Use of rational subgrouping to understand variation and opportunity for improvement in time to ultrasound

OBJECTIVE

To understand factors that contribute to variation in time to abdominal and/or pelvic ultrasound in pediatric patients in an emergency department (ED) by utilizing rational subgrouping to assess opportunity for improvement.

METHODS

All abdominal and pelvic ultrasounds conducted in the Alberta Children's Hospital ED from May 2019 to April 2021 were included. Time of study order and time of study completion were obtained from the electronic health record. Statistical process control (SPC) I-charts were used to analyze the quarterly median number of minutes from ultrasound order to completion. Rational subgrouping was used to stratify the data based on sex, age, and ED shift type, and identify special cause variation between groups. Findings were used to inform local decision-making.

RESULTS

Special cause variation was detected among subgroups for sex, age group, and shift type. The median time from order of an abdominal and/or pelvic ultrasound to completion of study was 155 min. Females had a median order to completion time of 178 min, while males had a completion time of 131 min. From age 0 to 3, the median time was 110 min, compared to 149 min for ages 4 to 11 and 171 min for ages 12 and older. Day shifts had a median order to completion time of 145 min, compared to 129 min for evening shifts and 269 min for night shifts.

CONCLUSIONS

Longer time to study completion was observed in female patients, older patients, and during night shifts. Use of rational subgrouping supported understanding of variation among subgroups of patients evaluated with abdominal and/or pelvic ultrasound. This allowed informed decision-making regarding opportunities for improvement. Rational subgrouping is a useful methodology in planning QI initiatives as it identifies sources of variation within a nonhomogeneous population and allows for judicious decision-making in a context of limited resources.

An Exploration of the Interplay Between Well-being and Quality and Safety

PURPOSE

Quality improvement and patient safety (QIPS) and clinician well-being work are interconnected and impact each other. Well-being is of increased importance in the current state of workforce shortages and high levels of burnout. The Canadian Association of Emergency Physicians (CAEP) Academic Symposium sought to understand the interplay between QIPS and clinician well-being and to provide practical recommendations to clinicians and institutions on ensuring that clinician well-being is integrated into QIPS efforts.

METHODS

A team of emergency physicians with expertise in well-being and QIPS performed a literature review, drafted goals and recommendations, and presented at the CAEP Academic Symposium in 2023 for feedback. Goals and recommendations were then further refined.

RESULTS

Three goals and recommendations were developed as follows: QIPS leaders and practitioners must (1) understand the potential intersection of well-being and QIPS, (2) consider a well-being lens for all QIPS work, and (3) incorporate QIPS methodology in efforts to improve clinician well-being.

CONCLUSION

QIPS and clinician well-being are often closely linked. By incorporating these recommendations, QIPS strategies can enhance clinician well-being.

An evaluation of satisfaction with emergency department care in children and adolescents with mental health concerns

OBJECTIVES

We hypothesized that an association exists between satisfaction with ED mental health care delivery and patient and system characteristics. Primary: To evaluate overall satisfaction with ED mental health care delivery. Secondary: To explore aspects of ED mental health care delivery associated with general satisfaction, and patient and ED visit characteristic associated with total satisfaction scores and reported care experience themes.

METHODS

We enrolled patients < 18 years of age presenting with a mental health concern between February 1, 2020 and January 31, 2021, to two pediatric EDs in Alberta, Canada. Satisfaction data were collected using the Service Satisfaction Scale, a measure of global satisfaction with mental health services. Association of general satisfaction with ED mental health care was evaluated using Pearson's correlation coefficient and variables associated with total satisfaction score was assessed using multivariable regression analyses. Inductive thematic analysis of qualitative feedback identified satisfaction and patient experience themes.

RESULTS

646 participants were enrolled. 71.2% were Caucasian and 56.3% female. Median age was 13 years (IQR 11-15). Parents/caregivers (n = 606) and adolescents (n = 40) were most satisfied with confidentiality and respect in the ED and least satisfied with how ED services helped reduce symptoms and/or problems. General satisfaction was associated with perceived amount of help received in the ED (r = 0.85) and total satisfaction with evaluation by a mental health team member (p = 0.004) and psychiatrist consultation (p = 0.05). Comments demonstrated satisfaction with ED provider attitudes and interpersonal skills and dissatisfaction with access to mental health and addictions care, wait time, and the impact of COVID-19.

CONCLUSIONS

There is a need to improve ED mental health care delivery, with a focus on timely access to ED mental health providers. Access to outpatient/community-based mental health care is needed to complement care received in the ED and to provide continuity of care for youth with mental health concerns.

Use of quality improvement methods to enhance implementation of a mental health care bundle in a pediatric emergency department

OBJECTIVES

We used quality improvement methods to implement a care bundle for children presenting to a pediatric emergency department (ED) with mental health concerns. A bundle novelty was that it included an option for assessment in a partnered clinic, not in the ED, to families of children assessed as having no medical or safety concerns. The primary aim of this study was to establish successful implementation of the bundle prior to studying its impact.

METHODS

The bundle included the Ask Suicide-Screening Questions to standardize risk assessment at triage, the HEADS-ED (Home, Education, Activities/Peers, Drug/Alcohol, Suicidality, Emotions/Behavior, Discharge Resources) tool for brief, scored mental health assessments, and offering an urgent appointment within 96 h for low-risk children as an alternative to ED-based assessment or as a follow-up option for patients assessed in the ED. We developed aims, driver diagrams, and outcome measures for each bundle element. Each element was introduced with small tests of change using iterative plan-do-study-act cycles. Run charts were used to determine successful completion of aims.

RESULTS

Rules for special cause were met through detection of shifts in performance 5 months after bundle implementation for the Ask Suicide-Screening Questions and HEADS-ED. These bundle elements were consistently used with ≥ 80% of eligible patients, representing aim achievement. During the 6 months of providing urgent appointments, 89.3% of 159 referred families received an appointment within 96 h.

CONCLUSIONS

Using quality improvement methods, we were able to successfully ensure reliable implementation of a new care bundle for pediatric patients presenting to the ED with mental health concerns and allow eligible low-risk patients to receive full assessments in a partnered clinic instead of the ED.

Clinical features at diagnosis of sickle cell disease prior to universal newborn screening in Alberta

Objectives

Sickle cell disease (SCD) is an inherited multisystem disorder with complications starting in the first year of life. Newborn screening (NBS) can identify infants with SCD and is associated with decreased morbidity and mortality. Variation in availability of NBS in Canada, and lack of standardized screening for immigrant children, may lead to delayed diagnosis.

Methods

This was a retrospective cohort study of 126 children aged 0-18 years with SCD registered with the SCD clinic at the Alberta Children's Hospital between January 2003 and January 2018, prior to province-wide universal NBS for SCD. Patient demographic information, circumstances of diagnosis, and other contextual information were collected from patient health records. Descriptive statistics were used to summarize data, with Mood's median test used to compare medians between groups.

Results

Forty-three (35%) patients were born in Alberta. Patients were mostly (95.3%) of African descent. Of patients born in Alberta, 63% (26/43) were diagnosed at >12 months of age, with a median age at diagnosis of 18 months (IQR = 4-39). This was significantly older (P < 0.001) than children born in the USA or in Canadian provinces with SCD NBS programs, where the median age at diagnosis was zero months (N = 36). Of the 42% of patients born outside North America, 64% were diagnosed following an acute complication.

Conclusions

This study highlights the importance of NBS for early detection and management of SCD, and the importance of screening at-risk immigrants who may not have received NBS for SCD.

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.

Evaluation of parent and youth experiences in advisory groups as part of a mental healthcare clinical trial: protocol for a mixed-method study

INTRODUCTION

Patient engagement in healthcare research is a necessity to ensure that research objectives align with priorities, outcomes and needs of the population under study, and to facilitate ease of implementation and adoption of findings. In clinical trials, there is an increasing focus on patient engagement during the planning and conduct of clinical trials due to the potential for ethical and methodological benefits. As patient engagement in clinical trials increases, there is a need to evaluate the approaches of these activities to contribute evidence on what is most appropriate and successful. The purpose of this study is to evaluate patient engagement processes and the activities of patient partners during and after a paediatric mental healthcare trial.

METHODS AND ANALYSIS

Using a mixed-methods study design, we will evaluate patient partners' engagement activities across set time-points during the trial and after trial completion. In this study, the term 'patient partner' is inclusive of two groups of people with lived experience: (1) caregivers (parents, formal/informal caregivers and family), and (2) youth (aged 15-24 years). Engagement will be evaluated using the participant and project questionnaires of the Public and Patient Engagement Evaluation Tool (PPEET), followed sequentially by semi-structured interviews. Quantitative data from the PPEET questionnaire will be analysed and reported using descriptive statistics. Data from open-ended questions from the PPEET questionnaires and semi-structured interviews will be analysed using thematic analysis.

ETHICS AND DISSEMINATION

Approval from Athabasca University Research Ethics Board will be obtained for this project. Findings will be disseminated at both academic and public venues whether in-person or online, and using platforms that are caregiver and youth friendly.

TRIAL REGISTRATION NUMBER

NCT04902391.

Impact of a 1-Year Pediatric Emergency Medicine Training Program for International Medical Graduates

OBJECTIVES

The Hospital for Sick Children in Toronto has offered a 1-year subspecialty residency training program in pediatric emergency medicine (PEM) to Canadian and internationally trained pediatricians and emergency physicians since 1993. The program is intended to support clinical service delivery while simultaneously offering a unique educational opportunity to Canadian and international physicians who desire 1 year of clinically focused training. We describe the experiences and career outcomes of participants who completed this program.

METHODS

Two surveys were sent to the 68 individuals who completed the clinical fellowship program from its inception in 1993 until 2014. A blinded survey focused on the fellowship experience and subsequent career activities. A nonblinded survey subsequently determined whether participants had served as a medical director or training program director.

RESULTS

Sixty of the 68 participants (88%) completed the blinded survey. Ninety-one percent were in practice in emergency medicine. Twenty-five percent of the participants were living in Canada, compared with 17% before completing the program. This net migration of 8% was not significant (P = 0.26). Thirty-six of the 50 participants (72%) who applied from outside Canada responded to the nonanonymous survey; 18 (50%) had served as an emergency department medical director, and 18 (50%) reported serving as a PEM training program director.

CONCLUSIONS

Many participants attained leadership positions in PEM in countries outside of North America and/or participated in training program development. There was no significant change in the proportion of participants living in North America at the time of application compared with the time of survey completion.

Practice Patterns and Assessment of Needs for Pediatric Pain Management in Alberta Emergency Departments

Purpose

Many rural and community emergency departments (EDs) experience barriers to providing optimal pain care to children. In preparation for a quality improvement initiative, our team conducted a provincial pediatric pain management practice and needs assessment.

Methods

An online survey was sent to ED administrators and educators from March to May 2017. Themes included pain assessment, pain and distress management strategies, available resources, education, barriers to care, and opportunities for improvement.

Results

Forty-five respondents, from 31 EDs representing all five geographic health zones in Alberta, completed the survey. Use of a pain assessment tool was reported at 93.5% (29/31 sites) of the sites. Topical anesthesia was employed “most of the time” before suturing at 67% (18/27) of sites, versus 15% (4/27) before blood work or IV insertion. Eighty-one percent (22/27) of sites reported physically restraining children for procedures “often”, while 37% (10/27) reported use of comfort positioning “often”. Digital distraction devices were available at 37% (10/27) of sites. Reported challenges included lack of resources (33.3%, 12/36), staff education/knowledge (33.3%, 12/36), and absent policies/poor policy adherence (25.0%, 9/36). Opportunities for improvement included staff member education (73.5%, 25/34) and more resources (58.8%, 20/34). Respondents rated their site’s overall ability to manage children’s pain as 50/100 [IQR:21,61].

Conclusion

General EDs report providing suboptimal children’s pain care, with use of physical restraint for medical procedures, and under-utilization of evidence-based, inexpensive treatment options. There are many gaps in children’s pain care in rural and community EDs which could be addressed through collaborative quality improvement initiatives.

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.

Introducing an innovative model of acute paediatric mental health and addictions care to paediatric emergency departments: a protocol for a multicentre prospective cohort study

INTRODUCTION

Children and youth with mental health and addiction crises are a vulnerable patient group that often are brought to the hospital for emergency department care. We propose to evaluate the effect of a novel, acute care bundle that standardises a patient-centred approach to care.

METHODS AND ANALYSIS

Two paediatric emergency departments in Alberta, Canada are involved in this prospective, pragmatic, 29-month interventional quasi-experimental study. The acute care bundle comprises three components, applied when appropriate: (1) assessing self-harm risk at triage using the Ask Suicide-Screening Questionnaire (ASQ) to standardise the questions administered, enabling risk stratification; (2) use of the HEADS-ED (Home, Education, Activities/peers, Drug/alcohol, Suicidality, Emotions and behaviour, Discharge Resources) to focus mental health evaluations for those who screen high risk on the ASQ; and (3) implementation of a Choice And Partnership Approach to enable shared decision making in care following the emergency department visit. The overarching goal is to deliver the right care at the right place and time for the patients. The study design involves a longitudinal collection of data 12 months before and after the introduction of the bundle and the use of quality improvement strategies such as Plan-Do-Study-Act cycles during a 5-month run-in period to test and implement changes. The primary study end-point is child/youth well-being 1 month after the emergency department visit. Secondary outcomes include family functioning, child/youth well-being at 3 and 6 months, satisfaction with emergency department care, and health system outcomes (hospital admissions, length of emergency department stays, emergency department revisits).

ETHICS AND DISSEMINATION

The study is registered at www.ClinicalTrials.gov and has received ethics and operational approvals from study sites. The results of the study will be reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology statement. Results will be shared broadly with key policy and decision makers and disseminated in peer-reviewed academic journals and presentations at conferences.

TRIAL REGISTRATION NUMBER

NCT04292379.

Patient-Reported Pain Outcomes for Children Attending an Emergency Department With Limb Injury

OBJECTIVES

The aim of this study was to describe patient-reported pain outcomes at various stages of an emergency department (ED) visit for pediatric limb injury.

METHODS

This prospective cohort consisted of 905 patients aged 4 to 17 years with acute limb injury and a minimum initial pain score of 4/10. Patients reported pain scores and treatments offered and received at each stage of their ED visit. Multiple logistic regression was used to identify predictors for severe pain on initial assessment and moderate or severe pain at ED discharge.

RESULTS

The initial median pain score was 6/10 (interquartile range, 4-6) and decreased at discharge to 4/10 (interquartile range, 2-6). Stages of the ED visit where the highest proportion of patients reported severe pain (score, ≥8 of 10) were fracture reduction (26.0% [19/73]; 95% confidence interval [CI], 17.1%-37.5%), intravenous insertion (24.4% [11/45]; 95% CI, 13.8%-39.6%), and x-ray (23.7% [158/668]; 95% CI, 20.6%-27.0%). Predictors of severe pain at initial assessment included younger age (odds ratio [OR], 0.92; 95% CI, 0.87-0.97), female sex (OR, 0.58; 95% CI, 0.40-0.84), and presence of fracture (OR, 1.58; 95% CI, 1.07-2.33) whereas, at discharge, older age (OR, 1.14; 95% CI, 1.06-1.23) predicted moderate/severe pain (score, ≥4 of 10).

CONCLUSIONS

These results on the location and predictors of severe pain during an ED visit for limb injury can be used to target interventions to improve pain management and patient outcomes.

Patient Reported Experience in a Pediatric Emergency Department

Objectives:

To describe patient-reported experience in a pediatric emergency department (ED) and determine: (1) whether there are differences between the experience children report in comparison to their parents; and (2) whether factors such as time of visit (day, evening, night) and ED census are associated with patient experience.

Methods:

We conducted a prospective cross-sectional survey of children ≥8 years of age and the parents/guardians of children 0 to 17 years who visited a pediatric ED using a validated patient experience measure. The proportion of respondents for each question indicating that an aspect of their care could have been improved was calculated as problem scores for each survey item. The primary outcome was the overall problem scores for all respondents combined and for children and parents separately.

Results:

A total of 237 parents and 109 children completed surveys. The areas with the highest problem scores identified by both parents and children were: having enough to do while waiting to be seen (53.5; 95% confidence interval [CI]: 48.1, 58.8) and when to restart usual activities (34.7; 95% CI: 29.7, 40.0). There were meaningful differences in problem scores between children and parents including: doctors and nurses explaining what they were doing (parents: 19; 95% CI: 14.3, 24.7, child 40.4; 95% CI: 31.2, 50.2) and privacy when examined and treated (parents: 17.3; 95% CI: 12.8, 22.9, child: 36.7; 95% CI: 27.8, 46.5).

Conclusion:

There are differences in reported experience between children and their parents. This highlights the importance of including children when assessing patient experience in a pediatric setting.

Treating and reducing anxiety and pain in the paediatric emergency department-TIME FOR ACTION-the TRAPPED quality improvement collaborative

BACKGROUND/OBJECTIVES

In 2013, the TRAPPED-1 survey reported inconsistent availability of pain and distress management strategies across all 15 Canadian paediatric emergency department (PEDs). The objective of the TRAPPED-2 study was to utilize a procedural pain quality improvement collaborative (QIC) and evaluate the number of newly introduced pain and distress-reducing strategies in Canadian PEDs over a 2-year period.

METHODS

A QIC was created to increase implementation of new strategies, through collaborative information sharing among PEDs. In 2015, 11 of the 15 Canadian PEDs participated in the TRAPPED QIC. At the end of the year, the TRAPPED-2 survey was electronically sent to a representative member at each of the 15 PEDs. The successful introduction of the chosen strategies by the QIC was assessed as well as the addition of new strategies per site. The number of new strategies introduced in the participating and nonparticipating QIC sites were described.

RESULTS

All 15 PEDs (100%) completed the TRAPPED-2 survey. Overall, 10/11 of QIC-participating sites implemented the strategy they had initially identified. All 15 Canadian PEDs implemented some new strategies during the study period; participants in the QIC reported a mean of 5.2 (1-11) new strategies compared to 2.5 (1-4) in the nonactively participating sites.

CONCLUSION

While all PEDs introduced new strategies during the study, QIC-participating sites successfully introduced the majority of their previously identified new strategies in a short time period. Sharing deadlines and information between centres may have contributed to this success.

Province-Wide Review of Pediatric Shiga Toxin-Producing Escherichia coli Case Management

OBJECTIVE

To identify the gaps in the care of children infected with Shiga toxin-producing Escherichia coli (STEC), we sought to quantitate care received and management timelines. Such knowledge is crucial to the design of interventions to prevent the development of hemolytic uremic syndrome (HUS).

STUDY DESIGN

We conducted a retrospective case-series study of 78 children infected with STEC in Alberta, Canada, through the linkage of microbiology and laboratory results, telephone health advice records, hospital charts, physician billing submissions, and outpatient antimicrobial dispensing databases. Outcomes were the time intervals between initial presentation and reporting of positive culture result and symptom onset to HUS and to describe the proportions that had baseline blood work performed and received antibiotics.

RESULTS

Seventy-eight children infected with STEC were identified; 13% (10/78) developed HUS. Median time from initial presentation to laboratory stool sample receipt was 33 hours (IQR 18, 42); time to positive culture was 120 hours (IQR 86, 205). Time from symptom onset to HUS diagnosis was 188 ± 37 hours. Baseline blood tests were obtained in 74% (58/78) of infected children. Antibiotics were administered to 50% (5/10) of those who developed HUS and 22% (15/78) of those who did not; P = .11. The provincial telephone advice system received 31 calls regarding 24 children infected with STEC; 23% (7/31) of callers were recommended to seek emergency department care.

CONCLUSIONS

A significant proportion of children developed HUS following multiple interactions with the health care system. Delays in the confirmation of STEC infection occurred. There are numerous opportunities to improve the timing, monitoring, and interventions in children infected with STEC.

Treating and Reducing Anxiety and Pain in the Paediatric Emergency Department (The Trapped 2 Survey): Time for Action – A Pediatric Emergency Research Canada (Perc) Project

BACKGROUND: Multiples barriers to appropriate analgesia provision are reported in the paediatric emergency department (PED), including limited accessibility to effective strategies.

OBJECTIVES: To evaluate the improvement in the accessibility of pain and anxiety management strategies in PEDs in Canada, after the creation of a national pediatric pain quality improvement collaborative, through Pediatric Emergency Research Canada.

DESIGN/METHODS: In 2013, the TRAPPED 1 survey was administered across Canadian PEDs, in order to evaluate the resources in place for pain and anxiety management. Subsequent to the TRAPPED 1, a pain Quality Improvement Collaborative was created to stimulate the implementation of new pain and anxiety management strategies through the sharing of information between PEDs. The TRAPPED 2 survey involved a cross sectional survey similar to TRAPPED 1, after a two year interval. Its main focus was to evaluate the improvement in the accessibility of specific, preferred strategies reported by each centre, after participating in this collaborative between December 2014 to November 2015, and then working to implement change within their own PEDs.

RESULTS: All 15/15 Canadian PEDs responded to TRAPPED 1 in 2013. In 2014, 11/15 agreed to participate in the national pain Quality Improvement Collaborative, with a goal of introducing new pain and anxiety management strategies within their own PEDs. An in-person meeting, email communication, and telephone meetings were employed for information sharing regarding experiences/challenges within each of the participating centres. Newly introduced strategies included education, distraction, nurse-initiated protocols, and policies/education to encourage the use of intranasal (IN) medications. 11/11 centres have responded to the interim follow up surveys in 2015. At the end of the project (Fall 2105), 15/15 Canadian PEDs agreed to complete the final TRAPPED 2 survey. When comparing the results of 2015 with 2013, an increased number of PEDs used face-based pain scales (14/15 vs 6/15) and behavioural scales (5/15 vs 1/15) for pain assessment of school-aged children and infants, respectively. Use of assessment room wall decoration for distraction increased from 7/15 to 11/15. Reminder posters for pain management at triage increased from 4/15 to 6/15. Availability of electronic distraction strategies (e.g. using tablets) increased from 4/15 to 10/15 centres. For skin-piercing procedure, nurses initiated protocols to use topical anesthetic creams and oral sucrose was available in 12/15 centres (compared to 10/15 in 2013), and 14/15 (compared to 12/15 in 2013) respectively. Availability of IN medications increased in the last two years: fentanyl 14/15 (9/15 in 2013) and midazolam in at least 10/15 (8/15 in 2013). 10/11 PEDS involved in the QI strategy reported the implementation of at least one of their strategies identified.

CONCLUSION: This study suggests that the use of a pain Quality Improvement Collaborative may improve the introduction of new strategies in multiple PEDs. It can help guide other centres when introducing new strategies to reduce pain and anxiety for children in community EDs. Future research can focus on the sustainability of the strategies, and as well the effect of the collaborative on the introduction of other pain treatment strategies.

Pediatric abdominal radiograph use, constipation, and significant misdiagnoses

OBJECTIVE

To determine the proportion of children diagnosed with constipation assigned a significant alternative diagnosis within 7 days (misdiagnosis), if there is an association between abdominal radiograph (AXR) performance and misdiagnosis, and features that might identify children with misdiagnoses.

STUDY DESIGN

We conducted a retrospective cohort study of consecutive children <18 years who presented to a pediatric emergency department in Toronto, between 2008 and 2010. Children assigned an International Statistical Classification of Diseases and Related Health Problems 10th Revision code consistent with constipation were eligible. Misdiagnosis was defined as an alternative diagnosis during the subsequent 7 days that resulted in hospitalization or an outpatient procedure that included a surgical or radiologic intervention. Constipation severity was classified employing text word categorization and the Leech score.

RESULTS

3685 eligible visits were identified. Mean age was 6.6 ± 4.4 years. AXR was performed in 46% (1693/3685). Twenty misdiagnoses (0.5%; 95% CI 0.4, 0.8) were identified (appendicitis [7%], intussusception [2%, bowel obstruction [2%], other [9%]). AXR was performed more frequently in misdiagnosed children (75% vs 46%; P = .01). These children more often had abdominal pain (70% vs 49%; P = .04) and tenderness (60% vs 32%; P =.01). Children in both groups had similar amounts of stool on AXR (P = .38) and mean Leech scores (misdiagnosed = 7.9 ± 3.4; not misdiagnosed = 7.7 ± 2.9; P = .85).

CONCLUSIONS

Misdiagnoses in children with constipation are more frequent in those in whom an AXR was performed and those with abdominal pain and tenderness. The performance of an AXR may indicate diagnostic uncertainty; in such cases, the presence of stool on AXR does not rule out an alternative diagnosis.

Identification of educational and infrastructural barriers to prompt antibiotic delivery in febrile neutropenia: a quality improvement initiative

BACKGROUND

Antibiotic administration within 60 minutes of presentation for medical care may be used as a treatment target for febrile neutropenia (FN); however, anecdotal evidence suggests this target is often missed. Few studies have examined the prevalence or causes of delay. We describe the median time to antibiotic administration at our institution, predictors of delay, and barriers to prompt administration to inform quality improvement strategies.

PROCEDURE

A random sample of 50 episodes of FN presenting to the emergency department (ED) between 2008 and 2009 were reviewed. Times between triage, MD assessment, lab results, and antibiotic administration were recorded. Patient and ED variables were examined as possible predictors of delay. In parallel, lean methodology was used to identify system inefficiencies. A trained moderator conducted group interviews with interdisciplinary representatives involved in the emergency care of neutropenic patients to identify process barriers to prompt antibiotics.

RESULTS

The median time from triage to antibiotics was 216 minutes (interquartile range [IQR] = 151-274 minutes). The greatest delay occurred following the reporting of lab results (152 minutes, IQR = 84-210 minutes). Only fall season predicted a longer time to antibiotics (P = 0.03). The lean process identified unnecessary areas of delay between departments.

CONCLUSIONS

Time to antibiotic administration exceeded 1 hour. The chart review and lean process suggested targets for educational and infrastructural interventions, including an ED pre-printed order sheet, targeted combined subspecialty education between emergency and hematology/oncology staff, and family education. A mixed methodology approach represents a model for improving process efficiency and meeting "best-practice" targets in medicine.

The crying infant: diagnostic testing and frequency of serious underlying disease

OBJECTIVE

To determine the proportion of children evaluated in an emergency department because of crying who have a serious underlying etiology. Secondary outcomes included the individual contributions of history, physical examination, and laboratory investigations in determining a diagnosis.

PATIENTS AND METHODS

We performed a retrospective review of all afebrile patients <1 year of age who presented with a chief complaint of crying, irritability, screaming, colic, or fussiness. All children with a serious underlying illness were identified by using a priori defined criteria. Chart review was conducted to determine if history, physical examination, or investigation data contributed to establishing the child's diagnosis.

RESULTS

Enrollment criteria were met by 237 patients, representing 0.6% of all visits. A total of 12 (5.1%) children had serious underlying etiologies with urinary tract infections being most prevalent (n = 3). Two (16.7%) of the serious diagnoses were only made on revisit. Of the 574 tests performed, 81 (14.1%) were positive. However, only 8 (1.4%) diagnoses were assigned on the basis of a positive investigation. History and/or examination suggested an etiology in 66.3% of cases. Unwell appearance was associated with serious etiologies. In only 2 (0.8%) children did investigations in the absence of a suggestive clinical picture contribute to the diagnosis. Both of these children were <4 months of age and had urinary tract infections. Among children <1 month of age, the positive rate of urine cultures performed was 10%. Ocular fluorescein staining and rectal examination with occult blood testing were performed infrequently, and results were negative in all cases. Successful follow-up was completed with 60% of caregivers, and no missed diagnoses were found.

CONCLUSIONS

History and physical examination remains the cornerstone of the evaluation of the crying infant and should drive investigation selection. Afebrile infants in the first few months of life should undergo urine evaluation. Other investigations should be performed on the basis of clinical findings.

Pediatric myocarditis: emergency department clinical findings and diagnostic evaluation

OBJECTIVE

The goal was to determine, in children with myocarditis, the frequency of various presenting symptoms and the sensitivity of clinical and laboratory investigations routinely available in the emergency department.

METHODS

We performed a retrospective review of all patients < 18 years of age who were diagnosed as having myocarditis at our institution between May 2000 and May 2006 and who initially presented to an emergency department. Patients were categorized as having definite myocarditis (positive endomyocardial biopsy results) or probable myocarditis (diagnosis assigned by a pediatric cardiologist on the basis of history, physical examination, and investigation results in the absence of an endomyocardial biopsy or in the presence of negative biopsy results). All patients were assigned a predominant category of symptoms at presentation on the basis of criteria defined a priori.

RESULTS

There were 16 cases of definite myocarditis and 15 cases of probable myocarditis. The age distribution was nonnormal, with peaks among children < or = 3 years and > or = 16 years of age. Of 14 patients who were seen by a physician before being diagnosed with myocarditis, 57% were originally diagnosed as having pneumonia or asthma. Thirty-two percent of patients presented with predominantly respiratory symptoms, 29% had cardiac symptoms, and 6% had gastrointestinal symptoms. Although evidence of cardiac dysfunction was frequently present in the form of respiratory distress, only a minority of children had evidence of hepatomegaly or abnormal cardiac examination results. The sensitivities of electrocardiograms and chest radiographs as screening tests were 93% and 55%, respectively. Among laboratory tests studied, aspartate aminotransferase measurement was the most sensitive (sensitivity: 85%).

CONCLUSIONS

Children with myocarditis present with symptoms that can be mistaken for other types of illnesses; respiratory presentations were most common. When clinical suspicion of myocarditis exists, chest radiography alone is an insufficient screening test. All children should undergo electrocardiography. Aspartate aminotransferase testing may be a useful adjunctive investigation.