Gia Badolato

Practice Pattern Variation in the Care of Children With Acute Asthma.

OBJECTIVES Pediatric asthma is a highly prevalent disease, affecting over 7 million U.S. children and accounting for 750,000 annual emergency department (ED) visits. Guidelines from the National Asthma Education and Prevention Program recommend limited use of chest radiography (CXR), complete blood counts (CBCs), and antibiotics when managing acute exacerbations of asthma. However, studies suggest frequent overutilization of these resources. The objective was to evaluate differences between pediatric and general EDs in rates of CXRs, CBCs, and use of antibiotics for pediatric asthma exacerbations. METHODS This was a repeated cross-sectional analysis of data from the National Hospital Ambulatory Medical Care Survey from 2000 through 2010 of CXR, CBCs, and antibiotics during ED visits for pediatric acute asthma exacerbations. Multivariable logistic regression was performed to identify differences in asthma management by ED type (pediatric vs. general) after adjusting for demographic covariates. RESULTS There were 3,313 observations, representing an estimated 10.9 million (95% confidence interval [CI] = 9.7 to 12.1 million) ED visits for acute asthma without bacterial coinfection. Of these, 17.4% occurred in pediatric EDs. Multivariable logistic regression revealed that visits to pediatric EDs were less likely to include CXRs (adjusted odds ratio [AOR] = 0.39; 95% CI = 0.25 to 0.60), CBCs (AOR = 0.42; 95% CI = 0.22 to 0.80), and antibiotics (AOR = 0.50; 95% CI = 0.31 to 0.82) after adjustment for race/ethnicity, triage level, academic ED, metropolitan statistical area, and geographic region. CONCLUSIONS There are substantial differences in diagnostic testing and antibiotic usage for management of acute exacerbations of asthma by ED type, suggesting potential resource overuse in general EDs. Future studies should focus on evaluating the effect of quality improvement efforts for ED asthma management.

Examining the Role of the Pediatric Emergency Department in Reducing Unintended Adolescent Pregnancy

Objectives To determine pregnancy risk and receptiveness to emergency department (ED)‐based pregnancy prevention interventions among adolescents accessing care in the ED. Study design Cross‐sectional electronic survey of adolescent females in a pediatric ED used to calculate the Pregnancy Risk Index, a validated measure estimating the annual risk of becoming pregnant based on recent sexual activity, contraceptive method(s), method‐specific contraceptive failure rates, and interest in receipt of ED‐based contraceptive services. Results Of 229 participants, 219 were not pregnant, and 129 reported sexual experience. Overall, 72.4% (n = 166) endorsed negative pregnancy intentions. The overall Pregnancy Risk Index for the 219 nonpregnant participants was 9.6 (95% CI 6.8–12.4), and was 17.5 (95% CI 12.8–22.2) for the 129 sexually experienced participants. A Pregnancy Risk Index greater than the national average of 5 was associated with older age (aOR 3.0; 95% CI 1.5–5.85), nonprivate insurance (aOR 7.1; 95% CI 1.6–32.1), prior pregnancy (aOR 2.7; 95% CI 1.2–6.0), and chief complaint potentially related to a reproductive health concern (aOR 2.6; 95% CI 1.4–5.1). In this cohort, 85.1% (n = 194) believed that the ED should provide information about pregnancy prevention, the majority of whom (64.9%; n = 148) believed that pregnancy prevention services should be offered at all ED visits. Conclusion This study demonstrates a high unintended pregnancy risk among adolescents accessing care in the ED. Adolescents report interest in receiving pregnancy prevention information and services in the ED, regardless of reason for visit. Strategies to incorporate successfully the provision of reproductive health services into ED care should be explored.

A Computerized Sexual Health Survey Improves Testing for Sexually Transmitted Infection in a Pediatric Emergency Department.

Objectives To assess whether clinical decision support, using computerized sexually transmitted infection (STI) risk assessments, results in increased STI testing of adolescents at high risk for STI. Study design In a 2‐arm, randomized, controlled trial conducted at a single, urban, pediatric emergency department, adolescents completed a computerized sexual health survey. For patients assigned to the intervention arm, attending physicians received decision support to guide STI testing based on the sexual health survey–derived STI risk; in the usual care arm, decision support was not provided. We compared STI testing rates between the intervention and usual care groups, adjusting for potential confounding using multivariable logistic regression. Results Of the 728 enrolled patients, 635 (87.2%) had evaluable data (323 intervention arm; 312 usual care arm). STI testing frequency was higher in the intervention group compared with the usual care group (52.3% vs 42%; aOR 2 [95% CI 1.1, 3.8]). This effect was even more pronounced among the patients who presented asymptomatic for STI (28.6 vs 8.2%; aOR 4.7 [95% CI 1.4‐15.5]). Conclusions Providing sexual health survey–derived decision support to emergency department clinicians led to increased testing rates for STI in adolescents at high risk for infection, particularly in those presenting asymptomatic for infection. Studies to understand potential barriers to decision support adherence should be undertaken to inform larger, multicenter studies that could determine the generalizability of these findings and whether this process leads to increased STI detection. Trial registration ClinicalTrials.gov: NCT02509572.

Sensitivity and Specificity of Empiric Treatment for Sexually Transmitted Infections in a Pediatric Emergency Department

Objective To determine test characteristics of provider judgment for empiric antibiotic provision to patients undergoing testing for a sexually transmitted infection. Study design We conducted a retrospective cross‐sectional electronic health record review of all patients aged 13–19 years who had Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) testing sent from an urban, academic pediatric emergency department in 2012. We abstracted data, including patient demographics, chief complaint, sexually transmitted infection test results, and treatment. We calculated test characteristics comparing clinician judgment for presumptive treatment for a sexually transmitted infection with the reference standard of the actual results of testing for a sexually transmitted infection. Results Of 1223 patient visits meeting inclusion criteria, 284 (23.2%) had a positive GC and/or CT test result. Empiric treatment was provided in 615 encounters (50.3%). Provider judgment for presumptive treatment had an overall sensitivity of 67.6% (95% CI, 61.8–73.0) and a specificity of 55% (95% CI, 51.7–58.2) for accurate GC and/or CT detection. Conclusions Many adolescents tested for GC and CT receive empiric treatment at the initial emergency department visit. Provider judgment may lack sufficient sensitivity and specificity for identifying infected patients, resulting in the potential for undertreatment of true disease, overtreatment of uninfected patients, or both.

US Emergency Department Trends in Imaging for Pediatric Nontraumatic Abdominal Pain.

This cross-sectional study explores national trends in ED use of diagnostic imaging for nontraumatic abdominal pain from 2007 to 2014. OBJECTIVES: To describe national emergency department (ED) trends in computed tomography (CT) and ultrasound imaging for the evaluation of pediatric nontraumatic abdominal pain from 2007 through 2014. METHODS: We used data from the National Hospital Ambulatory Medical Care Survey to measure trends in CT and ultrasound use among children with nontraumatic abdominal pain. We performed multivariable logistic regression to measure the strength of the association of ED type (pediatric versus general ED) with CT and ultrasound use adjusting for potential confounding variables. RESULTS: Of an estimated 21.1 million ED visits for nontraumatic abdominal pain, 14.6% (95% confidence interval [CI], 13.2%–16.0%) had CT imaging only, 10.9% (95% CI, 9.7%–12.1%) had ultrasound imaging only, and 1.9% (95% CI, 1.4%–2.4%) received both CT and ultrasound. The overall use of CT and ultrasound did not significantly change over the study period (P trend .63 and .90, respectively). CT use was lower among children treated in pediatric EDs compared with general EDs (adjusted odds ratio 0.34; 95% CI, 0.17–0.69). Conversely, ultrasound use was higher among children treated in pediatric EDs compared with general EDs (adjusted odds ratio 2.14; 95% CI, 1.29–3.55). CONCLUSIONS: CT imaging for pediatric patients with nontraumatic abdominal pain has plateaued since 2007 after the steady increase seen in the preceding 9 years. Among this population, an increased likelihood of CT imaging was demonstrated in general EDs compared with pediatric EDs, in which there was a higher likelihood of ultrasound imaging. Dissemination of pediatric-focused radiology protocols to general EDs may help optimize radiation exposure in children.

HIV and Syphilis Screening Among Adolescents Diagnosed With Pelvic Inflammatory Disease

In this retrospective cohort study, we used the PHIS database to demonstrate that adolescents with PID are underscreened for HIV and syphilis. BACKGROUND AND OBJECTIVES: Women with pelvic inflammatory disease (PID) are at an increased risk for syphilis and HIV, but screening rates among adolescents have been understudied. Our objective is to measure the frequency of HIV and syphilis screening among adolescents who are diagnosed with PID and identify patient- and hospital-level characteristics associated with screening. METHODS: We performed a retrospective cohort study using the Pediatric Health Information System from 2010 to 2015. We included visits to the emergency department by female adolescents who were diagnosed with PID and determined the frequency of HIV and syphilis screening. We performed separate multivariable logistic regression analyses to identify factors associated with screening. RESULTS: Of the 10 698 patients who were diagnosed with PID, 22.0% (95% confidence interval [CI] 21.2%–22.8%) underwent HIV screening, and 27.7% (95% CI 26.9%–28.6%) underwent syphilis screening. Screening rates varied by hospital (HIV: 2.6%–60.4%; syphilis: 2.9%–62.2%). HIV screening was more likely to occur in younger (adjusted odds ratio [aOR] 1.2; 95% CI 1.0–1.3), non-Hispanic African American (aOR 1.4; 95% CI 1.2–1.7), non–privately insured (publicly insured [aOR 1.3; 95% CI 1.1–1.5], uninsured [aOR 1.6; 95% CI 1.2–2.0]), and admitted patients (aOR 7.0; 95% CI 5.1–9.4) at smaller hospitals (aOR 1.4; 95% CI 1.0–1.8). Syphilis screening was more likely to occur in younger (aOR 1.1; 95% CI 1.0–1.3), non-Hispanic African American (aOR 1.8; 95% CI 1.2–2.8), non–privately insured (publicly insured [aOR 1.4; 95% CI 1.2–1.6], uninsured [aOR 1.6; 95% CI 1.2–1.9]), and admitted patients (aOR 4.6; 95% CI 3.3–6.4). CONCLUSIONS: We found low rates of HIV and syphilis screening among adolescents who were diagnosed with PID, with wide variability across hospitals.

Decreasing Blood Culture Contaminants in a Pediatric Emergency Department: An Interrupted Time Series Analysis

Introduction: High peripheral blood culture contamination rates (BCCR) in the emergency department (ED) contribute to overuse and harm. This study describes 2 years of quality improvement (QI) interventions that aimed to decrease a high BCCR in a pediatric ED. Methods: The QI team created a Key Driver Diagram with multiple Plan-Do-Study-Act (PDSA) cycles. PDSA interventions included a venipuncture sterility checklist (PDSA1), phlebotomist feedback system (PDSA2), and physician ordering guidelines (PDSA3). The specific aim was to decrease the BCCR by 50% within 24 months. The secondary aim was to decrease the peripheral blood culture ordering rate (BCOR) by 10% within 24 months. The balancing measure was the proportion of pathogenic bacteremia cases at ED return visits before and after PDSA3 implementation. A financial measure estimated the savings in charges between the observed and expected contaminants in PDSA3. An interrupted time series design applied statistical process control methodology to detect special cause variations. Results: The BCCR in the baseline, PDSA1, PDSA2, and PDSA3 periods were 3.02%, 2.30%, 1.58%, and 1.17%, respectively. The BCOR in the baseline, PDSA1, PDSA2, and PDSA3 periods was 4.80%, 4.26%, 3.82%, and 3.49%, respectively. Special cause variations occurred after PDSA cycle implementations for both BCCR and BCOR. There was no change in the balancing measure. The interventions were associated with an annual prevention of 95 contaminants and savings of

Development of a Sexual Health Screening Tool for Adolescent Emergency Department Patients.

300,070. Conclusions: Interventions that focused on improving venipuncture technique and limiting unnecessary blood cultures were associated with fewer contaminants and the achievement of the QI team’s project aims.