Increasing Mental Health Screening in Pediatric Subspecialty Clinics: An Improvement Project at Brooke Army Medical Center.

INTRODUCTION: Mental health screening allows for the early identification of patients at risk of mental health disorders such as anxiety and depression. The Defense Health Administration Procedures Manual 6025.01 established that patients older than 12 years of age should receive annual mental health screening assessing suicidality risk with a standardized screening tool. MATERIALS AND METHODS: To improve rates of mental health screening in this at-risk population, an A3 Lean approach to quality improvement was undertaken in the Pediatric Subspecialty Clinics at Brooke Army Medical Center. RESULTS: Baseline data of Patient Health Questionnaire-9 or General Anxiety Disorder-7 screening from pediatric pulmonology and cardiology clinics were 6.3%. Plan-Do-Study-Act quality improvement methods evaluated possible interventions to improve screening. A standard operating procedure (SOP) outlining scoring and interpretation recommendations was distributed in pediatric pulmonology and cardiology clinics. Using the Armed Forces Health Longitudinal Technology Application, a post-implementation chart review was conducted for 8 weeks. With the initiation of Military Health System Genesis, the SOP was adjusted and a root cause analysis was performed. The pediatric gastroenterology clinic cares for patients presenting with functional abdominal pain; therefore, the clinic was added to the second iteration to determine if anxiety or depression may play a role. Providers were educated on documentation and coding. A second post-implementation chart review was conducted for 8 weeks. Over two iterations, mental health screening of new adolescent patients in pediatric subspecialty clinics increased by 794% from baseline. Our providers screened 50% of the adolescent patients. CONCLUSIONS: With increased surveillance of an at-risk population, more adolescents will receive the standard of care. With refinement of the SOP and expansion to other subspecialties, this project has the potential to expand within Brooke Army Medical Center and other clinics in the Defense Health Administration.

BOTOX injection to treat strabismus after infant botulism type B infection.

PURPOSE: The significance of botulinum toxin to ophthalmologists is twofold. Botulism, a medical emergency, frequently presents with ocular findings including blurred vision, diplopia, ptosis, and photophobia as a result of the neurotoxin produced by Clostridium botulinum. However, botulinum toxins also have therapeutic uses for medical conditions including strabismus. The safety and efficacy of Botulinum toxin A in patients with a history of botulism has not been reported. OBSERVATIONS: We report a 9-week-old infant, diagnosed with type B toxin positive infant botulism treated with human botulism immune globulin, who developed a large angle exotropia. The infant was treated with intramuscular injections of botulinum toxin A to the extraocular muscles resulting in a favorable initial response but ultimately required strabismus surgery. Clinical manifestations and management of botulism are reviewed and botulinum toxin in the treatment of pediatric strabismus is discussed. CONCLUSIONS AND IMPORTANCE: This case demonstrates safe administration of onabotulinumtoxinA to an infant with a history of antitoxin-treated botulism, resulting in a transient improvement in control of infantile exotropia.

Teleophthalmology Prevents Unnecessary Evacuation from Warzone.

The purpose of this case report is to highlight the benefits of using teleconsultation to diagnose ophthalmologic conditions within the restraints of a combat environment. A previously healthy 49-year-old service member deployed in the Middle East presented with diplopia over the course of 2 weeks. Initial diagnosis by his primary care physician upon partial ophthalmologic exam was a pupil-sparing CN III palsy without ptosis. Initial teleconsultation response from Naval Medical Center Portsmouth was within 6 hours. After an ophthalmologic sensorimotor examination was videotaped and sent to the referred ophthalmologist, teleconsultation was completed and discussed with the patient. The updated diagnosis was CN IV palsy with slight right hypertropia worse on left gaze-most likely congenital in origin. Upon further follow-up stateside, his final diagnosis was diplopia related to thyroid disease. Overall, his diagnosis remained a nonurgent condition that allowed the service member to remain at his duty station and prevent an unnecessary evacuation. Ultimately, teleconsultation provided many benefits for the service member and the U.S. military.