1. Toxic Stress Screening and Documentation in a Resident Continuity Clinic
Jessica A. Lanerie, MD1 and Teresa K. Duryea, MD2
1Pediatric Resident- PGY-2, 2Associate Professor, Department of Pediatrics, Section of Academic General Pediatrics, Baylor College of Medicine
Introduction
Results
The American Academy of Pediatrics recommends that pediatric medical homes actively screen for precipitants of toxic stress that are common in their particular practices.1
The primary resident continuity clinic at Texas Children’s Hospital lacks an organized screening process for precipitants of toxic stress. Given the complexity of our patient population and the large number of residents serving the clinic, there is a need for a uniform screening process.
The Safe Environment for Every Kid (SEEK)2 parent questionnaire is a written parental response survey available in English and Spanish that was developed at the University of Maryland and screens for the family’s need for the number to poison control, smoke detectors in the home, food insecurity, caregiver substance abuse, caregiver depression/extreme stress, risk for inappropriate discipline, and intimate partner violence. Studies have shown that the SEEK model increases provider comfort with toxic stress screening and may even prevent some forms of child maltreatment.3
The data presented is from the first month of implementation.
Primary Outcomes studied include:
Percent of eligible patients who received the screen
Type and frequency of positive screens
Compliance with documentation of positive screens in the EMR
This project is ongoing. Further outcomes to be measured include provider’s perception of increased visit time, subjective improvement in toxic stress screening, and comfort with responding to positive screens.
Total number of eligible patients=105
Of these, 91 patients (87%) returned the SEEK questionnaire.
45% (n=41) of these 91 patients had a positive screen.
Percent of screens positive for >1 item: 44% (n=18)
Percent of positive screens documented in EMR: 37% (n=18)
Fig. 2 Results of Seek Questionnaire
Purpose
The purpose of this project was to improve the toxic stress screening at our clinic by developing a uniform process that utilizes an evidence based screening tool.
The objectives were:
Implement use of the SEEK parent questionnaire and handouts
Assess rates of screening, documentation, and prevalence of toxic stress in our patient population
Methods
Prior to implementation of the SEEK parent questionnaire in our clinic, an extensive literature search of toxic stress screening tools and discussions with key clinical stakeholders were performed. A workflow diagram was developed and posted in the physician work area, and faculty, staff, and residents were educated on the new screening process. A toolkit was created with a variety of community resources appropriate for each potential positive item. The SEEK parent handouts were modified for our clinic’s needs and included in the toolkit. Feedback and buy-in was also obtained from our clinic social worker, who agreed to assist with counseling, referrals, and additional resources as needed.
Beginning March 2015, the SEEK parent questionnaire was administered at all 6 month, 12 month, and 2-5 year well child checks. The questionnaire was completed by the caregiver while waiting to see the resident and then reviewed by the resident during the visit. For any positive screen, the resident provided counseling, resources, and referrals as indicated with the assistance of faculty and our clinic social worker. Residents were also asked to document all positive screens in their visit note in the electronic medical record.
(1)
(41)
(49)
Total returned questionnaires = 91
For those with positive screens, 44% (n=18) were positive for more than 1 item.
The recommended documentation for patients with a positive screen was complete in the electronic medical record for 37% (n=15).
Table 1 Breakdown of Positive Screens
(a patient may have >1 positive item)
Fig 1. Clinic Workflow Diagram
Conclusions
Most eligible patients were screened.
Possible precipitants of toxic stress are very common in the patient population served by our residency continuity clinic.
Caregiver extreme stress, food insecurity, and risk of inappropriate discipline were found to be most prevalent amongst our positive screens.
Many families screened positive for items that should often be included in anticipatory guidance, such as: poison control, smoking cessation, and smoke detectors.
We need to continue to improve our documentation of toxic stress screening in the electronic medical record.
Further quality improvement projects should focus on ensuring that we are adequately supporting families who are experiencing these stressors.
References
Garner, A. S., J. P. Shonkoff, B. S. Siegel, M. I. Dobbins, M. F. Earls, A. S. Garner, L. Mcguinn, J. Pascoe, and D. L. Wood. "Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health." Pediatrics (2011): E Web.
Dubowitz, H., W. G. Lane, J. N. Semiatin, L. S. Magder, M. Venepally, and M. Jans. "The Safe Environment for Every Kid Model: Impact on Pediatric Primary Care Professionals." Pediatrics (2011): E Web
Dubowitz, H., S. Feigelman, W. Lane, and J. Kim. "Pediatric Primary Care to Help Prevent Child Maltreatment: The Safe Environment for Every Kid (SEEK) Model." Pediatrics (2009): Web.
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