Preoperative Assessment Underestimates Complexity of Surgical ...

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the posterior vaginal fornix. The patient then admitted she had placed a foreign object (pen) into her vagina three years prior; she denied any past or current ...
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Poster Abstracts / J Pediatr Adolesc Gynecol 30 (2017) 299e331

Methods: Data from individual encounters in four clinics were collected, including (1) adolescent gynecology, (2) endocrinology, (3) adolescent medicine and (4) an obesity referral clinic. Inclusion criteria were obese or overweight girls ages 12-24 with PCOS, oligomenorrhea or irregular menses documented by ICD-9 codes. A systematic chart review was completed and baseline data were collected from December 2013 through September 2015. Baseline data included history suggestive of PCOS (infrequent or irregular menses, hirsutism, acne) and laboratory analysis performed (thyroid stimulating hormone, prolactin, free and total testosterone, follicle stimulating hormone and hyperandrogenism labs). Metabolic screening was also recorded, including evaluation for hypertension, hyperlipidemia, transaminitis, diabetes, and obstructive sleep apnea (OSA). After collection of baseline data, an educational intervention was performed consisting of: (1) provider education with small-group tutorials and educational material posted in clinical work areas, and (2) creation of provider tools including electronic medical record order sets and note templates. Each clinic was given the same intervention by the same personnel. Following the intervention, charts were again reviewed to collect follow-up data and a chi square test was performed on overall data to assess significance. Results: 120 patient encounters were included in the study; 74 prior to intervention and 46 post-intervention. Race and insurance status was similar between groups with the exception of more African Americans seen in Adolescent Medicine. At baseline, diagnostic testing was insufficient in all clinics, with pregnancy tests omitted most frequently. Following the intervention, rates of appropriate diagnostic testing improved in all clinics. At baseline >60% of obese girls with PCOS received appropriate metabolic screening. The most commonly missed test was OSA screening. Conclusions: Adolescents with PCOS require adequate, appropriate and evidence-based care regardless of where they enter the medical system. Our results confirm that practitioners in different medical subspecialties approach the diagnosis and evaluation of PCOS and comorbidities differently and that QI projects can standardize the approach regardless of specialty and presenting complaint. Within a single improvement cycle, appropriate diagnostic testing improved by 50% in all specialty clinics. However, additional studies are needed to evaluate whether multiple cycles can effect further improvements.

54. Text-Message Delivery of Sexually Transmitted Infection Test Results to Adolescents Following LongActing Reversible Contraceptive Placement Raina Vachhani Voss MD, RaNette Schaff RN, BSN, CPN, Julie Burns RN, BSN, Linda Smith RN, BSN, MN, Katherine Debiec MD, Anne-Marie Amies Oelschlager MD* Seattle Children’s Hospital, Seattle, WA

Background: Long-acting reversible contraceptives (LARC) are highly recommended as contraceptive methods for adolescents, who are at high risk of both unintended pregnancy and sexually transmitted infections (STI). STI testing at the time of intrauterine device placement is an important part of preventing pelvic inflammatory disease. Adolescents are often difficult to confidentially contact to provide important medical results and recommendations. Text-messaging has been shown to be effective for health promotion with adolescents, and text-messaging STI results has been proven effective with adults. In our Adolescent Medicine and Gynecology clinic, patients and staff identified a need for text-messaging communication to provide prompt, reliable and confidential STI results to adolescents following LARC placement. The aim of this project was to demonstrate feasibility of such a process. Methods: This project was approved through the Seattle Children’s Hospital Office of Quality and Safety as a Continuous Process Improvement project. A reliable method for text-messaging of STI test results was developed with input from the hospital’s ethics, legal services, risk management, and health information management services. Following approval, we began text messaging of STI results using a web-based texting system. Nurses met with adolescents at the time of LARC placement to

confirm their interest in receiving results via text. If the patient agreed, nurses collected the adolescent’s phone number and cell phone carrier at the time of LARC placement. Negative results were communicated using the message “Everything is OK ADO clinic” and positive results were communicated as “Please call the ADO clinic at 206-987-2028 #4.” Results: 50 adolescents were provided STI test results via text-message during our 4-month project period. Of these, one patient was positive for chlamydia. She responded to our text-message twenty minutes after it was sent, and treatment and follow-up was arranged. Nurses were able to provide results within the same business day that the providers requested patient notification. Nurses reported no problems with the new method, and also received positive feedback from patients. There were no reported incidents of breach of confidentiality due to text messaging. Discussion: This project demonstrates the feasibility of using text messaging for confidential, efficient, and effective delivery of STI test results to adolescents following LARC placement. We perceived high patient and nurse satisfaction with this method of communication. This project was undertaken as a pilot project, and further research should compare patient satisfaction, nursing satisfaction, and effectiveness of communication between text-messaging and traditional methods.

55. Preoperative Assessment Underestimates Complexity of Surgical Intervention Required for Successful Removal of Vaginal Foreign Object in a Patient Presenting With Prolonged Vaginal Bleeding Christine Pennesi MD, Rajan Thakkar MD, Brian Kenney MD, Christina Ching MD, Geri Hewitt MD, Katherine McCracken MD* Nationwide Children’s Hospital, Columbus, OH

Background: Heavy and prolonged menstrual bleeding is relatively common and has numerous etiologies. When vaginal bleeding is secondary to foreign bodies or penetrating injuries, assessment by physical exam and radiologic imaging may underestimate the extent of the actual injury. Case: A 13-year-old female, never sexually active, presented with persistent, prolonged, heavy menstrual bleeding despite combined oral contraceptive pill use as prescribed by her primary care provider. Initial evaluation included normal laboratory testing and normal physical findings e including external female genitalia. Pelvic ultrasound noted a complex right adnexal mass, normal uterus, and normal left ovary. Upon return to clinic, patient and mother expressed interest in a levonorgestrel intrauterine device for management of the heavy bleeding. Digital and speculum exam revealed a plastic foreign body embedded in the posterior vaginal fornix. The patient then admitted she had placed a foreign object (pen) into her vagina three years prior; she denied any past or current sexual abuse. Office attempts at removal of the foreign body were unsuccessful. CT pelvis confirmed the vaginal foreign body, complex right adnexal mass, and right hydroureter. There was no evidence of rectal or bladder involvement. She underwent exam under anesthesia, diagnostic laparoscopy, lysis of pelvic adhesions, tubo-ovarian abscess drainage, and appendectomy. She required conversion to exploratory laparotomy for complete removal of the foreign body (shampoo bottle pump, 10cm in length, removed in 5 pieces). The foreign body perforated the posterior vaginal wall and was embedded in the posterior pelvic cul-de-sac, abutting the rectum. Removal was complicated by rectal injury e requiring repair and diverting sigmoidostomy. She received post-operative antibiotics for the tubo-ovarian abscess. Repeat imaging noted resolution of both the tubo-ovarian abscess and right hydroureter. Comments: Foreign bodies not easily removed in the office should be considered for operative removal. Even with the advantage of general anesthesia and patient positioning, surgical removal may be more challenging than preoperative assessment suggests. In cases of foreign bodies or penetrative injuries history may be limited or misleading, and physical findings may not fully delineate the complexity of the clinical scenario. Typically, imaging helps localize the foreign object and affected pelvic anatomy, aiding in operative planning and consultation with other pediatric surgical specialties. However, in our case preoperative assessment led

Poster Abstracts / J Pediatr Adolesc Gynecol 30 (2017) 299e331

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56. Frequency & Patient Characteristics of Venous Thromboembolism in Adolescent Females Vrunda Patel MD, Catherine Hennessey IV MS, Veronica Gomez-Lobo MD* Children’s National Medical Center, Washington, D.C.

Background: Venous thromboembolisms (VTEs) in pediatric patients are

Figure 1. CT Abdomen/PelvisĂ

us to underestimate the extent of the trauma. Self-reported history was not compatible with the object found; physical exam suggested a simple penetrative injury with a linear solid object; and because the object was not radio-opaque, imaging did not delineate the shape and orientation of the shampoo pump and suggested minimal surrounding tissue involvement. It is critical to keep in mind that accidental penetrating injuries may closely mimic injuries associated with sexual assault. Both accidental and non-accidental injury should be considered during the evaluation.

thought to be a rare occurrence; however clinicians have been appreciating an increase in the number of cases. This clinical perception is supported by data from 2001-2007, which showed an increased in the incidence of VTEs in pediatric patients by 70% nationwide, with adolescents experiencing the greatest risk1,2.We sought to investigate the frequency of VTEs in adolescent females over a nine-year period at children’s hospitals across the country through the use of the Pediatric Health Information System (PHIS) database as adolescent females are often prescribed hormonal contraception which can increase the risk of VTEs. We hypothesized that the frequency of VTEs would decrease over this time frame due to the increasing use of long-acting hormonal contraception (LARCs). Methods: The PHIS database was queried to identify females aged 12-18 years old that were diagnosed with a VTE or pulmonary embolism (PE) from 2006-2015. Approval for this study was granted through the Institutional Review Board at Children’s National Medical Center. The PHIS database provides clinical and resource utilization data from forty-five participating children’s hospitals across the country. Patients diagnosed with a VTE were identified through coding of International Classification of Diseases, Ninth/Tenth Revision, Clinical Modification (ICD-9/10-CM) coding. Patient demographics (age, race, year admitted) and co-diagnoses (up to 5 additional ICD-9/10 codes) were also collected. Results: Figure 1 shows the distribution of VTEs in relationship to age from 2006-2015. The highest number (N¼783) of VTEs occurred in sixteen-year old females, with the lowest number occurring in twelve year old females (N¼263). Figure 2 reveals an increase in admissions for VTEs in adolescent girls between 2006-2015, with the highest frequency occurring in 2014. A significant number of patients were found to have other risk factors for VTEs such as obesity, malignancies, cystic fibrosis, lupus and transplant patients. Conclusions: Though rare, pediatric and adolescent health care providers should be aware that there is an increasing trend in VTEs in adolescent girls, despite the growing trend in uptake of LARCs. Peak incidence at age sixteen and seventeen may be attributable to the fact that older adolescent females may seek care at adult institutions. The risk of VTE in adolescent is also significantly influenced by other comorbid conditions. Assessment of patients’ risk factors should be thoroughly investigated prior to the initiation of estrogen-containing medications.

References 1. Raffini L, Huang YS, Witmer C, Feudtner C. (2009). Dramatic increase in venous thromboembolism in children’s hospitals in the United

Figure 2. Foreign BodyĂ

Figure 1. Ă