about safe sleep practices from 48.2% to 75.4% (P < .001). CONCLUSIONS: Multifactorial interventions by hospitalist teams in a multi-institutional program within 1 state's children's hospitals improved observed infant safe sleep behaviors and family report of safe sleep education. These behavior changes may lead to more appropriate safe sleep practices at home.