Comparing the Effectiveness of a Clinical Decision Support Tool in Reducing Pediatric Opioid Dose Calculation Errors: PediPain App vs. Traditional Calculators - A Simulation-Based Randomised Controlled Study.

Wrong dose calculation medication errors are widespread in pediatric patients mainly due to weight-based dosing. PediPain app is a clinical decision support tool that provides weight- and age- based dosages for various analgesics. We hypothesized that the use of a clinical decision support tool, the PediPain app versus pocket calculators for calculating pain medication dosages in children reduces the incidence of wrong dosage calculations and shortens the time taken for calculations. The study was a randomised controlled trial comparing the PediPain app vs. pocket calculator for performing eight weight-based calculations for opioids and other analgesics. Participants were healthcare providers routinely administering opioids and other analgesics in their practice. The primary outcome was the incidence of wrong dose calculations. Secondary outcomes were the incidence of wrong dose calculations in simple versus complex calculations; time taken to complete calculations; the occurrence of tenfold; hundredfold errors; and wrong-key presses. A total of 140 residents, fellows and nurses were recruited between June 2018 and November 2019; 70 participants were randomized to control group (pocket calculator) and 70 to the intervention group (PediPain App). After randomization two participants assigned to PediPain group completed the simulation in the control group by mistake. Analysis was by intention-to-treat (PediPain app = 68 participants, pocket calculator = 72 participants). The overall incidence of wrong dose calculation was 178/576 (30.9%) for the control and 23/544 (4.23%) for PediPain App, P < 0·001. The risk difference was - 32.8% [-38.7%, -26.9%] for complex and - 20.5% [-26.3%, -14.8%] for simple calculations. Calculations took longer within control group (median of 69 Sects. [50, 96]) compared to PediPain app group, (median 48 Sects. [38, 63]), P < 0.001. There were no differences in other secondary outcomes. A weight-based clinical decision support tool, the PediPain app reduced the incidence of wrong doses calculation. Clinical decision support tools calculating medications may be valuable instruments for reducing medication errors, especially in the pediatric population.

Experiences of Parental Presence in the Induction of Anesthesia in a Canadian Tertiary Pediatric Hospital: A Cross-Sectional Study.

Background Parental presence at induction of anesthesia remains controversial and has been reported to provide mixed results. As such, parental presence at induction of anesthesia is not practiced routinely everywhere. There are currently limited data describing the practice of parental presence at induction of anesthesia or the experiences and perceptions of parents in Canada. Objectives We sought to investigate (1) the frequency of parental presence at induction of anesthesia and (2) the experiences and perceptions of parents accompanying their child into the operating room compared to those who did not at a tertiary Canadian pediatric hospital. Methods Institutional quality improvement approval was obtained. This study was a cross-sectional survey. Parents waiting in the parent surgical waiting room during the procedure were invited to complete a web-based survey. Consent was implied via completing the survey. The cross-sectional survey elicited the prevalence of parental presence during induction of anesthesia as well as their experience and perceptions. We also investigated the parents' preferences for preoperative education. Results Of the 448 parents approached, 403 completed the survey between May and June 2017. Sixty-eight (16.9% [13.4-20.9]) parents accompanied their child into the operating room (parental presence at induction of anesthesia), while 335/403 (83.1% [79.1-86.7]) did not (no-parental presence at induction of anesthesia). Reasons for not accompanying their child into the operating room included "not being aware they could" (158/335, 47.2% [41.9-52.5]), "I didn't think my child needed me" (107/335, 31.9% [27.2-37.1]), "my child was coping well" (46/335, 13.4% [10.5-17.8]), and "I was anxious" (47/335, 14.0% [10.7-18.2]). Most of the parents in the parental presence at induction of anesthesia cohort (66/67, 98.5% [95.6-101.2]) reported that they believed their child benefited/would have benefited from their presence during induction of anesthesia compared to those in the no-parental presence at induction of anesthesia cohort (137/335, 40.9% [35.8-46.2]), P < 0.001. Overall, 51/335 (14.7%) parents in the no-parental presence at induction of anesthesia cohort and 3/67 (4.5%) of those in the parental presence at induction of anesthesia cohort felt that offering parental presence at induction of anesthesia should depend on factors including child's age as well as the level of coping and anxiety. More patients in the no-parental presence at induction of anesthesia cohort felt that parental presence at induction of anesthesia should also depend on the child's age and whether the child was coping. Parents felt that face-to-face discussions with clinicians are most effective for discussing future parental presence at induction of anesthesia. Conclusions We have shown that most parents at our institution do not undergo parental presence at induction of anesthesia and are for the most part comfortable with their child going unaccompanied into the operating room. Administrators and clinicians seeking to implement parental presence policies should consider navigating parental presence at induction of anesthesia with evidence-based approaches tailored to each parent and their child.

Effect of Wearing a Face Mask on Hand-to-Face Contact by Children in a Simulated School Environment: The Back-to-School COVID-19 Simulation Randomized Clinical Trial.

Importance: Wearing a face mask in school can reduce SARS-CoV-2 transmission but it may also lead to increased hand-to-face contact, which in turn could increase infection risk through self-inoculation. Objective: To evaluate the effect of wearing a face mask on hand-to-face contact by children while at school. Design, Setting, and Participants: This prospective randomized clinical trial randomized students from junior kindergarten to grade 12 at 2 schools in Toronto, Ontario, Canada, during August 2020 in a 1:1 ratio to either a mask or control class during a 2-day school simulation. Classes were video recorded from 4 angles to accurately capture outcomes. Interventions: Participants in the mask arm were instructed to bring their own mask and wear it at all times. Students assigned to control classes were not required to mask at any time (grade 4 and lower) or in the classroom where physical distancing could be maintained (grade 5 and up). Main Outcomes and Measures: The primary outcome was the number of hand-to-face contacts per student per hour on day 2 of the simulation. Secondary outcomes included hand-to-mucosa contacts and hand-to-nonmucosa contacts. A mixed Poisson regression model was used to derive rate ratios (RRs), adjusted for age and sex with a random intercept for class with bootstrapped 95% CIs. Results: A total of 174 students underwent randomization and 171 students (mask group, 50.6% male; control group, 52.4% male) attended school on day 2. The rate of hand-to-face contacts did not differ significantly between the mask and the control groups (88.2 vs 88.7 events per student per hour; RR, 1.00; 95% CI, 0.78-1.28; P = >.99). When compared with the control group, the rate of hand-to-mucosa contacts was significantly lower in the mask group (RR, 0.12; 95% CI, 0.07-0.21), while the rate of hand-to-nonmucosa contacts was higher (RR, 1.40; 95% CI, 1.08-1.82). Conclusions and Relevance: In this clinical trial of simulated school attendance, hand-to-face contacts did not differ among students required to wear face masks vs students not required to wear face masks; however, hand-to-mucosa contracts were lower in the face mask group. This suggests that mask wearing is unlikely to increase infection risk through self-inoculation. Trial Registration: ClinicalTrials.gov Identifier: NCT04531254.

Return to school and mask-wearing in class during the COVID-19 pandemic: Student perspectives from a school simulation study.

Objectives: This study examined children's perspectives about returning to in-person school following lockdown due to the pandemic and about mask-wearing in class, as well as the mental health of children and parents during the pandemic. Methods: This cross-sectional study was part of a 2-day school simulation exercise that randomized students to different masking recommendations. Parent-report of mental health and post-simulation child-report of COVID-19-related anxiety and mask-wearing were analyzed using descriptive and multiple regression analyses. Semi-structured focus groups were conducted with older students to supplement questionnaire data. Results: Of 190 students in this study, 31% were in grade 4 or lower 95% looked forward to returning to in-person school. Greater child anxiety about COVID-19 was predicted by increased parent/caregiver anxiety (ß=0.67; P<0.001), and lower parental educational attainment (ß=1.86; P<0.002). Older students were more likely than younger students to report that mask-wearing interfered with their abilities to interact with peers (χ2(1)=31.16; P<0.001) and understand the teacher (χ2(1)=13.97; P<0.001). Students in the group that did not require masks were more likely than students in the masking group to report worries about contracting COVID-19 at school (χ2(1)=10.07; P<0.05), and anticipated difficulty wearing a mask (χ2(1)=18.95; P<0.001). Conclusions: For children anxious about COVID-19, parental anxiety and education about COVID-19 may be targets for intervention. Future research should examine the impact of prolonged implementation of public health mitigation strategies in school on academic achievement and children's mental health.

Impact of COVID-19 Public Health Protocols on Teachers Instructing Children and Adolescents During an In-Person Simulation.

Objective: As a result of the COVID-19 pandemic, public health agencies and school boards across Canada enacted new protocols, including face masks, physical distancing and enhanced hygiene, to support the safe reopening of in-person school. This study explored the experiences and perceptions of teachers instructing children and adolescents in person during a two-day school simulation. Method: This study was part of a large school simulation exercise conducted in Toronto, Ontario. Kindergarten to grade 12 teachers taught in classrooms with either masked students, or students who were un-masked or only masked when physical distancing was not possible. A qualitative descriptive phenomenology approach was utilized, and data were collected via virtual focus groups. Qualitative data analysis involved multiple rounds of inductive coding to generate themes. Results: The sample included 14 teachers (92.9% female; 85.7% White), with a median of 9.5 years teaching experience. Three primary themes emerged: 1) learning to navigate public health measures, 2) needing to adapt teaching strategies and 3) striving to manage conflicting priorities. The majority of teachers reported that mask-wearing and physical distancing impacted their classroom teaching, communication and connection with students. Conclusions: As schools transition to in-person instruction, teachers will be required to play dual roles in education and public health, with implications on safety, teaching and professional identity. Public health agencies and school boards are encouraged to engage teachers in ongoing conversations regarding in-person school planning and operations. Furthermore, evidence-based interventions, including increased teaching development programs, are recommended to support teachers during the COVID-19 pandemic.

Objectif: Conséquemment à la pandémie de la COVID-19, les organismes de santé publique et les conseils scolaires de tout le Canada ont mis en œuvre de nouveaux protocoles, notamment des masques, une distanciation physique et une hygiène accrue, afin de soutenir la réouverture prudente de l'école en personne. La présente étude a exploré les expériences et les perceptions des professeurs instruisant les enfants et les adolescents en personne durant une simulation scolaire de deux jours. Méthode: La présente étude faisait partie d'un grand exercice de simulation scolaire mené à Toronto, Ontario. Les professeurs de la maternelle à la 12e année enseignaient dans des classes où les élèves étaient soit masqués, soit non masqués, soit seulement masqués quand la distanciation physique n'était pas possible. Une approche de phénoménologie qualitative descriptive a été utilisée, et les données ont été recueillies par des groupes de discussion virtuels. L'analyse des données qualitatives impliquait de multiples rondes de codage inductif pour générer des thèmes. Résultats: L'échantillon comportait 14 professeurs (92,9 % de sexe féminin; 85,7 % Blancs), avec une moyenne de 9,5 années d'expérience d'enseignement. Trois principaux thèmes ont émergé : 1) apprendre à naviguer les mesures de santé publique, 2) la nécessité d'adapter les stratégies d'enseignement et 3) s'efforcer de gérer les priorités conflictuelles. La majorité des professeurs a déclaré que le port du masque et la distanciation physique influaient sur leur enseignement en classe, sur la communication et la connexion avec les élèves. Conclusions: Tandis que les écoles font la transition à l'enseignement en personne, les professeurs devront assumer des doubles rôles en éducation et en santé publique, impliquant la sécurité, l'enseignement et l'identité professionnelle. Les organismes de santé publique et les conseils scolaires sont invités à faire participer les professeurs à des conversations actuelles relativement à la planification et aux activités de l'école en personne. En outre, les interventions fondées sur des données probantes, notamment les programmes accrus de développement de l'enseignement, sont recommandées pour soutenir les professeurs durant la pandémie de la COVID-19.

A prospective observational study of pediatric opioid prescribing at postoperative discharge: how much is actually used?

PURPOSE: Research describing opioid misuse in children after surgery currently describes single specialties, short follow-up, and heterogeneous data not conducive to comparative discussion. Our primary objective was to quantify opioids prescribed to pediatric surgical patients on discharge from hospital. Secondary objectives were quantifying opioids remaining unused at four-week follow-up, and family attitudes to safe storage and disposal. METHODS: We conducted a prospective observational study under counterfactual consent with telephone follow-up at four weeks of children who had undergone a surgical procedure and filled an opioid prescription at The Hospital for Sick Children, Toronto, ON, Canada. Exclusion criteria included opioid use within the previous six months, history of chronic pain, or discharge to a rehabilitation facility. Pre- and post-discharge prescribing, dispensing, and consumption data were collected prospectively in addition to parental reports of home opioid use. Opioid-dosing was converted to oral morphine milligram equivalents (MME). RESULTS: There were 8,672 MMEs prescribed to 110 patients. Twenty-one patients were lost to follow-up, accounting for 1,416 MME. Of the remaining 7,256 MME, 67% went unused. At follow-up, 78% of unused opioid remained in the home. Most opioids were stored in an easily accessible location in the home. CONCLUSION: These findings confirm overprescribing of opioids to pediatric surgical patients. Families tend not to return opioids that exceed post-discharge analgesic requirements at home and many of the reported disposal methods are unsafe. We recommend future studies focus on optimizing opioid prescriptions to meet, but not excessively surpass, home pain management requirements, and to encourage safe opioid disposal/return methods. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT03562013); registered 7 June, 2018.

RéSUMé: OBJECTIF : La recherche s'intéressant à la mauvaise utilisation des opioïdes après une chirurgie chez des enfants décrit actuellement des spécialités uniques, un suivi de courte durée et des données hétérogènes ne permettant pas de déboucher sur un débat comparatif. Notre objectif principal était de quantifier les opioïdes prescrits à des patients chirurgicaux pédiatriques au moment de leur congé de l'hôpital. Les objectifs secondaires étaient de quantifier les opioïdes inutilisés restant après quatre semaines de suivi et l'attitude des familles envers un stockage et une élimination sécuritaires. MéTHODES : Nous avons réalisé une étude observationnelle prospective sous consentement contre-factuel avec suivi téléphonique à quatre semaines d'enfants qui avaient subi une procédure chirurgicale et avaient reçu une prescription honorée d'opioïdes au Hospital for Sick Children de Toronto (ON, Canada). Les critères d'exclusion étaient l'utilisation d'opioïdes dans les six mois précédents, des antécédents de douleur chronique et un congé vers un établissement de réadaptation. Les prescriptions avant et après le congé, les données de remise et de consommation des médicaments ont été collectées de manière prospective en plus des rapports parentaux sur l'utilisation des opioïdes au domicile. Les doses d'opioïdes ont été converties en milligrammes équivalents de morphine (MEM) orale. RéSULTATS : Il y a eu 8 672 MEM prescrits à 110 patients. Vingt et un patients représentant 1 416 MEM ont été perdus au suivi. Sur les 7 256 MEM restants, 67 % n'ont pas été utilisés. Au suivi, 78 % des opioïdes non utilisés étaient encore au domicile. La majorité d'entre eux étaient conservés dans un endroit facile d'accès au domicile. CONCLUSION : Ces constatations confirment la prescription excessive d'opioïdes aux patients chirurgicaux pédiatriques. Les familles ont tendance à ne pas rapporter les opioïdes qui dépassent les besoins analgésiques après le congé et un grand nombre des méthodes d'élimination indiquées ne sont pas sécuritaires. Nous recommandons de concentrer les études futures sur l'optimisation des prescriptions d'opioïdes afin de satisfaire, mais sans dépasser de façon excessive, les besoins pour la gestion de la douleur au domicile et d'encourager des méthodes de retour/élimination sécuritaire des opioïdes. ENREGISTREMENT DE L'ESSAI CLINIQUE : www.ClinicalTrials.gov (NCT03562013); Enregistré le 7 juin 2018.

Use of Serratus Plane Block for Repair of Coarctation of Aorta: A Report of 3 Cases.

OBJECTIVES: The practice of regional anesthesia techniques (thoracic, epidural, paravertebral) in pediatric cardiac surgery enhances perioperative outcomes such as improved perioperative analgesia, decreased stress response, early extubation, and shortened hospital stay. However, these blocks can be technically challenging and can be associated with unacceptable failure rate and complications in infants. For these reasons, regional anesthesia is sometimes avoided in pediatric cardiac surgery. We describe the simple and effective serratus plane block for thoracotomy analgesia in 2 neonates and a child. CASE REPORT: We present 3 pediatric patients, each of whom was having coarctation repair and received an ultrasound-guided serratus plane block for thoracotomy analgesia. The patients were 3 days, 14 days, and 4 years old, weighing from 1.9 to 16 kg. The serratus plane block was performed prior to surgical incision. The block was technically simple compared with thoracic epidural or paravertebral block. All patients were extubated immediately after completion of surgery. Apart from the induction dose of fentanyl (2 µg/kg), no further opioids were required intraoperatively. Postoperative opioid requirements as well as duration of intensive care and hospital stay were lower than recent averages (for the same demographic and procedure) in our hospital. CONCLUSIONS: We propose that the serratus plane block is a simple procedure that provides good perioperative analgesia for infant thoracotomy, potentially facilitating early extubation and a shorter hospital stay.