Patient at Risk: Emergency medical service providers' opinions on improving an electronic emergency information form database for the medical care of children with special health care needs.

BACKGROUND: Patient at Risk (PAR) is an online database using an emergency information form (EIF) that parents of children with special health care needs (CSHCN) complete to store their child's medical information. Emergency medical service (EMS) providers can then access PAR during medical emergencies or for pre-planning. PAR was active for over 10 years but use by patients and EMS was limited. OBJECTIVE: To determine EMS perspectives on why PAR was not used to its full potential and how to improve PAR for EMS. METHODS: Seven questions regarding PAR were developed and presented in focus groups at 32 fire/ambulance houses in southeast and central Wisconsin from June to August 2017. Responses were transcribed and reviewed for themes. RESULTS: 146 EMS providers participated and 11% were aware of PAR. Many did not use PAR because of a lack of follow up or barriers such as limited internet access, inconvenience, other urgent responsibilities, and not knowing when to use PAR. Solutions to these issues include developing or purchasing new technology, involving the dispatch operator in PAR, and returning to a paper-based EIF. The EIF layout and content received very positive reviews with few changes suggested. Most providers felt PAR was important because it would help them provide better care and feel more comfortable treating CSHCN. CONCLUSION: Despite technological and logistical barriers, EMS providers want online EIF databases for pre-planning and utilization during ambulance runs so they can practice more informed and focused care, especially for vulnerable and medically challenging CSHCN.

Rapid human immunodeficiency virus testing in the pediatric emergency department: a national survey of attitudes among pediatric emergency practitioners.

OBJECTIVE: Human immunodeficiency virus (HIV) continues to be a significant public health concern for adolescents and young adults. Since 2006, the Centers for Disease Control and Prevention has recommended more aggressive routine screening for HIV for patients presenting to the emergency department (ED). Our objectives were to design and validate a survey of physician barriers toward the use of rapid HIV testing in the pediatric ED and then to use this validated tool to conduct a national survey of pediatric emergency practitioners' attitudes toward rapid HIV testing in the ED. METHODS: Survey design and initial validation steps were conducted with a panel of health care practitioners familiar to HIV testing. Several variables were identified as possible barriers toward rapid HIV testing. The survey was sent via electronic software to a national sample of pediatric emergency practitioners over 2 listservs. The previously identified variables were evaluated by factor analysis for internal consistency and homogeneity, and confirmatory factor analysis was conducted via promax and varimax rotation. All factor analyses were conducted using Stata software. Once the validation was complete, the surveys were sent to groups of pediatric emergency practitioners who had previously identified as having rapid HIV testing available in their EDs. Standard descriptive statistics were used, and group differences were evaluated with t test and χ(2) test. RESULTS: Four factors were identified during the validation process as being the most important barriers for rapid HIV testing in the pediatric ED: self efficacy, familiarity, external barriers, and a previously unidentified factor, which we interpreted as related to barriers to the specific environment of one's own ED. A total of 80 participants returned the final, validated survey. The participants came from 9 different pediatric emergency medicine groups (5 in areas of low rates of HIV infection, 4 in areas of high rates of HIV infection). Self-reported rates of testing were not different based on HIV infection rate in the community or the respondent's level of training. High testing was more common when a guideline was reported (39%) than when it was not (13.3%; difference, 25.7%; 95% confidence interval, 2.9%-48.5%). Of the 4 factors identified, we found statistically significant differences in scores on all 4 factors between high versus low testers, with high testers disagreeing more strongly with the various barrier questions proposed. We found no difference in the factor scores between areas of high versus low HIV infection rates. CONCLUSIONS: Our results suggest that several factors related to perceived provider barriers are associated with rates of HIV testing in the ED and that personal factors (eg, level of training) and community HIV prevalence were not associated with rates of testing. Our results confirm what has been speculated by numerous authors and provide data to inform efforts to improve compliance with national recommendations for increased testing.

A survey of emergency department use in patients with cyclic vomiting syndrome.

BACKGROUND: Cyclic vomiting syndrome (CVS), a chronic disorder characterized by recurrent episodes of vomiting, is frequently unrecognized and is associated with high utilization of emergency department (ED) services. METHODS: A web-based survey was posted on the Cyclic Vomiting Syndrome Association (CVSA) website to assess utilization of ED services in patients with CVS. RESULTS: Of 251 respondents, 104 (41.4%) were adult CVS patients and 147 (58.6%) were caregivers of pediatric and adult patients. In the adult group, the median number of ED visits for CVS symptoms was 15(range 1 - 200), with a median of 7 ED visits prior to a diagnosis of CVS (range 0 - 150). In the caregiver group, the median number of ED visits was 10 (range 1 - 175) and the median number of ED visits prior to a diagnosis of CVS was 5 (range 0 - 65). CVS was not diagnosed in the ED in 89/104 (93%) adults and 119/147 (93%) patients in the caregiver group. CVS was not recognized in the ED in 84/95 (88%) of adults and 97/122 (80%) of patients in the caregiver group, despite an established diagnosis of CVS. CONCLUSION: There is a sub-group of adult and pediatric CVS patients who are high utilizers of ED services and CVS is not recognized in the ED in the majority of patients. Improved efforts to educate ED physicians are indicated to optimize treatment of patients with CVS and to decrease potential overuse of ED services.

Update on sexually transmitted infections, 2008.

Sexually transmitted infections (STIs) continue to be a great concern in the adolescent population and of particular concern to the pediatric emergency medicine physician. The Centers for Disease Control and Prevention reports that rates of gonorrheal and chlamydial infections are greatest in female adolescents, aged 15 to 19 years, and many people acquire human papilloma virus and human immunodeficiency virus infections during their teenage years. Adolescents continue to be at a higher risk for acquiring STIs because of multiple factors, including being more biologically susceptible, more likely to engage in unprotected sex with multiple partners, as well as facing various obstacles to their use of the health care system. The pediatric emergency medicine physician must be aware of the various presentations of STIs in their patients, as well as how to adequately treat and offer counseling to this vulnerable population.

Emergency department management of sexually transmitted infections in US adolescents: results from the National Hospital Ambulatory Medical Care Survey.

STUDY OBJECTIVE: Adolescents are at risk for developing a variety of sexually transmitted infections for many reasons. Many of these adolescents present to the emergency department (ED) for their care. We describe the management of adolescent sexually transmitted infections in US EDs. METHODS: Data were obtained from the 1992 to 1998 National Hospital Ambulatory Medical Care Survey. All visits by adolescents aged 12 to 19 years were identified by any International Classification of Diseases, Ninth Revision code related to sexually transmitted infections. Treatment was reviewed and compared with existing guidelines from the US Centers for Disease Control and Prevention (CDC). Multivariate logistic regression was used to determine the independent association of each of the following variables on antibiotic prescribing rates: sex, race and ethnicity, hospital location, age, and insurance. RESULTS: Eighteen thousand nine hundred ninety-nine records that represented 70,693,603 adolescent visits to US EDs were identified during the 7-year study period, of which 351 records representing 1.2 million visits were for a sexually transmitted infection. Mean age was 17.1 years, and 92% were female patients. Overall, 80% of patients diagnosed with a sexually transmitted infection were treated (received antibiotics or were admitted to the hospital); 91% of patients had pelvic inflammatory disease and 71% of patients had other sexually transmitted infections. Eight percent of patients diagnosed with pelvic inflammatory disease were admitted to the hospital. However, treatment for female patients with pelvic inflammatory disease was fully compliant with CDC recommendations in only 35% of cases (95% confidence interval [CI] 19% to 45%) and partially compliant in another 45%; 20% (95% CI 12% to 31%) of patients received either no treatment or treatment not in accordance with guidelines. Male patients were more likely to be treated for sexually transmitted infection (adjusted odds ratio [OR] 6.3; 95% CI 1.0 to 38.7), and Hispanic patients were less likely (adjusted OR 0.3; 95% CI 0.1 to 0.9) to be treated. Age, insurance type, and hospital location were not a factor in receiving antibiotics. For female patients who had a sexually transmitted infection, only 43% had a pregnancy test done, and of all adolescents diagnosed with a sexually transmitted infection, only 1 (0.3%) had an HIV test performed. CONCLUSION: Significant numbers of adolescents sought care for sexually transmitted infections in US EDs. Evaluation and treatment of these adolescents is not optimal. Male patients are more likely to be treated for a sexually transmitted infection. Hispanic patients are less likely to be treated for a sexually transmitted infection. Pelvic inflammatory disease is not always treated with antibiotics, and few patients with pelvic inflammatory disease are admitted to the hospital. HIV testing was almost never done. Further study is necessary to explain these disparities and optimize care.

The effectiveness of a follow-up program at improving HIV testing in a pediatric emergency department.

BACKGROUND: HIV infection is on the rise in the adolescent population, with the most common risk for infection being sexual exposure for youth aged 15-24 years. Therefore screening for HIV infection should be performed on adolescent patients presenting to the emergency department (ED) with signs or symptoms of sexually transmitted disease (STD). Lack of opportunity for follow-up of HIV test results may prevent ED physicians from obtaining this test. OBJECTIVE: Our objective was to compare the rate of HIV testing in patients evaluated in the ED for STDs before and after the implementation of a follow-up program. METHODS: We conducted a retrospective chart review of all patients 12-18 years of age seen in the ED between April 1, 1993 and March 31, 1997 with ICD-9 codes for STD. The follow-up program started April 1, 1995. Rates of HIV testing were compared between the two years before and after the institution of the follow-up program to determine whether the follow-up program had an impact on the rate of HIV testing. RESULTS: We reviewed 862 records. Before the follow-up program was in place, 86 (18%) of the patients tested for STD in the ED were also tested for HIV and only 7 (8.1%) were called back with their results. After the follow-up program was in place, 100 (27%) of the patients tested for STD in the ED were also tested for HIV. Attempts were made to notify 57 (57%) of these patients of their HIV test results. Coincident with the implementation of the follow-up program, both the rate of HIV testing and patient notification of HIV results increased (p < 0.05). CONCLUSIONS: Coincident with the institution of an appropriate follow-up system, HIV testing in the ED increased and follow-up of these patients improved. However, further steps should be taken to improve the HIV testing in the pediatric ED.