A national survey of children's experiences and needs when attending Canadian pediatric emergency departments.

BACKGROUND: Optimizing a child's emergency department (ED) experience positively impacts their memories and future healthcare interactions. Our objectives were to describe children's perspectives of their needs and experiences during their ED visit and relate this to their understanding of their condition. METHODS: 514 children, aged 7-17 years, and their caregivers presenting to 10 Canadian pediatric EDs completed a descriptive cross-sectional survey from 2018-2020. RESULTS: Median child age was 12.0 years (IQR 9.0-14.0); 56.5% (290/513) were female. 78.8% (398/505) reported adequate privacy during healthcare conversations and 78.3% (395/504) during examination. 69.5% (348/501) understood their diagnosis, 89.4% (355/397) the rationale for performed tests, and 67.2% (338/503) their treatment plan. Children felt well taken care of by nurses (90.9%, 457/503) and doctors (90.8%, 444/489). Overall, 94.8% (475/501) of children were happy with their ED visit. Predictors of a child better understanding their diagnosis included doctors talking directly to them (OR 2.21 [1.15, 4.28]), having someone answer questions and worries (OR 2.51 [1.26, 5.01]), and older age (OR 1.08 [1.01, 1.16]). Direct communication with a doctor (OR 2.08 [1.09, 3.99]) was associated with children better understanding their treatment, while greater fear/ 'being scared' at baseline (OR 0.59 [0.39, 0.89]) or at discharge (OR 0.46 [0.22, 0.96]) had the opposite effect. INTERPRETATION: While almost all children felt well taken care of and were happy with their visit, close to 1/3 did not understand their diagnosis or its management. Children's reported satisfaction in the ED should not be equated with understanding of their medical condition. Further, caution should be employed in using caregiver satisfaction as a proxy for children's satisfaction with their ED visit, as caregiver satisfaction is highly linked to having their own needs being met.

Family caregivers' emotional and communication needs in Canadian pediatric emergency departments.

OBJECTIVES: To describe the extent to which caregivers' emotional and communication needs were met during pediatric emergency department (PED) visits. Secondary objectives included describing the association of caregiver emotional needs, satisfaction with care, and comfort in caring for their child's illness at the time of discharge with demographic characteristics, caregiver experiences, and ED visit details. STUDY DESIGN: Electronic surveys with medical record review were deployed at ten Canadian PEDs from October 2018 -March 2020. A convenience sample of families with children <18 years presenting to a PED were enrolled, for one week every three months, for one year per site. Caregivers completed one in-PED survey and a follow-up survey, up to seven days post-visit. RESULTS: This study recruited 2005 caregivers who self-identified as mothers (74.3%, 1462/1969); mean age was 37.8 years (SD 7.7). 71.7% (1081/1507) of caregivers felt their emotional needs were met. 86.4% (1293/1496) identified communication with the doctor as good/very good and 83.4% (1249/1498) with their child's nurse. Caregiver involvement in their child's care was reported as good/very good 85.6% (1271/1485) of the time. 81.8% (1074/1313) of caregivers felt comfortable in caring for their child at home at the time of discharge. Lower caregiver anxiety scores, caregiver involvement in their child's care, satisfactory updates, and having questions adequately addressed positively impacted caregiver emotional needs and increased caregiver comfort in caring for their child's illness at home. CONCLUSION: Approximately 30% of caregivers presenting to PEDs have unmet emotional needs, over 15% had unmet communication needs, and 15% felt inadequately involved in their child's care. Family caregiver involvement in care and good communication from PED staff are key elements in improving overall patient experience and satisfaction.

Factors Influencing Parental Decision-Making Regarding Analgesia for Children with Musculoskeletal Injury-Related Pain: A Qualitative Study.

OBJECTIVES: To explore and understand parental decision-making relating to acute pain management for their children presenting to the emergency department. STUDY DESIGN: This study employed one-on-one semistructured interviews. Parents of children with acute musculoskeletal injuries were recruited from 3 Canadian pediatric emergency departments. Interviews were conducted via telephone from June 2019 to March 2021. Verbatim transcription and thematic analyses occurred concurrently with data collection, supporting data saturation and theory development considerations. RESULTS: Twenty-seven interviews were completed. Five major themes regarding pain care emerged: (1) my child's comfort is a priority, (2) every situation is unique, (3) opioids only if necessary, (4) considerations when choosing opioids, and (5) pain research is important. Overall, parents were highly comfortable with their assessment of their child's pain. Participants' willingness to use opioid analgesia for their children was primarily dependent on perceptions of injury and pain severity. Opioid-averse and opioid-accepting families had similar considerations when making analgesic decisions but weighed risks and benefits differently. CONCLUSIONS: Parents assess and manage their children's pain globally and multimodally, with comfort being prioritized. For most parents, the desire to relieve their children's pain outweighed concerns of substance use disorder, misuse, and adverse events when making decisions about opioid analgesia for short-term use. These results can inform evidence-based family-centered approaches to co-decision-making of analgesic plans for children with acute pain.

A multicentre Canadian survey of caregiver perspectives on COVID vaccine-related pain and stress for their family.

Background: Caregiver hesitancy for their children to receive the COVID-19 vaccine remains due to concerns regarding safety and efficacy, but also due to fear of vaccine administration-related pain and distress. Study objectives were to determine caregivers' perceptions regarding both their personal and child's COVID-19 vaccine administration-related stress and fear and relate this to their likelihood to allow their child to receive COVID-19 vaccinations. Methods: This study was a secondary data analysis of a multicentre, cross-sectional survey of caregivers presenting to four Canadian pediatric emergency departments. Caregivers were surveyed between December 2020 and March 2021 and completed a digital survey on their own smartphones. Results: 331 caregivers responded to the survey (mean age 39.9 years [SD 7.71]); 74.2% (245/331) were mothers. Children's mean age was 8.8 years [SD 5.4]; 49.8% (165/331) were female. 64.1% (209/326) of caregivers were willing to vaccinate their child against COVID-19, while 35.9% (117/326) were not. Greater perceived COVID-19 vaccine administration-related pain (0.88 [0.80; 0.95], p = .003) and stress (0.82 [0.76; 0.89], p = <.001) for their child as well as greater perceived personal stress with their own COVID-19 vaccine administration (0.81 [0.75; 0.88], p = <.001) were associated with caregivers being less likely to vaccinate their child. Conclusions: During the time period between COVID-19 pandemic waves 2 and 3, and after the vaccine had been federally approved for adults, one-third of Canadian caregivers surveyed reported being unwilling to vaccinate their child against COVID-19 in the future. Managing children's and caregivers' vaccine administration-related fear and stress may improve vaccine uptake for children.

The responsibility to care: lessons learned from emergency department workers' perspectives during the first wave of the COVID-19 pandemic in Canada.

BACKGROUND: This study's objective was to examine emergency department (ED) workers' perspectives during the Canadian COVID-19 first wave. METHODS: This qualitative study included workers from nine Canadian EDs who participated in 3 monthly video focus groups between April and July 2020 to explore (1) personal/professional experiences, (2) patient care and ED work, (3) relationships with teams, institutions and governing bodies. Framework analysis informed data collection and analysis. RESULTS: Thirty-six focus groups and 15 interviews were conducted with 53 participants (including 24 physicians, 16 nurses). Median age was 37.5 years, 51% were female, 79% had more than 5 years' experience. Three main themes emerged. (1) Early in this pandemic, participants felt a responsibility to provide care to patients and solidarity toward their ED colleagues and team, while balancing many risks with their personal protection. (2) ED teams wanted to be engaged in decision-making, based on the best available scientific knowledge. Institutional decisions and clinical guidelines needed to be adapted to the specificity of each ED environment. (3) Working during the pandemic created new sources of moral distress and fatigue, including difficult clinical practices, distance with patients and families, frequent changes in information and added sources of fatigue. Although participants quickly adapted to a "new normal", they were concerned about long-term burnout. Participants who experienced high numbers of patient deaths felt especially unprepared. INTERPRETATION: ED workers believe they have a responsibility to provide care through a pandemic. Trust in leadership is supported by managers who are present and responsive, transparent in their communication, and involve ED staff in the development and practice of policies and procedures. Such practices will help protect from burnout and ensure the workforce's long-term sustainability.

RéSUMé: CONTEXTE: Cette étude avait pour objectif d'examiner le point de vue des travailleurs des services d'urgence pendant la première vague de la COVID-19 au Canada. MéTHODES: Cette étude qualitative a inclus des travailleurs de neuf services d'urgence canadiens qui ont participé à 3 groupes de discussion monsuels par visioconférence entre avril et juillet 2020, pour explorer: (1) leurs expériences personnelles/professionnelles, (2) les soins aux patients et le travail au service d'urgence, (3) leurs relations avec les équipes, les institutions et instances dirigeantes. Le "framework analysis" a guidé le receuil et l'analyse des données. RéSULTATS: Trente-six groupes de discussion et 15 entretiens individuels ont été menés avec 53 participants (dont 24 médecins et 16 infirmières). L'âge médian était de 37,5 ans, 51% étaient des femmes, 79% avaient plus de 5 ans d'expérience. Trois thèmes principaux sont ressortis. (1) Au début de cette pandémie, les participants se sont sentis responsables de prodiguer des soins aux patients et solidaires envers leurs collègues et leurs équipes des urgences, tout en cherchant à équilibrer la gestion de nombreux risques et leur protection personnelle. (2) Les équipes des services d'urgence souhaitaient participer aux prises de décision, informées par les meilleures connaissances scientifiques disponibles. Les décisions institutionnelles et les lignes directrices cliniques doivent être adaptées à la spécificité de chaque salle d'urgence. (3) Travailler pendant la pandémie a créé de nouvelles sources de détresse morale et de fatigue, notamment des pratiques cliniques difficiles, la distance avec les patients et les familles, les changements fréquents d'information. Bien que les participants se soient rapidement adaptés à une « nouvelle normalité¼, ils étaient préoccupés par l'épuisement professionnel des travailleurs au long terme. Les participants qui ont vécu un nombre élevé de décès de patients à l'urgence se sentaient particulièrement mal préparés. INTERPRéTATION: Les travailleurs des services d'urgence estiment qu'ils ont la responsabilité de fournir des soins en cas de pandémie. Un sentiment de confiance dans les décideurs peut être soutenu par des gestionnaires qui sont présents et réactifs, transparents dans leur communication, et qui impliquent le personnel des services d'urgence dans le développement des politiques et procédures cliniques. De telles pratiques aideront à protéger contre l'épuisement professionnel pour garantir le bien-être des travailleurs d'urgence.

Virtual reality-based distraction for intravenous insertion-related distress in children: a study protocol for a randomised controlled trial.

INTRODUCTION: Intravenous (IV) insertions are among the most performed procedures for children seeking medical care; they are often a painful and stressful experience for both children and their caregivers. Paediatric distress and pain that is inadequately treated may lead to a frightened and uncooperative child, repeated IV attempts and overall frustration with care for both the family and clinical team. We hypothesise that distraction via an immersive virtual reality (VR) experience may reduce the associated distress for children undergoing IV insertions. METHODS AND ANALYSIS: This two-armed randomised controlled superiority trial will be conducted in a Canadian paediatric emergency department and will aim to enrol 80 children overall. Children will be randomised to receive either departmental standard of care alone or standard of care plus an immersive VR experience. Children 6-17 years of age who are undergoing IV insertion and have topical anaesthetic application will be considered for inclusion. Our primary objective is to compare the reduction of distress between the two study arms. The primary outcome will be the child's observed distress score as measured by the Observational Signs of Behavioral Distress-Revised tool. Secondary outcomes include the child's pain intensity and fear, parental anxiety, satisfaction with the IV procedure, as well as adverse events. Recruitment launched in September 2020 and is expected to end in March 2022. ETHICS AND DISSEMINATION: This study has been approved by the Health Research Ethics Board (University of Alberta). Informed consent will be obtained from parents or guardians, and assent from children. Study data will be submitted for publication irrespective of results. This study is funded through a Women and Children's Health Research Institute Innovation grant. Purchase of the VR equipment was facilitated through a Stollery Children's Hospital Foundation small equipment grant. TRIAL REGISTRATION NUMBER: NCT04291404Cite Now.

An assessment of the psychometric properties of the Stoplight Pain Scale in a Canadian paediatric emergency department.

OBJECTIVE: This study aimed to validate a novel, three faced, colour-coded, action-oriented tool: The Stoplight Pain Scale (SPS). METHODS: A prospective observational cohort study was conducted at a Canadian paediatric emergency department from November 2014 to February 2017. Patients aged 3 to 12 years and their caregivers were asked to rate pain using the SPS and the Faces Pain Scale-Revised (FPS-R). Pain was measured just before analgesia administration, 30 minutes after analgesia administration, and immediately following a painful procedure. RESULTS: A total of 227 patients were included; 26.9% (61/227) were 3 to 5 years old while 73.1% (166/227) were 6 to 12 years old. Using Cohen's κ, agreement for SPS and FPS-R was 'fair' for children (0.28 [95% confidence interval {CI} 0.20 to 0.36]) and 'poor' for caregivers (0.14 [95% CI 0.07 to 0.21]), at initial measurement. The SPS had 'fair' agreement between child and caregiver scores, (0.37 [95% CI 0.27 to 0.47]), compared to FPS-R which showed 'poor' agreement (0.20 [95% CI 0.12 to 0.29]). Absolute agreement between child and caregiver SPS scores improved with repeat exposure; 30 minutes after analgesia administration, caregivers and children had fair agreement (κ=0.38, 95% CI 0.28 to 0.48); they had moderate agreement directly following painful procedures (κ=0.46, 95% CI 0.34 to 0.59). Overall, 72.4% (139/192) of children and 60.2% (118/196) of caregivers preferred SPS over FPS-R. CONCLUSION: The SPS demonstrates fair agreement with FPS-R for children and fair-moderate agreement between children and caregivers; agreement improved with repeat use. The SPS is simple and easy to use; it may have a role in empowering direct child and family involvement in pain management.

Paediatric injuries due to falls from windows and balconies: an 8-year prospective and retrospective review.

BACKGROUND: Unintentional falls from windows and balconies pose a serious health risk to children. Limited Canadian data describing such falls currently exist. This study aimed to describe the frequency, demographic characteristics, injury patterns, and risk factors associated with paediatric falls from windows and balconies. METHODS: This study employed both prospective data collection and retrospective medical record review. Prospectively, consenting families were enrolled from February 2015 to February 2017; retrospectively, charts from January 2009 to December 2014 were reviewed. Children 0 to 16 years of age, who presented to the Stollery Children's Hospital (Edmonton, Alberta) emergency department due to a fall from a window or balcony, were included. RESULTS: A total of 102 children were included; thirty were enrolled prospectively and 72 retrospectively. Median age was 4.5 years (interquartile range 2.83 to 6.83) with 63.7% (65 of 102) males. About 87.2% (89 of 102) of falls were from windows and 12.8% (13 of 102) from balconies. The median estimated height of fall was 4.1 m (interquartile range 3.04 to 4.73). About 58.4% (59 of 101) had at least one major injury (i.e., concussion, fractured skull, internal injury, fractured limb, severe laceration), 36.6% had minor injuries only (i.e., abrasions, contusions, sprains), and 5.0% had no documented injuries. There were no fatalities. About 30.4% (31 of 102) were admitted, with 48.4% of these children (15 of 31) requiring surgery. CONCLUSION: Most falls from windows and balconies occurred in children under the age of 5 years and were associated with serious morbidity, high admission rates, and need for surgery. Child supervision as well as installation of key safety features in windows may help minimize paediatric fall-related injuries.

A two-centre survey of caregiver perspectives on opioid use for children's acute pain management.

BACKGROUND: Given the current opioid crisis, caregivers have mounting fears regarding the use of opioid medication in their children. We aimed to determine caregivers' a) willingness to accept, b) reasons for refusing, and c) past experiences with opioids. METHODS: A novel electronic survey of caregivers of children aged 4 to 16 years who had an acute musculoskeletal injury and presented to two Canadian paediatric emergency departments (ED) (March to November 2017). Primary outcome was caregiver willingness to accept opioids for moderate pain for their children. RESULTS: Five hundred and seventeen caregivers participated; mean age was 40.9 (SD 7.1) years with 70.0% (362/517) mothers. Children included 62.2% (321/516) males with a mean age of 10.0 (SD 3.6) years. 49.6% of caregivers (254/512) reported willingness to accept opioids for ongoing moderate pain in the ED, while 37.1% (190/512) were 'unsure'; 33.2% (170/512) of caregivers would accept opioids for at-home use, but 45.5% (233/512) were 'unsure'. Caregivers' primary concerns were side effects, overdose, addiction, and masking of diagnosis. Caregiver fear of addiction (odds ratio [OR] 1.12, 95% confidence interval [CI] 1.01 to 1.25) and side effects (OR 1.25, 95% CI 1.11 to 1.42) affected willingness to accept opioids in the emergency department; fears of addiction (OR 1.19, 95% CI 1.07 to 1.32), and overdose (OR 1.15, 95% CI 1.04 to 1.27) affected willingness to accept opioids for at-home use. CONCLUSIONS: Only half of the caregivers would accept opioids for moderate pain, despite ongoing pain following nonopioid analgesics. Caregivers' fears of addiction, side effects, overdose, and masking diagnosis may have influenced their responses. These findings are a first step in understanding caregiver analgesic decision making.

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.

The impact of humanoid robot presence in the paediatric emergency department waiting room: A prospective cohort study.

BACKGROUND: The waiting room represents families' first point of contact with the emergency department (ED). We wished to study if a humanoid robot technology presence in the waiting room would improve satisfaction and decrease anxiety for caregivers in the paediatric ED. METHODS: This observational cohort study was conducted from September to December 2018 at a Canadian paediatric ED. All caregivers and children >11 years in the ED waiting room were eligible. We compared a robotic intervention (RI) to standard of care (SOC) education in the waiting room. The RI was a 5-minute psychoeducational program describing the ED process and flow. Specific days were designated for RI or SOC. An anonymous survey was administered twice, at the same times, on both SOC and RI days. The primary outcomes were (a) caregiver satisfaction with waiting room experience using a 5-point Likert scale; and (b) caregiver-reported anxiety in the waiting room, as measured by the State Trait Anxiety Inventory - State Scale. RESULTS: Six hundred and thirty-three caregivers participated, with a median age of 37 years (IQR 32 to 42); 80 children participated, with a median age of 15 years (IQR 13 to 16). Caregivers reported greater overall satisfaction in the RI cohort (174/200, 87.0%) compared to the SOC cohort (144/229, 62.9%; P<0.0001). Caregivers also reported lower anxiety in the RI cohort (39.38±11.38) compared to the SOC cohort (42.04±11.99; P=0.009). CONCLUSIONS: A humanoid robot-based psycho educational intervention in the paediatric ED waiting room has a positive impact on caregiver satisfaction and anxiety.

Study protocol for two complementary trials of non-steroidal or opioid analgesia use for children aged 6 to 17 years with musculoskeletal injuries (the No OUCH study).

INTRODUCTION: Musculoskeletal (MSK) injuries are a frequent cause for emergency department (ED) visits in children. MSK injuries are associated with moderate-to-severe pain in most children, yet recent research confirms that the management of children's pain in the ED remains inadequate. Clinicians are seeking better oral analgesic options for MSK injury pain with demonstrated efficacy and an excellent safety profile. This study aims to determine the efficacy and safety of adding oral acetaminophen or oral hydromorphone to oral ibuprofen and interpret this information within the context of parent/caregiver preference. METHODS AND ANALYSIS: Using a novel preference-informed complementary trial design, two simultaneous trials are being conducted. Parents/caregivers of children presenting to the ED with acute limb injury will be approached and they will decide which trial they wish to participate in: an opioid-inclusive trial or a non-opioid trial. Both trials will follow randomised, double-blind, placebo-controlled, superiority-trial methodology and will enrol a minimum of 536 children across six Canadian paediatric EDs. Children will be eligible if they are 6 to 17 years of age and if they present to the ED with an acute limb injury and a self-reported verbal Numerical Rating Scale pain score ≥5. The primary objective is to determine the effectiveness of oral ibuprofen+oral hydromorphone versus oral ibuprofen+oral acetaminophen versus oral ibuprofen alone. Recruitment was launched in April 2019. ETHICS AND DISSEMINATION: This study has been approved by the Health Research Ethics Board (University of Alberta), and by appropriate ethics boards at all recruiting centres. Informed consent will be obtained from parents/guardians of all participants, in conjunction with assent from the participants themselves. Study data will be submitted for publication regardless of results. This study is funded through a Canadian Institutes of Health Research grant. TRIAL REGISTRATION NUMBER: NCT03767933, first registered on 07 December 2018.