Increasing the use of anxiolysis and analgesia for paediatric procedures in a community emergency department network: a quality improvement initiative.

Prior reports describe the care children receive in community EDs (CEDs) compared with paediatric EDs (PEDs) as uneven. The Emergency Medical Services for Children (EMSC) initiative works to close these gaps using quality improvement (QI) methodology. Project champion from a community hospital network identified the use of safe pharmacological and non-pharmacological anxiolysis and analgesia (A&A) as one such gap and partnered with EMSC to address it. Our primary Specific, Measurable, Achievable, Relevant and Time-Bound (SMART) aim was to increase intranasal midazolam (INM) use for common, anxiety-provoking procedures on children <8 years of age from 2% to 25% in a year.EMSC facilitated a QI team with representation from the CED and regional children's hospitals. Following the model for improvement, we initiated a process analysis of this CED A&A practice. Review of all paediatric procedural data identified common anxiety-provoking simple procedures as laceration repairs, abscess drainage and foreign body removal. Our SMART aims were benchmarked to two regional PEDs and tracked through statistical process control. A balancing metric was ED length of stay (ED LOS) for patients <8 years of age requiring a laceration repair. Additionally, we surveyed CED frontline staff and report perceptions of changes in A&A knowledge, attitudes and practice patterns. These data prioritised and informed our key driver diagram which guided the Plan-Do-Study-Act (PDSA) cycles, including guideline development, staff training and cognitive aids.Anxiety-provoking simple procedures occurred on average 10 times per month in children <8 years of age. Through PDSA cycles, the monthly average INM use increased from 2% to 42%. ED LOS was unchanged, and the perceptions of provider's A&A knowledge, attitudes and practice patterns improved.A CED-initiated QI project increased paediatric A&A use in a CED network. An A&A toolkit outlines our approach and may simplify spread from academic children's hospitals to the community.

A Case of Internet Gaming Disorder: When #Play Apart Together Takes a Dark Turn.

Background: The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) places internet Gaming disorder (IGD) in its research appendix as a potential new behavioral addiction diagnosis that requires further investigation. As part of the media campaign #HealthyAtHome, recommendation to relieve stress and anxiety during COVID-19, the World Health Organization (WHO) advocated for the playing of video games. The encouragement and expansion of playing video games may have led to the unintentional consequence of increasing the prevalence of IGD as IGD has been postulated to be a maladaptive response to stress. Case: A 34 year old male presented to his primary care physician with decline in work function, increased depression, and anxiety. Before the COVID-19 pandemic he estimated that he spent 2 h a day playing games and socialized with friends weekly; however at the time of presentation, his social interactions were through online gaming only and he was playing games 14 h per day. The patient began paroxetine and bupropion, with good result, though declined concomitant psychotherapy. Discussion: Internet Gaming Disorder is a potential new behavioral addiction that is likely to increase in prevalence over the continuing course of the COVID-19 pandemic. While initial studies show promising effects of medication and psychosocial interventions, further study on standardized diagnostic criteria and effectiveness of treatment modalities is needed.