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Screening for Adverse Childhood Experiences in Primary Care: A Quality Improvement Project
ARTICLE
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Screening for Adverse Childhood Experiences in Primary Care: A Quality Improvement Project Charnita Bryant, DNP, MS, CPNP, & Brigit VanGraafeiland, DNP, CRNP, FAAN ABSTRACT Introduction: The American Academy of Pediatrics (AAP) advocates for the screening of Adverse Childhood Experiences (ACEs) during well-child care visits by pediatric health care providers. The evidence shows a strong correlation between children with high ACE scores and the likelihood of physical and mental health problems as adults. The purpose of this Quality Improvement (QI) project was to increase pediatric providers’ awareness on ACEs through education and increase the utilization of an ACE screening tool. Method: This QI project used a pre-post test to evaluate the effectiveness of the educational model and the utilization of the screening tool within an urban pediatric primary care clinic. Results: This project demonstrated an increase in provider awareness as well as a marked increase in the utilization of the screening tool. Discussion: Four hundred eighty ACE screening tools were collected over a 12-week period. By introducing the ACE screening tool as the standard of care in the primary care office, providers can provide early interventions to mitigate the potential untoward outcomes. This QI project also demonstrated that there was a statistical and clinical significance (p value < 0.001) in the provider’s
Charnita Bryant, Pediatric Nurse Practitioner, Johns Hopkins Harriet Lane Primary Care Clinic, Baltimore, MD. Brigit VanGraafeiland, Assistant Professor, Acute and Chronic Care, Johns Hopkins University School of Nursing, Baltimore, MD. Conflicts of interest: None to report. Correspondence: Brigit VanGraafeiland, DNP, CRNP, FAAN, Johns Hopkins University School of Nursing, 525 N. Wolfe St., Baltimore, MD 21205; e-mail: [email protected]. J Pediatr Health Care. (2019) 00, 1−6 0891-5245/$36.00 Copyright © 2019 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.pedhc.2019.09.001
www.jpedhc.org
knowledge pre-post the educational intervention. J Pediatr Health Care. (2019) XX, 1−6
KEY WORDS Adverse childhood experiences, primary care, trauma
INTRODUCTION Problem Description Ninety percent of children of all races, economic status, and geographic regions will experience at least one adverse childhood experience (ACE) in their lifetime (Hornor, 2015). ACEs are defined as traumatic events that occur during childhood. There are three categories of ACEs including child abuse, child neglect, and household challenges, such as witnessing a mother being abused, having a parent with substance use or mental illness, separation/divorce or death of a parent, or incarceration of a parent (Anda, Butchart, Felitti, & Brown, 2010; Shonkoff et al., 2012). The repeated exposure from ACEs, without a protective buffer, such as supportive parental relationships and supportive environments may lead to “toxic stress” (Shonkoff & Garner, 2012). Studies have shown that toxic stress interferes with brain development, learning, behavior, and mental health problems. It also affects body systems such as cardiovascular, autoimmune, central nervous system and endocrine that lead to chronic health problems into adulthood (Shonkoff & Garner, 2012). Children with positive ACE scores have an increased risk of having one or more chronic medical conditions such as asthma, obesity, diabetes, heart disease and stroke (Shonkoff & Garner, 2012). BACKGROUND Available Knowledge The American Academy of Pediatrics (AAP) released a policy statement on Adverse Childhood Experiences (ACEs) 000 2019
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ARTICLE IN PRESS i.e. Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science into Lifelong Health (Shonkoff & Garner, 2012). The policy describes the essential role of the primary care provider, including the pediatric nurse practitioner in screening routinely for ACEs. Kaiser Permanente along with the Centers for Disease and Control (CDC) conducted the initial study on ACEs in 1998 to identify a link between ACEs and current health status and behaviors in adults (Anda et al., 2010). The evidence demonstrated that adults with six or more ACEs have a reduction in life expectancy of 20 years, as compared with their counterparts without ACE exposures (Dowd et al., 2014). Current research estimates the costs associated with ACEs could range between $124-$585 billion across the lifespan because of chronic medical conditions, productivity loss in the workplace, mental health problems, incarceration and encounters with the criminal justice system, special education, child welfare, and poverty (Dowd et al., 2014). The evolution of ACEs has now become a public health topic. Rationale In 2016, nearly half of all children nationally (35%) had experienced at least one ACE event, (Child and Adolescent Health Measurement Initiative, 2017). The prevalence of ACEs in Maryland is 41.6% compared with Baltimore City, where 56% of children have experienced at least one ACE (Childhealth.org; Bethell, Gombojav, Solloway, & Wissow, 2016). Nineteen percent of children in Maryland have experienced more than two ACEs as compared with 30% of children residing in Baltimore City (Childhealth.org; Bethell et al., 2016). However, not all practices screen for ACEs. A community assessment of the project clinic’s surrounding neighborhoods demonstrated a lower readiness for kindergarten, higher incarceration rate, higher Intimate partner violence rate, higher dropout rates, and lower life expectancy than other areas in the city, making this patient population more vulnerable to these negative outcomes (Child and Adolescent Measurement Initiative, 2014). Children below or at poverty level are greater higher risk for ACEs, therefore requiring early screening, detection, prevention, and intervention (Bethell et al., 2016). Despite the prevalence and the lifelong effects, the project clinic did not have a systematic process of screening for ACEs or utilizing an ACEs screening tool in clinic. The AAP has advocated that the primary care provider (PCP) do more to address ACEs in primary care settings. The evidence suggests that training and educating in ACE screening and interventions in primary care will increase provider knowledge and competence (Flynn et al., 2015). Specific Aims Based on the AAP’s best practices to implement the ACEs screening tool, the purpose of this QI project was to increase pediatric provider awareness on the ACE screening tool, to implement the ACEs screening tool in the primary care clinic, and identify those patients at high risk. 2
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Aim 1 of the project was to assess the provider’s knowledge of ACEs and the screening tool at baseline, as measured by a pre-test, completion of an educational intervention, and followed by a post-test. Aim 2 was to introduce the screening tool into practice, as measured by the sum of the number of screening tools collected weekly. Aim 3 was to evaluate the percentage of providers who utilized the screening tool weekly. METHODS Context This was a QI project, utilizing an educational intervention and a pre-post test to determine if there was a difference in provider awareness and knowledge of ACEs. The target sample included all 59 primary care providers in an outpatient primary care clinic, which included 57 medical residents and two nurse practitioners. No providers were excluded. The providers that participated were from a single clinical site. Setting The setting was a pediatric primary care clinic within a large, urban academic-based hospital located in an inner city in the Mid-Atlantic area of the United States. The primary care clinic serves as a medical home for over 8,400 patients (aged 0−21 years), 90% of whom receive medical assistance and majority of families are African American. Forty percent of the patient population has had at least one chronic medical condition or significant psychosocial problem. Intervention The education intervention was adopted from the AAP trauma toolkit to form a trauma-informed care practice (http://www.aap.org/en-us/advocacy-and-policy/aaphealth-initiatives/healthy-foster-care-america/Pages/ Trauma-Guide.aspx). The educational intervention included a PowerPoint presentation which included, the background of the original ACE study, the definition of ACE, who/ what/why was this patient population is at risk, the importance of screening, how to overcome barriers, screening for ACEs in this clinic and next steps. All providers received the same educational intervention. Attendance was recorded to track when providers completed the training. There were additional educational sessions provided to the nurse practitioners, registered nurses, clinical nursing technicians, social workers, mental health providers, and case managers. During well-child care visits, over the 12-week implementation period, the nursing staff distributed the Center for Youth & Wellness (CYW) ACEs screening tool. A letter was attached to the screening tool, to state to caregivers and/or parents why the tool was being implemented, as this was one of the recommendations made in the AAP trauma toolkit. A symptoms checklist was also included in the letter, to allow patients and families to report any relevant symptomatology to allow the provider to integrate the ACE screening tool and relevant symptoms to determine if a referral was warranted.
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ARTICLE IN PRESS As part of the QI project, each clinic group received monthly face-to-face reminders, as well as e-mails to encourage them to screen for ACEs, as a result, the reminders may have influenced the increase in screening. As a way of gathering data, the ACEs screening tool was collected after well-child care visits in “real time” and tallied on a weekly basis. The electronic medical records were reviewed weekly to keep track of the total number of wellchild care visits (denominator) vs. the number of patients who completed the tool (numerator). The auditing of the electronic health record was used in conjunction with the collected screening tools to ensure the accuracy of the rates. Measures Data was collected by assessing the provider’s knowledge of ACEs. The knowledge survey was developed based on the recommendations of the AAP trauma tool kit (http://www. aap.org/en-us/advocacy-and-policy/aap-health-initiatives/ healthy-foster-care-america/Pages/Trauma-Guide.aspx), as well as evidence found in the literature as to the reasons providers did not screen (Szilagyi et al., 2016). Prior to distributing the pre-test survey, content validity of the survey was completed. Two clinic case managers, two social workers, two clinical technicians, one registered nurse, one patient service coordinator, and one pediatric nurse practitioner used the content validity evaluation tool based on questions used in the literature (Szilagyi et al., 2016). Both the pre- and post-survey included a 5-point Likert scale with questions ranging from strongly disagree to strongly agree to obtain baseline knowledge of the provider’s awareness of ACEs. The survey included how familiar providers were with ACEs, what the role of the PCP was, and comfort level of screening for sensitive information, barriers, and resources for positive screening. Analysis Paired t-tests were performed with each variable independently to analyze if there were any changes in the provider’s scores before and after the educational intervention. Paired t-tests were also performed to analyze the total scores of the provider’s knowledge of ACEs and screening. Descriptive statistics were utilized on participant demographics.
Ethical Considerations This project was reviewed and determine to be nonhuman subject research by Johns Hopkins Medicine’s Institutional Review Board. RESULTS Results Related to Provider Awareness Fifty-nine clinic providers participated in the QI project. There was a 100% response rate to the baseline ACE knowledge survey and an 88% (n = 52) response rate of the posttest survey. There were no exclusions. Project sample demographic characteristics of the providers was collected (Table 1). The age of the providers ranged from 24−63 years with the mean age of 30.78 years. There were more female providers than male providers and majority of the providers were White. The breakdown of providers included 29% interns, 29% assistant residents, 39% senior assistant residents, and 3% nurse practitioners. The number of providers in this clinic was like other pediatric resident’s primary care clinics in this geographic area. The pre-survey of the provider’s familiarity of ACEs and screening demonstrated a mean (SD) of 3.52 (1.04) and post-survey mean (SD) was 4.33 (0.52; see Table 2). There
TABLE 1. Health care provider demographic characteristics N = 59 n (%)
Characteristics Mean age in years § (SD) Gender Female Male Race White African American Asian Other Type of provider Intern Assistant esident Senior assistant resident Nurse practitioner
30.8 + 6.5 45 (76.3) 14 (23.7) 44 (74.6) 5 (8.5) 9 (15.3) 1 (1.7) 17 (28.8) 17 (28.8) 23 (39.0) 2 (3.4)
TABLE 2. Health care provider knowledge on ACEs pre- and posttest results Variable
Knowledgeable of ACEs & screening Role of PCP in screening for ACEs Provider’s comfort level in screening for ACEs Provider’s perception of having sufficient time to screen Provider’s Awareness of resources for positive screenings Provider’s total pre-post test scores of knowledge of screening for ACEs
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Difference in scores
p value
Pre-test scores (n=59) M (SD)
Post-test scores (n=52) M (SD)
3.52 (1.038) 4.19 (0.687) 3.06 (0.916) 2.38 (0.796) 2.50 (0.960)
4.33 (0.513) 4.35 (0.556) 3.75 (0.682) 2.75 (0.837) 3.63 (0.864)
0.81 0.15 0.69 0.37 .1.14
0.00 0.13 0.00 0.02 0.00
15.71 (2.585)
18.92 (2.222)
3.21
0.00
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ARTICLE IN PRESS was statistically significant improvement in the provider’s knowledge after ACE education (p < .001). The pre-survey of the provider’s role of screening for ACEs (mean [SD], 4.19 [0.69]) and post-survey (mean [SD], 4.35 [0.56]) showed an improvement in the mean scores of 0.15, which was not statistical significance (p = .13). The pre-survey of the provider’s comfort level of screening (mean [SD], 3.06 [0.92]) and post-survey (mean [SD], 3.75 [0.68]) showed an improvement in the mean scores of 0.69 and was statistically significant (p < .001). The pre-survey of the provider’s perception of sufficient time to screen for ACEs (mean [SD], 2.38 [0.8]) and post-survey (mean [SD], 2.75 [0.84]). The pre-survey of the provider’s awareness of resources for positive screening tools (mean [SD], 2.50 [0.96]) and post-survey (mean [SD], 3.63 [0.86]) showed a statistically significant improvement in the provider’s awareness of resources (p < .001) and an increase in the mean scores of 1.14. The pre-survey of the provider’s total knowledge scores of ACEs and screening (mean [SD], 15.71 [2.59]) and post-survey (mean [SD], 18.92 [2.22]) showed an improvement in the mean scores of 3.21 and was statistically significant (p values < 0.001).
Results Related to Practice Change Prior to implementation, the clinic did not use the screening tool. After 12 weeks of implementing the tool, the clinic collected 480 screening tools, with 31 tools that were incomplete. Overall, there were 93% (n = 55) of providers who utilized the screening tool and 7% (n = 4) of the providers that did not utilize the tool. Twenty-nine percent (n = 17) of providers used the tool with 1:3 patients, 25% (n = 15) used the tool with 4:6 patients, 22% (n = 13) used the tool with 7:9 patients and 17% (n = 10) used the tool with ≥10 patients. Other than the nurse practitioners (NP), who practice in clinic daily, the Monday morning clinic had the most patient usage of screening tools. This was clinically significant as we had such a high rate of screenings completed and high provider participation. The frequency of provider usage is shown in Figure 1 (mean [SD], 5.38 [3.99]). There was one outlier removed, which was an NP who utilized the tool almost daily. The providers (n = 52) were also surveyed to see how open they were to continue to screen for ACEs after the completion of this QI project. There were 87% (n = 45) of the providers who agreed or strongly agreed that they would continue to screen for ACEs. This was very encouraging as the plan is to continue to utilize the ACE screening tool in this practice. Over the 12 weeks of implementation, the number of opportunities for providers to use the screening tool, during well-child checks versus the actual number of tools collected in the clinic varied weekly, ranging from 22 to 61, as shown in Figure 2. Figure 3 reports the total percentages of parents or patients whom completed the tool weekly, ranging from 16%:47%. 4
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FIGURE 1. Frequency of provider use of the ACE screening tool.
(This figure appears in color online at www.jpedhc.org.)
DISCUSSION Summary Interpretation Most important finding to-date was the total number of children screened using the ACE tool. Four hundred eighty children were screened over a 12-week period. This has the potential to identify children and families at risk and initiate services in a timelier manner. Additionally, provider knowledge of ACEs and utilization of the screening tool during well-child care visits improved. The results of this project were successful in that, the clinic is now using the ACE screening tool as part of the regular screening during wellchild exams for children and families. It has been adopted by the practice and is part of the orientation for new providers, medical students, and residents. The providers in this clinic survey response was like other providers in other studies. A similar study performed by Szilagyi et al. (2016) found that 80% of providers were familiar with ACEs compared with the 68.2% of the providers in the current. In another study that involved medical residents, 89.9% reported they did not have enough time to screen compared with 62.7% of these providers (Tink, Tink, Turon, & Kelly, 2017). Another strength of this project was the continued attention from the AAP, local and national news on the impact of ACEs on our pediatric population. This raise of awareness helped to strengthen the provider’s commitment to the utilization of the screening tool. Every 4 weeks, the number of providers who utilized the screening tool would increase. Limitations One limitation was the fact that a patient could refuse to complete the screening tool. Therefore, it was also difficult to determine if the lack of screening tools completed were provider-dependent or patient-dependent. Another limitation was the burden on staff to distribute the screening tool during staffing shortages.
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ARTICLE IN PRESS FIGURE 2. Number of screening tools collected compared with number of well-child care visits weekly
(This figure appears in color online at www.jpedhc.org.)
FIGURE 3. Percentage of patients who completed the screening tool
(This figure appears in color online at www.jpedhc.org.)
CONCLUSIONS While this clinic did not utilize a screening tool at the beginning of the implementation phase, it progressed to the collection of 480 screening tools at the end of the 12 weeks. The results informed the clinic on ACEs and the importance of screening, that it is now standard of care to implement the ACE screening tool at each well-child visit. Additionally, the data of this project demonstrated that providers continued to feel that they did not have sufficient time to screen because of adding another task
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to their workload, although they have made great progress in screening for ACEs Future QI projects Future QI projects to include tracking those patients who have screened positive for ACEs with close follow-up to determine if identifying those patients and offering resources early can decrease chronic illnesses and school performances. The QI project would measure if early screening improved chronic illnesses and school performance.
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ARTICLE IN PRESS Providing ongoing training to providers on building resiliency in patients and families is important for providers to continue to screen for ACEs. Practice implications for this clinic includes receiving tow grants from the Primary Care Consortium (PCC) and Association of Pediatric Program to create and implement a curriculum to its providers in Adverse Childhood Experiences and Trauma Informed Care. The clinic also receive another grant designed to promote positive parent-child interactions. The literature shows that continuing education curriculums should include ACEs to increase provider’s awareness of ACEs (Flynn et al., 2015). Primary care providers can utilize their role as patient advocates outside of the healthcare setting to include supporting health policies locally and nationally and raise public awareness of ACEs (Girouard & Bailey, 2017). After the implementation and provider acceptance of this QI project, screening for Adverse Childhood Experiences will become a part of the clinical practice, based on best evidence based practice. Based on best evidence-based practices, education on screening will become a part of the residency-training program, beginning with the new academic year of 2019. Pediatric providers will also receive ongoing training through monthly lectures, screening tools, interventions, challenging cases, and provider self-care and resilience promotion. Those children who are identified with high scores on the ACEs screening tool will be referred to the core team of social work, mental health, case management, and the family resource desk. The core team has worked closely with the community to identify resources for children and their families. In addition, a new member has been added to the core team which includes a community health worker (CHW) through a Population Health Initiative. The CHW has close follow-up with patients and families to ensure connections are made.
SUPPLEMENTARY MATERIALS Supplementary material associated with this article can be found in the online version at https://doi.org/10.1016/j. pedhc.2019.09.001.
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REFERENCES Anda, R. F., Butchart, A., Felitti, V. J., & Brown, D. W. (2010). Building a framework for global surveillance of the public health implications of adverse childhood experiences. American Journal of Preventive Medicine, 39, 93–98. Bethell, C., Gombojav, N., Solloway, M., & Wissow, L. (2016). Adverse childhood experiences, resilience and mindfulnessbased approaches: Common denominator issues for children with emotional, mental or behavioral problems. Child and Adolescent Psychiatric Clinics of North America, 25, 139– 156. Child and Adolescent Measurement Initiative (2014). Adverse childhood experiences among Baltimore and Maryland’s children. Retrieved from http://childhealthdata.org/learn/NSCH Child and Adolescent Health Measurement Initiative (2017). A national and across-state profile on Adverse Childhood Experiences among U.S. Children and possibilities to heal and thrive. Retrieved from http://aaa.cahmi.org/wp-content/uploads/ 2017/10/aces_brief_final.pdf Dowd, M. D., Forkey, H., Gillespie, R. J., Pettersen, T., Spector, L., & Stirling, J. (2014). Healthy foster care American: Trauma guide. Retrieved from https://www.aap.org/en-us/advocacy-and-pol icy/aap-health-initiatives/healthyfoster-care-america/Pages/ Trauma-Guide Flynn, A. B., Fothergill, K. E., Wilcox, H. C., Coleclough, E., Horwitz, R., Ruble, A., . . . Wissow, L. S. (2015). Primary care interventions to prevent or treat traumatic stress in childhood: A systematic review. Academic Pediatrics, 15, 480–492. Girouard, S., & Bailey, N. (2017). ACEs implications for nurses, nursing education, and nursing practice. Academic Pediatrics, 17, S16–S17. Hornor, G. (2015). Childhood trauma exposure and toxic stress: What the PNP needs to know. Journal of Pediatric Health Care, 29, 191–198. Shonkoff, J. P., & Garner, A. S. (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129, e232 −46. Shonkoff, J. P., Garner, A. S., Siegel, B. S., Dobbins, M. I., Earls, M. F., Garner, A. S., . . . Wood, D. L. (2012). The lifelong effects and early childhood adversity and toxic stress. American Academy of Pediatrics Technical Report, 129, e232–e246. Szilagyi, M., Kerker, B. D., Storfer-Isser, A., Stein, R. E. K., Garner, A., . . . McCue Horwitz, S. (2016). Factors associated with whether pediatricians inquire about parents’ adverse childhood experiences. Academic Pediatrics, 16, 668–675. Tink, W., Tink, J. C., Turon, T. C., & Kelly, M. (2017). Adverse childhood experiences: Survey of resident practice, knowledge and attitudes. Society of Teachers of Family Medicine, 49(1), 7–13.
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Screening for Adverse Childhood Experiences in Primary Care: A Quality Improvement Project Charnita Bryant, DNP, MS, CPNP, & Brigit VanGraafeiland, DNP, CRNP, FAAN ABSTRACT Introduction: The American Academy of Pediatrics (AAP) advocates for the screening of Adverse Childhood Experiences (ACEs) during well-child care visits by pediatric health care providers. The evidence shows a strong correlation between children with high ACE scores and the likelihood of physical and mental health problems as adults. The purpose of this Quality Improvement (QI) project was to increase pediatric providers’ awareness on ACEs through education and increase the utilization of an ACE screening tool. Method: This QI project used a pre-post test to evaluate the effectiveness of the educational model and the utilization of the screening tool within an urban pediatric primary care clinic. Results: This project demonstrated an increase in provider awareness as well as a marked increase in the utilization of the screening tool. Discussion: Four hundred eighty ACE screening tools were collected over a 12-week period. By introducing the ACE screening tool as the standard of care in the primary care office, providers can provide early interventions to mitigate the potential untoward outcomes. This QI project also demonstrated that there was a statistical and clinical significance (p value < 0.001) in the provider’s
Charnita Bryant, Pediatric Nurse Practitioner, Johns Hopkins Harriet Lane Primary Care Clinic, Baltimore, MD. Brigit VanGraafeiland, Assistant Professor, Acute and Chronic Care, Johns Hopkins University School of Nursing, Baltimore, MD. Conflicts of interest: None to report. Correspondence: Brigit VanGraafeiland, DNP, CRNP, FAAN, Johns Hopkins University School of Nursing, 525 N. Wolfe St., Baltimore, MD 21205; e-mail: [email protected]. J Pediatr Health Care. (2019) 00, 1−6 0891-5245/$36.00 Copyright © 2019 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.pedhc.2019.09.001
www.jpedhc.org
knowledge pre-post the educational intervention. J Pediatr Health Care. (2019) XX, 1−6
KEY WORDS Adverse childhood experiences, primary care, trauma
INTRODUCTION Problem Description Ninety percent of children of all races, economic status, and geographic regions will experience at least one adverse childhood experience (ACE) in their lifetime (Hornor, 2015). ACEs are defined as traumatic events that occur during childhood. There are three categories of ACEs including child abuse, child neglect, and household challenges, such as witnessing a mother being abused, having a parent with substance use or mental illness, separation/divorce or death of a parent, or incarceration of a parent (Anda, Butchart, Felitti, & Brown, 2010; Shonkoff et al., 2012). The repeated exposure from ACEs, without a protective buffer, such as supportive parental relationships and supportive environments may lead to “toxic stress” (Shonkoff & Garner, 2012). Studies have shown that toxic stress interferes with brain development, learning, behavior, and mental health problems. It also affects body systems such as cardiovascular, autoimmune, central nervous system and endocrine that lead to chronic health problems into adulthood (Shonkoff & Garner, 2012). Children with positive ACE scores have an increased risk of having one or more chronic medical conditions such as asthma, obesity, diabetes, heart disease and stroke (Shonkoff & Garner, 2012). BACKGROUND Available Knowledge The American Academy of Pediatrics (AAP) released a policy statement on Adverse Childhood Experiences (ACEs) 000 2019
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ARTICLE IN PRESS i.e. Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science into Lifelong Health (Shonkoff & Garner, 2012). The policy describes the essential role of the primary care provider, including the pediatric nurse practitioner in screening routinely for ACEs. Kaiser Permanente along with the Centers for Disease and Control (CDC) conducted the initial study on ACEs in 1998 to identify a link between ACEs and current health status and behaviors in adults (Anda et al., 2010). The evidence demonstrated that adults with six or more ACEs have a reduction in life expectancy of 20 years, as compared with their counterparts without ACE exposures (Dowd et al., 2014). Current research estimates the costs associated with ACEs could range between $124-$585 billion across the lifespan because of chronic medical conditions, productivity loss in the workplace, mental health problems, incarceration and encounters with the criminal justice system, special education, child welfare, and poverty (Dowd et al., 2014). The evolution of ACEs has now become a public health topic. Rationale In 2016, nearly half of all children nationally (35%) had experienced at least one ACE event, (Child and Adolescent Health Measurement Initiative, 2017). The prevalence of ACEs in Maryland is 41.6% compared with Baltimore City, where 56% of children have experienced at least one ACE (Childhealth.org; Bethell, Gombojav, Solloway, & Wissow, 2016). Nineteen percent of children in Maryland have experienced more than two ACEs as compared with 30% of children residing in Baltimore City (Childhealth.org; Bethell et al., 2016). However, not all practices screen for ACEs. A community assessment of the project clinic’s surrounding neighborhoods demonstrated a lower readiness for kindergarten, higher incarceration rate, higher Intimate partner violence rate, higher dropout rates, and lower life expectancy than other areas in the city, making this patient population more vulnerable to these negative outcomes (Child and Adolescent Measurement Initiative, 2014). Children below or at poverty level are greater higher risk for ACEs, therefore requiring early screening, detection, prevention, and intervention (Bethell et al., 2016). Despite the prevalence and the lifelong effects, the project clinic did not have a systematic process of screening for ACEs or utilizing an ACEs screening tool in clinic. The AAP has advocated that the primary care provider (PCP) do more to address ACEs in primary care settings. The evidence suggests that training and educating in ACE screening and interventions in primary care will increase provider knowledge and competence (Flynn et al., 2015). Specific Aims Based on the AAP’s best practices to implement the ACEs screening tool, the purpose of this QI project was to increase pediatric provider awareness on the ACE screening tool, to implement the ACEs screening tool in the primary care clinic, and identify those patients at high risk. 2
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Aim 1 of the project was to assess the provider’s knowledge of ACEs and the screening tool at baseline, as measured by a pre-test, completion of an educational intervention, and followed by a post-test. Aim 2 was to introduce the screening tool into practice, as measured by the sum of the number of screening tools collected weekly. Aim 3 was to evaluate the percentage of providers who utilized the screening tool weekly. METHODS Context This was a QI project, utilizing an educational intervention and a pre-post test to determine if there was a difference in provider awareness and knowledge of ACEs. The target sample included all 59 primary care providers in an outpatient primary care clinic, which included 57 medical residents and two nurse practitioners. No providers were excluded. The providers that participated were from a single clinical site. Setting The setting was a pediatric primary care clinic within a large, urban academic-based hospital located in an inner city in the Mid-Atlantic area of the United States. The primary care clinic serves as a medical home for over 8,400 patients (aged 0−21 years), 90% of whom receive medical assistance and majority of families are African American. Forty percent of the patient population has had at least one chronic medical condition or significant psychosocial problem. Intervention The education intervention was adopted from the AAP trauma toolkit to form a trauma-informed care practice (http://www.aap.org/en-us/advocacy-and-policy/aaphealth-initiatives/healthy-foster-care-america/Pages/ Trauma-Guide.aspx). The educational intervention included a PowerPoint presentation which included, the background of the original ACE study, the definition of ACE, who/ what/why was this patient population is at risk, the importance of screening, how to overcome barriers, screening for ACEs in this clinic and next steps. All providers received the same educational intervention. Attendance was recorded to track when providers completed the training. There were additional educational sessions provided to the nurse practitioners, registered nurses, clinical nursing technicians, social workers, mental health providers, and case managers. During well-child care visits, over the 12-week implementation period, the nursing staff distributed the Center for Youth & Wellness (CYW) ACEs screening tool. A letter was attached to the screening tool, to state to caregivers and/or parents why the tool was being implemented, as this was one of the recommendations made in the AAP trauma toolkit. A symptoms checklist was also included in the letter, to allow patients and families to report any relevant symptomatology to allow the provider to integrate the ACE screening tool and relevant symptoms to determine if a referral was warranted.
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ARTICLE IN PRESS As part of the QI project, each clinic group received monthly face-to-face reminders, as well as e-mails to encourage them to screen for ACEs, as a result, the reminders may have influenced the increase in screening. As a way of gathering data, the ACEs screening tool was collected after well-child care visits in “real time” and tallied on a weekly basis. The electronic medical records were reviewed weekly to keep track of the total number of wellchild care visits (denominator) vs. the number of patients who completed the tool (numerator). The auditing of the electronic health record was used in conjunction with the collected screening tools to ensure the accuracy of the rates. Measures Data was collected by assessing the provider’s knowledge of ACEs. The knowledge survey was developed based on the recommendations of the AAP trauma tool kit (http://www. aap.org/en-us/advocacy-and-policy/aap-health-initiatives/ healthy-foster-care-america/Pages/Trauma-Guide.aspx), as well as evidence found in the literature as to the reasons providers did not screen (Szilagyi et al., 2016). Prior to distributing the pre-test survey, content validity of the survey was completed. Two clinic case managers, two social workers, two clinical technicians, one registered nurse, one patient service coordinator, and one pediatric nurse practitioner used the content validity evaluation tool based on questions used in the literature (Szilagyi et al., 2016). Both the pre- and post-survey included a 5-point Likert scale with questions ranging from strongly disagree to strongly agree to obtain baseline knowledge of the provider’s awareness of ACEs. The survey included how familiar providers were with ACEs, what the role of the PCP was, and comfort level of screening for sensitive information, barriers, and resources for positive screening. Analysis Paired t-tests were performed with each variable independently to analyze if there were any changes in the provider’s scores before and after the educational intervention. Paired t-tests were also performed to analyze the total scores of the provider’s knowledge of ACEs and screening. Descriptive statistics were utilized on participant demographics.
Ethical Considerations This project was reviewed and determine to be nonhuman subject research by Johns Hopkins Medicine’s Institutional Review Board. RESULTS Results Related to Provider Awareness Fifty-nine clinic providers participated in the QI project. There was a 100% response rate to the baseline ACE knowledge survey and an 88% (n = 52) response rate of the posttest survey. There were no exclusions. Project sample demographic characteristics of the providers was collected (Table 1). The age of the providers ranged from 24−63 years with the mean age of 30.78 years. There were more female providers than male providers and majority of the providers were White. The breakdown of providers included 29% interns, 29% assistant residents, 39% senior assistant residents, and 3% nurse practitioners. The number of providers in this clinic was like other pediatric resident’s primary care clinics in this geographic area. The pre-survey of the provider’s familiarity of ACEs and screening demonstrated a mean (SD) of 3.52 (1.04) and post-survey mean (SD) was 4.33 (0.52; see Table 2). There
TABLE 1. Health care provider demographic characteristics N = 59 n (%)
Characteristics Mean age in years § (SD) Gender Female Male Race White African American Asian Other Type of provider Intern Assistant esident Senior assistant resident Nurse practitioner
30.8 + 6.5 45 (76.3) 14 (23.7) 44 (74.6) 5 (8.5) 9 (15.3) 1 (1.7) 17 (28.8) 17 (28.8) 23 (39.0) 2 (3.4)
TABLE 2. Health care provider knowledge on ACEs pre- and posttest results Variable
Knowledgeable of ACEs & screening Role of PCP in screening for ACEs Provider’s comfort level in screening for ACEs Provider’s perception of having sufficient time to screen Provider’s Awareness of resources for positive screenings Provider’s total pre-post test scores of knowledge of screening for ACEs
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Difference in scores
p value
Pre-test scores (n=59) M (SD)
Post-test scores (n=52) M (SD)
3.52 (1.038) 4.19 (0.687) 3.06 (0.916) 2.38 (0.796) 2.50 (0.960)
4.33 (0.513) 4.35 (0.556) 3.75 (0.682) 2.75 (0.837) 3.63 (0.864)
0.81 0.15 0.69 0.37 .1.14
0.00 0.13 0.00 0.02 0.00
15.71 (2.585)
18.92 (2.222)
3.21
0.00
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ARTICLE IN PRESS was statistically significant improvement in the provider’s knowledge after ACE education (p < .001). The pre-survey of the provider’s role of screening for ACEs (mean [SD], 4.19 [0.69]) and post-survey (mean [SD], 4.35 [0.56]) showed an improvement in the mean scores of 0.15, which was not statistical significance (p = .13). The pre-survey of the provider’s comfort level of screening (mean [SD], 3.06 [0.92]) and post-survey (mean [SD], 3.75 [0.68]) showed an improvement in the mean scores of 0.69 and was statistically significant (p < .001). The pre-survey of the provider’s perception of sufficient time to screen for ACEs (mean [SD], 2.38 [0.8]) and post-survey (mean [SD], 2.75 [0.84]). The pre-survey of the provider’s awareness of resources for positive screening tools (mean [SD], 2.50 [0.96]) and post-survey (mean [SD], 3.63 [0.86]) showed a statistically significant improvement in the provider’s awareness of resources (p < .001) and an increase in the mean scores of 1.14. The pre-survey of the provider’s total knowledge scores of ACEs and screening (mean [SD], 15.71 [2.59]) and post-survey (mean [SD], 18.92 [2.22]) showed an improvement in the mean scores of 3.21 and was statistically significant (p values < 0.001).
Results Related to Practice Change Prior to implementation, the clinic did not use the screening tool. After 12 weeks of implementing the tool, the clinic collected 480 screening tools, with 31 tools that were incomplete. Overall, there were 93% (n = 55) of providers who utilized the screening tool and 7% (n = 4) of the providers that did not utilize the tool. Twenty-nine percent (n = 17) of providers used the tool with 1:3 patients, 25% (n = 15) used the tool with 4:6 patients, 22% (n = 13) used the tool with 7:9 patients and 17% (n = 10) used the tool with ≥10 patients. Other than the nurse practitioners (NP), who practice in clinic daily, the Monday morning clinic had the most patient usage of screening tools. This was clinically significant as we had such a high rate of screenings completed and high provider participation. The frequency of provider usage is shown in Figure 1 (mean [SD], 5.38 [3.99]). There was one outlier removed, which was an NP who utilized the tool almost daily. The providers (n = 52) were also surveyed to see how open they were to continue to screen for ACEs after the completion of this QI project. There were 87% (n = 45) of the providers who agreed or strongly agreed that they would continue to screen for ACEs. This was very encouraging as the plan is to continue to utilize the ACE screening tool in this practice. Over the 12 weeks of implementation, the number of opportunities for providers to use the screening tool, during well-child checks versus the actual number of tools collected in the clinic varied weekly, ranging from 22 to 61, as shown in Figure 2. Figure 3 reports the total percentages of parents or patients whom completed the tool weekly, ranging from 16%:47%. 4
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FIGURE 1. Frequency of provider use of the ACE screening tool.
(This figure appears in color online at www.jpedhc.org.)
DISCUSSION Summary Interpretation Most important finding to-date was the total number of children screened using the ACE tool. Four hundred eighty children were screened over a 12-week period. This has the potential to identify children and families at risk and initiate services in a timelier manner. Additionally, provider knowledge of ACEs and utilization of the screening tool during well-child care visits improved. The results of this project were successful in that, the clinic is now using the ACE screening tool as part of the regular screening during wellchild exams for children and families. It has been adopted by the practice and is part of the orientation for new providers, medical students, and residents. The providers in this clinic survey response was like other providers in other studies. A similar study performed by Szilagyi et al. (2016) found that 80% of providers were familiar with ACEs compared with the 68.2% of the providers in the current. In another study that involved medical residents, 89.9% reported they did not have enough time to screen compared with 62.7% of these providers (Tink, Tink, Turon, & Kelly, 2017). Another strength of this project was the continued attention from the AAP, local and national news on the impact of ACEs on our pediatric population. This raise of awareness helped to strengthen the provider’s commitment to the utilization of the screening tool. Every 4 weeks, the number of providers who utilized the screening tool would increase. Limitations One limitation was the fact that a patient could refuse to complete the screening tool. Therefore, it was also difficult to determine if the lack of screening tools completed were provider-dependent or patient-dependent. Another limitation was the burden on staff to distribute the screening tool during staffing shortages.
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ARTICLE IN PRESS FIGURE 2. Number of screening tools collected compared with number of well-child care visits weekly
(This figure appears in color online at www.jpedhc.org.)
FIGURE 3. Percentage of patients who completed the screening tool
(This figure appears in color online at www.jpedhc.org.)
CONCLUSIONS While this clinic did not utilize a screening tool at the beginning of the implementation phase, it progressed to the collection of 480 screening tools at the end of the 12 weeks. The results informed the clinic on ACEs and the importance of screening, that it is now standard of care to implement the ACE screening tool at each well-child visit. Additionally, the data of this project demonstrated that providers continued to feel that they did not have sufficient time to screen because of adding another task
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to their workload, although they have made great progress in screening for ACEs Future QI projects Future QI projects to include tracking those patients who have screened positive for ACEs with close follow-up to determine if identifying those patients and offering resources early can decrease chronic illnesses and school performances. The QI project would measure if early screening improved chronic illnesses and school performance.
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ARTICLE IN PRESS Providing ongoing training to providers on building resiliency in patients and families is important for providers to continue to screen for ACEs. Practice implications for this clinic includes receiving tow grants from the Primary Care Consortium (PCC) and Association of Pediatric Program to create and implement a curriculum to its providers in Adverse Childhood Experiences and Trauma Informed Care. The clinic also receive another grant designed to promote positive parent-child interactions. The literature shows that continuing education curriculums should include ACEs to increase provider’s awareness of ACEs (Flynn et al., 2015). Primary care providers can utilize their role as patient advocates outside of the healthcare setting to include supporting health policies locally and nationally and raise public awareness of ACEs (Girouard & Bailey, 2017). After the implementation and provider acceptance of this QI project, screening for Adverse Childhood Experiences will become a part of the clinical practice, based on best evidence based practice. Based on best evidence-based practices, education on screening will become a part of the residency-training program, beginning with the new academic year of 2019. Pediatric providers will also receive ongoing training through monthly lectures, screening tools, interventions, challenging cases, and provider self-care and resilience promotion. Those children who are identified with high scores on the ACEs screening tool will be referred to the core team of social work, mental health, case management, and the family resource desk. The core team has worked closely with the community to identify resources for children and their families. In addition, a new member has been added to the core team which includes a community health worker (CHW) through a Population Health Initiative. The CHW has close follow-up with patients and families to ensure connections are made.
SUPPLEMENTARY MATERIALS Supplementary material associated with this article can be found in the online version at https://doi.org/10.1016/j. pedhc.2019.09.001.
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REFERENCES Anda, R. F., Butchart, A., Felitti, V. J., & Brown, D. W. (2010). Building a framework for global surveillance of the public health implications of adverse childhood experiences. American Journal of Preventive Medicine, 39, 93–98. Bethell, C., Gombojav, N., Solloway, M., & Wissow, L. (2016). Adverse childhood experiences, resilience and mindfulnessbased approaches: Common denominator issues for children with emotional, mental or behavioral problems. Child and Adolescent Psychiatric Clinics of North America, 25, 139– 156. Child and Adolescent Measurement Initiative (2014). Adverse childhood experiences among Baltimore and Maryland’s children. Retrieved from http://childhealthdata.org/learn/NSCH Child and Adolescent Health Measurement Initiative (2017). A national and across-state profile on Adverse Childhood Experiences among U.S. Children and possibilities to heal and thrive. Retrieved from http://aaa.cahmi.org/wp-content/uploads/ 2017/10/aces_brief_final.pdf Dowd, M. D., Forkey, H., Gillespie, R. J., Pettersen, T., Spector, L., & Stirling, J. (2014). Healthy foster care American: Trauma guide. Retrieved from https://www.aap.org/en-us/advocacy-and-pol icy/aap-health-initiatives/healthyfoster-care-america/Pages/ Trauma-Guide Flynn, A. B., Fothergill, K. E., Wilcox, H. C., Coleclough, E., Horwitz, R., Ruble, A., . . . Wissow, L. S. (2015). Primary care interventions to prevent or treat traumatic stress in childhood: A systematic review. Academic Pediatrics, 15, 480–492. Girouard, S., & Bailey, N. (2017). ACEs implications for nurses, nursing education, and nursing practice. Academic Pediatrics, 17, S16–S17. Hornor, G. (2015). Childhood trauma exposure and toxic stress: What the PNP needs to know. Journal of Pediatric Health Care, 29, 191–198. Shonkoff, J. P., & Garner, A. S. (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129, e232 −46. Shonkoff, J. P., Garner, A. S., Siegel, B. S., Dobbins, M. I., Earls, M. F., Garner, A. S., . . . Wood, D. L. (2012). The lifelong effects and early childhood adversity and toxic stress. American Academy of Pediatrics Technical Report, 129, e232–e246. Szilagyi, M., Kerker, B. D., Storfer-Isser, A., Stein, R. E. K., Garner, A., . . . McCue Horwitz, S. (2016). Factors associated with whether pediatricians inquire about parents’ adverse childhood experiences. Academic Pediatrics, 16, 668–675. Tink, W., Tink, J. C., Turon, T. C., & Kelly, M. (2017). Adverse childhood experiences: Survey of resident practice, knowledge and attitudes. Society of Teachers of Family Medicine, 49(1), 7–13.
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