Recommendations for Choosing Wisely in Pediatric Emergency Medicine: Five Opportunities to Improve Value.

Unnecessary diagnostic tests and treatments in children cared for in emergency departments (EDs) do not benefit patients, increase costs, and may result in harm. To address this low-value care, a taskforce of pediatric emergency medicine (PEM) physicians was formed to create the first PEM Choosing Wisely recommendations. Using a systematic, iterative process, the taskforce collected suggested items from an interprofessional group of 33 ED clinicians from 6 academic pediatric EDs. An initial review of 219 suggested items yielded 72 unique items. Taskforce members independently scored each item for its extent of overuse, strength of evidence, and potential for harm. The 25 highest-rated items were sent in an electronic survey to all 89 members of the American Academy of Pediatrics PEM Committee on Quality Transformation (AAP COQT) to select their top ten recommendations. The AAP COQT survey had a 63% response rate. The five most selected items were circulated to over 100 stakeholder and specialty groups (within the AAP, CW Canada, and CW USA organizations) for review, iterative feedback, and approval. The final 5 items were simultaneously published by Choosing Wisely United States and Choosing Wisely Canada on December 1, 2022. All recommendations focused on decreasing diagnostic testing related to respiratory conditions, medical clearance for psychiatric conditions, seizures, constipation, and viral respiratory tract infections. A multinational PEM taskforce developed the first Choosing Wisely recommendation list for pediatric patients in the ED setting. Future activities will include dissemination efforts and interventions to improve the quality and value of care specific to recommendations.

Impact of a 1-Year Pediatric Emergency Medicine Training Program for International Medical Graduates.

OBJECTIVES: The Hospital for Sick Children in Toronto has offered a 1-year subspecialty residency training program in pediatric emergency medicine (PEM) to Canadian and internationally trained pediatricians and emergency physicians since 1993. The program is intended to support clinical service delivery while simultaneously offering a unique educational opportunity to Canadian and international physicians who desire 1 year of clinically focused training. We describe the experiences and career outcomes of participants who completed this program. METHODS: Two surveys were sent to the 68 individuals who completed the clinical fellowship program from its inception in 1993 until 2014. A blinded survey focused on the fellowship experience and subsequent career activities. A nonblinded survey subsequently determined whether participants had served as a medical director or training program director. RESULTS: Sixty of the 68 participants (88%) completed the blinded survey. Ninety-one percent were in practice in emergency medicine. Twenty-five percent of the participants were living in Canada, compared with 17% before completing the program. This net migration of 8% was not significant (P = 0.26). Thirty-six of the 50 participants (72%) who applied from outside Canada responded to the nonanonymous survey; 18 (50%) had served as an emergency department medical director, and 18 (50%) reported serving as a PEM training program director. CONCLUSIONS: Many participants attained leadership positions in PEM in countries outside of North America and/or participated in training program development. There was no significant change in the proportion of participants living in North America at the time of application compared with the time of survey completion.

Clinical features at diagnosis of sickle cell disease prior to universal newborn screening in Alberta.

Objectives: Sickle cell disease (SCD) is an inherited multisystem disorder with complications starting in the first year of life. Newborn screening (NBS) can identify infants with SCD and is associated with decreased morbidity and mortality. Variation in availability of NBS in Canada, and lack of standardized screening for immigrant children, may lead to delayed diagnosis. Methods: This was a retrospective cohort study of 126 children aged 0-18 years with SCD registered with the SCD clinic at the Alberta Children's Hospital between January 2003 and January 2018, prior to province-wide universal NBS for SCD. Patient demographic information, circumstances of diagnosis, and other contextual information were collected from patient health records. Descriptive statistics were used to summarize data, with Mood's median test used to compare medians between groups. Results: Forty-three (35%) patients were born in Alberta. Patients were mostly (95.3%) of African descent. Of patients born in Alberta, 63% (26/43) were diagnosed at >12 months of age, with a median age at diagnosis of 18 months (IQR = 4-39). This was significantly older (P < 0.001) than children born in the USA or in Canadian provinces with SCD NBS programs, where the median age at diagnosis was zero months (N = 36). Of the 42% of patients born outside North America, 64% were diagnosed following an acute complication. Conclusions: This study highlights the importance of NBS for early detection and management of SCD, and the importance of screening at-risk immigrants who may not have received NBS for SCD.

Characterizing Pain in Children with Acute Gastroenteritis Who Present for Emergency Care.

OBJECTIVE: To characterize the pain experienced by children with acute gastroenteritis (AGE) in the 24 hours before emergency department (ED) presentation. Secondary objectives included characterizing ED pain, discharge recommendations, overall analgesic use, and factors that influenced analgesic use and pain severity. STUDY DESIGN: A prospective cohort was recruited from 2 pediatric EDs (December 2014 to September 2017). Eligibility criteria included <18 years of age, AGE (≥3 episodes of diarrhea or vomiting in the previous 24 hours), and symptom duration <7 days at presentation. RESULTS: We recruited 2136 patients, median age 20.8 months (IQR 10.4, 47.4) and 45.8% (979/2136) female. In the 24 hours before enrollment, most caregivers reported moderate (28.6% [610/2136, 95% CI 26.7-30.5]) or severe (46.2% [986/2136, CI 44.0-48.3]) pain for their child. In the ED, they reported moderate (31.1% [664/2136, 95% CI 29.1-33.1]) or severe ([26.7% [571/2136, 95% CI 24.9-28.7]) pain; analgesia was provided to 21.2% (452/2131). The most common analgesics used in the ED were acetaminophen and ibuprofen. At discharge, these were also most commonly recommended. Factors associated with greater analgesia use in the ED were high pain scores during the index visit, having a primary care physician, earlier presentation to emergency care, fewer diarrheal episodes, presence of fever, and hospitalization at index visit. CONCLUSIONS: Most caregivers of children presenting to the ED with AGE reported moderate or severe pain, both before and during their visit. Future research should focus on the development of effective, safe, and timely pain management plans.

Patient-Reported Pain Outcomes for Children Attending an Emergency Department With Limb Injury.

OBJECTIVES: The aim of this study was to describe patient-reported pain outcomes at various stages of an emergency department (ED) visit for pediatric limb injury. METHODS: This prospective cohort consisted of 905 patients aged 4 to 17 years with acute limb injury and a minimum initial pain score of 4/10. Patients reported pain scores and treatments offered and received at each stage of their ED visit. Multiple logistic regression was used to identify predictors for severe pain on initial assessment and moderate or severe pain at ED discharge. RESULTS: The initial median pain score was 6/10 (interquartile range, 4-6) and decreased at discharge to 4/10 (interquartile range, 2-6). Stages of the ED visit where the highest proportion of patients reported severe pain (score, ≥8 of 10) were fracture reduction (26.0% [19/73]; 95% confidence interval [CI], 17.1%-37.5%), intravenous insertion (24.4% [11/45]; 95% CI, 13.8%-39.6%), and x-ray (23.7% [158/668]; 95% CI, 20.6%-27.0%). Predictors of severe pain at initial assessment included younger age (odds ratio [OR], 0.92; 95% CI, 0.87-0.97), female sex (OR, 0.58; 95% CI, 0.40-0.84), and presence of fracture (OR, 1.58; 95% CI, 1.07-2.33) whereas, at discharge, older age (OR, 1.14; 95% CI, 1.06-1.23) predicted moderate/severe pain (score, ≥4 of 10). CONCLUSIONS: These results on the location and predictors of severe pain during an ED visit for limb injury can be used to target interventions to improve pain management and patient outcomes.

Treating and reducing anxiety and pain in the paediatric emergency department-TIME FOR ACTION-the TRAPPED quality improvement collaborative.

BACKGROUND/OBJECTIVES: In 2013, the TRAPPED-1 survey reported inconsistent availability of pain and distress management strategies across all 15 Canadian paediatric emergency department (PEDs). The objective of the TRAPPED-2 study was to utilize a procedural pain quality improvement collaborative (QIC) and evaluate the number of newly introduced pain and distress-reducing strategies in Canadian PEDs over a 2-year period. METHODS: A QIC was created to increase implementation of new strategies, through collaborative information sharing among PEDs. In 2015, 11 of the 15 Canadian PEDs participated in the TRAPPED QIC. At the end of the year, the TRAPPED-2 survey was electronically sent to a representative member at each of the 15 PEDs. The successful introduction of the chosen strategies by the QIC was assessed as well as the addition of new strategies per site. The number of new strategies introduced in the participating and nonparticipating QIC sites were described. RESULTS: All 15 PEDs (100%) completed the TRAPPED-2 survey. Overall, 10/11 of QIC-participating sites implemented the strategy they had initially identified. All 15 Canadian PEDs implemented some new strategies during the study period; participants in the QIC reported a mean of 5.2 (1-11) new strategies compared to 2.5 (1-4) in the nonactively participating sites. CONCLUSION: While all PEDs introduced new strategies during the study, QIC-participating sites successfully introduced the majority of their previously identified new strategies in a short time period. Sharing deadlines and information between centres may have contributed to this success.

Province-Wide Review of Pediatric Shiga Toxin-Producing Escherichia coli Case Management.

OBJECTIVE: To identify the gaps in the care of children infected with Shiga toxin-producing Escherichia coli (STEC), we sought to quantitate care received and management timelines. Such knowledge is crucial to the design of interventions to prevent the development of hemolytic uremic syndrome (HUS). STUDY DESIGN: We conducted a retrospective case-series study of 78 children infected with STEC in Alberta, Canada, through the linkage of microbiology and laboratory results, telephone health advice records, hospital charts, physician billing submissions, and outpatient antimicrobial dispensing databases. Outcomes were the time intervals between initial presentation and reporting of positive culture result and symptom onset to HUS and to describe the proportions that had baseline blood work performed and received antibiotics. RESULTS: Seventy-eight children infected with STEC were identified; 13% (10/78) developed HUS. Median time from initial presentation to laboratory stool sample receipt was 33 hours (IQR 18, 42); time to positive culture was 120 hours (IQR 86, 205). Time from symptom onset to HUS diagnosis was 188 ± 37 hours. Baseline blood tests were obtained in 74% (58/78) of infected children. Antibiotics were administered to 50% (5/10) of those who developed HUS and 22% (15/78) of those who did not; P = .11. The provincial telephone advice system received 31 calls regarding 24 children infected with STEC; 23% (7/31) of callers were recommended to seek emergency department care. CONCLUSIONS: A significant proportion of children developed HUS following multiple interactions with the health care system. Delays in the confirmation of STEC infection occurred. There are numerous opportunities to improve the timing, monitoring, and interventions in children infected with STEC.

Pediatric abdominal radiograph use, constipation, and significant misdiagnoses.

OBJECTIVE: To determine the proportion of children diagnosed with constipation assigned a significant alternative diagnosis within 7 days (misdiagnosis), if there is an association between abdominal radiograph (AXR) performance and misdiagnosis, and features that might identify children with misdiagnoses. STUDY DESIGN: We conducted a retrospective cohort study of consecutive children <18 years who presented to a pediatric emergency department in Toronto, between 2008 and 2010. Children assigned an International Statistical Classification of Diseases and Related Health Problems 10th Revision code consistent with constipation were eligible. Misdiagnosis was defined as an alternative diagnosis during the subsequent 7 days that resulted in hospitalization or an outpatient procedure that included a surgical or radiologic intervention. Constipation severity was classified employing text word categorization and the Leech score. RESULTS: 3685 eligible visits were identified. Mean age was 6.6 ± 4.4 years. AXR was performed in 46% (1693/3685). Twenty misdiagnoses (0.5%; 95% CI 0.4, 0.8) were identified (appendicitis [7%], intussusception [2%, bowel obstruction [2%], other [9%]). AXR was performed more frequently in misdiagnosed children (75% vs 46%; P = .01). These children more often had abdominal pain (70% vs 49%; P = .04) and tenderness (60% vs 32%; P =.01). Children in both groups had similar amounts of stool on AXR (P = .38) and mean Leech scores (misdiagnosed = 7.9 ± 3.4; not misdiagnosed = 7.7 ± 2.9; P = .85). CONCLUSIONS: Misdiagnoses in children with constipation are more frequent in those in whom an AXR was performed and those with abdominal pain and tenderness. The performance of an AXR may indicate diagnostic uncertainty; in such cases, the presence of stool on AXR does not rule out an alternative diagnosis.

Pediatric constipation in the emergency department: evaluation, treatment, and outcomes.

OBJECTIVES: Limited knowledge exists surrounding the pharmacologic management of pediatric constipation in the emergency department (ED) setting and the success of interventions. Our primary objective was to determine whether enema administration is associated with 7-day ED revisits for persistent symptoms. Secondary objectives focused on assessing other predictors of ED revisits. METHODS: We conducted a retrospective cohort study of children <18 years old, diagnosed as having constipation (International Classification of Diseases-10 codes F98.1 nonorganic encopresis, K59.0 constipation) in a pediatric ED in Toronto, Canada, between November 2008 and October 2010. RESULTS: A total of 3592 visits were included; 6% (n = 225) were associated with a revisit. Children with revisits more frequently had vomiting (28% vs 17%, P = 0.001), more pain (5.7 ±â€Š3.6 vs 4.6-3.6 of 10, P = 0.01), and underwent more blood tests (19% 05, 11%, 95% confidence interval [CI] of the difference 3%-14%] and diagnostic imaging (62% vs 47%, 95% CI of the difference 9%-22%). Children administered an enema were 1.54 times more likely to revisit the ED than those who did not receive an enema (8.6% vs 5.5%, 95% CI of the difference 1.1%-5.2%, P = 0.001). Type of enema administered varied by age (P < 0.001). Regression analysis identified the following independent predictors of revisits: diagnostic imaging (odds ratio [OR] 1.54, 95% CI 1.15-2.06), vomiting (OR 1.45, 95% CI 1.07-1.98), enema administration (OR 1.40, 95% CI 1.05-1.88), and significant medical history (OR 1.26, 95% CI 1.04-1.53). CONCLUSIONS: Enema administration and diagnostic imaging are associated with revisits in children diagnosed with constipation. Their role in the ED management of pediatric constipation requires further evaluation.

Use of rational subgrouping to understand variation and opportunity for improvement in time to ultrasound.

OBJECTIVE: To understand factors that contribute to variation in time to abdominal and/or pelvic ultrasound in pediatric patients in an emergency department (ED) by utilizing rational subgrouping to assess opportunity for improvement. METHODS: All abdominal and pelvic ultrasounds conducted in the Alberta Children's Hospital ED from May 2019 to April 2021 were included. Time of study order and time of study completion were obtained from the electronic health record. Statistical process control (SPC) I-charts were used to analyze the quarterly median number of minutes from ultrasound order to completion. Rational subgrouping was used to stratify the data based on sex, age, and ED shift type, and identify special cause variation between groups. Findings were used to inform local decision-making. RESULTS: Special cause variation was detected among subgroups for sex, age group, and shift type. The median time from order of an abdominal and/or pelvic ultrasound to completion of study was 155 min. Females had a median order to completion time of 178 min, while males had a completion time of 131 min. From age 0 to 3, the median time was 110 min, compared to 149 min for ages 4 to 11 and 171 min for ages 12 and older. Day shifts had a median order to completion time of 145 min, compared to 129 min for evening shifts and 269 min for night shifts. CONCLUSIONS: Longer time to study completion was observed in female patients, older patients, and during night shifts. Use of rational subgrouping supported understanding of variation among subgroups of patients evaluated with abdominal and/or pelvic ultrasound. This allowed informed decision-making regarding opportunities for improvement. Rational subgrouping is a useful methodology in planning QI initiatives as it identifies sources of variation within a nonhomogeneous population and allows for judicious decision-making in a context of limited resources.

RéSUMé: OBJECTIF: Comprendre les facteurs qui contribuent à la variation dans le temps de l'échographie abdominale et/ou pelvienne chez les patients pédiatriques dans un service d'urgence (ED) en utilisant un sous-groupe rationnel pour évaluer la possibilité d'amélioration. MéTHODES: Toutes les échographies abdominales et pelviennes effectuées à l'urgence de l'Hôpital pour enfants de l'Alberta de mai 2019 à avril 2021 ont été incluses. L'ordre et l'heure de fin de l'étude ont été obtenus à partir du dossier médical électronique. Des diagrammes en I de contrôle statistique des processus (SPC) ont été utilisés pour analyser le nombre médian trimestriel de minutes entre la commande d'échographie et l'achèvement. Un sous-groupe rationnel a été utilisé pour stratifier les données en fonction du sexe, de l'âge et du type de quart de travail aux urgences, et pour déterminer la variation des causes spéciales entre les groupes. Les conclusions ont été utilisées pour éclairer la prise de décisions à l'échelle locale. RéSULTATS: Une variation de cause spéciale a été détectée parmi les sous-groupes pour le sexe, le groupe d'âge et le type de poste. Le temps médian entre la commande d'une échographie abdominale et/ou pelvienne et la fin de l'étude était de 155 minutes. Les femelles avaient un délai médian de 178 minutes, tandis que les mâles avaient un délai de 131 minutes. De 0 à 3 ans, le temps médian était de 110 minutes, comparativement à 149 minutes pour les 4 à 11 ans et 171 minutes pour les 12 ans et plus. L'ordre médian des quarts de jour était de 145 minutes, comparativement à 129 minutes pour les quarts de soir et 269 minutes pour les quarts de nuit. CONCLUSIONS: On a observé un délai plus long avant l'achèvement de l'étude chez les patientes, les patientes âgées et pendant les quarts de nuit. L'utilisation de sous-groupes rationnels a permis de comprendre la variation entre les sous-groupes de patients évalués par échographie abdominale et/ou pelvienne. Cela a permis de prendre des décisions éclairées sur les possibilités d'amélioration. Le sous-regroupement rationnel est une méthode utile pour planifier les initiatives d'AQ, car il permet de déterminer les sources de variation au sein d'une population non homogène et de prendre des décisions judicieuses dans un contexte de ressources limitées.

An Exploration of the Interplay Between Well-being and Quality and Safety.

PURPOSE: Quality improvement and patient safety (QIPS) and clinician well-being work are interconnected and impact each other. Well-being is of increased importance in the current state of workforce shortages and high levels of burnout. The Canadian Association of Emergency Physicians (CAEP) Academic Symposium sought to understand the interplay between QIPS and clinician well-being and to provide practical recommendations to clinicians and institutions on ensuring that clinician well-being is integrated into QIPS efforts. METHODS: A team of emergency physicians with expertise in well-being and QIPS performed a literature review, drafted goals and recommendations, and presented at the CAEP Academic Symposium in 2023 for feedback. Goals and recommendations were then further refined. RESULTS: Three goals and recommendations were developed as follows: QIPS leaders and practitioners must (1) understand the potential intersection of well-being and QIPS, (2) consider a well-being lens for all QIPS work, and (3) incorporate QIPS methodology in efforts to improve clinician well-being. CONCLUSION: QIPS and clinician well-being are often closely linked. By incorporating these recommendations, QIPS strategies can enhance clinician well-being.

RéSUMé: OBJECTIF: Le travail d'amélioration de la qualité et de la sécurité des patients (QIPS) et le bien-être des cliniciens sont interreliés et ont des répercussions les uns sur les autres. Le bien-être est d'une importance croissante dans l'état actuel des pénuries de main-d'œuvre et des niveaux élevés d'épuisement professionnel. Le symposium universitaire de l'Association canadienne des médecins d'urgence (ACMU) visait à comprendre l'interaction entre le SPQI et le bien-être des cliniciens et à fournir des recommandations pratiques aux cliniciens et aux établissements pour assurer le bien-être des cliniciens. . .Le programme QIPS est intégré aux efforts du QIPS. MéTHODES: Une équipe de médecins urgentistes ayant une expertise en bien-être et QIPS a effectué une revue de la littérature, rédigé des objectifs et des recommandations, et présenté au symposium académique de l'ACMU en 2023 pour obtenir une rétroaction. Les objectifs et les recommandations ont ensuite été affinés. RéSULTATS: Trois objectifs et recommandations ont été élaborés : les dirigeants et les praticiens du SPQI doivent (1) comprendre l'intersection potentielle du bien-être et du SPQI, (2) envisager une optique du bien-être pour tous les travaux du SPQI, et (3) intégrer la méthodologie QIPS dans les efforts visant à améliorer le bien-être des cliniciens. CONCLUSIONS: Le SPQI et le bien-être des cliniciens sont souvent étroitement liés. En intégrant ces recommandations, les stratégies QIPS peuvent améliorer le bien-être des cliniciens.

Emergency department revisits in children with gastroenteritis.

OBJECTIVES: The aim of the study was to determine whether intravenous fluid administration is independently associated with a reduction in unscheduled emergency department (ED) revisits within 7 days. METHODS: We conducted a single-center, retrospective observational cohort study in a pediatric ED in Toronto, Canada. Participants were younger than 18 years, diagnosed as having gastroenteritis, and discharged home between July 2003 and June 2008. Multivariable regression models were used to determine the associations between the exposures (intravenous rehydration, triage severity score, age) and ED revisits and revisits with intravenous rehydration. Accuracy was assessed using bootstrap analysis. RESULTS: There were 22,125 potentially eligible visits; 3346 were included in our final cohort. A total of 497 children (15%) received intravenous rehydration and 543 (16%) had an unscheduled revisit. Regression analysis included 2874 children with complete data, and identified 5 independent predictors of an ED revisit: intravenous rehydration (odds ratio [OR] 1.76; 95% confidence interval [CI] 1.36-2.26); number of vomiting episodes (1.20; 95% CI 1.04-1.28/5 episode increase); days of diarrhea (OR 0.92; 95% CI 0.88-0.97/day increase); frequency of diarrhea (1.19; 95% CI 1.03-1.38/5 episode increase); and age (OR 0.94; 95% CI 0.91-0.98/year). Bootstrap methodology identified intravenous rehydration, age, number of vomiting episodes, days of diarrhea, and number of diarrheal stools a minimum of 500 of 1000 iterations. CONCLUSIONS: Intravenous rehydration is associated with unscheduled ED revisits after adjustment for clinical findings. Although children experiencing revisits were likely more unwell, our data do not support the provision of intravenous fluids to prevent unscheduled ED revisits in children with mild-to-moderate dehydration.

An evaluation of satisfaction with emergency department care in children and adolescents with mental health concerns.

OBJECTIVES: We hypothesized that an association exists between satisfaction with ED mental health care delivery and patient and system characteristics. Primary: To evaluate overall satisfaction with ED mental health care delivery. Secondary: To explore aspects of ED mental health care delivery associated with general satisfaction, and patient and ED visit characteristic associated with total satisfaction scores and reported care experience themes. METHODS: We enrolled patients < 18 years of age presenting with a mental health concern between February 1, 2020 and January 31, 2021, to two pediatric EDs in Alberta, Canada. Satisfaction data were collected using the Service Satisfaction Scale, a measure of global satisfaction with mental health services. Association of general satisfaction with ED mental health care was evaluated using Pearson's correlation coefficient and variables associated with total satisfaction score was assessed using multivariable regression analyses. Inductive thematic analysis of qualitative feedback identified satisfaction and patient experience themes. RESULTS: 646 participants were enrolled. 71.2% were Caucasian and 56.3% female. Median age was 13 years (IQR 11-15). Parents/caregivers (n = 606) and adolescents (n = 40) were most satisfied with confidentiality and respect in the ED and least satisfied with how ED services helped reduce symptoms and/or problems. General satisfaction was associated with perceived amount of help received in the ED (r = 0.85) and total satisfaction with evaluation by a mental health team member (p = 0.004) and psychiatrist consultation (p = 0.05). Comments demonstrated satisfaction with ED provider attitudes and interpersonal skills and dissatisfaction with access to mental health and addictions care, wait time, and the impact of COVID-19. CONCLUSIONS: There is a need to improve ED mental health care delivery, with a focus on timely access to ED mental health providers. Access to outpatient/community-based mental health care is needed to complement care received in the ED and to provide continuity of care for youth with mental health concerns.

RéSUMé: OBJECTIFS: Nous avons émis l'hypothèse qu'il existe un lien entre la satisfaction à l'égard de la prestation de soins de santé mentale aux urgences et les caractéristiques des patients et du système. Primaire : Évaluer la satisfaction globale à l'égard de la prestation des soins de santé mentale aux urgences. Secondaire : Explorer les aspects de la prestation des soins de santé mentale aux urgences associés à la satisfaction générale, et les caractéristiques du patient et de la visite aux urgences associées aux scores de satisfaction totale et aux thèmes d'expérience de soins signalés. MéTHODES: Nous avons inscrit des patients de moins de 18 ans présentant un problème de santé mentale entre le 1er février 2020 et le 31 janvier 2021 à deux services d'urgence pédiatriques en Alberta, au Canada. Les données relatives à la satisfaction ont été recueillies à l'aide de l'échelle de satisfaction du service, une mesure de la satisfaction globale à l'égard des services de santé mentale. L'association entre la satisfaction générale et les soins de santé mentale dispensés aux urgences a été évaluée à l'aide du coefficient de corrélation de Pearson et les variables associées au score total de satisfaction ont été évaluées à l'aide d'analyses de régression multivariables. L'analyse thématique inductive des commentaires qualitatifs a permis d'identifier des thèmes liés à la satisfaction et à l'expérience des patients. RéSULTATS: 646 participants ont été inscrits. 71,2 % étaient de race blanche et 56,3 % de sexe féminin. L'âge médian était de 13 ans (IQR, 11-15). Les parents/aidants (n = 606) et les adolescents (n = 40) étaient les plus satisfaits de la confidentialité et du respect à l'urgence et les moins satisfaits de la façon dont les services d'urgence ont contribué à réduire les symptômes et/ou les problèmes. La satisfaction générale était associée à la perception de l'aide reçue aux urgences (r = 0,85) et à la satisfaction totale à l'égard de l'évaluation par un membre de l'équipe de santé mentale (p = 0,004) et de la consultation d'un psychiatre (p = 0,05). Les commentaires ont fait état d'une satisfaction à l'égard des attitudes et des compétences interpersonnelles des prestataires de soins d'urgence et d'une insatisfaction à l'égard de l'accès aux soins de santé mentale et de toxicomanie, du temps d'attente et de l'impact de l'étude COVID-19. CONCLUSIONS: Il est nécessaire d'améliorer la prestation des soins de santé mentale aux urgences, en mettant l'accent sur l'accès en temps opportun aux fournisseurs de services de santé mentale des services d'urgence. L'accès à des soins de santé mentale en consultation externe ou en milieu communautaire est nécessaire pour compléter les soins reçus aux urgences et pour assurer la continuité des soins aux jeunes ayant des problèmes de santé mentale.

Use of quality improvement methods to enhance implementation of a mental health care bundle in a pediatric emergency department.

OBJECTIVES: We used quality improvement methods to implement a care bundle for children presenting to a pediatric emergency department (ED) with mental health concerns. A bundle novelty was that it included an option for assessment in a partnered clinic, not in the ED, to families of children assessed as having no medical or safety concerns. The primary aim of this study was to establish successful implementation of the bundle prior to studying its impact. METHODS: The bundle included the Ask Suicide-Screening Questions to standardize risk assessment at triage, the HEADS-ED (Home, Education, Activities/Peers, Drug/Alcohol, Suicidality, Emotions/Behavior, Discharge Resources) tool for brief, scored mental health assessments, and offering an urgent appointment within 96 h for low-risk children as an alternative to ED-based assessment or as a follow-up option for patients assessed in the ED. We developed aims, driver diagrams, and outcome measures for each bundle element. Each element was introduced with small tests of change using iterative plan-do-study-act cycles. Run charts were used to determine successful completion of aims. RESULTS: Rules for special cause were met through detection of shifts in performance 5 months after bundle implementation for the Ask Suicide-Screening Questions and HEADS-ED. These bundle elements were consistently used with ≥ 80% of eligible patients, representing aim achievement. During the 6 months of providing urgent appointments, 89.3% of 159 referred families received an appointment within 96 h. CONCLUSIONS: Using quality improvement methods, we were able to successfully ensure reliable implementation of a new care bundle for pediatric patients presenting to the ED with mental health concerns and allow eligible low-risk patients to receive full assessments in a partnered clinic instead of the ED.

RéSUMé: OBJECTIFS: Nous avons utilisé des méthodes d'amélioration de la qualité pour mettre en œuvre un ensemble de soins (bundle) pour les enfants qui se présentent à un service d'urgence pédiatrique avec des problèmes de santé mentale. Une nouveauté de ce bundle était qu'il comprenait une option d'évaluation dans une clinique partenaire, et non au service des urgences, pour les familles d'enfants évalués comme n'ayant aucun problème médical ou de sécurité. L'objectif premier de cette étude était d'assurer la réussite de la mise en œuvre du bundle avant d'en étudier l'impact. MéTHODES: Le bundle comprenait le questionnaire Ask Suicide-Screening Questions pour normaliser l'évaluation du risque au triage, l'outil HEADS-ED (Home, Education, Activities/Peers, Drug/Alcohol, Suicidality, Emotions/Behavior, Discharge Resources) pour des évaluations brèves et notées de la santé mentale, et l'offre d'un rendez-vous urgent dans les 96 heures pour les enfants à faible risque comme alternative à l'évaluation à l'urgence ou comme option de suivi pour les patients évalués à l'urgence. Nous avons élaboré des objectifs, des diagrammes de pilotage et des mesures de résultats pour chaque élément du bundle. Chaque élément a été introduit avec de petits tests de changement en utilisant des cycles itératifs planifier-faire-étudier-agir. Des diagrammes de progression ont été utilisés pour déterminer la réussite des objectifs. RéSULTATS: Les règles relatives à la cause spéciale ont été respectées grâce à la détection de changements dans les performances 5 mois après la mise en œuvre de bundle pour les questions de dépistage du suicide et HEADS-ED. Ces bundles ont été systématiquement utilisés avec plus de 80 % des patients éligibles, ce qui représente un objectif atteint. Au cours des six mois pendant lesquels des rendez-vous urgents ont été proposés, 89,3 % des 159 familles référées ont obtenu un rendez-vous dans les 96 heures. CONCLUSIONS: En utilisant des méthodes d'amélioration de la qualité, nous avons réussi à assurer une mise en œuvre fiable d'un nouveau bundle de soin pour les patients pédiatriques se présentant aux urgences avec des problèmes de santé mentale et à permettre aux patients à faible risque éligibles de recevoir des évaluations complètes dans une clinique partenaire plutôt qu'aux urgences.

Identification of educational and infrastructural barriers to prompt antibiotic delivery in febrile neutropenia: a quality improvement initiative.

BACKGROUND: Antibiotic administration within 60 minutes of presentation for medical care may be used as a treatment target for febrile neutropenia (FN); however, anecdotal evidence suggests this target is often missed. Few studies have examined the prevalence or causes of delay. We describe the median time to antibiotic administration at our institution, predictors of delay, and barriers to prompt administration to inform quality improvement strategies. PROCEDURE: A random sample of 50 episodes of FN presenting to the emergency department (ED) between 2008 and 2009 were reviewed. Times between triage, MD assessment, lab results, and antibiotic administration were recorded. Patient and ED variables were examined as possible predictors of delay. In parallel, lean methodology was used to identify system inefficiencies. A trained moderator conducted group interviews with interdisciplinary representatives involved in the emergency care of neutropenic patients to identify process barriers to prompt antibiotics. RESULTS: The median time from triage to antibiotics was 216 minutes (interquartile range [IQR] = 151-274 minutes). The greatest delay occurred following the reporting of lab results (152 minutes, IQR = 84-210 minutes). Only fall season predicted a longer time to antibiotics (P = 0.03). The lean process identified unnecessary areas of delay between departments. CONCLUSIONS: Time to antibiotic administration exceeded 1 hour. The chart review and lean process suggested targets for educational and infrastructural interventions, including an ED pre-printed order sheet, targeted combined subspecialty education between emergency and hematology/oncology staff, and family education. A mixed methodology approach represents a model for improving process efficiency and meeting "best-practice" targets in medicine.

Predictors of clinically significant upper gastrointestinal hemorrhage among children with hematemesis.

OBJECTIVES: The aim of the study was to determine the proportion of children with hematemesis who experience a clinically significant upper gastrointestinal hemorrhage (UGIH) and to identify variables predicting their occurrence. METHODS: A retrospective cohort study was conducted. All of the emergency department visits by children ages 0 to 18 years who presented with hematemesis between 2000 and 2007 were reviewed. The primary aim of the study was to determine the proportion of children who developed a clinically significant UGIH; the secondary aim was to identify risk factors predictive of a clinically significant UGIH. A significant UGIH was defined by any of the following: hemoglobin drop >20 g/L, blood transfusion, or emergent endoscopy or surgical procedure. RESULTS: Twenty-seven of 613 eligible children (4%; 95% confidence interval 3%-6%) had a clinically significant UGIH. Clinically significant hemorrhages were associated with older age (9.7 vs 2.9 years; P<0.001), vomiting moderate to large amounts of fresh blood (58% vs 20%; P<0.001), melena (37% vs 5%; P<0.001), significant medical history (63% vs 24%; P<0.001), unwell appearance (44% vs 6%; P<0.001), and tachycardia (41% vs 10%; P<0.001). The frequency of laboratory investigations increased with age (P<0.001). The hemoglobin level was the only laboratory investigation whose results differed between those with and without significant bleeds. The presence of any one of the following characteristics identified all of the children with a clinically significant hemorrhage: melena, hematochezia, unwell appearance, or a moderate to large volume of fresh blood in the vomitus, sensitivity 100% (95% confidence interval 85%-100%). CONCLUSIONS: The occurrence of a clinically significant UGIH was uncommon among children with hematemesis, especially in well-appearing children without melena, hematochezia, or who had not vomited a moderate to large amount of fresh blood.

Evaluation of parent and youth experiences in advisory groups as part of a mental healthcare clinical trial: protocol for a mixed-method study.

INTRODUCTION: Patient engagement in healthcare research is a necessity to ensure that research objectives align with priorities, outcomes and needs of the population under study, and to facilitate ease of implementation and adoption of findings. In clinical trials, there is an increasing focus on patient engagement during the planning and conduct of clinical trials due to the potential for ethical and methodological benefits. As patient engagement in clinical trials increases, there is a need to evaluate the approaches of these activities to contribute evidence on what is most appropriate and successful. The purpose of this study is to evaluate patient engagement processes and the activities of patient partners during and after a paediatric mental healthcare trial. METHODS AND ANALYSIS: Using a mixed-methods study design, we will evaluate patient partners' engagement activities across set time-points during the trial and after trial completion. In this study, the term 'patient partner' is inclusive of two groups of people with lived experience: (1) caregivers (parents, formal/informal caregivers and family), and (2) youth (aged 15-24 years). Engagement will be evaluated using the participant and project questionnaires of the Public and Patient Engagement Evaluation Tool (PPEET), followed sequentially by semi-structured interviews. Quantitative data from the PPEET questionnaire will be analysed and reported using descriptive statistics. Data from open-ended questions from the PPEET questionnaires and semi-structured interviews will be analysed using thematic analysis. ETHICS AND DISSEMINATION: Approval from Athabasca University Research Ethics Board will be obtained for this project. Findings will be disseminated at both academic and public venues whether in-person or online, and using platforms that are caregiver and youth friendly. TRIAL REGISTRATION NUMBER: NCT04902391.

An Innovative Model of Pediatric Emergency Department Mental Health Care: Protocol for a Multicenter Type 1 Effectiveness-Implementation Cluster Randomized Trial.

Over the past decade, visits to American and Canadian emergency departments (EDs) for child and youth mental health care have increased substantially.1,2 Acute mental health crises can occur as a result of a variety of concerns, including those that are life threatening (eg, suicide attempts), pose safety concerns (eg, suicidal intentions, aggressive behaviors, alcohol and other drug use), and are physically distressing to the child or youth (eg, panic attacks). ED health care providers play a vital role in assessing the safety and well-being of the child or youth and referring them to services for ongoing care.3,4 During the ED visit, assessment and care should pinpoint risks, inform treatment, and consider family needs and preferences as part of a patient-centered approach. Yet, this approach to care is not widely adopted in EDs. Most EDs do not require the use of pediatric-specific mental health tools to guide assessments or have patient-centered procedures in place to guide the care of patients with mental health emergencies.5-7 Our team believes these limitations have led to the provision of acute mental health care that can lack sufficient quality and efficiency. This study protocol describes a trial designed to evaluate if a novel mental health care bundle that was co-designed with parents and youth results in greater improvements in the well-being of children and youth 30 days after seeking ED care for mental health and/or substance misuse concerns compared with existing care protocols. We hypothesize that the bundle will positively impact child and youth well-being, while also providing cost-effective health care system benefits.

Practice Patterns and Assessment of Needs for Pediatric Pain Management in Alberta Emergency Departments.

PURPOSE: Many rural and community emergency departments (EDs) experience barriers to providing optimal pain care to children. In preparation for a quality improvement initiative, our team conducted a provincial pediatric pain management practice and needs assessment. METHODS: An online survey was sent to ED administrators and educators from March to May 2017. Themes included pain assessment, pain and distress management strategies, available resources, education, barriers to care, and opportunities for improvement. RESULTS: Forty-five respondents, from 31 EDs representing all five geographic health zones in Alberta, completed the survey. Use of a pain assessment tool was reported at 93.5% (29/31 sites) of the sites. Topical anesthesia was employed "most of the time" before suturing at 67% (18/27) of sites, versus 15% (4/27) before blood work or IV insertion. Eighty-one percent (22/27) of sites reported physically restraining children for procedures "often", while 37% (10/27) reported use of comfort positioning "often". Digital distraction devices were available at 37% (10/27) of sites. Reported challenges included lack of resources (33.3%, 12/36), staff education/knowledge (33.3%, 12/36), and absent policies/poor policy adherence (25.0%, 9/36). Opportunities for improvement included staff member education (73.5%, 25/34) and more resources (58.8%, 20/34). Respondents rated their site's overall ability to manage children's pain as 50/100 [IQR:21,61]. CONCLUSION: General EDs report providing suboptimal children's pain care, with use of physical restraint for medical procedures, and under-utilization of evidence-based, inexpensive treatment options. There are many gaps in children's pain care in rural and community EDs which could be addressed through collaborative quality improvement initiatives.

Patient Reported Experience in a Pediatric Emergency Department.

OBJECTIVES: To describe patient-reported experience in a pediatric emergency department (ED) and determine: (1) whether there are differences between the experience children report in comparison to their parents; and (2) whether factors such as time of visit (day, evening, night) and ED census are associated with patient experience. METHODS: We conducted a prospective cross-sectional survey of children ≥8 years of age and the parents/guardians of children 0 to 17 years who visited a pediatric ED using a validated patient experience measure. The proportion of respondents for each question indicating that an aspect of their care could have been improved was calculated as problem scores for each survey item. The primary outcome was the overall problem scores for all respondents combined and for children and parents separately. RESULTS: A total of 237 parents and 109 children completed surveys. The areas with the highest problem scores identified by both parents and children were: having enough to do while waiting to be seen (53.5; 95% confidence interval [CI]: 48.1, 58.8) and when to restart usual activities (34.7; 95% CI: 29.7, 40.0). There were meaningful differences in problem scores between children and parents including: doctors and nurses explaining what they were doing (parents: 19; 95% CI: 14.3, 24.7, child 40.4; 95% CI: 31.2, 50.2) and privacy when examined and treated (parents: 17.3; 95% CI: 12.8, 22.9, child: 36.7; 95% CI: 27.8, 46.5). CONCLUSION: There are differences in reported experience between children and their parents. This highlights the importance of including children when assessing patient experience in a pediatric setting.