Introduction:Emergency department evaluations for acute child sexual assault include anogenital photodocumentation as a standard of care, which has implications for accurate clinical care and forensic significance. If photodocumentation quality is suboptimal from a diagnostic standpoint, this may lead to wasted care and resources and place needless burdens on patients and families. Our project aimed to improve the diagnostic quality of anogenital photodocumentation at 2 sites in a pediatric emergency department, increasing it from a baseline of 24% to 50% during a 9-month intervention period.Methods:We surveyed multiple clinical teams to determine drivers of diagnostic quality. Using the Model for Improvement, we implemented multiple interventions (clinical pathway revisions, visual guidance, direct provider feedback, and an improved light source option) in the care process for these patients and measured diagnostic quality using a definition adapted from a validated photograph-scoring system. We used statistical process control charts to track diagnostic quality.Results:We detected no special-cause variation in the outcome measure of improved diagnostic quality. We detected special-cause variation for the process measure of whether care teams obtained photodocumentation, which increased from 77% to 89%.Conclusions:Interventions to improve the diagnostic quality of anogenital photodocumentation did not result in improvement; however, there was improvement in the likelihood of care teams obtaining photodocumentation in acute sexual assault evaluations.

Patient portals allow adolescents and caregivers of pediatric patients to better engage with health care, improving their medication adherence, health knowledge, self-efficacy, and receipt of preventive care. However, disparities in access to and comfort with using these portals persist. Hospitalization represents a promising opportunity to address these disparities among a high-risk population. We conducted a cross-sectional analysis to identify disparities in portal enrollment and use (logins, messaging, or telehealth use) among patients admitted to two pediatric hospitals within a single health system from 2022-2024. We calculated unadjusted rates of portal enrollment and use before, during, and after hospitalization, stratified by patient-level factors (age, race/ethnicity, insurance coverage, medical complexity), household-level factors (preferred language), and population-level factors (neighborhood opportunity). We then used multivariable logistic regression to identify associations between these factors and portal enrollment and use. Among 40,371 hospitalized patients, 93% had enrolled in our patient portal. Patients who identified as Non-Hispanic Black, were publicly insured, had a household language other than English, and lived in lower opportunity neighborhoods had significantly decreased odds of portal enrollment and use before, during, and after hospitalization. Despite high overall rates of portal enrollment among our patient population, we observed persistent disparities in portal enrollment and use. Efforts to promote equitable portal usage among hospitalized children may be most effective when focused on families who are publicly insured, prefer languages other than English, or live in lower opportunity neighborhoods.

OBJECTIVE:Patient portals allow patients and caregivers to better engage with health care. Disparities in portal use among high-risk populations, like hospitalized children, could limit their benefits. Additionally, little is known about the association between pediatric portal usage and acute care utilization. PATIENTS AND METHODS:We conducted a cross-sectional analysis to identify disparities in portal activation and use among patients admitted to 2 children's hospitals from 2022 to 2024. We described unadjusted patterns of portal use and then used multivariable regression to examine the association between portal activation and use before, during, and after hospitalization and patient-level factors, household-level factors, and population-level factors, as well as critical care admissions, hospital length of stay (LOS), and 30-day readmissions. RESULTS:Among 40 371 hospitalized patients, 93% had activated portal accounts. Patients who identified as non-Hispanic Black, were publicly insured, had a household language other than English, and lived in lower-opportunity neighborhoods had significantly lower odds of portal activation and use before, during, and after hospitalization. Patients with portal use before hospitalization had decreased odds of critical care admission (odds ratio, 0.64; 95% CI, 0.58-0.70) and shorter LOS (incident rate ratio, 0.74; 95% CI, 0.69-0.79), with no difference in readmissions. CONCLUSIONS:Despite high rates of portal activation in our sample, we observed persistent disparities in portal activation and use. Associations between portal activity and acute care utilization are complex and merit further investigation. Efforts to promote equitable portal usage among hospitalized children should focus on families who are publicly insured, prefer languages other than English, and live in lower-opportunity neighborhoods.

BACKGROUND AND OBJECTIVES:Intimate partner violence (IPV) and child physical abuse often co-occur, but the frequency and risk factors for abusive injuries in IPV-exposed children remain unknown. Our objectives were to (1) determine frequency of skeletal surveys (SSs) and neuroimaging use because of IPV and their diagnostic value in children aged less than 24 months evaluated by a child abuse pediatrics specialist (CAP) and (2) identify factors associated with performance of and findings on SS and neuroimaging. METHODS:We conducted a retrospective study of children aged less than 24 months undergoing CAP consultations because of IPV exposure from February 2021 to February 2024 in a multicenter child abuse research network. We analyzed use of SS and neuroimaging and associations between imaging use and sociodemographic factors and associations between imaging positivity and clinical factors (age, injury-related chief complaint, presenting trauma history, injury on physical examination). RESULTS:Among 326 children, 305 (93.6%) underwent SSs, with 29 (9.5%) positive for a new fracture. Among 267 children without signs/symptoms of head trauma, 110 (41.2%) had neuroimaging, with 7 (6.4%) positive for intracranial injury. There was no disproportionality in SS use, but race/ethnicity and insurance type were associated with the use of neuroimaging. The presence of an injury on physical examination finding was associated with newly identified fractures (15.7% vs 6.4%; P = .009). CONCLUSIONS:Current evidence supports use of SSs in children aged less than 24 months undergoing medical evaluations after exposure to IPV. Further research is needed to assess risk factors for positive findings on SSs and neuroimaging with larger sample sizes.

Patient portals are designed to enhance patient and caregiver engagement by providing access to health information, communication with care teams, and telehealth services, yet their impact on health care utilization among hospitalized children is not well understood. In this cross-sectional study, we examined associations between patient portal enrollment and use and hospitalization outcomes among 40,377 children admitted to an urban quaternary or suburban tertiary pediatric hospital between 2022 and 2024. Portal activity was defined by enrollment and any use (login, messaging, or telehealth) within specified periods before or during hospitalization. Using multivariable regression models adjusted for sociodemographic factors, neighborhood opportunity, insurance type, language, medical complexity, hospital site, and year, we evaluated associations with critical care admission, hospital length of stay (LOS), and 30-day readmissions. Portal enrollment and use in the year prior to hospitalization were associated with significantly lower odds of critical care admission and shorter LOS, with average reductions of 1.56 days for enrollment and 1.21 days for use. Neither portal enrollment nor use was significantly associated with 30-day readmissions. Future research should explore any potential mechanisms facilitating lower acuity at admission and shorter hospitalizations for those engaged with digital health. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Effort in conducting this study was supported in part by the Shanahan Family Foundation (ML, PS) and the Agency for Healthcare Research and Quality grant nos. K08HS029396 (AV). The Shanahan Family Foundation and AHRQ had no role in the design and conduct of the study. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study was deemed exempt by the Children's Hospital of Philadlephia's Institutional Review Board. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Interested parties can contact the first author for any data sharing requests.

BACKGROUND AND OBJECTIVES Recent regulations require that hospitals screen families for health-related social needs (HRSNs), but many hospitals lack the resources and infrastructure to address these needs. Social workers (SWs) and community health workers (CHWs) play a critical role in filling this gap. We aimed to understand SW and CHW perspectives regarding effective strategies for addressing HRSNs during and after inpatient pediatric hospitalizations. METHODS We conducted semi-structured interviews with inpatient SWs and CHWs at 3 academic children’s hospitals exploring participants’ experiences connecting families with resources, communicating with medical teams, and facilitating continued support for families after hospital discharge. Interviews were recorded, transcribed, and coded; themes were derived using thematic analysis. RESULTS We interviewed 28 participants (19 SWs, 9 CHWs). We then identified 4 themes (and 5 subthemes): (1) engagement with caregivers (SWs and CHWs aim to balance providing resources and promoting families’ self-sufficiency), (2) approach to addressing needs (SWs and CHWs have complementary skillsets, and they find maintaining updated resource repositories a significant challenge), (3) engagement with medical teams (communication with providers focuses on needs impacting medical care or discharge planning), and (4) approach to follow-up (ensuring families have continued support following hospital discharge is a challenge, particularly for select populations). CONCLUSIONS SWs and CHWs offer synergistic and complementary expertise to support families experiencing HRSNs. Participants highlighted opportunities to optimize processes for updating resource repositories and improve longitudinal support for families following hospital discharge.

INTRODUCTION:Poverty and associated health-related social needs can negatively impact child health. As pediatric health systems implement social needs screening programs, they should aim to measure and promote equal rates of screening across demographic groups and to support families in connecting to resources. METHODS:We describe implementation of the Linking Families to Support (LiFTS) quality improvement initiative, an inpatient social needs screening and support program. Our objectives were to (1) implement screening across inpatient units, (2) promote equal screening rates across demographic groups, and (3) optimize rates of resource connection. LiFTS was implemented at a quaternary care children's hospital. Families of children admitted to participating units during the study period (September 2022-February 2024) were eligible for screening. RESULTS:Over the 18-month project period, we implemented screening in 9 inpatient units. Of 2582 eligible caregivers, 1741 (67.4%) were offered screening. Of these caregivers, 667 (38.3%) declined screening and 1074 (61.6%) completed screening. A total of 496 families (46.2%) reported 1 or more social needs. In analyses stratified by child race, ethnicity, insurance status, and preferred language, we observed equal rates of screening. Among 233 families reached in follow-up, 183 (78.5%) recalled receiving resources and 133 (57.1%) reported connecting to 1 or more resources. DISCUSSION:Our interdisciplinary team successfully implemented social needs screening across 9 inpatient units, achieved equal rates of screening, and measured caregiver-reported rates of resource connection. Our approach could guide other health systems as they implement social needs screening programs that meet regulatory requirements, prioritize equality in screening, and support resource connection.

BACKGROUND AND OBJECTIVES:New regulations require hospitals to screen patients for health-related social needs (HRSNs). Neighborhood indices, like the Child Opportunity Index (COI), may help identify families at risk of experiencing HRSNs and inform targeting of health system-based resources and support. However, it is unknown how well the neighborhood-level COI predicts household-level HRSNs. METHODS:In this cross-sectional study of 1096 patients admitted to a quaternary children's hospital from July 2022 to August 2023, we combined data on household-level HRSNs from standardized screening with data on each patient's neighborhood COI. We used logistic regression to estimate odds of experiencing HRSNs among families in the 2 lowest COI quintiles (low/very low), relative to the 3 highest quintiles (moderate/high/very high). We then calculated positive and negative predictive values of low/very low COI in identifying household-level HRSNs and compared rates of resource connection among those with low/very low COI vs moderate/high/very high COI. RESULTS:Low/very low COI was associated with greater odds of reporting household-level HRSNs (odds ratio, 2.62; 95% CI, 2.04-3.36). COI showed low positive predictive value (3% to 31%) in identifying HRSNs and high negative predictive value for each need (91% to 99%) except mental health (76%). Resource connection rates were not significantly different across COI strata. CONCLUSIONS:Families in disadvantaged neighborhoods have greater odds of reporting HRSNs, but COI is a poor proxy for household-level screening. Findings suggest that health systems can use COI to focus HRSN screening and interventions on communities with the likely highest prevalence of reported HRSNs.

Telehealth presents both the potential to improve access to care and to widen the digital divide contributing to health care disparities and obliging health care systems to standardize approaches to measure and display telehealth disparities. Based on a literature review and the operational experience of clinicians, informaticists, and researchers in the Supporting Pediatric Research on Outcomes and Utilization of Telehealth (SPROUT)–Clinical and Translational Science Awards (CTSA) Network, we outline a strategic framework for health systems to develop and optimally use a telehealth equity dashboard through a 3-phased approach of (1) defining data sources and key equity-related metrics of interest; (2) designing a dynamic and user-friendly dashboard; and (3) deploying the dashboard to maximize engagement among clinical staff, investigators, and administrators.

Many children and families do not have access to specialized pediatric health care, including child abuse pediatricians. Medical evaluations in cases of suspected child maltreatment including physical abuse, sexual abuse, and neglect are a critical component of the multidisciplinary team response to these concerns. We review the role of child abuse pediatricians in cases of suspected child maltreatment. We discuss the advantages and disadvantages of current models of care including co-location of child abuse specialists within children's advocacy centers, hospital-based medical evaluation programs and community-based clinics. We review barriers to universal and equitable access to specialized care. We then highlight the significance of telemedicine as an important tool for improving access to care for children who would not otherwise have access.

OBJECTIVE:Parents of pediatric patients are key stakeholders in the design and implementation of health-related social needs (HRSN) screening programs. Yet, there is little research exploring their perspectives on the documentation and sharing of HRSN data. We aimed to examine parents' preferences regarding how HRSN data are documented and shared. METHODS:We conducted semi-structured interviews with parents of hospitalized children participating in an HRSN screening program at a quaternary care children's hospital. Interviews were coded using an inductive and deductive approach to identify emergent themes. RESULTS:The 20 interviewed parents were uniformly female with 55% identifying as Black or African American and 20% identifying as Hispanic or Latino. Parents expressed comfort with electronic health record documentation of HRSN data and the use of International Classification of Diseases, 10th Revision Z codes as long as this information was used to provide families with meaningful support. Most parents viewed social workers and medical teams as the most appropriate recipients of HRSN data. Few parents felt comfortable with HRSN data being shared with payors. Parents desired transparency around HRSN data sharing. Many expressed concerns that documentation and sharing of HRSN data could lead to unwanted or unsafe disclosures or result in child welfare referrals. CONCLUSIONS:Parents expressed comfort with HRSN documentation and sharing with health care providers, but requested that providers be transparent and respect parental preferences regarding data sharing to mitigate potential harms. When implementing HRSN support programs, health systems and payors should prioritize transparency around documentation and data sharing with families.

Introduction: Telemedicine studies specific to children in foster care are needed, given unique health care needs and barriers. It is important to utilize lessons learned from telemedicine programs deployed by necessity during the COVID-19 emergency. Objectives: Describe telemedicine health assessments for children in foster care performed during the COVID-19 pandemic. Compare medical recommendations resulting from telemedicine and in-person assessments. Methods: After navigating barriers specific to children in foster care including consent issues, we implemented a telemedicine program at our specialty clinic for children in foster care when in-person visits were restricted. Outcomes of telemedicine referrals were tracked. After each visit, physicians were asked to rate ability to express themselves, hear and see patients from 1 (strongly disagree) to 5 (strongly agree) using items from the validated Telehealth Usability Questionnaire. Recommendations for laboratory work, medication, and health services referrals were recorded and compared with 205 patients seen in-person the year prior. Results: From 91 referrals, 83 (91%) children with a mean age of 9 years completed telemedicine visits. Physicians rated receptive and expressive communications more favorably than visual quality. Most telemedicine patients (77%) received a referral for health care services but had significantly lower rates of laboratory work completion, vision referrals, and prescriptions for new medications compared with 205 patients seen in-person. Conclusions: Results suggest that telemedicine was accessible to most patients and highlighted essential in-person components of comprehensive health assessments. Findings could inform ongoing telemedicine applications and advocacy for underserved populations.

ObjectivesChild abuse should be considered in cases of sudden unexpected infant death (SUID). Postmortem skeletal surveys (PM-SS) are recommended to evaluate for abusive fractures in SUID. Little is known about the yield of PM-SS among infants presenting to emergency care with SUID. Our objectives were to (1) describe the presentation and care of infants with SUID at a tertiary children's hospital emergency department and (2) report PM-SS use and findings.MethodsWe performed a retrospective study of infants younger than 12 months with SUID presenting to an urban emergency department from 2007 to 2019. We describe their presentation and care, including PM-SS performance and findings, referrals to the medical examiner, and reports to child protective services (CPS). We assessed for associations between race, payer, and presentation with reports to CPS.ResultsOf 73 infants with SUID, concern for unsafe sleep was documented in 45 (61.6%) and 71 (97.3%) underwent cardiopulmonary resuscitation by a medical professional. All 73 (100%) underwent PM-SS and were referred to the medical examiner. Twelve definite fractures (11 rib, 1 classic metaphyseal lesion) and 8 possible fractures (7 rib, 1 classic metaphyseal lesion) were identified among 6 (8.2%) infants. Forty-three (58.9%) were reported to CPS. There were no associations between race, payer, age, or history of unsafe sleep and CPS reports.ConclusionsOne in 12 cases of SUID had a possible and/or definite fracture identified on plain radiography. Multicenter studies are needed to compare yield across different postmortem imaging modalities and populations.

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OBJECTIVE: Pediatric health systems are increasingly screening caregivers for unmet social needs. However, it remains unclear how best to connect families with unmet needs to available and appropriate community resources. We aimed to explore caregivers' perceived barriers to and facilitators of community resource connection. METHODS: We conducted semistructured interviews with caregivers of pediatric patients admitted to one inpatient unit of an academic quaternary care children's hospital. All caregivers who screened positive for one or more unmet social needs on a tablet-based screener were invited to participate in an interview. Interviews were recorded, transcribed, and coded by 2 independent coders using content analysis, resolving discrepancies by consensus. Interviews continued until thematic saturation was achieved. RESULTS: We interviewed 28 of 31 eligible caregivers. Four primary themes emerged. First, caregivers of children with complex chronic conditions felt that competing priorities related to their children's medical care often made it more challenging to establish connection with resources. Second, caregivers cited burdensome application and enrollment processes as a barrier to resource connection. Third, caregivers expressed a preference for geographically tailored, web-based resources, rather than paper resources. Last, caregivers expressed a desire for ongoing longitudinal support in establishing and maintaining connections with community resources after their child's hospital discharge. CONCLUSION: Pediatric caregivers with unmet social needs reported competing priorities and burdensome application processes as barriers to resource connection. Electronic resources can help caregivers identify locally available services, but longitudinal supports may also be needed to ensure caregivers can establish and maintain linkages with these services.

BACKGROUND: Prior single-site evaluations of Child Adult Relationship Enhancement in Primary Care (PriCARE), a 6-session group parent training, demonstrated reductions in child behavioral problems and improvements in positive parenting attitudes. OBJECTIVE: To measure the impact of PriCARE on disruptive child behaviors, parenting stress, and parenting attitudes in a multisite study. METHODS: Caregivers of children 2-to 6-year-old with behavior concerns recruited from 4 pediatric primary care practices were randomized 2:1 to PriCARE intervention (n = 119) or waitlist control (n = 55). Seventy-nine percent of caregivers identified as Black and 59% had annual household incomes under $22,000. Child behavior, parenting stress, and parenting attitudes were measured at baseline and 2 to 3 months after intervention using the Eyberg Child Behavior Inventory, Parenting Stress Index, and Adult-Adolescent Parenting Inventory-2. Marginal standardization implemented in a linear regression compared mean change scores from baseline to follow-up by treatment arm while accounting for clustering by site. RESULTS: Mean change scores from baseline to follow-up demonstrated greater improvements (decreases) in Eyberg Child Behavior Inventory problem scores but not intensity scores in the PriCARE arm compared to control, (problem: -4.4 [-7.5, -1.2] vs -1.8 [-4.1, 0.4], P=.004; intensity: -17.6 [-28.3, -6.9] vs -10.4 [-18.1, -2.6], P=.255). Decreases in parenting stress were greater in the PriCARE arm compared to control (-3.3 [-4.3, -2.3] vs 0 [-2.5, 2.5], P=.025). Parenting attitudes showed no significant changes (all P>.10). CONCLUSIONS: PriCARE showed promise in improving parental perceptions of the severity of child behaviors and decreasing parenting stress but did not have an observed impact on parenting attitudes.

AIMS:To evaluate the effect of an intimate partner violence intervention education component on nurses' attitudes in addressing intimate partner violence; complementary aims included understanding nurses' perceptions of the education and how it influenced their attitudes and confidence to address intimate partner violence in practice.DESIGN:An explanatory sequential mixed methods design embedded within a 15-site cluster randomized clinical trial that evaluated an intimate partner violence intervention within the Nurse-Family Partnership programme.METHODS:Data were collected between February 2011 and September 2016. Quantitative assessment of nurses' attitudes about addressing intimate partner violence was completed by nurses in the intervention (n = 77) and control groups (n = 101) at baseline, 12 months and at study closure using the Public Health Nurses' Responses to Women Who Are Abused Scale. Qualitative data were collected from nurses in the intervention group at two timepoints (n = 14 focus groups) and focused on their perceptions of the education component. Data were analysed using content analysis.RESULTS:Nurses in the intervention group reported large improvements in their thoughts, feelings and perceived behaviours related to addressing intimate partner violence; a strong effect of the education was found from baseline to 12 months and baseline to study closure timepoints. Nurses reported that the education component was acceptable and increased their confidence to address intimate partner violence.CONCLUSION:Nurses reported improved attitudes about and confidence in addressing intimate partner violence after receiving the education component. However, these findings need to be considered together with trial results showing no main effects for clients, and a low level of intervention fidelity.IMPACT:These evaluation findings underscore that improvement in nurses' self-reported educational outcomes about addressing intimate partner violence cannot be assumed to result in adherence to intervention implementation or improvement in client outcomes. These are important considerations for developing nurse education on intimate partner violence.