012 - Improving Rates of Adverse Childhood Experience Screenings at Well-Child Visits

Publication Number: 12.5153

Erin Smith, University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR, United States; Kristie Tso, University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR, United States; Elliot Taylor, University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR, United States; Rebecca Perin, Arkansas Children's Hospital, Little Rock, AR, United States

Background: Adverse Childhood Experiences (ACEs) are traumatic events in a child’s life that have been linked to poor health outcomes, academic setbacks, and relational disruption. These negative experiences can be identified by using the ACE-Questionnaire (ACE-Q) screener, which is a verified health screening tool for children. When physicians can screen and identify these at-risk children and plan trauma-informed interventions, negative outcomes can be improved.

Objective: This quality improvement project sought to increase the rate of ACE screening at Arkansas Children’s Hospital (ACH) outpatient teaching clinic. Pediatric residents rotate in this clinic throughout their training. Residents are expected to screen children ages 3-7 years old at well-child visits using the ACE-Questionnaire. Despite implementation in November 2021, ACE screening rates remained consistently low.

Design/Methods: This project involved five Plan-Do-Study-Act cycles to improve rates of ACE screening in the clinic. Cycle 1 involved 3 unique lectures on ACEs for residents, teaching faculty, and nursing staff. Cycle 2 adjusted the workflow of ACE screening, such that front desk staff was responsible for distributing ACE screeners to families, rather than overloaded nurses. Cycle 3 focused on patient and family education by posting informational ACEs flyers around clinic. Cycle 4 involved printing ACE screeners on bright colored paper to draw attention. For Cycle 5 an ACE-Q shortcut, or “dot phrase,” was created for the electronic medical record (EMR). The percentage of eligible children screened was plotted on a run chart to evaluate if statistically significant changes had been made.

Results: The center line (CL) was used to analyze statistically significant shifts in screening trends over these five PDSA cycles. When education occurred, the CL shifted from 2.00% to 4.55%. The largest shift in screening occurred when clinic workflow changed, and the CL shifted to 51.92%. There was a downward shift after posting educational flyers to a median of 31.25%. The creation of brightly colored screeners raised the CL to 55.77%. The CL remained at 55.77% after the “dot phrase” intervention.

Conclusion(s): Pediatric clinics desiring to increase ACE screening may benefit from a comprehensive approach that incorporates staff education, clinic flow improvement, and resident empowerment. Future interventions may integrate the ACE-Q into the EMR. Screening for ACEs remains a crucial step in identifying children at risk for poor health outcomes who may benefit from positive interventions.

Percentage of Patients Screened for ACEs at COF Clinic
Pediatric patients ages 3-7 were screened for ACEs at well-child visits at COF. Five interventions (staff education, workflow changes, educational flyers, updated colorful screeners, and creation of a "dot phrase" shortcut in the EMR) were implemented from 2023 to 2024 to improve screening rates. The median, or center line, was used to compare interventions.

Percentage of Patients Screened for ACEs at COF Clinic
Pediatric patients ages 3-7 were screened for ACEs at well-child visits at COF. Five interventions (staff education, workflow changes, educational flyers, updated colorful screeners, and creation of a "dot phrase" shortcut in the EMR) were implemented from 2023 to 2024 to improve screening rates. The median, or center line, was used to compare interventions.