70. Improvements in Management of Abnormal Uterine Bleeding in Adolescents after Implementation of a Clinical Decision Guideline within the Emergency Room Setting

Abstract

<h3>Background</h3> Abnormal uterine bleeding (AUB) is a common gynecologic problem among adolescents, and is broadly described as menstrual bleeding that is abnormal in timing, duration, or quantity. While there are abundant guidelines for assessment and management of this condition in adults, there is no current standard of practice for the adolescent population. This lack of standardized recommendations, combined with provider knowledge gaps, often leads to disorderly workup and management. Dell Children's Medical Center (DCMC) created an AUB clinical guidelines pathway, published in May 2015, for use in the emergency department to standardize clinical decision-making. The utilization rate by emergency department practitioners, as well as the impact of standardizing practice with this pathway, has yet to be studied. <h3>Methods</h3> A 14-question survey was designed to assess if DCMC providers have awareness of the protocol, if they use it to assist with management, and their general knowledge of broad concepts reinforced within the protocol. The survey was emailed to attending physicians, associate providers, fellows, and pediatrics and emergency medicine resident physicians who have worked in the ER at Dell Children's for at least 6 months. <h3>Results</h3> A response rate of 40% was achieved. Half of respondents were residents. 72% reported that they do refer to the above-mentioned protocol for guidance on management and treatment of adolescent patients, and over 90% access the protocol through the DCMC intranet. Of those who don't use the protocol, 30% stated they use their own personal practice guidelines. All answered correctly that "A sterile speculum exam is not indicated for every patient", and 86% appropriately answered "false" to the statement "A pelvic ultrasound is always the first step in work-up for abnormal uterine bleeding in adolescents". However, despite most providers stating that they used the protocol, over half (53%) answered "false" to the statement "All patients presenting with AUB should be screened for a bleeding disorder". Additionally, 22% of respondents answered incorrectly when asked about absolute contraindications to estrogen therapies. <h3>Conclusions</h3> Overall, the response rate and respondent make-up of this survey provided an accurate representation of the providers that work in the DCMC emergency department. While most providers have knowledge of the clinical guidelines protocol and state they use it, the responses reveal significant knowledge gaps in the appropriate diagnosis and management of this condition from both resident and attending providers. Further education of physicians regarding AUB in adolescents, as well as easier access to the protocol may be helpful in improving provider compliance.