Emergency department utilization by adolescents

Contraceptive counseling for adolescents in the emergency department: A novel curriculum for nurse practitioners and physician assistants

ABSTRACT

Many adolescents use the emergency department (ED) as their primary source of health care. As a result, the ED serves as a unique opportunity to reach adolescents. Although many adolescent visits to the ED are related to reproductive health, ED providers report barriers to providing this care, including lack of training. Nurse practitioners (NPs) and physician assistants (PAs) serve a vital role in the provision of consistent care to adolescents in the ED. The purpose of this study was to create a curriculum to train NPs and PAs at two pediatric institutions to provide patient-centered contraceptive counseling to adolescents in the pediatric ED regardless of their chief complaint. To do this, we created a four-part webinar followed by an in-person training session. Participants completed training and then conducted counseling sessions with adolescents in the ED. Counseling sessions were recorded and reviewed for fidelity to delineated counseling principles, and data from post-counseling surveys were collected. 27 NPs and PAs completed the training and conducted 99 counseling sessions. Nearly all sessions incorporated essential content and communication principles such as shared decision making (90%) and teach-back methods (75%). All NPs and PAs who participated reported satisfaction and subjective improvement in knowledge and competence from the training. This curriculum offers a novel and feasible approach to train NPs and PAs to deliver patient-centered contraception counseling to adolescents in the ED setting, and it can serve as a model for how to educate different providers to incorporate reproductive health education into the busy ED visit.

Using machine-learning risk prediction models to triage the acuity of undifferentiated patients entering the emergency care system: a systematic review

BACKGROUND

The primary objective of this review is to assess the accuracy of machine learning methods in their application of triaging the acuity of patients presenting in the Emergency Care System (ECS). The population are patients that have contacted the ambulance service or turned up at the Emergency Department. The index test is a machine-learning algorithm that aims to stratify the acuity of incoming patients at initial triage. This is in comparison to either an existing decision support tool, clinical opinion or in the absence of these, no comparator. The outcome of this review is the calibration, discrimination and classification statistics.

METHODS

Only derivation studies (with or without internal validation) were included. MEDLINE, CINAHL, PubMed and the grey literature were searched on the 14th December 2019. Risk of bias was assessed using the PROBAST tool and data was extracted using the CHARMS checklist. Discrimination (C-statistic) was a commonly reported model performance measure and therefore these statistics were represented as a range within each machine learning method. The majority of studies had poorly reported outcomes and thus a narrative synthesis of results was performed.

RESULTS

There was a total of 92 models (from 25 studies) included in the review. There were two main triage outcomes: hospitalisation (56 models), and critical care need (25 models). For hospitalisation, neural networks and tree-based methods both had a median C-statistic of 0.81 (IQR 0.80-0.84, 0.79-0.82). Logistic regression had a median C-statistic of 0.80 (0.74-0.83). For critical care need, neural networks had a median C-statistic of 0.89 (0.86-0.91), tree based 0.85 (0.84-0.88), and logistic regression 0.83 (0.79-0.84).

CONCLUSIONS

Machine-learning methods appear accurate in triaging undifferentiated patients entering the Emergency Care System. There was no clear benefit of using one technique over another; however, models derived by logistic regression were more transparent in reporting model performance. Future studies should adhere to reporting guidelines and use these at the protocol design stage.

REGISTRATION AND FUNDING

This systematic review is registered on the International prospective register of systematic reviews (PROSPERO) and can be accessed online at the following URL: https://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42020168696This study was funded by the NIHR as part of a Clinical Doctoral Research Fellowship.

Association of age and opioid use for adolescents and young adults in community emergency departments

OBJECTIVES

Adolescents and young adults are at high risk for opioid misuse and abuse. The emergency department (ED) plays a key role in treatment of acute and chronic pain and is a primary place that this patient population is exposed to prescription opioids. We evaluate the effect of patient age on use of opioids for adolescents and young adults in community EDs.

METHODS

Retrospective cohort study of adolescent and young adult encounters in 14 community EDs from 2013 to 2014. We evaluate the percent of ED encounters with parenteral and/or oral opioids administered, morphine milligram equivalents per ED patient encounter, and percent of patient encounters discharged with an opioid prescription. Age was the main exposure. The association between outcomes and age was examined using bivariate and multivariate logistic regression adjusting for measurable confounders.

RESULTS

There were 259,632 adolescent and young adult encounters in our sample, average age 17.6 years, with 15.8% given opioids. Increasing patient age was associated with a significant increase in the percent of encounters with opioids given (AOR, 1.11; 95% CI 1.10-1.11), morphine milligram equivalents administered (β 0.38; 95% CI 0.33-0.43 for parenteral and β 0.26; 95% CI 0.23-0.28 for oral), and percent of patients receiving outpatient prescriptions (AOR, 1.14; 95% CI 1.13-1.14). Significant variability also existed between medical centers (AOR, 2.02; 95% CI 1.86-2.20).

CONCLUSION

For adolescent and young adult patients in the ED, there is a significant association between opioid prescribing and increasing age. This describes an opportunity to reduce opioid use in older adolescents and young adults.

Examining the Role of the Pediatric Emergency Department in Reducing Unintended Adolescent Pregnancy

OBJECTIVES

To determine pregnancy risk and receptiveness to emergency department (ED)-based pregnancy prevention interventions among adolescents accessing care in the ED.

STUDY DESIGN

Cross-sectional electronic survey of adolescent females in a pediatric ED used to calculate the Pregnancy Risk Index, a validated measure estimating the annual risk of becoming pregnant based on recent sexual activity, contraceptive method(s), method-specific contraceptive failure rates, and interest in receipt of ED-based contraceptive services.

RESULTS

Of 229 participants, 219 were not pregnant, and 129 reported sexual experience. Overall, 72.4% (n = 166) endorsed negative pregnancy intentions. The overall Pregnancy Risk Index for the 219 nonpregnant participants was 9.6 (95% CI 6.8-12.4), and was 17.5 (95% CI 12.8-22.2) for the 129 sexually experienced participants. A Pregnancy Risk Index greater than the national average of 5 was associated with older age (aOR 3.0; 95% CI 1.5-5.85), nonprivate insurance (aOR 7.1; 95% CI 1.6-32.1), prior pregnancy (aOR 2.7; 95% CI 1.2-6.0), and chief complaint potentially related to a reproductive health concern (aOR 2.6; 95% CI 1.4-5.1). In this cohort, 85.1% (n = 194) believed that the ED should provide information about pregnancy prevention, the majority of whom (64.9%; n = 148) believed that pregnancy prevention services should be offered at all ED visits.

CONCLUSION

This study demonstrates a high unintended pregnancy risk among adolescents accessing care in the ED. Adolescents report interest in receiving pregnancy prevention information and services in the ED, regardless of reason for visit. Strategies to incorporate successfully the provision of reproductive health services into ED care should be explored.

Adolescent presentations to an adult hospital emergency department

OBJECTIVE

Age-related policies allow adolescents to access paediatric and adult EDs. Anecdotally, paediatric and adult EDs report challenges when caring for older and younger adolescents, respectively. Our aim was to describe the characteristics of an adolescent population attending an adult ED, co-located with a tertiary paediatric ED.

METHODS

The Westmead Hospital ED database was accessed for 14.5-17.9 years old presentations between January 2010 and December 2012. Patient diagnosis coding (SNOMED) was converted to ICD-10. De-identified data were transferred into Microsoft Excel with analysis performed using spss V22.

RESULTS

There were 5718 presentations made to the Westmead Hospital, Sydney, Australia ED by 4450 patients, representing 3.3% (95% CI 3.2-3.4) of total visits from all patients 14.5 years and above. The mean age of the sample was 16.6 years (male 51.8%). Presentations triaged as level 4 or 5 represented 61.0% (95% CI 58.7-61.3) of visits. The proportion of patients who did not wait to receive care was 13.8% (95% CI 12.9-14.7), which was significantly higher than adult rates (P < 0.01). There were 279 unscheduled return visits (visits made <72 h of discharge) representing 4.9% (95% CI 4.4-5.8) of all presentations. Injury was the most common diagnosis (30.2%, 95% CI 28.8-31.6). Chronic physical illness and alcohol-related visits comprised 2.1% (95% CI 1.7-2.5) and 0.8% (95% CI 0.6-1.0) of adolescent presentations, respectively.

CONCLUSION

Contrary to reported staff perceptions, adolescent chronic physical illness presentations were not a major burden. Alcohol was likely under-recorded as a contributing factor to presentations.

A Qualitative Analysis of Adolescent and Caregiver Acceptability of Universally Offered Gonorrhea and Chlamydia Screening in the Pediatric Emergency Department

STUDY OBJECTIVE

We qualitatively explore adolescent and parent or guardian attitudes about benefits and barriers to universally offered gonorrhea and chlamydia screening and modalities for assessing interest in screening in the pediatric emergency department (ED).

METHODS

A convenience sample of forty 14- to 21-year-olds and parents or guardians of adolescents presenting to an urban and community pediatric ED with any chief complaint participated in individual, semistructured, confidential interviews. Topics included support of universally offered gonorrhea and chlamydia screening, barriers and benefits to screening, and modalities for assessing interest in screening. Data were analyzed with framework analysis.

RESULTS

Almost all adolescents (37/40; 93%) and parents (39/40; 98%) support offering ED gonorrhea or chlamydia screening. Benefits included earlier diagnosis and treatment, convenience and transmission prevention (cited by both groups), and improved education and long-term health (cited by parents/guardians). Barriers included concerns about confidentiality and cost (cited by both groups), embarrassment (cited by adolescents), and nondisclosure to parents or guardians (cited by parents/guardians). Adolescents preferred that the request for gonorrhea or chlamydia screening be presented in a private room, using tablet technology. Both groups noted that the advantages to tablets included confidentiality and adolescents' familiarity with technology. Adolescents noted that tablet use would address concerns about bringing up gonorrhea or chlamydia screening with clinicians, whereas parents or guardians noted that tablets might increase screening incidence but expressed concern about the lack of personal interaction.

CONCLUSION

Universally offered gonorrhea and chlamydia screening in a pediatric ED was acceptable to the adolescents and parents or guardians in this study. Offering a tablet-based method to assess interest in screening may increase participation.

A Computerized Sexual Health Survey Improves Testing for Sexually Transmitted Infection in a Pediatric Emergency Department

OBJECTIVES

To assess whether clinical decision support, using computerized sexually transmitted infection (STI) risk assessments, results in increased STI testing of adolescents at high risk for STI.

STUDY DESIGN

In a 2-arm, randomized, controlled trial conducted at a single, urban, pediatric emergency department, adolescents completed a computerized sexual health survey. For patients assigned to the intervention arm, attending physicians received decision support to guide STI testing based on the sexual health survey-derived STI risk; in the usual care arm, decision support was not provided. We compared STI testing rates between the intervention and usual care groups, adjusting for potential confounding using multivariable logistic regression.

RESULTS

Of the 728 enrolled patients, 635 (87.2%) had evaluable data (323 intervention arm; 312 usual care arm). STI testing frequency was higher in the intervention group compared with the usual care group (52.3% vs 42%; aOR 2 [95% CI 1.1, 3.8]). This effect was even more pronounced among the patients who presented asymptomatic for STI (28.6 vs 8.2%; aOR 4.7 [95% CI 1.4-15.5]).

CONCLUSIONS

Providing sexual health survey-derived decision support to emergency department clinicians led to increased testing rates for STI in adolescents at high risk for infection, particularly in those presenting asymptomatic for infection. Studies to understand potential barriers to decision support adherence should be undertaken to inform larger, multicenter studies that could determine the generalizability of these findings and whether this process leads to increased STI detection.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02509572.

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.

Injury prevention: opportunities in the emergency department

Because injury is the leading cause of morbidity and mortality in young patients, emergency departments have a significant opportunity to provide injury-prevention interventions at a teachable moment. The emergency department has the ability to survey injuries in the community, use the hospital setting to screen patients, provide products, offer resources to assist families within this setting to change their risky behaviors, and connect families to community resources. With a thoughtful, collaborative approach, emergency departments are an excellent setting within which to promote injury prevention among patients and families.

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.

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.

Parental relations and referral of adolescents to Norwegian mental health clinics

OBJECTIVE

Many youngsters with mental health problems are not referred to mental health clinics. Parents play an important role in the referral process of youngster to mental health clinics. The main aim of this study was to explore the role of the parent-child relation for referral of adolescents to outpatient psychiatric clinics.

METHOD

Employing a cross-sectional design, we compared a referred sample of 39 adolescents in outpatient psychiatric treatment with a non-referred matched control sample of 39 adolescents. The Parental Bonding Instrument and Youth Self-Report were employed to assess the characteristics of these two population groups.

RESULTS

Adolescents referred to Norwegian mental health clinics for mental health problems report more perceived care from mothers and a trend of more care from fathers compared with non-referred controls matched on level of mental health problems, age and gender. Implications of the finding for the role of parents on referral of adolescents to mental health clinics and for treatment compliance are discussed.

A pilot study to assess candidacy for emergency contraception and interest in sexual health education in a pediatric emergency department population

OBJECTIVES

The objective of the study was to assess potential candidacy for hormonal emergency contraception (EC) and desire for sexual health education among female adolescents presenting for care to a pediatric emergency department (ED).

METHODS

We used an anonymous, cross-sectional, written survey of girls aged 15 to 19 years seeking care in an urban, children's hospital ED. The survey included questions about personal sexual history and desire for sexual health education about sexually transmitted infections and contraception options.

RESULTS

One hundred thirty-four patients were eligible for participation; 77 (57%) consented and completed the survey. The mean age was 16.6 years. Fifty-six percent reported ever having had sexual intercourse. Of those, 6 (14%; confidence interval, 5%-28%) stated that they had unprotected sexual intercourse within the previous 5 days. When asked about their interest in sexual health education in the ED, 48% of all subjects wanted information about sexually transmitted infections, 36% wanted information about HIV, and 34% wanted information about preventing pregnancy.

CONCLUSIONS

Among sexually active adolescents seeking care in an urban, children's hospital ED, a significant proportion could potentially utilize EC if they so chose. Furthermore, adolescents with and without a history of sexual activity expressed interest in learning about sexual health issues in the ED setting.

Characteristics that distinguish adolescents who present to a children's hospital emergency department from those presenting to a general emergency department

OBJECTIVE

To identify characteristics of adolescents who access health care in a children's hospital emergency department (ED) compared with a general ED.

METHODS

We performed a retrospective comparative study of an urban children's ED and the adjacent general ED. Participants included randomly selected ED visits of adolescents aged 15 to 19 years who presented during a 1-year period. Demographic data, triage category, chief complaint, and comorbid conditions were collected and analyzed by site of care.

RESULTS

Ten percent of visits to each location was reviewed. Adolescents in the general ED were more often female (72% vs 60%), uninsured (32% vs 12%), and presented with abdominal pain (46% vs 17%). Adolescents in the children's ED more frequently identified a primary care provider (94% vs 58%) and were triaged as non-urgent (40% vs 22%). In the children's ED, more complaints were injury-related (30% vs 19%). The prevalence of complaints related to violence or chronic diseases did not vary. Through logistic regression analysis, adolescents using the general ED were more likely to be older (odds ratio [OR], 4.1, 95% confidence interval [CI], 3.2-5.3) and to complain of abdominal pain (OR, 5.0; 95% CI, 2.8-8.8); those using the children's ED were more likely to present with a non-urgent complaint (OR, 2.7; 95% CI, 1.5-4.9) and identify a primary care provider (OR, 16.6; 95% CI, 17.6-36.4).

CONCLUSIONS

When a children's and general ED are in close proximity, there are unique characteristics of the adolescents at each site. Understanding the differences can assist clinicians to provide care tailored to meet the needs of each group.

Exploring emergency contraception knowledge, prescription practices, and barriers to prescription for adolescents in the emergency department

OBJECTIVE

The objective of this study was to assess the proportion of emergency medicine physicians who had prescribed emergency contraception pills to adolescents, to identify potential barriers to emergency contraception pill prescription for adolescents, and to assess physician knowledge of emergency contraception pills.

PARTICIPANTS AND METHODS

A cross-sectional, anonymous, Internet-based survey of members of the American Academy of Pediatrics Section of Emergency Medicine was conducted. Providers were included in analysis if they were attending physicians caring for children (<22 years of age) in the emergency department setting >30% of the time. Survey questions included demographics, emergency contraception pill prescription rates for adolescents, attitudes toward emergency contraception pills for adolescents, and emergency contraception pill knowledge questions.

RESULTS

A total of 1005 Section of Emergency Medicine members were contacted; 424 (42%) responded, and 133 did not meet inclusion criteria. Of the 291 eligible respondents, 282 had complete surveys. Eighty-five percent of the respondents stated that they had prescribed emergency contraception pills to adolescents, 71% within the previous year. Of those, 81% prescribed emergency contraception pills <5 times. The 5 most frequently cited barriers were concern for lack of follow-up (72%), time constraints (40%), lack of clinical resources (33%), discouraging regular contraceptive use (29%), and concern about birth defects (27%). Thirty-nine percent of respondents identified >/=5 barriers to emergency contraception pill prescriptions for adolescents. Forty-three percent incorrectly answered >50% of the questions. Physicians were more likely to report prescribing emergency contraception pills if they had answered >3 of the knowledge-based questions correctly and were less likely to report prescribing if they identified >5 barriers.

CONCLUSIONS

Although a large proportion of emergency department physicians reported prescribing emergency contraception pills to adolescents, the pills were prescribed infrequently. Factors associated with nonprescription were decreased knowledge of emergency contraception pills and identifying >5 barriers. Identification of these potential barriers and education regarding emergency contraception pills may ultimately improve adolescent access to emergency contraception pills in the emergency department.

Description of a novel pediatric emergency department-based HIV screening program for adolescents

Several emergency department (ED)-based HIV screening programs have been described. However, the majority of these programs have been aimed at adults and older adolescents, and few have taken place in a dedicated pediatric ED. Given that many adolescents seek care in hospital EDs, and that the ED may be an adolescent's only contact with the health care system, we decided to implement an HIV-counseling and testing program in the ED of an urban children's hospital. The program included a dedicated health educator who provided sexual health counseling in a 30-minute session as well as optional HIV testing and test results to patients aged 14-24 years, and arranged necessary follow-up care for adolescents who tested positive for HIV. We collected aggregate data on the number of youth counseled, tested, and followed up. A total of 1287 patients were approached for potential counseling and testing during the first 3 years of the project. Of these, 643 (50.0%) agreed to meet with the health educator and were counseled. Three hundred eighteen (49.5%) of these patients agreed to HIV testing. One hundred eighty-seven (58.8%) patients returned for follow-up. Two patients (0.6%) whose previous HIV status was unknown tested positive for HIV; both of these patients were successfully linked to care. Fifty-six health care providers (17.3% of ED providers) were surveyed about their opinions of the program; although 93% were supportive of the program, several respondents were concerned about the appropriateness of HIV testing in the ED setting. This project suggests that, if appropriate resources are available, a dedicated HIV counseling and testing program can be successfully implemented in a busy, urban, pediatric ED. Providing access to these services to high-risk adolescents has the potential to significantly impact their health.

Pacientes psiquiátricos en el servicio de urgencias de pediatría de un hospital terciario: revisión de un período de 6 meses

INTRODUCTION

In the last few years, a marked increase in the number of psychiatric emergencies treated at pediatric emergency departments has been observed. The aim of the present study was to characterize these patients.

PATIENTS AND METHODS

We performed a descriptive, prospective, cross sectional study, based on all psychiatric emergencies treated at the pediatric emergency department of Hospital General Universitario Gregorio Marañón, Madrid, from 1-10-04 to 31-3-05. The following variables were analyzed: age, sex, time of consultation, day of the week, day of the month, month of the year, psychiatric antecedents, previous psychiatric pharmacologic treatment, the person or service who took the child to hospital, diagnosis, and whether the patient was admitted to the hospital.

RESULTS

Of a total of 36,449 emergencies, 79 were psychiatric (0.21 %). Sex rates were 48.1 % boys and 51.9 % girls. The mean (+/-2 SD) age was 13.73 +/- 2.5 years. Visits were most frequent on Mondays (19 %), in the evening, and in January and February. A total of 13.23 % of the patients were brought by extrahospital services. The main diagnoses were: behavioral disorders (36.76 %), anxiety disorders (20.58 %) and suicidal ideation or suicide attempt (13.23 %). There was a clear male predominance in behavioral disorders (67.85 %) and a female predominance in anxiety disorders (71.42 %) and suicidal ideation or suicide attempt (76.92 %). The hospitalization rate among these patients was 32.35 %.

CONCLUSIONS

The incidence of psychiatric disorders in our pediatric emergency department was low. The patients were aged 11-15 years old, without differences between the sexes. Peak demand was reached on Mondays in January and February, at the end of the evening and beginning of the night. The most common diagnosis was behavioral disorder. The hospitalization rate was exceptionally high, more than 6 times higher than the average in our hospital.

Urban emergency department utilization by adolescents

This study describes urban emergency department (ED) utilization and follow-up referral patterns among adolescents. ED visits for 14-19-year-old patients at an urban university hospital with adjacent adult and pediatric emergency departments during specified months in 1993 were retrospectively reviewed. A subgroup (n=150) was randomly selected for detailed chart review. One thousand six hundred and thirty-six adolescents were seen in the ED during the study period. Public assistance (n=763; 47%) and commercial insurance (n=480; 29%) were the most common forms of insurance, followed by self-pay (n=357; 22%). The majority of triage codes for ED visits were nonurgent (n=140; 93%). Twenty-five patients (17%) were not referred for follow-up upon ED discharge. Adolescents on public assistance or without insurance may frequently utilize an urban ED for nonurgent medical problems. A group of patients did not identify a primary care provider at triage and were not referred for follow-up. Defining medical problems for which adolescents utilize the ED may help health professionals to tailor community resources to better serve adolescent health care needs.

Opportunistic urine ligase chain reaction screening for sexually transmitted diseases in adolescents seeking care in an urban emergency department

STUDY OBJECTIVE

Neisseria gonorrhoeae and Chlamydia trachomatis are the most common bacterial sexually transmitted diseases (STDs) in sexually active youth and many infections are asymptomatic or unrecognized. This study used ligase chain reaction assays for determination of prevalence of gonococcal and chlamydial infections in adolescents seeking care at an urban emergency department.

METHODS

An unlinked prevalence study was performed with ligase chain reaction tests on voided urine specimens from a convenience sample of adolescents 14 years or older who sought care at the Children's Hospital of Alabama ED. Demographic data and data on care provided in the ED were determined from retrospective chart review of those patients whose urine specimens were tested.

RESULTS

Of 282 urine specimens screened, 13.5% (38) yielded positive findings on ligase chain reaction testing for either or both pathogens (20 [7%] positive for N gonorrhoeae, 23 [8%] positive for C trachomatis). In the context of acute care, gonorrhea or chlamydial infection was diagnosed in 5 (1.8%). STD prevalence did not vary significantly by age. Only 39% (15/38) of patients with infections detected by ligase chain reaction testing received potentially effective antibiotics as a result of their urgent care evaluation.

CONCLUSION

Many adolescents use the ED for nonurgent care and unsuspected STDs are often missed. Urine ligase chain reaction testing is a sensitive, noninvasive means of detecting STDs by which unsuspected adolescent STD cases can be detected in an ED setting.

Utilization of physician offices by adolescents in the United States

Recent guidelines for adolescent primary care call for the specification of clinical services by three adolescent age subgroups. Yet analyses of office visits have either merged adolescence into one stage or divided it at age 15 years.

OBJECTIVE

To explore the utilization of physician offices in the United States by early (11-14 years), middle (15-17 years), and late (18-21 years) adolescents.

DESIGN

Secondary analysis of the 1994 National Ambulatory Medical Care Survey, focusing on visits made by the three adolescent age groups.

SETTING

Nationally representative sample of 2426 physicians in nonfederal, nonhospital offices.

SUBJECTS

A total of 33 598 visits by patients of all ages, representing 681.5 million visits in 1994.

MAIN OUTCOME MEASURES

Number of visits, health insurance, providers seen, duration of visits, reasons for visits, resulting diagnoses, and counseling provided.

RESULTS

Adolescents aged 11 to 21 years made 9.1% (61.8 million) of the total office visits and represented 15.4% of the total US population in 1994. This underrepresentation in visits held across all three adolescent age subgroups. Within the adolescent cohort, whites were overrepresented relative to their population proportion (78.5% of visits, 67.6% of population) and blacks and Hispanic adolescents were underrepresented (8.3% and 9.3% of visits, 15.5% and 13.1% of population). Middle adolescence signaled a life turning point from male to female predominance in office visits. Peak lifetime uninsurance rates occurred at middle adolescence for females (18.7%) and late adolescence for males (24.0%). Between childhood and early adolescence, public insurance decreased from 24.7% to 15.7% and uninsurance increased from 12.7% to 19.7%. Pediatricians accounted for the highest proportion of early adolescent visits (41.2%), family physicians for middle adolescent visits (35.3%), obstetrician-gynecologists for late adolescent female visits (37.3%), and family physicians for late adolescent male visits (34.8%). Mean visit duration during adolescence was 16 minutes, did not differ by age subgroup or sex, exceeded that of children (14.6 minutes), and was shorter than that of adults (19.3 minutes). Obstetrician-gynecologists spent more time with adolescents than did other physicians. Education or counseling was included in 50.4% of adolescent visits, ranging from 65.1% for obstetrician-gynecologists to 34.8% for internists. During early adolescence, the leading reasons for both male and female visits were respiratory (19.4%), dermatological (10.0%), and musculoskeletal (9.7%). A similar profile was found for middle and late adolescent males. For middle and late adolescent females, the leading reason for visits was special obstetrical-gynecological examination (12.8% and 21.1%), and the leading diagnosis resulting from visits was pregnancy (9.5% and 20.4%).

CONCLUSIONS

Adolescents underutilize physician offices and are more likely to be uninsured than any other age group. Visits are short, and counseling is not a uniform component of care. As adolescents mature, their providers, presenting problems, and resulting diagnoses change. The data from the National Ambulatory Medical Care Survey support a staged approach to adolescent preventive services, targeted to the needs of three age subgroups.

Emergency department utilization by adolescents in the United States

BACKGROUND

Adolescents in the United States have been shown to underutilize primary care services and therefore may rely heavily on emergency service. Although several small studies have explored local emergency services for youth, there are no published reports of adolescent utilization of emergency services on a national scale. Furthermore, emergency services data have not been aggregated according to the age subgroups used by the current guidelines for adolescent care.

OBJECTIVE

To explore the utilization of emergency departments in the United States by early (11 to 14 years), middle (15 to 17 years), and late (18 to 21 years) adolescent subgroups.

DESIGN

Secondary analysis of the emergency department component of the 1994 National Hospital Ambulatory Medical Care Survey.

SETTING

Nationally representative sample of 418 emergency departments in the United States.

PATIENTS

Approximately 26,547 visits by patients of all ages, representing 93.4 million total visits in 1994 and 14.8 million adolescent visits.

OUTCOME MEASURES

Number of visits, health insurance, reasons for visits, urgency of visits, resulting diagnoses, and hospitalization rates.

RESULTS

Adolescents accounted for 15.4% of the population and 15.8% of emergency department visits in 1994. Late adolescents were overrepresented in emergency department visits relative to their population proportion (6.8% of visits, 5.3% of population), whereas early adolescents were underrepresented (4.6% of visits, 5.9% of population). Lack of health insurance was more common among 11- to 21-year-olds (26.2%) than either children (13.6%) or adults (22.7%). By ages 18 to 21 years, 40.5% of male visits and 27.6% of female visits were uninsured. Injury-related visits were more common among adolescents (28.6%) than either children (23.1%) or adults (18.2%). Injury was the leading reason for visits among all adolescent age-sex subgroups (36.6% to 42.0% of male visits and 14.1% to 27.2% of female visits) except females aged 18 to 21 years for whom digestive reasons ranked first (18.8%). Injury was the leading diagnosis for all adolescent age-sex subgroups, with peaks at early adolescence of 61.6% for males and 45.8% for females. Across all adolescent age-sex subgroups, 3.1% to 5.3% of visits resulted in hospitalization, and 41.0% to 52.5% of visits were urgent. These rates did not differ from those of children but were lower than those of adults.

CONCLUSIONS

Utilization of emergency departments increases and health insurance decreases during adolescence, suggesting that adolescents with inadequate health insurance may rely heavily on emergency departments for their health care needs. Most adolescent visits to emergency departments are not urgent and might be better treated through nonemergency, primary care sites.