Asynchronous Learning Module for Pediatric Emergency Medicine Physicians on How to Manage Vaginal Birth and Neonatal Resuscitation in the Emergency Department.

OBJECTIVES: Newborn deliveries and neonatal resuscitation events are rare but essential skills for pediatric emergency medicine (PEM) physicians. We sought to evaluate the effect of an online module on PEM physicians' knowledge and confidence in managing newborn deliveries and neonatal resuscitation. METHODS: A team of experts in PEM, obstetrics, neonatology, and medical education developed a self-directed, 1-hour online module on managing newborn deliveries with neonatal resuscitation. The module was designed to address the learning needs of the targeted group. The module was piloted before dissemination to PEM faculty. A 10-question multiple choice test was given to assess knowledge of the material covered. A 10-point Likert scale questions survey was used to evaluate confidence. Measures were administered before initiation, after module completion, and 6 months after completion. Paired t tests were used to compare mean knowledge scores, and rank sum tests were used to compare median confidence levels. RESULTS: Most (n = 47, 89%) of the PEM faculty members completed the module. The majority (n = 43, 91%) thought the information was relevant to their practice. After completing the module, physicians' overall knowledge scores improved by 18% (mean [SD]: 74% [14.7] vs 92% [8.0], P < 0.01). Self-assessed confidence improved after the module in terms of managing uncomplicated vaginal deliveries (median 5 vs 7, P < 0.01), care of patients with complicated vaginal deliveries (2 vs 5, P < 0.01), and managing neonatal resuscitation (7 vs 8, P < 0.01). During the 6-month follow-up, there was sustained improvement in physicians' overall knowledge score (82% [16.9], P = 0.007) and self-assessed confidence in managing complicated vaginal deliveries (median 2 vs 4, P = 0.0012); however, other measures were not statistically significant. CONCLUSIONS: An online module is an appropriate method for training PEM providers about rarely used but essential skills such as managing vaginal deliveries and neonatal resuscitation.

Relationship Between Food Insecurity and Neighborhood Child Opportunity Index.

OBJECTIVES: To evaluate the association between the Child Opportunity Index (COI) and food insecurity. STUDY DESIGN: This was a secondary analysis of a comprehensive screening instrument for social determinants of health and behavioral health risks. It was administered in 2 urban pediatric emergency departments to adolescents aged 13-21 years and caregivers of children aged 0-17 years. Food insecurity was assessed using the 2-item Hunger Vital Sign. Residential addresses were geocoded and linked with COI data. Bivariable and multivariable logistic regression models were developed to measure the relationship between COI and food insecurity. RESULTS: Of the 954 participants (384 adolescents, 570 caregivers) who underwent screening, 15.7% identified food insecurity (14.3% of adolescent and 16.7% of caregiver participants). The majority of participants were non-Hispanic Black (overall, 62.3%; food secure, 60.9%; food insecure, 72.0%), were publicly insured (overall, 56.6%; food secure, 53.1%; food insecure, 73.3%), and lived in neighborhoods of low/very low opportunity (overall, 76.9%; food secure, 74.7%; food insecure, 88.3%). In adjusted analyses, participants living in neighborhoods of low/very low child opportunity had 3-fold greater odds of being food insecure compared with children living in neighborhoods of high child opportunity (aOR, 3.0; 95% CI, 1.4-6.3). CONCLUSION: We demonstrate that food insecurity is associated with lower neighborhood opportunity. Our results could inform future screening initiatives and support the development of novel, place-based interventions to tackle the complex issue of food insecurity.

Experiencing Bullying Is Associated With Firearm Access, Weapon Carriage, Depression, Marijuana Use, and Justice Involvement in Adolescents.

OBJECTIVES: The aims of this study were to assess whether bullying experience among youths is associated with firearm access and to evaluate assault perpetration risk factors between bullied and nonbullied adolescents. METHODS: This was a secondary analysis of a cross-sectional survey designed to measure self-reported social determinants of health and behavioral health risks among adolescents (13-21 years) in a pediatric emergency department between July 2017 and August 2019. Participants were included in this subanalysis if they responded to a survey item that assessed bullying. Multivariable logistic regression was used to measure the association of firearm access, weapon carriage, and assault perpetration factors (violence, mental health, substance abuse, and justice involvement) with bullying after adjustment for sex, race/ethnicity, and insurance status. RESULTS: Of the 369 participants meeting inclusion criteria, 147 adolescents (40.5%) reported experiencing bullying. Bullied teenagers had higher odds of a gun in the home (adjusted odds ratio [aOR], 3.0; 95% confidence interval [CI], 1.2-7.8]), weapon carriage (aOR, 5.6; 95% CI, 1.6-18.8), witnessing an assault (aOR, 3.0; 95% CI, 1.6-5.6), negative experience with law enforcement (aOR, 4.5; 95% CI, 2.2-9.2), mental health diagnosis (aOR, 3.9; 95% CI, 2.3-6.7), and marijuana use (aOR, 2.7; 95% CI, 1.1-7.0]). CONCLUSIONS: More than 1 in 3 adolescents presenting to the emergency department report having ever experienced bullying. Bullied teenagers have a higher likelihood of firearm access, weapon carriage, and violent injury perpetration risk factors compared with nonbullied youths. Further studies are needed to understand the relationship between bullying and assault perpetration.

Predictors of Elevated Social Risk in Pediatric Emergency Department Patients and Families.

OBJECTIVE: This study aimed to identify predictors of high unmet social needs among pediatric emergency department (ED) patients. We hypothesized that obesity, frequent nonurgent visits, reported food insecurity, or an at-risk chief complaint (CC) would predict elevated social risk. METHODS: We administered a tablet-based survey assessing unmet social needs in 13 domains to caregivers of patients aged 0 to 17 years presenting to an urban pediatric ED. Responses were used to tabulate a social risk score (SRS). We performed multivariable logistic regression to measure associations between a high SRS (≥3) and obesity, frequent nonurgent visits, food insecurity, or an at-risk CC (physical abuse, sexual abuse, assault, mammalian bites, reproductive/sexual health complaints, intoxication, ingestion/poisoning, psychiatric/behavioral complaints, or any complaint triaged as "least urgent"). RESULTS: Five hundred seventy caregivers completed the survey. Eighty-one percent reported at least one unmet social need, and 33% identified ≥3 social needs. Caregivers of patients with an at-risk CC had twice the odds of a high SRS (adjusted odds ratio [aOR], 1.8; 95% confidence interval [CI], 1.0-3.3). Caregivers of patients reporting food insecurity had 4 times the odds of a high SRS (aOR, 4.3; 95% CI, 2.5-7.3). Neither obesity (aOR, 1.5; 95% CI, 0.9-2.6) nor frequent nonurgent visits (aOR, 0.9; 95% CI, 0.4-1.9) were predictive of a high SRS. CONCLUSIONS: Unmet social needs are prevalent among caregivers of pediatric ED patients, supporting universal screening in this population. Patients with an at-risk CC or reported food insecurity might benefit from proactive intervention. Future studies should examine optimal methods for ED-based interventions that address social determinants of health.

Home Fire Safety Practices and Smoke Detector Program Awareness in an Urban Pediatric Emergency Department Population.

OBJECTIVES: Risk factors for residential fire death (young age, minority race/ethnicity, and low socioeconomic status) are common among urban pediatric emergency department (ED) patients. Community-based resources are available in our region to provide free smoke detector installation. The objective of our study was to describe awareness of these resources and home fire safety practices in this vulnerable population. METHODS: In this cross-sectional study, a brief survey was administered to a convenience sample of caregivers accompanying patients 19 years of age or younger in an urban pediatric ED in Washington, DC. Survey contents focused on participant knowledge of available community-based resources and risk factors for residential fire injury. RESULTS: Five hundred eleven eligible caregivers were approached, and 401 (78.5%) agreed to participate. Patients accompanying the caregivers were 48% male, 77% African American, and had a mean (SD) age of 6.5 (5.9) years. Of study participants, 256 (63.8%) lived with children younger than 5 years. When asked about available community-based resources for smoke detectors, 240 (59.9%) were unaware of these programs, 319 (79.6%) were interested in participating, and 221 (55.1%) enrolled. Presence of a home smoke detector was reported by 396 respondents (98.7%); however, 346 (86.3%) reported testing these less often than monthly. Two hundred fifty-six 256 (63.8%) lacked a carbon monoxide detector, and 202 (50.4%) had no fire escape plan. Sixty-five (16%) reported indoor smoking, and 92 (22.9%) reported space heater use. CONCLUSIONS: In this urban pediatric ED population, there is limited awareness of community-based resources but high rates of interest in participating once informed. Whereas the self-reported prevalence of home smoke detectors is high in our study population, other fire safety practices are suboptimal.

Social Navigation for Adolescent Emergency Department Patients: A Randomized Clinical Trial.

PURPOSE: Adolescent emergency department (ED) patients have unmet social needs that contribute to ED use. This study aimed to evaluate the effect of social needs navigation for adolescents on subsequent ED visits and community resource use and to identify characteristics associated with elevated social risk. METHODS: Between July 2017 and August 2019, we used a random date generator to establish intervention and control group enrollment dates. All adolescents completed a social needs survey. Adolescents enrolled on intervention dates received in-person, risk-tailored social needs navigation. Those enrolled on control dates received a preprinted resource guide. We used chart review and follow-up calls to assess 12-month ED revisits and community resource use. Logistic regression was used to compare these outcomes between groups. We measured the association between ≥3 reported unmet needs and characteristics hypothesized a priori to be associated with elevated social risk (nonurgent visits, obesity, or any of nine "socially sensitive" chief complaints) using logistic regression. RESULTS: A total of 399 adolescents were randomized. There was no difference between groups in the number of ED revisits. There was increased community resource use in the intervention group (adjusted odds ratio [aOR]: 3.5 [95% confidence interval {CI}: 1.5, 8.2]). Adolescents with a socially sensitive chief complaint had increased odds of ≥3 unmet needs (aOR: 2.2 [95% CI: 1.3, 3.6]), as did those with food insecurity in a post hoc analysis (aOR: 9.9 [95% CI: 4.0, 24.6]). DISCUSSION: Social needs navigation increased community resource use but not subsequent ED visits. Adolescents with socially sensitive chief complaints or food insecurity reported increased unmet needs.

Screening for Social Determinants of Health in Hospitalized Children.

OBJECTIVES: Outpatient screening for social determinants of health (SDH) improves patient access to resources. However, no studies have examined if and how inpatient pediatric providers perform SDH screening. We aimed to identify inpatient pediatric provider screening practices for SDH, barriers to screening, and the acceptability of screening for hospitalized patients. METHODS: We conducted a multicenter descriptive study at 4 children's hospitals surveying inpatient hospitalists and nurses on the general wards about their SDH screening practices. A survey instrument was developed on the basis of literature pertaining to SDH, content expert review, cognitive interviews, and survey piloting. Descriptive statistics and logistic regression analyses are reported. RESULTS: Results from 146 hospitalists and 227 nurses were analyzed (58% and 26% response rate, respectively). Twenty-nine percent of hospitalists and 41% of nurses reported screening for ≥1 SDH frequently or with every hospitalized patient. Only 26% of hospitalists reported consistently communicating SDH needs with primary care providers. Most respondents (97% of hospitalists and 65% of nurses) reported they do not use a specific screening tool, and only 34% of hospitalists and 32% of nurses reported feeling competent screening for SDH. Lack of time, resources, and a standardized inpatient screening tool were reported as barriers to screening. CONCLUSIONS: Hospitalization provides an opportunity for SDH screening and connecting patients to resources; however, a minority of pediatric providers currently report screening. Professional development activities training inpatient providers in SDH screening, using a screening instrument, and communicating identified needs to primary care providers may improve the effectiveness of SDH screening in the hospital.

Acceptability of Adolescent Social and Behavioral Health Screening in the Emergency Department.

PURPOSE: The American Academy of Pediatrics recommends routine screening for social and behavioral health risks (SBHR) in adolescents. Because adolescents who seek care in emergency departments (EDs) may have riskier behaviors than adolescents who access primary care, the ED may be a strategic additional setting for screening. We sought to identify acceptable domains for comprehensive SBHR screening in a pediatric ED. METHODS: We conducted a cross-sectional survey to assess adolescent and caregiver acceptance of ED-based SBHR screening across multiple domains. Logistic regression was performed to identify factors associated with screening acceptance. McNemar's test was used to assess agreement within patient/caregiver dyads across domains. RESULTS: Among our 516 study participants (347 adolescents and 169 caregivers), those who indicated that they "agree" or "strongly agree" that ED-based screening should be conducted were classified as finding screening acceptable. Acceptability rates ranged from 45.0% (firearm access) to 77.5% (suicidality) among adolescents and 61.5% (firearm access) to 84.0% (substance use) among caregivers. After adjusting for gender, race/ethnicity, and insurance status, adolescents were less accepting than caregivers of screening for: substance use (adjusted odds ratio [aOR]: .51; .31, .83; p < .01); violence (aOR: .63; .41, .97; p = .04); depression (aOR: .65; .42, .99; p = .04); human trafficking (aOR: .58; .39, .86; p < .01); and access to firearms (aOR: .47; .32, .70; p < .01). Shared agreement within adolescent/caregiver dyads ranged from 25.2% to 67.1%. CONCLUSIONS: A majority of adolescents and caregivers agree that ED-based SBHR screening should be conducted across most domains. Caregivers generally had higher rates of screening acceptance than adolescents.

Adolescent use of the emergency department instead of the primary care provider: who, why, and how urgent?

PURPOSE: Adolescents frequently rely on emergency medical care, rather than using primary care providers (PCPs). Our objectives were to characterize a population of adolescents presenting to a large, urban emergency department (ED) and to examine the reasons why they present to the ED, rather than to their PCP's office. METHODS: Adolescents ages 12 to 21 years and their parents/guardians were invited to participate and asked to complete a brief online survey. Demographic data and triage information were collected from electronic medical records. RESULTS: Of 203 participants, 66% (n = 134) had public insurance, and 40% (n = 82) were triaged as nonurgent. Nearly all (93%, n = 189) reported having a PCP or primary clinic. The most common reasons given for presenting to the ED were participant perception of illness requiring immediate care (34%), followed by PCP referral to the ED (21%). Those with public insurance (odds ratio = 4.44; 95% CI 2.01 to 9.81) or no insurance/unknown insurance status (odds ratio = 4.77; 95% CI 1.34 to 17.01) were more likely to be triaged as nonurgent than those with private insurance. CONCLUSIONS: Many adolescents in this study were triaged as nonurgent, with several participants perceiving they were acutely ill requiring immediate physician care. Further analyses revealed that private insurance was significantly associated with urgent triage status. Future studies could educate adolescents and families about appropriate use of the ED or examine PCP offices directly to determine practices for phone triage and ED referrals of adolescents.