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The Covid-19 pandemic resulted in unprecedented restrictions on many public, private, and workplace activities throughout the United States and elsewhere. When restrictions were imposed, we were conducting a type III hybrid effectiveness-implementation trial in 10 pediatric trauma centers. In response to several pandemic-based restrictions, we had to develop procedures for engaging with potential research participants while limiting nonclinical, in-person interactions. This manuscript describes the procedures and challenges of obtaining electronic informed consent and assent in a multisite trauma center-based research study. We developed, tested, and trained staff to implement three options for obtaining informed consent. Twenty-five participants were enrolled in the effectiveness-implementation multisite trial during the first six months of utilization of the consent options, with eleven of these individuals enrolled using hybrid or electronic consent procedures. The challenges we identified involving electronic consent procedures included confusion over who would complete the electronic consent process and difficulties reconnecting with families. Lessons learned can strengthen electronic consent and assent procedures for future studies. More research is needed to further strengthen this process and increase its utilization.

Study Objective To explore minority, adolescent birth and perinatal experiences to inform and improve quality of care for this unique group. Design Mixed quantitative and qualitative study guided by Bourdieu's Social Fields framework. Setting Clinic dedicated to parenting adolescents, and a local charter school founded to serve pregnant and parenting young adults. Participants Sample size for quantitative data: n = 27; qualitative data: n = 14. Average age was 16.39 years (SD = 1.29); most self-identified as Latina/Hispanic or African American/Black/Afro-Caribbean/African. Interventions and Main Outcome Measures We used 2 validated surveys: Birth Satisfaction Scale-Revised (BSS-R), and the Postpartum Worry Scale-Revised (PWS-R). The BSS-R has 10 items, and quantifies labor and delivery experiences. The PWS-R has 20 items, and quantifies maternal, infant, and social-emotional worries. The qualitative, semistructured 30-minute interviews with a subset of survey respondents further explored perinatal mental health, labor experiences, and support networks. Results BSS-R data resulted in an average score of 25.14 (SD = 5.35), which correlated to moderate satisfaction with birth experience (range, 0-40 with 0 = most negative). The PWS-R average score of 55.79 (SD = 21.06) indicated elevated postpartum worry (range, 20-100 with 20 = most worry). Qualitative interviewees worried about relationships and newborn well-being; support networks fluctuated; distinct events, pain, and fear during labor dominated birth stories. Advice for peers included: tending to social support, stress, and self-care. Nonjudgmental communication, empathy, and emotional connection were desired attributes of their health care team. Participants had anxiety related to social networks and newborn care. Although birth experiences were moderately positive, they were also described as stressful. However, participants were resourceful, insightful, and took advantage of social supports. Conclusion Birth experiences, patterns of stress, and support networks are uniquely identified and utilized by adolescent mothers. Being heard and feeling connected to providers empowered this group of young, minority adolescents. Participant advice could inform future educational courses, programs, and hospital innovations for perinatal adolescents.

STUDY OBJECTIVE Emergency department (ED)-based naloxone distribution and peer-based behavioral counseling have been shown to be feasible, but little is known about utilization maintenance over time and clinician, patient, and visit level factors influencing implementation. METHODS We conducted a retrospective cohort study of an ED overdose prevention program providing take-home naloxone, behavioral counseling, and treatment linkage for patients treated for an opioid overdose at two Rhode Island EDs from 2017 to 2020: one tertiary referral center and a community hospital. Utilizing a Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, we evaluated program reach, adoption, implementation modifiers, and maintenance using logistic and Poisson regression. RESULTS Seven hundred forty two patients were discharged after an opioid overdose, comprising 966 visits (median: 32 visits per month; interquartile range: 29, 41). At least one intervention was provided at most (86%, 826/966) visits. Take-home naloxone was provided at 69% of visits (637/919). Over half (51%, 495/966) received behavioral counseling and treatment referral (65%, 609/932). Almost all attending physicians provided take-home naloxone (97%, 105/108), behavioral counseling (95%, 103/108), or treatment referral (95%, 103/108) at least once. Most residents and advanced practice practitioners (APPs) provided take home naloxone (78% residents; 72% APPs), behavioral counseling (76% residents; 67% APPs), and treatment referral (80% residents; 81% APPs) at least once. Most clinicians provided these services for over half of the opioid overdose patients they cared for. Patients were twice as likely to receive behavioral counseling when treated by an attending in combination with a resident and/or APP (adjusted odds ratio: 2.29; 95% confidence interval, 1.68, 3.12) compared to an attending alone. There was no depreciation in use over time. CONCLUSIONS ED naloxone distribution, behavioral counseling, and referral to treatment can be successfully integrated into usual emergency care and maintained over time with high reach and adoption. Further work is needed to identify low-cost implementation strategies to improve services use and dissemination across clinical settings.

BACKGROUND: Emergency departments (ED) interface with large numbers of patients that are often missed by conventional HIV testing approaches. ED-based HIV self-testing (HIVST) is an innovative engagement approach which has potential for testing gains among populations that have failed to be reached. This systematic review and meta-analysis evaluated acceptability and uptake of HIVST, as compared to standard provider-delivered testing approaches, among patients seeking care in ED settings. METHODS: Six electronic databases were systematically searched (Dates: January 1990 – May 2021). Reports with data on HIVST acceptability and/or testing uptake in ED settings were included. Two reviewers identified eligible records (kappa=0.84); quality was assessed using formalized criteria. Acceptability and testing uptake metrics were summarized, and pooled estimates were calculated using random-effects models with assessments of heterogeneity. RESULTS: Of 5,773 records identified, seven met inclusion criteria. The cumulative sample was 1,942 subjects, drawn from three randomized control trials (RCTs) and four cross-sectional studies. Four reports assessed HIVST acceptability. Pooled acceptability of self-testing was 92.6% (95% confidence interval [CI]:88.0%−97.1%). Data from two RCTs demonstrated that HIVST significantly increased testing uptake as compared to standard programs (risk ratio [RR]=4.41, 95% CI:1.95–10.10, I(2)=25.8%). Overall, quality of evidence was low (42.9%) or very low (42.9%), with one report of moderate quality (14.2%). CONCLUSIONS: Available data indicate that HIVST may be acceptable and may increases testing among patients seeking emergency care, suggesting that expanding ED-based HIVST programs could enhance HIV diagnosis. However, given the limitations of the reports, additional research is needed to better inform the evidence-base.

Background The American College of Surgeons Committee on Trauma recommends universal alcohol screening be part of the evaluation of admitted trauma patients. Yet, suboptimal screening rates have been reported for admitted adult and adolescent trauma patients. This lack of screening, in turn, has limited the ability of trauma services to provide patients with brief interventions during their hospital admission and subsequent referrals to treatment after discharge. The primary aim of this study was to examine current rates of alcohol and other drug screening with admitted injured adolescents across a national cohort of 10 pediatric trauma centers. Methods This retrospective observational study was nested within a larger adolescent screening, brief intervention, and referral to treatment implementation study (Clinicaltrials.gov NCT03297060). Ten pediatric trauma centers participated in a retrospective chart review of a random sample of adolescent trauma patients presenting for care between March 1, 2018, and November 30, 2018. Results Three hundred charts were abstracted across the 10 participating trauma centers (n = 30 per site). Screening rates varied substantially across centers from five (16.7%) to 28 (93.3%) of the 30 extracted charts. The most frequent screening type documented was blood alcohol concentration (BAC) (N = 80, 35.2% of all screens), followed by the CRAFFT (N = 79, 26.3%), and then the urine drug screen (UDS) (N = 77, 25.6%). The BAC test identified 11 patients as positive for recent alcohol use. The CRAFFT identified 11 positive patients. Conclusions Alcohol and drug screening is underutilized for adolescents admitted to pediatric trauma centers. More research is warranted on how best to utilize the teachable moment of the pediatric trauma visit to ensure comprehensive screening of adolescent alcohol or other drug (AOD) use.

The Cambodian community is the largest Southeast Asian cultural identity in Rhode Island (RI) with high poverty rates and limited healthcare access. Investigators conducted a cross-sectional observational survey study from 2016 to 2017 on eligible Cambodians to better understand their healthcare experiences. Questions were reviewed by the RI Cambodian Society for cultural sensitivity. 123 surveys were collected; 98 respondents had medical providers. Respondents with providers reported difficulty understanding of their providers (59%) and limited access to medical interpreters (50%). The non-provider group were less likely to have medical insurance (54.2% vs. 88.8%, p = .0001) and more likely to visit the emergency department (47.1% vs. 15.3%; p

Objectives Risky alcohol use before surgery is associated with an increased risk of postoperative complications and longer hospital stays. Preoperative alcohol interventions can improve surgical outcomes but are not commonly integrated into routine care. This study sought to better understand patient's and provider's perceptions of alcohol-related surgical health and healthcare practices and illuminate gaps in care and how they could be improved. Methods This study used a descriptive qualitative research design. Data were collected between July 2017 and March 2018. One-on-one interviews assessed domains related to knowledge, gaps in alcohol-related screening and intervention, and interest in enhancing alcohol-related care. Key themes emerged from a process of iterative coding and thematic analysis. Results Participants included elective surgical patients who met alcohol screening criteria (n = 20) and surgical healthcare providers (n = 9). Participants had modest or low awareness of alcohol-related surgical health risks. Basic alcohol screening was a routine part of care, but results were often discounted or overlooked. Providers did not routinely initiate preoperative alcohol education or intervention. Providers viewed improving alcohol-related clinical practices as a low priority. Patients were interested in receiving alcohol interventions before surgery if they were delivered in a nonjudgement style and focused on surgical health optimization. Conclusions This study highlights potential gaps in alcohol-related knowledge and care, and found providers place a low priority on alcohol interventions in the perioperative context. Given the high complication rate associated with preoperative alcohol use, these topics are worthy of future research. To be successful strategies to overcome specific barriers to alcohol screening and intervention must address the needs of patients and providers.

Emergency Department-based HIV self-testing (ED-HIVST) could increase HIV testing services to under-reached key groups. Injury patients presenting to the Kenyatta National Hospital Accident and Emergency Department were enrolled from March-May 2021. Likert item data on HIVST assessing domains of general acceptability, personal acceptability, and acceptability to distribute to social and/or sexual networks were collected. Ordinal regression was performed yielding adjusted odds ratios (aOR) to identify characteristics associated with high HIVST acceptability across domains. Of 600 participants, 88.7% were male, and the median age was 29. Half reported having primary care providers (PCPs) and 86.2% reported prior HIV testing. For each Likert item, an average of 63.5% of participants reported they “Agree Completely” with positive statements about ED-HIVST in general, for themselves, and for others. In adjusted analysis for general acceptability, those

Moderate to vigorous physical activity (MVPA), sports, and reduced screen time are associated with favorable youth risk profiles. We evaluated the association of MVPA, sports, and screen time with adolescent behaviors among pediatric emergency department youth. Adolescents were assessed for alcohol/drug use, risky behavior, conduct disorder, and depressive mood. MVPA was activity for ≥5 days/week and ≥60 minutes/day. Increased screen time was ≥3 hours/day computer/TV use for non-schoolwork. Multivariable regression studied association between MVPA, sports, and increased screen time and outcomes adjusting for demographics and academic achievement. Older age and lower academic achievement were significantly associated with risky behaviors, conduct disorder, and depression. Youth who endorsed MVPA and sports participation had less depression (odds ratio [OR] = 0.76; confidence interval [CI] = 0.66-0.87). Increased screen time was associated with conduct disorder (OR = 1.6; CI = 1.3-2.1), depression (OR = 1.2; CI = 1.0-1.4), and drug use (OR = 1.8; CI = 1.1-2.8). In pediatric emergency department youth, MVPA and sports participation is associated with less depression. Increased screen time is associated with conduct disorders, depression, and drug use.

ObjectivesThe primary objective of this study was to examine opioid prescription frequency and identify differences across a national cohort of pediatric trauma centers in rates of prescribing opioids to injured adolescents at discharge.MethodsThis was a retrospective observational study using electronic health records of injured adolescents (12–17 years) admitted to one of 10 pediatric trauma centers.ResultsOf the 1345 electronic health records abstracted, 720 (53.5%, 95% CI 50.8 to 56.2) patients received opioid prescriptions at discharge with variability across sites (28.6%–72%). There was no association between patient factors and frequency of prescribing opioids. Center’s trauma volume was significantly positively correlated with a higher rate of opioid prescribing at discharge (r=0.92, p=0.001). There was no significant difference between the frequency of opioid prescriptions at discharge among alcohol and other drugs (AOD)-positive patients (53.8%) compared with AOD-negative patients (53.5%).ConclusionsAcross a sample of 10 pediatric trauma centers, just over half of adolescent trauma patients received an opioid prescription at discharge. Prescribing rates were similar for adolescent patients screening positive for AOD use and those screening negative. The only factor associated with a higher frequency of prescribing was trauma center volume. Consensus and dissemination of outpatient pain management best practices for adolescent trauma patients is warranted.Level of evidenceIII—prognostic.Trial registration numberNCT03297060.

Background Falls represent the leading cause of nonfatal unintentional injuries among children in the United States. Although unintentional injury risks have been studied, neighborhood impact on falls remains underexplored. This study examined the association of neighborhood attributes with rates of fall-related injuries. Methods This is a retrospective study of children who presented to emergency departments within a statewide hospital network for fall-related injuries between 2005 and 2014. Patients’ home addresses were geocoded to identify US Census block groups (BGs). Average annual fall rates were computed for each BG. A neighborhood risk index was constructed using 8 socioeconomic BG measures (education, crowding, vacancy, renter occupancy, poverty, family structure, race/ethnicity, and housing age). Public outdoor recreational facilities in each BG were enumerated. Linear regression analysis was used to assess the association of neighborhood risk and recreational facilities with fall rates. Results From 2005 to 2014, there were 139,986 unintentional injury emergency department visits; of these, 42,691 (30%) were for falls. The largest proportion of falls were among males (58%), children ages 1 to 4 years (39%), non-Hispanic whites (59%), and children with public health insurance (53%). Higher quintiles of neighborhood risk were associated with higher annual fall rates compared to the lowest quintile of risk: quintile 2, β = 0.44, 95% confidence interval (CI), 0.20–0.68; quintile 3, β = 0.85, 95% CI, 0.61–1.10; quintile 4, β = 1.11, 95% CI, 0.85–1.37; quintile 5, β = 1.57, 95% CI, 1.29–1.85. The presence of public outdoor recreational facilities was not associated with fall rates (β = 0.01; 95% CI, –0.14 to 0.15). Conclusion Neighborhood-level socioeconomic characteristics are associated with higher fall-related injuries. Injury prevention programs could be tailored to address these neighborhood risks.

Altered composition or function of the human micro- biome, termed dysbiosis, has been associated with a variety of immune-mediated diseases. Antibiotic use is a well-studied cause of dysbiosis. We conducted an electronic survey of 351 antibiotic-prescribing clinicians in Rhode Island to evaluate antibiotic prescription patterns, knowledge and opinions regarding the importance of the human microbiome and its relation to antibiotics and the immune system. We found that clinicians view the health of the human microbiome as important when prescribing antibiotics; however, they do not feel well-informed or confident in their knowledge about the microbiome or its relevance to patient health. A higher level of self- reported knowledge about the microbiome was associated with increased importance placed on the microbiome and its relevance to medical practice. Our results indicate that clinicians may benefit from continuing medical education on the link between antibiotic-induced dysbiosis and immune-mediated disease.

BACKGROUND: Emergency physicians require competence performing critical and routine procedures. The clinical practice of emergency medicine (EM) alone may be insufficient for the acquisition and maintenance of skills. Prior studies suggest the presence of trainees in academic settings and/or the low frequency of procedures increase the risk of skills attrition among faculty. We sought to develop a valid needs assessment survey to inform a faculty procedural skills (FPS) maintenance curriculum. METHODS: A Web‐based FPS survey was designed to assess experiences performing procedures, self‐reported confidence with procedures, and learning preferences for skills maintenance. The survey was administered at a large academic department of EM. Responses were analyzed to determine survey construct validity, faculty attitudes about procedural attrition, and preferred learning methods. RESULTS: Among EM faculty, confidence was significantly higher for common versus uncommon procedures (p

BACKGROUND Alcohol and cannabis use frequently co-occur, which can result in problems from social and academic impairment to dependence (i.e., alcohol use disorder [AUD] and/or cannabis use disorder [CUD]). The Emergency Department (ED) is an excellent site to identify adolescents with alcohol misuse, conduct a brief intervention, and refer to treatment; however, given time constraints, alcohol use may be the only substance assessed due to its common role in unintentional injury. The current study, a secondary data analysis, assessed the relationship between adolescent alcohol and cannabis use by examining the National Institute of Alcohol Abuse and Alcoholism (NIAAA) two question screen's (2QS) ability to predict future CUD at one, two, and three years post-ED visit. Methods: At baseline, data was collected via tablet self-report surveys from medically and behaviorally stable adolescents 12-17 years old (n = 1,689) treated in 16 pediatric EDs for non-life-threatening injury, illness, or mental health condition. Follow-up surveys were completed via telephone or web-based survey. Logistic regression compared CUD diagnosis odds at one, two, or three-year follow-up between levels constituting a single-level change in baseline risk categorization on the NIAAA 2QS (nondrinker versus low-risk, low- versus moderate-risk, moderate- versus high-risk). Receiver operating characteristic curve methods examined the predictive ability of the baseline NIAAA 2QS cut points for CUD at one, two, or three-year follow-up. Results: Adolescents with low alcohol risk had significantly higher rates of CUD versus nondrinkers (OR range: 1.94-2.76, p < .0001). For low and moderate alcohol risk, there was no difference in CUD rates (OR range: 1.00-1.08). CUD rates were higher in adolescents with high alcohol risk versus moderate risk (OR range: 2.39-4.81, p < .05). Conclusions: Even low levels of baseline alcohol use are associated with risk for a later CUD. The NIAAA 2QS is an appropriate assessment measure to gauge risk for future cannabis use.

The pediatric emergency department (PED) represents an opportune time for alcohol and drug screening. The National Institute of Alcohol Abuse and Alcoholism (NIAAA) recommends a two-question alcohol screen for adolescents as a predictor of alcohol and drug misuse.A multi-site PED study was conducted to determine the association between the NIAAA two-question alcohol screen and adolescent cannabis use disorders (CUD), cigarette smoking, and lifetime use of other drugs.Participants included 12-17-year olds (n = 4834) treated in one of 16 participating PEDs. An assessment battery, including the NIAAA two-question screen and other measures of alcohol, tobacco and drug use, was self-administered on a tablet computer.A diagnosis of CUD, lifetime tobacco use or lifetime drug use was predicted by any self-reported alcohol use in the past year, which indicates a classification of moderate risk for middle school ages and low risk for high school ages on the NIAAA two-question screen. Drinking was most strongly predictive of a CUD, somewhat weaker for lifetime tobacco use, and weakest for lifetime drug use. This same pattern held for high school and middle school students and was stronger for high school students over middle school students for all three categories. This association was also found across gender, ethnicity and race. The association was strongest for CUD for high school students, sensitivity 81.7% (95% CI, 77.0, 86.5) and specificity 70.4% (95% CI, 68.6, 72.1). Conclusions/Importance: A single question about past year alcohol use can provide valuable information about other substance use, particularly marijuana.

Introduction Emergency medicine (EM) providers are in an opportunistic position to identify and intervene with patients at risk for alcohol misuse and related problems. However, alcohol screening, brief intervention, and referral to treatment (SBIRT) services are underutilized within the emergency department. Providing SBIRT training to trainees may help to increase utilization of these valuable services in the future. An SBIRT training program for EM faculty and trainees was developed and delivered to increase trainees' skills and practice of SBIRT services. Methods The SBIRT training program included unique tracks for medical students, physician assistant (PA) students, EM residents and faculty preceptors. Faculty and trainees completed performance measures at the end of each training session, 30 days post-training and 12 months later. Results SBIRT training was provided to 238 trainees and 65 faculty members. At all follow-up time points, satisfaction of training and usefulness varied by trainee type with PA students rating constructs higher than both medical students and EM residents. At the 12-month follow-up survey, there was no significant difference in ratings of sharing the information (χ2 (2)=0.38, P=0.33) between these trainees, with the majority of all trainees (96% of PA students, 83% of residents and 68% of medical students) responding that they had applied what they learned in the training to their work. Conclusion An SBIRT training curriculum for EM trainees was delivered successfully and utilized 12 months after implementation.

Objective:Unintentional injury is the leading cause of death for infants and young children in the USA, and the children of young mothers are at an even higher risk. Mobile health (mHealth) interventions have been successful in promoting behaviour change for many health conditions. This study assessed interest in mSafety, a text and video messaging mHealth intervention targeting injury prevention knowledge, behaviour and self-efficacy in young mothers.Design:Interviews with young mothers were conducted using a semi-structured interview guide.Setting:Interviews took place at a health clinic for teenage mothers and their children and at a local public charter high school which serves pregnant teenagers and young mothers.Method:A trained research assistant conducted semi-structured interviews with 20 young mothers (ages 15–20). Participants were asked both closed and open-ended questions to elicit opinions about their willingness to utilise mSafety.Results:The results of the interviews were positive. Participants were most interested in learning about the prevention of falls and poisonings, as well as safe sleep. Many emphasised that the language of the messages should be simple and that videos could be included to demonstrate methods of injury prevention. Most interviewees were willing to participate in a ‘virtual home safety visit’ in which participants text home photos to an expert to evaluate home safety practices.Conclusion:The concept of an mHealth intervention that would provide young mothers with the tools to prevent injuries among their children received positive feedback.

Background Opioid medication to treat acutely injured patients is usual care in trauma settings. A higher prevalence of alcohol and other substance misuse in this population compared to the general population increases the vulnerability of such patients to both misuse of their prescribed opioids, and also unintentional opioid overdose. The primary purpose of this study was to assess the prevalence of substance use and unintentional opioid overdose risk among acutely injured trauma patients, and to examine the frequency and predictors of high opioid dose at discharge. Methods A retrospective electronic medical record (EMR) review of three-months of data from two Level 1 trauma centers. We assessed the prevalence of substance misuse, unintentional opioid overdose risk, and presence of documentation of clinical strategies to mitigate these risks, such as co-prescription of the opioid agonist naloxone. Results In total, 352 patient EMRs were examined. Over 40% of the patients reviewed had at least one indication of substance misuse (42.5% [95%CI: 37.3, 47.7]); at least 1 unintentional opioid overdose risk factor was identified in 240 EMR reviewed (68.2% [95%CI: 63.3, 73.1]). Dose of opioid medication was not significantly different for patients with substance misuse versus those without. There was no co-prescription of naloxone for any of the discharged patients. Conclusions Our results indicate that despite the high rates of substance misuse, the potential for misuse, dependence and unintentional overdose risk from prescribed opioid medications are prevalent among acutely injured trauma patients. Prescribing after acute trauma care should address these risk factors.

Childhood head injury has been associated with the development of behavioural and psychological problems. This study examined the relationship between head injury in young childhood and subsequent criminal behaviour.Data were from the Providence cohort of the Collaborative Perinatal Project, a multicentre longitudinal study aimed at identifying the role of perinatal and prenatal factors on child health. History of head injury between ages 0 and 7 years was ascertained from health records of 2893 children. In total, 120 (4%) of children had a head injury. Propensity score matching was used to match each head injury case to five controls. Negative binomial regression was used to estimate the relationship between head injury and number of arrests, and log binomial regression was used to estimate risk of conduct problems.Those who suffered any head injury from ages 0 to 7 years had approximately 1.5 times the rate of arrests and risk of conduct problems compared with uninjured controls, though results did not meet the p0.05 threshold for statistical significance. Severe head injury was associated with a twofold increased rate of juvenile arrests (incident rate ratio=2.44, 95% CI 0.93 to 6.46) and risk of conduct problems (risk ratio=2.47, 95% CI 0.90 to 6.74) that approached statistical significance.Head injury in childhood was associated with increased criminality and conduct problems. Future work should identify mechanisms of this association in order to develop interventions to prevent criminal behaviour resulting from head injury.

Objectives Frequent use of the emergency department (ED) is often targeted as a quality improvement metric. The objective of this study was to assess ED visit frequency by the demographic and health characteristics of children who visit the ED to better understand risk factors for high ED utilization. Methods The majority of pediatric ED services in Rhode Island are provided by a hospital network that includes the state's only children's hospital. Using 10 years of data (2005-2014) from this statewide hospital network, we examined ED use in this network for all children aged 0 to 17 years. Patients' home addresses were geocoded to assess their neighborhood characteristics. Results Between 2005 and 2014, 17,844 children visited 1 or more of the network EDs at least once. In their year of maximum use, 67.8% had only 1 ED visit, 20.1% had 2 visits, 6.9% had 3 visits, and 5.2% had 4 or more visits. In the adjusted multinomial logistic regression model, age, race/ethnicity, language, insurance coverage, medical complexity, neighborhood risk, and distance to the ED were found to be significantly associated with increased visit frequency. Conclusions Risk factors for frequent ED use by children include age, race/ethnicity, language, insurance coverage, medical complexity, neighborhood risk, and distance to the hospital. To decrease frequent pediatric ED use, improved medical management of complex medical problems is needed, but it is also essential to address modifiable social determinants of health care utilization in this population.

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based method to identify, reduce, and prevent the harmful use of alcohol and illicit substances. However, SBIRT remains underused by physicians and other healthcare providers. Integrating interprofessional SBIRT training in medical curricula may better prepare future providers to care for patients with substance use disorders.The authors report the development and outcomes of a longitudinal, interprofessional SBIRT curriculum organized in partnership with health professions' schools in nursing, pharmacy, and social work. Primary results: From October 2015 to April 2017, 1,327 students were trained in SBIRT, resulting in the screening of 4,520 individuals and interventions in 897 individuals. 553 (42%) trainees were medical students, providing 3,330 (74%) screenings and 412 (46%) interventions.These initial data demonstrate the feasibility of including SBIRT in undergraduate medical curricula. Broadly implemented, SBIRT training offers potential to normalize its practice as part of standard, evidenced-based patient care.

Introduction Emergency medicine (EM) providers are in an opportunistic position to identify and intervene with patients at risk for alcohol misuse and related problems. However, alcohol screening, brief intervention, and referral to treatment (SBIRT) services are underutilized within the emergency department. Providing SBIRT training to trainees may help to increase utilization of these valuable services in the future. An SBIRT training program for EM faculty and trainees was developed and delivered to increase trainees’ skills and practice of SBIRT services. Methods The SBIRT training program included unique tracks for medical students, physician assistant (PA) students, EM residents and faculty preceptors. Faculty and trainees completed performance measures at the end of each training session, 30 days post-training and 12 months later. Results SBIRT training was provided to 238 trainees and 65 faculty members. At all follow-up time points, satisfaction of training and usefulness varied by trainee type with PA students rating constructs higher than both medical students and EM residents. At the 12-month follow-up survey, there was no significant difference in ratings of sharing the information (χ2 (2)=0.38, P=0.33) between these trainees, with the majority of all trainees (96% of PA students, 83% of residents and 68% of medical students) responding that they had applied what they learned in the training to their work. Conclusion An SBIRT training curriculum for EM trainees was delivered successfully and utilized 12 months after implementation.

Study Objective or Background: To assess Rhode Island (RI) physician knowledge, attitudes, and confidence to succeed in Accountable Care Organizations (ACOs). Study Design and Methods: We surveyed RI physicians' attitudes and beliefs about ACOs, including scales measuring Physician Knowledge (7 Multiple Choice and True/False items), Attitudes (8 Likert scale items), and Confidence (7 Likert Scale Items), and examined how physician characteristics related to these measures. Primary Results: The response rate was 6 percent (72/1183). Means (100-point scale) and standard deviations were calculated for Knowledge 65.3 (22), Attitudes for ACO participants 56.3 (13.2) and ACO non-participants 42.7 (14.3), and Confidence 32.4 (25.9). Primary care physicians had higher Attitudes compared with specialists among ACO participants (60.2 vs. 51.8, p=.047) and ACO non-participants (48.2 vs. 34.4, p=.030). Principal Conclusions: RI Physicians have low scores in Knowledge, Attitudes, and Confidence scales in ACOs. Primary care physicians have more positive Attitudes about ACOs than specialists. This study is limited by its low response rate. [Full article available at http://rimed.org/rimedicaljournal-2019-03.asp].

Background and aims Coeliac disease (CD) is widely prevalent in North America, but case-finding techniques currently used may not be adequate for patient identification. We aimed to determine the adequacy of CD screening in an academic gastroenterology (GI) practice. Methods Consecutive initial visits to a tertiary academic GI practice were surveyed over a 3-month period as a fellow-initiated quality improvement project. All electronic records were reviewed to look for indications for CD screening according to published guidelines. The timing of screening was noted (before or after referral), as well as the screening method (serology or biopsy). Data were analysed to compare CD screening practices across subspecialty clinics. Results 616 consecutive patients (49±0.6 years, range 16–87 years, 58.5% females, 94% Caucasian) fulfilled inclusion criteria. CD testing was indicated in 336 (54.5%), but performed in only 145 (43.2%). The need for CD screening was highest in luminal GI and inflammatory bowel disease clinics, followed by biliary and hepatology clinics (p Conclusions More than 50% of patients in a tertiary GI clinic have indications for CD screening, but

© 2016 Taylor & Francis Group, LLC. Background: Addressing violence along with drug use change goals is critical for women with coexisting intimate partner violence (IPV) and substance use disorders (SUDs). Methods: This was an acceptability and feasibility study of BSAFER, a brief Web-based program and booster phone call addressing violence and drug use. A screening survey identified women with recent drug use and IPV in the emergency department (ED). Participants were randomized to BSAFER or a Web-based control program and booster call providing education about home fire safety. Program completion, usability, satisfaction, and motivational interviewing (MI) adherence were primary outcomes. Drug use and IPV outcomes were measured at baseline, 1 month, and 3 months. Results: Forty women were enrolled (21 BSAFER, 19 control); 50% were nonwhite and mean age was 30 years. The most commonly used drugs were marijuana (88%) and cocaine (30%); 45% reported physical abuse, and 33% reported severe combined physical and sexual abuse. Thirty-nine (98%) completed the Web program, 30 (75%) completed the booster, and 29 (73%) completed the 3-month follow-up. Mean System Usability Scale (SUS) for the BSAFER Web program was 84 (95% confidence interval [CI]: 78–89) of 100; mean Client Satisfaction Questionnaire (CSQ-8) was 28 (95% CI: 26–29) of 32. MI adherence scores were high and similar for both the Web program and the booster. Both intervention and control groups had small mean decreases in weekly drug use days (0.7 vs. 1.5 days); participants using drugs other than marijuana demonstrated greater average reductions in drug use than those using marijuana only. Conclusions: An ED Web-based intervention for SUDs and IPV in women demonstrated feasibility and acceptability. Future studies will examine efficacy of the BSAFER program and investigate whether specific subgroups of drug using women may be most responsive to ED-based Web interventions.

Previous studies show that elements of spirituality, including prayer and religious services, may contribute to reductions in harmful alcohol use. The objective of this study was to assess the acceptability of prayer as a component of emergency department (ED) interventions for risky alcohol use. A 12-question multiple-choice questionnaire was developed, piloted, and refined by the study team. The questionnaire included questions about current beliefs and attitudes toward prayer and assessed interest in various means of delivering prayer or prayer support for reducing alcohol use. The questionnaire was administered to a consecutive sample of 111 patients recruited from the 12-month follow-up of a parent RCT study on reducing alcohol use among injured ED patients (ReDIAL). To qualify for the parent study, participants needed an ASSIST v3.0 alcohol score ≥ 11. 90 participants (81%) consented to answer questions about prayer. The participating sample was 38% female and 29% nonwhite; mean age was 36 years. Of these participants, 64% reported that they currently pray; of those, 88% reported praying daily or weekly; 79% agreed that prayer helps with coping in difficult times; 68% agreed that prayer could assist in achieving difficult goals; and 48% agreed that prayer helps reduce alcohol use. Interest in various means of utilizing prayer to reduce alcohol use was assessed in all participants (regardless of whether they currently prayed or not): 45% were interested in having others pray for them to reduce alcohol use; 40% were interested in receiving text reminders to pray; 42% were interested in receiving text messages with specific prayers to use; and 47% were interested in receiving text messages that someone was praying for them. 33.3% of the entire sample stated that they would attend services if provided information on spiritual or religious groups in the community. The incorporation of prayer in alcohol interventions was considered acceptable by a proportion of our sample of risky alcohol users, even those who do not currently use prayer as a resource in their lives. Given the promising data on ED patients’ perceptions of the significance and acceptability of spiritual practices in reducing alcohol use, prayer may emerge as a useful adjunctive tool in future ED interventions for alcohol use disorders.

The aims of this study were to evaluate the effects on opioid medication prescribing, patient opioid safety education, and prescribing of naloxone following implementation of a Safer Opioid Prescribing Protocol (SOPP) as part of the electronic health record (EHR) system at a Level I trauma center. This was a prospective observational study of the EHR of trauma patients pre- (n = 191) and post-(n = 316) SOPP implementation between 2014 and 2016. At a comparison Level I trauma site not implementing SOPP, EHRs for the same time period were assessed for any historical trends in opioid and naloxone prescribing. After SOPP implementation, the implementation site increased the use of nonnarcotic pain medication, decreased dispensing high opioid dose (≥100 MME [milligram morphine equivalent]), significantly increased the delivery of opioid safety education to patients, and initiated prescribing naloxone. These changes were not found in the comparison site. Opioid prescribing for acute pain can be effectively reduced in a busy trauma setting with a guideline intervention incorporated into an EHR. Guidelines can increase the use of nonnarcotic medications for the treatment of acute pain and increase naloxone coprescription for patients with a higher risk of overdose.

BACKGROUND: The National Institute on Alcohol Abuse and Alcoholism (NIAAA) 2-question screen is a valid adolescent alcohol screening tool. No studies have examined if this tool predicts future alcohol problems. We conducted a study at 16 pediatric emergency departments to determine the tool’s predictive validity for alcohol misuse and alcohol use disorders (AUDs). METHODS: Participants (N = 4834) completed a baseline assessment battery. A subsample of participants completed the battery at 1, 2, and 3 years follow up. RESULTS: Of the 2209 participants assigned to follow-up, 1611 (73%) completed a 1-year follow-up, 1591 (72%) completed a 2-year follow-up, and 1377 (62%) completed a 3-year follow-up. The differences in AUDs between baseline NIAAA screen nondrinkers and lower-risk drinkers were statistically significant at 1 year (P = .0002), 2 years (P CONCLUSIONS: The NIAAA 2-question screen can accurately characterize adolescent risk for future AUDs. Future studies are needed to determine optimaluse of the screen.

Background: Identifying problem drinkers and providing brief intervention (BI) for those who screen positive are required within all level I trauma centers. While parent–adolescent relationships impact adolescent alcohol use, parenting skills are rarely included in adolescent alcohol BIs within pediatric trauma centers. Introduction: The primary objective of this study was to examine the feasibility and acceptability of an electronic parenting skills intervention for parents of injured adolescents who report alcohol or drug use. Materials and Methods: Across three pediatric level I trauma centers, admitted trauma patients 12–17 years of age, screening positive for alcohol or drug use, were consented along with one parent. Adolescent–parent dyads were enrolled and assigned to the intervention (Parenting Wisely web-based modules coupled with text messaging) or standard care conditions using a 2:1 allocation ratio. Teens completed 3- and 6-month follow-up surveys; parents completed 3-month follow-up surveys. Results: Thirty-seven dyads were enrolled into the study. Only one-third of parents accessed the web-based Parenting Wisely after baseline. All parents completed the text message program. At 3-month follow-up, 78% of parents endorsed that they would recommend the program to others. There were no significant differences in adolescent substance use or parenting behaviors between groups at follow-up. Discussion: A texting component is well received, but web-based components may be underutilized. Larger studies are necessary to determine if an electronic skills intervention has an effect on parenting skills and adolescent substance use. Conclusions: This study demonstrated accessibility and feasibility of an e-parenting intervention with more utilization of text components than web-based.

Adolescents/young adults, and especially men, are high-risk key populations that have been systematically missed by HIV services in low and middle-income countries (LMICs). Because these groups are also more likely to suffer injuries in LMICs, there are significant opportunities to engage these hard-to-reach persons via integrated HIV-injury programming provided during commonly sought acute/emergency care treatments of injuries. However, current facilities based HIV testing and treatment programs have failed to adequately capture these high-risk individuals. As such, research to address the knowledge gaps in HIV care delivery among the injured is needed and has great potential to inform interventions that would identify and treat adolescents/young adults, many of whom have the greatest individual and societal margins for long-term benefits with HIV care globally.

Background U.S. opioid overdose deaths have increased five-fold since 1999. In 2014, two Rhode Island emergency departments (EDs) began providing take-home naloxone and peer recovery coach consultation to patients identified at risk of opioid overdose. Similar programs have been initiated throughout the country, but patient outcomes of ED naloxone distribution and recovery coach consultation have yet to be evaluated. Methods This is an observational, retrospective cohort study of ED patients discharged after a non-fatal opioid overdose in the six months after implementation of an ED naloxone distribution and recovery coach consultation program, September 2014 to February 2015. By provider and patient discretion, patients received either: usual care, take-home naloxone, or a recovery coach with take-home naloxone. Primary outcomes one year from index ED visit were initiation of medication for opioid use disorder (OUD), repeat ED visit for opioid overdose, and all-cause mortality. Results 151 adults met study inclusion criteria. Sixty (39.7%) received usual care, 26 (17.2%) received take-home naloxone alone, and 72 (47.7%) received take-home naloxone and a peer recovery coach. Less than a third (28.5% 48/151) initiated medication for OUD. Median time to new initiation of medication for OUD was shorter among those who got a recovery coach (81.5 days vs 139 days usual care). Thirty (19.9%) were treated in the ED for a repeat opioid overdose. Seven (4.6%) died within one year of initial ED visit. A smaller proportion of deaths occurred among those receiving services. Conclusion Preliminary patient outcomes demonstrate a high frequency of death and repeat overdose one-year following an ED visit for opioid overdose. A minority initiate medication for OUD. Among those who got a recovery coach and naloxone, median.

OBJECTIVE: Problem behaviors such as substance use and peer aggression frequently co-exist, and are common among youth seen in emergency departments (EDs). EDs are increasingly urged to screen for both psychological distress and problem behaviors. To inform screening and intervention efforts, we aimed to identify classes of problematic substance use and peer aggression in a sample of adolescents from 16 pediatric EDs, and to examine the relative prevalence of psychological distress in identified classes. METHODS: We completed a cross-sectional survey of youth (n = 5001) presenting for any reason to 16 pediatric EDs across the United States, using validated measures of demographics, alcohol and substance use, and peer aggression. We used standard latent class analysis (LCA) techniques to create behavioral risk classes of adolescents, based on violence and substance use variables; then conducted logistic regression to examine the relationship between psychological distress and latent classes. RESULTS: Three classes of problem behaviors were identified: low-risk (few problem behaviors, 91.2% of sample), medium risk (high cigarette smoking; moderate violence, alcohol, substance use, 5.2%), and high risk (high levels of all problem behaviors, 3.5%). A significant directional association (p < .001) between worse psychological distress and higher risk behavior classes was noted, even after adjusting for demographics. CONCLUSIONS: Youth seen in the ED for any reason, who report higher levels of past-year substance use and peer aggression, are significantly more likely to report negative mood symptoms. Targeted screening and interventions for this population may be indicated.

OBJECTIVE Rising rates of opioid overdose deaths require innovative programs to prevent and reduce opioid-related morbidity and mortality. This study evaluates adoption, utilization, and maintenance of an emergency department (ED) take-home naloxone and peer recovery coach consultation program for ED patients at risk of opioid overdose. METHODS Using a Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework, we conducted a retrospective provider survey and electronic medical record (EMR) review to evaluate implementation of a naloxone distribution and peer recovery coach consultation program at two EDs. Provider adoption was measured by self-report using a novel survey instrument. EMRs of discharged ED patients at risk for opioid overdose were reviewed in three time periods: preimplementation, postimplementation, and maintenance. Primary study outcomes were take-home naloxone provision and recovery coach consultation. Secondary study outcome was referral to treatment. Chi-square analysis was used for study period comparisons. Logistic regression was conducted to examine utilization moderators. Poisson regression modeled utilization changes over time. RESULTS Most providers reported utilization (72.8%, 83/114): 95.2% (79/83) provided take-home naloxone and 85.5% (71/83) consulted a recovery coach. There were 555 unique patients treated and discharged during the study periods: 131 preimplementation, 376 postimplementation, and 48 maintenance. Postimplementation provision of take-home naloxone increased from none to more than one-third (35.4%, p

Study objective We conduct a randomized controlled trial to test efficacy of a telephone intervention for injured emergency department (ED) patients with alcohol misuse to decrease alcohol use, impaired driving, alcohol-related injuries, and alcohol-related negative consequences. Methods ED patients screening positive for alcohol misuse were randomized to a 3-session telephone brief motivational intervention on alcohol, delivered by a counselor trained in motivational interviewing during 6 weeks, or a control intervention of a scripted home fire and burn safety education delivered in 3 calls. Patients were followed for 12 months and assessed for changes in alcohol use, impaired driving, alcohol-related injuries, and alcohol-related negative consequences. Results Seven hundred thirty ED patients were randomized; 78% received their assigned intervention by telephone, and of those, 72% completed 12-month assessments. There were no differential benefits of telephone brief motivational intervention versus assessment and a control intervention in all 3 variables of alcohol use (frequency of binge alcohol use during the previous 30 days, maximum number of drinks at one time in the past 30 days, and typical alcohol use in the past 30 days), alcohol-impaired driving, alcohol-related injuries, and alcohol-related negative consequences. Conclusion Despite the potential advantage of delivering a telephone brief motivational intervention in not disrupting ED clinical care, our study found no efficacy for it over an assessment and control intervention. Potential causes for our finding include that injury itself, alcohol assessments, or the control intervention had active ingredients for alcohol change.

This retrospective cohort study provides a descriptive analysis of a population that frequently uses an urban emergency medical service (EMS) and identifies factors that contribute to use among all frequent users. For purposes of this study we divided frequent users into the following groups: low- frequent users (4 EMS transports in 2012), medium-frequent users (5 to 6 EMS transports in 2012), high-frequent users (7 to 10 EMS transports in 2012) and super-frequent users (11 or more EMS transports in 2012). Overall, we identified 539 individuals as frequent users. For all groups of EMS frequent users (i.e. low, medium, high and super) one or more hospital admissions, receiving a referral for follow-up care upon discharge, and having no insurance were found to be statistically significant with frequent EMS use (P

Objective: Addressing violence and linking women to community services in parallel with drug change goals is critical for women with coexisting intimate partner violence (IPV) and substance use disorders (SUD). Our objective was to develop a Web-based intervention to address violence and drug use among women patients in the emergency department (ED). Methods: The intervention was developed in a 5-step process: (1) Initial intervention development based on selected theoretical frameworks; (2) In-depth interviews with the target population; (3) Intervention adaptation, with iterative feedback from further interviews; (4) Beta testing and review by an advisory committee of domestic violence advocates; (5) Acceptability and feasibility testing in a small open trial. Results: Themes supported the selection of motivational interviewing (MI) and empowerment models but also guided major adaptations to the intervention, including the introduction of videos and a more robust booster phone call. Participants in the open trial reported high scores for satisfaction, usability, and consistency with essential elements of MI. Conclusions: This qualitative work with our target population of women in the ED with SUD experiencing IPV underscored the importance of connection to peers and empathetic human contact. We developed an acceptable and feasible intervention distinct from prior ED-based brief interventions for substance-using populations.