Do We Know Where They Go? Obtaining Travel History in Pediatric Patients.

OBJECTIVE: To determine how often travel histories are obtained in pediatric patients. METHODS: A retrospective medical record review was performed at a single tertiary care children's hospital for patients aged 2 months to 18 years who were admitted October 2015-December 2017 with International Classification of Diseases, 10th Revision codes for potential travel-related illnesses. Demographic information and travel history documentation were obtained, along with travel-related testing. From May to June 2018, prospective, single-blinded, direct observation of a convenience sample of pediatric residents was performed during the initial patient encounter to determine the frequency and quality of travel histories obtained regardless of documentation. RESULTS: Of 249 charts reviewed, 27 (10.8%) patients had a travel history query documented. Patients with complex chronic conditions were significantly less likely to have a travel history documented (37% vs 67%; P = 0.005). Age, sex, length of stay, race, payer status, and critical care admission did not significantly differ between groups. Those with a travel history documented were more likely to have a documented exposure history (100% vs 52%; P < 0.001) and additional testing performed (56% vs 13%, P < 0.001). During this time, a simulation course with residents featuring travel-related diagnoses led to a significant increase in documented travel histories (5% prior versus 21% after, P = 0.03). A total of 37 patient encounters were observed; travel history was asked for 4 times (4/37, 10.8%). CONCLUSIONS: Travel histories are rarely asked for in pediatric patients. Missed diagnoses may not only affect the patient but also have broader public health implications. Simulation is an effective tool to improve history-taking skills, yet more work is still needed.

Travel Histories in Children: How Well Do Interns and Medical Students Do?

OBJECTIVE: To evaluate the knowledge of obtaining travel histories in medical students and interns. METHODS: Medical students and interns participated in a high-fidelity pediatric simulation with two cases (malaria or typhoid fever) that hinged on travel history. After the simulation, appropriate methods of obtaining travel histories were discussed. Participants completed surveys regarding their previous education and comfort with obtaining travel histories. If and how a travel history was obtained was derived from simulation observation. RESULTS: From June 2016 to July 2017, 145 medical trainees participated in 24 simulation sessions; 45% reported no prior training in obtaining travel histories. Participants asked for a travel history in all but 2 simulations; however, in 9 of 24 simulations (38%), they required prompting by either a simulation confederate or laboratory results. Participants were more comfortable diagnosing/treating conditions acquired from US domestic travel than from international travel (32.9% vs 22.4%, P < 0.001). Previous education in obtaining travel histories and past international travel did not significantly influence the level of comfort that participants felt with travel histories. CONCLUSIONS: This study highlights the lack of knowledge regarding the importance of travel histories as part of basic history taking. Medical students and interns had low levels of comfort in obtaining adequate travel histories and diagnosing conditions acquired from international travel.

Outpatient pain clinic and intranasal fentanyl to improve sickle cell disease outcomes.

BACKGROUND: Acute pain events are a leading complication for sickle cell patients. In an attempt to improve pain outcomes, we developed an outpatient pain clinic, and included intranasal fentanyl in the opioid emergency department (ED) pain order set. We evaluated admission rates and opioid administration for patients that attended both the outpatient pain clinic and ED within a 3-month period. METHODS: We recorded the admission rate, IV morphine equivalents, and time from triage for each opioid order and administration from both an outpatient pain clinic and ED visit within a 3-month period for an individual pediatric patient with sickle cell disease. RESULTS: Thirty patients received acute pain management in both settings. We identified a significant reduction in hospital admission when patients received care in the pain clinic as compared to the ED (17% vs 43%, P = .02). Additionally, outpatient pain clinic patients received significantly less IV morphine equivalents than patients received in the ED (5.6 vs 10.6 IV morphine equivalents, P < .0001). In the ED, intranasal fentanyl was administered in a significantly shorter time than patients ordered intravenous opioid (43 vs 75 min, P = .02). The mean time to receiving an opioid in the outpatient pain clinic was 57 min. CONCLUSION: The use of an outpatient pain clinic can reduce admission rates as compared to the ED. The use of intranasal fentanyl reduced the time to first opioid administration in the ED. Patient-centered research or quality improvement projects should continue to focus on novel approaches to acute pain event management.

Barriers and Facilitators to Cervical Cancer Screening, Diagnosis, Follow-Up Care and Treatment: Perspectives of Human Immunodeficiency Virus-Positive Women and Health Care Practitioners in Tanzania.

BACKGROUND: This study was conducted to identify barriers and facilitators to cervical cancer screening, diagnosis, follow-up care, and treatment among human immunodeficiency virus (HIV)-infected women and clinicians and to explore the acceptability of patient navigators in Tanzania. MATERIALS AND METHODS: In 2012, we conducted four focus groups, two with HIV-positive women and two with clinicians who perform cervical cancer screening, diagnosis, follow-up care, and treatment. Transcriptions were analyzed using thematic analysis. RESULTS: Findings from the patient focus groups indicate the prevalence of fear and stigma surrounding cervical cancer as well as a lack of information and access to screening and treatment. The clinician focus groups identified numerous barriers to screening, diagnosis, follow-up care, and treatment. Participants in both types of groups agreed that a patient navigation program would be an effective way to help women navigate across the cancer continuum of care including screening, diagnosis, follow-up care, and treatment. CONCLUSION: Given the fear, stigma, misinformation, and lack of resources surrounding cervical cancer, it is not surprising that patient navigation would be welcomed by patients and providers. IMPLICATIONS FOR PRACTICE: This article identifies specific barriers to cervical cancer screening and treatment from the perspectives of both clinicians and patients in Tanzania and describes the acceptability of the concept of patient navigation.

Acceptance of peer navigators to reduce barriers to cervical cancer screening and treatment among women with HIV infection in Tanzania.

OBJECTIVE: To identify barriers to cervical cancer screening and treatment, and determine acceptance toward peer navigators (PNs) to reduce barriers. METHODS: A cross-sectional study was conducted among women with HIV infection aged 19 years or older attending HIV clinics in Dar es Salaam, Tanzania, between May and August 2012. Data for sociodemographic characteristics, barriers, knowledge and attitude toward cervical cancer screening and treatment, and PNs were collected by questionnaire. RESULTS: Among 399 participants, only 36 (9.0%) reported previous cervical cancer screening. A higher percentage of screened than unscreened women reported being told about screening by someone at the clinic (25/36 [69.4%] vs 132/363 [36.4%]; P=0.002), knew that screening was free (30/36 [83.3%] vs 161/363 [44.4%]; P<0.001), and obtained "good" cervical screening attitude scores (17/36 [47.2%] vs 66/363 [18.2%]; P=0.001). Most women (382/399 [95.7%]) did not know about PNs. When told about PNs, 388 (97.5%) of 398 women said they would like assistance with explanation of medical terms, and 352 (88.2%) of 399 said they would like PNs to accompany them for cervical evaluation and/or treatment. CONCLUSION: Use of PNs was highly acceptable and represents a novel approach to addressing barriers to cervical cancer screening and treatment.