Emergency department utilization by adolescents in the United States

Screening for Asymptomatic Gonorrhea and Chlamydia in the Pediatric Emergency Department

BACKGROUND

Because adolescents rely heavily on emergency services for health care, a pediatric emergency department (PED) visit may be their only opportunity for sexually transmitted infection (STI) screening. The primary objectives of this study were to determine the proportion of Neisseria gonorrheae (GC) and Chlamydia trachomatis (CT) infections in asymptomatic PED adolescents and patient-perceived barriers to STI screening.

METHODS

A convenience sample of patients aged 14 to 21 years presenting to an urban PED with nongenitourinary complaints was offered screening for GC and CT. Regardless of declining or accepting screening, all were asked to complete a questionnaire designed to identify barriers to screening.

RESULTS

Sixty-eight percent of those approached participated (n = 719). Those who agreed to STI screening were more likely to be nonwhite (61.4% vs. 38.6%, P = 0.001) and publically insured (63.3%) versus privately insured (29.3%) or no insurance (7.58%). Four hundred three (56%) participants provided urine samples, and of those, 40 (9.9%) were positive for an STI. Controlling for other demographics, race was a significant predictor, with the odds of testing positive for nonwhite participants 5.90 times that of white participants. Patients who refused testing were more likely to report not engaging in sexual activity (54.3% vs. 42.4%, P = 0.009) and less likely to perceive that they were at risk for STIs.

CONCLUSIONS

There are high proportions of GC and CT among asymptomatic adolescents visiting an academic urban PED. A universal PED STI screening program may be an important component of STI reduction initiatives, especially among adolescents who do not perceive that they are at risk and may not receive testing elsewhere.

Mobile Health Technology to Communicate Discharge and Follow-Up Information to Adolescents From the Emergency Department

OBJECTIVE

Adolescents are the largest users of mobile technology; yet, there are little data regarding their receptivity to the use of mobile health technology (mHealth) from the emergency department (ED). The objective of this study was to determine adolescents' preferences for receiving ED discharge and follow-up information via mHealth and factors associated with those preferences.

METHODS

We administered an anonymous self-reporting survey to patients aged 14 to 19 years discharged from an urban pediatric ED. We conducted exploratory bivariate analyses to evaluate differences in communication preferences based on patient characteristics. We used multivariable logistic regression to determine whether preference for health information via mHealth is associated with frequent information technology (IT) use, adjusting for age, sex, ethnicity, and insurance status.

RESULTS

Four hundred thirty-nine adolescents completed the survey. Most were female (n = 279, 64%), 14 to 17 years old (n = 247, 57%), Hispanic (n = 359, 86%), and insured (n = 388, 88%). Adolescents used IT often, texting more than 30 times a day (58%) and emailing more than once a day (61%). Most (n = 335, 78%) were interested in electronic communication from the ED. Teens expressed particular interest in using email for discharge instructions (n = 196, 47%), physician referrals (n = 197, 48%), and test results (n = 201, 48%) and using texting for medication (n = 155, 38%) and appointment reminders (n = 170, 41%). Individuals tended to prefer communication with IT modes that they typically used, although only email was independently associated with preference for this mode (adjusted odds ratio, 2.8; 95% confidence interval, 1.5-5.3).

CONCLUSIONS

Adolescent patients are interested in receiving health information from the ED, mainly via email and texting. Future ED interventions should evaluate the effectiveness of these modalities to communicate with patients after discharge.

Factors associated with the over-treatment and under-treatment of gonorrhea and chlamydia in adolescents presenting to a public hospital emergency department

OBJECTIVES

The purpose of this study was to measure the prevalence of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) and the rates and factors associated with their over-treatment (OT) and under-treatment (UT).

METHODS

A retrospective chart review was performed of patients aged 13-24 years who were screened for GC/CT in the emergency department (ED) of a public hospital. Descriptive statistics were obtained for all variables, and multivariate log binomial regression was performed to ascertain the factors associated with OT and UT.

RESULTS

Seven hundred and ninety-seven adolescents and young adults were screened for GC/CT. The overall sexually transmitted infection (STI) positivity rate was 21.6%; 136 (21.6%) subjects were over-treated and 74 (43.4%) subjects were under-treated. Patients presenting with STI exposure or genito-urinary symptoms were more likely to be OT. Additionally, females aged 18-19 years or with a prior history of STIs were more likely to be OT. Females (83.6%) were more likely to be UT, while STI exposure, genito-urinary symptoms, and a prior history of STI were protective of UT .

CONCLUSION

Adolescents and young adults screened for STIs have a high prevalence of GC/CT. A significant proportion of these patients end up over-treated and an even higher proportion are under-treated.

Adolescent Female Text Messaging Preferences to Prevent Pregnancy After an Emergency Department Visit: A Qualitative Analysis

Background

Over 15 million adolescents use the emergency department (ED) each year in the United States. Adolescent females who use the ED for medical care have been found to be at high risk for unintended pregnancy. Given that adolescents represent the largest users of text messaging and are receptive to receiving text messages related to their sexual health, the ED visit represents an opportunity for intervention.

Objective

The aim of this qualitative study was to explore interest in and preferences for the content, frequency, and timing of an ED-based text message intervention to prevent pregnancy for adolescent females.

Methods

We conducted semistructured, open-ended interviews in one urban ED in the United States with adolescent females aged 14-19 years. Eligible subjects were adolescents who were sexually active in the past 3 months, presented to the ED for a reproductive health complaint, owned a mobile phone, and did not use effective contraception. Using an interview guide, enrollment continued until saturation of key themes. The investigators designed sample text messages using the Health Beliefs Model and participants viewed these on a mobile phone. The team recorded, transcribed, and coded interviews based on thematic analysis using the qualitative analysis software NVivo and Excel.

Results

Participants (n=14) were predominantly Hispanic (13/14; 93%), insured (13/14; 93%), ED users in the past year (12/14; 86%), and frequent text users (10/14; 71% had sent or received >30 texts per day). All were interested in receiving text messages from the ED about pregnancy prevention, favoring messages that were “brief,” “professional,” and “nonaccusatory.” Respondents favored texts with links to websites, repeated information regarding places to receive “confidential” care, and focused information on contraception options and misconceptions. Preferences for text message frequency varied from daily to monthly, with random hours of delivery to maintain “surprise.” No participant feared that text messages would violate her privacy.

Conclusions

Adolescent female patients at high pregnancy risk are interested in ED-based pregnancy prevention provided by texting. Understanding preferences for the content, frequency, and timing of messages can guide in designing future interventions in the ED.

Physician Perspectives on Obesity Screening in Hospitalized Children

Nearly one-third of the children in the United States are obese or overweight and face associated physical and mental health issues.(1,2) Parents often misperceive and underreport their child's weight status.(3-5) This misperception is a major barrier to increasing healthy lifestyle choices, such as limiting screen time, increasing physical activity, improving diet, and participating in prevention programs.(6-8) Increasing parental awareness of children's weight status is an important initial step in addressing the obesity epidemic.

Older adolescent presentations to a children's hospital emergency department

OBJECTIVES

To describe the characteristics, diagnoses and outcomes of older adolescents, aged 16-19 years, presenting to a paediatric ED.

METHODS

A retrospective review of total ED presentations by older adolescents to a tertiary paediatric hospital between 2010 and 2012, inclusive, was undertaken to determine if behavioural or mental health problems were common.

RESULTS

A total of 1184 ED presentations by 730 older adolescents were identified. Injury and abdominal pain were the most common complaints for presentations by older adolescents to the ED. The median length of stay in ED was 241 (range: 0-3873) min. More than 60% of the older adolescent ED presentations were triaged urgent or semi-urgent, and 39% of all these presentations resulted in hospital admission. Two-thirds of these older adolescents had a chronic illness, which accounted for 77% of all ED presentations by older adolescents. The history of chronic illness was considered related or relevant in the evaluation and management of over 80% of older adolescents. Of all the ED presentations by older adolescents with chronic illness, only one quarter had transition planning documentation.

CONCLUSIONS

A high prevalence of chronic illness was found in older adolescents attending the paediatric ED. There was no evidence that behavioural and mental health issues dominated. These findings reflect admission policy.

Pediatric Use of Emergency Medical Services: The Role of Chronic Illnesses and Behavioral Health Problems

OBJECTIVE

The increasing use of prehospital emergency medical services (EMS) and its contribution to rising emergency department use and healthcare costs point to the need for better understanding factors associated with EMS use to inform preventive interventions. Understanding patient factors associated with pediatric use of EMS will inform pediatric-specific intervention. We examined pediatric patient demographic and health factors associated with one-time and repeat use of EMS.

METHODS

We reviewed data from Baltimore City Fire Department EMS patient records over a 23-month period (2008-10) for patients under 21 years of age (n = 24,760). Repeat use was defined as involvement in more than one EMS incident during the observation period. Analyses compared demographics of EMS users to the city population and demographics and health problems of repeat and one-time EMS users. Health comparisons were conducted at the patient and incident levels of analysis.

RESULTS

Repeat users (n = 1,931) accounted for 9.0% of pediatric users and 20.8% of pediatric incidents, and were over-represented among the 18-20 year age group and among females. While trauma accounted for approximately one-quarter of incidents, repeat versus one-time users had a lower proportion of trauma-related incidents (7.2% vs. 26.7%) and higher proportion of medical-related incidents (92.6% vs. 71.4%), including higher proportions of incidents related to asthma, seizures, and obstetric/gynecologic issues. In patient-level analysis, based on provider or patient reports, greater proportions of repeat compared to one-time users had asthma, behavioral health problems (mental, conduct and substance use problems), seizures, and diabetes.

CONCLUSIONS

Chronic somatic conditions and behavioral health problems appear to contribute to a large proportion of the repeat pediatric use of this EMS system. Interventions may be needed to engage repeat users in primary care and behavioral health services, to train EMS providers on the recognition and management of behavioral health emergencies, and to improve family care and self-management of pediatric asthma and other chronic conditions.

Universal Screening for Sexually Transmitted Infections among Asymptomatic Adolescents in an Urban Emergency Department: High Acceptance but Low Prevalence of Infection

OBJECTIVES

To evaluate acceptance of sexually transmitted infection (STI) screening and measure STI prevalence in an asymptomatic adolescent emergency department (ED) population.

STUDY DESIGN

This was a prospectively enrolled cross-sectional study of 14- to 21-year-old patients who sought care at an urban pediatric ED with non-STI related complaints. Participants completed a computer-assisted questionnaire to collect demographic and behavioral data and were asked to provide a urine sample to screen for Chlamydia trachomatis and Neisseria gonorrhoeae infection. We calculated STI screening acceptance and STI prevalence. We used logistic regression to identify factors associated with screening acceptance and presence of infection.

RESULTS

Of 553 enrolled patients, 326 (59.0%) agreed to be screened for STIs. STI screening acceptability was associated with having public health insurance (aOR 1.7; 1.1, 2.5) and being sexually active (sexually active but denying high risk activity [aOR 1.7; 1.1, 2.5]; sexually active and reporting high risk activity [aOR 2.6; 1.5, 4.6]). Sixteen patients (4.9%; 95% CI 2.6, 7.3) had an asymptomatic STI. High-risk sexual behavior (aOR 7.2; 1.4, 37.7) and preferential use of the ED rather than primary care for acute medical needs (aOR 4.0; 1.3, 12.3) were associated with STI.

CONCLUSIONS

STI screening is acceptable to adolescents in the ED, especially among those who declare sexual experience. Overall, there was a low prevalence of asymptomatic STI. Risk of STI was higher among youth engaging in high-risk sexual behavior and those relying on the ED for acute health care access. Targeted screening interventions may be more efficient than universal screening for STI detection in the ED.

Factors Associated With Interest in Same-Day Contraception Initiation Among Females in the Pediatric Emergency Department

PURPOSE

The purposes were to describe interest in hormonal contraception initiation among female adolescent in the emergency department (ED) and to assess for associations with factors known to increase pregnancy risk such as violence victimization.

METHODS

We used a computerized survey to assess sexual and dating practices, pregnancy history/likelihood, contraception use (including long-acting reversible contraception [LARC]) and concerns, contraception initiation interest, violence victimization, medical utilization, and demographics among sexually experienced females aged 14-19 years in our ED. The primary outcome was interest in contraception initiation. We compared responses between subgroups using the chi-square test.

RESULTS

A total of 168 adolescents participated (82% of approached; mean age 16.6 years; 41% white; 48% black; 21% commercial insurance). Interest in contraception initiation was high: 60% overall and 70% among those not using hormonal contraception (n = 96). Among those using non-LARC contraception (n = 59), 29% were interested in LARC initiation. Contraception/LARC interest was positively associated with lack of recent well care (p < .06) and concerns about cost (p < .01), privacy (p = .03), and where to obtain contraception (p < .01). Nearly all planned on avoiding pregnancy, although many (23%) used no contraception at last intercourse. One third (36%) reported violence victimization. Most (70%) reported ≥1 concern about contraception (most commonly cost).

CONCLUSIONS

Many reported behaviors and exposures, including violence victimization, that increase their risk for pregnancy and most expressed interest in same-day initiation of hormonal contraception, including LARC. These findings may inform novel strategies for increased adolescent access to contraception and pregnancy prevention through use of nontraditional sites such as EDs.

Managing adolescent behavioural and mental health problems in the Emergency Department

Children and young people with behavioural issues frequently present to Emergency Departments. These are complex cases, often with a long preceding history. Caring for them requires a structured approach to ensure safety for the patient and all those involved. The HEADSS assessment is used as a framework. The Emergency Department focuses on treatment of the acute behavioural issues in the least restrictive manner possible. Ongoing behavioural issues are managed with referral to community and specialist resources.

Brief Behavioral Intervention to Improve Adolescent Sexual Health: A Feasibility Study in the Emergency Department

OBJECTIVE

Although emergency department (ED) visits offer an opportunity to deliver brief behavioral interventions to improve health, provision of ED-based interventions targeting adolescent sexual health is uncommon. The objectives for this study were to evaluate the feasibility and preliminary effects of a novel sexual health service intervention for adolescents.

METHODS

In this cross-sectional feasibility study, sexually active patients aged 14 to 19 years presenting to a Midwestern pediatric ED were recruited to receive an intervention to improve sexual health. The intervention, based on motivational interviewing (MI), included agenda setting, exploration of behaviors, a decisional balance exercise, tailored feedback, and provision of personalized health services (including condoms, prescription for emergency contraception, urine testing for Chlamydia trachomatis and Neisseria gonorrheae, and referral to the hospital-affiliated adolescent clinic). Data were collected before and after intervention administration and at a 3-month follow-up telephone interview. Surveys assessed sexual risk behaviors, satisfaction with the intervention, health care use, and demographics. Feasibility criteria were (1) subject-rated interventionist fidelity to MI principles (Likert scale 1 [strongly agree] to 4 [strongly disagree]), (2) subject satisfaction (Likert scale 1 [not at all] to 5 [very]), and (3) session duration (minutes, recorded by the interventionist). A secondary outcome was the proportion of subjects who completed at least 1 health service. Services provided at the adolescent clinic were determined by an electronic medical record review. Comparisons of responses between sex subgroups were analyzed using Χ test.

RESULTS

From August to November 2012, 69 adolescents were approached, 66 (96%) completed the screening survey, and 24 (37%) reported previous sexual activity. Of those, 20 (83%) agreed to participate. The mean (SD) age was 16.2 (1.4) years; 60% were female. Most (78%) reported that the interventionist maintained high fidelity to MI principles and most (80%) were very satisfied with the intervention. Mean (SD) intervention length was 15.7 (2.2) minutes. Most subjects (65%) accepted 1 or more health services, including 42% who completed clinic follow-up. In the ED or the referral clinic, the following services were provided to the subjects: condoms (n = 11), emergency contraception prescription (n = 5), C. trachomatis/N. gonorrheae testing (n = 4), hormonal birth control provision (n = 2), and human immunodeficiency virus testing (n = 3). Fifteen subjects (75%) were reached for the 3-month follow-up, and condom use was maintained by 67% of those reporting sexual activity.

CONCLUSIONS

This study demonstrated the feasibility and potential utility of an MI-based service navigation intervention to connect youth with point-of-care services as well as resources for ongoing sexual health needs.

Predictors of Sustained Prescription Opioid Use After Admission for Trauma in Adolescents

PURPOSE

The study objectives are to describe the longitudinal trajectory of prescription opioid use among adolescents requiring a trauma admission and then identify predictors of sustained opioid use.

METHODS

Randomly sampled adolescents (12-18 years) admitted to a Level I trauma center were surveyed. Follow-up assessments were obtained at 2, 5, and 12 months. Self-reported prescription opioid use, defined as "taking an opioid prescribed by a physician," was obtained at baseline and every follow-up time point. At the baseline interview, validated mental health measures and pain scales were obtained as well as preinjury substance use. A fixed-effects mixed Poisson regression analysis was performed to predict prescription opioid use over time.

RESULTS

A total of 120 adolescents (mean age 15.5 years [1.9 standard deviation], 75% male) completed the baseline interview with 98% follow-up at 12 months. At baseline, 7% of adolescents reported prescription opioid use before their trauma, with rates of prescription opioid use of 52% at 2 months, 13.3% at 5 months, and 12.5% at 12 months after discharge. After adjusting for demographic characteristics and injury severity score, those with sustained prescription opioid use were more likely to report preinjury marijuana use and higher baseline pain scores.

CONCLUSIONS

Approximately one in eight adolescents (12.5%) was using prescription opioids 12 months after injury hospitalization. Readily identifiable risk factors predicted sustained prescription opioid use, including preinjury marijuana use and baseline pain score. Screening for substance use including marijuana at the time of injury could help identify patients at risk for both substance use problems and sustained prescription opioid use.

Health outcomes in US children with abdominal pain at major emergency departments associated with race and socioeconomic status

OBJECTIVE

Over 9.6 million ED visits occur annually for abdominal pain in the US, but little is known about the medical outcomes of these patients based on demographics. We aimed to identify disparities in outcomes among children presenting to the ED with abdominal pain linked to race and SES.

METHODS

Data from 4.2 million pediatric encounters of abdominal pain were analyzed from 43 tertiary US children's hospitals, including 2.0 million encounters in the emergency department during 2004-2011. Abdominal pain was categorized as functional or organic abdominal pain. Appendicitis (with and without perforation) was used as a surrogate for abdominal pain requiring emergent care. Multivariate analysis estimated likelihood of hospitalizations, radiologic imaging, ICU admissions, appendicitis, appendicitis with perforation, and time to surgery and hospital discharge.

RESULTS

Black and low income children had increased odds of perforated appendicitis (aOR, 1.42, 95% CI, 1.32- 1.53; aOR, 1.20, 95% CI 1.14 - 1.25). Blacks had increased odds of an ICU admission (aOR, 1.92, 95% CI 1.53 - 2.42) and longer lengths of stay (aHR, 0.91, 95% CI 0.86 - 0.96) than Whites. Minorities and low income also had lower rates of imaging for their appendicitis, including CT scans. The combined effect of race and income on perforated appendicitis, hospitalization, and time to surgery was greater than either separately.

CONCLUSIONS

Based on race and SES, disparity of health outcomes exists in the acute ED setting among children presenting with abdominal pain, with differences in appendicitis with perforation, length of stay, and time until surgery.

Impact of Post-visit Contact on Emergency Department Utilization for Adolescent Women with a Sexually Transmitted Infection

STUDY OBJECTIVES

To understand Emergency Department (ED) utilization patterns for women who received sexually transmitted infection (STI) testing and explore the impact of post-visit telephone contact on future ED visits.

DESIGN, SETTING, PARTICIPANTS

We performed a secondary analysis on a prospectively collected dataset of ED patients ages 14-21 years at a children's hospital.

INTERVENTIONS AND MAIN OUTCOME MEASURES

The dataset documented initial and return visits, STI results, race, age and post-visit contact success (telephone contact ≤7 days of visit). Logistic regression was performed identifying variables that predicted a return visit to the ED, a return visit with STI testing, and subsequent positive STI results.

RESULTS

Of 922 women with STI testing at their initial ED visit, 216 (23%) were STI positive. One-third (315/922) returned to the ED, 15% (141/922) returned and had STI testing, and 4% (38/922) had a subsequent STI. Of 216 STI-positive women, 59% were successfully contacted. Of those who returned to the ED, age ≥ 18 and Black race were associated with increased STI testing at a subsequent visit. Successful contact reduced the likelihood of STI testing at a subsequent ED visit (OR 0.28, 95% CI 0.01-0.8), and ED empiric antibiotic treatment had no effect on subsequent STI testing.

CONCLUSION

Contacting women with STI results and counseling them regarding safe sex behaviors may reduce the number of ED patients who return with symptoms or a new exposure necessitating STI testing. The high STI prevalence and frequent return rate suggest that ED interventions are needed.

Prevalence of 3 sexually transmitted infections in a pediatric emergency department

OBJECTIVE

This study aimed to determine the prevalence of Chlamydia trachomatis, Neisseria gonorrheae, and Trichomonas vaginalis and to describe factors associated with sexually transmitted infection (STI) in a pediatric emergency department (ED).

METHODS

Adolescents aged 14 to 19 years presenting to a Midwestern pediatric ED were asked to provide urine for STI testing and complete a survey about previous sexual activity (PSA), high-risk behaviors, demographics, and visit reason (reproductive: genitourinary complaints, abdominal pain, or a female with vomiting). Comparisons between subgroups were analyzed using Χ test.

RESULTS

Among 200 subjects (64% of approached), mean age was 15.6 years; 63% were female. Eleven subjects (6%; 95% confidence interval, 2.3-8.7) tested positive for 1 or more STIs: 10 for C. trachomatis (one denied PSA), 3 for T. vaginalis (all coinfected with C. trachomatis), and 1 for N. gonorrheae. Half reported PSA; of these, 71% reported 1 or more high-risk behaviors, most commonly first sex before the age of 15 years (51%) and no condom at last sex (42%). Among those with PSA and nonreproductive visit (n = 73), 11.0% had 1 or more STIs (95% confidence interval, 3.4-18.1). Two factors were associated with greater likelihood of positive STI test result, namely, reporting PSA versus no PSA (10% vs 1%, P = 0.005) and last sex within 1 month or less versus more than 1 month (20% vs 0%, P = 0.001). In this sample, none of the following characteristics were associated with STI: insurance, race, high-risk behaviors, age, or ED visit reason.

CONCLUSIONS

Approximately 1 in 10 sexually active adolescent ED patients without reproductive complaints had 1 or more STIs. This suggests the need for strategies to increase STI testing for this population.

Screening adolescents for sexually transmitted infections in the pediatric emergency department

OBJECTIVES

The objectives of this study were to determine the prevalence of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) infections among adolescents presenting to a pediatric emergency department (PED), to assess the association between these infections and certain risk factors, and to assess the feasibility of routine screening for sexually transmitted infections (STIs) in the PED.

METHODS

This was a prospective, observational cohort study. Three hundred seven adolescents aged 13 to 17 years in an urban PED in Bronx, NY, were enrolled in the study. Subjects provided urine samples for nucleic acid amplification testing for CT and GC and self-completed a confidential questionnaire to assess health care-seeking patterns, high-risk social behaviors, and the presence of abuse, depression, and suicidal ideation. Outcome measures include prevalence of STIs and association of STIs with responses to the confidential questionnaire.

RESULTS

Twenty subjects (6.5%) tested positive for an STI. Seventeen (5.5%) were positive for CT, 2 (0.7%) for GC, and 1 (0.3%) for both. Fourteen adolescents (70%) with a positive test were asymptomatic. Logistic regression yielded 4 factors significantly associated with an STI: female sex (odds ratio [OR], 4.02; 95% confidence interval [CI], 1.1-15.2), illicit drug use (OR, 3.3; 95% CI, 1.1-9.3), disclosure of sexual activity (OR, 9.3; 95% CI, 1.1-76.9), and report of a sexual encounter resulting in pregnancy (OR, 3.7; 95% CI, 1.3-10.4).

CONCLUSIONS

Sexually transmitted infections were common in asymptomatic adolescents presenting to the PED. We identified 4 risk factors that were significantly associated with STIs. Our findings may facilitate identification of adolescents at highest risk for STIs, help prevent further transmission of infection, and decrease morbidity in this marginalized population.

Barriers to and enablers of contraceptive use among adolescent females and their interest in an emergency department based intervention

OBJECTIVE

Over 15 million adolescents, many at high risk for pregnancy, use emergency departments (EDs) in the United States annually, but little is known regarding reasons for failure to use contraceptives in this population. The purpose of this study was to identify the barriers to and enablers of contraceptive use among adolescent females using the ED and determine their interest in an ED-based pregnancy prevention intervention.

STUDY DESIGN

We conducted semistructured, open-ended interviews with females in an urban ED. Eligible females were 14-19 years old, sexually active, presenting for reproductive health complaints and at risk for pregnancy, defined as nonuse of effective (per the World Health Organization) contraception. Interviews were recorded, transcribed and coded based on thematic analysis. Enrollment continued until no new themes emerged. A modified Health Belief Model guided the organization of the data.

RESULTS

Participants (n=14) were predominantly Hispanic (93%), insured (93%) and in a sexual relationship (86%). The primary barrier to contraceptive use was perceived health risk, including effects on menstruation, weight and future fertility. Other barriers consisted of mistrust in contraceptives, ambivalent pregnancy intentions, uncertainty about the future, partner's desire for pregnancy and limited access to contraceptives. Enablers of past contraceptive use included the presence of a school-based health clinic and clear plans for the future. All participants were receptive to ED-based pregnancy prevention interventions.

CONCLUSIONS

The identified barriers and enablers influencing hormonal contraceptive use can be used to inform the design of future ED-based adolescent pregnancy prevention interventions.

IMPLICATIONS

Adolescents who visit the emergency department (ED) identify contraceptive side effects, mistrust in contraceptives, limited access, pregnancy ambivalence and partner pregnancy desires as barriers to hormonal contraception use. They expressed interest in an ED-based intervention to prevent adolescent pregnancy; such an intervention could target these themes to maximize effectiveness.

Youth health care utilization in Nova Scotia: what is the role of age, sex and socio-economic status?

OBJECTIVE

Youth have distinct health care needs that are not always met within a framework designed for children or adults. In Canada, little attention has been given to how youth utilize health care services and limited data are available. The aim of this study was to identify whether age, sex, socio-economic status (SES) and geographic location were significant mediators of youth health care utilization in Nova Scotia.

METHODS

The NSYOUTHS database comprises health care utilization information for all youth aged 12 to 24 years, resident in Nova Scotia between 1997 and 2007. We calculated health care utilization rates by provider, stratified by sex, age, SES, urban/rural residence and year. Negative binomial regression was used to model the variation in health care utilization by sex, SES and urban/rural location.

RESULTS

Health care utilization declined over time and varied by age. Females were more frequent users of services. Youth from lower SES areas had fewer family physician contacts but more outpatient, emergency and inpatient contacts compared to those from higher SES areas. Rural residents had fewer family physician and emergency contacts but more outpatient contacts than youth from urban areas. Ten percent of the youth were responsible for 32% of all health care contacts, whereas 11% had no health care contacts.

CONCLUSION

Specific subgroups, including youth from rural areas and of lower SES, utilize health care services differently than other youth. The challenge is to provide health care that is responsive to the needs of this heterogeneous population. Meeting this challenge requires accurate information on youth health care utilization.

Sexual history taking in the emergency department - more specificity required

BACKGROUND

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) are the most reported diseases in the United States, and emergency departments (ED) serve a population presenting with increased infection risk. However, identifying patients for whom sexually transmitted infection (STI) screening is appropriate requires accurate sexual history reporting.

STUDY OBJECTIVES

To examine the consistency with which ED patients answer general and specific sexual activity questions, and how responses relate to perceived STI risk.

METHODS

Urban ED patients aged 15-34 years completed a sexual history survey containing sexual activity and perceived infection risk questions and provided urine and pharyngeal specimens for CT/GC analysis.

RESULTS

Participants included 192 males and 301 females with a mean age of 25.2 years and were 65.7% white and 33.3% black. Thirty-eight (7.7%) were infected with CT or GC. In patients denying sexual activity in the past year (general question), 40.7% of such males and 45.0% of females also reported some form of specific sexual activity (activity misclassification). Among self-identified heterosexuals, 7.2% males and 7.5% females reported some form of homosexual activity (orientation misclassification; OM). OM individuals were more likely to perceive themselves at risk of infection both orally (odds ratio 2.92, confidence interval 1.12-7.63) and genitally (odds ratio 3.36, confidence interval 1.55-7.30).

CONCLUSIONS

Given that reported sexual activity and age are the only criteria for routine female screening, and that homosexual activity is one of the few screening criteria for males, our results show that a substantial proportion of ED patients eligible for screening may not be identified by reliance upon general sexual history questions.

Demand for hospital emergency departments: a conceptual understanding

BACKGROUND

Emergency departments (EDs) are critical to the management of acute illness and injury, and the provision of health system access. However, EDs have become increasingly congested due to increased demand, increased complexity of care and blocked access to ongoing care (access block). Congestion has clinical and organisational implications. This paper aims to describe the factors that appear to influence demand for ED services, and their interrelationships as the basis for further research into the role of private hospital EDs.

DATA SOURCES

Multiple databases (PubMed, ProQuest, Academic Search Elite and Science Direct) and relevant journals were searched using terms related to EDs and emergency health needs. Literature pertaining to emergency department utilisation worldwide was identified, and articles selected for further examination on the basis of their relevance and significance to ED demand.

RESULTS

Factors influencing ED demand can be categorized into those describing the health needs of the patients, those predisposing a patient to seeking help, and those relating to policy factors such as provision of services and insurance status. This paper describes the factors influencing ED presentations, and proposes a novel conceptual map of their interrelationship.

CONCLUSION

This review has explored the factors contributing to the growing demand for ED care, the influence these factors have on ED demand, and their interrelationships depicted in the conceptual model.

Emergency department visits in the United States for pediatric depression: estimates of charges and hospitalization

OBJECTIVES

The objective of this study was to calculate national estimates of depression-related emergency department (ED) visits and associated health care resource use among children and adolescents 17 years or younger. Another goal was to explore the effects of certain sociodemographic and health care system factors and comorbidities on ED charges and subsequent hospitalization in the United States.

METHODS

The authors analyzed data from the 2006 and 2009 National Emergency Department Sample (NEDS), the largest source of U.S. ED data. ED visits with all listed diagnoses (i.e., principal diagnosis plus secondary conditions) of depression were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 293.83, 296.2X, 296.3X, 300.4, and 311. Population-based estimates of ED visits, hospitalization, resource use, comorbidities, and demographics associated with pediatric depression were calculated. Potentially significant covariate associations were also explored using ED charges and hospital admission from the ED.

RESULTS

The 2006 and 2009 NEDS sample contained 365,713 ED visits for pediatric depression; the majority were made by adolescents (87.9%). Of these, 27.2% were admitted to the hospital, 69.5% were treated and released, and <0.1% died in ED. The ED charges in 2012 U.S. dollars summed to a hospital bill of $443.8 million, with the ED plus inpatient charges ($1.2 billion) being more than double that amount. The median inpatient length of stay (LOS) was 4.0 days. Suicide and intentional self-inflicted injury were attempted by 31.4% of the patients. Attention-deficit, conduct, and disruptive disorders; anxiety disorders; substance use disorders; asthma; and infections were the most common comorbidities. In year 2009, a higher number of diagnoses, older age, being female, key comorbidities, and suicide and intentional self-inflicted injury were significantly associated with higher ED charges (all p < 0.05). Increased odds of hospital admission from the ED were significantly associated with a higher number of diagnoses, key comorbidities, and suicide and intentional self-inflicted injury (all p < 0.05).

CONCLUSIONS

Pediatric depression is common in the ED and is associated with significant burden to the health care system. Certain factors such as a higher number of diagnoses, key comorbidities, and suicide and intentional self-inflicted injury are associated with increased health care costs and resource use. Special attention should be given to these factors, when present.

US emergency department use by children, 2001-2010

OBJECTIVE

Children commonly use emergency departments (EDs) for a variety of health care needs. We describe recent trends in US ED use by children.

METHODS

This is a cross-sectional analysis of the National Hospital Ambulatory Medical Care Survey, a nationally representative sample of ED visits, and US Census data between 2001 and 2010. We examined demographic trends, visit characteristics, insurance status, disposition, hospital variables, diagnoses, reason for visit, and resource use among patients younger than 19 years. Linear regression was used to evaluate significance of trends.

RESULTS

Approximately one quarter of all ED visits was made by patients younger than 19 years. Emergency department visits by children increased 14.4% between 2001 and 2010 (P = 0.04); the rate of visits increased from 36.4 to 40.6 per 100 population. Trauma is the most common reason for pediatric ED visits. Black children had the highest rate of ED use (61.9 per 100 in 2010). Visit rates by Hispanic children were relatively low but increased by 82.7% since 2001 (P = 0.00). The proportion of ED visits by Medicaid beneficiaries rose from 32.0% to 51.9% (P = 0.00). The volume and frequency of diagnostic testing, administration of intravenous fluids, medication administration, and discharge prescriptions increased. Visits with computed tomography or magnetic resonance imaging almost doubled from 3.1% of the visits in 2001 to 6.6% of the visits in 2010 (P = 0.00).

CONCLUSIONS

The use of ED by children is growing faster than population growth, and the intensity of ED care has risen sharply. Hispanic children and Medicaid beneficiaries represent the fastest growing populations of children using the ED.

Adolescents' and young adults' perspectives on their emergency care

OBJECTIVES

The aim of this study was to assess the perspectives of adolescents and young adults seen in the emergency department (ED) on the optimal age for transition from a pediatric ED (PED) to an adult ED (AED) as well as the appropriateness of their assigned ED site. Secondary aims were to determine ED physicians' understanding and assessment of their psychosocial needs, to determine whether subjects had a primary care provider (PCP), as well as to identify resources they felt would improve their ED experience.

METHODS

This study used in-person structured interviews on a convenience sample of ED patients aged 15 to 25 years. Data were analyzed with the SPSS for Windows (v15.0) using t tests and uncertainty coefficients.

RESULTS

We interviewed 200 subjects; the mean age was 20.5 (SD, 3) years, 65% were female, and 54% were seen in the PED. The subjects reported a mean age of 18.5 years as optimal for transition to an AED (mode, 18; second peak, 21); only 5% chose an age older than 21 years. The AED subjects more likely felt that their site of care was appropriate (Likert scale, 1-3; 2.5 vs 2.2, P < 0.05). HEADSS (Home, Education/Employment, Activity, Drugs, Sexuality, Suicide) topics were rarely addressed in both ED sites. The PED subjects more often identified a PCP (87% vs 68%); there was no difference in notifying their PCP (27% vs 19%). The PED subjects more often desired magazines (83% vs 70%) and entertainment videos (61% vs 34%).

CONCLUSIONS

Adolescents and young adults identify the age of 18 years as optimal for transition from a PED to an AED setting. Instituting a standardized HEADSS assessment protocol and offering age-appropriate resources may enhance the emergency experience for this population.

The acceptability of incorporating a youth smoking prevention intervention in the pediatric emergency department

The pediatric emergency department (PED) is under-utilized as a setting in which to provide tobacco prevention interventions for at-risk children. We sought to determine the acceptability and feasibility of incorporating a brief, parental tobacco prevention intervention to 520 parents during the PED visit. Mean age (SD) of parents and children was 38.6 (7.1) and 11.5 (1.1), respectively; 47% of children were female; 45% were African American; 36% of parents had an annual income less than $25,000; 28.8% of parents were current smokers. Over 90% of parents said the intervention provided "useful" and "easy to understand" information and 97% of practitioners said it did not "interfere with clinical care." Given the high prevalence of parental smoking in the PED, there is a high likelihood that their children will initiate smoking in the future. Thus, the use of the PED as a venue to providing tobacco prevention interventions warrants further evaluation.

Frequency of pregnancy testing among adolescent emergency department visits

OBJECTIVES

The objective was to estimate the frequency of pregnancy testing among adolescent emergency department (ED) patients and to determine factors associated with testing.

METHODS

This was a retrospective cross-sectional study using the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2005 through 2009 of ED visits by females ages 14 to 21 years. The frequency of pregnancy testing among all visits was estimated for potential reproductive health complaints and for those associated with exposure to potentially teratogenic radiation. Multivariable logistic regression modeling was performed to calculate adjusted probabilities and odds ratios (ORs) with 95% confidence intervals (CIs) to evaluate factors associated with pregnancy testing by patient characteristics.

RESULTS

The authors identified 11,531 visits, representing an estimated 41.0 million female adolescent ED visits. Of these, 20.9% (95% CI = 19.3% to 22.5%) included pregnancy testing. Among visits for potential reproductive health complaints and those associated with exposure to potentially teratogenic radiation, 44.5% (95% CI = 41.3% to 47.8%) and 36.7% (95% CI = 32.5% to 40.9%), respectively, included pregnancy testing. Among the entire study population, we found statistically significant differences in pregnancy testing by age, race or ethnicity, hospital admission, and geographic region (p < 0.001 for all).

CONCLUSIONS

A minority of female adolescent ED visits included pregnancy testing, even if patients presented with potential reproductive health complaints or received exposure to ionizing radiation. Small but statistically significant differences in pregnancy testing rates were noted based on age, race or ethnicity, ED disposition, and geographic region. Future studies should focus on designing quality improvement interventions to increase pregnancy testing in adolescent ED patients, especially among those in whom pregnancy complications or the risk of potentially teratogenic radiation exposure is higher.

Adolescent use of the emergency department instead of the primary care provider: who, why, and how urgent?

PURPOSE

Adolescents frequently rely on emergency medical care, rather than using primary care providers (PCPs). Our objectives were to characterize a population of adolescents presenting to a large, urban emergency department (ED) and to examine the reasons why they present to the ED, rather than to their PCP's office.

METHODS

Adolescents ages 12 to 21 years and their parents/guardians were invited to participate and asked to complete a brief online survey. Demographic data and triage information were collected from electronic medical records.

RESULTS

Of 203 participants, 66% (n = 134) had public insurance, and 40% (n = 82) were triaged as nonurgent. Nearly all (93%, n = 189) reported having a PCP or primary clinic. The most common reasons given for presenting to the ED were participant perception of illness requiring immediate care (34%), followed by PCP referral to the ED (21%). Those with public insurance (odds ratio = 4.44; 95% CI 2.01 to 9.81) or no insurance/unknown insurance status (odds ratio = 4.77; 95% CI 1.34 to 17.01) were more likely to be triaged as nonurgent than those with private insurance.

CONCLUSIONS

Many adolescents in this study were triaged as nonurgent, with several participants perceiving they were acutely ill requiring immediate physician care. Further analyses revealed that private insurance was significantly associated with urgent triage status. Future studies could educate adolescents and families about appropriate use of the ED or examine PCP offices directly to determine practices for phone triage and ED referrals of adolescents.

Providing adolescent sexual health care in the pediatric emergency department: views of health care providers

OBJECTIVES

The purpose of this study was to explore health care providers' (HCPs') attitudes and beliefs about adolescent sexual health care provision in the emergency department (ED) and to identify barriers to a health educator-based intervention.

METHODS

We conducted focused, semistructured interviews of HCPs from the ED and adolescent clinic of a children's hospital. The interview guide was based on the theory of planned behavior and its constructs: attitudes, subjective norms, perceived behavioral control, and intention to facilitate care. We used purposive sampling and enrollment continued until themes were saturated. Interviews were recorded and transcribed. Transcripts were analyzed using directed content analysis.

RESULTS

Twenty-nine interviews were required for saturation. Participants were 12 physicians, 12 nurses, 3 nurse practitioners, and 2 social workers; the majority (83%) were female. Intention to facilitate care was influenced by HCP perception of (1) their professional role, (2) the role of the ED (focused vs expanded care), and (3) need for patient safety. Health care providers identified 3 practice referents: patients/families, peers and administrators, and professional organizations. Health care providers perceived limited behavioral control over care delivery because of time constraints, confidentiality issues, and comfort level. There was overall support for a health educator, and many felt the educator could help overcome barriers to care.

CONCLUSIONS

Despite challenges unique to the ED, HCPs were supportive of the intervention and perceived the health educator as a resource to improve adolescent care and services. Future research should evaluate efficacy and costs of a health educator in this setting.

Characteristics of youth seeking emergency care for assault injuries

OBJECTIVE

To characterize youth seeking care for assault injuries, the context of violence, and previous emergency department (ED) service utilization to inform ED-based injury prevention.

METHODS

A consecutive sample of youth (14-24) presenting to an urban ED with an assault injury completed a survey of partner violence, gun/knife victimization, gang membership, and context of the fight.

RESULTS

A total of 925 youth entered the ED with an assault injury; 718 completed the survey (15.4% refused); 730 comparison youth were sampled. The fights leading to the ED visit occurred at home (37.6%) or on streets (30.4%), and were commonly with a known person (68.3%). Fights were caused by issues of territory (23.3%) and retaliation (8.9%); 20.8% of youth reported substance use before the fight. The assault-injured group reported more peer/partner violence and more gun experiences. Assault-injured youth reported higher past ED utilization for assault (odds ratio [OR]: 2.16) or mental health reasons (OR: 7.98). Regression analysis found the assault-injured youth had more frequent weapon use (OR: 1.25) and substance misuse (OR: 1.41).

CONCLUSIONS

Assault-injured youth seeking ED care report higher levels of previous violence, weapon experience, and substance use compared with a comparison group seeking care for other complaints. Almost 10% of assault-injured youth had another fight-related ED visit in the previous year, and ~5% had an ED visit for mental health. Most fights were with people known to them and for well-defined reasons, and were therefore likely preventable. The ED is a critical time to interact with youth to prevent future morbidity.

Developing emergency department-based education about emergency contraception: adolescent preferences

OBJECTIVES

The objective was to identify adolescent preferences for emergency department (ED)-based education about emergency contraception.

METHODS

This was a cross-sectional computerized survey, using adaptive conjoint analysis (ACA). Patients were eligible if they were females ages 14 through 19 years old and were seeking care in one of two urban EDs. Patients were excluded if they were too ill to participate in the survey or if they were non-English speaking. Participants completed a computerized survey that used ACA, a technique that can be used to assess patients' relative preferences for services. ACA uses the individual's answers to update and refine questions through trade-off comparisons, so that each respondent answers a customized set of questions. The survey assessed preferences for the following attributes of emergency contraception education: who should deliver the education, if anyone (e.g., nurse, doctor); how the education should be delivered (e.g., by a person or via video); how often the education should be offered if patients were to frequent the ED (e.g., every time or only when asking for it); length (e.g., 5 minutes, 10 minutes); and chief complaint that would trigger the education (e.g., headache or stomach pain).

RESULTS

A total of 223 patients were enrolled (37.2% at Hospital 1 and 62.8% at Hospital 2). The mean (±SD) age of the participants was 16.1 (±1.3) years. Just over half (55%) reported a history of sexual activity; 8% reported a history of pregnancy. Overall, the participants preferred education that was delivered by a person, specifically a doctor or nurse. They preferred a slightly longer education session and preferred education directed at patients seeking care in the ED for complaints potentially related to sexual activity.

CONCLUSIONS

Adolescents have specific preferences for how education about emergency contraception would best serve their needs. This information can inform clinicians as they work to improve adolescents' knowledge about pregnancy prevention and emergency contraception in particular.

National trends in pelvic inflammatory disease among adolescents in the emergency department

PURPOSE

In 2002, the Centers for Disease Control and Prevention (CDC) broadened the pelvic inflammatory disease (PID) diagnostic criteria to increase detection and prevent serious sequelae of untreated PID. The impact of this change on PID detection is unknown. Our objectives were to estimate trends in PID diagnosis among adolescent emergency department (ED) patients before and after the revised CDC definition and to identify factors associated with PID diagnoses.

METHODS

We performed a retrospective repeated cross-sectional study using the National Hospital Ambulatory Medical Care Survey from 2000 to 2009 of ED visits by 14- to 21-year-old females. We calculated national estimates of PID rates and performed multivariable logistic regression analyses and tests of trends.

RESULTS

During 2000-2009, of the 77 million female adolescent ED visits, there were an estimated 704,882 (95% confidence interval [CI], 571,807-837,957) cases of PID. After the revised criteria, PID diagnosis declined from 5.4 cases per 1,000 United States adolescent females to 3.9 cases per 1,000 (p = .03). In a multivariable model, age ≥17 years (odds ratio, 2.14; 95% CI, 1.25-3.64) and black race (odds ratio, 2.04; 95% CI, 1.36-3.07) were associated with PID diagnosis.

CONCLUSIONS

Despite broadened CDC diagnostic criteria, PID diagnoses did not increase over time. This raises concern about awareness and incorporation of the new guidelines into clinical practice.

Sexual health behaviors, preferences for care, and use of health services among adolescents in pediatric emergency departments

OBJECTIVES

The objective of this study was to describe sexual health behaviors, as well as prior use of and preferences for sexual health services among adolescents in the pediatric emergency department (ED).

METHODS

In this cross-sectional study, subjects aged 14 to 19 years who presented to an urban or suburban ED from a single Midwestern hospital system completed a written survey. The survey included questions on previous sexual activity, high-risk behaviors (first sex before age 15 years, no condom at last sex, substance use at last sex, >3 partners in past 3 months, and >4 lifetime partners), and sexual health service use and preferences. Comparisons of responses between subgroups were analyzed using χ2 test. Multiple logistic regression was used to identify factors associated with high-risk behaviors. Care preferences were scored using a 4-point Likert scale; mean scores were ranked.

RESULTS

Subjects included 306 adolescents (85% of approached). The mean age was 15.5 years. Almost half (45%) reported previous sexual activity, and of those, 63% reported 1 or more high-risk behaviors (most commonly first sex before age 15 years [43%] and no condom at last sex [29%]). Almost all wanted to prevent pregnancy, but only one third received birth control counseling before sexual debut, and 14% reported no contraception at last sex. Younger age was associated with 1 or more high-risk behaviors (odds ratio, 3.7; confidence interval, 1.39-9.84). Preferences for care included caring, knowledgeable providers, and low/no cost.

CONCLUSIONS

Because of high prevalence of high-risk behaviors among adolescents presenting in the ED, strategies should be developed to link these patients to comprehensive sexual health care.

Acceptability of sexual health discussion and testing in the pediatric acute care setting

OBJECTIVE

The objective of this study was to determine acceptability of sexual health discussion and testing among adolescents, parents, and health care providers (HCPs).

METHODS

We conducted a cross-sectional study of acute care patients (aged 14-19 years), parents, nurses, and physicians/nurse practitioners. Subjects rated sexual health discussion, sexually transmitted disease and pregnancy testing as acceptable/unacceptable and verbally explained their reasoning. Reasons were transcribed verbatim, coded, and analyzed. Agreement with individual adolescent responses was determined. Controlling for visit type, logistic regression was used to evaluate association between location and acceptance with odds ratios (ORs). Visits were categorized as reproductive/nonreproductive.

RESULTS

Subjects included 127 adolescents, 90 parents, and 190 HCP responses. Mean adolescent age was 15.5 years; 57% were female; 43% reported previous intercourse; 43% were black, and 39% were white. Most visits (76%) were nonreproductive. Adolescents and parents were highly accepting of discussion and testing and were more accepting than HCPs. Acceptance was more likely for reproductive versus nonreproductive visits (P ≤ 0.05). Emergency department HCPs were more likely to accept discussion (OR, 2.8) and sexually transmitted disease testing (OR, 3.1) than urgent care HCPs. Acceptance themes among adolescents were comfort with system/HCP, confidentiality concerns, and desire for good health; among parents, acceptance themes were identification as a safe place for disclosure and desire for adolescent good health and information; and among HCPs, these were relevance to chief complaint and perception of appropriate care.

CONCLUSIONS

In contrast to HCPs, adolescents and parents expressed broad support for sexual health discussion and testing, which may inform HCP practice to improve access to care.

Guidelines for alcohol screening in adolescent trauma patients: a report from the Pediatric Trauma Society Guidelines Committee

BACKGROUND

Alcohol misuse is an important source of preventable injuries in the adolescent population. While alcohol screening and brief interventions are required at American College of Surgeons-accredited trauma centers, there is no standard screening method. To develop guidelines for testing, we reviewed available evidence regarding adolescent alcohol screening after injury, focusing on the questions of which populations require screening, which screening tools are most effective, and at which time point screening should be performed.

METHODS

A comprehensive PubMed search for articles related to alcoholism, trauma, and screening resulted in 1,013 article abstracts for review. Eighty-five full-length articles were considered for inclusion. Articles were excluded based on study type, location (non-US), year of publication, and nonapplicability to the study questions.

RESULTS

Twenty-six articles met full inclusion criteria. Results support universal screening for alcohol misuse in the adolescent trauma population. Although adolescents 14 years and older are more likely to test positive for alcohol misuse, studies suggest screening may need to start at 12 years or younger. Both survey and biochemical screens can identify at-risk adolescents, with the Alcohol Use Disorders Identification Test and the two-question survey based on the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition criteria for alcohol-use disorders being the most sensitive surveys available.

CONCLUSION

Injured adolescent trauma patients should be universally screened for alcohol misuse during their hospital visit. To maximize the number of at-risk adolescents targeted for interventions, screening should begin at minimum at 12 years. As no screen identifies all at-risk adolescents, a serial screening method using both biochemical tests and standardized questionnaires may increase screening efficacy.

Knowledge, attitudes, and beliefs about emergency contraception: a survey of female adolescents seeking care in the emergency department

OBJECTIVES

This study aimed to assess urban adolescents' knowledge of and attitudes about emergency contraception (EC) and to assess the intention to use EC in particular hypothetical situations. We hypothesized that knowledge about EC would be limited, but that adolescents would support using EC in certain situations.

METHODS

A cross-sectional survey of English-speaking, 14- to 19-year-old adolescent girls presenting for care at 2 urban pediatric emergency departments. The survey was based on previous research with this target population and the constructs of the theory of planned behavior.

RESULTS

We enrolled 223 adolescents; 56% reported a history of sexual activity. Sixty-four percent stated that they had heard of EC. Participants with a history of sexual activity were more likely to have heard of EC compared with those without (odds ratio, 2.6; 95% confidence interval, 1.4-4.7), as were those 17 years and older (odds ratio, 2.3; 95% confidence interval, 1.2-4.3). The majority of participants were concerned about potential short-term and long-term adverse effects (86% and 78%, respectively); many participants were concerned about the cost of EC (45%) and about being able to get to a doctor for a prescription (45%). Participants supported using EC in the following situations: rape (88%), the condom breaks (82%), or no birth control was used (76%). Fewer supported using EC in the following situations: missed 1 oral contraceptive pill (51%) or first sexual experience (57%).

CONCLUSIONS

Participants indicated that although they would support EC use in several situations, they have concerns about EC use and access. Awareness of these factors and potential influences of EC use can guide providers toward effective counseling and interventions aimed to increase adolescents' use of EC in appropriate settings.

Sexually transmitted infection prevalence in symptomatic adolescent emergency department patients

OBJECTIVES

This study aimed to determine the prevalence of sexually transmitted infections (STIs) in symptomatic adolescent female patients presenting to a pediatric emergency department (ED). Secondary objectives included determining correlates of infection.

METHODS

This was a prospective prevalence study of a consecutive sample of female patients aged 14 to 19 years presenting to a pediatric ED with lower-abdominal or genitourinary complaints between August 2009 and January 2010. Patients were tested for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis. Descriptive statistics, sensitivity analysis to account for untested patients, and logistic regression to understand correlates of STI were performed.

RESULTS

A total of 276 patients met inclusion criteria; 236 underwent STI testing. The prevalence of any STI was 26.3% (95% confidence interval [CI], 20.6%-31.9%) among patients who had testing performed, with C. trachomatis infection being most prevalent (19.7%; 95% CI, 14.5%-24.9%). Assuming all eligible patients who did not undergo STI testing were not infected, sensitivity analysis revealed a minimum STI prevalence of 22.5% (95% CI, 17.5%-27.4%). Multivariable logistic regression revealed no significant association between STI and patient age, chief complaint, or insurance status. There was a significant association between STI and black or African-American race (odds ratio, 9.5; 95% CI, 2.1-44.1).

CONCLUSIONS

A large percentage of our study population had an STI, and therefore, STI testing should be considered in all symptomatic adolescent ED female patients. Future studies should focus on understanding barriers to STI testing and designing interventions to increase testing within an adolescent ED population.

Identifying adolescent females at high risk of pregnancy in a pediatric emergency department

PURPOSE

Emergency departments (EDs) care for adolescent females with unmet reproductive health care needs. Our objective was, among adolescents presenting to a pediatric ED, to estimate pregnancy risk, describe pregnancy intentions, and identify potentially modifiable factors associated with pregnancy risk.

METHODS

Using a paper-based questionnaire, we surveyed females aged 15-19 years presenting to our ED, assessing health care access, sexual behaviors, pregnancy intentions, and receptivity to interventions. We calculated the pregnancy risk index (PRI), which estimates pregnancy risk in the subsequent 12 months, by assessing recent sexual activity, contraception at last intercourse, and known contraceptive failure rates. Independent sample t tests and analysis of variance were used to identify risk factors associated with increased PRI.

RESULTS

Of 459 females enrolled, 13% were pregnant and 20% reported prior pregnancy. Among 399 nonpregnant females, 238 (60%) had intercourse in the prior 3 months and 73 (31%) used no contraception at last intercourse. Among nonpregnant adolescents, the PRI was 19.5, which equates to 19.5 expected pregnancies per 100 females per year. Factors associated with higher PRI included lacking a primary provider, prior ED visits, wanting a baby now, and reported partner wantedness of pregnancy. Half believed ED doctors should discuss pregnancy prevention, and one-quarter were interested in starting contraception in the ED.

CONCLUSIONS

Nearly one-third of adolescent females in a pediatric ED were either pregnant or could be expected to become pregnant within a year. Screening questions can identify adolescents at high risk of pregnancy in the ED setting. These females should be the target for future pregnancy prevention interventions.

Adolescent satisfaction in an urban pediatric emergency department

OBJECTIVES

We studied the satisfaction reported by adolescents when visiting a pediatric emergency department (ED) and elicited suggestions for improving the ED for teenage patients.

METHODS

A 33-question survey was developed for this study assessing adolescents' overall satisfaction with their ED care as well as their views on the waiting time and setting, medical staff, treatment and discharge plans, and comparisons to general hospital EDs. The survey was administered at discharge home or admission to the hospital.

RESULTS

Two hundred eighty-two patients completed the survey. Two hundred fifty-nine respondents (92%) rated their experience as good or better. A decreased level of satisfaction was reported among adolescents waiting to see a physician in excess of 2 hours. Satisfaction was not affected by age, diagnosis, procedure, or disposition. Respondents felt safe in our department and were satisfied with the physicians and nurses treating them and their treatment and discharge plans. One hundred seventy respondents offered suggestions for an improved ED setting. Of the 161 patients who had previously attended a general hospital ED, only 11 patients (7%) preferred the general hospital setting. It was concerning that 184 respondents (65% of total) reported not having an opportunity to meet with their physician alone.

CONCLUSIONS

Adolescents were satisfied with care in our pediatric ED. Long wait times are associated with decreased level of satisfaction among adolescents. The waiting room setting and meeting a physician alone were important to adolescents visiting our ED.

Children injured by violence in the United States: emergency department utilization, 2000-2008

OBJECTIVES

Children victimized by violence are often treated in the emergency department (ED). However, our understanding of the magnitude and financial costs of this patient population is inadequate. The authors examined the scope, risk factors for, and financial cost of ED visits for intentional injury in children in the United States over time.

METHODS

Using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2000 through 2008, the records of children aged 0 to 17 years evaluated in an ED for intentional injuries were examined. Nationally representative rates of ED visits for intentional injuries, the proportion of ED visits accounted for by children with intentional injuries, and risk factors for intentional injury visits were calculated. The Web-based Injury Statistics Query and Reporting System (WISQARS) Cost of Injury Reports was used to generate the medical costs accrued by intentional injuries in children.

RESULTS

Almost 340,000 children were treated in U.S. EDs each year from 2000 through 2008 for intentional injuries, comprising 1.2% (95% confidence interval [CI] = 1.1% to 1.4%) of all U.S. pediatric ED visits. The rate of ED visits for violent injuries has not changed over time. In 2008, 49 children per 10,000 (95% CI = 36 to 61) were treated in the ED for a violent injury. In a multivariate model, increasing age, residing in a metropolitan area, African American race, and the lack of private insurance were independent predictors of intentional injury visits among children. In 2005, the aggregate medical cost of intentionally inflicted injuries in children in the United States was $765 million.

CONCLUSIONS

ED visits among children for violent injury still represent an important clinical, public health, and economic challenge. The ED could be considered as a potential venue for prevention and intervention efforts.

Racial disparities in testing for sexually transmitted infections in the emergency department

OBJECTIVES

The objective of this study was to determine predictors of sexually transmitted infection (STI) testing among adolescent females presenting to an urban pediatric emergency department (ED) with symptoms potentially suggestive of an STI.

METHODS

This was a secondary analysis of data collected in a prospective prevalence study of STIs among a consecutive sample of symptomatic females aged 14 to 19 years presenting to a pediatric ED with lower abdominal or genitourinary complaints. The outcome of interest was performance of an STI test. Correlates of interest included patient age, race, insurance status, chief complaint, presence of comorbid conditions, and treating physician sex.

RESULTS

Of the 328 adolescent females who presented to the ED with STI-related complaints and met inclusion criteria, 15.6% did not undergo STI testing. Univariable analysis revealed that black or African American race (odds ratio [OR] = 4.98, 95% confidence interval [CI] = 2.67 to 9.30) and nonprivate insurance (OR = 3.47; 95% CI = 1.83 to 6.58) were significantly associated with the performance of STI testing. In a multivariable model, only black or African American race (OR = 3.94; 95% CI = 1.96 to 7.91) remained significantly associated with the performance of STI testing.

CONCLUSIONS

A substantial number of adolescent females who presented with complaints suggestive of an STI did not undergo STI testing, and a racial disparity in STI testing was noted. The racial disparity in rates of STI testing among symptomatic adolescent girls presenting to the ED warrants further study to confirm validity, to determine if disparity reflects physicians' biases, and to inform strategies for controlling the present epidemic of STIs in adolescents.

Is pediatric emergency department utilization by pregnant adolescents on the rise?

OBJECTIVES

This study evaluates trends of pregnant adolescents' utilization of pediatric emergency departments (PEDs), describes patient demographics, and reviews common pregnancy-related conditions seen in the PED.

METHODS

This was a retrospective cross-sectional study of a large pediatric emergency medicine research network database including 11 freestanding PEDs, 3 separate PEDs from a site with a general ED, and 8 general EDs that see pediatric patients. Pediatric patients (<19 years old) were identified from January 1, 2003, to December 31, 2007, by any International Classification of Diseases, Ninth Revision pregnancy or pregnancy-related condition diagnosis code. Demographic information (age, race, payer type) and disposition (admit, discharge home, transfer) were recorded.

RESULTS

There were 15,190 unique pregnancy-related visits with an overall annual growth rate of 2.8% (P = 0.03). There was a statistically significant increase in visits to freestanding PEDs (P = 0.02) and separate PED from a site with a general ED (P = 0.03), but there was not in the general EDs (P = 0.16). The 3 most common pregnancy-related conditions were abdominal pain, genitourinary infection, and hemorrhage in early pregnancy.

CONCLUSIONS

Pregnant adolescents make up a small (<1%) but growing proportion of overall visits to PEDs. Future direction should include an evaluation of the educational opportunities provided during pediatric residency and pediatric emergency medicine fellowship training and, if inadequacies exist, work to develop an innovative curriculum for this particular patient population.

Adolescents' use of the emergency department: does source of primary care make a difference?

BACKGROUND

Many of the 18 million emergency department visits by adolescents annually in the United States are for nonurgent problems that might be addressed in a primary care setting.

METHODS

As part of a larger randomized controlled intervention, 1023 adolescents aged 12 to 21 years registering in an urban pediatric emergency department (PED) were tracked over the subsequent 365 days to record all visits to the PED. Adolescents identifying an adolescent medicine service (AMS) as the primary care source were compared with adolescents receiving primary care elsewhere in an integrated urban medical system (non-AMS) to determine how often after the index PED visit they revisited the PED, returned to primary care (PC), visited a subspecialist (SS), or were hospitalized. Mean values and odds ratios of each type of visit were compared between AMS and non-AMS patients using multivariate logistic and ordinary least squares regressions to control for covariates.

RESULTS

AMS patients (n = 124, 12%), compared to non-AMS patients (n = 899, 88%), were more likely female (75% vs 48%, P < .001) and used public insurance (52% vs 40%, P = .017). In unadjusted comparisons, AMS and non-AMS patients did not differ in the probability of any return PED visit (46% vs 37%, P = .052) in the 365 days following the index PED visit but differed in the mean number of return PED visits (1.35 vs 0.93, P = .026). AMS patients were more likely to be hospitalized (15% vs 7%, P = .006) after the index PED visit and also had a greater mean number of hospitalizations (0.41 vs 0.19, P = .048). Multivariate analyses controlling for demographic variables, triage level of initial PED visit, and hospitalizations showed AMS patients returned to primary care after an index PED visit 24.6 days earlier than non-AMS patients (P = .026).

CONCLUSIONS

This study demonstrates attending an AMS for primary care predicted earlier return to the primary care provider after an index PED visit. Elements of adolescent specialty care producing such outcomes are worthy of further study.

Advance provision of emergency contraception in an urban pediatric emergency department

STUDY OBJECTIVE

To assess whether a policy and educational intervention in an urban, pediatric emergency department (ED) increases advance provision of emergency contraception (EC) to patients.

DESIGN/SETTING/PARTICIPANTS

A pre- and post-intervention, retrospective chart review was conducted in an urban, pediatric ED assessing provider care of sexually active female adolescents and young adults. INTERVENTION/MAIN OUTCOME MEASURES: A policy was instituted recommending that ED providers prescribe EC and provide an educational handout to all sexually active female adolescents and young adults. ED providers were educated about EC and this policy. Charts, subsequently reviewed, included sexually active female patients, age 13-21 years, presenting to the ED status post sexual assault, seeking EC, or with an abdominal, gynecologic, or urologic complaint. Student's t-tests, Pearson's chi-square and Fisher's Exact tests compared pre- and post-intervention provider and patient characteristics and outcomes.

RESULTS

The mean age of the patient sample was 18.8 years (SD=1.7), 83% were Black or Hispanic, 43% were previously pregnant, 25% reported not using birth control. Last unprotected sexual intercourse was not documented for 87% of patients presenting with medical complaints. There was no difference in the advance prescribing of EC or the provision of the educational handout to patients pre- (3.3%) or post- (5.6%) intervention (P = 0.73).

CONCLUSIONS

Despite a policy and an educational intervention for providers, little change occurred in advance EC prescribing in an urban, pediatric ED. Additionally, many providers were not documenting last unprotected sexual intercourse, potentially missing an opportunity to treat patients with EC at the time of their visit.

Disparities in reproductive health-related visits to the emergency department in Maryland by age and race, 1999-2005

OBJECTIVE

To describe reproductive health-related visits to Maryland emergency departments (EDs) among women aged 15-44 years from 1999 to 2005.

METHODS

We obtained data from the Healthcare Cost and Utilization Project State Emergency Department Database and State Inpatient Database. ICD-9-CM diagnosis codes were used to classify reproductive health-related visits. We calculated the annual rate of reproductive health visits to Maryland EDs from 1999 to 2005 for women aged 15-44 years and tested time trends using linear regression. Admission rates were defined as the percentage of ED visits that resulted in inpatient admission. We calculated age-specific and race-specific rate ratios for diagnoses using Poisson regression and admission rate ratios using Cochran-Mantel-Haenszel statistics.

RESULTS

From 1999 to 2005, the rate of ED visits in Maryland increased 50%, from 28.0 to 42.1 visits per 1000 women. Lower genital tract infections were the most common diagnosis (21.4%). The rates were higher for women aged 15-24 than for women aged 25-44 (rate ratio 1.18, 95% confidence interval [CI] 1.17-1.18) and nearly three times higher for black women than white women (rate ratio 2.94, 95% CI 2.92-2.96). Admission rates were lower for women aged 15-24 than for women aged 25-44 (rate ratio 0.34, 95% CI 0.33-0.35) and were higher among black than white women (rate ratio 1.16, 95% CI 1.14-1.18).

CONCLUSIONS

Disparities by age and race are evident for reproductive health-related ED visits in Maryland, and many of these ED visits are for conditions that are amenable to preventive measures.

Evaluation and management of sexually transmitted infections in adolescent males presenting to a pediatric emergency department: is the chief complaint diagnostic?

OBJECTIVES

The objectives of the study were to (1) describe evaluation and treatment patterns for adolescent males presenting with a concern for sexually transmitted infection (STI) in a pediatric emergency department, (2) assess the rates of STIs in symptomatic males, and (3) determine the utility of urinalysis alone in predicting STIs in adolescent males.

METHODS

A retrospective cohort study was conducted of all patients presenting to our pediatric emergency department from January 1, 2007, to December 31, 2007. Inclusion criteria included males, aged 15 to 21 years, with an STI or urinary chief complaint. Exclusion criteria were referrals from pediatricians, a previous history of urinary tract infection or preexisting urologic condition, or primary complaint of scrotal and/or testicular pain.

RESULTS

A total of 270 patients were identified. Testing included urinalysis with microscopy (UA) (64%), urine culture (53%), Neisseria gonorrhoeae (GC), and Chlamydia trachomatis (CT) (93%), and Trichomonas vaginalis (5%). Sixty-four percent of males tested positive for either GC or CT, or both. Overall, 91% of patients were treated for CT and GC, 18% for T. vaginalis, and 5% for urinary tract infection. The sensitivity and specificity of a positive UA for presence of GC and/or CT were 86% and 82%, respectively, whereas the positive and negative predictive values were 89% and 77%, respectively. There were no positive urine cultures in the cohort.

CONCLUSIONS

Sixty-four percent of patients were diagnosed with either GC or CT. Although UA is helpful in predicting STI, limited use is warranted, given the high prevalence of disease in this selected population. The urine culture does not appear to be a necessary adjunct in the management of these patients.