ORIGINAL ARTICLE
A computerized kiosk to teach injury prevention: Is it as effective as human interaction? Michael A. Gittelman, MD, Wendy J. Pomerantz, MD, MS, Nicole McClanahan, Alison Damon, and Mona Ho, MS, Cincinnati, Ohio
An emergency department (ED) visit may be an effective place to screen and educate families about injury prevention. The purpose of this study was to determine if a computerized kiosk in a pediatric ED can screen families for injury risk and encourage them to make more safety changes at follow-up survey compared with an injury prevention specialist (IPS). METHODS: A prospective, randomized controlled study was performed with families of children younger than 14 years in an ED lobby. Families were screened for injury risk by computerized kiosk based on child’s age category at triage (birth to 1 year, 1Y4 years, 5Y9 years, or 10Y14 years). Families were randomized to receive either injury behavior instructions by kiosk printout or by IPS when answers to specific practices were deemed unsafe. Three weeks after intervention, families were telephoned to determine change in safety practices. RESULTS: Three hundred seventeen families completed ED kiosk screen at enrollment (172 kiosk, 145 IPS). On initial screen, kiosk families practiced 79.6% of behaviors safely versus 75.9% in the IPS group (p = 0.011). A total of 221 families (69.7%) were reached for follow-up (121 kiosk, 100 IPS). On average, IPS families improved their safe behavior responses by 8.3% versus 1.0% in the kiosk group (p G 0.0001). Significantly more families in the IPS group than in the kiosk group (36% vs. 23%, p G 0.03) used additional safety equipment after the intervention. CONCLUSION: A computerized kiosk based in a pediatric ED can help screen families for their injury risk. However, to elicit significant behavior change, an IPS discussing safety changes may be more effective. (J Trauma Acute Care Surg. 2014;77: S2YS7. Copyright * 2014 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Therapeutic study, level II. KEY WORDS: Kiosk; injury prevention; pediatric emergency department. BACKGROUND:
D
uring the last two decades, the emergency medicine literature has suggested that emergency department (ED) physicians should educate families about injury prevention (IP) practices in their setting.1Y5 In fact, a key component for the continuum of care for the pediatric patient, according to the Emergency Medical Service for Children IOM report,6 is IP. It has been postulated that the seriousness of an ED visit may render patients particularly receptive to a ‘‘teachable moment.’’7 Many patients present to the ED as a result of an injury; up to 17% of ED visits are caused by injuries,8 and 13% are severe enough to require hospital admission.9 This familiarity with injury care and the potential severity of the ED visit may offer ED physicians a unique opportunity to entice families to make significant IP behavior changes.10 Three studies, in particular, have shown that patients and families may change their safety practices based on the education they received in a pediatric ED setting. Johnston et al.11 Submitted: December 14, 2013, Revised: February 4, 2014, Accepted: February 17, 2014. From the Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio. This study was part of the oral presentation at the Annual Meeting of the Ambulatory Pediatric Association, April 2012, in Boston, Massachusetts. ClinicalTrials.gov Trial Registration Number: NCT01958099 Address for reprints: Michael A. Gittelman, MD, Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, MLC 2008 Cincinnati, OH 45229; email: [email protected]. DOI: 10.1097/TA.0000000000000317
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evaluated the impact of a 20-minute counseling session for teens presenting to the pediatric ED for changing an injuryrelated risk behavior (seat belt use, bicycle helmet use, driving after drinking, riding with an impaired driver, binge drinking, or carrying a weapon). At 3 months and 6 months after their visits, subjects that received IP counseling were more likely to use seat belts and bicycle helmets than controls. Posner et al.12 found similar results in a randomized trial of prevention education and safety device disbursement to youth presenting to a pediatric ED following injuries occurring in the home. They found that parents who had received the intervention had greater home safety knowledge, and more than 50% increased their use of home safety devices compared with control parents. Finally, a study conducted at the Cincinnati Children’s Hospital Medical Center (CCHMC) showed that youth injured in a minor motor vehicle collision and those seeking care for a noninjury complaint equally reported a 35% greater use in booster seats at follow-up after ED education.13 Unfortunately, screening for injury risk and providing education about IP are often not feasible in the ED because of limitations in staff, time, and a lack of IP knowledge by providers. Recently, computerized kiosks have been used to screen families for specific risky behaviors and then offer guided recommendations to families in a more cost-effective manner.14 Shields et al.15 showed that a pediatric ED kiosk can significantly increase knowledge about smoke alarm use and poison storage. The purpose of this study was to determine if a computerized kiosk in a pediatric ED can screen families for J Trauma Acute Care Surg Volume 77, Number 3, Supplement 1
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injury risk and encourage them to make more appropriate safety changes at follow-up survey compared with families receiving prevention recommendations from an IP specialist (IPS) in the same setting.
PATIENTS AND METHODS Study Design This was a prospective, randomized trial that occurred in the CCHMC pediatric ED. The study was conducted between August 16, 2010, and December 19, 2011. Approval was obtained from the CCHMC Institutional Review Board before initiating the study.
Study Setting and Population CCHMC is an academic, freestanding children’s hospital and a Level 1 trauma center with an annual pediatric ED volume of approximately 92,000 visits. The population served is diverse: 40% African American, 51% white, and 9% other. Roughly 20% of all pediatric ED visits are the result of injuries, and 1.5% of these visits are severe, requiring hospital admission. The average time to triage is 10 minutes to 15 minutes, and the average time to see a physician is 1 hour. Clinical research coordinators (CRCs) are available from 8:00 AM to 12:00 midnight Monday through Friday and 12:00 noon to 9:00 PM on Saturday and Sunday. A safety resource center that sells safety equipment at wholesale prices is located in the ED lobby and staffed Monday through Friday from 12:00 noon to 8:00 PM. Study participants were any parent/legal guardian with a child between the ages of birth through 14 years presenting to the ED for any chief complaint with a designated acuity of urgent or nonurgent. Any parent/guardian of a patient who was critically ill or triaged as emergent, any nonYEnglish-speaking individual, or any parent/guardian not present at the time of his or her child’s evaluation was excluded. If a participant left to an examination room before survey completion, an attempt was made to have them finish the study after their ED visit. Families who did not complete the kiosk survey or receive recommendations for change from either the kiosk printout or the IPS were excluded.
Screening Tool The computerized kiosk was obtained from Kiosk Information Systems, Inc. in Louisville, Colorado. The type was a Thinman-Dell with a 19-in LCD touchscreen. Software for the kiosk was developed by Intouch Kiosk Services in Atlanta, Georgia, with input from the study team. Questions were based on age-appropriate IP recommendations adapted from the American Academy of Pediatrics TIPP program.16 CRCs initiated the survey by typing in an assigned study number for the participant and then the appropriate age category for the child being seen in the ED. Age-based IP questions were grouped by the ages less than 1 year, 1 year to 4 years, 5 years to 9 years, and 10 years to 14 years. The survey consisted of baseline demographic information about the respondent (e.g., age, level of education, race, income, and sex) and several IP questions about current preventative behaviors they use for
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their child at that time. Families of children younger than 1 year answered 18 age-appropriate safety questions, while there were 21 questions for 1-year-olds to 4-year-olds, 21 for 5-yearolds to 9-year-olds, and 19 for 10-year-olds to 14-year-olds. Topics ranged from the use of bike helmets, child passenger safety seats, smoke or carbon monoxide detectors, and home safety equipment, depending on the age of the child at presentation to the ED. At completion, specific recommendations for behavior change, based on the family’s current practices, were provided at the kiosk by a computer printout (e.g., purchase a new product such as a booster seat or change an existing behavior such as batteries in a smoke detector). The screening tool was pretested with approximately 10 parents to ensure question clarity, ease of completion, and comfort with candidness in responding before study enrollment.
Study Protocol Families entering triage, Monday through Friday from 12 noon to 8:00 PM, that met inclusion criteria, were eligible for being approached based on CRC availability. Parents/guardians were given a summary sheet outlining participation and signed a waiver of documentation of consent after their initial triage assessment. Consenting participants were randomized on specific days of the week to receive IP recommendations from an IPS or from the computerized kiosk. A 20-day block random numbers table was used to determine the intervention chosen for that day. All families were initially screened using the computerized kiosk located in the corner of the large, ED waiting room. CRCs were available for questions or problems during kiosk use. Participants were asked to answer injury screening questions based on the age of the child they brought to the ED on that encounter. If two children were brought to be seen, the family could answer questions based on either aged child. After kiosk screening was completed, CRCs retrieved the computer printout with recommended behavior changes for the family. Depending on randomization, either families were handed the kiosk printout or they were taken to the IPS for verbal discussion about safety behavior recommendations based on IP categories in which parents were deemed to need a change from the kiosk screen. IPSs were located in the ED waiting room, in proximity to the kiosk, and they received specialized education on child passenger safety and IP practices through formal course training. IPS families were not provided with the kiosk printout. The time for completion and number of recommendations offered for both arms of the study were recorded by CRCs. On the waiver of consent form, families were asked for their two best telephone numbers to be contacted 3 weeks after enrollment. CRCs calling for follow-up were blinded as to what IP recommendations they received and how they received them. If the telephone numbers provided were disconnected or four calls during a 2-week period were attempted without connection, the family was considered lost to follow-up. The parent/legal guardian who completed the survey in the ED was the only person interviewed at follow-up. Follow-up surveys were similar to those posed at study onset to determine if self-reported changes of behavior were made based on recommendations. The percentage of mean correct responses before and after the surveys were compared. Moreover, questions regarding parent
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satisfaction with the survey tool and the recommendations received were asked.
Data Collection/Analysis Data were collected regarding why families declined participation. All data obtained by the kiosk were transferred automatically into an Excel spreadsheet. Data obtained pertaining to behavior change recommendations offered by the IPS were entered into the same Excel spreadsheet by the CRC. All data were identified by study number only. Data were compiled and analyzed using the SAS version 9.3 (Cary, NC). Frequencies were calculated for all demographic data. For the primary outcome, change in percentage of mean correct behavior responses per age, survey questions in the initial and follow-up surveys were compared. Moreover, at follow-up, families were asked if they made any change in their safety behavior from information they learned by the kiosk in the ED, and their responses were compared with the IPS group. W2 analysis for categorical variables and Student’s t test for continuous variables were used to determine if there was a difference between groups. A p G 0.05 was considered statistically significant.
Sample Size Sample size calculation was based on the primary outcome, percentage of families making a self-reported behavior change in each group. Estimates for sample size calculations were taken from our previous intervention work, showing that approximately 10% to 30% of the families make a self-reported behavior change after IPS counseling.13,17 Assuming the kiosk group receives more information specifically tailored to their child’s needs, we estimated that at least 30% of the families would make a self-reported behavior change at follow-up (20% more families would make the change based on the kiosk compared with the IPS). Based on this assumption, with a Type I error of 0.05 and power of 0.80, the desired sample size was 125 participants in each group to complete initial screen and follow-up survey.
RESULTS Figure 1 depicts participant enrollment into the study. Of the 637 approached, 359 (56%) consented to participate. Of those who consented, 191 (53.2%) were randomized to receive instructions from the kiosk printout, while 168 (46.8%) were given guidance by the IPS. Of these 359, 42 (11.7%) did not complete the initial screen in the ED and withdrew, leaving 172 (47.9%) in the kiosk group and 145 (40.4%) in the IPS education group. One hundred twenty-one families (70.3%) completed follow-up in the kiosk group, and 100 (69.0%) were reached in the IPS education group. There were no significant differences between the kiosk and IPS groups with regard to the demographic information for the respondents and the children except for age of the respondents (p = 0.03) (Table 1). Ages of the children enrolled, injuries sustained requiring a doctor’s visit, and family incomes between the groups were similar. On the initial screen, families randomized to receive education from the kiosk printout answered more questions correctly, reporting safer behaviors than those randomized to receive education from the IPS (p G 0.011) (Table 2). This difference in initial score was mainly seen in the age range 1 year to 4 years, while all other ages showed no difference in the percentage of questions answered correctly. Overall, families of older children reported to practice less safe behaviors compared with families with younger children. Table 2 shows the injury practices most commonly answered incorrectly on the initial screen by age. Families who received education from the IPS significantly improved on the repeat survey after guidance was provided compared with the kiosk group. (Table 3) Overall, parents educated by the IPS increased their self-reported changes in behavior on the screening tool by 8% compared with only 1% when receiving information from the kiosk. This improvement was seen in all age groups except for the children younger than 1 year. Moreover, families who received education from the IPS, when asked on the follow-up survey, reported to make
Figure 1. Numbers for study enrollment and follow-up. S4
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TABLE 1. Comparison of Demographic Variables Between Kiosk and IPS Education Group Kiosk (n = 172) Parent/guardian G 35 y* White race (child) Female sex (child) Mother taking survey Education high school graduate or lower Income G $30,000 annually Q2 children in the home Age of child enrolled G1 y 1Y4 y 5Y9 y 10Y14 y Zero injuries in the past requiring a doctor’s visit
IPS (n = 145)
Total (n = 317)
101 (58.7%) 102 (70.3) 203 (64.0%) 103 (60.0%) 96 (66.2%) 199 (62.8%) 85 (49.4%) 73 (50.3%) 158 (49.8%) 158 (91.9%) 131 (90.3%) 289 (91.2%) 58 (33.7%) 51 (35.2%) 109 (34.4%) 81 (47.1%) 114 (66.7%) 24 (14.0%) 59 (34.3%) 44 (25.6%) 45 (26.2%) 77 (45.0%)
55 (37.9%) 136 (42.9%) 99 (68.3%) 213 (67.2%) 23 56 42 24 75
(15.9%) 47 (14.8%) (38.6%) 115 (36.3%) (29.0%) 86 (27.1%) (16.6%) 69 (21.8%) (51.7%) 152 (47.9%)
*p G 0.05
a change in safety behavior in their home significantly more than the kiosk group (36% vs. 23%, p = 0.03). More IPS families compared with kiosk families reported that they made a purchase of new safety equipment, yet this was not shown to be significantly different (19% vs. 11%, p = 0.12). Families were more satisfied with the education they received from the IPS compared with the kiosk (91% vs. 81%, p = 0.03). The time to complete the screen and education in the ED was 2.1 minutes shorter with the kiosk group than with the IPS group (6.3 minutes vs. 8.4 minutes, p G 0.0001).
DISCUSSION This study demonstrates several important findings regarding IP screening and counseling in the pediatric ED setting.
TABLE 3. Change in Percent Correct Responses From Preevaluation to Postevaluation Period Percent Change in Appropriate Responses, Mean (SD)
Age Group (Kiosk, IPS), y Overall (121, 100) G1 (18, 15) 1Y4 (39, 43) 5Y9 (31, 26) 10Y14 (33, 16)
Kiosk
IPS
p
1.05 (9.04) 2.95 (7.83) j0.45 (9.92) 2.58 (8.13) 0.37 (9.36)
8.31 (8.62) 7.65 (10.16) 7.59 (8.74) 9.82 (9.04) 8.44 (6.14)
G0.0001 0.144 0.0002 0.002 0.003
First, it showed that families can be screened for their child’s risk of injury using a computerized kiosk in a busy ED waiting room. Most of the families were satisfied with the education they received, and the screening process was completed, on average, in 6 minutes. Another important finding was that families counseled by an IPS on IP topics in the ED setting had a greater mean percentage of behavior responses correct on follow-up surveys compared with families provided with specific written recommendations from the kiosk. Participants improved on their IP practices based on the screening tool by 8% at follow-up, and 36% reported to make at least one new behavior change after IPS counseling. Thus, screening for injury risk using a computerized kiosk is fast and easy, yet counseling about changing behavior may be more effective if provided by an individual. Similar to other ED studies in which a kiosk was used to screen families for injury, our study showed that families were generally satisfied with the tool and many were willing to participate while waiting in the lobby.14,18Y20 Vaca et al.21 showed that 75% of the participants preferred learning about an intervention for alcoholism from a computer rather than a medical professional. In our study, 81% in the kiosk education group were satisfied with the information they received; however, unlike the study of Vaca et al., there was greater satisfaction with a human specialist providing information compared
TABLE 2. Comparison of Initial Percent Questions Per Age Answered Correctly by Study Group and Most Common Questions Answered Incorrectly Kiosk Mean % Correct (n = 172)
IPS Mean % Correct (n = 145)
p
All ages G1
79.6 85.2
75.9 82.7
0.011 0.468
1Y4
82.9
75.0
0.0002
5Y9
79.3
77.8
0.623
10Y14
72.4
68.3
0.116
Age, y
Most Common Questions Answered Incorrectly (Both Groups) Hot water heater set atG120- (51%) Window guards used (34%) Carbon monoxide detector used (64%) Guard to protect stove (33%) Stair gates used (41%) Window guards used (45%) Booster seat when appropriate (48%) Child wears bike helmet always (61%) Carbon monoxide detector used (64%) Wears bike helmet always (47%) Sits in back seat always (54%) Stores medicines locked (61%)
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with the kiosk. Moreover, only 11.7% of the participants were unable to complete the screen while waiting in our ED lobby. If the tool were placed on a handheld device, changing locations would not have affected participation. This study showed that kiosks can rapidly screen families for large amounts of information to detect high-risk practices. The time to complete screening using our kiosk was only 6 minutes, and almost all evaluations were finished as families were waiting in the lobby. The idea of using a kiosk as a tool for screening in the ED setting has been shown in other studies as well.14,21 Moreover, computerized screening tools in the clinical environment allows an individual to answer uncomfortable topics, such as alcohol abuse or interpersonal violence, more freely.21,22 Besides screening for risk, the logic within the kiosk generated recommendations for families to make behavior changes. Our study showed that families were more likely to report a behavior change if they were counseled by a human IPS than if they received recommendations from a computerized printout. On rescreen of current safety practices, participants educated by the IPS improved on their correct responses by 8% compared with only 1% in the kiosk group. In addition, more participants in the IPS group made behavior changes in their home at follow-up compared with those who received kiosk instructions. Our study, like others, showed that families who receive recommendations from a computerized kiosk learn information and will make behavior changes.14,15,19,20 However, families are more likely to report a behavior change if human counseling is provided. Possibly, the ability to ask questions and receive information from an individual through social interaction helps to entice a family to practice safer behaviors than an impersonal computerized printout. The IPS has the ability to adapt education and responses based on the questions and needs of the family.23 This research has several limitations. First, the sample selected was based on convenience of the CRC with the ED setting. Families were only approached when CRCs were available. No demographic data were able to be collected on individuals who declined participation. The implications of bias from this limitation would be low in that both groups were screened similarly, and the main objective was to compare instructions offered by kiosk versus the IPS. Another potential limitation was that the IPS worked at the ED safety resource center. As a result, patients may have felt encouraged to purchase equipment after they were counseled by the IPS. However, only two participants made a purchase at the safety store from the IPS group and the kiosk was located adjacent to the safety resource center. Another limitation was that the kiosk group seemed to practice safer behaviors at the initial kiosk screen. This could limit the amount of change the kiosk group could make compared with the IPS group. Moreover, as in most studies with follow-up, some participants were unable to be reached; however, the amount lost was comparable in each group. Finally, follow-up to determine safety behavior changes was self-reported. The scope of this study would have made home visits too labor intensive. By comparing both groups similarly, one would expect that both groups would have the same bias in self-reporting, making comparisons between the groups reasonable. S6
Despite the limitations, this study demonstrated that a computerized kiosk in an ED waiting room may be an appropriate place to screen families for their child’s risk of injury. The time to complete screening was short, and families were satisfied with the service. Participants reported to practice safer behaviors after IPS counseling compared with those who received information from a kiosk, but both groups made changes. In the future, finding ways to combine kiosk screening in concert with human counseling may be the best approach to maximize behavior change. AUTHORSHIP M.A.G. contributed to all aspects of this article including the study design, literature search, drafting the institutional review board proposal, data analysis, drafting the initial manuscript, and approving the final manuscript. W.J.P. contributed to the study design, literature search, data analysis, and approval of the final manuscript. N.M. and A.D. contributed to the patient recruitment, kiosk implementation, education of the IPS, and approval of the final manuscript as submitted. M.H. contributed to the data analysis, data interpretation, tables, and figures and to the approval of the final manuscript.
DISCLOSURE This study was supported by the Ohio Department of Public ServiceY EMS Injury Prevention Research Grant, ‘‘Determining Efficacy of a Kioskbased Injury Prevention Education System in a Children’s Emergency Department,’’ July 1, 2009, to December 31, 2010, $116,205.
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12. Posner JC, Hawkins LA, Garcia-Espana F, Durbin DR. A randomized controlled trial of a home safety intervention based in an emergency department setting. Pediatrics. 2004;113:1603Y1608. 13. Gittelman MA, Pomerantz WJ, Ho M, Hornung R, McClanahan N. Is an emergency department encounter for a motor vehicle collision truly a ‘‘teachable moment’’. J Trauma Acute Care Surg. 2012;73(9 Suppl 3): S258YS261. 14. Gielen AC, McKenzie LB, McDonald EM, Shields WC, Wang MC, Cheng YJ, Weaver NL, Walker AR. Using a computer kiosk to promote child safety: results of a randomized, controlled trial in an urban pediatric emergency department. Pediatrics. 2007;120(2):330Y339. 15. Shields WC, McDonald EM, McKenzie L, Wang MC, Walker AR, Gielen AC. Using the pediatric emergency department to deliver tailored safety messages: results of a randomized controlled trial. Pediatr Emerg Care. 2013;29(5):628Y634. 16. Patient Education Online. The Injury Prevention Program. Available at: http://patiented.aap.org/categoryBrowse.aspx?catID=27. Accessed May 9, 2013. 17. Gittelman MA, Pomerantz WJ, Frey LK. Use of a safety resource center in a pediatric emergency department. Pediatr Emerg Care. 2009;25(7):429Y433.
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18. Shields WC, McDonald EM, Stepnitz R, McKenzie LT, Gielen AC. Dog bites: an opportunity for parent education in the pediatric emergency department. Pediatr Emerg Care. 2012;28(10):966Y970. 19. McDonald EM, Solomon B, Shields W, Serwint JR, Jacobsen H, Weaver NL, Kreuter M, Gielen AC. Evaluation of kiosk-based tailoring to promote household safety behaviors in an urban pediatric primary care practice. Patient Educ Couns. 2005;58(2):168Y181. 20. Maio RF, Shope JT, Blow FC, Gregor MA, Zakrajsek JS, Weber JE, Nypaver MM. A randomized controlled trial of an emergency departmentbased interactive computer program to prevent alcohol misuse among injured adolescents. Ann Emerg Med. 2005;45:420Y429. 21. Vaca F, Winn D, Anderson C, Kim D, Arcila M. Feasibility of emergency department bilingual computerized alcohol screening, brief intervention, and referral to treatment. Subst Abus. 2010;31(4):264Y269. 22. Houry D, Kemball R, Rhodes KV, Kaslow NJ. Intimate partner violence and mental health symptoms in African American female ED patients. Am J Emerg Med. 2006;24(4):444Y450. 23. Reid CA, Davis JL, Green JD. The power of change: interpersonal attraction as a function of attitude similarity and attitude alignment. J Soc Psychol. 2013;153:700Y719.
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A computerized kiosk to teach injury prevention: Is it as effective as human interaction? Michael A. Gittelman, MD, Wendy J. Pomerantz, MD, MS, Nicole McClanahan, Alison Damon, and Mona Ho, MS, Cincinnati, Ohio
An emergency department (ED) visit may be an effective place to screen and educate families about injury prevention. The purpose of this study was to determine if a computerized kiosk in a pediatric ED can screen families for injury risk and encourage them to make more safety changes at follow-up survey compared with an injury prevention specialist (IPS). METHODS: A prospective, randomized controlled study was performed with families of children younger than 14 years in an ED lobby. Families were screened for injury risk by computerized kiosk based on child’s age category at triage (birth to 1 year, 1Y4 years, 5Y9 years, or 10Y14 years). Families were randomized to receive either injury behavior instructions by kiosk printout or by IPS when answers to specific practices were deemed unsafe. Three weeks after intervention, families were telephoned to determine change in safety practices. RESULTS: Three hundred seventeen families completed ED kiosk screen at enrollment (172 kiosk, 145 IPS). On initial screen, kiosk families practiced 79.6% of behaviors safely versus 75.9% in the IPS group (p = 0.011). A total of 221 families (69.7%) were reached for follow-up (121 kiosk, 100 IPS). On average, IPS families improved their safe behavior responses by 8.3% versus 1.0% in the kiosk group (p G 0.0001). Significantly more families in the IPS group than in the kiosk group (36% vs. 23%, p G 0.03) used additional safety equipment after the intervention. CONCLUSION: A computerized kiosk based in a pediatric ED can help screen families for their injury risk. However, to elicit significant behavior change, an IPS discussing safety changes may be more effective. (J Trauma Acute Care Surg. 2014;77: S2YS7. Copyright * 2014 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Therapeutic study, level II. KEY WORDS: Kiosk; injury prevention; pediatric emergency department. BACKGROUND:
D
uring the last two decades, the emergency medicine literature has suggested that emergency department (ED) physicians should educate families about injury prevention (IP) practices in their setting.1Y5 In fact, a key component for the continuum of care for the pediatric patient, according to the Emergency Medical Service for Children IOM report,6 is IP. It has been postulated that the seriousness of an ED visit may render patients particularly receptive to a ‘‘teachable moment.’’7 Many patients present to the ED as a result of an injury; up to 17% of ED visits are caused by injuries,8 and 13% are severe enough to require hospital admission.9 This familiarity with injury care and the potential severity of the ED visit may offer ED physicians a unique opportunity to entice families to make significant IP behavior changes.10 Three studies, in particular, have shown that patients and families may change their safety practices based on the education they received in a pediatric ED setting. Johnston et al.11 Submitted: December 14, 2013, Revised: February 4, 2014, Accepted: February 17, 2014. From the Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio. This study was part of the oral presentation at the Annual Meeting of the Ambulatory Pediatric Association, April 2012, in Boston, Massachusetts. ClinicalTrials.gov Trial Registration Number: NCT01958099 Address for reprints: Michael A. Gittelman, MD, Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, MLC 2008 Cincinnati, OH 45229; email: [email protected]. DOI: 10.1097/TA.0000000000000317
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evaluated the impact of a 20-minute counseling session for teens presenting to the pediatric ED for changing an injuryrelated risk behavior (seat belt use, bicycle helmet use, driving after drinking, riding with an impaired driver, binge drinking, or carrying a weapon). At 3 months and 6 months after their visits, subjects that received IP counseling were more likely to use seat belts and bicycle helmets than controls. Posner et al.12 found similar results in a randomized trial of prevention education and safety device disbursement to youth presenting to a pediatric ED following injuries occurring in the home. They found that parents who had received the intervention had greater home safety knowledge, and more than 50% increased their use of home safety devices compared with control parents. Finally, a study conducted at the Cincinnati Children’s Hospital Medical Center (CCHMC) showed that youth injured in a minor motor vehicle collision and those seeking care for a noninjury complaint equally reported a 35% greater use in booster seats at follow-up after ED education.13 Unfortunately, screening for injury risk and providing education about IP are often not feasible in the ED because of limitations in staff, time, and a lack of IP knowledge by providers. Recently, computerized kiosks have been used to screen families for specific risky behaviors and then offer guided recommendations to families in a more cost-effective manner.14 Shields et al.15 showed that a pediatric ED kiosk can significantly increase knowledge about smoke alarm use and poison storage. The purpose of this study was to determine if a computerized kiosk in a pediatric ED can screen families for J Trauma Acute Care Surg Volume 77, Number 3, Supplement 1
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injury risk and encourage them to make more appropriate safety changes at follow-up survey compared with families receiving prevention recommendations from an IP specialist (IPS) in the same setting.
PATIENTS AND METHODS Study Design This was a prospective, randomized trial that occurred in the CCHMC pediatric ED. The study was conducted between August 16, 2010, and December 19, 2011. Approval was obtained from the CCHMC Institutional Review Board before initiating the study.
Study Setting and Population CCHMC is an academic, freestanding children’s hospital and a Level 1 trauma center with an annual pediatric ED volume of approximately 92,000 visits. The population served is diverse: 40% African American, 51% white, and 9% other. Roughly 20% of all pediatric ED visits are the result of injuries, and 1.5% of these visits are severe, requiring hospital admission. The average time to triage is 10 minutes to 15 minutes, and the average time to see a physician is 1 hour. Clinical research coordinators (CRCs) are available from 8:00 AM to 12:00 midnight Monday through Friday and 12:00 noon to 9:00 PM on Saturday and Sunday. A safety resource center that sells safety equipment at wholesale prices is located in the ED lobby and staffed Monday through Friday from 12:00 noon to 8:00 PM. Study participants were any parent/legal guardian with a child between the ages of birth through 14 years presenting to the ED for any chief complaint with a designated acuity of urgent or nonurgent. Any parent/guardian of a patient who was critically ill or triaged as emergent, any nonYEnglish-speaking individual, or any parent/guardian not present at the time of his or her child’s evaluation was excluded. If a participant left to an examination room before survey completion, an attempt was made to have them finish the study after their ED visit. Families who did not complete the kiosk survey or receive recommendations for change from either the kiosk printout or the IPS were excluded.
Screening Tool The computerized kiosk was obtained from Kiosk Information Systems, Inc. in Louisville, Colorado. The type was a Thinman-Dell with a 19-in LCD touchscreen. Software for the kiosk was developed by Intouch Kiosk Services in Atlanta, Georgia, with input from the study team. Questions were based on age-appropriate IP recommendations adapted from the American Academy of Pediatrics TIPP program.16 CRCs initiated the survey by typing in an assigned study number for the participant and then the appropriate age category for the child being seen in the ED. Age-based IP questions were grouped by the ages less than 1 year, 1 year to 4 years, 5 years to 9 years, and 10 years to 14 years. The survey consisted of baseline demographic information about the respondent (e.g., age, level of education, race, income, and sex) and several IP questions about current preventative behaviors they use for
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their child at that time. Families of children younger than 1 year answered 18 age-appropriate safety questions, while there were 21 questions for 1-year-olds to 4-year-olds, 21 for 5-yearolds to 9-year-olds, and 19 for 10-year-olds to 14-year-olds. Topics ranged from the use of bike helmets, child passenger safety seats, smoke or carbon monoxide detectors, and home safety equipment, depending on the age of the child at presentation to the ED. At completion, specific recommendations for behavior change, based on the family’s current practices, were provided at the kiosk by a computer printout (e.g., purchase a new product such as a booster seat or change an existing behavior such as batteries in a smoke detector). The screening tool was pretested with approximately 10 parents to ensure question clarity, ease of completion, and comfort with candidness in responding before study enrollment.
Study Protocol Families entering triage, Monday through Friday from 12 noon to 8:00 PM, that met inclusion criteria, were eligible for being approached based on CRC availability. Parents/guardians were given a summary sheet outlining participation and signed a waiver of documentation of consent after their initial triage assessment. Consenting participants were randomized on specific days of the week to receive IP recommendations from an IPS or from the computerized kiosk. A 20-day block random numbers table was used to determine the intervention chosen for that day. All families were initially screened using the computerized kiosk located in the corner of the large, ED waiting room. CRCs were available for questions or problems during kiosk use. Participants were asked to answer injury screening questions based on the age of the child they brought to the ED on that encounter. If two children were brought to be seen, the family could answer questions based on either aged child. After kiosk screening was completed, CRCs retrieved the computer printout with recommended behavior changes for the family. Depending on randomization, either families were handed the kiosk printout or they were taken to the IPS for verbal discussion about safety behavior recommendations based on IP categories in which parents were deemed to need a change from the kiosk screen. IPSs were located in the ED waiting room, in proximity to the kiosk, and they received specialized education on child passenger safety and IP practices through formal course training. IPS families were not provided with the kiosk printout. The time for completion and number of recommendations offered for both arms of the study were recorded by CRCs. On the waiver of consent form, families were asked for their two best telephone numbers to be contacted 3 weeks after enrollment. CRCs calling for follow-up were blinded as to what IP recommendations they received and how they received them. If the telephone numbers provided were disconnected or four calls during a 2-week period were attempted without connection, the family was considered lost to follow-up. The parent/legal guardian who completed the survey in the ED was the only person interviewed at follow-up. Follow-up surveys were similar to those posed at study onset to determine if self-reported changes of behavior were made based on recommendations. The percentage of mean correct responses before and after the surveys were compared. Moreover, questions regarding parent
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satisfaction with the survey tool and the recommendations received were asked.
Data Collection/Analysis Data were collected regarding why families declined participation. All data obtained by the kiosk were transferred automatically into an Excel spreadsheet. Data obtained pertaining to behavior change recommendations offered by the IPS were entered into the same Excel spreadsheet by the CRC. All data were identified by study number only. Data were compiled and analyzed using the SAS version 9.3 (Cary, NC). Frequencies were calculated for all demographic data. For the primary outcome, change in percentage of mean correct behavior responses per age, survey questions in the initial and follow-up surveys were compared. Moreover, at follow-up, families were asked if they made any change in their safety behavior from information they learned by the kiosk in the ED, and their responses were compared with the IPS group. W2 analysis for categorical variables and Student’s t test for continuous variables were used to determine if there was a difference between groups. A p G 0.05 was considered statistically significant.
Sample Size Sample size calculation was based on the primary outcome, percentage of families making a self-reported behavior change in each group. Estimates for sample size calculations were taken from our previous intervention work, showing that approximately 10% to 30% of the families make a self-reported behavior change after IPS counseling.13,17 Assuming the kiosk group receives more information specifically tailored to their child’s needs, we estimated that at least 30% of the families would make a self-reported behavior change at follow-up (20% more families would make the change based on the kiosk compared with the IPS). Based on this assumption, with a Type I error of 0.05 and power of 0.80, the desired sample size was 125 participants in each group to complete initial screen and follow-up survey.
RESULTS Figure 1 depicts participant enrollment into the study. Of the 637 approached, 359 (56%) consented to participate. Of those who consented, 191 (53.2%) were randomized to receive instructions from the kiosk printout, while 168 (46.8%) were given guidance by the IPS. Of these 359, 42 (11.7%) did not complete the initial screen in the ED and withdrew, leaving 172 (47.9%) in the kiosk group and 145 (40.4%) in the IPS education group. One hundred twenty-one families (70.3%) completed follow-up in the kiosk group, and 100 (69.0%) were reached in the IPS education group. There were no significant differences between the kiosk and IPS groups with regard to the demographic information for the respondents and the children except for age of the respondents (p = 0.03) (Table 1). Ages of the children enrolled, injuries sustained requiring a doctor’s visit, and family incomes between the groups were similar. On the initial screen, families randomized to receive education from the kiosk printout answered more questions correctly, reporting safer behaviors than those randomized to receive education from the IPS (p G 0.011) (Table 2). This difference in initial score was mainly seen in the age range 1 year to 4 years, while all other ages showed no difference in the percentage of questions answered correctly. Overall, families of older children reported to practice less safe behaviors compared with families with younger children. Table 2 shows the injury practices most commonly answered incorrectly on the initial screen by age. Families who received education from the IPS significantly improved on the repeat survey after guidance was provided compared with the kiosk group. (Table 3) Overall, parents educated by the IPS increased their self-reported changes in behavior on the screening tool by 8% compared with only 1% when receiving information from the kiosk. This improvement was seen in all age groups except for the children younger than 1 year. Moreover, families who received education from the IPS, when asked on the follow-up survey, reported to make
Figure 1. Numbers for study enrollment and follow-up. S4
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TABLE 1. Comparison of Demographic Variables Between Kiosk and IPS Education Group Kiosk (n = 172) Parent/guardian G 35 y* White race (child) Female sex (child) Mother taking survey Education high school graduate or lower Income G $30,000 annually Q2 children in the home Age of child enrolled G1 y 1Y4 y 5Y9 y 10Y14 y Zero injuries in the past requiring a doctor’s visit
IPS (n = 145)
Total (n = 317)
101 (58.7%) 102 (70.3) 203 (64.0%) 103 (60.0%) 96 (66.2%) 199 (62.8%) 85 (49.4%) 73 (50.3%) 158 (49.8%) 158 (91.9%) 131 (90.3%) 289 (91.2%) 58 (33.7%) 51 (35.2%) 109 (34.4%) 81 (47.1%) 114 (66.7%) 24 (14.0%) 59 (34.3%) 44 (25.6%) 45 (26.2%) 77 (45.0%)
55 (37.9%) 136 (42.9%) 99 (68.3%) 213 (67.2%) 23 56 42 24 75
(15.9%) 47 (14.8%) (38.6%) 115 (36.3%) (29.0%) 86 (27.1%) (16.6%) 69 (21.8%) (51.7%) 152 (47.9%)
*p G 0.05
a change in safety behavior in their home significantly more than the kiosk group (36% vs. 23%, p = 0.03). More IPS families compared with kiosk families reported that they made a purchase of new safety equipment, yet this was not shown to be significantly different (19% vs. 11%, p = 0.12). Families were more satisfied with the education they received from the IPS compared with the kiosk (91% vs. 81%, p = 0.03). The time to complete the screen and education in the ED was 2.1 minutes shorter with the kiosk group than with the IPS group (6.3 minutes vs. 8.4 minutes, p G 0.0001).
DISCUSSION This study demonstrates several important findings regarding IP screening and counseling in the pediatric ED setting.
TABLE 3. Change in Percent Correct Responses From Preevaluation to Postevaluation Period Percent Change in Appropriate Responses, Mean (SD)
Age Group (Kiosk, IPS), y Overall (121, 100) G1 (18, 15) 1Y4 (39, 43) 5Y9 (31, 26) 10Y14 (33, 16)
Kiosk
IPS
p
1.05 (9.04) 2.95 (7.83) j0.45 (9.92) 2.58 (8.13) 0.37 (9.36)
8.31 (8.62) 7.65 (10.16) 7.59 (8.74) 9.82 (9.04) 8.44 (6.14)
G0.0001 0.144 0.0002 0.002 0.003
First, it showed that families can be screened for their child’s risk of injury using a computerized kiosk in a busy ED waiting room. Most of the families were satisfied with the education they received, and the screening process was completed, on average, in 6 minutes. Another important finding was that families counseled by an IPS on IP topics in the ED setting had a greater mean percentage of behavior responses correct on follow-up surveys compared with families provided with specific written recommendations from the kiosk. Participants improved on their IP practices based on the screening tool by 8% at follow-up, and 36% reported to make at least one new behavior change after IPS counseling. Thus, screening for injury risk using a computerized kiosk is fast and easy, yet counseling about changing behavior may be more effective if provided by an individual. Similar to other ED studies in which a kiosk was used to screen families for injury, our study showed that families were generally satisfied with the tool and many were willing to participate while waiting in the lobby.14,18Y20 Vaca et al.21 showed that 75% of the participants preferred learning about an intervention for alcoholism from a computer rather than a medical professional. In our study, 81% in the kiosk education group were satisfied with the information they received; however, unlike the study of Vaca et al., there was greater satisfaction with a human specialist providing information compared
TABLE 2. Comparison of Initial Percent Questions Per Age Answered Correctly by Study Group and Most Common Questions Answered Incorrectly Kiosk Mean % Correct (n = 172)
IPS Mean % Correct (n = 145)
p
All ages G1
79.6 85.2
75.9 82.7
0.011 0.468
1Y4
82.9
75.0
0.0002
5Y9
79.3
77.8
0.623
10Y14
72.4
68.3
0.116
Age, y
Most Common Questions Answered Incorrectly (Both Groups) Hot water heater set atG120- (51%) Window guards used (34%) Carbon monoxide detector used (64%) Guard to protect stove (33%) Stair gates used (41%) Window guards used (45%) Booster seat when appropriate (48%) Child wears bike helmet always (61%) Carbon monoxide detector used (64%) Wears bike helmet always (47%) Sits in back seat always (54%) Stores medicines locked (61%)
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with the kiosk. Moreover, only 11.7% of the participants were unable to complete the screen while waiting in our ED lobby. If the tool were placed on a handheld device, changing locations would not have affected participation. This study showed that kiosks can rapidly screen families for large amounts of information to detect high-risk practices. The time to complete screening using our kiosk was only 6 minutes, and almost all evaluations were finished as families were waiting in the lobby. The idea of using a kiosk as a tool for screening in the ED setting has been shown in other studies as well.14,21 Moreover, computerized screening tools in the clinical environment allows an individual to answer uncomfortable topics, such as alcohol abuse or interpersonal violence, more freely.21,22 Besides screening for risk, the logic within the kiosk generated recommendations for families to make behavior changes. Our study showed that families were more likely to report a behavior change if they were counseled by a human IPS than if they received recommendations from a computerized printout. On rescreen of current safety practices, participants educated by the IPS improved on their correct responses by 8% compared with only 1% in the kiosk group. In addition, more participants in the IPS group made behavior changes in their home at follow-up compared with those who received kiosk instructions. Our study, like others, showed that families who receive recommendations from a computerized kiosk learn information and will make behavior changes.14,15,19,20 However, families are more likely to report a behavior change if human counseling is provided. Possibly, the ability to ask questions and receive information from an individual through social interaction helps to entice a family to practice safer behaviors than an impersonal computerized printout. The IPS has the ability to adapt education and responses based on the questions and needs of the family.23 This research has several limitations. First, the sample selected was based on convenience of the CRC with the ED setting. Families were only approached when CRCs were available. No demographic data were able to be collected on individuals who declined participation. The implications of bias from this limitation would be low in that both groups were screened similarly, and the main objective was to compare instructions offered by kiosk versus the IPS. Another potential limitation was that the IPS worked at the ED safety resource center. As a result, patients may have felt encouraged to purchase equipment after they were counseled by the IPS. However, only two participants made a purchase at the safety store from the IPS group and the kiosk was located adjacent to the safety resource center. Another limitation was that the kiosk group seemed to practice safer behaviors at the initial kiosk screen. This could limit the amount of change the kiosk group could make compared with the IPS group. Moreover, as in most studies with follow-up, some participants were unable to be reached; however, the amount lost was comparable in each group. Finally, follow-up to determine safety behavior changes was self-reported. The scope of this study would have made home visits too labor intensive. By comparing both groups similarly, one would expect that both groups would have the same bias in self-reporting, making comparisons between the groups reasonable. S6
Despite the limitations, this study demonstrated that a computerized kiosk in an ED waiting room may be an appropriate place to screen families for their child’s risk of injury. The time to complete screening was short, and families were satisfied with the service. Participants reported to practice safer behaviors after IPS counseling compared with those who received information from a kiosk, but both groups made changes. In the future, finding ways to combine kiosk screening in concert with human counseling may be the best approach to maximize behavior change. AUTHORSHIP M.A.G. contributed to all aspects of this article including the study design, literature search, drafting the institutional review board proposal, data analysis, drafting the initial manuscript, and approving the final manuscript. W.J.P. contributed to the study design, literature search, data analysis, and approval of the final manuscript. N.M. and A.D. contributed to the patient recruitment, kiosk implementation, education of the IPS, and approval of the final manuscript as submitted. M.H. contributed to the data analysis, data interpretation, tables, and figures and to the approval of the final manuscript.
DISCLOSURE This study was supported by the Ohio Department of Public ServiceY EMS Injury Prevention Research Grant, ‘‘Determining Efficacy of a Kioskbased Injury Prevention Education System in a Children’s Emergency Department,’’ July 1, 2009, to December 31, 2010, $116,205.
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12. Posner JC, Hawkins LA, Garcia-Espana F, Durbin DR. A randomized controlled trial of a home safety intervention based in an emergency department setting. Pediatrics. 2004;113:1603Y1608. 13. Gittelman MA, Pomerantz WJ, Ho M, Hornung R, McClanahan N. Is an emergency department encounter for a motor vehicle collision truly a ‘‘teachable moment’’. J Trauma Acute Care Surg. 2012;73(9 Suppl 3): S258YS261. 14. Gielen AC, McKenzie LB, McDonald EM, Shields WC, Wang MC, Cheng YJ, Weaver NL, Walker AR. Using a computer kiosk to promote child safety: results of a randomized, controlled trial in an urban pediatric emergency department. Pediatrics. 2007;120(2):330Y339. 15. Shields WC, McDonald EM, McKenzie L, Wang MC, Walker AR, Gielen AC. Using the pediatric emergency department to deliver tailored safety messages: results of a randomized controlled trial. Pediatr Emerg Care. 2013;29(5):628Y634. 16. Patient Education Online. The Injury Prevention Program. Available at: http://patiented.aap.org/categoryBrowse.aspx?catID=27. Accessed May 9, 2013. 17. Gittelman MA, Pomerantz WJ, Frey LK. Use of a safety resource center in a pediatric emergency department. Pediatr Emerg Care. 2009;25(7):429Y433.
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