Improving the Safety of the Manchester Triage System for Children with Congenital Heart Disease

This study is a prospective evaluation of the validity of a Manchester Triage System (MTS) modification for detecting under-triaged pediatric patients with congenital heart disease (CHD). Children with CHD visiting the emergency unit of the Department of Pediatrics and Adolescent Medicine, Vienna General Hospital, in 2014 were included. The MTS modification updated the prioritization of patients with complex syndromic diseases, specific symptoms related to chronic diseases, decreased general condition (DGC), profound language impairment, unknown medical history, or special needs. A four-level outcome severity index based on diagnostic and therapeutic interventions, admission to hospital, and follow-up strategies, was defined as a reference standard for the correct clinical classification of the MTS urgency level. Of the 19,264 included children, 940 had CHD. Of this group, 266 fulfilled the inclusion criteria for the modified triage method. The MTS modification was significantly more often applied in under-triaged (65.9%) than correctly or over-triaged (25%) children with CHD (p-value χ²test <0.0001, OR 5.848 95% CI: 3.636-9.6).Conclusion: The MTS urgency level upgrade modification could reduce under-triage in children with CHD. Applying a safety strategy concept to the MTS could mitigate under-triage in such a high-risk patient group.

146 Provision of Adolescent Confidential Care in a Tertiary Care Setting

Primary Subject area Adolescent Medicine Background Adolescents are more likely to seek care and disclose sensitive health information if confidentiality is assured. Several national societies endorse the need for confidential care at all health-related encounters with adolescents. Many adolescents have infrequent contact with the medical system other than unscheduled urgent care in pediatric hospitals. Little is known regarding the effectiveness and feasibility of providing confidential care to adolescents in a tertiary pediatric hospital setting. Objectives We sought to evaluate the frequency, quality and factors associated with the provision of confidential care to adolescent patients at a pediatric teaching hospital. Design/Methods We undertook a cross-sectional survey of adolescents presenting to an urban tertiary pediatric hospital from December 2019 to December 2020. Adolescents eligible for confidential care under Quebec legislation (aged 14-18) were recruited from a convenience sample either when presenting to the Emergency Department (ED) for low acuity visits (CTAS 3-5) or when hospitalized on the pediatric inpatient medical ward. Participants completed a standardized, self-administered electronic questionnaire regarding the confidential care provided at their initial ED or inpatient medical encounter. Multivariable logistic regression was used to identify factors associated with the provision of confidential care. Results A total of 406 adolescents completed the survey (335 ED; 71 inpatient). The majority of respondents identified as female (233, 57.4%), white/Caucasian (260, 64.0%) and presented to the hospital with a parent (367, 90.4%). Overall, confidential care was offered to 137 (33.7%) respondents, with 95 (69.3%) accepting confidential time alone with their doctor. Among participants receiving confidential care, 43.2% endorsed that the limits of confidentiality were not reviewed, 24.2% reported that their private issues were still discussed in front of family members and 15.8% had private information that they had wished to discuss but were not asked. When offered, there was no difference between hospitalized and ED patients declining confidential care (32/100 vs. 10/37; p=0.73). The most common reasons identified for declining private time were that it was deemed unnecessary (29/42, 69.0%), perceived risk of parental conflict (8/42, 19.0%), or concerns for violation of trust by the medical team (5/42, 11.9%). Multivariable analysis found inpatient location (aOR 2.28, 1.04-5.01), female gender (aOR 2.02, 1.21-3.38), age (aOR 1.67, 1.03-2.69), psychiatric diagnosis (aOR 8.10, 1.47-44.6), resident involvement (aOR 1.96, 1.09-3.53) and overnight assessment (aOR 0.23, 0.06-0.90) were all associated with the provision of confidential care, after adjusting for patient- and hospital-level covariates. Conclusion Survey results suggest inadequate provision of confidential care in an academic pediatric hospital. Adolescents receiving confidential care were not consistently explained to regarding the limits of confidentiality, and breaches were reported in a quarter of all cases. Confidentiality-specific education initiatives are necessary to improve the frequency and quality of confidential care for adolescents in tertiary care settings.

104 New Presentations of Anorexia Nervosa and Atypical Anorexia Nervosa In Adolescents During the COVID-19 Pandemic

Primary Subject area Adolescent Medicine Background The coronavirus (COVID-19) pandemic has had profound effects on adolescent mental health. Beginning in mid-March 2020, public health measures were implemented throughout the province of Quebec, including full school closure and confinement. Previous studies have demonstrated the association between stressful events and the exacerbation of anorexia nervosa (AN), however the association of the COVID-19 pandemic on new AN diagnoses remains unknown. Objectives To assess the incidence and severity of newly diagnosed AN or atypical AN (AAN) cases among adolescents during the COVID-19 pandemic compared to the five preceding years. Design/Methods We performed a retrospective analysis from Jan 1 2015 to Nov 15 2020 of new eating disorder assessments at an urban tertiary pediatric hospital. Baseline demographic information and clinical assessment variables were collected. The primary outcomes were the incidence of de novo AN or AAN diagnoses and hospitalization within 7 days of diagnosis. Event rate time trends were compared during the period of pandemic public health measures (March 2020 to November 2020) to the proceeding 5-years (January 2015 to February 2020) using an interrupted time series and logistic mixed modeling. Results Overall, 353 patients met inclusion criteria during the study period. Median patient age was 15.9 (IQR 13.8-16.9) years, 93% were female, and 65% of patients were diagnosed with atypical AN. For the full cohort at diagnosis, %mBMI was 92% (SD ±15%) and mean weight loss was 11 Kg (SD ±7Kg). In the 5 years preceding the pandemic, there were 4.5 new AN/AAN cases per month with a modest downward trend (ßcoeff=-0.016). During confinement, new diagnoses rose to 8.0/month with a steep upward trend (ßcoeff=1.417, p &lt; 0 .001). Similarly, hospitalizations for new cases increased from 0.8 to 2.6/month with a significant increase in linear tend (ßcoeff -0.012 vs. 0.500, p &lt; 0 .001). Moreover, patients diagnosed during COVID-19 confinement had a shorter duration of symptoms (6 months vs. 10 months, p=0.001), with a higher percentage of body weight loss (19% vs. 16%, p=0.03) at a faster rate (2.3kg/mo vs. 1.5Kg/mo, p=0.001). Bradycardia was more pronounced at diagnosis during the pandemic (55 bpm vs. 62 bpm, p=0.001) with a greater proportion meeting threshold for admission (38% vs. 19%, p=0.001). Conclusion During the COVID-19 confinement, new diagnoses of AN and AAN nearly doubled and hospitalizations for these patients more than tripled. Markers for disease severity were more pronounced and evolved more rapidly. Findings highlight the urgent need for increased community resources during the pandemic, as well as prospective research to understand drivers and prognosis for these patients more effectively.

Acceptability, feasibility, and quality of telehealth for adolescent healthcare delivery during the COVID-19 pandemic: A cross-sectional study of patient and family experiences (Preprint)

BACKGROUND Telehealth acceptability, feasibility, and quality data are lacking among adolescents and young adults (AYA) and their parents and caregivers (caregivers). OBJECTIVE To assess non-inferiority of telehealth vs in-person visits, comparing acceptability with respect to efficiency, effectiveness, equity, patient-centeredness, and confidentiality. METHODS Cross-sectional web-based survey sent to caregivers and AYA following video visits within an adolescent medicine subspecialty clinic, May-July, 2020. Proportions of AYA and caregivers who rated telehealth as non-inferior were compared using chi-square tests. Feasibility was assessed via items measuring technical difficulties. Deductive thematic analysis, using the Institute of Medicine (IOM) dimensions of healthcare quality, was used to code open-ended question responses. RESULTS Survey response rates were 20.5% (n=55) for AYA and 21.8% (n=123) for caregivers. The majority of respondents were White, cisgender females. Most AYA and caregivers rated telehealth as noninferior to in-person visits with respect to confidentiality, communication, medication management, and mental health care. A higher proportion of AYA, compared to caregivers, found telehealth inferior with respect to confidentiality (22% vs 3%, p<0.01). One quarter of patients and 32% of caregivers reported technical difficulties. Dominant themes in qualitative data included advantages of telehealth for efficiency and equity of healthcare delivery. However, respondents’ concerns included reduced safety and effectiveness of care, particularly for patients with eating disorder, due to lack of hands-on exams, collection of vital signs, and laboratory testing. CONCLUSIONS Telehealth was highly acceptable among AYA and caregivers. Future optimization should include improving privacy, ameliorating technical difficulties, and standardizing at-home methods of obtaining patient data to assure patient safety.

Optimizing e-Consultations to Adolescent Medicine Specialists: Qualitative Synthesis of Feedback From User-Centered Design

Background e-Consultations between primary care physicians and specialists are a valuable means of improving access to specialty care. Adolescents and young adults (AYAs) face unique challenges in accessing limited adolescent medicine specialty care resources, which contributes to delayed or forgone care. e-Consultations between general pediatricians and adolescent medicine specialists may alleviate these barriers to care. However, the optimal application of this model in adolescent medicine requires careful attention to the nuances of AYA care. Objective This study aims to qualitatively analyze feedback obtained during the iterative development of an e-consultation system for communication between general pediatricians and adolescent medicine specialists tailored to the specific health care needs of AYAs. Methods We conducted an iterative user-centered design and evaluation process in two phases. In the first phase, we created a static e-consultation prototype and storyboards and evaluated them with target users (general pediatricians and adolescent medicine specialists). In the second phase, we incorporated feedback to develop a functional prototype within the electronic health record and again evaluated this with general pediatricians and adolescent medicine specialists. In each phase, general pediatricians and adolescent medicine specialists provided think-aloud feedback during the use of the prototypes and semistructured exit interviews, which was qualitatively analyzed to identify perspectives related to the usefulness and usability of the e-consultation system. Results Both general pediatricians (n=12) and adolescent medicine specialists (n=12) perceived the usefulness of e-consultations for AYA patients, with more varied perceptions of potential usefulness for generalist and adolescent medicine clinicians. General pediatricians and adolescent medicine specialists discussed ways to maximize the usability of e-consultations for AYAs, primarily by improving efficiency (eg, reducing documentation, emphasizing critical information, using autopopulated data fields, and balancing specificity and efficiency through text prompts) and reducing the potential for errors (eg, prompting a review of autopopulated data fields, requiring physician contact information, and prompting explicit discussion of patient communication and confidentiality expectations). Through iterative design, patient history documentation was streamlined, whereas documentation of communication and confidentiality expectations were enhanced. Conclusions Through an iterative user-centered design process, we identified user perspectives to guide the refinement of an e-consultation system based on general pediatrician and adolescent medicine specialist feedback on usefulness and usability related to the care of AYAs. Qualitative analysis of this feedback revealed both opportunities and risks related to confidentiality, communication, and the use of tailored documentation prompts that should be considered in the development and use of e-consultations with AYAs.

Adolescent Patient Text Messaging Through Peer Networks to Increase Youth Access Healthcare and STI Testing (Preprint)

UNSTRUCTURED Adolescents are disproportionately affected by sexually transmitted infections (STI), including HIV. Many youth with asymptomatic STI or related symptoms do not seek treatment and may not be screened if accessing the healthcare system for other reasons. We examined the feasibility and acceptability of a peer-driven, text messaging strategy to connect youth to STI and HIV services. Using an interrupted time series design consecutive patients at an adolescent medicine clinic were enlisted to send five text messages to peers they believed were sexually active and lived in the clinic's service area. Analyses conducted in 2015 used a generalized linear mixed model. Data were collected from 2013-2014. Of 153 patients approached to participate, 100 agreed to send text messages. Most (55%) reported no concerns with sending the text message. No adverse events or negative outcomes were reported. Adolescent STI testing, positive test results and reported risk behavior increased post intervention, although not statistically significant, likely because of the small sample size. Given low youth uptake of healthcare services and STI/HIV screening, in particular, new strategies are needed to address access barriers. Common approaches for reaching youth are resource-intensive and often miss youth not connected to school or community programs. The peer-based, text messaging strategy showed promise for both increasing the number of youth accessing health services and finding youth engaging in sexual risk behaviors and most in need of sexual health screening and services.

P–647 How do migraine attacks change during puberty?

Study question How do the stage of puberty and the menstrual cycle influence characteristics of migraine? Summary answer During puberty, the frequency of migraine attacks increases, especially during the follicular phase. The pattern of migraine changes to a typical adult pattern of migraine. What is known already Up to puberty, headaches are as common in girls as in boys. After the onset of puberty migraine is more prevalent in adolescent girls suggesting an association with sex hormones. Attacks of menstrual migraine are characterized by a longer duration, tend to be more severe, and are less responsive to acute medication compared to migraine attacks which are independent from the menstrual cycle phase. Study design, size, duration For this prospective cohort study 47 girls were recruited from two Departments of Pediatrics and Adolescent Medicine between 01/2016 and 12/2018. Participants/materials, setting, methods Girls between 7 and 18 years old, diagnosed with migraine without aura according to the “International Classification of Headache Disorders II” diagnostic criteria, took part. Three groups (pre-, peri-, and postpubertal) were formed according to the Tanner stage and the onset of a regular menstruation. Girls kept a daily headache and menstrual cycle diary over 8 weeks. Ovulatory cycles were analyzed by weekly progesterone saliva tests. Main results and the role of chance Three groups according to Tanner stage and onset of regular menstruation were compared: pre- (n = 16), peri- (n = 19) and post-pubertal (n = 12) girls. A significant difference in migraine frequency was found between pre- and post- pubertal girls (p = 0.005). Headache characteristics did not differ significantly between the three groups. Interestingly, a higher frequency of attacks in follicular phase occurred compared to luteal phase (p = 0.030). Limitations, reasons for caution Repeated blood sampling would have been a more reliable technique compared to saliva assays. The sample size is small. Wider implications of the findings: During puberty, the number of migraine attacks but not the specific headache characteristics changes in adolescent girls which should be taken into consideration regarding the management of these patients. Trial registration number AN2013–0027