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

Pediatric Emergency Physicians' Knowledge, Attitudes, and Behaviors Regarding Confidential Adolescent Care

OBJECTIVES

More than 19 million adolescents seek care in the emergency department (ED) annually. We aimed to describe the knowledge, attitudes, and behaviors related to confidential adolescent care among pediatric ED physicians.

METHODS

We conducted a cross-sectional questionnaire of US physician members of the Pediatric Emergency Medicine Collaborative Research Committee survey listserv. The 24-item questionnaire assessed familiarity with adolescent confidentiality laws, attitudes toward providing confidential care, frequency of discussing behavioral health topics confidentially, and factors influencing the decision to provide confidential care. We dichotomized Likert responses and used χ 2 to compare subgroups.

RESULTS

Of 476 eligible physicians, 151 (32%) participated. Most (91. 4%) had completed pediatric emergency medicine fellowship. More participants reported familiarity with all sexual health-related laws compared with all mental health-related laws (64% vs 49%, P < 0.001). The median age at which participants thought it was important to begin routinely providing confidential care was 12 years; 9% thought confidential interviews should not be routinely conducted until older adolescence or at all. Their decision to provide confidential care was influenced by the following: chief complaint (97%), time (43%), language (24%), presence of family (23%) or friends (14%), and space (22%).

CONCLUSIONS

Respondents reported moderate familiarity with adolescent confidentiality laws. Although they viewed confidential care as something they were comfortable providing, the likelihood of doing so varied. Barriers to confidential care were influenced by their assessment of adolescents' behavioral health risk, which may contribute to health inequity. Future efforts are needed to develop strategies that augment confidential ED care for adolescents.

Impact of risk-based sexually transmitted infection screening in the emergency department

OBJECTIVES

Sexually transmitted infections (STIs), including chlamydia, gonorrhea, and human immunodeficiency virus (HIV) pose a significant health burden in adolescents. Many adolescents receiving care in the emergency department (ED) are in need of testing, regardless of their chief complaint. Our objective was to determine whether an electronic, risk-based STI screening program in our ED was associated with an increase in STI testing among at-risk adolescents.

METHODS

We conducted a retrospective cohort analysis of patient outcomes in our pediatric ED after integrating an Audio-enhanced Computer-Assisted Self-Interview (ACASI) as standard of care. It obtained a focused sexual history and generated STI testing recommendations. Patient answers and testing recommendations were integrated in real-time into the electronic health record. Patients who tested positive received treatment according to our standard-of-care practices. All patients 15-21 years of age were asked to complete this on an opt-out basis, regardless of the reason for their ED visit. Exclusions included those unable to independently use a tablet, severe illness, sexual assault, or non-English speaking. Our primary outcome was to describe STI-testing recommendations and test results among ACASI participants. We also compared STI testing between ACASI participants and those who were eligible but did not use it.

RESULTS

In the first 13 months, 28.9% (1788/6194) of eligible adolescents completed the ACASI and 44.2% (321/790) accepted recommended STI testing. The mean age of participants was 16.6 ± 1.3 years, with 65.4% (1169) being female. Gonorrhea/chlamydia testing was significantly higher among participants vs. non-participants (20.1% [359/1788] vs 4.8% [212/4406]; p < 0.0001). The proportion of positive STI tests was similar between the two groups: 24.8% (89/359) vs. 24.5% (52/212; p = 0.94) were positive for chlamydia and/or gonorrhea, while 0.6% (2/354) participants vs. 0% non-participants (p > 0.99) were positive for HIV. Among participants whose chief complaints were unlikely to be related to STIs but accepted recommended testing, 20.9% (37/177) were positive for gonorrhea or chlamydia.

CONCLUSIONS

Our program facilitated STI testing in the ED and identified many adolescents with STIs, even when their ED complaint was for unrelated reasons. More rigorous implementation is needed to determine the impact of deployment of ACASI to all eligible adolescents and addressing barriers to accepting STI testing recommendations.

A Clinic-Based Quality Improvement Initiative to Increase Screening for Gonorrhea and Chlamydia in Adolescents

BACKGROUND

Universal screening is a strategy for addressing the limitations of risk-based screening for gonorrhea and chlamydia (GC/CT). This quality improvement (QI) initiative aimed to improve GC/CT screening by implementing universal annual screening for all adolescents ≥ 13 years old.

METHODS

At an academic pediatric resident continuity clinic, an interdisciplinary team designed and conducted multiple Plan-Do-Study-Act (PDSA) cycles over one year. The primary aim, and process measure, was to increase the percentage of encounters with screening for GC/CT in the 12 months prior to the encounter to 80%. The secondary outcome measure was rate of detection of GC or CT infection. Further, pulse checks of provider/staff knowledge and adherence were conducted. The balancing measure was denied insurance claims.

RESULTS

The mean screening rate of 29.2% increased during the project implementation to 65.1% with several bundles of PDSA cycles. There were no cases of gonorrhea detected in the baseline period or implementation period. The case rate of chlamydia was similar during both periods (from 9.7 per 1,000 adolescent encounters to 10.8 per 1,000 adolescent encounters, p = 0.74). There was similarly high provider/staff knowledge about (p = 0.35) and adherence to (p = 0.06) the screening protocol at 6 and 12 months of implementation. There was no increase in percentage of denied insurance claims.

CONCLUSION

This QI initiative doubled rates of GC/CT screening with no statistically significant increase in number of cases.

Effectiveness of a Universally Offered Chlamydia and Gonorrhea Screening Intervention in the Pediatric Emergency Department

PURPOSE

Adolescents represent more than half of the newly diagnosed sexually transmitted infections in the U.S. annually. Emergency departments (EDs) may serve as an effective, nontraditional setting to screen for chlamydia/gonorrhea (CT/GC). The objective was to evaluate the effectiveness of a universally offered CT/GC screening program in two pediatric ED settings.

METHODS

This was a prospective, delayed start pragmatic study conducted over 18 months in two EDs within the same academic institution among ED adolescents aged 14-21 years with any chief complaint. Using a tablet device, adolescents were confidentially informed of CT/GC screening recommendations and were offered screening. If patients agreed to CT/GC testing, a clinical decision support tool was triggered to inform the provider and order testing. The main and key secondary outcomes were the proportion of CT/GC testing and positive CT/GC test results in each respective ED.

RESULTS

Both EDs experienced modest but statistically significant increases in CT/GC testing post- versus pre-intervention (main: 11.5% vs. 7.9%; confidence interval [CI]: 2.9-4.2; p < .0001 and satellite: 3.8% vs. 2.6%; 95% CI: .7-1.7; p < .0001). Among those tested, the positivity rate at the main ED did not significantly change post- versus pre-intervention (24.1% vs. 23.2%; 95% CI: -1.9 to 3.8; p = .71) but significantly decreased at the satellite ED (7.6% vs. 14.8%; 95% CI: -12.2 to -2.2; p = .01).

CONCLUSIONS

A universally offered screening intervention increased the proportion of adolescents who were tested at both EDs and the detection rates for CT/GC at the main ED, but patient acceptance of screening was low.