Increasing Frequency of Affirmed Name and Pronoun Documentation in a Pediatric Emergency Department

The UPMC Children’s Hospital of Pittsburgh ED sees ∼80 000 patients per year and is the only pediatric ED in the greater Pittsburgh area. UPMC Children’s Hospital of Pittsburgh ED is also the home of the only clinic providing gender-affirming medications to youth aged <18 in western Pennsylvania. Given 9.2% of Pittsburgh area high school students’ gender identity differs from their sex assigned at birth,¹  there are likely many youths who desire to receive gender-affirming medical care, but experience barriers to doing so.¹⁰  This highlights the need to improve access to pediatric gender care providers by developing additional pathways to connect TGD youth and their families to these services. Given the frequency with which TGD are seen in the ED in acute mental health crisis,⁹  we prioritized the pediatric ED setting to facilitate connection to pediatric gender care providers, because we felt it would help capture youth at highest risk for experiencing negative mental health outcomes.

A few months after name and pronoun fields became operational in our EHR, a multidisciplinary team was established to increase affirmed name and pronoun documentation frequency in the pediatric ED. This team included ED physicians, ED nurses, a clinical informatics nurse, ED and hospital social workers, a transgender community navigator, and gender-clinic medical and social work providers. We began by identifying a median baseline for how often the optional EHR-affirmed name and pronoun rooming form was completed (most often by ED nurses when rooming a patient) during clinical encounters between January and June of 2019. Our primary outcome was the monthly percentage of total ED visits for patients aged 5 years and older with pronouns documented. Our multidisciplinary research team chose to include only patients aged 5 and older for this study because, by this age, a majority of children have a clear idea of their name and gender identity,¹¹  and because we felt children of this age would be able to verbalize how they would like to be referred during a clinical encounter.

The goal of our quality-improvement (QI) project was to increase the frequency of affirmed name and pronoun documentation by 50% from a baseline of ∼14% over our 2 year study period. Using a key driver diagram and process mapping, we identified 5 key drivers (Fig 1). The key driver diagram was continuously updated during the study period to include new ideas and drivers that arose throughout implementation. Interventions were implemented over 3 Plan–Do–Study–Act (PDSA) cycles.

During initial meetings with ED stakeholders about existing barriers to documenting affirmed name and pronouns during the rooming process, ED nurses identified uncertainty about how to ask patients about their pronouns as a key barrier. In response to this, in July of 2019, we added language to the EHR rooming form to prompt ED nursing staff to ask the following questions during the rooming process: “What name do you go by?” and “What pronouns do you use?” Once documented in the rooming form, the name and pronouns a patient reported using automatically displayed in the EHR banner bar and remained visible during subsequent ED encounters. The following month, a member of our multidisciplinary QI team, who is an ED nurse, presented a didactic education session with the ED nursing team during protected time for preshift huddles to capture as many staff members as possible. A portion of this education session was devoted to discussing the implementation of the name and pronoun rooming form and the importance of creating affirming environments for TGD youth in the ED setting.

After PDSA cycle 1, we reviewed the rates of form completion and ED provider documentation, and began meeting bimonthly to discuss the interim progress and identify successes and challenges. In these meetings, ED nursing staff requested additional training focused on the health disparities TGD youth face and the positive impact of using affirmed name and pronouns on mental health. This training was provided, again by a member of the ED nursing staff who is a member of the QI team during protected time for ED nursing education, in early March 2020. In our bimonthly meetings, we also identified an important balancing measure that, in some cases, even when nurses completed the pronoun form during rooming, ED providers continued to misgender TGD patients in their ED visit documentation. This finding was the impetus for the prioritization of additional education for ED medical providers and the development of a 1-page toolkit (Fig 2). The medical provider training was one hour in length, both didactic and case based and was presented during protected time for ED provider education by one of the physician members of the QI team. The content presented in the session was then made available in a repository of educational materials to ensure it was available to providers who were unable to attend. The 1-page toolkit was modeled after an existing ED resource used to provide discharge planning support for patients with asthma. The goal of this resource was to help ED providers triage patients according to their level of need for additional gender related support, facilitate connection to gender-affirming care if desired, and confidentially provide youth with appropriate gender care resources. Following its development in March 2020, the toolkit was then introduced to the ED faculty and fellows as a part of a 1 hour morbidity and mortality conference facilitated by a physician member of the QI team involving a TGD patient in May 2020. Two months later, a training with the social work department was conducted by a gender clinic social worker who was also a member of the QI team. This training was two hours in length and occurred during protected time meeting time for the social work department. It combined didactic education, case presentations and role play scenarios that centered on facilitating conversations with youth and their families about gender, how to triage the level of support needed, and provided education about using the triage toolkit. Finally, in September 2020, the toolkit was introduced to the ED nursing staff during a monthly staff meeting by a physician member of our QI team and then emailed out to all ED staff which concluded PDSA cycle 2.

In a bimonthly meeting in September 2020, gender clinic team members and a member of an existing community advisory board,¹²  advocated to adjust the language in the rooming form prompts (Fig 3). After receiving additional feedback from ED staff about the need for pediatric residents to receive additional training in how to support TGD youth in the ED, a gender-clinic physician, who was also a member of our multidisciplinary QI team, provided a 1-hour didactic training session with all pediatric residents, which was recorded and kept in a central repository of resources available to all residents, including those who were unable to attend the session in real time. This training, which occurred in November 2020, included information about the updated language included in the rooming form and introduced the toolkit that had been recently made available in the ED. In December 2020, a gender-clinic physician and member of the QI team was made aware of a case involving a gender-clinic patient who presented to the ED in mental health crisis. Despite having their name and pronouns documented in numerous recent gender-clinic notes, the name and pronoun form was not completed for this patient in the ED and they were subsequently misgendered throughout their ED stay and the hospital admission that followed. This case was brought to the attention of the QI team and escalated to ED leadership, which provided an overview of the case and stressed to all ED staff the importance of form completion through departmentwide communication in team meetings and through e-mail listservs.

Our primary outcome was the percentage of monthly ED visits for patients aged 5 years and over with completed pronoun documentation. This was calculated by dividing the number of completed forms over the total number of encounters for patients aged 5 years and over seen in the ED per month (Fig 4). Baseline data were collected by calculating the median percentage of form completion in the 6 months before the initiation of PDSA cycle 1, January and June of 2019. The percentage of monthly ED visits with completed pronoun documentation was calculated monthly and plotted on a run chart (Fig 4). Findings were analyzed to identify special cause variation using established run chart rules¹³  to identify runs, trends, shifts, and astronomical points.

A secondary measure was to estimate the number of TGD youth identified per month through the process of asking about affirmed name and pronouns. Because, at the time, patients were not being asked directly about their gender identity nor was this frequently documented in an EHR, the number of TGD youth was estimated by calculating the number of patients with a discordance between their pronouns and their sex listed in the EHR. For each encounter with discordant EHR sex and pronouns, the reason for visit and demographic characteristics (age, race, and zip code) were obtained by 1 member of the study team (K.M.K) via EHR review. Distance from UPMC Children’s Hospital of Pittsburgh was calculated as the distance in miles driven between the center of the zip code listed in the EHR and the hospital.

The QI project was reviewed and approved by the UPMC Quality Review Committee quality review committee (project ID: 1825). Data analysis, including pronoun form completion frequency calculations, were conducted in Microsoft Excel and Stata version 14.2 (Stata Corp LLC, College Station, TX). Run charts were created using QI Charts 2.0 Excel add-in (Process Improvement Products, Austin, TX).

Per run chart rules,¹³  our median line was adjusted as special cause was identified, starting from an initial baseline of 13.8%. There was an upward shift to 15.5% in July 2019 and again to 20.1% in January 2020 (PDSA cycle 1; Fig 4). The most notable increase in form completion occurred in January 2021 during PDSA cycle 3, immediately after ED-wide dissemination of a near-miss and subsequent call for improvement in form documentation by ED leadership in December 2020. This final upward shift resulted in a new baseline median of 47.8%.

During the 2 year study period, 312 encounters were identified as having pronouns discordant with the sex listed in the EHR. This represented an average of 12 ED encounters per month and 1.7% of all encounters with pronouns documented. With respect to distinct patients, 196 were identified as using pronouns discordant with their EHR sex. This group of patients had a mean age of 14 years, were majority White, had a female EHR sex, and lived within 30 miles driving distance from UPMC Children’s Hospital of Pittsburgh (Table 1).

A QI initiative consisting of a combination of education and EHR-based interventions increased the frequency of pronoun documentation in the pediatric ED. Small increases in pronoun documentation that occurred early in the project can be attributed to the inclusion of EHR prompts during the rooming process, targeted provider training, and the development of a triage toolkit for ED providers. The most notable increase in form completion occurred in January 2021, immediately after ED-wide dissemination of a near-miss case that contributed to a transgender adolescent being misgendered in the ED and subsequent call to improve the frequency of form completion by ED division leadership. Our team believes there were multiple factors that led to the successful design and implementation of our QI project. The first factor was beginning our project with the creation of a multidisciplinary team that included both a community navigator who is a member of the transgender community and members of the Children’s Hospital of Pittsburgh gender-clinic team, but also individuals from hospital informatics, ED faculty leadership, ED nursing, and the department of social work. This allowed us to ensure that, when educational interventions were delivered, they were facilitated by someone who was a member of the team receiving the education. Secondly, by including ED leadership, we were able to distribute materials and updates using departmentwide communications and incorporate educational sessions into time that was already blocked for preshift huddles, monthly meetings, or provider education to ensure that as many staff members as possible were able to attend. Finally, the inclusion of ED leadership also allowed us to advocate successfully for making name and pronoun fields required for all patients upon conclusion of the study.

The frequency of encounters with EHR sex discordant pronouns (1.7%) is in line with recent national data investigating the prevalence of transgender adolescents.²  However, this figure is notably lower than the 9.2% of high school-aged TGD youth in a local, school-based study conducted in our city just before the initiation of this QI project.¹⁴  This discrepancy may be because of fact that TGD youth do not feel safe disclosing their name and pronouns in the health care setting because of fear of discrimination¹⁵  or because they were only asked this in front of their parent or guardian. Nevertheless, these findings highlight the continued need to improve the frequency of affirmed name and pronoun documentation and the importance of facilitating confidential conversations in the pediatric ED with all adolescent patients.

The demographic characteristics of patients with discordant EHR sex and pronouns are similar to those seen previously in clinic-based samples of TGD youth. Namely, in our study, youth with discordant EHR sex and pronouns were disproportionately White and assigned female at birth. This is a notable contrast from our recent study, which collected data from a nonclinical, population-based sample of youth via the Youth Risk Behavior Survey.¹  These data showed a higher prevalence of gender diversity in youth of color than in their White peers, and had an equivalent number of TGD youth assigned male and female sex at birth.¹  The reasons for these notable differences in the demographic characteristics between the clinical versus population-based samples of TGD youth are likely multifactorial. It is likely that both historical and ongoing racism and transphobia in the health care setting contribute to the TGD youth of color being less likely to receive care across clinical settings in comparison with their White peers. It is also possible that previous experiences of discrimination in the health care setting contribute to TGD youth feeling less comfortable disclosing their affirmed name and pronouns in acute care settings, where they do not have ongoing relationships with care providers.⁴  Further investigation is needed to understand the experiences of TGD youth, and especially TGD of color, as they access medical care to guide adaptation of our clinical settings to be more welcoming and inclusive.

Though our QI project resulted in a 3.5-fold increase in pronoun documentation over the 2 year study period, overall rates of form completion upon completion of the study remained <50%. This was brought to the attention of ED leadership and prompted them to decide to make the name and pronoun form a required part of rooming for all patients starting in July 2021. It was also the impetus for a similar project to increase name and pronoun documentation in ambulatory clinics across our health system. These data have also helped advocate for additional resources, including increased ED social work time to ensure youth and their families are able to receive timely support and connection to gender-affirming care services in the ED setting. Moving forward, our team is working to develop more robust methods of tracking the frequency in which gender-specific resources provided in the ED are accessed by patients and families, and the impact their provision has on access to connecting to gender-affirming medical care. We are hopeful that this work will encourage other health systems to develop similar initiatives to improve access to care for TGD youth.

Our study findings should be interpreted within the context of the following limitations. First, the study was conducted in a large, pediatric ED in 1 urban, mid-Atlantic city. Additionally, because our findings were limited to information available in the EHR, we were unable to identify a patient’s gender identity directly because this was not routinely or reliably documented. It is important to acknowledge that the measure used, discordant EHR sex and pronouns, is not, and should not be, the gold standard for identifying TGD youth in EHRs. This was used as a proxy for the gold standard, a patient’s self-reported gender identity. In addition, discordant EHR sex and pronouns would not capture the subset of TGD youth who have changed their EHR sex to reflect their gender identity. Given the process of changing one’s EHR sex requires completion of a legal gender marker change (which in Pennsylvania requires a letter from a medical provider), we suspect that youth who have already changed their EHR sex are less likely to need gender-related medical support than those who have not. Additionally, the total number of patients over age 5 years seen per month did include patients with emergency severity index level 1, as well as those who were nonverbal, which may explain why, at least in part, form completion never reached 50%. Finally, though our baseline appeared to be relatively stable, we were limited to a total of 6 data points to generate our baseline median value of 13.8%.

In conclusion, a combination of educational and EHR-based interventions can increase the frequency of affirmed name and pronoun documentation in the pediatric ED. This improvement has the potential to improve the quality of care provided to TGD youth in the ED and identify patients who may benefit from additional gender-affirming resources and support.

We thank Alicyn Simpson, the community navigator for the Children’s Hospital of Pittsburgh Gender and Sexual Development Program, and Lori Rutman, MD, MPH, associate professor in the Department of Pediatrics and Division of Emergency Medicine at the University of Washington, for their support with this project.