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.

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.

A pilot QI primary care practice program to help reduce infant mortality risks.

BACKGROUND: Tobacco smoke exposure (TSE) and inappropriate sleep position/environments contribute to preventable infant deaths. The objective of our quality improvement (QI) program was to increase primary care provider (PCP) screening and counseling for TSE and safe sleep risks at well-child visits (WCVs) and to assess caregiver behavior changes at subsequent visits. METHODS: Pediatric practices, recruited from the Ohio Chapter, American Academy of Pediatrics' database, self-selected to participate in this TSE and safe sleep PCP QI program. At every WCV over a 10-month period, caregivers with children < 1 year old were to be screened and counseled by providers. Caregiver demographics, TSE, and safe sleep practices were assessed. Individual PCP results were paired with subsequent family screening tools at follow up visits to determine changes in TSE and safe sleep practices. Differences in frequencies were determined and paired t-tests were used to compare means. RESULTS: Fourteen practices (60 providers) participated; 7289 screens were completed: 3972 (54.5%) initial screens and 1769 (24.3%) subsequent WCV screens. Caregivers on the initial screen were primarily white (61.7%), mothers (86.0%) with public insurance (41.7%). Within the first month after QI program initiation, PCPs TSE screening was during 80% of WCVs, which increased to > 90% by end of the QI program. A total of 637 /3953 (16.1%) screened positive for home TSE on the initial visit: 320/3953 (8.1%) exposed by at least the primary caregivers, and 317/3953 (8.0%) exposed by a home adult smoker (not the identified caregiver). Of caregivers receiving smoking counseling with subsequent follow-up WCV (n = 100), the mean number of cigarettes smoked daily decreased significantly from 10.6 to 4.6 (p = 0.03). Thirty-four percent of caregivers (34/100) reported they quit smoking at their second visit. A total of 1072 (27%) infants screened at risk for inappropriate sleep position or environment at their initial visit. Of these at-risk infants whose caregivers received safe sleep counseling, 49.1% practiced safer sleep behaviors at follow-up. CONCLUSIONS: PCPs participating in a QI program increased screening at WCVs for infant mortality risks. After counseling and providing resources about TSE and safe sleep, many caregivers reported practicing safer behaviors at their next WCV.

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.

A quality improvement program in pediatric practices to increase tailored injury prevention counseling and assess self-reported changes made by families.

BACKGROUND: Many pediatric providers struggle to screen families for the majority of age-appropriate injury risks and educate them when appropriate. Standardized tools have helped physicians provide effective, more purposeful counseling. In this study, pediatricians utilized a standardized, injury prevention screening tool to increase targeted discussions and families were re-screened at subsequent visits to determine changes in their behavior. METHODS: Pediatric practices, recruited from the Ohio Chapter, American Academy of Pediatrics database, self-selected to participate in a quality improvement program. Two screening tools, for children birth-4 month and 6-12 month, with corresponding talking points, were to be implemented into every well child visit. During the 7-month collaborative, screening results and pediatrician counseling for reported unsafe behaviors were calculated. Patients who completed a screening tool at subsequent visits were followed up at a later visit to determine self-reported behavior changes. We examined statistically significant differences in frequencies using the X2 test. Providers received maintenance of certification IV credit for participation. RESULTS: Seven practices (39 providers) participated. By the second month, participating providers discussed 75% of all inappropriate responses for birth-4 month screenings and 87% for 6-12 months. Of the 386 families who received specific counseling and had a follow-up visit, 65% (n = 94/144) of birth-4 month and 65% (n = 59/91) of 6-12 month families made at least one behavior change. The X2 test showed that families who received counseling versus those that did not were significantly more likely to change inappropriate behaviors (p < 0.05). Overall, of all the risks identified, 45% (136) of birth-4 month and 42% (91) of 6-12 month behaviors reportedly changed after a practitioner addressed the topic area. CONCLUSIONS: Participation in a quality improvement program within pediatric offices can increase screening for injury risks and encourage tailored injury prevention discussions during an office encounter. As a result, significantly more families reported to practice safer behaviors at later visits.

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.

A pilot quality improvement program to increase pediatrician injury anticipatory guidance.

BACKGROUND: Because of a lack of time and training, many pediatricians often address few, if any, injury topics during well-child visits. The project goal was to increase the injury anticipatory guidance topics covered by pediatricians during well-child visits by offering screening tools and focused talking points through a quality improvement learning collaborative. METHODS: Screening tools were developed and pretested. Pediatric practices, recruited through the Ohio American Academy of Pediatrics, were taught quality improvement theory and injury prevention strategies at a learning session. Pediatricians worked to implement screening tools and talking points into every well-child visit for children 1 year or younger. Monthly, providers reviewed five random charts for each of the six well-child visits for screening tool use and age-appropriate injury prevention discussion. Providers received maintenance of Certification IV credit. RESULTS: Sixteen pediatricians (six practices) participated. Screening tool use increased from 0% to 97.2% in just 3 months of the program. For each well-child care visit, injury prevention discussion increased by 89.5% for newborn visit, 88.1% for 2-month, 93.6% for 4-month, 94.0% for 6-month, 88.1% for 9-month, and 90.3% for 12-month-old babies. During the quality improvement program, discussion points for all children 1 year or younger increased for all age-appropriate topics. The greatest percent increase in discussions occurred with water safety (from 10.8% to 95.7%, n = 231), play safety (from 17.9% to 93.5%, n = 154), and supervision safety (from 20.8% to 94.4%, n = 251). More commonly addressed topics also had a significant increase in discussions: sleep safety (from 48% to 93.9%, n = 262), choking (from 44.7% to 95.4%, n = 172), and car safety (from 41.2% to 80.1%, n = 332). CONCLUSION: Participation in a maintenance of Certification IV quality improvement program within pediatric offices can increase screening and discussion of injury anticipatory guidance. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.