Virtual family-centered rounds: a quality improvement initiative to adapt inpatient care during COVID-19 using a human-centred participatory design approach.

BACKGROUND: Family-centered rounds (FCR) are fundamental to pediatric inpatient care. During the COVID-19 pandemic, we aimed to design and implement a virtual family-centered rounds (vFCR) process that allowed continuation of inpatient rounds while following physical distancing guidelines and preserving personal protective equipment (PPE). METHODS: A multidisciplinary team developed the vFCR process using a participatory design approach. From April through July 2020, quality improvement methods were used to iteratively evaluate and improve the process. Outcome measures included satisfaction, perceived effectiveness, and perceived usefulness of vFCR. Data were collected via questionnaire distributed to patients, families, staff and medical staff, and analyzed using descriptive statistics and content analysis. Virtual auditors monitored time per patient round and transition time between patients as balancing measures. RESULTS: Seventy-four percent (51/69) of health care providers surveyed and 79% (26/33) of patients and families were satisfied or very satisfied with vFCR. Eighty eight percent (61/69) of health care providers and 88% (29/33) of patients and families felt vFCR were useful. Audits revealed an average vFCR duration of 8.4 min (SD = 3.9) for a single patient round and transition time between patients averaged 2.9 min (SD = 2.6). CONCLUSION: Virtual family-centered rounds are an acceptable alternative to in-person FCR in a pandemic scenario, yielding high levels of stakeholder satisfaction and support. We believe vFCR are a useful method to support inpatient rounds, physical distancing, and preservation of PPE that may also be valuable beyond the pandemic. A rigorous process evaluation of vFCR is underway.

A pediatric virtual care evaluation framework and its evolution using consensus methods.

BACKGROUND: The use of virtual care has increased dramatically in response to the COVID-19 pandemic, yet evidence is lacking regarding the impact of virtual care on patient outcomes, particularly in pediatrics. A standardized evaluation approach is required to support the integration of virtual care into pediatric health care delivery programs. The objective of this work was to develop a comprehensive and structured framework for pediatric virtual care evaluation. This framework is intended to engage and guide care providers, health centres, and stakeholders towards the development of a standardized approach to the evaluation of pediatric virtual care. METHODS: We brought together a diverse multidisciplinary team, including pediatric clinicians, researchers, digital health leads and analysts, program leaders, a human factors engineer, a family advisor and our manager of health equity and diversity. The team reviewed the literature, including published evaluation frameworks, and used a consensus-based method to develop a virtual care evaluation framework applicable to a broad spectrum of pediatric virtual care programs. We used an iterative process to develop framework components, including domains and sub-domains, examples of evaluation questions, measures, and data sources. Team members met repeatedly over seven months to generate and provide feedback on all components of the framework, making revision as needed until consensus was reached. The framework was then applied to an existing virtual care program. RESULTS: The resulting framework includes four domains (health outcomes, health delivery, individual experience, and program implementation) and 19 sub-domains designed to support the development and evaluation of pediatric virtual care programs. We also developed guidance on how to use the framework and illustrate its utility by applying it to an existing pediatric virtual care program. CONCLUSIONS: This virtual care evaluation framework expands on previously developed frameworks by providing additional detail and a structure that supports practical application. It can be used to evaluate a wide range of pediatric virtual care programs in a standardized manner. Use of this comprehensive yet easy to use evaluation framework will inform appropriate implementation and integration of virtual care into routine practice and support its sustainability and continuous improvement.

Innovative virtual care delivery in a Canadian paediatric tertiary-care centre.

Health care systems and providers have rapidly adapted to virtual care delivery during this unprecedented time. Clinical programs initiated a variety of virtual care delivery models to maintain access to care, preserve personal protective equipment, and minimize infectious disease spread. Herein, we first describe the context within paediatric health delivery during the COVID-19 pandemic in Canada that fueled the rise of virtual care delivery. We then summarize the development, implementation, and beneficial impact of the innovative virtual care delivery programs currently in use at Children's Hospital of Eastern Ontario (CHEO) for both inpatient and outpatient care, specifically in our ambulatory clinics, emergency department, and mental health program. We highlight the transferable unique ways CHEO has integrated virtual care delivery through our governance structure, stakeholder engagement including patient, caregivers and health care providers and staff, development, and use of eHealth tools and novel approaches for patient care requiring physical assessment. We conclude with our vision for the future of virtual care, one component of paediatric care delivery in the post-COVID-19 era, which requires a common framework for virtual care evaluation. Importantly, rapid implementation of a primarily virtual care model at CHEO sustained high volume quality paediatric care. We believe many of these programs should and will remain in the post-pandemic era. A comprehensive, unified approach to evaluation is essential to yield meaningful results that inform sustainable care delivery models that integrate virtual care, and ultimately help ensure the best health outcomes for our patients.

Patterns of utilization of complementary and alternative medicine in 2 pediatric gastroenterology clinics.

OBJECTIVES: The aim of the present study was to assess the prevalence and patterns of complementary and alternative medicine (CAM) use among pediatric patients with gastrointestinal (GI) disorders at academic clinics in Canada. METHODS: The survey was carried out at 2 hospital-based gastroenterology clinics: the Stollery Children's Hospital in Edmonton and the Children's Hospital of Eastern Ontario (CHEO) in Ottawa. RESULTS: CAM use at the Stollery was 83% compared with 36% at CHEO (P < 0.001). The most common reason for not using CAM was lack of knowledge about it. Most respondents felt comfortable discussing CAM in their clinic and wanted more information on CAM. The most common CAM products being taken were multivitamins (91%), calcium (35%), vitamin C (32%), probiotics (14%), and fish oil/omega-3 fatty acids (13%). The most common CAM practices being used were massage (43%), chiropractic (27%), faith healing (25%), and relaxation (18%). Most respondents believed that CAM was helpful, and most of the 23 reported adverse effects were minor. Seven were reported as moderate, and 3 were reported as severe. Many (42%) patients used CAM at the same time as prescription medicines, and of these patients, concurrent use was discussed with their physician (76%) or pharmacist (52%). CONCLUSIONS: CAM use is high among pediatric patients with GI disorders and is much greater among those in Edmonton than in Ottawa. Most respondents reported their CAM use as helpful, with little or no associated harm. Many patients fail to disclose their concurrent use of CAM and conventional medicines to their doctors, increasing the likelihood of interactions.

Complementary and alternative medicine: A survey of its use in children with chronic respiratory illness.

BACKGROUND: The use of complementary and alternative medicine (CAM) has increased in recent years, with especially high prevalence in individuals with chronic illnesses. In the United States, the prevalence of CAM use in pediatric asthma patients is as high as 89%. OBJECTIVE: To investigate the epidemiology of pediatric CAM use in respiratory subspecialty clinics. METHODS: A survey was conducted at two hospital-based respiratory clinics in Edmonton (Alberta) and Ottawa (Ontario). Caregivers (most often parents) of children <18 years of age were asked questions regarding child and caregiver use of CAM, including products and practices used, beliefs about CAM, trust in information sources about CAM and characteristics of the respondents themselves. RESULTS: A total of 202 survey questionnaires were completed (151 from Edmonton and 51 from Ottawa). Pediatric CAM use in Edmonton was 68% compared with 45% in Ottawa, and was associated with caregiver CAM use, poorer health and health insurance coverage for CAM. The majority (67%) of children using CAM had taken prescription drugs concurrently and 58% of caregivers had discussed this with their doctor. DISCUSSION: Lifetime use of CAM at these pediatric clinics was higher than reported for children who do not have chronic diseases. CAM practices that are popular may be worthy of further research to evaluate their effectiveness and safety profile with regard to drug interactions. Health care providers should be encouraged to discuss CAM use at every visit, and explore their patient's health-related beliefs, behaviours and treatment preferences.

HISTORIQUE: L'utilisation de la médecine complémentaire et parallèle (MCP) a augmenté ces dernières années. Sa prévalence est particulièrement élevée chez les personnes atteintes d'une maladie chronique. Aux États-Unis, sa prévalence chez les patients asthmatiques d'âge pédiatrique atteint les 89 %. OBJECTIF: Examiner l'épidémiologie de l'utilisation de la MCP en pédiatrie dans des cliniques spécialisées en santé respiratoire. MÉTHODOLOGIE: Les chercheurs ont effectué un sondage dans deux cliniques de santé respiratoire en milieu hospitalier, à Edmonton (Alberta) et à Ottawa (Ontario). Les personnes qui s'occupaient d'enfants de 18 ans ou moins (en général, les parents) se sont fait poser des questions sur l'utilisation de la MCP par l'enfant et par elles, y compris les produits et pratiques utilisés, les croyances au sujet de la MCP, la confiance envers les sources d'information sur la MCP et leurs caractéristiques personnelles. RÉSULTATS: Au total, 202 sondages ont été remplis (151 à Edmonton et 51 à Ottawa). L'utilisation de la MCP en pédiatrie à Edmonton s'élevait à 68 %, et à 45 % à Ottawa. Elle s'associait à l'utilisation de MCP par la personne qui s'occupait de l'enfant, à une moins bonne santé et à une couverture d'assurance pour la MCP. La majorité des enfants (67 %) qui utilisaient la MCP prenaient simultanément des médicaments sur ordonnance, et 58 % des personnes qui s'occupaient d'eux en avaient parlé avec leur médecin. EXPOSÉ: À ces cliniques de pédiatrie, l'utilisation générale de MCP était plus élevée que celle déclarée chez les enfants qui n'ont pas de maladie chronique. Les pratiques de MCP qui sont populaires devraient peut-être faire l'objet de recherches supplémentaires pour en évaluer l'efficacité et le profil d'innocuité en matière d'interactions médicamenteuses. Il faut encourager les dispensateurs de soins à parler de MCP à chaque rendez-vous et à explorer les croyances de leurs patients liées à la santé, leurs comportements et leurs préférences thérapeutiques.

The helpful or hindering effects of in-hospital patient monitor alarms on nurses: a qualitative analysis.

Patient monitors generate alarms to signal changes in vital signs. Some research suggests these alarms can improve patient safety. Other reports caution that these systems generate false alarms and create nursing workflow interruptions. These findings require contextualization by qualitatively investigating the lived experiences of nurses working with these monitors. Research into the dynamics involved in nursing responses to alarms can provide insights for monitor development and implementation. This study's purposes were (1) to describe the frequency of alarms generated by patient monitors and nursing responses and (2) to report nurses' explanations of the impact of alarms on workflow and strategies for responding to alarms. Forty-nine hours of observations and 14 interviews were conducted at a Canadian medical center. Four hundred forty-six monitor alarms (1 every 6.59 minutes) were observed. Of these, 70% had no immediate response from nurses. Furthermore, 34 red alarms (potential life-threatening) were observed, with 41% having no immediate response. Nurses reported feeling overloaded by alarm frequency. They described learning to interpret alarm data and developing workaround strategies (eg, ignoring alarms). Paradoxically, alarms prompted nurses to regularly consider and interpret patient information. We suggest the interpretive work associated with workarounds may hold benefits mitigating the potential harms of ignoring alarms.

Administration of the adjuvanted pH1N1 vaccine in egg-allergic children at high risk for influenza A/H1N1 disease.

BACKGROUND: In Canada, the pH1N1 influenza vaccine is recommended for children, particularly those less than 5 years of age or with chronic underlying disease. The pH1N1 vaccine, which contains residual allergenic egg white proteins, may pose a risk for vaccination of egg-allergic children. OBJECTIVE: To describe the outcome of pH1N1 influenza vaccine administration to egg-allergic children at risk for severe H1N1 disease. DESIGN/METHOD: Prospective observational cohort study. Children identified as at high risk for egg allergy and H1N1 influenza were vaccinated using a two-dose split protocol in a controlled medical setting. Children were given an initial test dose; if no reaction was noted, the remainder of the dose was administered and the children were followed for allergic reactions. Those who tolerated the split dose and required a second dose of vaccine were offered vaccination four weeks later as one injection. RESULTS: Sixty-two egg-allergic children considered at high risk for H1N1 disease received the adjuvanted pH1N1 vaccine. Egg allergy was diagnosed both clinically by an allergist and using skin and/or serum IgE testing. Within one hour of immunization, 2 children developed hives, 1 had a vasovagal response and 1 had a hypo-responsive episode. Fourteen children received the second H1N1 dose and 1 developed erythema and itching. There were no anaphylactic reactions. CONCLUSION: Administration of the adjuvanted pH1N1 vaccine in egg-allergic children at risk for severe H1N1 influenza was safe when performed in a two-dose split protocol in a controlled medical setting.

Effect of point of care information on inpatient management of bronchiolitis.

BACKGROUND: We studied the effects of access to point-of-care medical evidence in a computerised physician order entry system (CPOE) on management and clinical outcome of children with bronchiolitis. METHODS: This was a before-after study that took place in a Canadian tertiary care paediatric teaching hospital. The intervention was a clinical evidence module (CEM) for bronchiolitis management, adapted from Clinical Evidence (BMJ Publishing Group) and integrated into the hospital CPOE. CPOE users were medical trainees under the supervision of staff physicians working in the infant ward. Use of antibiotics, bronchodilators and corticosteroids; disease severity; length of hospital admission; and trainee use and perception of the CEM were measured before and after CEM introduction. RESULTS: 334 paediatric inpatients age 2 weeks to 2 years, with a clinical diagnosis of bronchiolitis; 147 children the year preceding and 187 children the year following introduction of a Clinical Evidence Module (CEM). The percentage of patients receiving antibiotics fell from 35% to 22% (relative decrease 37%) following the introduction of the CEM (p = 0.016). Bronchodilator use was high but following the CEM patients no longer received more than one variety. Steroid usage and length of hospitalisation were low and unaffected. Trainees found the CEM to be educational. CONCLUSION: Readily accessible clinical evidence at the point of care was associated with a significant decrease in antibiotic use and an end to multiple bronchodilator use. The majority of physician trainees found the CEM to be a useful educational tool.

Home safety measures and the risk of unintentional injury among young children: a multicentre case-control study.

BACKGROUND: Young children may sustain injuries when exposed to certain hazards in the home. To better understand the relation between several childproofing strategies and the risk of injuries to children in the home, we undertook a multicentre case-control study in which we compared hazards in the homes of children with and without injuries. METHODS: We conducted this case-control study using records from 5 pediatric hospital emergency departments for the 2-year period 1995-1996. The 351 case subjects were children aged 7 years and less who presented with injuries from falls, burns or scalds, ingestions or choking. The matched control subjects were children who presented during the same period with acute non-injury-related conditions. A home visitor, blinded to case-control status, assessed 19 injury hazards at the children's homes. RESULTS: Hazards found in the homes included baby walkers (21% of homes with infants), no functioning smoke alarm (17% of homes) and no fire extinguisher (51% of homes). Cases did not differ from controls in the mean proportion of home hazards. After controlling for siblings, maternal education and employment, we found that cases differed from controls for 5 hazards: the presence of a baby walker (odds ratio [OR] 9.0, 95% confidence interval [CI] 1.1-71.0), the presence of choking hazards within a child's reach (OR 2.0, 95% CI 1.0-3.7), no child-resistant lids in bathroom (OR 1.6, 95% CI 1.0-2.5), no smoke alarm (OR 3.2, 95% CI 1.4-7.7) and no functioning smoke alarm (OR 1.7, 95% CI 1.0-2.8). INTERPRETATION: Homes of children with injuries differed from those of children without injuries in the proportions of specific hazards for falls, choking, poisoning and burns, with a striking difference noted for the presence of a baby walker. In addition to counselling parents about specific hazards, clinicians should consider that the presence of some hazards may indicate an increased risk for home injuries beyond those directly related to the hazard found. Families with any home hazard may be candidates for interventions to childproof against other types of home hazards.

Child protection: a neglected area of pediatric residency training.

BACKGROUND: Child maltreatment is prevalent in Canadian society, and medical professionals are frequently required to provide care in these cases. Physician knowledge and training in child protection have been questioned. This study examined the experience, perceived adequacy of training, and perceived competency of Canadian pediatric residents in child protection. METHODS: Structured questionnaires were sent to child protection program directors (CPPDs), pediatric program directors (PPDs) and pediatric residents at the 16 Canadian pediatric academic centers. Data were analyzed using descriptive statistics, chi(2)-analyses, a Mann-Whitney test, and linear regression. RESULTS: Responses were obtained from 15 of 16 CPPDs, all 16 PPDs, and 190 of 348 (54.6%) residents. All programs provided didactic teaching sessions. Only 3 programs had mandatory clinical rotations, 9 programs offered clinical electives, and 7 programs did not offer any specific clinical experience in child protection. Half of the residents had seen 5 or fewer cases of maltreatment. Residents and program directors most commonly rated the training as "somewhat adequate, needs improvement" with a significant minority rating it as "poor, inadequate." Residents' self-rating of competency was positively associated with number of years of training and number of cases of maltreatment seen. Almost all residents (92%) felt that they needed further training in child protection, including 85% of graduating residents. Some of the residents (16.4%) did not anticipate dealing with child protection cases as practicing pediatricians. CONCLUSIONS: Canadian pediatric residents receive little exposure and limited training in child abuse and neglect. As a result, even senior pediatric residents feel poorly trained. These results highlight the need to establish effective training programs for residents in child protection.

Prevention of shaken baby syndrome: Never shake a baby.

Shaken baby syndrome (SBS) represents injuries to the head, skeleton and eyes of a young child and is the leading cause of fatal or life-threatening child abuse. SBS is preventable. The dangers and consequences of shaking a baby are not well appreciated by the general public. Simple educational programs and community nursing support programs have been shown to be helpful. Inadequate physician training and knowledge in child maltreatment have also been identified as problems. This article outlines the evidence for interventions in the prevention of SBS and recommendations for health care providers and educators.

Complementary and alternative medicine: a survey of its use in pediatric cardiology.

BACKGROUND: The use of complementary and alternative medicine is high among children and youth with chronic illnesses, including patients with cardiac conditions. Our goal was to assess the prevalence and patterns of such use among patients presenting to academic pediatric cardiology clinics in Canada. METHODS: A survey instrument was developed to inquire about current or previous use of complementary and alternative medicine products and practices, including indications, beliefs, sources of information and whether this use was discussed with physicians. Between February and July 2007, the survey was administered to patients (or their parents/guardians) presenting to 2 hospital-based cardiology clinics: the Stollery Children's Hospital in Edmonton, Alberta, and the Children's Hospital of Eastern Ontario in Ottawa, Ontario. RESULTS: At the Stollery Children's Hospital, 64.1% of the 145 respondents had used complementary and alternative medicine compared with 35.5% of the 31 respondents at the Children's Hospital of Eastern Ontario (p = 0.003). Overall, the most common products in current use were multivitamins (70.6%), vitamin C (22.1%), calcium (13.2%), unspecified "cold remedies" (11.8%) and fish oil or omega-3 fatty acids (11.8%). The most common practices in current use were massage (37.5%), faith healing (25.0%), chiropractic (20.0%), aromatherapy (15.0%) and Aboriginal healing (7.5%). Many patients (44.9%) used complementary and alternative medicine products at the same time as conventional prescription drugs. Concurrent use was discussed with physicians or pharmacists by 64.3% and 31.3% of respondents, respectively. INTERPRETATION: Use of complementary and alternative medicine products and practices was high among patients seen in the pediatric cardiology clinics in our study. Most respondents believed that the use of these products and practices was helpful; few reported harms and many did not discuss this use with their physicians, increasing the potential for interactions with prescribed medications.

CAM use in pediatric neurology: an exploration of concurrent use with conventional medicine.

BACKGROUND: Previous studies have found that up to 60% of children with neurologic conditions have tried complementary and alternative medicine (CAM). OBJECTIVE: To assess the use of CAM among patients presenting to neurology clinics at two academic centers in Canada. METHODS: A survey instrument was developed to inquire about use of CAM products and therapies, including reasons for use, perceived helpfulness, and concurrent use with conventional medicine, and administered to patients or their parents/guardians at the Stollery Children's Hospital in Edmonton and the Children's Hospital of Eastern Ontario (CHEO) in Ottawa. RESULTS: Overall CAM use at the Stollery was 78%, compared to 48% at CHEO. The most common CAM products used were multi-vitamins (84%), vitamin C (37%), homeopathic remedies (24%), and fish oil/omega 3 s (22%). The most common CAM practices used were massage (47%), chiropractic (37%), faith healing (18%), aromatherapy (16%), homeopathy (16%), and relaxation (16%). Many patients used CAM products at the same time as conventional medicine but just over half (57%) discussed this concurrent use with their physician. CONCLUSION: CAM use is common in pediatric neurology patients and most respondents felt that it was helpful, with few or no harms associated. However, this use is often undisclosed, increasing possibility of interactions with conventional drugs. We urge clinicians to inquire about CAM use during routine history taking at every patient visit. Parents would clearly like more information about CAM from their specialty clinics; such information would be easier to share if more primary data were available about the safety and effectiveness of commonly used therapies.

Growth and development in thanatophoric dysplasia - an update 25 years later.

KEY CLINICAL MESSAGE: Thanatophoric dysplasia is typically a neonatal lethal condition. However, for those rare individuals who do survive, there is the development of seizures, progression of craniocervical stenosis, ventilator dependence, and limitations in motor and cognitive abilities. Families must be made aware of these issues during the discussion of management plans.

Complementary and alternative medicine: a survey of its use in pediatric oncology.

Background. The use of complementary and alternative medicine (CAM) is high among children and youths with chronic illnesses, including cancer. The objective of this study was to assess prevalence and patterns of CAM use among pediatric oncology outpatients in two academic clinics in Canada. Procedure. A survey was developed to ask patients (or their parents/guardians) presenting to oncology clinics at the Stollery Children's Hospital in Edmonton and the Children's Hospital of Eastern Ontario (CHEO) in Ottawa about current or previous use of CAM products and practices. Results. Of the 137 families approached, 129 completed the survey. Overall CAM use was 60.5% and was not significantly different between the two hospitals. The most commonly reported reason for not using CAM was lack of knowledge about it. The most common CAM products ever used were multivitamins (86.5%), vitamin C (43.2%), cold remedies (28.4%), teething remedies (27.5%), and calcium (23.0%). The most common CAM practices ever used were faith healing (51.0%), massage (46.8%), chiropractic (27.7%), and relaxation (25.5%). Many patients (40.8%) used CAM products at the same time as prescription drugs. Conclusion. CAM use was high among patients at two academic pediatric oncology clinics. Although most respondents felt that their CAM use was helpful, many were not discussing it with their physicians.

Complementary and alternative medicine use by pediatric specialty outpatients.

OBJECTIVE: Complementary and alternative medicine (CAM) use is high among children and youth with chronic illnesses. The objective of this study was to assess the prevalence and patterns of CAM use in 10 subspecialty clinics in Canada and to compare CAM use between 2 geographically diverse locations. METHODS: This survey was carried out at 1 Children's Hospital in western Canada (Edmonton) and 1 Children's Hospital in central Canada (Ottawa). Questionnaires were completed by parents in either French or English. RESULTS: Although demographic characteristics of the 2 populations were similar, CAM use at the western hospital was 71% (n = 704) compared with 42% (n = 222) at the central hospital (P < .0001). Most respondents agreed or strongly agreed that they feel comfortable discussing CAM in their clinic. The most common CAM products currently used were multivitamins/minerals, herbal products, and homeopathic remedies. The most common CAM practices currently used were massage, chiropractic, relaxation, and aromatherapy. Eighty adverse effects were reported, and 55 (68.8%) of these were self-assessed as minor. CONCLUSIONS: Results of this study indicate that CAM use is high among pediatric specialty clinic outpatients and is much greater in the western than in the central hospital. Most respondents felt that their CAM use was helpful with few or no harms associated. Many patients, using CAM alongside their conventional medicines, are still not discussing their CAM use with their physicians and are increasing the likelihood for potential interactions and preventable harms.