Emergency department visits and hospital admissions for suicidal ideation, self-poisoning and self-harm among adolescents in Canada during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic had profound effects on the mental wellbeing of adolescents. We sought to evaluate pandemic-related changes in health care use for suicidal ideation, self-poisoning and self-harm. METHODS: We obtained data from the Canadian Institute for Health Information on emergency department visits and hospital admissions from April 2015 to March 2022 among adolescents aged 10-18 years in Canada. We calculated the quarterly percentage of emergency department visits and hospital admissions for a composite outcome comprising suicidal ideation, self-poisoning and self-harm relative to all-cause emergency department visits and hospital admissions. We used interrupted time-series methods to compare changes in levels and trends of these outcomes between the prepandemic (Apr. 1, 2015-Mar. 1, 2020) and pandemic (Apr. 1, 2020-Mar. 31, 2022) periods. RESULTS: The average quarterly percentage of emergency department visits for suicidal ideation, self-poisoning and self-harm relative to all-cause emergency department visits was 2.30% during the prepandemic period and 3.52% during the pandemic period. The level (0.08%, 95% confidence interval [CI] -0.79% to 0.95%) or trend (0.07% per quarter, 95% CI -0.14% to 0.28%) of this percentage did not change significantly between periods. The average quarterly percentage of hospital admissions for the composite outcome relative to all-cause admissions was 7.18% during the prepandemic period and 8.96% during the pandemic period. This percentage showed no significant change in level (-0.70%, 95% CI -1.90% to 0.50%), but did show a significantly increasing trend (0.36% per quarter; 95% 0.07% to 0.65%) during the pandemic versus prepandemic periods, specifically among females aged 10-14 years (0.76% per quarter, 95% CI 0.22% to 1.30%) and females aged 15-18 years (0.56% per quarter, 95% CI 0.31% to 0.81%). INTERPRETATION: The quarterly change in the percentage of hospital admissions for suicidal ideation, self-poisoning and self-harm increased among adolescent females in Canada during the first 2 years of the COVID-19 pandemic. This underscores the need to promote public health policies that mitigate the impact of the pandemic on adolescent mental health.

Predictors of Adherence to Short-Course Probiotics Among Children with Gastroenteritis who are Enrolled in a Clinical Trial.

BACKGROUND: To improve our understanding of adherence to discharge medications in the ED and within research trials, we sought to quantify medication adherence and identify predictors thereof in children with acute gastroenteritis (AGE). METHODS: We conducted a secondary analysis of a randomized trial of twice daily probiotic for 5 days. The population included previously healthy children aged 3-47 months with AGE. The primary outcome was patient-reported adherence to the treatment regimen, defined a priori as having received >70% of the prescribed doses. Secondary outcomes included predictors of treatment adherence and concordance between patient-reported adherence and the returned medication sachet counts. RESULTS: After excluding participants with missing data on adherence, 760 participants were included in this analysis: 383 in the probiotic arm (50.4%); and 377 in the placebo arm (49.6%). Self-reported adherence was similar in both groups (77.0% in probiotic versus 80.3% in placebo). There was good agreement between self-reported adherence and sachet counts (87% within limits of agreement (-2.9 to 3.5 sachets) on the Bland-Altman plots). In the multivariable regression model, covariates associated with adherence were greater number of days of diarrhea post-emergency department visit, and the study site; covariates negatively associated with adherence were age 12-23 months, severe dehydration and greater total number of vomiting and diarrhea episodes after enrolment. CONCLUSIONS: Longer duration of diarrhea and study site were associated with higher probiotic adherence. Age 12-23 months, severe dehydration and greater number of vomiting and diarrhea episodes post enrolment negatively predicted treatment adherence.

Essential Content for Discharge Instructions in Pediatric Emergency Care: A Delphi Study.

OBJECTIVE: The aim of this study was to identify the 5 most essential discharge instruction content elements that should be communicated to all caregivers of children who present to the emergency department (ED) with asthma, vomiting/diarrhea, abdominal pain, fever, minor head injury, or bronchiolitis. METHODS: A discharge information content list was developed for each illness presentation following a review of the literature. Using a modified Delphi technique, 6 lists were distributed to a panel of experts from EDs across Canada using a secure online survey tool with the goal of achieving the 5 most essential discharge instruction elements. RESULTS: A total of 37 emergency clinicians completed all 4 rounds of the Delphi. Consensus for the final 30 content items ranged from 51.4% to 100%. Items pertaining to diarrhea/vomiting, abdominal pain, fever, and bronchiolitis obtained relatively high levels of consensus for all top 5 items. The majority of items (n = 19 [63.3%]) that reached consensus across the illness presentations were associated with instructions intended to educate caregivers on instances when they should return to the ED department. CONCLUSIONS: Findings from this study provide a better understanding of what should be communicated to caregivers of children who present to the ED with a number of different illness presentations. Results from this study suggest that health care providers agree on the importance of providing information to caregivers regarding when to return to the ED with their child. Reaching consensus among all experts in this study provides insight into the difficulty of standardizing discharge communication in the absence of widely accepted guidelines.

The impact of an educational intervention on knowledge about infant crying and abusive head trauma.

BACKGROUND: Infants follow a predictable trajectory of increased early crying. Frustration with crying is reported to be a trigger for abusive head trauma (AHT). OBJECTIVE: To evaluate the impact of postpartum delivery of the educational program, the Period of PURPLE Crying (PURPLE), in a group of first-time mothers. The primary objective was to determine whether there was a change in knowledge about infant crying and shaking after exposure to PURPLE. Factors associated with change in knowledge were also examined. METHOD: A total of 93 participants were recruited over a four-month period at a tertiary care hospital in Nova Scotia. Pre- and postintervention data were collected. RESULTS: Knowledge about infant crying increased significantly after program delivery (P=0.001). Low baseline crying knowledge was a significant predictor of increased knowledge about infant crying (P≤0.01). There was an insignificant decrease in shaking knowledge (P=0.5), which may have been the consequence of high baseline knowledge. CONCLUSION: An educational program for new parents appears to be warranted, especially with respect to improving knowledge about infant crying. This may have a positive benefit in AHT prevention. Additional studies are required to evaluate the impact of the program on other caregivers and on rates of AHT.

HISTORIQUE: Les nourrissons suivent une trajectoire prévisible d'augmentation des pleurs peu après la naissance. La frustration à l'égard de ces pleurs est considérée comme un déclencheur des traumatismes crâniens non accidentels (TCNA). OBJECTIF: Évaluer l'effet de la transmission d'un programme d'éducation postnatale, la Period of PURPLE Crying (PURPLE), à un groupe de mères d'un premier enfant. L'objectif primaire consistait à déterminer si les connaissances relatives aux pleurs et aux secousses des nourrissons changeaient après l'exposition à PURPLE. Les facteurs liés aux changements de connaissances ont également été examinés. MÉTHODOLOGIE: Les chercheurs ont recruté 93 participantes sur une période de quatre mois dans un hôpital de soins tertiaires de la Nouvelle-Écosse. Ils ont colligé les données avant et après l'intervention. RÉSULTATS: Les connaissances sur les pleurs des nourrissons augmentaient de manière significative après la prestation du programme (P=0,001). Le peu de connaissances sur les pleurs en début d'étude était un prédicteur important d'augmentation des connaissances sur les pleurs des nourrissons (P≤0,01). Il y avait une diminution non significative des connaissances sur les secousses (P=0,5), qui peut découler des connaissances importantes avant l'intervention. CONCLUSION: Un programme d'éducation pour les nouveaux parents semble justifié, particulièrement pour accroître les connaissances sur les pleurs des nourrissons. Il pourrait contribuer à prévenir les TCNA. Il faudra réaliser d'autres études pour évaluer l'effet du programme auprès d'autres personnes qui s'occupent de nourrissons et sur le taux de TCNA.

Pediatric Pain Management in the Emergency Department: The Triage Nurses' Perspective.

UNLABELLED: Understanding triage nurses' perspectives of pain management is essential for timely pain care for children in the emergency department. Objectives of this study were to describe the triage pain treatment protocols used, knowledge of pain management modalities, and barriers and attitudes towards implementation of pain treatment protocols. METHODS: A paper-based survey was administered to all triage nurses at three Canadian pediatric emergency departments, between December 2011 and January 2012. RESULTS: The response rate was 86% (n=126/147). The mean respondent age was 40 years (standard deviation [SD] 9.3) with 8.6 years (SD 7.7) of triage experience. General triage emergency department (GTED) nurses rated adequacy of triage pain treatment lower than pediatric-only triage emergency department (PTED) nurses (P < .001). GTED nurses reported a longer acceptable delay between triage time and administration of analgesia than PTED nurses (P < .002). Most nurses rated more comfort with a protocol involving administration of acetaminophen (97 mm, interquartile range [IQR] 92, 99) or ibuprofen (97 mm, IQR 93, 100) than for oral morphine (67 mm, IQR 35, 94) or oxycodone (57 mm, IQR 15, 81). The top three reported barriers to triage-initiated pain protocols were monitoring capability, time, and access to medications. Willingness to implement a triage-initiated pain protocol was rated as 81 mm (IQR 71, 96). DISCUSSION: Triage nurses are willing to implement pain protocols for children in the emergency department, but differences in comfort and experience exist between PTED and GTED nurses. Provision of triage initiated pain protocols and associated education may empower nurses to improve care for children in pain in the emergency department.

Instituting a Palliative Care Trigger in a Surgical Intensive Care Unit (SICU): Survey Results of SICU Team Members.

Increasing palliative care presence in the intensive care unit (ICU) improves symptom management, increases goals-of-care discussion, and reduces unnecessary procedures in ICU patients. An interdisciplinary study team developed a palliative care trigger program in a 17-bed surgical ICU (SICU). Surgical ICU patients who met 3 triggers (ICU length of stay > 10 days, repeat ICU admission, and metastatic cancer) automatically received a palliative care consult. The purpose of the current study was to survey SICU health care professionals before and after the institution of the palliative care trigger program. Overall, the palliative care trigger program was viewed positively by interdisciplinary team members with increased team communication and decreased resistance for the inclusion of palliative care in the SICU plan of care. The palliative care trigger program was successfully developed and implemented in a SICU and was accepted by the interdisciplinary team members caring for SICU patients. Team member feedback is being used to expand the palliative care trigger program to improve care for SICU patients.

Non-suicidal self-injury at a Canadian paediatric emergency department.

OBJECTIVE: Our primary objective was to determine agreement between non-suicidal self-injury recorded at triage and during subsequent mental health assessment. The secondary objective was to describe patients who reported non-suicidal self-injury. METHODS: This is a health records review of patients aged 12-18 years who had an Emergency Mental Health Triage form on their health record from an ED visit June 1, 2017-May 31, 2018. We excluded patients with diagnoses of autism spectrum disorder or schizophrenia. We abstracted data from the Mental Health Triage form, Emergency Mental Health and Addictions Service Assessment forms and Assessment of Suicide and Risk Inventory. We calculated Cohen's Kappa coefficient, sensitivity, and negative predictive value to describe the extent to which the forms agreed and the performance of triage for identifying non-suicidal self-injury. We compared the cohort who reported non-suicidal self-injury with those who did not, using t-tests, Wilcoxon rank-sum tests, and chi-square tests. RESULTS: We screened 955 ED visits and included 914 ED visits where 558 (58.4%) reported a history of non-suicidal self-injury. There were significantly more females in the group reporting non-suicidal self-injury (82.1%, n = 458) compared to the group not reporting non-suicidal self-injury (45.8%, n = 163). Patients reporting non-suicidal self-injury did so in triage and detailed Mental Health Assessment 64.7% of the time (Cohen's Kappa Coefficient 0.6); triage had sensitivity of 71.5% (95% CI 67.3-75.4) and negative predictive value of 71.2% (95% CI 68.2-74.0). Cutting was the most common method of non-suicidal self-injury (80.3%). CONCLUSION: Screening at triage was moderately effective in identifying non-suicidal self-injury compared to a detailed assessment by a specialised mental health team. More than half of children and adolescents with a mental health-related concern in our ED reported a history of non-suicidal self-injury, most of which were female. This symptom is important for delineating patients' coping strategies.

RéSUMé: OBJECTIFS: Notre objectif principal était de déterminer l'accord entre les blessures non suicidaires enregistrées au triage et lors de l'évaluation subséquente de la santé mentale. L'objectif secondaire était de décrire les patients qui ont déclaré une automutilation non suicidaire. MéTHODES: Il s'agit d'un examen des dossiers de santé de patients âgés de 12 à 18 ans qui avaient un formulaire de triage d'urgence en santé mentale dans leur dossier de santé à la suite d'une visite à l'urgence du 1er juin 2017 au 31 mai 2018. Nous avons exclu les patients présentant un diagnostic de trouble du spectre autistique ou de schizophrénie. Nous avons extrait des données du formulaire de triage en santé mentale, des formulaires d'évaluation des services d'urgence en santé mentale et en toxicomanie et de l'évaluation du suicide et de l'inventaire des risques. Nous avons calculé le coefficient de Kappa de Cohen, la sensibilité et la valeur prédictive négative pour décrire la mesure dans laquelle les formes étaient d'accord et la performance du triage pour identifier l'automutilation non suicidaire. Nous avons comparé la cohorte qui a déclaré une automutilation non suicidaire avec celles qui ne l'ont pas fait, en utilisant des tests t-tests, des tests Wilcoxon rank-sum et des tests chi-carrés. RéSULTATS: Nous avons examiné 955 visites à l'urgence et inclus 914 visites à l'urgence où 558 (58,4 %) ont signalé des antécédents d'automutilation non suicidaire. Il y avait beaucoup plus de femmes dans le groupe déclarant une automutilation non suicidaire (82,1 %, n = 458) que dans le groupe ne déclarant pas une automutilation non suicidaire (45,8 %, n = 163). Les patients ayant déclaré une automutilation non suicidaire l'ont fait dans le cadre du triage et de l'évaluation détaillée de la santé mentale 64,7 % du temps (coefficient de Kappa de Cohen 0,6); le triage avait une sensibilité de 71,5 % (IC à 95 % 67,3­75,4) et une valeur prédictive négative de 71,2 % (IC à 95 % 68,2­74,0). La coupe était la méthode la plus courante d'automutilation non suicidaire (80,3 %). CONCLUSION: Le dépistage au triage a été modérément efficace pour identifier les blessures non suicidaires comparativement à une évaluation détaillée par une équipe spécialisée en santé mentale. Plus de la moitié des enfants et des adolescents ayant un problème de santé mentale à notre DE ont signalé des antécédents d'automutilation non suicidaire, dont la plupart étaient des femmes. Ce symptôme est important pour délimiter les stratégies d'adaptation des patients.

Medication-related emergency department visits and hospital admissions in pediatric patients: a qualitative systematic review.

OBJECTIVE: To review and describe the current literature pertaining to the incidence, classification, severity, preventability, and impact of medication-related emergency department (ED) and hospital admissions in pediatric patients. STUDY DESIGN: A systematic search of PubMED, Embase, and Web of Science was performed using the following terms: drug toxicity, adverse drug event, medication error, emergency department, ambulatory care, and outpatient clinic. Additional articles were identified by a manual search of cited references. English language, full-reports of pediatric (≤18 years) patients that required an ED visit or hospital admission secondary to an adverse drug event (ADE) were included. RESULTS: We included 11 studies that reported medication-related ED visit or hospital admission in pediatric patients. Incidence of medication-related ED visits and hospital admissions ranged from 0.5%-3.3% and 0.16%-4.3%, respectively, of which 20.3%-66.7% were deemed preventable. Among ED visits, 5.1%-22.1% of patients were admitted to hospital, with a length of stay of 24-72 hours. The majority of ADEs were deemed moderate in severity. Types of ADEs included adverse drug reactions, allergic reactions, overdose, medication use with no indication, wrong drug prescribed, and patient not receiving a drug for an indication. Common causative agents included respiratory drugs, antimicrobials, central nervous system drugs, analgesics, hormones, cardiovascular drugs, and vaccines. CONCLUSION: Medication-related ED visits and hospital admissions are common in pediatric patients, many of which are preventable. These ADEs result in significant healthcare utilization.

Performance of the Canadian Triage and Acuity Scale for children: a multicenter database study.

STUDY OBJECTIVE: We evaluate the association between triage levels assigned using the Canadian Triage and Acuity Scale and surrogate markers of validity for real-life children triaged in multiple emergency departments (EDs). METHODS: This was a retrospective cohort study evaluating the triage assessment and outcomes of all children presenting to 12 pediatric EDs, all of which are members of the Pediatric Emergency Research Canada group, during a 1-year period (2010 to 2011). Anonymous data were retrieved from the ED computerized databases. The primary outcome measure was the proportion of children hospitalized for each triage level. Other outcomes were ICU admission, proportion of patients who left without being seen by a physician, and length of stay in the ED. Evaluation of all children visiting these EDs during 1 year was expected to provide more than 1,000 patients in each triage category. RESULTS: A total of 550,940 children were included. Pooled data demonstrated hospitalization proportions of 61%, 30%, 10%, 2%, and 0.9% for patients in Canadian Triage and Acuity Scale levels 1, 2, 3, 4, and 5, respectively. There was a strong association between triage level and admission to the ICU, probability of leaving without being seen by a physician, and length of stay. CONCLUSION: The strong association between triage level and multiple markers of severity in 12 Canadian pediatric EDs suggests validity of the Canadian Triage and Acuity Scale for children.

Evidence-Based Pearls: Chest Trauma.

The challenge in caring for patients who sustain traumatic chest injuries centers on their complex needs from high acuity and the potential for multisystem effects and complications. Hemorrhage and respiratory compromise are common sequela of thoracic trauma. Patients must be resuscitated and their injuries managed with the primary goals of restoring cardiopulmonary structural integrity and preventing complications. There are evolving strategies for the management of the thoracic trauma victim including damage control resuscitation and surgery, endovascular repairs, and assessments implementing severity scores to aid in planning interventions.

Assessing the Feasibility and Implementation of Palliative Care Triggers in a Surgical Intensive Care Unit to Improve Interdisciplinary Collaboration for Patient and Family Care.

Although palliative care focuses on supporting patients and families through serious illness, it is underutilized in the surgical intensive care unit (SICU). In 2020, patients in the SICU represented only 2.75% of our palliative team's consults. We hypothesize that utilization of palliative care triggers in the SICU will increase collaboration between SICU and palliative care teams and improve patient/family experiences. After reviewing our team's consultation records and the published literature, a consult trigger program was implemented for patients with a SICU length of stay >10 days, unplanned SICU readmission, or new diagnosis of metastatic cancer. A pre-intervention survey assessed SICU providers' perceptions of palliative care. Retrospective analysis evaluated qualitative and quantitative measures. 97% of SICU providers felt increased palliative care would be helpful. During the 6-month project, January 1, 2021 - June 30, 2021, our palliative team performed 27 triggered consults, representing 3.3% of the total 818 consults performed during this period and thus a 20% increase in SICU palliative consults. Triggered consults represented many primary surgical services and the most common consult reason was length-of-stay. All consults included discussions about goals of care and 16 of the 27 patients/families expressed restorative goals. Numerous notes documented family appreciation.

Machine learning to identify attributes that predict patients who leave without being seen in a pediatric emergency department.

PURPOSE: To characterize patients who left without being seen (LWBS) from a Canadian pediatric Emergency Department (ED) and create predictive models using machine learning to identify key attributes associated with LWBS. METHODS: We analyzed administrative ED data from April 1, 2017, to March 31, 2020, from IWK Health ED in Halifax, NS. Variables included: visit disposition; Canadian Triage Acuity Scale (CTAS); triage month, week, day, hour, minute, and day of the week; sex; age; postal code; access to primary care provider; visit payor; referral source; arrival by ambulance; main problem (ICD10); length of stay in minutes; driving distance in minutes; and ED patient load. The data were randomly divided into training (80%) and test datasets (20%). Five supervised machine learning binary classification algorithms were implemented to train models to predict LWBS patients. We balanced the dataset using Synthetic Minority Oversampling Technique (SMOTE) and used grid search for hyperparameter tuning of our models. Model evaluation was made using sensitivity and recall on the test dataset. RESULTS: The dataset included 101,266 ED visits where 2009 (2%) records were excluded and 5800 LWBS (5.7%). The highest-performing machine learning model with 16 patient attributes was XGBoost which was able to identify LWBS patients with 95% recall and 87% sensitivity. The most influential attributes in this model were ED patient load, triage hour, driving minutes from home address to ED, length of stay (minutes since triage), and age. CONCLUSION: Our analysis showed that machine learning models can be used on administrative data to predict patients who LWBS in a Canadian pediatric ED. From 16 variables, we identified the five most influential model attributes. System-level interventions to improve patient flow have shown promise for reducing LWBS in some centres. Predicting patients likely to LWBS raises the possibility of individual patient-level interventions to mitigate LWBS.

RéSUMé: BUT: Caractériser les patients qui sont partis sans être vus (left without being seen LWBS) d'un service d'urgence (SU) pédiatrique canadien et créer des modèles prédictifs utilisant l'apprentissage automatique pour identifier les attributs clés associés au LWBS. MéTHODES: Nous avons analysé les données administratives de SU du 1er avril 2017 au 31 mars 2020 provenant de l'urgence de IWK Health à Halifax, en Nouvelle-Écosse. Les variables comprenaient: disposition de la visite; l'échelle canadienne de triage de la gravité (ETG); mois, semaine, jour, heure, minute et jour de la semaine; sexe; âge; code postal; accès au fournisseur de soins primaires; payeur de la visite; source de l'aiguillage; arrivée par ambulance; principal problème (CIM10); durée du séjour en minutes; distance de conduite en minutes; et la charge de patients de l'urgence. Les données ont été divisées de manière aléatoire en ensembles de données de formation (80%) et de test (20%). Cinq algorithmes de classification binaire d'apprentissage automatique supervisés ont été mis en œuvre pour former des modèles de prévision des patients atteints de LWBS. Nous avons équilibré l'ensemble de données à l'aide de la technique de suréchantillonnage synthétique des minorités (SMOTE) et utilisé la recherche de grille pour le réglage des hyperparamètres de nos modèles. L'évaluation du modèle a été faite en utilisant la sensibilité et le rappel sur l'ensemble de données d'essai. RéSULTATS: L'ensemble de données comprenait 101266 visites aux urgences où les enregistrements de 2009 (2%) ont été exclus et 5800 LWBS (5,7%). Le modèle d'apprentissage automatique le plus performant avec 16 attributs de patient était XGBoost, qui a été en mesure d'identifier les patients LWBS avec 95% de rappel et 87% de sensibilité. Les attributs les plus influents dans ce modèle étaient la charge de patients à l'urgence, l'heure de triage, les minutes de conduite entre l'adresse du domicile et l'urgence, la durée du séjour (minutes depuis le triage) et l'âge. CONCLUSION: Notre analyse a montré que les modèles d'apprentissage automatique peuvent être utilisés sur des données administratives pour prédire les patients qui sont partis sans être vus dans un service d'urgence pédiatrique canadien. À partir de 16 variables, nous avons identifié les cinq attributs de modèle les plus influents. Les interventions au niveau du système visant à améliorer le flux de patients se sont révélées prometteuses pour réduire les LWBS dans certains centres. La prévision des patients susceptibles de LWBS soulève la possibilité d'interventions individuelles au niveau des patients pour atténuer le LWBS.

Implementation of a Virtual Interprofessional ICU Learning Collaborative: Successes, Challenges, and Initial Reactions From the Structured Team-Based Optimal Patient-Centered Care for Virus COVID-19 Collaborators.

Initial Society of Critical Care Medicine Discovery Viral Infection and Respiratory illness Universal Study (VIRUS) Registry analysis suggested that improvements in critical care processes offered the greatest modifiable opportunity to improve critically ill COVID-19 patient outcomes. OBJECTIVES: The Structured Team-based Optimal Patient-Centered Care for Virus COVID-19 ICU Collaborative was created to identify and speed implementation of best evidence based COVID-19 practices. DESIGN SETTING AND PARTICIPANTS: This 6-month project included volunteer interprofessional teams from VIRUS Registry sites, who received online training on the Checklist for Early Recognition and Treatment of Acute Illness and iNjury approach, a structured and systematic method for delivering evidence based critical care. Collaborators participated in weekly 1-hour videoconference sessions on high impact topics, monthly quality improvement (QI) coaching sessions, and received extensive additional resources for asynchronous learning. MAIN OUTCOMES AND MEASURES: Outcomes included learner engagement, satisfaction, and number of QI projects initiated by participating teams. RESULTS: Eleven of 13 initial sites participated in the Collaborative from March 2, 2021, to September 29, 2021. A total of 67 learners participated in the Collaborative, including 23 nurses, 22 physicians, 10 pharmacists, nine respiratory therapists, and three nonclinicians. Site attendance among the 11 sites in the 25 videoconference sessions ranged between 82% and 100%, with three sites providing at least one team member for 100% of sessions. The majority reported that topics matched their scope of practice (69%) and would highly recommend the program to colleagues (77%). A total of nine QI projects were initiated across three clinical domains and focused on improving adherence to established critical care practice bundles, reducing nosocomial complications, and strengthening patient- and family-centered care in the ICU. Major factors impacting successful Collaborative engagement included an engaged interprofessional team; an established culture of engagement; opportunities to benchmark performance and accelerate institutional innovation, networking, and acclaim; and ready access to data that could be leveraged for QI purposes. CONCLUSIONS AND RELEVANCE: Use of a virtual platform to establish a learning collaborative to accelerate the identification, dissemination, and implementation of critical care best practices for COVID-19 is feasible. Our experience offers important lessons for future collaborative efforts focused on improving ICU processes of care.

The Canadian Triage and Acuity Scale for children: a prospective multicenter evaluation.

STUDY OBJECTIVE: The aims of the study are to measure both the interrater agreement of nurses using the Canadian Triage and Acuity Scale in children and the validity of the scale as measured by the correlation between triage level and proxy markers of severity. METHODS: This was a prospective multicenter study of the reliability and construct validity of the Canadian Triage and Acuity Scale in 9 tertiary care pediatric emergency departments (EDs) across Canada during 2009 to 2010. Participants were a sample of children initially triaged as Canadian Triage and Acuity Scale level 2 (emergency) to level 5 (nonurgent). Participants were recruited immediately after their initial triage to undergo a second triage assessment by the research nurse. Both triages were performed blinded to the other. The primary outcome measures were the interrater agreement between the 2 nurses and the association between triage level and hospitalization. Secondary outcome measures were the association between triage level and health resource use and length of stay in the ED. RESULTS: A total of 1,564 patients were approached and 1,464 consented. The overall interrater agreement was good, as demonstrated by a quadratic weighted κ score of 0.74 (95% confidence interval 0.71 to 0.76). Hospitalization proportions were 30%, 8.3%, 2.3%, and 2.2% for patients triaged at levels 2, 3, 4, and 5, respectively. There was also a strong association between triage levels and use of health care resources and length of stay. CONCLUSION: The Canadian Triage and Acuity Scale demonstrates a good interrater agreement between nurses across multiple pediatric EDs and is a valid triage tool, as demonstrated by its good association with markers of severity.

Acute Responses to Infectious and Inflammatory Disorders of the Gastrointestinal System.

Infectious and inflammatory disorders of the gastrointestinal system are life-threatening and occur frequently in hospitalized adults. Inflammatory and inflammation-related diseases of the gastrointestinal tract seen in the acutely and critically ill have numerous causes. In acute pancreatitis and toxic infections caused by the bacterium Clostridium difficile, where severe infections can develop, inflammation plays a causative and crucial role. Severe acute pancreatitis puts a patient at risk for infected necrosis, which can result in septicemia and shock. Similarly, patients treated with antibiotics are at risk for C difficile colitis, which can progress to toxic megacolon. These conditions require volume resuscitation and interventions supported by current evidence. Percutaneous or surgical interventions are often undertaken at a critical point in these illnesses. Patients who require surgery for these diagnoses present challenges for the interprofessional team. Inflammatory and infectious disorders often can lead to complications of systemic inflammatory response syndrome, sepsis, and multiorgan failure. New strategies are on the horizon to prevent the onset of and improve care for patients with severe acute pancreatitis, fulminant C difficile infection, and megacolon.

Organizational Interventions to Support Second Victims in Acute Care Settings: A Scoping Study.

OBJECTIVES: Health care providers that experience harm after adverse events have been termed "second victims." Our objective was to characterize the range and context of interventions to support second victims in acute care settings. METHODS: We performed a scoping study using Arksey and O'Malley's process. A library scientist searched PubMed, Cumulative Index of Nursing and Allied Health, EMBASE, and Cochrane Central Register of Controlled Trials in September 2017, and updated the search in November 2018. We sought gray literature (Canadian Electronic Library, Proquest and Scopus) and searched reference lists of included studies. Stakeholder organizations and authors of included studies were contacted. Two reviewers independently reviewed titles and abstracts and extracted data. A qualitative approach was used to categorize the context and characteristics of the 22 identified interventions. RESULTS: After screening 5634 titles and abstracts, 173 articles underwent full-text screening. Twenty-two interventions met the criteria and were categorized as providing peer support (n = 8), proactive education (n = 6), or both (n = 8). Programs came from Canada (n = 2), Spain (n = 2), and the United States (n = 18). A specific traumatic event triggered the development of 5 programs. Some programs used a standard definition of second victims, (n = 6), whereas other programs had a broader scope (n = 12). Confidentiality was explicitly assured in 9 peer support programs. Outcome measures were often not reported. CONCLUSIONS: This is a new area of study with little qualitative data from which to determine whether these programs are effective. Many programs had a similar design, based on the structure proposed by the same small group of experts in this new field. Concerns about potential legal proceedings hinder documentation and study of program effectiveness.

Advancing Antibiotic Stewardship Nursing Practice Through Standardized Education: A Pilot Study.

Background Antibiotic resistance is a leading global public health threat. Nurses are well positioned to optimize antibiotic use via targeted antibiotic stewardship (AS) nursing practices. However, standardized AS education for nurses is lacking. The objective of this study was to evaluate the effect of an online AS for nurses continuing education program on nurses' antibiotic resistance, antibiotic, and AS knowledge and their intent to integrate AS into their clinical practice. Method A quasi-experiential pretest-posttest design was used with a convenience sample of nurses at a U.S. academic medical center. Focus groups were conducted with those completing the program. Results Forty-seven of 100 eligible nurses completed the program and the pre- and posttest surveys. Participation resulted in statistically significant increases (p < .05) in antibiotic resistance, antibiotic, and AS knowledge, confidence, and perceptions related to the role of nursing in AS. Focus group participants had multiple recommendations for ways to integrate AS in daily nursing practice. Conclusion Completing a comprehensive AS nursing continuing education program could prove instrumental to motivating nurses to adopt AS nursing practices. [J Contin Educ Nurs. 2022;53(9):417-423.].

Hematochezia in children with acute diarrhea seeking emergency department care - a prospective cohort study.

OBJECTIVES: Although the passage of blood in stools in children represents a medical emergency, children seeking emergency department (ED) care remain poorly characterized. Our primary objective was to compare clinical characteristics and etiologic pathogens in children with acute diarrhea with and without caregiver-reported hematochezia. Secondary objectives were to characterize interventions and resource utilization. METHODS: We conducted a secondary analysis of the Alberta Provincial Pediatric EnTeric Infection TEam (APPETITE) database. Children <18 years presenting to two pediatric EDs within a 24-hour period and <7 days of symptoms were consecutively recruited. RESULTS: Of 1,061 participants, 115 (10.8%) reported hematochezia at the enrollment visit at which time those with hematochezia, compared to those without, had more diarrheal episodes/24-hour period (9 vs. 6; difference: 2; 95% confidence interval [CI]: 2.0, 4.0; p < 0.001), and were less likely to have experienced vomiting (54.8% vs. 80.2%; difference: -25.4; 95% CI: -34.9, -16.0; p < 0.001). They were more likely to receive intravenous fluids (33.0% vs. 17.9%; difference: 15.2; 95% CI: 6.2, 24.1; p < 0.001) and require repeat health care visits (45.5% vs. 34.7%; difference: 10.7; 95% CI: 0.9, 20.6; p = 0.03). A bacterial pathogen was identified in 33.0% of children with hematochezia versus 7.9% without (difference: 25.1; 95% CI: 16.3, 33.9; p < 0.001); viruses were detected in 31.3% of children with hematochezia compared to 72.3% in those without (difference: -41.0%, 95% CI: -49.9, -32.1; p < 0.001). CONCLUSION: In children with acute diarrhea, caregiver report of hematochezia, compared to the absence of hematochezia, was associated with more diarrheal but fewer vomiting episodes, and greater resource consumption. The former group of children was also more likely to have bacteria detected in their stool.

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.

The Effect of an Educational Program on Nursing Knowledge and Empowerment in Antimicrobial Stewardship in a Surgical Intensive Care Unit.

BACKGROUND: Hospital antimicrobial stewardship (AS) interventions have been shown to reduce the overuse and misuse of antimicrobials and rates of resistant organisms. To date, nurses have had limited involvement in AS. Improving nursing AS knowledge and sense of empowerment may improve their engagement in AS. OBJECTIVE: The purpose of this study was to evaluate the impact of an educational intervention on AS knowledge and sense of empowerment among bedside registered nurses (RNs) in a surgical intensive care unit in an academic medical center. METHODS: This was a quasi-experimental pre-post study. RESULTS: Forty-four RNs (85%) participated. There was a statistically significant (P < .01) increase in both AS knowledge and empowerment level of staff RNs. Registered nurses identified participation in patient care rounds and use of antibiotic timeouts as strategies for increasing their AS engagement. Perceived barriers included lack of physician/other team member support and knowledge deficits. CONCLUSIONS: The findings of this study indicate that educating nurses on their role in AS improves their knowledge and sense of empowerment for this emerging role. Future studies should examine how nurses apply this knowledge and sense of empowerment to engage in unit-based AS activities and the resultant patient outcomes.