Erin Isaacson’s research while affiliated with Southern Illinois University School of Medicine and other places

Objective The aim of the study is to assess the effect of an emergency department (ED) standardized clinical guideline for adolescent heavy menstrual bleeding on the rate of return ED visits and ED provider history-taking and management of this condition. Methods This was a retrospective cohort study. Patients less than 18 years old presenting to a single academic children's hospital ED between 2010 and 2020 with a chief complaint of heavy menstrual bleeding were included. Patient demographics were collected, along with a 10-point scale of provider documentation of specific medical and menstrual history components and required laboratory workup. Planned treatment plans were collected, as well as hospital admissions and return ED visits (within 3 weeks). Results Total number of patients was 267 (n = 106 pre- and n = 161 post-), with similar distribution of age ranges between groups (14.6 [2.2] and 14.5 [2.0], P = 0.73). On the 10-point scale of required history and laboratory evaluations, postimplementation patients received 1.9 more points than the precohort ( P < 0.001). Age (−0.22 [95% confidence interval {CI} −0.36 to −0.08]) and evaluation by a trainee physician (0.75, [95% CI 0.09 to 1.41]) were also associated with significant differences in point totals. Documentation of outpatient follow-up with primary care physician or an adolescent medicine/gynecology specialist significantly increased (50% and 90% P < 0.001). Implementation was associated with a decrease in ED return visits in multivariate analysis (odds ratio 0.27, [95% CI 0.08 to 0.92], P = 0.036). Conclusions Implementation of a clinical guideline pathway improved provider documentation and history taking, increased referrals to specialist care, and significantly decreased return ED visits within 3 weeks for heavy menstrual bleeding complaints.

Background: Abnormal uterine bleeding (AUB) is a common adolescent gynecologic complaint, yet there is limited research for best management practices. A evidence-based clinical guideline was published in 2015 for abnormal uterine bleeding at Dell Children's Emergency Department (ED) to assist in clinical decision-making, with a stepwise lab and exam assessment and treatment decision tree. Studies have shown improved provider confidence and management plans after implementation of standardized protocols. We hypothesized that implementation of this protocol has standardized history-taking and management, reduced return ED visits, and decreased admissions Methods: The study was approved by the UT-Dell IRB. Subjects included menarchal females less than 18 years old who presented to the ED between January 2014-December 2016 for abnormal uterine bleeding. They were categorized into two groups of patients pre- and post-2015 guideline implementation. Variables recording demographics, patient history documentation, laboratory workup, and treatments were included in the analysis. Frequencies and proportions of responses were reported. Means and proportions were compared between the groups, reporting p-values calculated using student t-tests and two-proportion z-tests, as well as Chi-square tests for categorical data. Stratification of patients by hemoglobin level and history documentation variables were also included in sub-analyses Results: There were 105 total subjects(n=51 and n=53), with similar distribution of racial backgrounds with nearly 50% identifying as Hispanic. Post-implementation, there was a significant increase of critical documented screening for history of bleeding disorder(n=18 and n=31, p=0.0048) or thrombotic event(n=12 and n=22, p=0.021). There was a significant increase in obtaining a screening TSH(n=16 vs n=25, p=0.0418). Establishment of outpatient follow-up with Adolescent medicine or gynecology significantly rose between pre and post implementation (n=35 and 44, p=0.0109). There was no change in admission rates between groups (28% vs 35 %, p= 0.407). A downward trend of repeat visits to the ER was noted (n=7 vs n=4), however due to the small case number this was not statistically significant Conclusions: This retrospective review demonstrated that the clinical guidelines pathway protocol has improved provider documentation of critical screening, history and lab work as well as boosted follow-up with outpatient specialty providers. An important trend was also noted toward decreased return ER visits. Continued study with an expanded cohort will provide more insight into how this guideline impacts provider workup and management, as well as leading to areas for improvements in education and protocol adoption as the standard of care

Background Abnormal uterine bleeding (AUB) is a common gynecologic problem among adolescents, and is broadly described as menstrual bleeding that is abnormal in timing, duration, or quantity. While there are abundant guidelines for assessment and management of this condition in adults, there is no current standard of practice for the adolescent population. This lack of standardized recommendations, combined with provider knowledge gaps, often leads to disorderly workup and management. Dell Children's Medical Center (DCMC) created an AUB clinical guidelines pathway, published in May 2015, for use in the emergency department to standardize clinical decision-making. The utilization rate by emergency department practitioners, as well as the impact of standardizing practice with this pathway, has yet to be studied. Methods A 14-question survey was designed to assess if DCMC providers have awareness of the protocol, if they use it to assist with management, and their general knowledge of broad concepts reinforced within the protocol. The survey was emailed to attending physicians, associate providers, fellows, and pediatrics and emergency medicine resident physicians who have worked in the ER at Dell Children's for at least 6 months. Results A response rate of 40% was achieved. Half of respondents were residents. 72% reported that they do refer to the above-mentioned protocol for guidance on management and treatment of adolescent patients, and over 90% access the protocol through the DCMC intranet. Of those who don't use the protocol, 30% stated they use their own personal practice guidelines. All answered correctly that "A sterile speculum exam is not indicated for every patient", and 86% appropriately answered “false” to the statement "A pelvic ultrasound is always the first step in work-up for abnormal uterine bleeding in adolescents". However, despite most providers stating that they used the protocol, over half (53%) answered “false” to the statement “All patients presenting with AUB should be screened for a bleeding disorder”. Additionally, 22% of respondents answered incorrectly when asked about absolute contraindications to estrogen therapies. Conclusions Overall, the response rate and respondent make-up of this survey provided an accurate representation of the providers that work in the DCMC emergency department. While most providers have knowledge of the clinical guidelines protocol and state they use it, the responses reveal significant knowledge gaps in the appropriate diagnosis and management of this condition from both resident and attending providers. Further education of physicians regarding AUB in adolescents, as well as easier access to the protocol may be helpful in improving provider compliance.