Information Technology-Assisted Screening for Gonorrhea and Chlamydia in a Pediatric Emergency Department.

PURPOSE: The aim of the study was to design and implement a novel, universally offered, computerized clinical decision support (CDS) gonorrhea and chlamydia (GC/CT) screening tool embedded in the emergency department (ED) clinical workflow and triggered by patient-entered data. METHODS: The study consisted of the design and implementation of a tablet-based screening tool based on qualitative data of adolescent and parent/guardian acceptability of GC/CT screening in the ED and an advisory committee of ED leaders and end users. The tablet was offered to adolescents aged 14-21 years and informed patients of Centers for Disease Control and Prevention GC/CT screening recommendations, described the testing process, and assessed whether patients agreed to testing. The tool linked to CDS that streamlined the order entry process. The primary outcome was the patient capture rate (proportion of patients with tablet data recorded). The secondary outcomes included rates of patient agreement to GC/CT testing and provider acceptance of the CDS. RESULTS: Outcomes at the main and satellite EDs, respectively, were as follows: 1-year patient capture rates were 64.6% and 64.5%; 9.9% and 4.4% of patients agreed to GC/CT testing, and of those, the provider ordered testing for 73% and 72%. CONCLUSIONS: Implementation of this computerized screening tool embedded in the clinical workflow resulted in patient capture rates of almost two-thirds and clinician CDS acceptance rates >70% with limited patient agreement to testing. This screening tool is a promising method for confidential GC/CT screening among youth in an ED setting. Additional interventions are needed to increase adolescent agreement for GC/CT testing.

The Reliability of Computerized Physician Order Entry Data for Research Studies.

OBJECTIVES: In the United States, adolescents account for nearly half of the newly diagnosed sexually transmitted infections annually, and many of these infections are asymptomatic. Adolescents often seek care in pediatric emergency departments; thus, the emergency department is an important setting to implement adolescent sexually transmitted infection screening. Before implementation, baseline data reflecting current screening rates of symptomatic and asymptomatic patients were needed. This study aimed to evaluate the accuracy of provider-reported rates of symptomatic and asymptomatic chlamydia (CT) and gonorrhea (GC) testing in adolescents overall and pre-electronic health record (EHR) and post-EHR order modification in preparation for a research intervention. METHODS: This was a 1-year prospective, observational study. Provider reason for CT/GC testing was added to the existing EHR order. Chart reviews were performed to ensure the accuracy of clinician CT/GC testing choices (symptomatic vs asymptomatic). Frequencies of testing choices were obtained. Order modifications were made to further clarify the definitions. A Student t test was used to compare data preorder and postorder modification. RESULTS: When relying on providers to report reasons for CT/GC testing (symptomatic vs asymptomatic), many patients were misclassified based on a priori defined testing reasons. After order modification, rates of provider-reported symptomatic testing remained unchanged (P = 0.16). Provider-reported asymptomatic testing significantly declined (P = 0.004); however, 23.2% of those tested continued to be misclassified. CONCLUSIONS: Provider-entered EHR data are increasingly being used in research studies; thus, it is important to ensure its accuracy and reliability before study implementation.

Biomarkers to distinguish surgical etiologies in females with lower quadrant abdominal pain.

OBJECTIVES: Lower abdominal pain is a common complaint in girls and young women presenting to a pediatric emergency department (PED). An extensive evaluation may be required to exclude surgical emergencies such as appendicitis and ovarian torsion. However, clinicians and families prefer to limit invasive procedures and radiation exposure. The literature suggests that serum biomarkers such as the cytokine interleukin-6 (IL-6) can predict ovarian torsion in adults, while the membrane glycoprotein cluster of differentiation-64 (CD64) has been linked with bacterial infections and sepsis. Therefore, the study objective was to assess whether plasma IL-6 or neutrophil CD64 surface levels would assist clinicians in distinguishing surgical diagnoses (ovarian torsion and appendicitis) from nonsurgical diagnoses in young females with lower abdominal pain. METHODS: This study was a prospective, cross-sectional, pilot study of young females presenting with lower abdominal pain. Demographics, clinical and laboratory data, and final diagnoses were recorded. Plasma IL-6 and neutrophil CD64 were quantified. Nonparametric Kruskal-Wallis test was used to detect significant differences in IL-6 and CD64 values between surgical and nonsurgical patients. Further analysis was done to detect differences among the surgical patients (appendicitis vs. ovarian torsion). A bivariate analysis using the Wilcoxon rank sum was used to test for significant differences in IL-6 and CD64 by selected clinical factors. RESULTS: There were 112 female subjects ages 6 to 21 years enrolled. Final diagnoses were grouped as appendicitis (n = 38, 34%), ovarian torsion (n = 15, 13%), and nonsurgical (n = 59, 53%). Surgical cases had significantly higher levels of IL-6 compared to nonsurgical cases (p < 0.0001), and appendicitis patients had significantly higher CD64 indexes compared to ovarian torsion patients (p = 0.007). The clinical characteristics of fever of ≥38°C (p = 0.0002) and constant pain (p = 0.02) were significantly associated with elevated IL-6. Fever of ≥38°C (p = 0.02) was significantly associated with a higher CD64 index. CONCLUSIONS: Interleukin-6 was significantly elevated in surgical patients compared to nonsurgical patients in this sample of young females, and CD64 was significantly elevated in appendicitis patients compared to ovarian torsion patients. These data suggest that with larger sample sizes and future confirmatory studies, these biomarkers may be useful in the evaluation of young women with lower quadrant abdominal pain.